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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

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 Presentation

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Page 1: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

Social and Familial Factors in the Course of Bipolar

Disorder: Basic Processes and Relevant Interventions

By David Miklowitz & Sheri Johnson

Presented by Liz Lusk

Page 2: 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

Page 3: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 4: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 5: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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)

Page 6: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 7: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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)

Page 8: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 9: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 10: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 11: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 12: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 13: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 14: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 15: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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.

Page 16: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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

Page 17: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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/

Page 18: By David Miklowitz & Sheri Johnson Presented by Liz Lusk

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.