Bipolar disorder between episodes (BS yen)

COMORBIDITY BIPOLAR DISORDER IS MORE OFTEN ASSOCIATED WITH ANOTHER MENTAL ILLNESS THAN ANY OTHER PSYCHIATRIC DISORDER 92.3% OF BIPOLAR PATIENTS HAVE ONE OR MORE OTHER MENTAL DISORDERS.

Dr James Telfer MBBS FRANZCP

Consultant Psychiatrist The Royal North Shore Hospital &

Community Health Service NSW, Australia

Clinical Lecturer, Faculty of Medicine,

The University of Sydney

Member, International Psychoanalytic Association and Sydney Institute

for Psychoanalysis

BIPOLAR DISORDER BETWEEN

EPISODES

MANAGEMENT STRATEGIES

BIPOLAR DISORDER IS A FAMILY OF RELATED ILLNESSES

• MANIA & HYPOMANIA

• DEPRESSION & DYSTHYMIA

• ANXIETY DISORDERS

• BIPOLAR SPECTRUM DISORDER

• ? CHILDHOOD BIPOLAR DISORDER

COMORBIDITY

BIPOLAR DISORDER IS MORE OFTEN ASSOCIATED WITH ANOTHER MENTAL ILLNESS THAN ANY OTHER PSYCHIATRIC DISORDER

92.3% OF BIPOLAR PATIENTS HAVE ONE OR MORE OTHER MENTAL

DISORDERS

HEALTH PROBLEMS BETWEEN

BIPOLAR EPISODES

1 Dysthymia

2 Hypomania

3 Anxiety Disorders in 75%

4 Drug Abuse & Addiction

5 Pathological Gambling – Genetic Link

6 Suicide Risk

7 Type 2 Diabetes

8 Cardiovascular Disease

9 Attention Deficit Hyperactivity Disorder

10 Medication Side Effects

11 Denial of Illness, Non Compliance

12 Trouble with Family, Partner, Work, The Family shares the

same genetics.

13 Impaired Creativity, shame, loss of status and role5

14 Impulse Control Disorder

ANXIETY DISORDERS WITH

BIPOLAR DISORDER

75% HAVE ANXIETY DISORDERS

(MERIKANGAS, 2007)

ANXIETY IN BIPOLAR

DISORDER

MANY PATIENTS HAVE SEVERAL ANXIETY DISORDERS

(MERIKANGAS, 2007)

EFFECTS OF ANXIETY DISORDERS ON THE BIPOLAR

PATIENT

 Bipolar symptoms last longer

 Recovery to good function is delayed

 Onset of Bipolar illness is earlier with panic disorder

 Suicide attempts and deaths are higher

 Lower quality of life

 Treatment for anxiety can make Bipolar

Disorder worse or trigger episodes

 Higher risk of relapse

 Greater risk of addiction

WHEN A DIAGNOSIS OF ANXIETY DISORDER IS MADE

CONSIDER THE POSSIBILITY OF BIPOLAR DISORDER

CHILDREN OF BIPOLAR I PARENTS HAVE HIGH RISK OF GENERALIZED

ANXIETY DISORDER 42% (CHEN 1995)

• CHECK FAMILY HISTORY

• CHECK PAST HISTORY – use mood disorder checklist

PANIC ATTACKS IN YOUNG PATIENTS ARE

PREDICTORS OF LATER BIPOLAR

DISORDER

A GENETIC PREDISPOSITION FOR PANIC ATTACKES IN BIPOLAR SUBJECTS IS LINKED TO CHROMOSOME 18

(MACKINNON, 1998)

POST TRAUMATIC STRESS DISORDER

(PTSD)

 Increased trauma in childhood in Bipolar families

 Trouble caused in manic episode later shame

 Bipolar women have twice the rate of PTSD compared to Bipolar men

(21%)

TREATMENT OF ANXIETY IN PATIENTS

WITH BIPOLAR DISORDER

The usual treatments for anxiety are harmful to Bipolar patients.

SEROTONERGIC ANTIDEPRESSANTS have a risk of

adverse effects in Bipolar patients.

SECOND GENERATION ANTIPSYCHOTICS have limited

benefit Risperidone has no benefit for anxiety in

Bipolar Patients.

BENZODIAZEPINES carry risk of addiction Withdrawal causes rebound anxiety and mood may be destabilized ANTICONVULSANTS – no evidence

LITHIUM – no evidence for anxiety disorders

PSYCHOLOGICAL TREATMENT

OF ANXIOUS BIPOLAR

PATIENTS

There are no published studies of psychotherapy for anxiety in Bipolar

Patients

Studies are for psychotherapy for mood

RECOMMENDATIONS FOR PSYCHOLOGICAL TREATMENT IN

BIPOLAR DISORDER EVIDENCE BASED

1 COGNITIVE BEHAVIOURAL THERAPY – possible

benefit , benefits may not last Exposure

therapy is for PTSD is risky in Bipolar Disorder, may help OCD CBT in groups may assist PTSD.

2 PSYCHOEDUCATION – necessary, but little

benefit shown by itself, involvement of family increases patients’ anxiety.

3 INTERPERSONAL PSYCHOTHERAPY – no benefit

4 MINDFULNESS – BASED COGNITIVE THERAPY

with individual Psychoeducation some benefit for anxiety or depression

5 More than one treatment approach is needed.

CREATIVITY AND BIPOLAR DISORDER

People who have exceptional talent and creative ability are more likely to

have Bipolar Disorder

People who have Bipolar Disorder are more likely to have exceptional talent and creative ability

PSYCHOANALYTIC UNDERSTANDING OF

CREATIVITY IN BIPOLAR DISORDER

If the creative energy or special ability of the person is not realized in a

social group, the person becomes depressed and may seek relief in

intoxicants and addictions

TREATMENT OF THE PERSON

WITH SPECIAL ABILITY

• Define the persons’ special talent or ability

• Support a social group where the ability is realized in work

• Further education, training and group support necessary

• Prevent the person from seeking to induce mania by sleep deprivation and drug use

THE THERAPEUTIC ALLIANCE IS

A MOOD STABILIZER

Talking with the individual patient with regular appointments to examine and understand the predicament of the person, their whole life situation and

the patients’ sense of meaning and purpose

(HAVENS, L.L; GHAEMI, S.N 2005) “Existential despair and Bipolar disorder: The Therapeutic Alliance as a Mood Stabilizer”

AMERICAN JOURNAL OF PSYCHOTHERAPY 59 (2) 137-147