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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part V

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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part V

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

Treatment (cont.)

Psychoeducation is universally accepted as an integral part of the psychosocial treatment protocol and includes learning aspects of healthy habits, behavioral changes, symptom management, and adherence (Colom & Vieta, 2006). Colom and colleagues (2003) designed a 21-session program, which educates patients about all aspects of their illness, such as treatment, symptoms, drug use, life style and stress management.  Other common goals of psychosocial treatment include decreasing denial, challenging assumption, monitoring moods, managing environmental triggers, relapse prevention and enhancing social and occupational functioning (Miklowitz, 2006).

Cognitive behavioral techniques are useful, since bipolar patients have distinct attributional styles and cognitive distortions.   Research linking stress and lowered social support to bipolar episodes suggest treatment target stress reduction, improvement of relationships, and altering perceptions, and treatment that addresses these psychosocial vulnerabilities may help alter the course of Bipolar I disorder (Cohen, Hammen, Henry, & Daley, 2004).   Patients are then taught to plan for potential events and learn new ways of resolving interpersonal difficulties.  This approach has shown great promise for the treatment of BD (Colom & Vieta, 2006).  Combination CBT and medication has shown to delay relapse, improve symptoms, and sometimes increase social functioning (Miklowitz, 2006).

Interpersonal Social Rhythm Therapy revolves around the notion that sleep-wake cycles are primary to symptoms and disruption of the cycles can act as a stressor.  Social rhythms, such as exercise and personal habit routines, social stimulation, and work, affect the sleep cycle (Miklowitz, 2006).  Social routines may actually entrain circadian rhythms; disruption may cause bipolar episodes, suggesting that minimization of stressful and social rhythm disruptions may prevent episodes (Malkoff-Schwartz, Frank, Anderson, Hlastala, Luther, & Houck, 2000). The client is encouraged to track mood, sleep, and events that lead to a disruption of the social-rhythm, such as a lost night of sleep.   Bipolar manic episodes may be more sensitive to social rhythm disruption and life events, as compared to other types of bipolar and unipolar episodes (Malkoff-Schwartz, Frank, Anderson, Hlastala, Luther, & Houck, 2000

Other treatment modalities are available.  Family-focused therapy focuses on family interactions and use of family members as allies in the treatment process (Miklowitz, 2006).  Skill training is used to reduce negative expression of emotion, which result in stress.  Group therapy is also used, which help patients learn to feel accepted and learn self-care strategies from one another.

I am personally interested in the use of biofeedback and neurofeedback to treat BD. Although there is no real “hard” evidence about its effectiveness with BD, largely due to the difficulty in replicating treatment in controlled experiments, anecdotal information from such people as Siegfried Othmer (one of the “fathers” of neurofeedback) convince me that the possibility for treating BD with neurofeedback are just beginning to emerge.   The use of biofeedback techniques for stress management in those with BD are useful, but must be administered with care.   Over-activation of the parasympathetic or sympathetic nervous system may induce a bipolar event.

Of direct implication from the kindling hypothesis is the timing of intervention.  Intervention may be much more effective at the initial stages of expression than at later stages (Monroe & Harkness, 2005, p. 442).  By tackling the stressful life situations of those at risk early on, the course of the disorder may be changed.  How much of the developmental process is a reaction to life course and how much is an independent psychobiological process is as yet unknown, but begs for further investigation.  “The key implication of this study is that childhood adversity may be related to a more challenging presentation of bipolar disorder, with an earlier age at onset and greater vulnerability to experiencing recurrences of mood episodes in the face of even mild stress. Earlier onset and a more difficult course of bipolar disorder may have serious consequences for both the efficacy of treatment of bipolar disorder and for the functioning of bipolar individuals.  If childhood adversity is a trigger of earlier onset and sensitizes individuals to stress, preventing stress exposure in high risk families, or promoting coping capabilities in such youngsters might have positive consequences on the course of illness”  (Dienes, Hammen, Henry, Cohen, & Daley, 2006, p. 49).  Prevention of stress and early intervention may be critical in reducing the severity of the disorder in later life.

– Julie Myers, PsyD, MSCP

http://www.DrJulieMyers.com

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Copyright (2011) Julie Myers, PsD

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Written by Julie Myers, PsyD, MSCP

July 13, 2011 at 5:44 pm

The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part II

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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder  (Part II)

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

 

The Comorbidity of Bipolar Disorder and Stress disorders

 Comorbidity is common in BD, further complicating the diagnosis.  In one study, a comorbid disorder was found in all of the samples, and in 59% the condition preceded the onset of BD symptoms (Kessler, Rubinow, Holmes, Abelson, & Ahao, 1997).  Common among the comorbid disorders are anxiety, substance abuse, ADHD, Oppositional-Defiant Disorder, Bulimia, Social Phobia, Panic Disorder, and Obsessive Compulsive Disorder  (Correll, et al., 2007) and (Perugi, Ghaemi, & Akiskal, 2006), many of which are stress related.  Personality disorders also occur at a higher rate than the general public, which may actually be an expression of phenotypic expression of a bipolar diathesis (Correll, et al., 2007).  BD has the highest prevalence of any psychiatric disorder for alcohol and other substance use disorders, with a lifetime comorbidity estimated from 17 – 61% (Vizzarri, et al., 2007).  In one large study of 500 bipolar patients, a lifetime substance use disorders was found in the entire sample (Simon, et al., 2004).     In many cases, it is unclear whether these co-occurring disorders are truly biologically distinct, or simply risk markers, prodromal states, overlapping  characteristics, or subtypes (Correll, et al., 2007).

 Comorbidity of BD with anxiety disorders is particularly high.  In one large study of 500 BD patients, the lifetime comorbidity with anxiety disorder occurred in over half the sample (Simon, et al., 2004); approximately 11-63% had panic disorder, 8-47% social anxiety disorder, 3-35% obsessive compulsive disorder, 7-39% posttraumatic stress disorder and 7-32% generalized anxiety disorder.   Overall anxiety comorbidity was higher in Bipolar I disorder than Bipolar II disorder. The presence of anxiety predicted a lower age of onset (about 16 as opposed 20 years old) and a shorter time in the euthymic state.  Presence of anxiety disorder also was associated with impaired function, poorer quality of life, decreased likelihood of recovery, greater prevalence of substance abuse, and greater likelihood of suicide attempt.    In my experience, those in hypomanic states have a high reactivity to stress, often engaging in activities to relieve stress, such as compulsive shopping, sexual activity, or risk-taking.  Substances are often used to “self-medicate.”

When chronic stress in family, romantic, and peer relationships is present, there is less improvement in mood symptoms in adolescents.  “The association between chronic stress in peer relationships and mania symptoms is likely a recursive one in which the most impaired youths generate the highest levels of peer-related stress, which further exacerbates their mood symptomatology”  (Kim, Miklowitz, Biuckians, & Mullen, 2007, p. 37).  Possibly, this may create a pattern of dysfunctional reactivity to stress.

In one case example, Bob is an 18 year old male, who expressed BD at the age of 5 after a family stress.  Although he did not receive a diagnosis of BD until the age of 12, his symptoms where characteristic of juvenile BD.   He had symptoms of obsessive compulsive disorder, social anxiety disorder, separation anxiety, and generalized anxiety disorder.  His mind was often occupied with ruminative “bad” thoughts.  He developed many compensatory behaviors to relieve his stress including a shut-down depressive state, psychomotor agitation and tics.  Bob manifested psychotic symptoms and suicidal ideation during times of heightened stress.  School, for example, was a continual source of stress from teachers and peers, resulting in poor performance and exacerbation of bipolar switching.  This further resulted in a deterioration of peer relationships, recursively leading to a greater number of bipolar episodes.

Copyright (2011):  Julie Myers, PsyD:   All rights reserved.

Written by Julie Myers, PsyD, MSCP

June 25, 2011 at 6:48 pm

The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part I

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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part I

 

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

It is generally agreed in the literature that stress affects the course and severity of Bipolar Disorder (BD.)  Stress, particularly in early life, appears to have lasting effect and marks for early onset, although the exact mechanism of this effect is poorly understood.  The relationship of stress to the onset of the disorder and its course has implications for the treatment and management of the disorder, and perhaps even its onset.  In this paper, I discuss the characteristics of BD and its co-occurrence with anxiety disorders, and the etiology and the treatment of BD in relationship to stress management techniques.  Case examples are presented.

 

The Nature of Bipolar Disorder

 Bipolar Disorder is a mood disorder, characterized by shifting states between mania or hypomania and depression.   The length of time that a person spends in either the up or the down phases are not fixed in length nor in severity, although those with Bipolar I Disorder have periods of mania, while those with Bipolar II Disorder only reach hypomania.  Periods may last from years to hours in rapid or ultra-rapid cycling BD.  In most cases, it is a progressive disorder, with the length of time spent in the depressive stage increasing with time.  Those with BD have other characteristics, such as delayed-sleep cycle and neurocognitive deficits (Correll, et al., 2007).

The DSM-IV (APA, 1994) characterizes those with mania as having pronounced and persistent moods of euphoria, grandiosity or elevated self-esteem, decreased need for sleep, rapid pressure speech, racing thoughts, distractibility, increased activity or psychomotor agitation, behavior that reflects expansiveness, and poor judgment.  Hypomania is the occurrence of a persistent elevated, irritable or expansive mood for at least four days, with the presence of three additional symptoms including “inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences (p. 335.)

The depressive state of BD is much like that of Major Depressive Disorder, although there is usually an increased need for sleep and psychomotor retardation rather than agitation.  Other signs include depressed mood, anhedonia, fatigue, feelings of worthless, guilt, thoughts of suicide, and executive functioning difficulties such as trouble concentrating.  Periods of mixed states or dysphoric mania also occur with BD. Symptoms of dysphoric mania include, marked irritability, severe agitation or anxiety, pessimism and unrelenting worry and despair, marked insomnia, and decreased need for sleep (APA, 1994).   In my experience, it is these mixed states that are the most troublesome, and they appear to be marked by severe stress reactivity.

Diagnosis is particularly difficult, because those with BD often do not recognize their hypomanic episodes as being abnormal and so do not report its presence; insight is state-dependent.  They may also loathe to give-up these hypomanic states. Patients usually present for help during the depressive stage (Perugi, Ghaemi, & Akiskal, 2006), and when in a depressive state, patients with BD have difficulty remembering their hypomanic states, feeling that they have always felt low. “Diagnosis may only be possible retrospectively utilizing histories from patients who have distorted recollections” (Stahl, 2005, p. 14.)     Because of these distorted recollections, it is important to have collaborating information from family members or close friends. The hypomania, which the client so often enjoys, is often more problematic to those close to the patient than to the patient themselves and may lead to dysfunctional family interactions and stress.  In my opinion, it is the client’s unwillingness to disclose these hypomanic states and the stressful events that trigger them that often leads to misdiagnosis.

(to be continued…….)

Copyright (2011) Julie Myers, PsyD:  All Rights Reserved

Stress Relievers for Urge Control

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Stress Relievers for Urge Control

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego, California

 

Have you ever thought about how much stress triggers your using?   Stress (and the resulting anxiety or anger) drives people to seek relief.   For many people, such stress means searching out relief with drugs and/or alcohol.   But there are other ways to relieve stress!  Here are just a few:

  • Exercise.  Try a walk or even something with more exertion!
  • Slow, regular breathing
  • Call a friend and talk it out
  • Make a plan for how you’ll deal with stressful events
  • Develop coping statements to redirect yourself.
  • Soothing music

Try some of your own brainstorming, make a list, and keep it handy.    When a stressful event occurs, you’ll be glad to have a list of alternatives to using!

Julie Myers, PsyD, MSCP

Licensed Psychologist, MS Clinical Psychopharmacology, Master Addiction Counselor, Board Certified Biofeedbachttp://www.DrJulieMyers.com.