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INTRODUCTION
Bipolar disorder is a
major psychiatric illness, with a life time prevalence of 1-3%. It is
estimated that an adult developing Bipolar disorder in his/her mid 20s
effectively loses 9 years of life, 12 years of normal health, and 14 years
of work activity. In addition, the psychosocial repercussions of this
illness, such as disability are severe. The heritability of bipolar
disorder has contributed to a focus on pharmacological treatments, but
only about 60% of bipolar patients respond to Li or anticonvulsants alone.
Furthermore, only about 40% of patients remain without an illness
recurrence over 2-3 year period even when maintained on standard dosages.
Also it is clear that even with remission of affective episodes,
substantial subsyndromal symptoms, particularly depression remain in a
large proportion of patients. It has been estimated that psychosocial
factors may contribute to 25-30% to the outcome variance in bipolar
disorder. So, these statistics, as well as QOL and cost of care can be
improved on by integrating psychosocial treatments with the widely used
drug regimens.
PSYCHOSOCIAL ISSUES IN
BIPOLAR DISORDER
Most patients with
bipolar disorder will struggle with some of the following issues, which
need consideration in all psychosocial interventions (Jamison and
Goodwin, 1983).
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Emotional consequences
of affective episodes.
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Developmental
deviations and delays caused by past episodes.
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Problems associated
with stigmatization.
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Fears of recurrence and
consequent inhibition of normal psychosocial functioning.
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Interpersonal
difficulties
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Problems in learning to
discriminate normal from abnormal moods.
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Academic and
occupational problems.
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Marriage, family, child
bearing and parenting issues.
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Concerns about genetic
transmission.
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Realistic losses due to
treatment: These occur for the patient who is truly more creative or
productive during hypomania or who experiences significant side effects
from treatment.
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Symbolic losses due to
treatment: Having a chronic illness and needing medication for life can
lead to lowered self-esteem and feelings of defectiveness. The treatment
may also be scapegoated, by projection, for unrelated failures in life,
or damaging periods of mania are falsely recalled as productive.
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For all patients, some
psychosocial interventions (in addition to pharmacological management)
will be needed to address these issues, although the form, intensity and
focus of psychotherapeutic treatments are likely to vary over time for
each patient.
PSYCHOSOCIAL
INTERVENTIONS FOR ACUTE MANIC EPISODES
The desired goal of
psychotherapy in acute mania is not cure of the episode which only time or
medications will accomplish, but moderation of the most extreme manic
behaviour that can irreversibly devastate lives.
Isolation of the patient
from other individuals may sometimes be required to protect both the
patient and others. A regular schedule of meetings with the patient may be
helpful. Since the manic patient is stimulated by outside events, TV,
music and alcohol can heighten manic thought process and activities. Thus
a quiet room with fewer distractions may be desirable. Manic patients may
also need room to pace or exercise as a way to use energy and ensure
sleep. Patients and their families should be advised that during manic
episodes patients may engage in reckless driving. Counseling families to
disengage from specific arguments and stay calm while maintaining a
protective stance may help patients stay in greater control. The
psychiatrist may also make concrete interventions, such as “mopping up”
after the episode by arranging with merchants for return of
inappropriately purchased luxury items.
Janowsky et al., (1974)
enumerate five interpersonal and psychodynamic aspects of acute mania,
each implying certain therapeutic maneuvers.
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There is manipulation of
self-esteem of others. When the psychiatrist suddenly feels very good or
very bad about himself, it is correct to explore the patient’s need to
exert leverage.
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Manics are perceptive to
vulnerability and conflict. Diversionary attempts to embarrass a doctor or
nurse, by pointing out physical features for e.g. or to divide the staff
by exposing controversy within the group, are confronted. Staff meetings
are used to thwart division.
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The patient projects
responsibility for his actions. The psychiatrist must not accept the
predictable train of excuses.
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There is a progressive
limit testing. Failure to strictly enforce limits from the start leads to
a worsening spiral of lack of control. It may be true that the psychotic
manic patient hears most easily the nonverbal communication implicit in
the setting of limits.
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The family members are
alienated. Parents and spouses, trying to care for a loved one, are forced
to become adversaries. It may be possible to make the patient see how his
or her actions reflect an ambivalent wish to be taken care of causing
simultaneously dependency and emotional distance.
Often a patient will
develop insight only after repeated, remembered episodes. It may buy
precious time until medications work or a hospital bed is available to
remind the patient who has some capacity for self observation. “You are
manic. This has happened before and it is happening again. Act as normally
as possible and try to control yourself until you are feeling better.”
Eventually the patient may be able to say words like this and carry them
out even while acutely ill.
Euphoric patients try to
impress and manipulate. Often, the patient is not interested in
explanations, and better relatedness may come when the psychiatrist
finally does strongly disapprove. When the range is thus provoked, the
psychiatrist might be able to point out the patient’s conflicting wishes
to control and to be loved.
The main
countertransference problems in treating manics are excessive anger or
excessive fear. Urges to punish are detectable in diverse actions, from
overmedication to prematurely “firing” the obstreperous patient.
Undertreatment can also result from failure to accept the narcissistic
defeat that one’s own patient has relapsed. Euphoric hypomania requires
the most complex decision-making. Countertransference envy of the
“superman” qualities of the patient and identification may lie at the core
of problems in this stage of treatment. On the other hand, vicarious
thrills in listening to fantasies and exploits can stimulate the
psychiatrist to keep the patient hyperactive as long as possible. An
optional counter transference might include pleasurable appreciation of
the omnipotential fantasies of the hypomanic, tempered by savvy watchful
eye and a willingness to confront poor judgment.
PSYCHOTHERAPIES FOR
DEPRESSIVE EPISODES
There are a range of
psychotherapeutic interventions that may be useful for patients with major
depressive episodes. Some of these interventions have been studied in
patients with bipolar depression as well as in those with unipolar
depression. It is not clear to what extent patients with bipolar and
unipolar depression are similar in their responsiveness to psychotherapy.
However, it seems likely that the following treatments may benefit some
patients with bipolar depressive episodes, especially when the depressive
episodes seem to be precipitated or exacerbated by psychosocial issues or
are the cause of significant psychosocial morbidity.
Psychodynamic
psychotherapy and psychoanalytic treatments clarify intrapsychic processes
that may precipitate and/or perpetuate affective dysregulation in
vulnerable patients, and help them to anticipate and master disabilities
and neutralize conflicts through the process of insight. Interpersonal
therapy seeks to recognize and explore depressive precipitants that
involve interpersonal losses, role disputes and transitions, and is
especially effective in ameliorating occupational and social aspects of
the patient’s dysfunction. Behaviour therapy of depression is based on
functional analysis of behaviour therapy and /or social learning theory.
The techniques involve activity scheduling, self-control therapy, social
skills training, and problem solving. Cognitive therapy maintains that
irrational beliefs and distorted attitudes towards the self, the
environment and the future perpetuate depressive affects and these beliefs
may be reversed through CBT. Marital and family approaches for the
treatment of depression include behavioral approaches, a psychoeducational
approach and a “strategic marital therapy” approach. Group therapy may be
particularly useful in the treatment to depression in the context of
bereavement.
All these treatments are
reported to be effective in the acute treatment of patients with mild to
moderately severe unipolar depression, especially when combined with
pharmacotherapy. The utility of these therapies in continuation and
maintenance phase treatment of patients with bipolar depression has not
been subjected to controlled trials. Expert Consensus Guideline for
treatment of Bipolar disorder (1996) suggests psychotherapy as second line
treatment for depressive episodes, to be added when firstline treatment
with a mood stabilizer and an antidepressant fails.
SPECIFIC
PSYCHOTHERAPEUTIC APPROACHES
The available
psychotherapeutic treatments for Bipolar disorder are discussed as
separate entities, even though in practice, psychiatrists commonly use a
combination or synthesis of different approaches depending on the
patient’s needs and preferences.
Psychoanalysis
Patients suffering from
bipolar disorder did not fare particularly well with most earlier
psychoanalytic writers as potential candidates for psychoanalytic
treatment. In the 1950s and 1960s, a group associated with Mabel Cohen
applied developmental theories of Melanie-Klein to pathogenesis,
transference and countertransference, and claimed greater success in long
term outcome. Successes were claimed by various groups for long term
outcomes in small number of intensively treated patients (Rosenfeld, 1963;
Scott, 1963) Analytic techniques focused on the depressive phase of the
illness or the putative underlying depression during mania, using
transference and countertransference to explore abandonment fears,
repressed rage, manic defenses and need for engagement through testing of
limits.
Reviewing the recent
literature, there are only a few studies that are not merely description
of individual cases (Ornstein, 1981; Kestenbaum & Kron, 1987). Although
its efficiency has not been proved, Kahn (1993) postulated the use of
psychoanalytically based psychotherapy to diminish the frequency of future
episodes. Loeb and Loeb (1987) reported that the emergence of increased
sexual drives heralding hypomania was manifest in transference material
during psychoanalysis of bipolar patients. Patients became more conscious
of these processes early in the cycle, allowing for more timely
pharmacological interventions.
Psychoeducation
Psychoeducation can be
defined as a mutual process that attempts to improve a patient's illness
management skills through the bi-directional sharing of relevant
information. In psychoeducation a lower level of psychological ability
than in other approaches is needed, so it is cheaper and easier to
evaluate. It only requires extensive knowledge of the illness and its
management and communication skills. Yet bipolar patients frequently
complain about the lack of information they receive.
Psychoeducation is
appropriate for patients in all stages of the illness; however depending
on symptoms, content and methods vary. Ideally the process involves key
members of the person’s social network, including spouse, family members
and caregivers. It is generally held that the partner can more easily
discuss the problems without the patient being present.
Aims of psychoeducative
treatment for bipolar patients:
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Providing information,
assistance, insight and support to the patient and his family.
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Enhancing illness
awareness and destigmatization preventing or mitigating recurrences
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Enhancing treatment
compliance
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Avoiding drug abuse
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Identifying relapse
symptoms
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Stress management
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Enhancing knowledge and
coping of psychosocial consequences of past and future episodes.
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Preventing suicidal
behaviour.
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Improving interpersonal
and social interepisode functioning.
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Coping with subsyndromal
residual symptoms and impairment.
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Increasing well-being and
quality of life.
A small number of studies
have looked at the effect of psychoeducational interventions in bipolar
disorder. Clarkin et al (1990) using a structured psychoeducational
intervention for patients and their spouses, Harvey and Peet (1991)
showing a videotaped lecture about Li, and Perry et al (1999) with a
program oriented toward recognizing the early symptoms of manic relapse
reported encouraging results. Honig et al (1997) used a psychoeducational
program for bipolar patients and key relatives focused on developing
coping skills and recognizing the need for social supports and found
significant reductions in expressed emotions in families, with an
associated decrease in relapses.
Family therapy
Bipolar patient relatives
often state that information given to the patient is really useful for
them as well. While applying family therapy in this population, the
treatment issues one should anticipate are three fold.
As soon as manic or
depressive episode is over, the patient frequently wants to resume normal
relations immediately. After the ordeal that the family members has been
just through, however they are not ready to do so, and an atmosphere of
conflict results.
Dysfunctional patterns
frequently arise around the issue of dependence. For example, immediately
after discharge, family members are often active in ensuring medication
compliance. While it is appropriate for a time, continued too long such
activity becomes dysfunctional and deprives the patient of the chance to
assume full responsibility for his/ her well being.
Family members, consumed
with worry about the onset of another episode, find danger in virtually
any expression of anger or sadness on the part of the patient. This
reinforces the patient’s dependent position and also disqualifies
virtually all of his or her emotional expression.
Goals of family therapy
in bipolar disorder are accepting the reality of the illness, identifying
precipitating stresses and likely future stress inside and outside the
family, elucidating family interactions that produce stress on the
patient, planning strategies for managing and/or minimizing future
stresses, and bringing about the patient’s family’s acceptance of the need
for continued treatment. Family therapy should also aim at the family’s
adoption and continued use of communication and problems-solving skills,
which should help reduce tension in post episode family milieu. Studies
have shown that in India, families are more tolerant of deviant behaviour
and more willing to take care of the ill member.
Fitzgerald (1972) using
an eclectic therapy with a strong educational component, Haas et al (1988)
and Spencer et al (1988) comparing two groups of patients receiving family
therapy and individual therapy, Miller et al (1991) and Keitner (1997)
have reported on beneficial effects of family therapy in improving family
communication and decreasing relapse rates.
Family focused treatment
(Miklowitz et al, 1990) is based on the assumption that acute episodes of
bipolar disorder have disorganized effects on the family unit that are
reflected in disturbances in affective and communication styles of key
family members. Based on behavioural family management techniques, FFT
involves not only the patient but also the significant others. The program
consists of 4 modules: (1) assessment of family and marital milieu. (2)
Psychoeducation for patient and family about Bipolar disorder. (3)
Communication enhancement training. (4) Problem-solving skills training. A
recently concluded randomized controlled trial (Miklowitz et al, 2000)
showed that compared to patients who received follow up crisis management,
patients assigned to FFT had fewer relapses (especially depressive), the
most dramatic improvement being in patients whose families were high in
expressed emotion.
Marital therapy
There is a 45% separation
or divorce rate among patients of bipolar disorder, compared with 18% in
controls. This fact underlines the importance of marital therapy for this
population.
Mayo (1979) describes the
issues in marital therapy for bipolar patients. With improvement from an
affective episode, modification of the couple’s customary mode of
interaction is necessary. Problems in the marital relationship, sexual
relation, time schedules, handling of money and care of children must be
dealt with differently. Children are frequently pressured to take sides
during parental arguments. They develop ambivalent attitudes about the
apparent inadequacy of the “well” parent in face of continued “bad
behaviour” of the sick parent. During therapy, attention is focused on
enabling the spouse to assume more responsibility for his/her own
behaviour that may lead to exacerbation of symptoms in the patient. Also
the clinic provides the spouse with a vehicle for ventilation of negative
feelings. Partners are helped to see that attempts to control by punitive
behaviour (with holding of sex, food and/or money) or by threats of
hospitalization not only do not work but further intensify feelings of
anger, guilt, rejection, and inadequacy. Once each partner can begin to
accept responsibility for his/her own behaviour, affective energy can be
traced to redefine family roles, clarify attitudes, and develop new coping
styles. Patients and partners are taught to recognize early signs of
emerging symptoms, to trust verbal feedback of slight shifts in usual
behaviour as objectively based, and to call the clinic for an appointment
forthwith.
Group Therapy
Arguments in favour of
group therapy for bipolar patients are based on illness effects in social
adjustment, interpersonal aspects of coping with the illness, and the
well-known economic advantages of treating chronic illnesses in group
setting. The group can also offer a safe and controlled atmosphere, which
could function as a buffer during stressful periods, and would allow an
effective change of denial mechanisms. Other authors suggest starting
group therapy during hospitalization, even when in acute phase.
Goals of bipolar groups
include educating the patients on nature of the disease, helping them
learn ways of coping with its symptoms and encouraging them to discuss
relevant psychodynamic and interpersonal issues. To achieve these goals,
several investigators have explored alternative group approaches for this
population. Davenport et al (1977) with emphasis on compliance, Shakir et
al, (1979)using an interactional ‘here and now’ approach, Volkmar et al
(1981) who completed the former study, Kripke and Robinson (1985) using a
problem-solving approach, and
Rosen
(1980) using monthly Li group meetings reported improved compliance and
outcome in treated patients. Wynther & Sorenson (1989) showed that with
carefully selected patients, outpatient group therapy may proceed without
severe disturbance. Recently, Bauer and McBride (1996) have presented
their Life Goals Program, a structured group psychotherapy specifically
designed for bipolar affective disorder, which has proved to decrease
emergency room use and costs.
Cognitive Behavioural
Therapy
In bipolar affective
disorder, behavioural therapy may be useful for patients with mildly
depressed or dysthymic moods, or on postmanic dysphoria when the patient
quite often remains hypoactive and abulic. Self control techniques, stress
management and inoculation, exposition and coping might be useful in the
treatment of specific problems derived from the illness. Simple
behavioural techniques (such as pairing tablet-taking with a routine
activity) can be used to facilitate adherence.
Leahy and Beck (1988)
defend the use of classic cognitive techniques to treat depression and
hypomania. Cochran (1984) used an adaptation of Beck's cognitive
behavioural inventory to modify specific behavioural and cognitive
patterns hypothesized to interfere with medication compliance, and found
that CBT group had fewer recurrences. The work of Basco and Rush (1996)
incorporates elements of both CBT and psychoeducation. The goals of the
programme are to educate the patient regarding bipolar affective disorder
and its treatment, teaching cognitive behavioural skills for coping with
psychosocial stressors and attendant problems, helping patients to
recognize dysfunctional patterns of information processing in order to
prevent relapse, facilitate compliance with treatment and monitor the
occurrence and severity of symptoms.
Satterfield (1999) in an
empirical case study suggest that cognitive - behavioural or similarly
structured psychosocial treatment models could enhance the medical
treatment of rapid-cycling bipolar patients - Post et al (1988) with a
more behavioural approach, use registers to enhance identification of
stress-related specific and recurrent factors with a special meaning to
the patient, which usually flock together with each new episode. The
heirarchization of potential stressors allows the use of techniques such
as systematic desensitization.
Interpersonal and social
rhythm therapy (IPSRT)
IPSRT of Frank et al
(2000) integrates interpersonal therapy with social rhythm therapy. It
focuses on stabilizing social rhythms, such as patterns of social
stimulation and sleep-wake schedule, and on improving interpersonal
relationships as a means to develop better coping skills. IPSRT begins
while the patient is in the acute episode of illness. Sessions are
initially focused on assessing the contribution of life events and social
rhythm disruptions to previous episodes. When the patient has stabilized,
the maintenance phase focuses on tracking social rhythms and identifying
triggers that disrupt these rhythms. The final phase focuses on prevention
of episodes. It is established trial IPSRT helps patients achieve more
stable social rhythms. A randomized controlled trial is currently going on
testing the efficacy of IPSRT as an adjunctive maintenance treatment for
bipolar affective disorder.
Milieu Therapy
The term milieu therapy
has been used to describe an environment which is in some way therapeutic.
Bjork et al (1977) observed that principles of treatment derived from the
therapeutic community model - democratization and permissiveness- are
generally incompatible with the effective treatment of manic patients.
They stress that milieu modifications are necessary to meet individual
treatment needs, and describe approaches to managing manic patients in
four phases- preadmission evaluation, and the post admission, middle and
termination phases of inpatient treatment.
Support Groups
Many support groups
provide useful information about bipolar affective disorder and its
treatment. Patients in these groups often benefit from hearing the
experiences of others who are struggling with such issues as denial versus
acceptance of the need for medications, problems with side effects and how
to shoulder other burdens associated with the illness and its treatment.
In India we have volunteer groups like friends of NIMHANS, a women’s group
that had developed and administers with volunteer help a psychosocial
rehabilitation centre for psychiatric patients.
Approaches in development
Sleep Management: Wehr et al. (1998) worked with a rapid cycling patient over a 2 year
period to help him maintaining bed rest in a dark room for 14 hours each
night. The regimen resulted in sleep and mood stabilization, and a single
case replication has been reported (Justice et al., 1999).
Insight Intervention:
Davidoff et al. (1988) showed individuals with a range of psychotic
conditions videotapes of their own behaviour captured during the first 2
days of hospital admission. The videotape intervention, compared with a
control condition, resulted in significant improvements in treatment
attitudes and delusionality, although not in other symptom areas.
Psychodynamic Group Therapy:
In a small study of psychodynamic group therapy (Kanas & Cox, 1998)
bipolar patients obtained higher engagement and lower anxiety, conflict
and avoidance ratings on a measure of group process compared with groups
of schizophrenic or neurotic patients.
Ongoing Research: Includes
CBT for comorbid bipolar and substance use disorders (Weiss, et al. 1999)
and CBT in a group format (Palmer et al., 1995). Finally, the NIMH STEP
program, a very large multi-site trial of family treatment, CBT and IPSRT is particularly promising because the design involves extensive
control over medication pathways.
SOCIAL APPROACHES
Social approaches can be
divided into 2 categories, environmental manipulation and behavioural
change.
Environmental
manipulation
Treatment Setting:
Inpatient care is indicated for the suicidal, for those with severe or
non-responsive illnesses and for those without an adequate social support
network. The timing of hospitalization may be important in order not to
damage further the fragile self-esteem of the individual or to foster
dependency. Some patients fear stigmatization, but this anxiety can be
reduced by educating the patient about the potential benefits of being
allowed space to improve current coping responses in a less stressful
environment.
Life-Style Counseling:
Practical help in dealing with financial, housing and other areas may be
required. A change to a less vulnerable employment may be indicated.
However, reducing stress for an individual should not condemn him or her
to an unfulfilling life.
Enhancing Social Support:
O’connell et al. (1985) showed that social support was the psychosocial
factor most strongly correlated with a good treatment outcome. One study
done in our institute (Singh & Nizamie, 1991) confirmed this finding, and
also found that in our population, the ‘mother’ is the most important role
relationship from whom the highest average actual or ideal support is
available to bipolar affective disorder patients. These studies emphasize
an increasingly important role for a family support component in any
treatment package. Such interventions should improve the quality of the
domestic environment and reduce the level of maladaptive behaviours in the
patient and relatives. Bennett (1981) describes the use of ‘network
therapy’ to engage all members of the patient’s primary social group in
taking responsibility in initiating change.
Behavioural change
Improving Coping Skills:
If exposure to specific life events cannot be reduced, it may be possible
to alleviate the stress experienced by changing the meaning of the events
for the individual or changing the behavioural response. At a general
level, all patients will benefit from broad-based problem solving
training. Rehearsing now to act or cope with anticipated difficulties will
lead to development of protective behaviours.
Social Skills Training: Social skills training entails the patient’s learning specific
interpersonal skills and competencies through methods that promote the
maintenance and generalization of the new or rehabilitated skills. Studies
on role of social skills training in bipolar affective disorder are
lacking.
Rehabilitation
10-30% of patient with
bipolar affective disorder show evidence of moderate or severe social
impairment. The latter is usually a consequence of affective symptoms,
even if these are relatively trivial in themselves. Patients with bipolar
affective disorder may suffer from some features of the negative symptom
complex, like social eccentricity and isolation, and apparent lack of
motivation and spontaneous activity. It is now recognized that there is a
role for rehabilitation in the management of these patients.
Before instituting a
rehabilitation programme, the psychosocial assessment must address the
complex interaction of preexisting personal and social problems: the
disruptive effects of the disorder upon self-esteem and social
functioning, and the current affective psychopathology. For the majority
of patients with bipolar affective disorder the primary aim of
rehabilitation is to enhance personal adaptation. Shaw and Koch suggest
that cognitive therapy may be useful in rehabilitating these individuals.
Compared to its applications for patients with schizophrenia, vocational
rehabilitation of patients with bipolar affective disorder focuses less on
work performance and more on work for restoring confidence and self-esteem
and enhancing feelings of mastery. Few patients with bipolar affective
disorder show persistent psychotic symptoms or gross behavioural
disturbance. For this group, rehabilitation interventions parallel those
used for other chronic mentally ill patients. This incorporates four
priority areas focusing on social skills and self-care, maximizing role
performance, reducing or eliminating inappropriate behaviours and engaging
the help of one close contact (who might support the individual on return
to the community).
SPECIFIC CONSIDERATIONS
FOR SPECIAL GROUPS
Children and adolescents
Psychiatric management of
children and adolescents with bipolar affective disorder must be informed
by an assessment of the individual’s emotional, social and academic
capacities and skills, as chronic mood lability and major mood episodes
may interfere with normal development in these areas. Comorbid conditions
such as learning problems also need to be addressed.
Glaussuer et al (1985)
point out that family factors appear to be more important in early onset
bipolar affective disorder, and Stierlin and Weber (1986) characterized
all families having a young adult offspring with bipolar affective
disorder as “extremely rigid and bound up systems”, with many showing
“restrictive parental complementarity” and “reciprocal delegation”. So,
some children and adolescents will benefit from specific, more intensive
interventions. For e.g., individual and / or family treatment may be
indicated to address conflicts. School consultations may be necessary to
develop an appropriate educational environment.
Elderly
Foelker et al (1986) made
the first psychotherapy program for elderly bipolar patients, integrating
traditional therapy approaches with psychoeducation, Li level monitoring
and case management. Some fear that learning based theories may have less
value because older people tend to be more rigid psychologically and less
inclined to change, but there is ample evidence that normal elder people
can continue to learn. Family members should be instructed about the
importance of maintaining adequate hydration, especially considering
various fasts in our country, as dehydration can lead to Li toxicity.
Other interventions include keeping the medicines in bottles with name of
the medication written in big letters.
Pregnancy
Because of the risks of
pharmacologic treatment, psychotherapy alone is an important alternative
for female patients who are pregnant or planning to conceive. Bipolar
women who are maintained on Li deserve family planning as a planned
pregnancy increases available options. Individuals with bipolar affective
disorder who are considering having children may benefit from genetic
counseling.
Patients exposed to
recent life events
The observation has been
made repeatedly that bipolar patients are sensitive to life events. One
study in our institute (Singhal & Pandey, 1980) showed that 55% of
subjects experienced life events before the onset of manic episode, and
that the most common stress found was failure in achieving a target
(examination, election), economical crises and the death of a first degree
relative. Patients and their families should work with the psychiatrist to
develop an understanding of the unique association for each individual
patient between stressful events and the onset of symptoms; and they
should be encouraged to contact the psychiatrist during such times.
Patients with associated
comorbidity and complications
Patients with bipolar
affective disorder remain vulnerable to other psychiatric disorders, most
common being substance use disorders and personality disorders. Each of
these has particular consequences and increases overall psychosocial
vulnerability of the patient. So, psychosocial interventions should
address these disorders also.
Special considerations in
applying psychotherapeutic principles to Indian patients
Surya and Jayaram (1964)
pointed out that in psychotherapy, the language becomes important to lay
bare the inner meaning and nuances of emotions and feelings that can be
expressed best in the mother tongue. As compared to his Western
counterpart, the Indian patient is more ready to expect and accept
dependency relationships; more ready to accept overt situational support,
less ready to seek intrapsychic explanations; more insistent and
importunate with regard to personal needs and time and more ready to
discard ego bounds and involve the therapist in direct role relations. The
Indian patient from whatever class he is drawn, more readily alludes to
conceptual references like Karma, Dharma and traditional figures for
orientation and identification than his western counterpart with regard to
concepts like conscience, superego or to Greek mythology. For e.g.,
attributing ones illness to the needs of previous life far from generating
guilt, relieves it by a process of rationalization, as in evident in
depressive episodes. Venkoba Rao (1983) points that illustrations from
epics are acceptable to the patients. For e.g. to say Lord Krishna said
this or Lord Rama said this would impress the patients. It is useful
discussing with the patients about Arjuna’s depression and treatment by
Lord Krishna, and Rama’s depression treated by the royal sage Vasishta.
This has a more lasting effect than what the therapist tells the patient.
In resolving conflicts, advice to cultivate the art of detachment and
equanimity will be useful, as enunciated in Gita.
CONCLUSION
Among various
psychosocial approaches described for treatment of bipolar affective
disorder, evidence in most robust for the efficiency of psychoeducation,
family therapy, and IPSRT, while group therapy and CBT are supported by
weaker evidence. The effects seem stronger for depressive symptoms, while
literature on Li and anticonvulsants suggests their greater stabilizing
effects on manic symptoms. Also, various psychosocial interventions help
to improve patient’s compliance with medications and to deal with
psychosocial consequences of the illness. Thus, mood stabilizers and
psychosocial interventions are complementary treatment approaches that if
administered conjointly will offer more efficacious, effective and lasting
treatment for patients with bipolar affective disorder.
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