by david miklowitz & sheri johnson presented by liz lusk
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Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions. By David Miklowitz & Sheri Johnson Presented by Liz Lusk. Bipolar Disorder 101. What is a Major Depressive Episode? - PowerPoint PPT PresentationTRANSCRIPT
Social and Familial Factors in the Course of Bipolar
Disorder: Basic Processes and Relevant Interventions
By David Miklowitz & Sheri Johnson
Presented by Liz Lusk
Bipolar Disorder 101What is a Major Depressive Episode?
Must have 5 or more of the following symptoms during same 2-week period (depressed mood or loss of interest of pleasure are necessary) Depressed mood most of the day, nearly every day Diminished interest or pleasure in almost all activities Weight gain / weight loss, increase or decrease in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue Feelings of worthlessness or excessive guilt Inability to think or concentrate Recurrent thoughts of death
Bipolar Disorder 101What is a Manic Episode?
Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is necessary)
Must have 3 or more of the following symptoms (4 if the mood is only irritable) Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas / racing thoughts Distractibility Increase in goal-directed activity Excessive involvement in pleasurable activities that are high risk
Bipolar Disorder 101What is a Mixed Episode?
Criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1 week period
What are the two major differences between a Manic and Hypomanic Episode?
Time frame: distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days
Severity: Episode is not severe enough to cause marked impairment in social or occupational functioning
Bipolar Disorder 101 What is the difference between Bipolar Disorder
I and Bipolar Disorder II? Bipolar I: characterized by the occurrence of
one or more Manic Episodes or Mixed Episodes. Often individuals have also had one or more Major Depressive Episodes (but not necessary for diagnosis)
Bipolar II: characterized by the occurrence of one or more Major Depressive Episode accompanied by at least one Hypomanic Episode (never a manic or mixed episode)
Bipolar Disorder (BD) Affects about 2-4 % of the U.S. population (Merikangas et al., 2007) National Comorbidity Survey Replication found that Bipolar I and II
affect 2.6 %, with 82.9% of those being categorized as serious in severity (17.1% moderate and 0 mild)
Course can be looked at from a developmental psychopathology perspective with episodes resulting from a complex interaction between genes, neurobiology, stress and psychological vulnerabilities at different points in development.
http://www.webmd.com/bipolar-disorder/bipolar-tv/default.htm Miklowitz and Johnson review the evidence for the role of social
variables, live events, family discord and psychological variables in the course of BD, then briefly reviews effective interventions
Personality and Temperament BD patients often diagnosed also with personality disorders,
with Cluster B personality disorders being most common When examining BD individuals in remission, found a co-diagnosis in
28.8% of participants (George, Miklowitz, Richards, Simoneau & Taylor, 2003)
In 100 BD participants, found that 30% met criteria for a cluster B personality disorder (Garno, Goldberg, Ramirez and Ritzler, 2005)
Individuals with BD report higher global positive affect in their everyday lives regardless of how it is was measured
Undergrads at risk for hypomania endorsed high levels of dispositional pride and joy, but do not tend to show elevations of more prosocial positive emotions (love and compassion)
Personality and Temperament
Neuroticism has received much research attention Lahey reported in his article “Public Health Significance of Neuroticism” that
out of all the Axis I disorders, the effect size was largest between neuroticism and mood disorders
Two cross-sectional studies found neuroticism to be related to the severity of depressive symptoms in those with BD or with undiagnosed symptoms
Relatively higher rates of depressive symptoms seen in bipolar II than in bipolar I disorder so you may expect elevated neuroticism or other negative affectivity in BPD II
BD II described themselves as more labile in mood, sensitive, and brooding than those with BD I. They also endorsed being highly energetic and assertive.
Suggests that interepisode temperamental variables can be informative during periods of recovery in distinguishing between different forms of mood disorders
Personality and Temperament
Among those with BD who have a comorbid personality disorder, the course of the mood disorder is worse
Research has also focused on predicting future manic episodes versus depressive symptoms from personality profiles Trait positive affectivity has been found to predict a more severe
course of mania over a 6 month period among people already hospitalized for BD (baseline levels of positive affectivity may be important as a predictor of the course of manic symptoms)
Assessing temperamental and personality variables could help clinicians distinguish between BD I, II and MDD, especially in those in remission, and identify those at risk for depression and at greater risk for severe mania
Context is important
Life Events Focus on 3 types of events related to BD: negative life events,
social-rhythm disrupting and goal attainment1. Negative life events
2 out or 3 cross-sectional studies found that negative life events were more common in the months before a bipolar depressive episode than during control intervals
Severe independent negative events associated with increase in risk of relapse as well as increase in time until recovery
Negative life events also associated with recurrence of depressive symptoms in college students at risk for BD who had negative cognitive styles (mediation / moderation?)
Chronic interpersonal stress in adolescents (family and romantic relationships) experienced more sustained depressive symptoms over time
Overall do not see same effect of negative life events on mania
Life Events
2. Live events that Disrupt Social Rhythms Evidence suggests that BD is related to poor
regulation of sleep and circadian rhythms Sleep disruption can trigger manic symptoms (more than 10% of
patients with bipolar depression develop hypomanic or manic symptoms after induced sleep deprivation)
Biological circadian rhythms and schedule disrupting life events
Life Events3. Goal-Attainment Life Events Growing body of research on sensitivity to cues of
reward – stemming from observations that mania may be tied to brain regions involved in regulating responses to reward cues
Elevated activity in the basal ganglia and ventral tegmental area (regions involved in reward sensitivity)
Basal ganglia activity particularly elevated during periods of mania
Reward pathways may be overly sensitive in BD Which came first the chicken or the egg? Dopamanergic pathways trigger positive affect. When the
system is activated you get increased effort, energy, focus on goal pursuit…sound familiar?
Reward sensitivity also predicts increases in manic symptoms
Impairment in Family Relationships
Low social support predicts higher levels of depression over time among those with BD
Expressed Emotion (EE) – is an index of the degree to which caregiving relatives express critical, hostile, or emotionally overinvolved or overprotextive attitudes toward the patient when interviewed during or shortly after an acute episode Several longitudinal studies show high EE in family is
associated with higher rates of relapse The EE/outcome relationship appears to be stronger for
depressive than manic relapses in Bipolar I Family impairment and poor family problem solving also related
to depressive symptoms…why? Family support can be a protective factor http://www.youtube.com/watch?v=WCsUJ380ww8
Impairment in Family Relationships Expressed Emotion (EE) continued…
During period of stabilization, high EE family members of bipolar I individuals are more likely to attribute negative events to personal and controllable factors than low-EE families (same seen in families of those with MDD and Schizophrenia)
High EE couples/families - characterized by high conflict that is bidirectional and negative interactions that escalate and become personal
Low EE – able to interrupt escalations Negativity also associated with relapse
Family Factors in Childhood-Onset Bipolar Disorder
Family can be a risk factor or protective factor depending on when BD is diagnosed, if parents have mood disorders, conflict resolution style and whether the family is intact Sometimes family impairment is more of a function of the
parent’s diagnoses than the parent’s reactions to their children’s BD
When child had BD, the association between
parental and child diagnoses was mediated
by whether parents reported
high levels of family conflict.
Facial Emotion Processing The accurate perception of facial emotions is believed to be
key to social competence and conflict resolution since one must code subtle changes in another’s emotion in order to respond effectively
Studies show that bipolar adults show impairments in processing facial emotion
Bipolar youth make facial emotion recognition errors as well BD children are likely to misclassify neutral facial expressions
as hostile and threatening, even though they don’t rate angry faces as more angry than healthy controls BD youth, regardless of emotion, require more intense facial
expressions before accurate identification of emotion No study to date has demonstrated that emotion labeling
deficits predict the onset of BD in genetically at risk youth
Interventions Need combination of medication and psychosocial
interventions Family, group, interpersonal and cognitive-behavioral
approaches to relapse prevention and episode stabilization found to be effective
Common element: psychoeducation Comparative effects of different forms of psychotherapy were
examined in a large-scale randomized trial conducted across 15 sites, known as the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) http://www.stepbd.org/
Miklowitz & Johnson Summary Review of research illustrates that personality, temperament,
life stress and family discord are important influences on the course of BD
How do you see these variables interacting with each other to influence the course of BD?
Future research to focus on replication, looking at the interactions of risk and protective factors at different phases of the life cycle, cost effective methods for training clinicians and the identification of subgroups of
patients who respond best to each form of treatment.