✅ L5 - Bipolar Disorder

Question 1

What are the subtypes of bipolar disorders?

Answer 1

1. Bipolar disorder is on a spectrum, consist of 5 defining stages:
   (1) Major depression
   (2) Sub-syndromal depression
   (3) Sub-syndromal elevated mood
   (4) Hypothemia
   (5) Mania
2. Subtypes:
   - Unipolar depression (4 only)
   - Bipolar I (1 -> 5)
   - Bipolar II (mainly 1 -> 4)
   - Bipolar I - unipolar mania (mainly 4 -> 5, never falls below 2)
   - Cyclothymia: From 2 -> 3 ONLY, experience mood swings that do not qualify for bipolar, but still cause impairment to daily functioning (experienced for >2 years)
   - Other specified bipolar disorder (does not match any of the main types, short duration or lack of symptoms for specific stages)

Question 2

Characterisations of mood
episodes in bipolar disorder?

Answer 2

1. Mood episode associated with atypical change in functioning
2. Symptoms cause significant distress or impairment in functioning (social, occupational, etc.)
3. Disturbance in mood and change in functioning is observable (by others)

Question 3

What are the symptoms of major depression in bipolar disorder? (related to W4 Depression)

Answer 3

1. At least 2 weeks of:
   - Depressed mood experienced in most days
   - Markedly diminished interest or pleasure in (almost) all, activities most days.
2. Plus at least three symptoms:
   - Significant change in appetite or weight
   - Insomnia or hypersomnia
   - Psychomotor agitation/ retardation
   - Fatigue or loss of energy
   - Feelings of worthlessness and/or inappropriate guilt
   - Diminished ability to concentrate
   - Recurrent suicidal thoughts (plan, death)

Question 4

What are the symptoms of mania and hypomania in bipolar disorder?

Answer 4

1. Mania (>1 week) OR Hypomania (>4 days) of:
   - Abnormal &persistent elevated mood AND
   - Abnormal & persistent increased activity/energy
2. Plus at least 3 of:
   - Inflated self esteem
   - Decreased need for sleep
   - More talkative than usual, pressure of speech
   - Racing thoughts
   - Distractibility
   - Increased in goal-directed activity/physical agitation
   - Excessive involvement in pleasurable risky activities
3. Mania must lead to marked impairment in functioning, hospitalisation, or psychosis

Question 5

Criticism: how do we know if the symptoms of a disorder are ‘NORMAL’?

Answer 5

1. Require an objective diagnostic:
   - Are they on a continuum, i.e. part of a ‘normal’ distribution
   - Do people without a disorder experience them?
   - Can a person experience them and function effectively
   - Can they be explained by within ‘normal’ accounts of cognitive functioning?
2. Example: Mood Disorder Questionnaire to assess lifetime history of (hypo)manic experience among undergrad students
   => Student have some symptoms, but not quite meet the threshold for bipolar disorders

Question 6

What are the 4 predictors of relapse?

Answer 6

1. Stressful interpersonal life events
2. High ‘Expressed Emotion’ (hostility, overprotectiveness, criticism) in family members
3. Disrupted social rhythm events, including sleep changes
4. Goal-attainment Events => for manic symptoms and not depression

Question 7

What is the prevalence of bipolar disorder and the importance of early identification?

Answer 7

• Bipolar disorder affects 1-3% of the population
• Average duration of illness (DUI) is 6-10 years, or longer for onset in adolescence
• Longer DUI is associated with more mood episodes & higher risks of suicide
• Economic impact in the UK is predicted £8.2 billion (2026)

Question 8

What are the criteria of Bipolar At Risk (BAR)?

Answer 8

1. Early detection of BD focus on familial risk & trait-like states
2. Standardised BAR criteria, where youth (15-25) experience:
   - Short duration/less high & low mood
   - First degree relative with BD plus low mood (heritability)
3. BAR criteria has predictive validity (NHS context)

Question 9

What are the biological factors of bipolar disorder?

Answer 9

1. High heritability
2. Separate heritability of mania & depression
3. Genes for mania may involve reward pathways, (e.g. dopamine function)

Question 10

What is the NICE guideline for primary care and secondary care for bipolar disorder?

Answer 10

1. Primary care:
   - Review treatment and medication (e.g. antidepressants, mood stabilisers - lithium, antipsychotics) => high relapse rate despite adequate medications
   - Offer evidence-based psychological intervention
2. Secondary care:
   - Refer urgently if symptoms worsen for depression, or reveal symptoms of hypomania & mania
   - Pharmacological interventions (e.g. stop antidepressants if signs of hypomania & mania show, offering antipsychotics instead)
   - Offer evidence-based psychological intervention

=> Clients often ask for help to treat depression or mania symptoms (extremes)

Question 11

What are the steps or psychoeducation/relapse prevention treatment?

Answer 11

Key stages: PROVIDE - IDENTIFY - WORK

1. Provide information about bipolar disorder AND better coping.
2. Identify warning signs – also called ‘prodromes’ or ‘relapse signature’.
3. Work collaboratively to identify effective coping strategies (can get feedback from family members)

Question 12

What are the steps for Family Focused Therapy (FFT) treatment?

Answer 12

Key stages: WORK - PROVIDE - IDENTIFY

1. Work with families
2. Provide psychoeducation to improve understanding of bipolar (prevent blaming)
3. Identify hostility, criticism, and overprotectiveness
   => Help build up more collaborative and positive communication

Question 13

What are the steps for CBT bipolar disorder focused treatment?

Answer 13

1. Develop problem list with client based on stages:
   - During depression, identify and challenge ‘negative automatic thoughts’, activity scheduling
   - During hypomania, identify coping strategies
   - During remission, engage in relapse prevention
2. Personalised treatment based on clients’ ‘schemas’ & test with behavioural experiments
   => Example: ‘I must be a complete success or my life is worthless’ – experiment with ‘less than perfect’ work

Question 14

What are the efficacy for each type of bipolar disorder psychological treatment? (Relapse prevention, FFT, CBT)

Answer 14

Relapse prevention:
1. Perry et al. (1999):
- Intervention: 7-12 sessions of relapse prevention vs. treatment as usual
- Results: over 18 months, mania (longer relapse time), no effects for depression relapse time
2. Colom et al. (2003)
- Intervention: 21 sessions of group psychoeducation versus treatment as usual
- Results: reduced rates of relapse of mania and depression (>2 years)
——
FFT:
1. Miklowitz et al. (2003)
- Intervention: 21 sessions of family-focused intervention vs crisis management
- Results: reduced relapse rates and mood symptoms over 2 years
2. Rea et al. (2003)
- Compared FFT to individual psychoeducation
- Results: lower rates of rehospitalisation
——-
CBT:
1. Lam et al., (2003, 2005)
- Intervention: 20 sessions Individual CBT vs treatment as usual
- Results: reduced symptoms of depression, longer time to relapse, improved functioning
2. STEP trial – Systematic Treatment Enhancement Programme (Miklowitz et al., 2007)
- Result: Equal efficacy sessions of FFT, interpersonal therapy and CBT vs. minimal care => all effective in community settings
- Limitation: modest effect size, focus on relapse prevention rather than current symptoms and recovery

Question 15

What is the integrative cognitive model (ICM) of bipolar disorder?

Answer 15

1. Features/theory: Mood swings are due to multiple, conflicted, extreme, personal appraisals of changes in internal state
   - feelings of high energy = imminent success vs. mental breakdown
   - feelings of low energy = safe, relax vs. failure, boring
2. How? leads to internal struggle trying to exert extreme control over internal states
   => Cognitive appraisal is also influenced by personal beliefs and life experiences
3. How to measure cognitive appraisal: using Hypomanic and Positive predictions Inventory (example)

Question 16

What is the key research on the ICM model, and their aim in solving conflicting cognitive appraisal?

Answer 16

1. Key research:
   - Beliefs about internal states within the model assessed by the HAPPI scale
   - Clearly differentiates Bipolar from Unipolar depression & health controls
   - Predicts bipolar symptoms over one month in 50 patients
   - Reduced conviction in beliefs after successful CBT
   - A range of studies: diary, experimental & qualitative interview
   => Emerging evidence to support the model
2. Key aim: for clients to tolerate & accept wider range of moods to pursue life goals (rather than moving between extreme ends (e.g. Icarus’s wings analogy)

Question 17

What is the next research priority for bipolar disorder treatment?

Answer 17

Answer: Effective treatment for bipolar at risk (BAR)

1. NICE guidelines: recommend offering people with BD evidence-based psychological interventions -> CBT may be effective for BAR.
2. Importance:
   - Early intervention in psychosis services show health & economic benefits
   - Youth service models propose to widen intake criteria to include BD & those at risk of developing BD
   - Can yield £29 million in savings in the UK