Treating Bipolar Disorder
By: Ellen Frank, PhD
This innovative manual presents a powerful approach for helping people manage bipolar illness and protect against the recurrence of manic or depressive episodes. From Ellen Frank, the developer of interpersonal and social rhythm therapy (IPSRT) and a leading researcher and clinician in the field, the book vividly details each phase of the treatment and marshals clear evidence for its effectiveness. Lucidly written, timely, and evidence based, this is an invaluable contribution to the biopsychosocial treatment literature.
Providing all needed tools for implementing IPRST, the book takes the clinician step by step from screening, assessment, and case conceptualization, through acute therapy, maintenance treatment, and periodic booster sessions. Interventions are grounded in the latest knowledge about the neurobiology, etiology, and course of bipolar disorder, and focus on addressing key potential pathways along which new affective episodes develop. Demonstrated are proven ways to stabilize moods by improving medication adherence, building coping skills and relationship satisfaction, and shoring up the regularity of daily rhythms or routines, even in times of stress. Patients are also given the opportunity to grieve for what Frank terms “the lost healthy self” and come to terms with how the disorder has altered their lives, thereby reducing denial and increasing acceptance of the lifelong nature of the illness. Throughout, rich case examples illustrate strategies for tailoring treatment to each patient’s individual needs and current symptomatology. Special features of the volume include reproducible assessment tools and a chapter on how to overcome specific treatment challenges.
The first complete guide to this promising therapeutic approach, this highly practical book belongs on the desks of practitioners in clinical psychology, psychiatry, social work, and related mental health fields.
Ellen Frank, PhD is Professor of Psychiatry and Psychology at the University of Pittsburgh School of Medicine. She received her doctorate in psychology from the University of Pittsburgh in 1979. Dr. Frank’s work focuses on the treatment of mood disorders, with particular emphasis on the prevention of recurrence. She is the author of over 350 journal articles, books, and book chapters.
- Appreciate the extraordinary high level of stigma associated with Bipolar Disorder and the ways in which patients suffer from it.
- Recognize the tremendous disparity that persons with Bipolar Disorder experience between their educational attainments and their current employment status.
- Recognize that the psychiatric community discourages persons with Bipolar Disorder from pursuing and participating in activities important to them.
- Understand that persons who suffer from Bipolar Disorder need more than medications to treat their conditions.
- Appreciate that what patients with Bipolar Disorder and their families want most of all is to get attention to their psychosocial issues associated with the condition and receive accurate information about the disorder.
- Recognize the critical role that family members of patient with Bipolar Disorder play in the successful treatment of manic-depressive illness.
- Recognize that the author proposes the introduction of social rhythms or routines as part of the larger behavior modification program into the existing interpersonal psychotherapy models.
- Understand that IPSRT integrates efforts to regularize the social rhythms (thus protecting circadian systems from disruptions) of persons with Bipolar Disorder to improve the quality of their interpersonal relationships and social role functioning.
- Understand that IPSRT rationale understands the pathophysiology of all recurrent mood disorders in physiological instability as central to the disorder.
- Understand that many persons suffering from manic-depressive illness never receive psychosocial treatment or psychoeducation.
- Appreciate that some persons with Bipolar Disorder manage to regulate their emotions for long periods of time with a regular routine, sufficient sleep and structure to their lives.
- Recognize that challenges to circadian system and changes in hormonal states can be at the root of the onset of an episode in patients with Bipolar Disorder.
- Understand the deleterious effects that social isolation has on the prognosis for recovery and/or functioning in Bipolar Disorder.
- Understand the importance given in IPSRT to grieving for the loss of the healthy self and former (to illness) life functioning.
- Appreciate the risk that overstimulation has on the onset of manic episodes in persons with Bipolar Disorder.
- Understand that Interpersonal and Social Rhythm Therapy (IPSRT) was developed to deal with the late adolescent and adult patient with Bipolar I Disorder.
- Appreciate that the time it takes from the onset of the illness to the time patients receive a correct diagnosis averages ten years.
- Understand that the requirements of IPSRT are that major psychotic symptoms have receded or are absent at the outset of treatment, a moderate level of literacy and a great deal of motivation to change on the part of the patient.
- Understand that while IPSRT was not used with individuals of Hispanic backgrounds, the interpersonal aspects, and the social routines involved in this treatment are adaptable to virtually any cultural or subcultural background.
- Understand that Bipolar Disorder is a biologically based disorder with multiple psychological components, as well as factors reactive to environmental changes.
- Appreciate that Bipolar Disorder is likely a complex genetic disorder, consisting of several distinct genetic vulnerability traits that are passed on from one generation to the next.
- Appreciate the complexity of pharmacologic agents interplay in the nature of the “chemical imbalance” theory attributed to Bipolar Disorder.
- Understand the role of circadian systems involved in sleep-wake, appetite, energy, and alertness dysregulation by changes in social times cues (“time givers”) on affective episodes.
- Become familiar with the existing psychosocial theories including those emanating from the psychoeducational treatment model, the cognitive treatment model, negative life events theory, family hostility theory, and expressed emotionality in the family the
- Understand the principles of the integrative model of social zeitgeber theory.
- Recognize that individuals with Bipolar Disorder are believed to possess “fragile” biological clocks which are vulnerable to chronic states of desynchronization.
- Understand the importance of social rhythm stability as one possible protective factor in individuals with a history of manic-depressive illness.
- Understand that life events are factors which can account for synchronizing circadian rhythms and can account for disruption of circadian rhythms.
- Become aware that the common somatic treatment of Bipolar Disorder is done with the use of anticonvulsant medications such as Depakote, Tegretol, Topamax and Lamictal whereas Lithium is less likely to be prescribed.
- Become aware that the common somatic treatment of acute mania is done with the use of atypical antipsychotics such as Risperdal and Zyprexa for sleep-induction.
- Become aware of the common somatic treatment of acute Bipolar depression with the use of antidepressants such as SSRI drugs because of the inherent risks involved in the use of MAOIs and the risks of inducing mania if antidepressants are not combined with
- Adopt the recommendation that when a patient with Bipolar Disorder refuses to take medications, ongoing contact with a well informed clinician may allow for future acceptance of the need for medications.
- Understand the role of psychotherapy in the treatment of Bipolar Disorder to address the patient=s psychosocial difficulties and to enhance the patient=s ability to manage the illness in order to bring about a full and sustained recovery.
- Realize that treatment outcomes for Bipolar Disorder are better when pharmacological treatment is combined with psychotherapy.
- Know the types of psychotherapeutic treatments for which there is some evidence of efficacy in the treatment of Bipolar Disorder.
- Realize that the best time to initiate IPSRT is when the Pt is either acutely ill (for depressive episodes) or just beginning to recover (for manic episodes).
- Know the likely three sources of new Bipolar Disorder episodes.
- Recognize the primary goal of IPSRT is to prevent new episodes of illness or, at least, extend the interval between episodes.
- Know the basic elements of IPSRT as management of affective symptoms by the use of pharmacotherapy, through regularizing social rhythms and by resolution of interpersonal problems.
- Understanding IPSRT as comprised of modules: Assessment, psychoeducation, social rhythm regularization, and interpersonal problem areas.
- Recognize the inherent difficulties in the correct assessment of Bipolar Disoder because of the process being longitudinal, in that data will be collected over a long period of time.
- Understand the important role of history taking in the assessment of Bipolar Disorder because family history of mood disorder is a strong predictor of the illness and useful in the establishment of a correct diagnosis.
- Understand the importance of educating the patient and the family members about Bipolar Disorder.
- Recognize the challenges to differential diagnosis of Bipolar Disorder from Borderline Personality Disorder, and in the younger patients from ADHD, given the commonalities, and the difference between Schizoaffective Disorder and various types of Bipolar
- Become aware of common comorbidities in patients with Bipolar Disorder such as panic, alcohol and substance abuse or dependence, PTSD, eating disorders, as well as ADHD in younger patients and Borderline Personality Disorder.
- Understand that according to IPSRT, case formulation is arrived at by history taking, interpersonal inventory and the Social Rhythm Metric (SRM) completion at the outset of treatment.
- Know that the IPSRT case formulation articulates the kinds of relationships between interpersonal problems, external demands, and rhythm disruptions leading up to presentation of symptoms in the particular history of each Bipolar Disorder patient.
- Understand that history taking focuses on disruptions to the patient=s life (routines, interpersonal interactions) which preceded the development of symptoms.
- Recognize how constructing the illness history timeline is beneficial to educate the patient about Bipolar illness.
- Understand that taking an interpersonal inventory means to review the patient’s present and past meaningful relationships and to extract the patterns they suggest.
- Become familiar with the Social Rhythm Metric (SRM) as an instrument in the use of IPSRT assessment procedure.
- Understand that while the assessment procedure orients the patient to IPSRT, alternative treatment approaches must be considered and discussed with the patient.
- Appreciate that the treatment plan must be described and discussed with the patient in terms of needs established during the assessment phase.
- Recognize the ways in which the individualized symptom management plan is created, involving pharmacotherapy and behavioral interventions focused on rhythm stabilization and mood regulation.
- Appreciate that most of the symptom management interventions in IPSRT are built around the results of the Social Rhythm Metric (SRM) to regularize activity believed to impact mood.
- Learn to search for triggers for rhythm disruption which are the result of the patient=s life style and modulate with the patient the frequency and intensity of triggers in the patient=s life.
- Understand that the goal of symptoms management is to establish an ongoing and flexible enough balance between activity and inactivity to attain social rhythm stabilization.
- Appreciate the value of behavioral activation in the prevention of a depressive episode.
- Understand the importance of allowing grief and unresolved grief to be processed during the intermediate phase of IPSRT to facilitate resolution of grief and attain appropriate mourning process.
- Understand that acceptance of the Bipolar illness involves grieving the lost healthy self and mourn the person that patient once was but cannot be anymore.
- Incorporate the resolution of interpersonal disputes into the treatment of Bipolar illness.
- Appreciate the need of persons with Bipolar illness to receive therapeutic help in making role transitions manageable to them without those transitions precipitating a major episode.
- Recognize the likely feelings of shame, guilt, self-blame, recrimination, and bitterness often induced in persons with Bipolar illness as a result of involuntary role transitions.
- Understand how interpersonal deficits in persons with Bipolar Disorder result in chronic dissatisfaction from interpersonal relationships; and in few and limited social contacts which are largely insufficient, because of the patient=s irritability and ten
- Incorporate a “rescue” protocol for patients with Bipolar Disorder when they experience a deterioration in their euthymic state which includes introduction of sleep inducing medicines, family members to hospitalize the patient, or to contact a clinician.
- Understand the role of the clinician in regularly monitoring the effects of the pharmacological treatment, the side effects of medicines, and to maintain a consultative contact with both patient and pharmacotherapist to sustain patient emotional stability
- Appreciate the disruptive role that alcohol and other illicit substances can have on the efforts to stabilize the Bipolar patient and to discourage it completely.
- Recognize that both moderate exercise and healthy weight management through nutritional consultation are likely to result in improvement of treatment outcomes and to anchor other social rhythms.
- Consider the manipulation of daylight exposure in consultation with the patient=s pharmacotherapist while monitoring so as not to induce a manic state.
- Consider the benefits of involving family members in the care and support of patients with Bipolar illness and the benefits of involving patients and family members in support groups.
- Understand the clinician’s role in monitoring symptomatic change by identifying early warning signs of impending change, and by regularly measuring symptomatic change.
- Implement the use of the Social Rhythm Metric (SRM) and Mood Monitoring Chart by the patient with Bipolar illness as a way to enhance treatment adherence over time.
- Realize that the therapeutic stance in IPSRT is warm, empathic and open, while allowing other theoretical considerations and and clinicians’ training backgrounds to be incorporated into the treatment protocol, unless the patient seems to deteriorate as a
- Understand that problems in the therapeutic relationship with patients suffering from Bipolar Disorder are common and likely, and that they may require the clinician to adjust the therapeutic style.
- Recognize that “treatment-resistant” patients require the clinician to evaluate the sources of difficulty such as comorbidity, changes in medicine metabolism, seasonal mood variations, countertransference, and make adjustments accordingly.
- Recognize that given the chronic nature of Bipolar Disorder, termination of treatment may not be possible and that ongoing maintenance treatment with IPSRT is the more likely and the recommended outcome for many patients.