Chap 2. Class & Epidemiology
CHAPTER 10BIPOLAR DISORDERSTEVE JONES, DOMINIC LAM & ELIZABETH TYLER CASE EXAMPLESarah is a 38 year old woman with a diagnosis of bipolar I disorder. She reported a difficult childhood with a mother who struggled with low mood. Her parents separated when she was 10 years old and she was raised by her mother with very little contact with her father. At initial assessment she described feeling very different from her peers at school and often felt lonely and isolated. She experienced some bullying and by the age of 14 she was regularly skipping classes. She left school at 16 with very few qualifications and began working as a waitress in a local restaurant. It was here that she began to form friendships and described feeling accepted and liked for the first time. Sarah was diagnosed with bipolar disorder at the age of 27 after being hospitalised for a manic episode. Prior to this she had recently moved down to London to live with some friends. She had been experimenting with a number of substances such as cocaine, ecstasy and acid (LSD), and was a regular user of cannabis and alcohol. During the next three years Sarah experienced a number of episodes of both mania and depression. She had various jobs such as waitressing and bar work. However, she struggled to maintain a stable income and at one point became homeless. After a year and a half of living in both squat houses and on the street, Sarah re-contacted her mother and asked if she could move back to the family home. Sarah moved back to the north of England where she was referred to a community mental health team and received support from her care coordinator – a community psychiatric nurse (CPN). Sarah and her CPN worked together to develop an early warning sign and coping plan which she found useful at times. However she still was experiencing fluctuations in her mood and was worried about experiencing an acute episode again. Sarah had taken up a job in a local chain restaurant in the neighbouring town and was on track for a promotion to management.When Sarah arrived at therapy she already had acquired some knowledge about her bipolar experiences due to the work she had carried out with her CPN. However, the early warning sign and coping plan developed with her CPN was very medically focused. Coping strategies included taking more medication and calling the psychiatrist. There were still periods of time where she experienced fluctuations in her mood, which worried her. There were also other areas of her life that she did not feel happy with, in particular her ability to form new relationships. She was currently single and her last relationship was three years ago. She felt that her past episodes of bipolar disorder had made it difficult for her to maintain a stable relationship. She had gained two stone in weight and this made her feel unattractive and low in confidence. She had previously been a very active person who enjoyed going to the gym and being involved in local community arts projects. However since moving back to her home town she had not pursued any of her previous interests. CLINICAL FEATURESBipolar disorder is characterised by episodes of mania or hypomania and depression. Much of the clinical research on bipolar disorder has been based on cases diagnosed using criteria in DSM-IV-TR (American Psychiatric Association, 2000) and these criteria will therefore be described below. It is of note that these criteria have recently been updated in DSM-5 (American Psychiatric Association, 2013). Where these changes significantly impact on criteria this is highlighted in the text. Diagnostic criteria for bipolar disorder from DSM-5 and ICD-10 are given in Figure 10.1. Depression in bipolar disorder has the same diagnostic criteria as in unipolar major depression. These criteria are given in Table 9.1 in chapter 9. The client has to have five (or more) of the following symptoms present during the same two-week period and these symptoms must represent a change from previous functioning: depressed mood, marked diminished interest or pleasure, significant weight loss when not dieting (or weight gain) or decease or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or excessive guilt, impaired concentration or indecisiveness, recurrent thoughts of death or recurrent suicidal ideation. These symptoms have to be present most of the day and nearly every day. At least one of the symptoms has to be either depressed mood or loss of interest or pleasure. In contrast, the DSM-IV-TR criteria for mania are a distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting for one week (DSM-5 requires the presence of increased energy or activity alongside any of these mood symptoms.) During the period of mood disturbance, three (or more) of the following have to be present to a significant degree: inflated self-esteem or grandiosity, decreased need for sleep (e.g. feel rested after only three hours of sleep), more talkative than usual or pressure of speech, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences. One of the symptoms has to be either inflated self-esteem or irritability. If irritability is the persistent mood, then four other symptoms have to be present. For a hypomanic episode, the criteria are similar to a manic episode with the exception that the duration is at least four days. If an episode lasts at least a week and is not severe enough to cause marked impairment in social or occupational functioning, then it is classified as hypomania, not mania. If there are psychotic features or the client has to be admitted to hospital, the episode is classified mania, not hypomaniaFor a mixed episode, the criteria for both a manic episode and for a major depressive episode have to be fulfilled nearly every day for at least a two-week period. Furthermore, the mood disturbance has to be sufficiently severe to cause marked social or occupational impairment or the episode necessitates hospitalisation to prevent harm to self or others, or there are psychotic features. Mixed bipolar episodes are rare according to DSM-lV-TR criteria. In DSM-5 there is no longer a specific diagnostic subcategory of mixed episode. Instead DSM-5 makes provision for a mixed specifier, which can be applied to either manic or depressive episodes. A mixed specifier can be added to manic or hypomanic episodes when at least three depressive symptoms are experienced during the episode. Conversely, the mixed specifier can be added to a depressive episode when at least three manic/hypomanic symptoms are present during the episode Rapid cycling is defined as at least four episodes of a mood disturbance in the previous 12 months that meet criteria for a major depression, manic, mixed or hypomanic episode. There are two main subtypes for bipolar disorder. For clients to suffer from bipolar I disorder, there has to be at least one manic episode or mixed episode and one major depressive episode. For clients to suffer from bipolar ll disorder, there has to be at least one hypomanic episode and one major depressive episode but no manic or mixed episodes. EPIDEMIOLOGYBipolar disorder is relatively common. Prevalence studies in the UK, continental Europe and the US indicate a prevalence rate of 1-1.9% of clients meeting formal diagnostic criteria for bipolar disorder ADDIN EN.CITE <EndNote><Cite><Author>ten Have</Author><Year>2002</Year><RecNum>336</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12063148</ACCESSION_NUMBER><VOLUME>68</VOLUME><NUMBER>2-3</NUMBER><YEAR>2002</YEAR><DATE>Apr</DATE><TITLE>Bipolar disorder in the general population in The Netherlands (prevalence, consequences and care utilisation): results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS)</TITLE><PAGES>203-13</PAGES><AUTHOR_ADDRESS>Netherlands Institute of Mental Health and Addiction, P.O. Box 725, 3500 AS, Utrecht, The Netherlands. mhave@trimbos.nl</AUTHOR_ADDRESS><AUTHORS><AUTHOR>ten Have, M.</AUTHOR><AUTHOR>Vollebergh, W.</AUTHOR><AUTHOR>Bijl, R.</AUTHOR><AUTHOR>Nolen, W. A.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Affect Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*epidemiology/psychology</KEYWORD><KEYWORD>Cross-Cultural Comparison</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Health Surveys</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mental Health Services/*utilization</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Netherlands/epidemiology</KEYWORD><KEYWORD>Patient Acceptance of Health Care/statistics & numerical data</KEYWORD><KEYWORD>Patient Care Team/utilization</KEYWORD><KEYWORD>Primary Health Care/*utilization</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL> epidemiology of bipolar affective disorder</TITLE><PAGES>279-92</PAGES><AUTHOR_ADDRESS>MRC Social & Community Psychiatry Unit, Institute of Psychiatry, London, UK.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Bebbington, P.</AUTHOR><AUTHOR>Ramana, R.</AUTHOR></AUTHORS><SECONDARY_TITLE>Soc Psychiatry Psychiatr Epidemiol</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/*epidemiology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Incidence</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Prevalence</KEYWORD><KEYWORD>Sex Factors</KEYWORD><KEYWORD>World Health</KEYWORD></KEYWORDS><URL> disorders in five United States communities</TITLE><PAGES>141-53</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, Yale University, New Haven, CT.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Weissman, M. M.</AUTHOR><AUTHOR>Leaf, P. J.</AUTHOR><AUTHOR>Tischler, G. L.</AUTHOR><AUTHOR>Blazer, D. G.</AUTHOR><AUTHOR>Karno, M.</AUTHOR><AUTHOR>Bruce, M. L.</AUTHOR><AUTHOR>Florio, L. P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Age Factors</KEYWORD><KEYWORD>Aged</KEYWORD><KEYWORD>Bipolar Disorder/*epidemiology</KEYWORD><KEYWORD>California</KEYWORD><KEYWORD>Connecticut</KEYWORD><KEYWORD>Depressive Disorder/*epidemiology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Maryland</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Missouri</KEYWORD><KEYWORD>North Carolina</KEYWORD><KEYWORD>Sex Factors</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL>;(Bebbington & Ramana, 1995; Merikangas, Akiskal, Angst, Greenberg, Hirshfiled, Petukhova et al., 2007; Ten Have, Vollebergh, Bijl & Nolen, 2002; Weissman, Leaf, Tischler & Blazer, 1988). Angst and colleagues have argued that in fact current diagnostic criteria for bipolar disorder incorrectly exclude people with illnesses that fit within a bipolar spectrum; when these clients are included, prevalence rates increase to around 11% ADDIN EN.CITE <EndNote><Cite><Author>Angst</Author><Year>2003</Year><RecNum>225</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12507746</ACCESSION_NUMBER><VOLUME>73</VOLUME><NUMBER>1-2</NUMBER><YEAR>2003</YEAR><DATE>Jan</DATE><TITLE>Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania</TITLE><PAGES>133-46</PAGES><AUTHOR_ADDRESS>Zurich University Psychiatric Hospital, Lenggstrasse 31, P O Box 68, CH-8029, Zurich, Switzerland. jangst@bli.unizh.ch</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Angst, J.</AUTHOR><AUTHOR>Gamma, A.</AUTHOR><AUTHOR>Benazzi, F.</AUTHOR><AUTHOR>Ajdacic, V.</AUTHOR><AUTHOR>Eich, D.</AUTHOR><AUTHOR>Rossler, W.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Affect Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Affect</KEYWORD><KEYWORD>Bipolar Disorder/*classification/*epidemiology/psychology</KEYWORD><KEYWORD>Cohort Studies</KEYWORD><KEYWORD>Disease Progression</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Prevalence</KEYWORD><KEYWORD>Prognosis</KEYWORD><KEYWORD>Prospective Studies</KEYWORD><KEYWORD>Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>;(Angst, Gamma, Benazzi, Ajdacic, Eich & Roessler, 2003). This would include clients who experienced symptoms of euphoria, overactivity and irritability for shorter periods than in current DSM-IV-TR criteria, but who exhibited a significant change in functioning. In addition to this being a relatively common mental health problem, by no means all people meeting criteria for bipolar disorder are involved in psychiatric services. Ten Have and colleagues reported that in their population-based prevalence study, 25.5% of clients with bipolar disorder had never sought any form of professional help ADDIN EN.CITE <EndNote><Cite><Author>ten Have</Author><Year>2002</Year><RecNum>336</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12063148</ACCESSION_NUMBER><VOLUME>68</VOLUME><NUMBER>2-3</NUMBER><YEAR>2002</YEAR><DATE>Apr</DATE><TITLE>Bipolar disorder in the general population in The Netherlands (prevalence, consequences and care utilisation): results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS)</TITLE><PAGES>203-13</PAGES><AUTHOR_ADDRESS>Netherlands Institute of Mental Health and Addiction, P.O. Box 725, 3500 AS, Utrecht, The Netherlands. mhave@trimbos.nl</AUTHOR_ADDRESS><AUTHORS><AUTHOR>ten Have, M.</AUTHOR><AUTHOR>Vollebergh, W.</AUTHOR><AUTHOR>Bijl, R.</AUTHOR><AUTHOR>Nolen, W. A.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Affect Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*epidemiology/psychology</KEYWORD><KEYWORD>Cross-Cultural Comparison</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Health Surveys</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mental Health Services/*utilization</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Netherlands/epidemiology</KEYWORD><KEYWORD>Patient Acceptance of Health Care/statistics & numerical data</KEYWORD><KEYWORD>Patient Care Team/utilization</KEYWORD><KEYWORD>Primary Health Care/*utilization</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL>;(Ten Have et al., 2002).Historically bipolar disorder was seen as being characterised by periods of mania and depression interspersed with periods of ‘normality’. Contrary to this view, Judd and others have conducted a series of long term follow-up studies in which individuals with bipolar I and II disorders spend 32-50% of time in between episodes experiencing significant mood symptoms primarily depression-related (Post et al., 2003; Judd et al., 2002, 2003). Such subsyndromal symptoms are associated with increased problems in functioning and interpersonal relationships and increased risk of future relapses (Judd et al., 2002; Morriss et al., 2013). Furthermore, there is evidence that, if anything, the course of bipolar disorder can become more severe with age ADDIN EN.CITE <EndNote><Cite><Author>Goodwin</Author><Year>1990</Year><RecNum>134</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Goodwin, F. K.</AUTHOR><AUTHOR>Jamison, K.</AUTHOR></AUTHORS><YEAR>1990</YEAR><TITLE>Manic-Depressive Illness</TITLE><PLACE_PUBLISHED>New York</PLACE_PUBLISHED><PUBLISHER>Oxford University Press</PUBLISHER><PAGES>938</PAGES><KEYWORDS><KEYWORD>manic depression, bipolar disorder</KEYWORD></KEYWORDS></MDL></Cite></EndNote>(Goodwin & Jamison, 1990). Clients later on in the illness course require only relatively modest external stressors to trigger a mood episode ADDIN EN.CITE <EndNote><Cite><Author>Post</Author><Year>1986</Year><RecNum>342</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>3535979</ACCESSION_NUMBER><VOLUME>149</VOLUME><YEAR>1986</YEAR><DATE>Aug</DATE><TITLE>Conditioning and sensitisation in the longitudinal course of affective illness</TITLE><PAGES>191-201</PAGES><AUTHORS><AUTHOR>Post, R. M.</AUTHOR><AUTHOR>Rubinow, D. R.</AUTHOR><AUTHOR>Ballenger, J. C.</AUTHOR></AUTHORS><SECONDARY_TITLE>Br J Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Behavior</KEYWORD><KEYWORD>Brain/metabolism</KEYWORD><KEYWORD>Conditioning (Psychology)</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Kindling (Neurology)</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Models, Psychological</KEYWORD><KEYWORD>Mood Disorders/metabolism/*psychology</KEYWORD></KEYWORDS><URL> events and mania. A special relationship?</TITLE><PAGES>235-40</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, Leicester Royal Infirmary.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Ambelas, A.</AUTHOR></AUTHORS><SECONDARY_TITLE>Br J Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Age Factors</KEYWORD><KEYWORD>Aged</KEYWORD><KEYWORD>Bipolar Disorder/etiology/*psychology</KEYWORD><KEYWORD>Disease/psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>*Life Change Events</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mental Disorders/genetics</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Pregnancy</KEYWORD><KEYWORD>Puerperal Disorders/psychology</KEYWORD><KEYWORD>Retrospective Studies</KEYWORD><KEYWORD>Sex Factors</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Time Factors</KEYWORD></KEYWORDS><URL>;(Post, Rubinow & Ballenger, 1986; Ambelas, 1987). There are consequently reductions in inter episode periods with increasing age (Kessing et al., 2004).Bipolar disorder is associated with high risk of self-harm and suicide. ADDIN EN.CITE <EndNote><Cite><Author>Tondo</Author><Year>2003</Year><RecNum>221</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12751919</ACCESSION_NUMBER><VOLUME>17</VOLUME><NUMBER>7</NUMBER><YEAR>2003</YEAR><TITLE>Suicidal behaviour in bipolar disorder: risk and prevention</TITLE><PAGES>491-511</PAGES><AUTHOR_ADDRESS>Department of Psychology, University of Cagliari, Centro Lucio Bini-Stanley Medical Research Institute Research Center, Cagliari, Sardinia, Italy. tondol@</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Tondo, L.</AUTHOR><AUTHOR>Isacsson, G.</AUTHOR><AUTHOR>Baldessarini, R.</AUTHOR></AUTHORS><SECONDARY_TITLE>CNS Drugs</SECONDARY_TITLE><KEYWORDS><KEYWORD>Bipolar Disorder/complications/epidemiology/*psychology/therapy</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Risk Assessment</KEYWORD><KEYWORD>*Risk Factors</KEYWORD><KEYWORD>Suicide/*prevention & control/statistics & numerical data</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>, Isacsson and Baldesserini (2003) in a review reported an annual rate of suicide in bipolar clients of 0.4%, which is twenty times higher than in the general population. A 34-38 year follow-up study of people with bipolar disorder reported a twelve-fold increase in successful suicide attempts, which although somewhat lower that that found by Tondo et al. (2003) still represents a substantially elevated risk ADDIN EN.CITE <EndNote><Cite><Author>Angst</Author><Year>2002</Year><RecNum>343</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12063145</ACCESSION_NUMBER><VOLUME>68</VOLUME><NUMBER>2-3</NUMBER><YEAR>2002</YEAR><DATE>Apr</DATE><TITLE>Mortality of patients with mood disorders: follow-up over 34-38 years</TITLE><PAGES>167-81</PAGES><AUTHOR_ADDRESS>Institute of Social and Preventive Medicine, Zurich University, Zurich, Switzerland. jangst@mailhost.unizh.ch</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Angst, F.</AUTHOR><AUTHOR>Stassen, H. H.</AUTHOR><AUTHOR>Clayton, P. J.</AUTHOR><AUTHOR>Angst, J.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Affect Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Aged</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/mortality/psychology</KEYWORD><KEYWORD>Cardiovascular Diseases/diagnosis/mortality/psychology</KEYWORD><KEYWORD>Cause of Death</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mood Disorders/diagnosis/*mortality/psychology</KEYWORD><KEYWORD>Prospective Studies</KEYWORD><KEYWORD>Risk Assessment</KEYWORD><KEYWORD>Sex Factors</KEYWORD><KEYWORD>Suicide/statistics & numerical data</KEYWORD><KEYWORD>Survival Analysis</KEYWORD><KEYWORD>Switzerland/epidemiology</KEYWORD></KEYWORDS><URL>;(Angst, Stassen, Clayton & Angst, 2002). Estimates vary for rates of suicide attempts. Thirty-four percent of bipolar clients within the Stanley Bipolar Research Network were found to have a history of suicide attempts ADDIN EN.CITE <EndNote><Cite><Author>Leverich</Author><Year>2003</Year><RecNum>220</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12755652</ACCESSION_NUMBER><VOLUME>64</VOLUME><NUMBER>5</NUMBER><YEAR>2003</YEAR><DATE>May</DATE><TITLE>Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network</TITLE><PAGES>506-15</PAGES><AUTHOR_ADDRESS>Stanley Foundation Bipolar Treatment Outcome Network, Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, Biological Psychiatry Branch, Bethesda, MD 20892-1272, USA. levericg@intra.nimh.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Leverich, G. S.</AUTHOR><AUTHOR>Altshuler, L. L.</AUTHOR><AUTHOR>Frye, M. A.</AUTHOR><AUTHOR>Suppes, T.</AUTHOR><AUTHOR>Keck, P. E., Jr.</AUTHOR><AUTHOR>McElroy, S. L.</AUTHOR><AUTHOR>Denicoff, K. D.</AUTHOR><AUTHOR>Obrocea, G.</AUTHOR><AUTHOR>Nolen, W. A.</AUTHOR><AUTHOR>Kupka, R.</AUTHOR><AUTHOR>Walden, J.</AUTHOR><AUTHOR>Grunze, H.</AUTHOR><AUTHOR>Perez, S.</AUTHOR><AUTHOR>Luckenbaugh, D. A.</AUTHOR><AUTHOR>Post, R. M.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Clin Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Age of Onset</KEYWORD><KEYWORD>Bipolar Disorder/*diagnosis/epidemiology/psychology</KEYWORD><KEYWORD>Child</KEYWORD><KEYWORD>Child Abuse/psychology/statistics & numerical data</KEYWORD><KEYWORD>Comorbidity</KEYWORD><KEYWORD>Comparative Study</KEYWORD><KEYWORD>Family Health</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Incidence</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mental Disorders/epidemiology</KEYWORD><KEYWORD>Prospective Studies</KEYWORD><KEYWORD>Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Retrospective Studies</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD><KEYWORD>Suicide, Attempted/psychology/*statistics & numerical data</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL>;(Leverich et al., 2003), whilst a Dutch study found that 20% of its bipolar sample had attempted suicide and 59% experienced suicidal ideation ADDIN EN.CITE <EndNote><Cite><Author>ten Have</Author><Year>2002</Year><RecNum>336</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12063148</ACCESSION_NUMBER><VOLUME>68</VOLUME><NUMBER>2-3</NUMBER><YEAR>2002</YEAR><DATE>Apr</DATE><TITLE>Bipolar disorder in the general population in The Netherlands (prevalence, consequences and care utilisation): results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS)</TITLE><PAGES>203-13</PAGES><AUTHOR_ADDRESS>Netherlands Institute of Mental Health and Addiction, P.O. Box 725, 3500 AS, Utrecht, The Netherlands. mhave@trimbos.nl</AUTHOR_ADDRESS><AUTHORS><AUTHOR>ten Have, M.</AUTHOR><AUTHOR>Vollebergh, W.</AUTHOR><AUTHOR>Bijl, R.</AUTHOR><AUTHOR>Nolen, W. A.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Affect Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*epidemiology/psychology</KEYWORD><KEYWORD>Cross-Cultural Comparison</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Health Surveys</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Mental Health Services/*utilization</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Netherlands/epidemiology</KEYWORD><KEYWORD>Patient Acceptance of Health Care/statistics & numerical data</KEYWORD><KEYWORD>Patient Care Team/utilization</KEYWORD><KEYWORD>Primary Health Care/*utilization</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL>;(Ten Have et al., 2002). Risk of completed suicide is also higher for people meeting criteria for bipolar disorder with recent service contacts than for those who meet criteria for other forms of severe mental health problem (Clements et al., 2013).Family studies consistently estimate a higher morbid risk for relatives of bipolar clients to develop the disorder than the general population (Baldessarini et al., 2012), ranging from 2-10 times increased risk (Craddock & Jones, 2001; ADDIN EN.CITE <EndNote><Cite><Author>Gershon</Author><Year>1983</Year><RecNum>489</RecNum><MDL><REFERENCE_TYPE>7</REFERENCE_TYPE><AUTHORS><AUTHOR>Gershon, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>The genetics of affective disorders</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>Grinspoon L.</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>Pyschiatry Unpdate</SECONDARY_TITLE><PLACE_PUBLISHED>Washington, DC</PLACE_PUBLISHED><PUBLISHER>American Psychiatric Press</PUBLISHER><VOLUME>2</VOLUME></MDL></Cite></EndNote> Gershon, Berrettini, Nurnberger, & Goldin 1989). It is of note that figures for increased depression in family members are substantially higher than those for bipolar disorder (Craddock & Jones, 2001: Goodwin & Jamison, 1990). A large twin study by McGuffin and colleagues (2003) estimated 85% heritability for bipolar disorder. They found that most of the genetic liability to mania is specific to the manic syndrome even though there are substantial genetic and non-shared environmental correlations between mania and depression. It is, however, worth noting that the concept of heritability can be problematic. There is an assumption that high heritability means that a particular outcome is genetically predetermined and that findings can be readily generalised across samples. This is not the case, because heritability estimates are based on the assumption that environment and genes do not interact which is rarely true (Visscher, Hill & Wray, 2008: Joseph, 2003).There are a number of co-morbid conditions, especially personality, substance use and anxiety disorders, that need to be considered with respect to bipolar disorder.Personality disorders Personality Disorders have been estimated to occur in 10-13% of community samples ADDIN EN.CITE <EndNote><Cite><Author>Weissman</Author><Year>1993</Year><RecNum>50</RecNum><MDL><REFERENCE_TYPE>7</REFERENCE_TYPE><AUTHORS><AUTHOR>Weissman, M.M.</AUTHOR></AUTHORS><YEAR>1993</YEAR><TITLE>The epidemiology of personality disorders</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>R. Michels</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>Psychiatry</SECONDARY_TITLE><PLACE_PUBLISHED>Philadelphia</PLACE_PUBLISHED><PUBLISHER>Lippincott</PUBLISHER></MDL></Cite></EndNote>(Samuels, 2011; Weissman, 1993). A replication of the National Comorbidity Survey in US based on a community sample of 5692 adults reported an odds ratio of 9.8 for risk of any personality disorder in participants with bipolar disorder, with figures particularly elevated for the presence of comorbid antisocial or borderline personality disorder (Lenzenweger et al., 2007). The presence of a personality disorder has been associated with more severe residual mood symptoms in adults ( ADDIN EN.CITE <EndNote><Cite><Author>George</Author><Year>2003</Year><RecNum>185</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12680901</ACCESSION_NUMBER><VOLUME>5</VOLUME><NUMBER>2</NUMBER><YEAR>2003</YEAR><DATE>Apr</DATE><TITLE>The comorbidity of bipolar disorder and axis II personality disorders: prevalence and clinical correlates</TITLE><PAGES>115-22</PAGES><AUTHOR_ADDRESS>Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA. egeorge@psych.colorado.edu</AUTHOR_ADDRESS><AUTHORS><AUTHOR>George, E. L.</AUTHOR><AUTHOR>Miklowitz, D. J.</AUTHOR><AUTHOR>Richards, J. A.</AUTHOR><AUTHOR>Simoneau, T. L.</AUTHOR><AUTHOR>Taylor, D. O.</AUTHOR></AUTHORS><SECONDARY_TITLE>Bipolar Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Alcoholism/epidemiology</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*epidemiology/therapy</KEYWORD><KEYWORD>Diagnostic and Statistical Manual of Mental Disorders</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Patient Compliance/statistics & numerical data</KEYWORD><KEYWORD>Personality Disorders/diagnosis/*epidemiology/therapy</KEYWORD><KEYWORD>Predictive Value of Tests</KEYWORD><KEYWORD>Prevalence</KEYWORD><KEYWORD>Psychotherapy</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL>, Miklowitz, Richards, Simoneau & Taylor, 2003) and adolescents ADDIN EN.CITE <EndNote><Cite><Author>Kutcher</Author><Year>1990</Year><RecNum>100</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>2347830</ACCESSION_NUMBER><VOLUME>29</VOLUME><NUMBER>3</NUMBER><YEAR>1990</YEAR><DATE>May</DATE><TITLE>Adolescent bipolar illness and personality disorder</TITLE><PAGES>355-8</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, Sunnybrook Medical Centre, University of Toronto, Ontario, Canada.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Kutcher, S. P.</AUTHOR><AUTHOR>Marton, P.</AUTHOR><AUTHOR>Korenblum, M.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Am Acad Child Adolesc Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Bipolar Disorder/*diagnosis/psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Personality Disorders/*diagnosis/psychology</KEYWORD><KEYWORD>Personality Tests</KEYWORD></KEYWORDS><URL>;(Kutcher, Marton & Korenblum, 1990).Substance misuseThe US Epidemiological Catchment Area study reported that 61% of clients with bipolar I disorder also met lifetime criteria for substance use disorders ADDIN EN.CITE <EndNote><Cite><Author>Regier</Author><Year>1990</Year><RecNum>126</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Regier, D. A.</AUTHOR><AUTHOR>Farmer, M. E.</AUTHOR><AUTHOR>Rae, D. S.</AUTHOR><AUTHOR>Locke. B. Z.</AUTHOR><AUTHOR>Keith, S. J.</AUTHOR><AUTHOR>Judd, L. L.</AUTHOR><AUTHOR>Goodwin, F. K.</AUTHOR></AUTHORS><YEAR>1990</YEAR><TITLE>Comorbidity of mental disorders with alcoho and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study</TITLE><SECONDARY_TITLE>Journal of the American Medical Association</SECONDARY_TITLE><VOLUME>264</VOLUME><PAGES>2511-2518</PAGES><KEYWORDS><KEYWORD>Bipolar Disorder, alcohol abuse, cannabis abuse, substance abuse, outcome</KEYWORD></KEYWORDS></MDL></Cite></EndNote>(Regier et al., 1990). High rates of substance use disorders among those with bipolar disorder have been reported in numerous studies across a range of different populations in different countries ADDIN EN.CITE <EndNote><Cite><Author>Strakowski</Author><Year>2000</Year><RecNum>352</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>10721497</ACCESSION_NUMBER><VOLUME>20</VOLUME><NUMBER>2</NUMBER><YEAR>2000</YEAR><DATE>Mar</DATE><TITLE>The co-occurrence of bipolar and substance use disorders</TITLE><PAGES>191-206</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, University of Cincinnati College of Medicine, OH 45267-0559, USA. strakosm@email.uc.edu</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Strakowski, S. M.</AUTHOR><AUTHOR>DelBello, M. P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Clin Psychol Rev</SECONDARY_TITLE><KEYWORDS><KEYWORD>Alcoholism/complications/etiology</KEYWORD><KEYWORD>Bipolar Disorder/*complications/etiology</KEYWORD><KEYWORD>Comorbidity</KEYWORD><KEYWORD>Diagnosis, Dual (Psychiatry)</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Risk Factors</KEYWORD><KEYWORD>Substance-Related Disorders/*complications/etiology</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL> abuse in bipolar disorder</TITLE><PAGES>181-8</PAGES><AUTHOR_ADDRESS>Duke-Umstead Bipolar Disorders Program, Duke University, Durham, NC 27710, USA. cassi002@mc.duke.edu</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Cassidy, F.</AUTHOR><AUTHOR>Ahearn, E. P.</AUTHOR><AUTHOR>Carroll, B. J.</AUTHOR></AUTHORS><SECONDARY_TITLE>Bipolar Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Age Distribution</KEYWORD><KEYWORD>Bipolar Disorder/*complications/diagnosis</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Incidence</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD><KEYWORD>Sex Distribution</KEYWORD><KEYWORD>Substance-Related Disorders/*complications/*epidemiology</KEYWORD></KEYWORDS><URL>;(Strakowski & DelBello, 2000; Cassidy, Ahearn & Carroll, 2001). The recent updated NICE guidelines for bipolar disorder reported a lower, but still elevated, substance use disorder rate of 40% in people meeting criteria for bipolar I or II disorders (NICE, 2014).AnxietyMany people who live with bipolar disorder also experience significant anxiety symptoms. Lifetime anxiety disorders have been reported in 93% and concurrent anxiety disorders in 32% of individuals with bipolar disorder (McIntyre et al., 2006; Otto et al., 2006). The presence of comorbid anxiety is associated with a range of issues including poorer treatment response and greater risk of further episodes of mania and depression (Feske et al., 2000: Rucci et al., 2002). These findings have led Provencher et al. (2011), among others, to call for the development of psychological approaches to addressing anxiety in the context of bipolar disorder. A current trial by our team is therefore evaluating the benefits of delivering an integrated CBT intervention for both bipolar disorder and anxiety (Jones et al., 2013). Co-morbid personality disorders, anxiety disorders and alcohol and drug problems are all associated with poorer therapeutic outcomes, potential difficulties with therapeutic engagement, higher levels of symptomatology and more frequent hospitalisations. Each of these issues can also elevate risks of self-harming and suicidal behaviours. In addition to consideration of the role of co-morbid conditions, there is also the issue of distinguishing bipolar disorder from other disorders, especially schizoaffective disorder. Structured interview approaches indicate that it is possible to reliably diagnose bipolar I and bipolar II disorders ADDIN EN.CITE <EndNote><Cite><Author>Rice</Author><Year>1992</Year><RecNum>360</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>1417436</ACCESSION_NUMBER><VOLUME>49</VOLUME><NUMBER>10</NUMBER><YEAR>1992</YEAR><DATE>Oct</DATE><TITLE>Stability of psychiatric diagnoses. An application to the affective disorders</TITLE><PAGES>824-30</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, Washington University School of Medicine, St Louis, MO 63110.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Rice, J. P.</AUTHOR><AUTHOR>Rochberg, N.</AUTHOR><AUTHOR>Endicott, J.</AUTHOR><AUTHOR>Lavori, P. W.</AUTHOR><AUTHOR>Miller, C.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/psychology</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Depressive Disorder/*diagnosis/psychology</KEYWORD><KEYWORD>Family</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Probability</KEYWORD><KEYWORD>Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Sex Factors</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL> of lifetime diagnosis. A multicenter collaborative perspective</TITLE><PAGES>400-5</PAGES><AUTHORS><AUTHOR>Andreasen, N. C.</AUTHOR><AUTHOR>Grove, W. M.</AUTHOR><AUTHOR>Shapiro, R. W.</AUTHOR><AUTHOR>Keller, M. B.</AUTHOR><AUTHOR>Hirschfeld, R. M.</AUTHOR><AUTHOR>McDonald-Scott, P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Anxiety Disorders/diagnosis</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis</KEYWORD><KEYWORD>Cyclothymic Disorder/diagnosis</KEYWORD><KEYWORD>Depressive Disorder/diagnosis</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Mental Disorders/*diagnosis</KEYWORD><KEYWORD>Substance-Related Disorders/diagnosis</KEYWORD></KEYWORDS><URL> reliability of bipolar II disorder</TITLE><PAGES>736-40</PAGES><AUTHOR_ADDRESS>Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA. sylvia.simpson@uchsc.edu</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Simpson, S. G.</AUTHOR><AUTHOR>McMahon, F. J.</AUTHOR><AUTHOR>McInnis, M. G.</AUTHOR><AUTHOR>MacKinnon, D. F.</AUTHOR><AUTHOR>Edwin, D.</AUTHOR><AUTHOR>Folstein, S. E.</AUTHOR><AUTHOR>DePaulo, J. R.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/*diagnosis/epidemiology/genetics</KEYWORD><KEYWORD>Depressive Disorder/diagnosis/genetics</KEYWORD><KEYWORD>Diagnostic Errors</KEYWORD><KEYWORD>Family</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Predictive Value of Tests</KEYWORD><KEYWORD>Psychiatric Status Rating Scales/*statistics & numerical data</KEYWORD><KEYWORD>Psychiatry/standards/statistics & numerical data</KEYWORD><KEYWORD>Psychometrics</KEYWORD><KEYWORD>Reproducibility of Results</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL>;(Andreasen, Grove et al., 1981; Rice et al., 1992; Simpson et al., 2002). The main diagnosis that overlaps significantly with bipolar disorder is schizoaffective disorder. With DSM diagnostic criteria psychotic symptoms can occur in extremes of mania or depression. The difference between psychotic symptoms associated with bipolar disorder and schizophrenia-spectrum diagnoses, such as schizoaffective disorder, is that in bipolar disorder psychotic symptoms abate when mood symptoms resolve. Some diagnostic confusion can occur when the bipolar disorder is chronic, as the psychotic symptoms may then appear to be persistent. ASSESSMENTA comprehensive assessment is a prerequisite for therapy. There is also an interaction between assessment and therapy processes. In many cases, the information drawn together through a proper assessment will provide the client with their first opportunity to understand the relationships between experiences, emotions and behaviour, often previously recalled as separate events. This alone will potentially be therapeutic, as well as enhancing engagement with the therapeutic process. Also, although much of the assessment will occur early in therapy, there will be times later in therapy when opportunities to acquire additional information may occur, such as through meetings with third parties. This interaction between therapy and assessment is a characteristic of successful therapy with bipolar clients. Individual and family historyThe assessment process should begin with an interview designed to elicit information about the history of the individual and their family. We know from research that many people with bipolar disorder will have other family members who present with affective disorders of various types. Where there has been affective disorder amongst the client’s parents, this may have caused disruption during their development due to parenting style being affected by mood. For example, when the affected parent was depressed, they may have been more cold and critical and when they were high, they may have been less responsible with their financial affairs or less involved with their children. Identifying this, and their perception of its impact on the client’s life, is an important part of assessment. In general, as with other forms of cognitive therapy, the aim of history taking is to get a sense of how the individual has come to his or her own particular beliefs about the world, self and others. Mental health history is also a crucial part of assessment. Many clients will have experience of psychiatric interviews and may not immediately see the relevance of reviewing this area. The key difference for a psychological assessment is that you are working with the client to identify their own perception of mood fluctuations, whether or not these amounted to ‘psychiatric symptoms’ at the time. Once information concerning mood change is collected, it is helpful to lay it out chronologically on a life chart, on which is also included information about life events, medication, education and occupation. The development of a life chart, drawn up collaboratively with the client, may show interrelationships between mood and other important factors. It can provide an important summary of key episodes. It may also help clients look for patterns of illness, stresses, educational and occupational achievements. This information also serves to illustrate that often mood change occurs within a context, rather than being an event that occurs out of the blue. Furthermore, by linking medication, mood, episodes and academic/occupational/personal achievements, clients are helped to see that all these factors are linked and have potentially important roles in helping clients’ to manage their bipolar disorder. Life charts can help to provide evidence for which of these elements are most important in influencing clients’ mood and in achieving better occupational and social functioning. A life chart for Sarah, the subject of the case study at the start of this chapter, is presented in Figure 10.1. This life chart illustrates significant mood variability prior to Sarah’s first diagnosed manic episode. It also demonstrates how changes in her mood appear to have been associated with a number of life events and stresses. A further important issue is that clients will have views about both medication and diagnosis. Clients will often have mixed feelings about the medication that they have been prescribed. Considering these views and feelings in relation to the life chart can prove a useful introduction to later sessions at which adherence issues are discussed. Clients will also vary in their views of their diagnosis and exploring this may be an important factor. Some people will feel that their diagnosis is helpful to explain and validate their mood experiences and may provide a pathway to appropriate treatment. In contrast, other clients will believe that the diagnosis is a label that they do not accept, as it is associated with stigma and a loss of identity. In both cases awareness of the client’s perception will be key to the development of shared therapy goals and avoiding harmful conflicts within therapy.Other areas which assessment can usefully address include current mood state, initial information on coping with early warning signs of the onset of manic or depressive episodes, levels of dysfunctional beliefs and experience of stigma. In addition, given the patterns of self-harm and suicide risk associated with bipolar disorder, it is important to assess hopelessness and suicidality during a preliminary evaluation and subsequently. Information can also be obtained on the resources at the individual’s disposal, both in terms of social skills and sources of professional and informal support. All of this information can be helpful in understanding each client’s experience of personal recovery and quality of life. For each of these areas, it important to use careful questioning within the assessment interview. However, it is usually helpful to combine this with self-report and observer-rated measures to provide a comprehensive picture. Useful measures are considered below. Self Monitoring During assessment it is explained that self-monitoring is an important part of treatment. It is emphasised that a lot of the important aspects of therapy will happen between session and having information about how the client is feeling and what they are doing between sessions is important in ensuring that they achieve the best possible outcome for the intervention. Initially clients will complete brief mood measures. As therapy proper progresses, monitoring of activities, mood and thoughts becomes increasingly important. Standardised MeasuresThere are a number of measures that we have found helpful in initial and ongoing assessment during therapy. These are discussed in turn below. In each case the information from these measures is used in combination with information from assessment and questioning of the client regarding the issue under consideration.Current mood state measuresBeck Depression Inventory (Second Edition), (BDI-II; Beck & Steer, 1987; Beck, Steer & Brown, 1996). This is a 21 item self-report inventory that assesses for symptoms of depression. Total score cut offs are: 0-13 (normal/minimal depression), 14-19 (mild depression), 20-28 (moderate depression), and >29 (severe depression). The Beck Hopelessness Scale (BHS; Beck & Steer, 1988). This is a 20-item self-report measure. Beck reported that scores of 9 or above were signi?cantly predictive of eventual suicide in individuals with suicidal ideas followed up over up to 10 years (Beck et al. 1985). Score ranges are: 0–3 normal, 4–8 mild, 9–14 moderate and >14 severe.The Internal States Scale (ISS; Bauer et al., 1991, 2000). On this instrument clients use visual analogue scales to rate 16 different internal states covering perceived con?ict, activation, well-being, depression and global bipolar.The Altman Self Rating Mania Scale (ASRM; Altman et al, 1994). This is a self-report questionnaire for measuring manic symptoms. It consists of five groups of five statements. Clients are required to read each group of statements and chose one statement from each group that describes the way they have been feeling for the past week. A total score of 5 or more indicates mania. RecoveryThe Bipolar Recovery Questionnaire (BRQ; Jones et al, 2012). This is a 36-item self-report measure, developed through extensive consultation with individuals with lived experience of bipolar disorder. It is designed to assess personal experiences of recovery in bipolar disorder. Quality of lifeThe Brief Quality of Life in Bipolar Disorder (QoL.BD; Michalak & Murray, 2010). This is a 12-item disorder-specific quality of life measure in bipolar disorder. Early warning signs and copingThe Coping with Prodromes Interview (Lam et al., 2001). This provides a helpful initial indication of the individual’s approach to mania and depression early warning signs. It allows the clinician to capture the individual nature of each person’s early warning signs. This information is then included in the assessment of prodromal coping as part of the cognitive therapy intervention. It can also be helpful to use a checklist of the sort developed by Lobban et al (2011) to facilitate the identi?cation of early warning signs. These are particularly helpful if the client is ?nding it difficult to identify or articulate the symptoms which they experience.Clinical rating scales Observer rated measures can provide a useful was of evaluating a client’s current mood state. Training is required to administer them correctly. The following may be suitable:Hamilton Depression Rating Scale (HDRS; Hamilton, 1960). This assesses 17 symptoms of depression. Total HRDS score is categorised as follows: <10 (no depression), 10-13 (mild depression), 14-17 (mild to moderate depression) and > 17 (moderate to severe depression).Mania Rating Scale (MRS; Bech, Rafaelsen et al., 1978). This assess 11 symptoms of mania or hypomania based on observations during the clinical interview. The total MRS score is categorised as follows: 0-5 (no mania), 6-9 (hypomania), 10-14 (probable mania) and >15 (definite mania). A small battery of tests can usefully be employed at the beginning and end of therapy, which includes the BRQ, QoLBD and the BHS. If necessary, the BDI and ISS may be employed on a sessional basis to obtain essential clinical information.TREATMENT FOR BIPOLAR DISORDERBipolar disorder has traditionally been perceived as a genetic and biological illness, with medications such as lithium prescribed as the main source of treatment. However over the past 15 - 20 years the importance of psychological treatment for bipolar disorder has been recognised. Structured psychological therapies are now recommended in the UK National Institute of Clinical Excellence guidelines (NICE, 2014) for the treatment of bipolar disorder. There is increasing evidence that psychological and social factors have an important impact on the onset and course of bipolar disorder. A number of studies have demonstrated the relationship between life events (e.g. stress) and the onset, severity and duration of both manic and depressive episodes (e.g. Alloy et al, 2005). Psychotherapy for bipolar disorder is often carried out in conjunction with pharmacotherapy. Stress which precipitates the onset of episodes of depression or mania does not have to be an acute upsetting life event. It can be a build up of life’s hassles. The way an individual responds to these life hassles can alleviate or exacerbate them. Psychotherapy may help clients to examine strategies that help them deal with the stress that may present in their life. In addition to a biomedical approach, there are four major approaches to psychotherapy for bipolar disorder: psychoeducation (Colom et al., 2006), cognitive therapy or cognitive-behaviour therapy (CT or CBT, Lam et al. 2010), interpersonal and social rhythm treatment (IPSRT, Frank, 2005) and family focused treatment (FFT, Miklowitz, 2008). These approaches will be described below, with particular emphasis on CBT clinical practice with clients with bipolar affective disorder. Psychoeducation is a common element for all of these approaches, and will briefly be discussed first.PSYCHO-EDUCATIONPsycho-education is based on the rationale that treating a condition such as bipolar disorder is not just about prescribing medication. It assumes that with more information about bipolar disorder clients will be able to engage more actively with their own treatment and therefore improve their clinical outcomes. Colom reported a randomised controlled study of 120 bipolar clients. The treatment group received medication and 20 sessions of group psycho-education ADDIN EN.CITE <EndNote><Cite><Author>Colom</Author><Year>2003</Year><RecNum>175</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12695318</ACCESSION_NUMBER><VOLUME>60</VOLUME><NUMBER>4</NUMBER><YEAR>2003</YEAR><DATE>Apr</DATE><TITLE>A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission</TITLE><PAGES>402-7</PAGES><AUTHOR_ADDRESS>Bipolar Disorders Program, Institut d'Investigacions Biomediques August Pi Sunyer-IDIBAPS Barcelona, Spain.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Colom, F.</AUTHOR><AUTHOR>Vieta, E.</AUTHOR><AUTHOR>Martinez-Aran, A.</AUTHOR><AUTHOR>Reinares, M.</AUTHOR><AUTHOR>Goikolea, J. M.</AUTHOR><AUTHOR>Benabarre, A.</AUTHOR><AUTHOR>Torrent, C.</AUTHOR><AUTHOR>Comes, M.</AUTHOR><AUTHOR>Corbella, B.</AUTHOR><AUTHOR>Parramon, G.</AUTHOR><AUTHOR>Corominas, J.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/*prevention & control/psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Hospitalization</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Length of Stay</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Patient Education/*methods</KEYWORD><KEYWORD>Psychotherapy, Group/*methods</KEYWORD><KEYWORD>Recurrence/prevention & control</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL>;(Colom et al., 2003, 2009). The control group received medication and 20 non-structured group sessions. Group sessions were 90 minutes each and each group consisted of eight to twelve euthymic clients (Young Mania Rating Scale < 6, Hamilton Depression Rating Scale <8). The therapists’ style was directive but also encouraged clients’ participation. Topics included in the psychoeducation group included prompting illness awareness, medication adherence, early detection of prodromes and prompting life style regularity. There was a significant impact on relapse rates and number of episodes in participants in the psychoeducation group both during therapy and at two-year follow-up (Colom et al., 2003). This study is unusual in finding objective evidence of increased medication adherence in the psychoeducation group at follow-up. The gains were still present at five year follow-up. The psycho education group had fewer recurrences of any type and spent less time acutely ill (Colom et al., 2009). There are two potential problems with this approach. First, its expense, as it was delivered by senior clinicians. Secondly, clients have to be very stable with minimal symptoms for six months prior to the start of the group. It is unclear how easy it is to gather such a group of bipolar clients in routine practice, as most experience significant levels of subsyndromal symptoms and how well this directive approach would be received in settings different to the specialist treatment centre where the research was conducted. Morriss et al. (2011) are in the process of evaluating a multi-centre trial to determine the clinical and cost effectiveness of delivering a joint expert patient and health professional led 21-week group psychoeducation for bipolar disorder versus unstructured peer group support.BIOMEDICAL APPROACHESThe treatment for bipolar disorder in the past three decades has been predominantly pharmacological. There are several pharmacotherapy treatment guidelines for bipolar disorder This include the second edition of the American Psychiatric Association Practice (2010) Guideline for the Treatment of Patients with Bipolar Disorder, the World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Bipolar Disorders, Part 1: Treatment of Bipolar Depression ADDIN EN.CITE <EndNote><Cite><Author>Grunze</Author><Year>2002</Year><RecNum>499</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12478876</ACCESSION_NUMBER><VOLUME>3</VOLUME><NUMBER>3</NUMBER><YEAR>2002</YEAR><DATE>Jul</DATE><TITLE>World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of bipolar disorders. Part I: Treatment of bipolar depression</TITLE><PAGES>115-24</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany. grunze@psy.med.uni-muenchen.de</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Grunze, H.</AUTHOR><AUTHOR>Kasper, S.</AUTHOR><AUTHOR>Goodwin, G.</AUTHOR><AUTHOR>Bowden, C.</AUTHOR><AUTHOR>Baldwin, D.</AUTHOR><AUTHOR>Licht, R.</AUTHOR><AUTHOR>Vieta, E.</AUTHOR><AUTHOR>Moller, H. J.</AUTHOR></AUTHORS><SECONDARY_TITLE>World J Biol Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Antidepressive Agents/*therapeutic use</KEYWORD><KEYWORD>Antimanic Agents/*therapeutic use</KEYWORD><KEYWORD>*Biological Psychiatry</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/epidemiology/*therapy</KEYWORD><KEYWORD>Carbamazepine/therapeutic use</KEYWORD><KEYWORD>Electroconvulsive Therapy/*methods</KEYWORD><KEYWORD>Evidence-Based Medicine</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>International Cooperation</KEYWORD><KEYWORD>Lithium Carbonate/therapeutic use</KEYWORD><KEYWORD>Triazines/therapeutic use</KEYWORD><KEYWORD>Valproic Acid/therapeutic use</KEYWORD></KEYWORDS><URL>;(Grunze, Kasper et al., 2002), the Evidence-based guideline for treating bipolar disorder: recommendations from the British Association for Psychopharmacology ADDIN EN.CITE <EndNote><Cite><Author>Goodwin</Author><Year>2003</Year><RecNum>500</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12870562</ACCESSION_NUMBER><VOLUME>17</VOLUME><NUMBER>2</NUMBER><YEAR>2003</YEAR><DATE>Jun</DATE><TITLE>Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology</TITLE><PAGES>149-73; discussion 147</PAGES><AUTHOR_ADDRESS>University Department of Psychiatry, Warneford Hospital, Oxford, UK.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Goodwin, G. M.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Psychopharmacol</SECONDARY_TITLE><KEYWORDS><KEYWORD>Antidepressive Agents/administration & dosage/*therapeutic use</KEYWORD><KEYWORD>Antimanic Agents/administration & dosage/*therapeutic use</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*drug therapy</KEYWORD><KEYWORD>Drug Administration Schedule</KEYWORD><KEYWORD>Evidence-Based Medicine</KEYWORD><KEYWORD>Great Britain</KEYWORD><KEYWORD>Human</KEYWORD></KEYWORDS><URL>;(Goodwin, 2003), as well the recently updated UK NICE (2014) guidelines for bipolar disorder which makes specific pharmacological and psychological recommendations for each phase of bipolar disorder. Readers are recommended to refer to these guidelines for more details when necessary. This section summarises the recommendations.Pharmacotherapy in bipolar disorder can be divided into treatment of acute manic, depressive, or mixed episodes, as well as long-term preventive treatment. For severe acute manic or mixed episodes, an antipsychotic or mood stabiliser such as haloperidol, olanzapine, quetiapine or risperidone is suggested. For less severe manic episodes, lithium may also be used as a short-term therapeutic agent. If the client is taking antidepressants, these are normally tapered and discontinued. For acute depression, NICE recommends fluoxetine and olanzapine as the first line pharmacological with an alternative option of quetiapine. For long-term treatment, a number of agents are used to prevent relapses, which require careful serum level monitoring. Based on current evidence lithium is recommended as the first line medication for long-term relapse prevention. Alternatives if this proves ineffective or unacceptable to the client are valproate or olanzapine.Twenty to 40% of bipolar clients do not appear to benefit from lithium ADDIN EN.CITE <EndNote><Cite><Author>Prien</Author><Year>1990</Year><RecNum>344</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>2087538</ACCESSION_NUMBER><VOLUME>26</VOLUME><NUMBER>4</NUMBER><YEAR>1990</YEAR><TITLE>NIMH workshop report on treatment of bipolar disorder</TITLE><PAGES>409-27</PAGES><AUTHOR_ADDRESS>Division of Clinical Research, National Institute of Mental Health, Rockville, MD 20857.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Prien, R. F.</AUTHOR><AUTHOR>Potter, W. Z.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychopharmacol Bull</SECONDARY_TITLE><KEYWORDS><KEYWORD>Bipolar Disorder/*therapy</KEYWORD><KEYWORD>Electroconvulsive Therapy</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Psychotherapy</KEYWORD><KEYWORD>Psychotropic Drugs/therapeutic use</KEYWORD></KEYWORDS><URL> workshop report on treatment of bipolar disorder</TITLE><PAGES>409-27</PAGES><AUTHOR_ADDRESS>Division of Clinical Research, National Institute of Mental Health, Rockville, MD 20857.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Prien, R. F.</AUTHOR><AUTHOR>Potter, W. Z.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychopharmacol Bull</SECONDARY_TITLE><KEYWORDS><KEYWORD>Bipolar Disorder/*therapy</KEYWORD><KEYWORD>Electroconvulsive Therapy</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Psychotherapy</KEYWORD><KEYWORD>Psychotropic Drugs/therapeutic use</KEYWORD></KEYWORDS><URL> guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology</TITLE><PAGES>149-73; discussion 147</PAGES><AUTHOR_ADDRESS>University Department of Psychiatry, Warneford Hospital, Oxford, UK.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Goodwin, G. M.</AUTHOR></AUTHORS><SECONDARY_TITLE>J Psychopharmacol</SECONDARY_TITLE><KEYWORDS><KEYWORD>Antidepressive Agents/administration & dosage/*therapeutic use</KEYWORD><KEYWORD>Antimanic Agents/administration & dosage/*therapeutic use</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*drug therapy</KEYWORD><KEYWORD>Drug Administration Schedule</KEYWORD><KEYWORD>Evidence-Based Medicine</KEYWORD><KEYWORD>Great Britain</KEYWORD><KEYWORD>Human</KEYWORD></KEYWORDS><URL>;(Prien & Potter, 1990; Goodwin, 2003).This may be due to both difficulties with adherence as well as limitations in the effectiveness of the medication itself. Non-adherence rates for lithium have been estimated at between 18-53% ADDIN EN.CITE <EndNote><Cite><Author>Goodwin</Author><Year>1990</Year><RecNum>134</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Goodwin, F. K.</AUTHOR><AUTHOR>Jamison, K.</AUTHOR></AUTHORS><YEAR>1990</YEAR><TITLE>Manic-Depressive Illness</TITLE><PLACE_PUBLISHED>New York</PLACE_PUBLISHED><PUBLISHER>Oxford University Press</PUBLISHER><PAGES>938</PAGES><KEYWORDS><KEYWORD>manic depression, bipolar disorder</KEYWORD></KEYWORDS></MDL></Cite><Cite><Author>Maj</Author><Year>2003</Year><RecNum>139</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12780872</ACCESSION_NUMBER><VOLUME>5</VOLUME><NUMBER>3</NUMBER><YEAR>2003</YEAR><DATE>Jun</DATE><TITLE>The effect of lithium in bipolar disorder: a review of recent research evidence</TITLE><PAGES>180-8</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, University of Naples SUN, Italy. majmario@tin.it</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Maj, M.</AUTHOR></AUTHORS><SECONDARY_TITLE>Bipolar Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Antimanic Agents/*therapeutic use</KEYWORD><KEYWORD>Bipolar Disorder/*drug therapy/prevention & control/psychology</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Lithium Compounds/*therapeutic use</KEYWORD><KEYWORD>Prognosis</KEYWORD><KEYWORD>Suicide/prevention & control</KEYWORD><KEYWORD>Treatment Refusal</KEYWORD></KEYWORDS><URL>;(Goodwin & Jamison, 1990; Maj, 2003). Lithium has a narrow therapeutic band, meaning that therapeutic and toxic levels of lithium are quite close to each other. Although many other new mood stabilizers are commonly used in clinical practise ADDIN EN.CITE <EndNote><Cite><Author>Solomon</Author><Year>1995</Year><RecNum>338</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Solomon, D. A.</AUTHOR><AUTHOR>Keitner, G. I.</AUTHOR><AUTHOR>Miller, I. W.</AUTHOR><AUTHOR>Shea, M. T.</AUTHOR><AUTHOR>Keller, M. B.</AUTHOR></AUTHORS><YEAR>1995</YEAR><TITLE>Course of illness and maintenance treatments for patients with bipolar disorder</TITLE><SECONDARY_TITLE>J Clin Psychiatry</SECONDARY_TITLE><VOLUME>56</VOLUME><NUMBER>1</NUMBER><PAGES>5-13</PAGES><DATE>Jan</DATE><ACCESSION_NUMBER>7836345</ACCESSION_NUMBER><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Anticonvulsants/therapeutic use</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/prevention & control/*therapy</KEYWORD><KEYWORD>Clinical Trials</KEYWORD><KEYWORD>Combined Modality Therapy</KEYWORD><KEYWORD>Course</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Lithium/*therapeutic use</KEYWORD><KEYWORD>Multicenter Studies</KEYWORD><KEYWORD>Probability</KEYWORD><KEYWORD>*Psychotherapy</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL> of Psychiatry and Human Behavior, Brown University, Providence, R.I.</AUTHOR_ADDRESS></MDL></Cite><Cite><Author>Moncrieff</Author><Year>1995</Year><RecNum>503</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Moncrieff, J.</AUTHOR></AUTHORS><YEAR>1995</YEAR><TITLE>Lithium revisited: A re-examination of the placebo controlled trials of lithium prophylaxis in manic depressive disorder</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>167</VOLUME><PAGES>569-574</PAGES></MDL></Cite></EndNote>(Moncrieff, 1995; Solomon et al., 1995), it was recently concluded that ‘the only medication with incontrovertible proof of efficacy in multiple maintenance-phase studies is lithium’ (Gnanadesikan, Freeman & Gelenberg, 2003). With regard to the newer mood stabilizers, olanzapine is more effective in preventing mania whereas lamotrigine has been found to have a long-term role in delaying or preventing the recurrence of depressive episodes. (Calabrese, Shelton, Rapport, Kimmel & Elhaj, 2002). Other antipsychotics such as clozapine are also used clinically but more research is needed as the adverse side effects associated with antipsychotics may outweigh the benefits ADDIN EN.CITE <EndNote><Cite><Author>Kusumakar</Author><Year>2002</Year><RecNum>510</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kusumakar, V.</AUTHOR></AUTHORS><YEAR>2002</YEAR><TITLE>Antidepressants and antipsychotics in the long-term treatment of bipolar disorder</TITLE><SECONDARY_TITLE>Journal of Clinical Psychiatry</SECONDARY_TITLE><VOLUME>63 (Suppl. 10)</VOLUME><PAGES>23-28</PAGES></MDL></Cite></EndNote>(Kusumakar, 2002). COGNITIVE BEHAVIOURAL APPROACHRationale for the cognitive behavioural approachThe manifestation of bipolar disorder is predominately affective, cognitive and behavioural. Clinically, it has been observed that mania can fuel itself. The chaotic and disruptive lifestyle which occurs during manic episodes can lead to more episodes. This suggests that psychotherapy targeting these areas can be useful. Some individuals with bipolar disorder who have frequent relapses often engage in striving behaviour to “make up for lost time”. Hence, it is important to help clients develop good daily living routines and to target their extreme striving or goal-attainment beliefs, and related behaviours. Early detection of early warning signs of manic or depressive episodes and application of effective coping strategies during the prodromal phases are also important in preventing the development of a fullblown episode. Both promoting a good daily routine and helping clients detect and cope with early warning signs or manic or depressive episodes involve self-monitoring and self-regulation. These skills are learned in CBT. CBT is based on the assumption that our thoughts, mood and behaviour affect each another. Therapists work with clients to develop a formulation and set of goals for therapy. Following this a range of cognitive and behavioural techniques are utilized to monitor, examine and change patterns of unhelpful thinking and behaviour that are associated with undesirable mood states. Hence, CBT is well suited to helping bipolar clients to develop enhanced coping skills. A number of randomized controlled trials of individual CBT have been published (Ball et al, 2006; Jones et al, 2015; Lam et al., 2003, 2005; Meyer et al, 2012; Miklowitz et al, 2007; Perry et al, 1999; Scott et al, 2001, 2006; Zaretsky et al, 1999). These studies show that CBT has been most effective in preventing episodes for individuals who are euthymic and in the reduction of depressive symptoms (Lam et al., 2010).A study by Lam et al. (2003) illustrates the positive effect of cognitive therapy (CT) on bipolar disorder. Lam et al. conducted a randomised controlled study of 103 DSM-lV bipolar I clients who were experiencing frequent relapses whilst taking prescribed commonly used mood stabilisers. Participants were randomised into a CT group or a control group. Both groups received mood stabilisers and regular psychiatric follow-up. The CT group received, on average, 14 sessions of CT during the first six months and two booster sessions in the second six months. Over the 12-month period, the CT group had significantly fewer bipolar episodes, days in a bipolar episode and admissions. They also had significantly higher social functioning and showed less mood symptoms on monthly mood questionnaires as well as less fluctuation in manic symptoms. In a two year post-therapy follow-up there remained a significant effect in favour of therapy for relapse prevention of depressive but not manic relapses. However, the impact on relapse was restricted to the first 18 months of follow-up (Lam et al., 2005). The findings indicate that CT specifically designed for relapse prevention in bipolar affective disorder is a useful intervention in conjunction with mood stabilisers. It was suggested that the effect of booster sessions or maintenance therapy should be investigated to extend the impact on relapse beyond the 18-month follow-up period. Both Scott et al. (2001) and Ball et al. (2006), using a similar approach with bipolar patients, reported improvement mainly in depressive episodes. Not all controlled trials of CBT for bipolar disorder have found it to be helpful. In a study of 253 participants, Scott et al (2006) did not find any beneficial effects of the addition of CBT to routine medication. However, participants were at various stages of illness. Thirty-two percent of the sample were in an acute episode of depression, mania, hypomania or mixed state. Lam (2006) argued that there were inherent difficulties with the study design, which included the therapeutic techniques that were utilized at different phases of illness, meaning that it was hard to interpret what was being evaluated. More recently, Jones et al (2015) compared CBT designed to enhance personal recovery outcomes in individuals with recent bipolar disorder (<5 years) with treatment as usual. This study of 67 individuals found evidence of significant improvements in personal recovery and increased time to relapse of depression or mania over up to 15 months follow-up.Coping with bipolar early warning signsIn bipolar disorder, the early warning sign period extends from the time of the first appearance of symptoms to the time when a full-blown episode is evident. The phrase “early warning sign” is often used as shorthand for the symptoms at this early stage of an episode. A number of retrospective studies have shown that individuals with bipolar disorder can detect early warning signs ADDIN EN.CITE <EndNote><Cite><Author>Molnar</Author><Year>1988</Year><RecNum>328</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>3195679</ACCESSION_NUMBER><VOLUME>145</VOLUME><NUMBER>12</NUMBER><YEAR>1988</YEAR><DATE>Dec</DATE><TITLE>Duration and symptoms of bipolar prodromes</TITLE><PAGES>1576-8</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, State University of New York, Buffalo.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Molnar, G.</AUTHOR><AUTHOR>Feeney, M. G.</AUTHOR><AUTHOR>Fava, G. A.</AUTHOR></AUTHORS><SECONDARY_TITLE>Am J Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*psychology</KEYWORD><KEYWORD>Depressive Disorder/psychology</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Individuality</KEYWORD><KEYWORD>Interpersonal Relations</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Social Adjustment</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL> symptoms in manic depressive psychosis</TITLE><PAGES>245-8</PAGES><AUTHOR_ADDRESS>Department of Psychology, University of Sydney, Australia.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Smith, J. A.</AUTHOR><AUTHOR>Tarrier, N.</AUTHOR></AUTHORS><SECONDARY_TITLE>Soc Psychiatry Psychiatr Epidemiol</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Awareness</KEYWORD><KEYWORD>Bipolar Disorder/*diagnosis/psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>*Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Recurrence</KEYWORD></KEYWORDS><URL> behaviour and rehospitalization in bipolar affective disorder</TITLE><PAGES>521-5</PAGES><AUTHORS><AUTHOR>Joyce, P. R.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/*psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Aged</KEYWORD><KEYWORD>Patient Compliance</KEYWORD><KEYWORD>*Patient Readmission</KEYWORD><KEYWORD>Recurrence</KEYWORD><KEYWORD>*Sick Role</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>, coping strategies, insight and social functioning in bipolar affective disorders</TITLE><PAGES>1091-100</PAGES><AUTHOR_ADDRESS>Department of Psychology, Institute of Psychiatry, London.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Wong, G.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>*Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Aged</KEYWORD><KEYWORD>*Behavioral Symptoms/psychology</KEYWORD><KEYWORD>Bipolar Disorder/physiopathology/*psychology</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Disease Progression</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Regression Analysis</KEYWORD><KEYWORD>*Self Assessment (Psychology)</KEYWORD><KEYWORD>*Social Adjustment</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>;(Joyce, 1985; Lam & Wong, 1997; Molnar, Feeney & Fava, 1988; Smith & Tarrier, 1992), a finding confirmed in a longitudinal study by Perry et al. (1999) that evaluated the effectiveness for people with bipolar disorder of an intervention for identifying early warning signs and the development of action plans. They reported a significant reduction in manic episodes, which was maintained at 18-month follow-up. Lobban et al. (2010) used a cluster RCT design and trained care-coordinators to deliver enhanced relapse prevention in their multidisciplinary environments. This study found that time to relapse was increased in people receiving the intervention and social and occupational functioning was improved. There is a consensus that each client's pattern or combination of early warning signs and symptoms may be unique. Hence using a checklist to elicit early warning signs has the inherent problem of losing some of the more idiosyncratic early warning signs. Asking for spontaneous reports of early warning signs has the advantage of personalising the early warning signs in the individual's context. Some examples of idiosyncratic early warning signs are “Thought for the Day” on Radio 4 seemed to convey a special message to the client or the client’s family dog became evil. However checklists can be helpful at times as a starting point if a client is struggling to detect idiosyncratic signs (e.g., Lobban et al., 2011; Smith & Tarrer, 1992).Studies have found that 25 - 30% of bipolar clients could not detect early warning signs of depression whereas only 7.5% could not detect early warning signs of mania ADDIN EN.CITE <EndNote><Cite><Author>Molnar</Author><Year>1988</Year><RecNum>328</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>3195679</ACCESSION_NUMBER><VOLUME>145</VOLUME><NUMBER>12</NUMBER><YEAR>1988</YEAR><DATE>Dec</DATE><TITLE>Duration and symptoms of bipolar prodromes</TITLE><PAGES>1576-8</PAGES><AUTHOR_ADDRESS>Department of Psychiatry, State University of New York, Buffalo.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Molnar, G.</AUTHOR><AUTHOR>Feeney, M. G.</AUTHOR><AUTHOR>Fava, G. A.</AUTHOR></AUTHORS><SECONDARY_TITLE>Am J Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adolescent</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*psychology</KEYWORD><KEYWORD>Depressive Disorder/psychology</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Individuality</KEYWORD><KEYWORD>Interpersonal Relations</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Social Adjustment</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD></KEYWORDS><URL>, coping strategies, insight and social functioning in bipolar affective disorders</TITLE><PAGES>1091-100</PAGES><AUTHOR_ADDRESS>Department of Psychology, Institute of Psychiatry, London.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Wong, G.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>*Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Aged</KEYWORD><KEYWORD>*Behavioral Symptoms/psychology</KEYWORD><KEYWORD>Bipolar Disorder/physiopathology/*psychology</KEYWORD><KEYWORD>Cross-Sectional Studies</KEYWORD><KEYWORD>Disease Progression</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Regression Analysis</KEYWORD><KEYWORD>*Self Assessment (Psychology)</KEYWORD><KEYWORD>*Social Adjustment</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>;(Lam & Wong, 1997; Molnar et al., 1988). The high proportion of clients who couldn’t detect depression early warning signs could be due to its insidious onset. Another problem for many bipolar clients is that some depression early warning signs are not qualitatively different from their residual symptoms. This makes the detection of such early warning signs more difficult. Across the studies that listed individual early warning signs, there was strong agreement about early warning signs of mania. Six most often reported early warning signs of mania were sleeping less, more goal-directed behaviour, irritability, increased sociability, thoughts starting to race and increased optimism. The most common early warning signs of depression reported across studies were loss of interest in activities or people, not able to put worries or anxieties aside, interrupted sleep, and feeling sad or wanting to cry. Clients reported fewer depression early warning signs and there seemed to be diversity in the report of prodromal signs and symptoms of depression. ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>2001</Year><RecNum>116</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>11722154</ACCESSION_NUMBER><VOLUME>31</VOLUME><NUMBER>8</NUMBER><YEAR>2001</YEAR><DATE>Nov</DATE><TITLE>Prodromes, coping strategies and course of illness in bipolar affective disorder--a naturalistic study</TITLE><PAGES>1397-402</PAGES><AUTHOR_ADDRESS>Institute of Psychiatry, London.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Wong, G.</AUTHOR><AUTHOR>Sham, P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>*Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*prevention & control/*psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Patient Education</KEYWORD><KEYWORD>Psychological Tests</KEYWORD><KEYWORD>Recurrence/prevention & control</KEYWORD><KEYWORD>Reproducibility of Results</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD></KEYWORDS><URL>, Wong and Sham (2001) reported that bipolar clients could reliably report mania and depression early warning signs eighteen months apart. The duration of manic or depressive early warning stages varies from individual to individual. However, it is encouraging that most clients have a reasonable period for early intervention prior to a full-blown episode. For example, Smith and Tarrier (1992) reported that in their study, average duration of early warning signs of depression was 19 days (Standard Deviation = 19 days) and average duration of mania early warning signs was 29 days (Standard Deviation = 28 days). However, Molnar et al. (1988) reported that for his sample, mania early warning signs lasted on average 20.5 days (with a range from 1 to 84 days) whereas average length of depression early warning signs was 11 days (with a range from 2 to 31 days).Ratings of how clients coped with mania early warning signs contributed significantly to the clients’ level of functioning at baseline after clients’ depression and mania symptoms were controlled for statistically (Lam & Wong, 1997). These also predicted clients’ manic symptoms eighteen months later and whether clients had relapsed during the eighteen months after the levels of mood symptoms at baseline were controlled for ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>2001</Year><RecNum>116</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>11722154</ACCESSION_NUMBER><VOLUME>31</VOLUME><NUMBER>8</NUMBER><YEAR>2001</YEAR><DATE>Nov</DATE><TITLE>Prodromes, coping strategies and course of illness in bipolar affective disorder--a naturalistic study</TITLE><PAGES>1397-402</PAGES><AUTHOR_ADDRESS>Institute of Psychiatry, London.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Wong, G.</AUTHOR><AUTHOR>Sham, P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Med</SECONDARY_TITLE><KEYWORDS><KEYWORD>*Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/diagnosis/*prevention & control/*psychology</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Follow-Up Studies</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Patient Education</KEYWORD><KEYWORD>Psychological Tests</KEYWORD><KEYWORD>Recurrence/prevention & control</KEYWORD><KEYWORD>Reproducibility of Results</KEYWORD><KEYWORD>Severity of Illness Index</KEYWORD></KEYWORDS><URL>;(Lam, Wong, & Sham, 2001). The most common good coping strategies for early warning signs of mania employed by participants were: ‘modifying high activities and restraining themselves', ‘engaging in calming activities', ‘taking extra time to rest or sleep' and ‘seeing a doctor'. Poor coping strategies included ‘continuing to move about and take on more tasks', ‘enjoying the feeling of high', and ‘going out more and spending money’. It is interesting to note that the spontaneous coping strategies reported by clients are behavioural. The most common coping strategies for depression early warning signs were ‘getting myself organised and keeping busy', ‘getting social support and meeting people', ‘distracting myself from negative thoughts by doing more’ and ‘recognising realistic thoughts and evaluating if things are worth worrying about'. Poor coping strategies included ‘staying in bed and hoping it would go away', ‘doing nothing' and ‘ taking extra medication such as lithium or sleeping pills'Dysfunctional attitudesDespite the encouraging outcome in developing CBT for bipolar affective disorder ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>2003</Year><RecNum>105</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12578431</ACCESSION_NUMBER><VOLUME>60</VOLUME><NUMBER>2</NUMBER><YEAR>2003</YEAR><DATE>Feb</DATE><TITLE>A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year</TITLE><PAGES>145-52</PAGES><AUTHOR_ADDRESS>Department of Psychology, Institute of Psychiatry, London, England. spjtdhl@iop.kcl.ac.uk</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D. H.</AUTHOR><AUTHOR>Watkins, E. R.</AUTHOR><AUTHOR>Hayward, P.</AUTHOR><AUTHOR>Bright, J.</AUTHOR><AUTHOR>Wright, K.</AUTHOR><AUTHOR>Kerr, N.</AUTHOR><AUTHOR>Parr-Davis, G.</AUTHOR><AUTHOR>Sham, P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/prevention & control/*therapy</KEYWORD><KEYWORD>*Cognitive Therapy</KEYWORD><KEYWORD>Combined Modality Therapy</KEYWORD><KEYWORD>Comparative Study</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Hospitalization/statistics & numerical data</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Outcome Assessment (Health Care)</KEYWORD><KEYWORD>Patient Compliance</KEYWORD><KEYWORD>Personality Inventory</KEYWORD><KEYWORD>Psychotropic Drugs/therapeutic use</KEYWORD><KEYWORD>Recurrence/prevention & control</KEYWORD><KEYWORD>Social Adjustment</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL>, Jan</AUTHOR><AUTHOR>Garland, A.</AUTHOR><AUTHOR>Moorhead, S.</AUTHOR></AUTHORS><TITLE>A pilot study of cognitive therapy in bipolar disorders</TITLE><YEAR>2001</YEAR><SECONDARY_TITLE>Psychological Medicine</SECONDARY_TITLE><VOLUME>31</VOLUME><NUMBER>3</NUMBER><PAGES>459-467</PAGES><KEYWORDS><KEYWORD>*Bipolar Disorder</KEYWORD><KEYWORD>*Cognitive Therapy</KEYWORD><KEYWORD>*Psychiatric Hospitalization</KEYWORD><KEYWORD>*Relapse (Disorders)</KEYWORD><KEYWORD>*Symptoms</KEYWORD><KEYWORD>Activities of Daily Living</KEYWORD><KEYWORD>Self Report</KEYWORD><KEYWORD>Cognitive Therapy [3311].</KEYWORD><KEYWORD>Human. Male. Female. Adulthood (18 yrs & older).</KEYWORD></KEYWORDS></MDL></Cite><Cite><Author>Lam</Author><Year>1999</Year><RecNum>231</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Jones, S. H.</AUTHOR><AUTHOR>Hayward, P.</AUTHOR><AUTHOR>Bright, J.</AUTHOR></AUTHORS><YEAR>1999</YEAR><TITLE>Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>J. Mark G. Williams</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>The Wiley Series in Clinical Psychology</SECONDARY_TITLE><PLACE_PUBLISHED>Chichester</PLACE_PUBLISHED><PUBLISHER>John Wiley & Sons</PUBLISHER><PAGES>308</PAGES></MDL></Cite></EndNote>(Lam, et al., 2010; Lam, Watkins et al., 2003; Scott, Garland & Moorhead, 2001), very little is known about whether there are any differences in dysfunctional attitudes between unipolar clients, bipolar clients and normal controls. The cognitive model for bipolar disorder postulates high goal striving as a risk factor for bipolar disorder ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>1999</Year><RecNum>231</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Jones, S. H.</AUTHOR><AUTHOR>Hayward, P.</AUTHOR><AUTHOR>Bright, J.</AUTHOR></AUTHORS><YEAR>1999</YEAR><TITLE>Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>J. Mark G. Williams</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>The Wiley Series in Clinical Psychology</SECONDARY_TITLE><PLACE_PUBLISHED>Chichester</PLACE_PUBLISHED><PUBLISHER>John Wiley & Sons</PUBLISHER><PAGES>308</PAGES></MDL></Cite><Cite><Author>Wright</Author><Year>2003</Year><RecNum>497</RecNum><MDL><REFERENCE_TYPE>7</REFERENCE_TYPE><AUTHORS><AUTHOR>Wright, K.</AUTHOR><AUTHOR>Lam, D.</AUTHOR></AUTHORS><YEAR>2003</YEAR><TITLE>A cognitive theory for bipolar affective disorder</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>M. Power</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>Mood disorders: A Handbook of Science and Practice</SECONDARY_TITLE><PUBLISHER>Wiley</PUBLISHER></MDL></Cite></EndNote>(Lam et al., 2010; Wright and Lam, 2003). Scott and colleagues (2001) found that euthymic bipolar clients showed significantly higher scores on the Dysfunctional Attitudes Scale (DAS) as well as the “Need for Approval” and “Perfectionism” subscales than healthy control. ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>in press</Year><RecNum>498</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Wright, K.</AUTHOR><AUTHOR>Smith, N.</AUTHOR></AUTHORS><YEAR>in press</YEAR><TITLE>Dysfunctional assumptions in bipolar disorder</TITLE><SECONDARY_TITLE>Journal of Affective Disorders</SECONDARY_TITLE></MDL></Cite></EndNote>Lam, Wright et al. (2004) in a principal component analysis of the 24-item short DAS of 143 bipolar 1 clients found three factors: factor 1 “Goal-attainment”, factor 2 “Dependency” and factor 3 “Achievement”. No significant differences were found when the validation sample of 143 bipolar 1 clients was compared with 109 clients suffering from unipolar depression on any of the three factors. When participants who were likely to be in a major depressive episode were excluded, the scores of bipolar clients were significantly higher than euthymic unipolar clients in factor 1 “Goal attainment”. Goal-attainment also correlated with the number of past hospitalisations due to manic episodes and to bipolar episodes as a whole.Clinical practice: cognitive therapy techniquesEngagementAs with any form of psychological therapy, engagement is crucial for good therapeutic outcomes. For a cognitive therapy approach to bipolar disorder, it is important that the client understands and accepts a version of our basic vulnerability-stress model of bipolar disorder. However, like all other aspects of therapy with this client group, this cannot be achieved in a didactic fashion. Engaging clients with the model needs to be achieved in a collaborative manner, which makes sense to them in terms of their own individual experience. There are several approaches to this that we normally take in therapy. Written informationWe usually provide the client with written information about cognitive therapy for bipolar disorder and the model on which it is based. This is typically done in the first or second session. The handout which we use has been published elsewhere ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>1999</Year><RecNum>231</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Lam, D.</AUTHOR><AUTHOR>Jones, S. H.</AUTHOR><AUTHOR>Hayward, P.</AUTHOR><AUTHOR>Bright, J.</AUTHOR></AUTHORS><YEAR>1999</YEAR><TITLE>Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice</TITLE><SECONDARY_AUTHORS><SECONDARY_AUTHOR>J. Mark G. Williams</SECONDARY_AUTHOR></SECONDARY_AUTHORS><SECONDARY_TITLE>The Wiley Series in Clinical Psychology</SECONDARY_TITLE><PLACE_PUBLISHED>Chichester</PLACE_PUBLISHED><PUBLISHER>John Wiley & Sons</PUBLISHER><PAGES>308</PAGES></MDL></Cite></EndNote>(Lam et al., 2010). The client is asked to read this and to give feedback on the elements of this information that is helpful and less helpful. The client is given clear permission to disagree with some or all of the information, so that we can engage in a genuine discussion about the approach.There are two issues that can arise, either following discussion of the handout above or in general. Mental health difficulties on a continuumSome clients do not believe that the diagnosis that they have been given is correct. They may either think that their experiences are just part of who they are and therefore not an illness; or sometimes that there is an illness present but not bipolar disorder. Where this issue arises, it is not helpful to get into a debate about the rights and wrongs of diagnosis. Usually it is helpful to have a discussion about the psychological approach to mental health/illness that assumes that an individual’s' propensity for different mental health problems is arrayed across continua. Therefore, if an individual can acknowledge that they are having some problems in living which they would like help with, it is usually possible to engage in therapy even if they deny that they have bipolar disorder per se.Integrating medical and psychological models of illnessSome clients are over-compliant with a medical model of illness. This means that they see their illness in terms of a chemical imbalance that requires pharmacological correction. This is not surprising, as clients often report that this is the message they have taken from their meetings with their psychiatrists. It can often be helpful in this situation to engage in a discussion about the interaction between psychological and social factors in a wide range of medical problems including asthma, arthritis and diabetes. This can help the client to see that there is a false dichotomy between medical and psychological aspects of both physical and mental health problems and that optimal outcomes are often achieved by an appropriate combination of both approaches.Engagement as a processEngagement is not something that happens in the first few sessions of therapy and is then safely ignored. Although you need to engage clients to begin therapy, you also need to maintain this as therapy continues. For individuals with strong achievement motivation and perfectionism, characteristic of many bipolar clients, the overall cognitive behavioural approach is very helpful in maintaining engagement. Taking a genuinely collaborative problem-solving stance in therapy can help therapists to avoid getting locked into conflicts or battles of wills with the client. It is crucial to respect the client’s own perspective even when this does not seem to be correct therapeutically, but also to explore this with Socratic questioning and other cognitive techniques. This balance is important, as in our experience bipolar clients are very alert to when therapists are using questioning in a more directive or didactic way. Life charts and shared account of symptom developmentLife charts are a common part of cognitive behaviour therapy. An example of a life chart for Sarah, the subject of the case study described at start of this chapter, is given in Figure 10.1. Life charts are especially crucial for engagement and therapy with bipolar clients. The process of developing and applying life chart information is dealt with in detail later in the chapter. At this stage it is useful to highlight that working with the client to generate accounts of the interaction between mood episodes, psychological factors, behaviour, life events, medication and substance use is crucial to engagement. When the client is aware that there is a pattern to their experiences it also indicates that this pattern can potentially be changed. Many individuals will initially see their episodes as coming out of the blue. The realisation that this is not the case is often a key moment in engaging clients with the therapeutic intervention.FormulationCBT for bipolar disorder is best delivered on the basis of an individual formulation. The client and therapist work together to build an initial formulation and set of goals for therapy. This includes information gathered during the assessment phase such as symptom and life histories and also from formal psychometric measures, which are detailed in the previous section. Generating a large, detailed formulation can sometimes be overwhelming for the client. It can therefore be helpful to start with simple, maintenance formulations as proposed by Kinderman and Lobban (2000). A simple formulation presented in Figure 10.2 was developed for Sarah, mentioned in the case study at the start of the chapter. The formulation is based on a past episode of mania. When Sarah returned from London she started work at a bar in her nearest town. The bar was short-staffed so Sarah took on extra shifts and was working almost every day. She also began to stay late as there was a culture of staff drinks after closing hours. She enjoyed the social aspects of the job as everyone was a similar age and shared common interests. The change to Sarah’s social and sleep routine triggered the early warning sign phase. As Sarah was unaware of the change in her mood she continued to engage in activities which further disrupted her sleep, social and work routine, which eventually led to a full blown manic episode.Building a formulation of this type allows the client to begin to see how specific elements of CBT (including intervention during the early warning sign stage) can impact on their own pattern of thoughts, feelings and behaviours. Goal SettingThe setting of agreed goals is a further important part of cognitive therapy. There are a broad range of goals that clients might report and some of the main areas are discussed below. It is important the therapist and client work together to identify the goals which are important for the client. Therapists therefore need to be alert to goals which are generated for others or because the client ‘feels they should’. As with other client groups, unless the bipolar client has ownership of his or her therapy goals, the hard work of therapy will be made substantially more difficult. Areas for goal setting include both symptom reduction, and pursuing valued life goals.Symptom reductionClients will often highlight a desire to learn cognitive therapy techniques to help them to reduce and control symptoms of mania or depression. Sometimes initial goals are unrealistic, for example, ‘to never feel low again’ or ‘to be happy whatever happens’. Clearly it is important to acknowledge that such goals are understandable but also unrealistic. This can lead onto a discussion of what could be reasonably expected in these areas.Whilst Sarah (mentioned in the case study at the start of the chapter) had not experienced an acute episode of depression or mania for the past three years, she still was experiencing fluctuations in her mood, in particular depression. Sarah was due a promotion to management. Because of her past experiences she was worried that this might trigger an acute episode. She identified a goal of increasing control over her mood symptoms so they had less impact upon her life. This would be achieved by further exploration of her early warning signs and the development of a detailed coping plan. Life goalsWhilst some clients will highlight symptom issues from the outset, others will not. Many people will come to therapy frustrated and upset with the impact that their illness has had on practical aspects of their life. This may be in terms of family relationships, work, study or other areas. This frustration will often be associated with a desire to fix problems totally and immediately. Again this should be discussed in an open way. With functional goals it will often be important to work out what might be realistically achievable within therapy and then to break down the steps towards such large valued life goals.Sarah was currently single and her last relationship was three years ago prior to her last manic episode. She had gained two stone in weight and this made her feel unattractive and low in confidence. She had previously been a very active person who enjoyed going to the gym and being involved in local community arts projects. Sarah’s goals for therapy were to lose weight through both diet and exercise, take up drawing again and become more involved in the local art community. She felt this would give her the confidence to seek out a new relationship, which was her long-term goal. Sarah and the therapist worked together in a collaborative manner to evaluate each of these goals. They discussed over what time scale each goal might be realistically possible and the circumstances which might enhance or impede progress. From there it was possible to identify specific steps with respect to each goal.In addition to symptom reduction, and pursuing valued life goals additional goals may include medication adherence, building social networks, challenging dysfunctional beliefs, introducing structure and routine into one’s life, reducing risky behaviour, identifying early warning signs for relapse, and working with unrealistic positive thoughts. These issues are discussed below. Medication adherenceEvidence to date indicates that cognitive therapy is effective for bipolar disorder in conjunction with appropriate medication. Therefore adherence to medication regimes may be identified as therapeutic goal. The target here would be to work with the client to identify an adhere to an optimum system of pharmacological treatment. This involves the client being supported in working actively with their psychiatric team to address limitations of current medications and for clients to have a clear say in their own treatment. In our experience, it is important for clients to identify a prescribing clinician with whom they can develop a collaborative relationship (including use of PRN (as needed) medication to address prodromal changes). Building social networksAs indicated in the assessment section above, many bipolar clients, even when remitted, will have some social difficulties. These are often made worse by having a limited social network. Sometimes this network will have been reduced over time as a consequence of episodes of illness. Working with the client to build up a combination of formal and informal support can be important in maintaining therapy gains. One of Sarah’s goals for therapy was to become more involved in the local arts community. She had tried going to events in the past but was very nervous about arriving on her own and had left early without talking to anyone. Working together, the therapist and Sarah identified a local drawing group. Sarah felt anxious about the first session but the pros and cons of attending were evaluated. The therapist and Sarah discussed her past experience of attending events and brainstormed ideas so that she felt more in control of managing the situation. This included staying until the end of the group where there was time to initiate conversations with people. With this support Sarah was able to attend the drawing class and by the end of therapy had taken a small role in the organisation of a local arts and craft event. Challenging dysfunctional beliefsThere is no evidence that dysfunctional beliefs have a causal role in the onset of bipolar illness. Indeed they may act as a coping mechanism. However, it is postulated that these beliefs may interact with the illness and predispose bipolar clients to have a more severe course of illness. Clinically it is observed that clients with highly driven beliefs are more at risk of further episodes, sometimes through lack of routine and structure and at other times through disappointment. These beliefs can be tackled by traditional cognitive therapy techniques. A list of pros and cons of such extreme beliefs can help clients to step back and examine the drawbacks of such beliefs. In doing so, it is important to acknowledge the advantages of having such beliefs. A life chart (such as that given in Figure 10.1) can also be a very useful tool for both the client and the therapist for clarifying the nature and effects of past coping behaviour. It is important that further behaviour experiments are carried out to help clients to consolidate their intellectual understanding of altering dysfunctional beliefs and establishing more functional behaviour. For example, having understood that “catching up for lost time” is part of very driven behaviour which can be counter-productive, clients can be encouraged to have more regular work and rest patterns that may lead to more stable mood, which in turn lead to more productive work results.Structure and routineVulnerability-stress models note the importance of daily structure and routine for individuals with bipolar disorder. The development of structure is an important part of cognitive therapy. Clients record their patterns of activity from early on in therapy, completing an activity schedule that covers 24 hours a day. This is important as many clients will not have a stable routine when they enter therapy. They may have very erratic sleep patterns and may be more active at night than during the day. Working to improve this situation is not as simple as it may first appear. Many individuals with bipolar disorder are highly motivated, driven people. If they feel that they are being asked to engage in behaviour that they see as restrictive or limiting, they will not engage. The information used from the assessment process is employed to look at the extent to which chaos may have been associated with previous mood history. There then follows a baseline period of activity recording to establish current patterns. Normally the client will also record their mood on the same chart for each day between -10 (lowest ever) and +10 (highest ever). It is then possible in session to review the connections between mood, activity and sleep. The process of increasing daily structure and routine is best done as an experiment to see whether it has an impact on mood and mood stability. When planning this, the therapist is aiming to increase the predictability of key markers in the day, such as sleep, wake and main meal times. It also provides an opportunity to plan for a balance of activities during the week between domestic, leisure and work tasks. Although clients may be initially sceptical about this process, they often find that it has significant benefits. They often report being more productive and creative when their routine is less chaotic. There is also the potential for planning for periods when disruption is unavoidable. For instance when a client is going to undertake transatlantic travel, it is important that they plan their activities to allow them to cope with the circadian disruption that this causes. The outcome of this planning is often that individuals are able to cope with a broader range of activities and challenges than when routine seemed more spontaneous.When producing the life chart in Figure 10.1 with Sarah it became apparent that the majority of her past episodes had been triggered by loss of structure and routine. Following her last episode of mania (described above in the formulation section) Sarah stopped working and spent a lot of time at home. She lost contact with all of her new friends and decided that she needed to try to avoid any sources of stress. If she had disturbed sleep during the night, she would spend the next day in bed to compensate for this. If she had tasks to do, she would put them off in case they caused any more pressure for her. The experience of being at home alone, with little to do, led to a period of depression. After working with her care coordinator Sarah acknowledged that there were activities that she had avoided because she was fearful of becoming unwell again. They gradually re-introduced some activities into Sarah’s life, which included applying for a new job. Sarah was successful in her application and was currently on track for a promotion. Sarah had voiced her worries to the therapist about becoming unwell and the importance of maintaining a stable routine was highlighted. This included making sure she had two days off a week, not working for more than eight hours in a row and ensuring that if she was working the following morning that she was in bed by 11pm the previous night. Moderating risky behaviour and avoiding risky situationsA particular important component of cognitive therapy is to examine risky behaviour or risky situations that have led to manic or depressive episodes in the past and so may lead to relapses in the future. This is very idiosyncratic and is best done by going through the client’s life chart, like that in Figure 10.1. The aim is to identify any situations that may lead to risky behaviour such as use of street drugs or excessive alcohol, preparing for examinations, or engaging in work situations that involve the client switching into a disorganised daily routine or a state of sleep deprivation. Work involving long hours and extensive travel requirements can be associated with onset of prodromal symptoms. It is therefore important that the individual acts to moderate these areas as far as is possible. A balanced life style, which involves regular and consistent work hours, often in fact enhances work output and performance in the long run. Furthermore, risky behaviour often has an impulsive element. The delaying tactics described below can be a useful technique for controlling impulsivity. It is not unusual for risky, impulsive behaviour to be an early warning sign of the onset of a relapse, in which case, delaying tactics can be used as part of coping. Early warning signs and copingTo define the individual’s pattern of early warning signs, clients are asked to describe what aspects of their behaviour, thinking or mood in their experience suggests they are entering a manic or depressive episode. It is important to consider that the symptoms have to be specific and easily detectable. Often it is helpful to ask them to anchor their early warning signs in a social context, for example in their social interaction with others and comments from other people. Each individual early warning sign is written on a piece of paper. Clients are encouraged to sort the pile of papers into three groups: the early, middle and late stages. Most clients find it useful to sort the pile of papers first into early and late stages and the rest go into the middle stage. The therapist and client then further fine-tune the pattern of early warning signs to make sure there is no ambiguity in wording. Mood states are difficult to gauge. Hence, they are often carefully defined and anchored in the clients’ social context if possible. The behaviour linked to the mood state should be mapped out. Often behaviour is easier to monitor. For example, if irritability is an early warning sign, therapists can ask how the irritability shows itself. One client was able to say that he is usually irritable with his wife and picks on her at the very early stage of an episode. As the episode unfolds he is usually irritable with his daughter and at the final stage, he is irritable with almost anyone. In practice, the last stage is almost a full-blown manic or depressive episode for most clients. However, it is important to distinguish it from the full-blown episode. Sometimes clients find the transition into the full-blown episode quite blurry and usually move from the late stage of mania early warning signs to a full-blown episode within a day. The signs of these three stages are copied onto an early warning signs form. Next, the therapist ask clients to estimate the time intervals they have before the very early stage becomes the middle stage and the middle stage becomes the late stage. The therapist then discusses with the client ways of coping with bipolar early warning signs using cognitive and behavioural techniques. The cognitive model of emotional disorder about the way thinking, behaviour and mood can affect each other is used. Some examples of coping strategies of mania early warning signs are: avoiding stimulation, engaging in calming activities, resisting the temptation to engage in further goal-directed behaviour and prioritising tasks. Cognitive behavioural techniques of routine, prioritising, pleasurable and mastery activities and challenging of negative thoughts have an important part in coping with depression early warning signs. During the depression early warning sign stage, activating the client’s social network for support is important. Social companionship and shared activities can prevent clients from ruminating about their depression leading to an increase in depression symptoms ADDIN EN.CITE <EndNote><Cite><Author>Nolen-Hoeksema</Author><Year>1991</Year><RecNum>2655</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Nolen-Hoeksema, S.</AUTHOR></AUTHORS><YEAR>1991</YEAR><TITLE>Responses to depression and their effects on the duration of depressed mood</TITLE><SECONDARY_TITLE>Journal of Abnormal Psychology</SECONDARY_TITLE><VOLUME>100</VOLUME><PAGES>569-582</PAGES></MDL></Cite><Cite><Author>Lam</Author><Year>2003</Year><RecNum>105</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12578431</ACCESSION_NUMBER><VOLUME>60</VOLUME><NUMBER>2</NUMBER><YEAR>2003</YEAR><DATE>Feb</DATE><TITLE>A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year</TITLE><PAGES>145-52</PAGES><AUTHOR_ADDRESS>Department of Psychology, Institute of Psychiatry, London, England. spjtdhl@iop.kcl.ac.uk</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Lam, D. H.</AUTHOR><AUTHOR>Watkins, E. R.</AUTHOR><AUTHOR>Hayward, P.</AUTHOR><AUTHOR>Bright, J.</AUTHOR><AUTHOR>Wright, K.</AUTHOR><AUTHOR>Kerr, N.</AUTHOR><AUTHOR>Parr-Davis, G.</AUTHOR><AUTHOR>Sham, P.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adaptation, Psychological</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Bipolar Disorder/drug therapy/prevention & control/*therapy</KEYWORD><KEYWORD>*Cognitive Therapy</KEYWORD><KEYWORD>Combined Modality Therapy</KEYWORD><KEYWORD>Comparative Study</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Hospitalization/statistics & numerical data</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Middle Age</KEYWORD><KEYWORD>Outcome Assessment (Health Care)</KEYWORD><KEYWORD>Patient Compliance</KEYWORD><KEYWORD>Personality Inventory</KEYWORD><KEYWORD>Psychotropic Drugs/therapeutic use</KEYWORD><KEYWORD>Recurrence/prevention & control</KEYWORD><KEYWORD>Social Adjustment</KEYWORD><KEYWORD>Treatment Outcome</KEYWORD></KEYWORDS><URL>;(Lam et al., 2003; Nolen-Hoeksema, 1991) . Most clients find it helpful to discuss unrealistic worries with a close companion. An empathic confidant can inject some reality into clients’ overwhelming and unrealistic worries. Medical appointments and self-medication can be seen as good coping strategies. Making good use of hospital and professional help is part of clients’ coping strategy. It is very important for clients to have a mutually respectful and trusting relationship with their psychiatrists. A significant proportion of bipolar clients obtain their medication from general practitioners. It is often helpful for clients to show their key workers or prescribing doctors their record of “Coping with Early Warning Sign Form”. It may be a good practice to enclose this record in the discharge report. How early professionals should be called upon to help depends on the clients’ resources as well as how long the stages are for that particular client. It is important to bear in mind that each list of coping strategies is idiosyncratic and is tailored to the client’s circumstances and needs rather than being an idealised list of ‘perfect’ strategies. Sarah had developed an early warning sign and coping plan with her care coordinator. However, she felt that this was very medically focused. The main coping strategies were calling her psychiatrist and taking more medication. One of her goals for therapy was to develop a more detailed plan that explored the use of a range of coping strategies in response to early warning signs. Box 10.1 shows an example of “Coping with Manic Early Warning Signs Form from Sarah”. There are several considerations to bear in mind when eliciting early warning signs. First, the decision of where the early warning sign stage ends and a full-blown episode of illness begins can be difficult where onset is more gradual. The onset of mania is often more acute and is less of a problem. However, a depressive episode may gradually become worse over several weeks or months. Second, it is not unusual for some clients to experience residual symptoms, which may be similar to early warning signs. Where this is the case, it is even harder to define when residual symptoms change to the early warning sign stage. As mentioned above, some clients find it hard to detect early warning signs spontaneously, particularly for depression. Consistent with the ethos of monitoring and regulating, therapists should take every opportunity to map out the details of individual patterns of early warning signs whenever clients are in this stage and help clients to practice a more adaptive way of coping. For clients who truly cannot list early warning signs spontaneously, it is often helpful to suggest that they should discuss them with close companions or family members. As a last resort, a list of common early warning signs can be presented to help clients to identify those that are applicable to them. However, great care should be taken that these early warning signs identified are then elaborated and anchored in the client’s idiosyncratic context. Lastly, bipolar clients can experience frightening psychotic symptoms at an early stage and as the episode deepens. These psychotic experiences can become increasingly bizarre. Often clients find it helpful to discuss these frightening experience with someone who is treating them with empathy and understanding. These experiences can be very “lonely” if clients cannot share them even with their intimate partners or close friends. In working out coping strategies, it is important to consider the clients’ resources as well as problems. Therapists should rely on Socratic questioning and guided discovery rather than prescribing coping strategies. If therapists rely on persuasion or prescribing coping strategies, clients may find their sense of autonomy offended and hence reject therapists’ suggestions. In any case, clients’ circumstances are different. Techniques prescribed routinely without taking clients’ experience and circumstances into consideration are unlikely to work. It is not unusual for bipolar clients to like the early stages of mania. They find being more confident, energetic and sociable enjoyable. They may want to pursue certain risky behaviours to get the best out of their high levels of energy. The temptation is understandable, particularly when clients usually suffer from depressive residual symptoms. Therapists should respect the clients’ opinions but discuss the pros and cons of certain coping strategies in order to guide them to come to a conclusion about whether these strategies are dysfunctional. It often works better if clients can see the pros and cons and then decide on the most appropriate coping strategies for managing the early warning signs for manic episodes.Working with unrealistic positive ideas Many of the features of cognitive therapy for bipolar clients, particularly concerning episodes of low mood, are recognisable from CBT for clients with depression. The issue of working with the thoughts associated with elevated mood can present a different problem. Whereas when working with low mood and negative thoughts both therapist and client are working to try to remove unwanted symptoms, with elevated mood and positive thoughts many clients are at best ambivalent at first. The main approaches that are important here are retrospective evaluation of thoughts and outcomes, challenging unrealistic, overoptimistic thoughts, and using delaying tactics. Retrospective evaluation of thoughts and outcomesThe therapist asks the client to recall an episode of mania or hypomania and the symptoms that may have accompanied it. They then recall how they behaved and thought in particular situations within this episode. Often there will be a situation in which the person engaged in risky or impulsive behaviour, which can then be explored for associated thoughts and outcomes. In recalling this, it is important to work with the client to try to identify early changes in thinking and to track these as the situation developed. As the client begins to see such thinking as symptomatic of a particular mood state, rather than ‘its just me’, it becomes more likely that they will be able to intervene when such thoughts occur in the future. Another important issue in evaluating such situations is to clarify the outcomes. There is often a tendency for the client to focus on the positive aspects of changed mood and to down-play the immediate and later negative consequences of their actions. Exploring these negative consequences can help clients to make informed choices about changes that they want to make to their lives so as to achieve their valued life goals. Sarah, the subject of the case study that opened the chapter, recalled a situation when she was living in London and working in a bar as one of the supervisors. After a period of low mood she came to work feeling very positive. As she began drafting the new work rota she started to think about how the bar could be managed better. As she thought about possible improvements she became more excited and when she finished work for the day she went home to work on a development plan. Sarah mentioned to her manager that she had some good ideas, to which he responded neutrally, with little interest. The following day she informed him that she had developed a three-year plan for the bar that she was certain would revolutionise the way it was run, which would lead to an increase in bar sales compared to their other competitors. When he questioned some of her ideas and refused to act immediately on the plan, she responded angrily. She then left work and spent the day at home phoning managers from the other bars in the chain in an effort to move her plans forward. Again she became very angry as she felt that others were not recognising the revolutionary nature of the plan that she had developed. This continued over a period of several days after which she was called into work and given a formal warning over her behaviour. Soon after this, her mood declined and she experienced an episode of severe depression. In therapy it was important to clarify the true nature of this episode. When Sarah first described it, she mainly recalled feeling positive, excited and full of good ideas. It was only on further discussion that it became clear that the manner in which she had approached her managers and her level of interest with this particular idea was out of character. She also became aware that she had put her job at risk as a result of her approach to this. Given her relatively junior role within the bar it was not realistic to expect her to be given responsibility for planning an overall strategy for its development.Challenging thoughtsOnce it is agreed that there are episodes where patterns of thinking are symptomatic of mood change towards hypomania, clients may be asked to work on thought challenges. They will first do this retrospectively, recalling the unrealistic, overly optimistic, non-adaptive thoughts they had in specific situations, such as described by Sarah above. They would then work with the therapist to identify alternative more realistic, adaptive thoughts – just as when dealing with pessimistic thoughts associated with depression. The primary difference here is that bipolar clients will only engage with this process once they understand why it might be appropriate to alter what at first glance may feel like ‘good thoughts’.Delaying tacticsAs indicated above it is extremely helpful to build up cognitive therapy skills for challenging unrealistic thoughts when the client is in remission so that they can then draw on them when significant mood changes occur. However this is not always possible. Some clients come into therapy in an elevated mood before it has been possible for them to establish skilful cognitive approaches to coping with early warning signs. In these cases it is very important to avoid getting into battles with such clients. If they come in, often after a period of low mood, excited about a good idea, they will not welcome a negative reaction from their therapist. One approach, which was first described by Monica Basco is the delaying tactic ADDIN EN.CITE <EndNote><Cite><Author>Basco</Author><Year>1996</Year><RecNum>29</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Basco, Monica Ramirez</AUTHOR><AUTHOR>Rush, A. John</AUTHOR></AUTHORS><TITLE>Cognitive-behavioral therapy for bipolar disorder</TITLE><PUBLISHER>New York, NY, US: The Guilford Press. (1996). xix, 291pp.</PUBLISHER><KEYWORDS><KEYWORD>*Bipolar Disorder</KEYWORD><KEYWORD>*Cognitive Therapy</KEYWORD><KEYWORD>Cognitive Therapy [3311].</KEYWORD><KEYWORD>Human.</KEYWORD></KEYWORDS><ISBN>1-57230-090-6 (hardcover)</ISBN><YEAR>1996</YEAR></MDL></Cite></EndNote>(Basco & Rush, 1996). Here the therapist asks the client to describe the idea that they have. If it appears to be a risky or potentially harmful idea, it is helpful to explore with the client what they see as the positive and negative aspects of trying to implement the idea. Often clients identify other people being resistant to the new idea as the main negative aspect of their risky or potentially harmful thoughts. It is also helpful to review whether the client can identify previous periods when they have had ideas that excited them in this way and what the positive and negative outcomes were. It is important here to take an open-minded approach. Many bipolar clients are creative individuals and some ideas that do not immediately make sense to the therapist may in fact be very positive. The delaying tactic allows for this possibility. The client will usually be adamant that this plan is a very good one and that it is not associated with any mental health issues. The therapist therefore asks the client if they are willing to put the idea to the test. If it is a good idea now, it will be a good idea in a day or two. Clients will normally acknowledge this and that their patience in fully evaluating their idea might bring others round. It also gives time for their mood to change again. Thus, if the evidence accumulates to indicate that the idea has merit, the client gets more support. If it is mood driven, it increases the chances of potential harm being avoided.INTERPERSONAL AND SOCIAL RHYTHM THERAPYRationale for social rhythm therapy: Sleep disruptions in bipolar affective disorderAlthough there is strong evidence that bipolar clients experience more life events prior to the onset of an episode compared to non-psychiatric controls ADDIN EN.CITE <EndNote><Cite><Author>Kennedy</Author><Year>1983</Year><RecNum>505</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kennedy, S.</AUTHOR><AUTHOR>Thompson, R.</AUTHOR><AUTHOR>Stancer, H.</AUTHOR><AUTHOR>Roy, A.</AUTHOR><AUTHOR>Persad, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>Life events precipitating mania</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>142</VOLUME><PAGES>398-403</PAGES></MDL></Cite><Cite><Author>Kennedy</Author><Year>1983</Year><RecNum>505</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kennedy, S.</AUTHOR><AUTHOR>Thompson, R.</AUTHOR><AUTHOR>Stancer, H.</AUTHOR><AUTHOR>Roy, A.</AUTHOR><AUTHOR>Persad, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>Life events precipitating mania</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>142</VOLUME><PAGES>398-403</PAGES></MDL></Cite><Cite><Author>Kennedy</Author><Year>1983</Year><RecNum>505</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kennedy, S.</AUTHOR><AUTHOR>Thompson, R.</AUTHOR><AUTHOR>Stancer, H.</AUTHOR><AUTHOR>Roy, A.</AUTHOR><AUTHOR>Persad, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>Life events precipitating mania</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>142</VOLUME><PAGES>398-403</PAGES></MDL></Cite><Cite><Author>Kennedy</Author><Year>1983</Year><RecNum>505</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kennedy, S.</AUTHOR><AUTHOR>Thompson, R.</AUTHOR><AUTHOR>Stancer, H.</AUTHOR><AUTHOR>Roy, A.</AUTHOR><AUTHOR>Persad, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>Life events precipitating mania</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>142</VOLUME><PAGES>398-403</PAGES></MDL></Cite><Cite><Author>Kennedy</Author><Year>1983</Year><RecNum>505</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Kennedy, S.</AUTHOR><AUTHOR>Thompson, R.</AUTHOR><AUTHOR>Stancer, H.</AUTHOR><AUTHOR>Roy, A.</AUTHOR><AUTHOR>Persad, E.</AUTHOR></AUTHORS><YEAR>1983</YEAR><TITLE>Life events precipitating mania</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>142</VOLUME><PAGES>398-403</PAGES></MDL></Cite><Cite><Author>Jones</Author><Year>2002</Year><RecNum>107</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>12190719</ACCESSION_NUMBER><VOLUME>4</VOLUME><NUMBER>4</NUMBER><YEAR>2002</YEAR><DATE>Aug</DATE><TITLE>Cognitive behaviour therapy in the treatment of bipolar disorder</TITLE><PAGES>275</PAGES><AUTHORS><AUTHOR>Jones, S.</AUTHOR></AUTHORS><SECONDARY_TITLE>Bipolar Disord</SECONDARY_TITLE><KEYWORDS><KEYWORD>Bipolar Disorder/*therapy</KEYWORD><KEYWORD>Cognitive Therapy/*methods</KEYWORD><KEYWORD>Human</KEYWORD></KEYWORDS><URL>, H.</AUTHOR></AUTHORS><YEAR>1984</YEAR><TITLE>Life events and depression: Part 2. Results in diagnostic subgroups and in relation to the recurrence of depression</TITLE><SECONDARY_TITLE>Journal of Affective Disorders</SECONDARY_TITLE><VOLUME>7</VOLUME><PAGES>25-36</PAGES></MDL></Cite><Cite><Author>Bebbington</Author><Year>1993</Year><RecNum>504</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Bebbington, P.</AUTHOR><AUTHOR>Wilkins, S.</AUTHOR><AUTHOR>Jones, P.</AUTHOR><AUTHOR>Forester, A.</AUTHOR><AUTHOR>Murray, R.</AUTHOR><AUTHOR>Toone, B.</AUTHOR><AUTHOR>Lewis, S.</AUTHOR></AUTHORS><YEAR>1993</YEAR><TITLE>Life events and psychosis: Initial results from the Camberwell Collaborative Psychosis studies.</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>162</VOLUME><PAGES>72-79</PAGES></MDL></Cite></EndNote>(Bebbington et al., 1993; Johnson & Roberts, 1995; Jones, 2002; Kennedy, Thompson et al., 1983; Perris, 1984 ADDIN EN.CITE <EndNote><Cite><Author>Johnson</Author><Year>1995</Year><RecNum>158</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>7777648</ACCESSION_NUMBER><VOLUME>117</VOLUME><NUMBER>3</NUMBER><YEAR>1995</YEAR><DATE>May</DATE><TITLE>Life events and bipolar disorder: implications from biological theories</TITLE><PAGES>434-49</PAGES><AUTHOR_ADDRESS>Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island 02912, USA.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Johnson, S. L.</AUTHOR><AUTHOR>Roberts, J. E.</AUTHOR></AUTHORS><SECONDARY_TITLE>Psychol Bull</SECONDARY_TITLE><KEYWORDS><KEYWORD>Bipolar Disorder/*psychology</KEYWORD><KEYWORD>Circadian Rhythm</KEYWORD><KEYWORD>Comparative Study</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>*Life Change Events</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Recurrence</KEYWORD><KEYWORD>Support, Non-U.S. Gov't</KEYWORD></KEYWORDS><URL>;) when compared to people with diagnoses of schizophrenia or unipolar depression rates of life events are similar ADDIN EN.CITE <EndNote><Cite><Author>Swann</Author><Year>1990</Year><RecNum>507</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Swann, A. C.</AUTHOR><AUTHOR>Secunda, S.K.</AUTHOR><AUTHOR>Stokes, P.E.</AUTHOR><AUTHOR>Croughon, J.</AUTHOR><AUTHOR>Davis, J.M.</AUTHOR><AUTHOR>Koslows, S.H.</AUTHOR><AUTHOR>Maas, J.W.</AUTHOR></AUTHORS><YEAR>1990</YEAR><TITLE>Stress, depression and mania: Relationship between perceived role of stressful events and clinical and biochemical characteristics</TITLE><SECONDARY_TITLE>Acta Psychiatrica Scandinavia</SECONDARY_TITLE><VOLUME>81</VOLUME><PAGES>389-397</PAGES></MDL></Cite><Cite><Author>Bebbington</Author><Year>1993</Year><RecNum>504</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Bebbington, P.</AUTHOR><AUTHOR>Wilkins, S.</AUTHOR><AUTHOR>Jones, P.</AUTHOR><AUTHOR>Forester, A.</AUTHOR><AUTHOR>Murray, R.</AUTHOR><AUTHOR>Toone, B.</AUTHOR><AUTHOR>Lewis, S.</AUTHOR></AUTHORS><YEAR>1993</YEAR><TITLE>Life events and psychosis: Initial results from the Camberwell Collaborative Psychosis studies.</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>162</VOLUME><PAGES>72-79</PAGES></MDL></Cite></EndNote>(Bebbington et al., 1993; Swann et al., 1990). Clinically it is also observed that some bipolar clients develop a manic episode after a couple of sleepless nights due to stress, long distance travelling or jetlag. Wehr and colleagues (1987) proposed that sleep disruption was a primary route to mania, with disruption of social routines and sleep leading to a state of sleepless hyperactivity. Malkoff-Schwartz and colleagues ADDIN EN.CITE <EndNote><Cite><Author>Malkoff-Schwartz</Author><Year>1998</Year><RecNum>492</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><ACCESSION_NUMBER>9707380</ACCESSION_NUMBER><VOLUME>55</VOLUME><NUMBER>8</NUMBER><YEAR>1998</YEAR><DATE>Aug</DATE><TITLE>Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes: a preliminary investigation</TITLE><PAGES>702-7</PAGES><AUTHOR_ADDRESS>Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, PA 15213, USA.</AUTHOR_ADDRESS><AUTHORS><AUTHOR>Malkoff-Schwartz, S.</AUTHOR><AUTHOR>Frank, E.</AUTHOR><AUTHOR>Anderson, B.</AUTHOR><AUTHOR>Sherrill, J. T.</AUTHOR><AUTHOR>Siegel, L.</AUTHOR><AUTHOR>Patterson, D.</AUTHOR><AUTHOR>Kupfer, D. J.</AUTHOR></AUTHORS><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><KEYWORDS><KEYWORD>Adult</KEYWORD><KEYWORD>Aged</KEYWORD><KEYWORD>Animals</KEYWORD><KEYWORD>Bipolar Disorder/*diagnosis/etiology</KEYWORD><KEYWORD>*Circadian Rhythm/physiology</KEYWORD><KEYWORD>Depressive Disorder/diagnosis/etiology</KEYWORD><KEYWORD>Educational Status</KEYWORD><KEYWORD>Female</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>*Life Change Events</KEYWORD><KEYWORD>Male</KEYWORD><KEYWORD>Marital Status</KEYWORD><KEYWORD>Middle Aged</KEYWORD><KEYWORD>Psychiatric Status Rating Scales</KEYWORD><KEYWORD>Sleep/physiology</KEYWORD><KEYWORD>*Social Behavior</KEYWORD><KEYWORD>Support, U.S. Gov't, P.H.S.</KEYWORD><KEYWORD>Wakefulness/physiology</KEYWORD></KEYWORDS><URL>;(1998) tested the role of social-rhythm-disruption events in bipolar disorder. Thirty-nine bipolar clients were monitored in a longitudinal study. Each life event was rated for threat (unpleasantness) and social rhythm disruptions (the extent to which the event disrupts social routine and sleep). Eight weeks prior to manic episodes, significantly more clients had social rhythm disruption events compared to eight-week episode-free periods for the same clients. More recent research has support the proposal that individuals with bipolar spectrum diagnoses are more likely to have increased mood disturbance following life events which disrupt sleep and social rhythms and that these events can themselves cause such disruption (Boland et al., 2012: Sylvia et al., 2009). IPSRT (Frank, 2005) is based on the instability theory first postulated by Goodwin and Jamison (1990) that bipolar disorder is characterised by a particular sensitivity to circadian disturbance which impact on sleep patterns and trigger mood episodes. IPSRT therefore helps clients to monitor and stabilise patterns of sleep and activity. It is also informed by interpersonal therapy (Klerman et al., 1984; Weissman et al., 2000) in that it provides individuals with support to address experiences of change and loss linked to their mental health issues. There have been three RCT evaluations of IPSRT to date (Frank et al. 1999, 2005; Miklowitz et al., 2007; Swartz et al., 2012). In the first study (Frank et al. 1999, 2005) 175 individuals with bipolar I disorder were recruited when acutely ill (66% depression, 44% mania). They were then randomised to receive either IPSRT or clinical management until stabilisation. Once stabilised, they were either maintained on the intervention previously offered or swapped to receive the alternate intervention. This relatively complex design therefore meant that people could either receive IPSRT/IPSRT, IPSRT/clinical management, clinical management/IPSRT or clinical management/clinical management across acute and maintenance phases. An interim analysis of 82 participants in this trial indicated that the primary predictor of better outcomes was whether the individual received the same intervention across both phases, irrespective of what this was (Frank et al., 1999). The analysis of the full trial data set over 2-year follow-up had different findings (Frank et al., 2005). This showed that there was longer time to relapse in individuals who received IPSRT during the acute treatment phase irrespective of what treatment was offered during maintenance. The two subsequent studies have focussed on individuals with acute depression at recruitment. Miklowitz and colleagues (Miklowitz et al., 2007) compared IPSRT with collaborative clinical management and other structured psychotherapies (CBT and FFT) in 293 participants with either bipolar I or II disorder. Although structured psychological therapies overall were associated with better and faster rates of recovery over the 12-month study period there were no differences between the therapy types. This study did not report on impact on relapse to depressed or manic episodes. A smaller study by Swartz et al., (2012) compared IPSRT with quetiapine in 25 individuals with a diagnosis of bipolar II disorder who were currently depressed. Individuals were either withdrawn from medication in the week prior to study baseline measures (N=6) or were routinely medication free. Over 12-week follow-up both groups improved on measures of depression and mania with no group differences. FAMILY FOCUSED TREATMENT (FFT)Family functioning, expressed emotion and bipolar affective disorderExpressed emotion ADDIN EN.CITE <EndNote><Cite><Author>Leff</Author><Year>1985</Year><RecNum>27</RecNum><MDL><REFERENCE_TYPE>1</REFERENCE_TYPE><AUTHORS><AUTHOR>Leff, J.</AUTHOR><AUTHOR>Vaugh, C.</AUTHOR></AUTHORS><YEAR>1985</YEAR><TITLE>Expressed emotion in Families: Its significance for Mental Illness</TITLE><PLACE_PUBLISHED>New York</PLACE_PUBLISHED><PUBLISHER>Guilford</PUBLISHER></MDL></Cite></EndNote>(EE, Leff & Vaughan, 1985) can be seen as an indication of the emotional environment the client lives in, normally at home. It is measured by the Camberwell Family Interview ADDIN EN.CITE <EndNote><Cite><Author>Vaughan</Author><Year>1976</Year><RecNum>493</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Vaughan, C.</AUTHOR><AUTHOR>Leff, J.</AUTHOR></AUTHORS><YEAR>1976</YEAR><TITLE>The measurement of expressed emotion in the families of schizophrenic patients</TITLE><SECONDARY_TITLE>British Journal of Clinical Psychology</SECONDARY_TITLE><VOLUME>15</VOLUME><PAGES>157-165</PAGES></MDL></Cite></EndNote>(Vaughan & Leff, 1976), which assesses criticism, hostility (over-generalisation of criticism or rejection), emotional over-involvement (over-protection or over-devotion) and warmth. Typically if one relative is rated as high-EE, the client is seen as living in a high-EE environment. Similar to findings from research on EE and schizophrenia, high levels of criticism or emotional over-involvement in parents or spouses lead to poor outcomes in terms of relapses or poor symptomatic outcome in bipolar disorder ADDIN EN.CITE <EndNote><Cite><Author>Honig</Author><Year>1997</Year><RecNum>50</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Honig, A.</AUTHOR><AUTHOR>Hofman, A.</AUTHOR><AUTHOR>Rozendaal, N.</AUTHOR><AUTHOR>Dingemans, P.</AUTHOR></AUTHORS><TITLE>Psycho-education in bipolar disorder: Effect on expressed emotion</TITLE><YEAR>1997</YEAR><SECONDARY_TITLE>Psychiatry Research</SECONDARY_TITLE><VOLUME>72</VOLUME><NUMBER>1</NUMBER><PAGES>17-22</PAGES><KEYWORDS><KEYWORD>*Manic Depressive Psychosis/dt [Drug Therapy]</KEYWORD><KEYWORD>*Manic Depressive Psychosis/th [Therapy]</KEYWORD><KEYWORD>*Manic Depressive Psychosis/di [Diagnosis]</KEYWORD><KEYWORD>Adult</KEYWORD><KEYWORD>Article</KEYWORD><KEYWORD>Controlled Study</KEYWORD><KEYWORD>Education</KEYWORD><KEYWORD>Emotion</KEYWORD><KEYWORD>Family Therapy</KEYWORD><KEYWORD>Hospital Admission</KEYWORD><KEYWORD>Human</KEYWORD><KEYWORD>Priority Journal</KEYWORD><KEYWORD>Prognosis</KEYWORD><KEYWORD>Questionnaire</KEYWORD><KEYWORD>Rating Scale</KEYWORD><KEYWORD>Relative</KEYWORD><KEYWORD>Speech Analysis</KEYWORD><KEYWORD>Lithium/dt [Drug Therapy]</KEYWORD></KEYWORDS></MDL></Cite><Cite><Author>Miklowitz</Author><Year>1988</Year><RecNum>120</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Miklowitz, D. J.</AUTHOR><AUTHOR>Goldstein, M. J.</AUTHOR><AUTHOR>Nuechterlein, K.H.</AUTHOR><AUTHOR>Snyder, K.S.</AUTHOR><AUTHOR>Mintz, J.</AUTHOR></AUTHORS><YEAR>1988</YEAR><TITLE>Family factors and the course of bipolar affective disorder</TITLE><SECONDARY_TITLE>Arch Gen Psychiatry</SECONDARY_TITLE><VOLUME>45</VOLUME><PAGES>225-231</PAGES></MDL></Cite><Cite><Author>Priebe</Author><Year>1989</Year><RecNum>494</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Priebe, S.</AUTHOR><AUTHOR>Wildgrube, C.</AUTHOR><AUTHOR>Muller-Oerlinghausen, B.</AUTHOR></AUTHORS><YEAR>1989</YEAR><TITLE>Lithium prophylaxis and expressed emotion</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>154</VOLUME><PAGES>396-399</PAGES></MDL></Cite><Cite><Author>Priebe</Author><Year>1989</Year><RecNum>494</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>Priebe, S.</AUTHOR><AUTHOR>Wildgrube, C.</AUTHOR><AUTHOR>Muller-Oerlinghausen, B.</AUTHOR></AUTHORS><YEAR>1989</YEAR><TITLE>Lithium prophylaxis and expressed emotion</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>154</VOLUME><PAGES>396-399</PAGES></MDL></Cite><Cite><Author>O'Connell</Author><Year>1991</Year><RecNum>508</RecNum><MDL><REFERENCE_TYPE>0</REFERENCE_TYPE><AUTHORS><AUTHOR>O'Connell, R.A.</AUTHOR><AUTHOR>Mayo, J.A.</AUTHOR><AUTHOR>Flatow, L.</AUTHOR><AUTHOR>Cuthbertson, B.</AUTHOR><AUTHOR>et al.</AUTHOR></AUTHORS><YEAR>1991</YEAR><TITLE>Outcome of bipolar disorder on long term treatment with lithium</TITLE><SECONDARY_TITLE>British Journal of Psychiatry</SECONDARY_TITLE><VOLUME>159</VOLUME><PAGES>123-129</PAGES></MDL></Cite></EndNote>(Honig, Hofman, Rozendaal, & Dingemans, 1997; Miklowitz et al., 1988; O'Connell et al., 1991; Priebe; Wildgrube & Mueller-Oerlinghausen, 1989).FFT was based on the finding that bipolar clients in a high EE environment fared worse than bipolar clients in a low EE environment. In particular, people who return home following hospitalization to families with high expressed emotion attitudes (including criticism, hostility or emotional over-involvement) are 2-3 times more likely to relapse in the nine months following admission than people in low expressed emotion families (Miklowitz, 2004, 2007). Miklowitz (2008) developed family focused treatment that was designed for people who had stabilized following a recent manic or depressive episode (with or without hospitalisation) and were living or in close association with caregiving family members, usually parents or spouses. The programme consists of psycho-education about bipolar disorder, family communication training and problem-solving skills training (Milkowitz, 2008, 2011). Crowe et al. (2010) conducted a systematic review of the effectiveness of psychosocial interventions for bipolar disorder. Nine studies were examined in the family intervention category and they argued that the series of studies by Miklowitz et al. (2000, 2003) indicated improved outcomes for FFT. Miklowitz (2000) found that individuals who had received FFT had fewer relapses and longer delays before the onset of an episode. They showed greater improvements in depressive but not manic symptoms. At follow-up they had fewer relapses, longer intervals between relapses, greater reductions in mood symptoms and better medication adherence (Miklowitz, 2003). The review of FFT for the NICE guidelines (NICE, 2014) concluded that there was some evidence for FFT being effective in improving depressive symptoms and possible impact of hospitalisation. However this review did not find reliable evidence as yet for impact of FFT on relapse prevention or mania symptoms.FFT involves 21 sessions over nine months: 12 weekly sessions, six fortnightly sessions, and three monthly sessions (Miklowitz, 2008). Clients, their partners, siblings, parents and older children may all be included in sessions, although often it is a couple who attends. The programme begins after symptoms have abated and the client is being maintained on mood stabilizing medication following a hypomanic episode. A contract to complete the programme is framed as an opportunity for the family or couples to understand bipolar disorder; to accept the concept of vulnerability to relapses; to accept the need for maintenance on mood stabilizing medication; to distinguish the person from the bipolar disorder; to recognise and cope with stressful situations that may precipitate relapses; and to re-establish a supportive relationship after the episode. An assessment of the family is conducted to determine their understanding of bipolar disorder, their capacity for clear communication, their problem solving skills, and the degree to which they can avoid becoming embroiled in stressful patterns of interaction characterised by either criticism or over-involvement. A framework for couples assessment is given in Chapter 6. Following assessment, which may span between two and four sessions, psychoeducation becomes the main focus until about session 10. The family is given detailed information about the symptoms, course, relapse pattern, probable causes and multimodal treatment of bipolar disorder. In some families the non-symptomatic partner over-identifies the person with the illness, becomes over-involved and treats the bipolar patient as an invalid. In other families, the non-symptomatic partner treats the patient in a critical aggressive way, doubting the reality of the disorder and blaming the patient for acting so irresponsibly. During psychoeducation, the therapist conveys that bipolar disorder is a challenge that the family must come to understand and cope with together, in the same way that families manage other medical challenges like diabetes. Adherence to medication regimes and avoidance of major life stresses that might precipitate relapse are given attention during psychoeducation. This information is given within the context of a formulation specific to the client and the families’ strengths and vulnerabilities. As part of psychoeducation, the family write a relapse drill in which they specify the patient’s prodromal signs of relapse and a list of ‘who will do what’ when these occur. The next seven sessions are devoted to communication enhancement training. Here families are coached in how to send clear unambiguous messages, to make clear statements, to make clear requests, to listen in an active empathic way and check that accurate understanding has occurred. Communication enhancement training is offered to families as a way of avoiding the sorts of relationship tension that can lead to relapses. Where family members have an overly critical or overly involved relational style and typically engage in communication where there is rapid turn taking and little thought to what is said or the accuracy of what is understood, communication enhancement training can slow this stressful process down. The next few sessions focus on helping families identify and define family problems in solvable terms, and then systematically select, plan, implement and evaluate these solutions. Common problems addressed during this part of therapy include how to manage daily or weekly routines, how to manage finances, and how to plan leisure time. Problem-solving skills training offers families a way to reduce stress by making their attempts at solving family problems more predictable, more co-operative and more effective. A detailed account of communication and problem-solving skills training is given in chapter 6. In later sessions, the use of communication and problem solving skills is reviewed, and relapse management is discussed. When reviewing the use of communication and problem solving skills the emphasis is on pinpointing and building on family’s’ strengths, and treating setbacks as new challenges that may be addressed with the families’ strengths. With relapse management, the focus is on helping families articulate and ‘own’ what they have learned about bipolar disorder, the importance of medication adherence, the importance of stress management, the necessity for clear communication and systematic joint problem-solving, and how they will recognise and mange prodromal signs associated with relapse. Families are also referred at the end of therapy to support groups for people with bipolar disorder and their families. SUMMARYBipolar disorder is characterised by episodes of mania or hypomania and depression. There are two primary subtypes: bipolar I disorder, with at least one manic episode or mixed episode and one major depressive episode, and bipolar II disorder, with at least one hypomanic episode and one major depressive episode but no manic or mixed episodes. Bipolar disorder is relatively common, with prevalence rate of 1-1.9% in Europe and the USA. While bipolar disorder was historically viewed as a condition with periods of mania and depression interspersed with periods of ‘normality’, recent evidence suggests that clients experience high levels of symptoms between episodes, are at high risk of relapse and have substantial social problems. A client who has recovered from a bipolar mood episode has a 50% risk of having a further episode within a year and the course of bipolar disorder can become more severe over time. Bipolar disorder is associated with high risk of self-harm and suicide, with an estimated annual rate of suicide of 0.4%, twenty times higher than in the general population. Family studies indicate substantially higher risk for relatives of bipolar clients to develop the disorder than the general population. Common co-morbid conditions include personality disorders, particularly in the B and C Clusters, alcohol and substance misuse and anxiety disorders. The presence of personality disorder is commonly associated with greater illness severity including higher risk of self-harm and suicide and poorer outcome. Co-existence of any of these disorders is associated with poorer therapeutic outcomes, due to more difficulties with therapeutic engagement, higher levels of symptomatology and more frequent hospitalisations. Gathering information from the client during assessment is a prerequisite for treatment planning, as well as an opportunity to come to a shared understanding with the client of how the disorder affects the client. A careful interview with the client will cover family history of mental health difficulties and the effects of these on the client, illness history and the relationship between life events and symptoms, and the client’s views on diagnosis and medication. Assessment of current mood state, coping with early warning signs, personal recovery, hopelessness and suicidality, quality of life, the client’s social skills and sources of professional and informal support may also be made at interview and through the use of self-monitoring forms, standardised self-report and observer measures. There are four evidence based psychological treatments for bipolar disorder which are offered in conjunction with mood stabilizing medication. These are: complex psychoeducation, cognitive-behaviour therapy (CBT), interpersonal social rhythm therapy (IPSRT) and family focused treatment (FFT). Complex psychoeducation incorporates information giving, problem-solving techniques and detection of early warning signs. CBT is based on the assumption that thinking, mood and behaviour affect each other. The therapist aims to work with the client techniques to monitor, examine and change unhelpful patterns of thinking and behaviour associated with undesirable mood states. Initial work on engaging the client is followed by goal setting and working with cognitive techniques towards goals around symptom reduction, longer-term life goals, medication adherence, building social networks, challenging dysfunctional beliefs, increasing structure and routine, moderating risky behaviours and identifying and responding effectively to prodomes or signs of relapse. The recently developed recovery-focussed CBT approach takes a broader approach of applying CBT strategies to the goals valued by the client which typically include both functional and mood related outcomes. IPSRT is based on the premise that bipolar disorder is characterised by a particular sensitivity to (1) circadian disturbance which impact on sleep patterns, and (2) interpersonal stresses. Both of these trigger episodes of mood disturbance. IPSRT helps clients to monitor and stabilise patterns of sleep and activity and address interpersonal stresses. FFT is based on the finding that bipolar clients in a family environment of high EE characterised by criticism, hostility and over-involvement, fare worse than bipolar clients in a low EE environment. After a bipolar episode, in FFT families are offered psycho-education about the illness, communication training and problem-solving skills training.EXERCISESFor each of these exercises, work in pairs with one person taking the role of a client with bipolar disorder and the other taking the role of the therapist. Engagement and goal settingThe client is an individual referred for CBT for bipolar disorder. However, the client’s main priority is to ‘get well’ so that they can re-establish a relationship with a partner that broke down six months ago when the client was high. The therapist’s task is to assess whether it is possible to agree on symptom and functional goals that would permit engagement with CBT.This exercise illustrates the process of negotiating realistic goals as part of the engagement process. It highlights that many clients do not appear at initial sessions with clearly defined symptom goals.Working with elevated moodThe therapist has known the client for two or three sessions and currently engagement is only partial. S/he notices as the session progresses that the client’s mood is elevated and the client mentions that s/he has stopped taking lithium. The therapist uses CBT techniques to encourage the client to moderate activity levels, engage in calming activities and re-start lithium. However, the client feels great, thinks they are fine and that the current mood change is a great opportunity to make up for lost time.Feedback to the facilitator on the processes, cognitions and emotions associated with being in the roles of client and therapist. This exercise illustrates the importance of shared formulation and proper collaborative relationship to achieve change.Identifying early warning signs and using the card-sort techniqueThe therapist and client brainstorm a list of possible early warning signs for mania. Once all possible signs have been elicited, these are each separately written onto index cards. The client and therapist work together to identify early, middle and late signs as the client allocates cards to each category. The client is encouraged to estimate the duration of early, middle and late stages. This task illustrates the need to have an in-depth shared knowledge of the client’s experience if early warnings signs are to be elicited and ordered in a meaningful manner. The client experience of attempting to order signs is important in understanding why some individuals might not find this easy to do. This also shows how, for most people, early signs are normally relatively mild and changeable, whilst later signs are more severe and require more intensive professional input.EVIDENCE SUMMARIESJones, S. H. (2004) A review of psychotherapeutic interventions for bipolar disorder. Journal of Affective Disorders, 80, 101-114.Keck, P. & McElroy, S. (2007). Pharmacological treatments for bipolar disorder. In P. Nathan & J. Gorman (Ed.), A Guide to Treatments that Work (Third Edition, pp. 323-350). New York: Oxford University Press.Lam, D.H., Burbeck, R., Wright, K., & Pilling S. (2009). Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention - Systematic review. Bipolar Disorders, 11, 474 -482.Miklowitz, D. & Craighead, W. (2007). Psychosocial treatments for bipolar disorder. In P. Nathan & J. Gorman (Ed.), A Guide to Treatments that Work (Third Edition, pp. 309-323). New York: Oxford University Press.Morriss, R. K., Faizal, M. A., Jones, A. P., Williamson, P. R., Bolton, C., McCarthy, J.P. (2007). Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database of Systematic Reviews. 2007;CD004854. NICE (2014). Bipolar Disorder: The assessment and management of bipolar disorder in adults, children and young people in primary and secondary care (Clinical guideline 185). London: National Institute of Clinical Excellence. FURTHER READING FOR PRACTITIONERSColom, F., Vieta, E., & Scott, J. (2006). Psychoeducation Manual for Bipolar Disorder. Cambridge: Cambridge University Press.Frank, E. (2005). Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy. New York: Guilford. Lam, D., Jones, S. & Hayward, P. (2010). Cognitive Therapy for Bipolar Disorder. A Therapist's Guide to Concepts, Methods and Practice (Second Edition). Chichester Wiley.Newman, C., Leahy, R., Beck, A., Reilly-Harrington, N. & Gyulai, L. (2002). Bipolar Disorder: A Cognitive Therapy: Approach. Washington, DC: American Psychological Association. Otto, M., Reilly, Harrington, N., Kogan, J., et al. (1999). Cognitive Behaviour Therapy for Bipolar Disorder: Treatment Manual. Massachusetts General Hospital Boston.Otto, M., Reilly-Harrington, N., Kogan, J., Henin, A., Kanuz, R.O. (2008). Managing Bipolar Disorder: Therapist Guide: A cognitive-behavioural approach: A Cognitive-behavioural Treatment Program (Treatments That Work). New York. Oxford University Press. Miklowitz, D. (2008) Bipolar Disorder: A Family-Focused Treatment Approach (Second Edition) New York: Guilford Press.FURTHER READING FOR CLIENTSJamison, K. (1995). An Unquiet Mind. London: Picador (Autobiographical account by psychologist). Jones, S. H., Hayward, P. & Lam, D.H. (2003) Coping with Bipolar Disorder (Second Edition). Oxford: Oneworld.Miklowitz, D.J. (2011). The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Second Edition). New York: Guilford Press.Owen, S. & Saunders, A. (2008). Bipolar Disorder: The Ultimate Guide. Oxford: Oneworld.Scott, J. (2010). Overcoming Mood Swings: A Self-Help Guide Using Cognitive-Behavioural Techniques. London: Robinson.ASSESSMENT INSTRUMENTSAltman, E., Hedeker, D., Janicak, P. et al., (1994). The Clinician Administered rating Scale for Mania (CARS-M). Development Reliability and validity. Biological Psychiatry, 36, 124-134. Bauer, M., Crits-Cristoph, P., Ball, W. & Dewees, E. et al. (1991). Independent assessment of manic and depressive symptoms by self-rating: Scale characteristics and implications for the study of mania. Archives of General Psychiatry, 48, 807-812. Beck, A. T. & Steer, R. A. (1988). Beck Hopelessness Scale. San Antonio, TX: Psychological Corporation.Beck , A. T. Steer, R. A. & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. Dausch, B., Milkowitz, D., & Richards, J. (1996). A scale for the global assessment of relational functioning. II. Reliability and validity in a sample of families of bipolar patients. Family Process, 35, 175-189. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology and Psychiatry, 23, 59-62.Jones, S., Mulligan, L.D, Higginson, S., Dunn, G., & Morrison, A.P. (2012). Bipolar Recovery Questionnaire: Psychometric properties of a quantitative measure of recovery experiences in bipolar disorder. Journal of Affective Disorders, 147(1-3), 34-43.Lobban, F. et al. (2011). Early Warning Signs Checklists for Bipolar Depression and Mania: utility, reliability and validity. Journal of Affective Disorders, 133, 413-422.Michalak, E.E, Murray, G., & Crest, B.D. (2010). Development of the QoL.BD: A disorder-specific scale to assess quality of life in bipolar disorder. Bipolar Disorders, 12, 727-740.Monk, T., Flaherty, J., Frank, E. et al. (1990). The Social Rhythm Metric: An instrument to quantify the daily rhythms of life. Journal of Nervous and Mental Diseases, 178, 120-126.Table 10.1. Diagnostic criteria for bipolar disorderDSM-5ICD-10Bipolar I Disorder. At least one manic episode. Manic and depressive episodes are not better explained by another disorder (e.g., a schizophrenia spectrum disorder) Bipolar II Disorder. One or more episodes of both hypomania and depression, but no manic episodes, which together cause clinically significant distress or functional impairment. Episodes are not better explained by another disorder (e.g., a schizophrenia spectrum disorder) Specify if the bipolar disorder is rapid cycling Rapid cycling involves at least four episodes of a mood disturbance (major depression, mania, or hypomania) over a 12-month period.Specify if the disorder occurs with anxious distress, mixed features, melancholic features, atypical features, mood congruent or incongruent psychotic features, catatonia, peripartum onset or seasonal pattern Criteria for a Manic EpisodeA. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least a week and present most of the day, nearly every day (or any duration if hospitalization is necessary).B. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour: 1. Inflated self-esteem or grandiosity2. Decreased need for sleep3. More talkative than usual or pressured speech4. Flight of ideas or racing thoughts5. Distractibility6. Increased goal-directed activity or psychomotor agitation7. Excessive involvement in activities that have a high potential for painful consequences (e.g. buying sprees or sexual indiscretion)C. Causes functional impairment or leads to hospitalization to prevent harm to self or others, or there are psychotic featuresD. Not due to the physiological effects of a substance, or a medical condition (although may be precipitated by antidepressants or ECT)Criteria for a hypomanic EpisodeA. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day B. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour and have been present to a significant degree: 1. Inflated self-esteem or grandiosity2. Decreased need for sleep3. More talkative than usual or pressured speech4. Flight of ideas or racing thoughts5. Distractibility6. Increased goal-directed activity or psychomotor agitation7. Excessive involvement in activities that have a high potential for painful consequences (e.g. buying sprees or sexual indiscretion)C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomaticD. The mood disturbance and change in functioning is observed by othersE. Does not cause marked functional impairment, psychotic features or hospitalization F. Not due to the physiological effects of a substance, or a medical condition (although may be precipitated by antidepressants or ECT)Criteria for a depressive episode are given in Table 9.1. Bipolar disorder is characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression). Characteristically, recovery is usually complete between episodes, and the incidence in the two sexes is more nearly equal than in other mood disorders. As patients who suffer only from repeated episodes of mania are comparatively rare, and resemble (in their family history, premorbid personality, age of onset, and long-term prognosis) those who also have at least occasional episodes of depression, such patients are classified as bipolar. Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depressions tend to last longer (median length about 6 months), though rarely for more than a year, except in the elderly. Episodes of both kinds often follow stressful life events or other mental trauma, but the presence of such stress is not essential for the diagnosis. The first episode may occur at any age. The frequency of episodes and the pattern of remissions and relapses are both very variable, though remissions tend to get shorter as time goes on and depressions to become commoner and longer lasting after middle age. ? Manic episodeDistinctions are made between hypomania, mania and mania with psychotic symptoms, mixed episodes and depressive episodes (described inTable 16.1). Mania. Mood is elevated out of keeping with the individual's circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep. Normal social inhibitions are lost, attention cannot be sustained, and there is often marked distractibility. Self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed. Perceptual disorders may occur, such as the appreciation of colours as especially vivid (and usually beautiful), a preoccupation with fine details of surfaces or textures, and subjective hyperacusis. The individual may embark on extravagant and impractical schemes, spend money recklessly, or become aggressive, amorous, or facetious in inappropriate circumstances. In some manic episodes the mood is irritable and suspicious rather than elated. The first attack occurs most commonly between the ages of 15 and 30 years, but may occur at any age. The episode should last for at least 1 week and should be severe enough to disrupt ordinary work and social activities more or less completely. The mood change should be accompanied by increased energy and several of the symptoms referred to above (particularly pressure of speech, decreased need for sleep, grandiosity, and excessive optimism).Hypomania. Hypomania is a lesser degree of mania, in which abnormalities of mood and behaviour are too persistent and marked to be included under cyclothymia but are not accompanied by hallucinations or delusions. There is a persistent mild elevation of mood (for at least several days on end), increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. Irritability, conceit, and boorish behaviour may take the place of the more usual euphoric sociability. Concentration and attention may be impaired, thus diminishing the ability to settle down to work or to relaxation and leisure, but this may not prevent the appearance of interests in quite new ventures and activities, or mild over-spending. Hypomania covers the range of disorders of mood and level of activities between cyclothymia and mania. The increased activity and restlessness (and often weight loss) must be distinguished from the same symptoms occurring in hyperthyroidism and anorexia nervosa; early states of "agitated depression" may bear a superficial resemblance to hypomania of the irritable variety. Mania with psychotic symptoms. The clinical picture is that of a more severe form of mania as described above. Inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution. In severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming incomprehensible. Severe and sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self-neglect. One of the commonest problems is differentiation of this disorder from schizophrenia, particularly if the stages of development through hypomania have been missed and the patient is seen only at the height of the illness when widespread delusions, incomprehensible speech, and violent excitement may obscure the basic disturbance of affect. Patients with mania that is responding to neuroleptic medication may present a similar diagnostic problem at the stage when they have returned to normal levels of physical and mental activity but still have delusions or hallucinations. Mixed episode. Although the most typical form of bipolar disorder consists of alternating manic and depressive episodes separated by periods of normal mood, it is not uncommon for depressive mood to be accompanied for days or weeks on end by overactivity and pressure of speech, or for a manic mood and grandiosity to be accompanied by agitation and loss of energy and libido. Depressive symptoms and symptoms of hypomania or mania may also alternate rapidly, from day to day or even from hour to hour. Note: Adapted from DSM-5 (APA, 2013) and ICD-10 (WH0, 1992).Box 10.1. Early warning signs and coping with mania form for SarahMy very early warning signs of mania are:Waking up early (2 hours)More energetic – e.g. spend an hour tidying my old belongings and want to do moreWanting to spend more time with people (ring up four or five of my friends in a week to arrange meeting them) Ideas flowing fastDrinking during the weekACTION:Relax by listening to soft musicHave a relaxing bath and go to bed earlier No drinking during the week and moderate drinking at the weekendOnly go out once during the week Defer planning My middle warning signs of mania are:Speaking a lot faster – mum would say slow down Increased spending on clothes and makeupReally wanting to go out – ringing anybody I knowTrouble sleeping – only four hours a nightSmoking up to 20 a day (normally a packet lasts three to four days)ACTION:Reduce hours at work and do relaxing activities such as walking and listening to soft music and sit by the pondGet medication to help me to sleepNo alcohol in the houseMake sure I only do the minimal in the house and no extra cleaningGive my credit card to my mum My late warning signs of mania are:Racing thoughts – lots of ideas about how to make improvements to the work place Increased sexual appetite Not going to bedSmoking cannabisACTION:Give my mobile phone to Mum at night timeCancel my social commitmentsSee my psychiatristTime off work Figure 10.1. Life chart for Sarah showing self-rated mood over time. Note: Values between ?5 and +5 are regarded as normal. Higher or lower values than this signify clinical mood disturbance.Figure 10.2. Formulation for Sarah based on a previous episode of maniaREFERENCESAlloy, L.Y., Urosevic, S., Walshaw, P.D., Nusslock, R. and Neeren, A. M. (2005). The psychosocial context of bipolar disorder: Environmental, cognitive, and developmental risk factors. Clinical Psychology Review, 8, 1043–1075.Altman, E., Hedeker, D., Janicak, P. et al., (1994). The Clinician Administered rating Scale for Mania (CARS-M). Development Reliability and validity. Biological Psychiatry, 36, 124-134. ADDIN EN.REFLIST Ambelas, A. (1987). Life events and mania. A special relationship? British Journal of Psychiatry, 150, 235-40.Andreasen, N. C., Grove, W. M. et al. (1981). Reliability of lifetime diagnosis. A multicenter collaborative perspective. Archives of General Psychiatry, 38(4), 400-5.Angst, F., Stassen, H. 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