Counseling Adults Who Have Bipolar Disorders

Contributors:
Victoria Kress, Walden University and Youngstown State University, Stephane Sedall, Youngstown State University, Matthew Paylo, Youngstown State University

The bipolar disorders are characterized by dramatic changes  in mood, activity, and/or  energy levels that significantly affect one’s functioning (NIMH, 2016). Those who have  these disorders  may display mixed episodes in which they demonstrate characteristics of both mania and depression. Manic or hypomanic episodes (up states that do not meet the criteria  for mania) are characterized by periods of elevated mood and high-energy, while  depressive episodes are characterized by periods of low mood and energy (APA, 2013; NIMH, 2016).

Estimates suggest that in the United  States,  2.6% of the adult  population  has one of the bipolar disorders  (NIMH, n.d). An equal number of men and women  develop  bipolar  disorder  although, research  findings support women have more depressive, mixed episodes, and experience rapid cycling more often than men (American  Psychiatric Association [APA], 2013).

Counselors can diagnose bipolar  1, bipolar  11, cyclothymia, and for clients who do not meet the criteria for these more traditional bipolar  disorder  diagnoses, counselors  might designate a diagnosis of other specified and unspecified related disorders (NIMH, 2016). Ultra-rapid cycling is a possible  feature  of bipolar disorders which involves multiple mood episodes within one week or even a single day. Rapid cycling is more common in women than men, and it may be caused by an interaction between  bipolar disorder  and substance abuse, triggered by the use of antidepressants, or associated thyroid  disease (White & Preston, 2009). To be diagnosed with the various  bipolar  disorders,  different  combinations of symptoms and frequency of symptoms must be present. Additional detail on the symptom  patterns associated with the various  bipolar disorders can be found in the DSM-5 (APA, 2013).

Resources:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. National  Institute  of Mental  Health. (n.d). Bipolar disorder among adults. Retrieved from: http://www.nimh.nih.gov/health/statistics/prevalence/bipolar-disorder-among-adults.shtml

National  Institute  of Mental  Health.  (2016). Bipolar disorder. Retrieved from:http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Identification/Assessment Strategies

Many  disorders  are comorbid  with  a bipolar  disorder  diagnosis including attention-deficit/hyper- activity disorder  (ADHD), substance use disorders,  and anxiety disorders.  The following section includes several  screening measures  that may be helpful in identifying bipolar disorders.

Mood Disorder Questionnaire
The Mood Disorder  Questionnaire (MDQ; Hirschfeld  et al., 2000) is a brief self-report  screening measure  that is used to help identify  individuals who have  bipolar  disorders.  The MDQ has both sensitivity and specificity, and it consists of 13 questions plus items assessing clustering of symptoms and functional impairment. If the patient answers  “yes” to seven or more of the 13 items in question
1, and “yes”  or “moderate” or “serious”  to question  3, this is considered a positive screen, and the possibility of disorders should be examined more closely.  The questionnaire takes 5 minutes or less to complete.

A pdf of the MDQ screen is available to view  at:http://www.drdianenguyen.com/images/Bipolar_screen.pdf

Composite International Diagnostic Interview: Bipolar Disorders Screening Scale
The Composite  International Diagnostic Interview (CIDI;  Kessler  et al., 2006) is a structured  interview assessment. The CIDI consists  of 12 questions  including two stem questions,  one question related  to criterion  B symptoms (from the DSM-5) screening, and nine questions  directly related to criterion  B symptoms. The more questions  answered in a positive,  affirming way  the greater  the likelihood  of a positive diagnosis. The scoring  is as follows: nine questions  with positive affirmation is very-high risk, 7-8 questions  with positive affirmation is high risk, six questions  with positive affirmation  is moderate  risk, five questions  with  positive affirmation is low risk, and 0-4 questions  with affirmation is very  low-risk.  The interview takes five minutes or less to complete.

A pdf of the CIDI screen is available to view  at: http://www.cqaimh.org/pdf/tool_cidi.pdf

The General Behavior Inventory
The General  Behavior  Inventory (GBI; Depue et al., 1981) is a self-screened measure  designed  to assess the severity of the core symptoms of bipolar disorders over the past year. The full 73 item version has demonstrated internal  consistency and reliability as well as sensitivity to detecting bipolar disorders.  The measure  is reported  on a 4-point  rating  scale and is easily  administered in a clinical setting.

A pdf of this inventory is available to view  at:https://cls.unc.edu/files/2014/06/GBI_self_English_v1a.pdf

Structured Clinical Interview for DSM-5
The Structured  Clinical Interview (SCID; Spitzer, Williams,  Gibbon,  & First, 1992) is a clinical  interview first designed  to be used as a part of the intake process. Over the years,  it has become  one of the most common assessment measures used to diagnose bipolar disorders in adults, in particular bipolar 1 disorder (Miller, Johnson, & Eisner, 2009). The SCID is a semi-structured interview that is broken up into different modules to cover different diagnoses; its bipolar module has demonstrated appropriate interrater  reliability (Miller et al., 2009).

To view  more information and/or to purchase  the SCID-5 visit:https://www.appi.org/products/structured-clinical-interview-for-dsm-5-scid-5

Intervention/Treatment Strategies

Psychoharmacotherapy
Because the bipolar  disorders are caused by a complex set of biological and genetic  factors, medication should always be used to treat those who receive  the diagnosis. In fact, most people who have bipolar disorder will need to take medication throughout their lives to manage the symptoms of their illness. Medication compliance is an important treatment goal when counseling those who have bipolar disorder. However, many bipolar medications involve short and long term side effects (i.e., weight gain,  nausea,  sleep and appetite  changes; NIMH, 2016) that may  cause  clients  to stop prematurely their medications.

There are strategies that the client  and the counselor can use to facilitate medication compliance. For example, counselors may work together  with the client to help set up electronic tools for periodic reminders.  They may also help the client set up a medication log that can help keep track of the medications, side effects, and other substances that may interfere  with the medications.

When prescribing medications, physicians first consider  what  level  of intervention a client  needs. These phases  include:  the acute phase, during  which  the goal  is to control  the most severe  symptoms of the manic,  mixed,  or depressive disorder;  the stabilization phase,  during  which  the goal is full recovery from the acute  phase,  and the treatment of residual  symptoms and psycho-social impairment; and lastly, the maintenance phase, during which the goal is to prevent  recurrences and continue  treating residual  symptoms (Barlow, 2008).

Mood stabilizers, such as lithium and valproic acid (e.g., Depakote), are the most common medications used to treat those who have  bipolar  disorders  (National  Institute  of Mental  Health [NIMH];
2016). Lithium is effective in addressing both mania and mixed states and it can significantly decrease the severity and frequency of mood swings  (Atkins, 2007; NIMH, 2016). Valproic acid (e.g., Depakote) is an anticonvulsant medication used as a mood stabilizer to treat adults  who have  “mixed” symptoms of mania and depression  and rapid cycling (NIMH, 2016).  Lamotrigine (e.g., Lamictal; Atkins,  2007), an anticonvulsant used to treat  symptoms of bipolar,  is recommended for the prevention  of acute mania and depressive episodes associated with bipolar 1, and it is sometimes  used in combination with Lithium (VA/DoD, 2010). Other anticonvulsants such as, carbamazepine (e.g., Tegretol)  and oxcarbazepine (e.g., Trileptal),  are commonly used to treat seizures  and neuropathic pain, but can also be used to treat symptoms of bipolar disorder  (VA/DoD, 2010).

Antipsychotic medications are also often used to stabilize  mood and to treat those who have  bipolar disorders. Lurasidone  (e.g., Latuda), a newer medication, is used to treat adults who have bipolar disorders and it can be taken alone or with a medication such as lithium or valproic acid (Franklin, Zorowitz, Corse, Widge, & Deckersbach, 2015). Aripiprazole (e.g., Abilify), an antipsychotic, is used to treat adults who have  acute manic  or mixed  episodes  associated with  bipolar  1 (Barlow, 2008). It can be used by itself or taken with  lithium  or valproic acid. Cariprazine (e.g., Vraylar) was recently approved by the FDA to treat bipolar 1 disorder in adults. Trials have demonstrated its efficiency in treating acute manic or mixed episodes associated with bipolar 1 (Durgam et al., 2015; McCormack, 2015).

Antidepressants are often used to treat those who have  bipolar  disorders.  However, it can take up to 4-6 weeks for an anti-depressant to have a full effect. As such, physicians often need to try several medications before finding  what  works best for a patient  (Harmer, Goodwin,  & Cowen,  2009). Antidepressant medications often used in conjunction with other mood stabilizing medications include SSRIs (selective serotonin  reuptake  inhibitors; e.g., Zoloft, Prozac) and SNRIs (i.e., selective serotonin and norepinephrine reuptake inhibitors; e.g., Effexor, Wellbutrin;  Atkins, 2007; Barlow 2008). It is important to note that antidepressants may lead to worsened rapid cycling and may stimulate hypomanic/manic episodes in adults who have bipolar disorders (Atkins, 2007; Barlow, 2008).

Resources:
For more information: http://www.bphope.com/blog/when-taking-bipolar-medications-becomes-overwhelming/
http://www.bphope.com/sticking-with-it/

Interpersonal and Social Rhythm Therapy
Interpersonal and social rhythm  therapy  (IPSRT; Frank, 2005; Hlastala,  Kotler, McClellan, & Mc- Cauley, 2010) is an evidence-based treatment approach  that can help with regulating biological and social rhythms  (i.e., sleeping, eating,  socializing, and exercise  patterns).  The goal of this approach  is to help clients identify  the disruptions that already exist in their daily  routine (i.e., sleep) as well as make the connection between  daily  routine/ rhythm  disruptions and mood destabilizations, which can escalate  symptoms if not properly managed. IPSRT helps recognize interpersonal conflicts that are disrupting daily  routine  and making  symptoms associated with  bipolar  worse.  This approach emphasizes techniques that can be used to help manage stressful life events, strategies for enhancing and managing social supports and relationships, and it aims to reduce disruptions in social rhythms. The counselor and the client may work together  to develop  a daily schedule focused on diminishing the conflicts and disruptions caused by the disorder.

Studies have concluded  that sleep is vital in regulating bipolar disorder and irregular sleep routines can have a negative impact  on those who have bipolar disorder, even between  mood episodes (Ng et al., 2016). Disturbed  sleep, or a lack of sleep even  when  not experiencing mood symptoms, has been correlated with  irregular social  rhythms  (Ng et al., 2016). For those who have  bipolar  disorders, a lack of sleep can increase  insomnia,  therefore  triggering a mood episode.  In addition,  disturbed sleep can incite  depressive episodes  (Ng et al., 2016). Counselors can have  clients  monitor the number of hours they sleep so that they can recognize patterns,  shifts in sleep patterns,  and how these relate to their mood and energy states. A regular,  consistent sleep-wake schedule  is essential in preventing and triggering symptoms of bipolar disorder.

Resources:
A downloadable pdf of a sleep log can be found at: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf

For more information:
http://www.bphope.com/blog/five-tips-for-better-sleep/
http://www.bphope.com/hope-harmony-headlines-bipolar-sleep-problems-and-solutions/
http://www.bphope.com/poor-sleep-predicts-mood-recurrence-in-remitted-bipolar-2/
http://www.huffingtonpost.com/wendy-k-williamson/sleep-the-other-half-of-bipolar-medica-tion_b_7985708.html?ir=Healthy%20Living?
http://www.bphope.com/sleep-irregularities-impact-more-than-just-mood/

Cognitive Behavioral Therapy
When combined  with  psychopharmacological intervention, cognitive behavioral therapy  (CBT) is an evidence-based approach  for treating bipolar  disorders.  CBT involves identifying distorted thoughts and helping  clients to learn how to control, manage,  and change  these thoughts (Driessen & Hollon, 2010). CBT is founded on the assumption that mood, thinking, and behavior all influence each other. Therefore,  in treating adults  who have  bipolar  disorders,  the first step is to determine the  problem  such  as identifying the  rapid  - distorted  thoughts and  behaviors and  the  emotions associated with  them.  CBT also focuses  on communication, problem-solving skills,  and teaching clients  the skills  required  to cope with  symptoms and the disruption  of routines  (i.e., sleep,  diet, social  interactions) that trigger  bipolar  episodes.  Instability of circadian rhythms  and impairment of the motivational/reward system  in the brain (i.e., goal attainment) are important factors that are affected  by bipolar  disorder.  Furthermore, applying self-regulation skills, promoting a routine  and schedule,  and challenging thoughts and behaviors can help reduce symptoms.

Studies  have  demonstrated that  CBT reduces  the frequency of bipolar  episodes,  enhances  social functioning, and stabilizes mood (Driessen  & Hollon,  2010;  Lam et al., 2003). Studies  have  also demonstrated that combining CBT with medication can reduce the risk of bipolar relapse and result in fewer  manic  episodes  as compared  to medication alone (Lam et al., 2003; Salcedo  et al., 2016; Watkins, 2003).

Mindfulness-based cognitive  therapy   (MBCT;  Segal,  Williams,  &  Teasdale,  2002)  was  recently adapted  for the treatment of bipolar  disorder  and shows  promise as an effective  intervention. This mindfulness-based approach  was designed  to prevent  relapse in patients  who have recurring major depressive episodes (Segal et al., 2002). MBCT combines the use of traditional CBT techniques (i.e., thought  and feeling connection) and mindfulness practice  (i.e., meditation, self-observation) to help clients become more aware of their thoughts and feelings through focusing their attention and being present.  Research examining the effectiveness of MBCT has demonstrated decreases  in relapse of depression  by 43% and decreases  in anxiety over time (Miklowitz et al., 2009; Stange  et al., 2011; Williams et al., 2014).

Resources:
More information on MBCT can be found at: http://mbct.com/
http://mbct.com/wp-content/uploads/Mindful-Future-of-Therapy-08_2016.pdf

Family-Focused Therapy
Family-focused therapy  (FFT; Miklowitz & Goldstein,  1997) is an evidence based  family  therapy approach  that involves the client and family  members  developing skills related to family  communication  and problem  solving, as well as diminishing family  conflict.  Social support plays  an important role in managing bipolar disorder, and thus a strong family  structure is crucial.  Family  structure helps  promote  stable,  consistent routines  (i.e., sleep  schedule,  eating  habits,  medication management; Reinares,  Bonnin, Hidalgo-Mazzei, Moreno-Sanchez, & Vieta, 2016). FFT involves providing psychoeducation to both the client and family  about illness-management strategies, relapse preven- tion, and adherence  to pharmacotherapy. It also involves enhancing the family’s  knowledge about the symptoms of bipolar disorder  and how to handle these symptoms (Miklowitz, 2006).

FFT applies  a biopsychosocial framework to encourage balance within the social  and family  environment (Miklowitz & Goldstein,  1997).  The term  expressed  emotion is used  to describe  hostile and critical  attitudes  that the family  members  may have  towards each other (Reinares  et al., 2016). Counselors work  with  the client  and family  members  to help  facilitate an awareness of expressed emotion and adaptive strategies that can be used to best facilitate family  communication. Treatment typically consists  of 21 sessions  over the course of 9 months  (Miklowitz et al., 2004). Studies  have demonstrated a decrease in depressive symptoms and expressed emotion among families, as well as an increase  in positive communication between  family  members  when FFT is applied (Rivas-Vazquez, Johnson, Rey, & Blais, 2002). FFT has been shown to improve  the clients’ level of social adjustment and perceptions of relationship functioning (Rivas-Vazquez et al., 2002).

Resources:
http://gracepointwellness.org/4-bipolar-disorder/article/11221-bipolar-disorder-treatment-family-focused-therapy-and-interpersonal-social-rhythm-therapy

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Published: September 2016
Updated: September 2016