What is Bipolar Affective Disorder? - A Factual Review
Bipolar affective disorder - A factual review. Written by Sana Kate Khan (2008)
Bipolar affective disorder is a severe brain disorder that causes unusual shifts in mood, energy and activity levels, and hinders the ability to carry out day-to-day tasks. Three elements of this condition include, depressive symptoms, manic symptoms and the cyclic nature of these moods (WHO, 1992). A holistic approach is required to understand and treat the full range of clinical symptoms that contribute to the burden of suffering with this disorder (Joffe, R., 2003). Bipolar disorder is now recognized as a potentially treatable psychiatric illness (Swan, A., 2006). Taking into consideration the most important aspects of biopsychology, pharmacotherapy and psychosocial paradigms, highlighting the contribution psychology can make, this paper will look specifically at a biopsychosocial model of treatment for bipolar disorder. Taking a starting point in biopsychology the paper will discuss the importance of genetic research as a key to understanding bipolar disorder. The work of Craddock and Jones (2001), will raise ethical issues in obtaining these results. The evidence from two structural imaging studies will be compared to test the reliability of biopsychological theories of bipolar disorder. Keeping in a biological framework, psycho-pharmacotherapy will be considered, emphasizing the key mood stabilizers lithium, valproic acid, and carbamazepine as treatment. Using controlled trials a critique will be offered on the efficacy of pharmacotherapy for bipolar disorder. Finally, psychosocial interventions will be discussed, using randomized studies and highlighting the contribution psychology can make in the treatments of bipolar disorder.
The Biological approach.
The National Institute of Mental Health (2000), reports that research is the key to understanding bipolar disorder. Genetics research, data from twin, family and adoption studies demonstrating involvements of genetic factors in the transmission of the disease (Tsuang & Faraone, 1990). This is likely to have an impact on the understanding of bipolar disorders, improving treatments for patients. However, this raises ethical issues (see Craddock & Jones, 2001). Structural imaging of the brain has lead to major a breakthrough in the research of etiology of bipolar disorder. The appearance of abnormalities, in the white matter of the brain in patients with bipolar disorder has been observed (Soares & Mann, 1997). This finding suggests that the white matter abnormalities seen with MRI are related to the presence of the disorder. However a study undertaken by Lopez, et al., 2001, tested for regional prefrontal gray and white matter abnormalities in bipolar disorder patients and the findings were very different. White matter differences were not observed in any of the prefrontal sub regions. In comparison, these results suggest that bipolar patients have sub region-specific gray matter volume reductions in the prefrontal cortex as compared to healthy subjects. To sum, based on the two studies conflicting results, further investigations into the role of specific prefrontal sub regions in bipolar disorder are warranted and necessary.
Lithium is one of the most widely used mood-stabilizing agents for the treatment of bipolar disorder (Yuan, S., et al., 2004). Two other effective drugs for bipolar disorder are valproic acid and carbamazepine (Kalat, 2004). These medications are more effective for patients with bipolar II disorder, which is characterised by depression and milder manic phases. Studies show that lithium appears to be more effective when treating bipolar I disorder, with depression and more severe manic phases (Kleindienst & Greil, 2000). However, studies have shown that when using lithium as monotherapy in treatment of bipolar illness the efficacy is not as great as other medications. One randomised controlled trial compared the efficacy of divalproex, lithium, and placebo as prophylactic therapy and found that patients treated with divalproex had better outcome shan those treated with placebo or lithium on several secondary outcome measures (Bowden et al., 2000). In addition, researchers are currently investigating the efficacy of newer anticonvulsant medications including lamotrigine and gabapentin, as mood stabilizers for treatment refractory bipolar disorder (Post, in progress). Conversely, the atypical antipsychotic medications clozapine and olanzapine that were used originally to treat positive symptoms in schizophrenia, (Williams, L., et al., 2002 and see Duggan, L., et al., 2005) have already been researched and found to have mood stabilizing effects on patients with bipolar disorder (see Suppes, et al., 1999 and also Tohen, et al., 1999). Neuropharmacologists and molecular biologists are making progress in elucidating various second-messenger pathways and gene-regulation pathways altered by various mood stabilizers. An improved understanding in this area will pave the way for a new generation of mood stabilizers for bipolar disorder (Marneras, A. & Angst, J., 2000).
An integration of psychotherapeutic techniques with pharmacotherapy has been recommended for the treatment of bipolar disorder (NICE, 2006). Prophylactic agents such as lithium for example, mentioned above, only provide long term benefit for around two thirds of patients (Goodwin, 2002 and see Prien & Potter, 1990). Due to the limitations of the use of pharmacotherapy alone and its efficacy, there has been interest in developing psychosocial treatments specifically designed for bipolar disorder (Lam, 2002). Psychoanalysis, cognitive-behavioural therapy, psycho education, and interpersonal therapy have been used in the treatment of bipolar patients. Psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness (Colom and Lam, 2005).
Psychoanalytical approach – psychoanalysis.
Bipolar disorder attracted the attention of psychoanalysts since the beginning of that treatment (Lam et al., 1999). The most comprehensive review of psychoanalytic thought on bipolar disorder is summarised by Fromm-Reichmann (1949). As with much psychoanalytical thought, the emphasis is placed on mechanisms related to unconscious conflicts that have their origin in early childhood development, the resolution of which will ameliorate present day symptoms (maj, et al. 2002). Rejecting the Freudian school of thought, Willick (1990), argues that there is insufficient evidence to conclude that the aetiology of bipolar disorder, can be attributed to failures in development or fixations during the earliest years of life. Furthermore, he argues that is incorrect to ascribe these failures of development to deficiencies in the early maternal environment. There have been no systematic reviews or controlled trials that have evaluated the psychoanalytical treatment of bipolar disorder (NICE, 2006). This raises thoughts on the efficacy of psychoanalysis.
Cognitive and behavioural approach – CBT.
One study by Lam & Wong (1997) showed that the coping strategies of prodromal symptoms reported by patients of bipolar disorder were behavioural. Cognitive Behavioural theory is a structured psychological intervention derived from the cognitive behavioural model of affective disorders (NICE, 2006). Studies have demonstrated the efficacy of cognitive behavioural interventions in the treatment of bipolar disorder for improving the outcomes for the patient and also in reducing the rate of relapse (Cochran, 1984 and Lam et al., 2000 also Scott, Garland and Moorhead, 2001). Whilst the evidence for cognitive and behavioural interventions for bipolar disorder predicts positive outcomes for relapse prevention, it is not without underlying concern for the efficacy of CBT for patients needing treatment for bipolar depression. Lithium maintenance therapy has been shown to confer a greater reduction in mania compared with depression (2.53- versus 1.8-fold) (Tondo, L. et al., 1998), therefore depression continues to be prevalent even in those bipolar patients who benefit from lithium’s antimanic effects. Despite this, only about one-third of individuals with bipolar depression are in treatment (MDF, 2009). Stahl, (2000) argues than an individual’s cognitions surrounding their depression is understood as a type of moral deficiency, which is shameful and should be hidden. Ultimately, the individual’s cognitions during a depressive episode influence their behaviours, resulting from this up, to 15% of severely depressed patients will commit suicide. One pilot study compares the efficacy of CBT combined with mood-stabilizer pharmacotherapy for bipolar depression; the results showed the preliminary findings suggested that CBT warrants further investigation as an effective psychosocial intervention for depression in bipolar patients (Zaretsky, 1999). Power (2002), argues the classic cognitive therapy framework has too simple a monolithic view of the self-concept; this problem is highlighted in the need for “bidirectional schemas” in the adaptation for bipolar disorders.
Humanistic approach – psychoeducation.
From the humanistic school of thought, pychoeducation- a psychosocial intervention involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs (Schoenstadt, 2006). Studies show psycho education should prove its positive influence on the course and outcome of bipolar disorder (Colom, et al., 1998). On the contrary, highlighting the vulnerabilities of psychoeducation, Simoneau (1999) assessed changes in face-to-face interactional behaviour over 1 year, among families of bipolar patients who received a 9-month family-focused psychoeducational therapy (FFT; n = 22), administered with maintenance pharmacotherapy. No corresponding decreases were seen in negative interactional behaviours.
Psychodynamic approach-Interpersonal and social rhythm therapy.
The approach draws on social-psychodynamic models that reflect the influence of the social psychoanalytic approach of Sullivan (1953) combined with the equal influence social psychiatrist Meyer (1957). Interpersonal and social rhythm therapy (IPSRT) is an interpersonally focused individual psychotherapy that considerers behavioural and environmental interventions. In mania, the subjective experience of time is sped up and in depression it is slowed down, reflecting differences in circadian pathophysiology (Ghaemi, 2006). The Social Rhythm Metric (SRM) (Monk et al., 1991) is completed as part of the assessment. Modulating both biological and psychosocial factors the therapist helps to stabilize the irregularities of sleep-wake cycles, IPSRT is designed to help patients focus on daily routines, be compliant with medications, manage affective symptoms and resolve interpersonal problems that relate to the onset and persistence of an affective episode (Frank, et al., 1999). However further studies are needed to determine whether the approach advocated by IPSRT is the most effective in the treatment of bipolar disorder and therefore requires further consideration. Further what is more, studies are limited. Future research will determine how ISPRT compares to CBT and other evidence based psycho social treatment for bipolar disorder (Frank, 2005).
It is evident that there is a clear need for more systematic clinical management that addresses biological aspects of bipolar disorder. Conflicting evidence from structural imaging studies creates confusion for biopsychology about the aetiology of bipolar disorder. Whilst pharmacotherapy treatment outcomes for lithium are debatable it still remains the ‘gold standard’ prophylactic treatment for bipolar disorder. Progress is being made in elucidating various second messenger pathways and gene regulation pathways. An improved understanding in this area will pave the way for a new generation of mood stabilizers.
There are general limitations to take in to consideration with all the studies based on the psycho social interventions. Most studies have been single-site investigations of single treatments compared with routine care. Based on the evidence there is a need for systematic clinical research on psychotherapy applied to bipolar disorder in order to show its true usefulness. Psychodynamic interventions have limited evidence to prove efficacy of treatment. Meanwhile CBT dominates most clinical practice but has been proven to be effective with only one third of those with bipolar depression in treatment. The frame work of CBT is described having a ‘monolithic view of the self concept’ raising worries about the efficacy in treating bipolar disorders. Psychoeducation is effective but demonstrates vulnerabilities in trials that bring to light the weaknesses in the underpinnings of its philosophy. Finally IPSRT studies prove promising for the treatment of bipolar disorder, but they are limited. Future research will be interesting to follow. Plans to test the strength of the psychodynamics of IPSRT against cognitive behavioural therapies and other evidence based psycho social treatment for will bring new and exciting results for psychology and bipolar disorder treatments.
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© 2019 Sana Kate Khan