telfer bipolar disorder between episodes

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 4 10 11 12 13 14 HEALTH PROBLEMS BETWEEN BIPOLAR EPISODES Dysthymia Hypomania Anxiety Disorders in 75% Drug Abuse & Addiction Pathological Gambling – Genetic Link Suicide Risk Type Diabetes Cardiovascular Disease Attention Deficit Hyperactivity Disorder Medication Side Effects Denial of Illness, Non Compliance Trouble with Family, Partner, Work, The Family shares the same genetics Impaired Creativity, shame, loss of status and role Impulse Control Disorder ANXIETY DISORDERS WITH BIPOLAR DISORDER 75% HAVE ANXIETY DISORDERS (MERIKANGAS, 2007) ANXIETY IN BIPOLAR DISORDER SOCIAL PHOBIA 37.8% SPECIFIC PHOBIA 35.5% GENERALIZED ANXIETY DISORDERS 29.6% POST TRAUMATIC STRESS DISORDER 24.2% PANIC DISORDER 20% OBSESSIVE COMPULSIVE DISORDER 13.6% 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) 10 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%) 11 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 Trigger Mania Cause Chronic Depression 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 12 PSYCHOLOGICAL TREATMENT OF ANXIOUS BIPOLAR PATIENTS There are no published studies of psychotherapy for anxiety in Bipolar Patients Studies are for psychotherapy for mood 13 RECOMMENDATIONS FOR PSYCHOLOGICAL TREATMENT IN BIPOLAR DISORDER EVIDENCE BASED 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 PSYCHOEDUCATION – necessary, but little benefit shown by itself, involvement of family increases patients’ anxiety INTERPERSONAL PSYCHOTHERAPY – no benefit MINDFULNESS – BASED COGNITIVE THERAPY with individual Psychoeducation some benefit for anxiety or depression More than one treatment approach is needed 14 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 15 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 16 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 17 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 18 .. .BIPOLAR DISORDER BETWEEN EPISODES MANAGEMENT STRATEGIES BIPOLAR DISORDER IS A FAMILY OF RELATED ILLNESSES • MANIA & HYPOMANIA • DEPRESSION & DYSTHYMIA • ANXIETY DISORDERS • BIPOLAR SPECTRUM DISORDER. .. Control Disorder ANXIETY DISORDERS WITH BIPOLAR DISORDER 75% HAVE ANXIETY DISORDERS (MERIKANGAS, 2007) ANXIETY IN BIPOLAR DISORDER SOCIAL PHOBIA 37.8% SPECIFIC PHOBIA 35.5% GENERALIZED ANXIETY DISORDERS... STRESS DISORDER 24.2% PANIC DISORDER 20% OBSESSIVE COMPULSIVE DISORDER 13.6% MANY PATIENTS HAVE SEVERAL ANXIETY DISORDERS (MERIKANGAS, 2007) EFFECTS OF ANXIETY DISORDERS ON THE BIPOLAR PATIENT  Bipolar