Thursday, April 7, 2011

Treating Bipolar Disorder Part II -- The Social Zeitgeber Theory in Action

So you have bipolar.  You know you have bipolar.  You are way past the denial stage.  You are into the pulling out your hair, screaming with frustration stage.  Or maybe moved on to despair stage.  Because:
  1. The medication sucks.
  2. You keep getting sick again anyway.
But contrary to what everybody has been telling you, medication is not the only thing that works.  It may be essential to your recovery and continued functioning.  But you can do better if you do more.  From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention?  Today we continue with Ellen Frank's Treating Bipolar Disorder, in which she describes this therapy of her invention.

What Happens In IPSRT

After diagnosis with bipolar I or II (primarily designed for bipolar I), IPSRT proceeds roughly in four stages:
  • history-taking with education about bipolar and orientation to the treatment
  • evaluating and then stabilizing social rhythms
  • addressing interpersonal problem areas appropriate to the individual
  • monitoring progress and termination

An Integrative Theoretical Model: Social Zeitgeber Theory

Therapy generally begins with history-taking, going over the client's life story with focus on factors related to the therapist's theoretical orientation.  The intake interview for IPSRT is guided by its own theory of how people with bipolar get off kilter.

Off Kilter.  Like:



Here is the flow chart for Social Zeitgeber Theory, with my comments in italics:

Well, first you start with your life.  Then, more life happens.

Life Events Affecting Interpersonal Relationships
and Social Roles

Like, you get laid off from work.


Change in Social Prompts (Social Zeitgebers)

So you don't have anywhere to go in the morning.

 
Change in Stability of Social Rhythms

So, whatever.  You party wherever, sleep whenever.


In these early stages, you may have a variety of mitigating factors, reducing the disruptive impact of whatever life event just started this slide.  Frank lists social supports, coping, gender and temperament as potential protection.  Maybe you have a dog who will insist on her 6 AM run, no matter what you have in mind.

 Good dog.

Change in Stability of Biological Rhythms

Lacking a dog to keep your social life sane and your out of bed hour regular, the hormones governing sleep don't know when to come online.


Change in Somatic Symptoms

Uh-oh.  Here comes the insomnia again.

Again, Frank lists mitigating factors.  You may have a genetic background that makes you more or less vulnerable to these disruptions.  Or you may have previous treatment experience, so that you recognize when you are in trouble and change your ways before you go off the rails.  If something doesn't turn this train around, then...


Mania or Depression = Pathological Entrainment of Biological Rhythms

In other words, mania and depression happen when your lack of normal becomes your normal.


Been here before, have we?

IPSRT Theory Integrates Social, Psychological and Biological Explanations Of Mood Episodes

Notice, life events, emotional and behavioral responses to these events, and subsequent physical symptoms are all included in the development of a mood episode -- the whole person, not just the final so-called chemical imbalance.  The target of medication is the bottom of the line.  But any of these stages is an appropriate point of intervention and prevention.

This is really good news for people whose medication isn't up to doing the whole job.

History Taking

Lots of case studies make the book readable and illustrate points along the way.  Frank tells the stories of individuals who functioned well until a disruption in social patterns triggered a depression or a mania.

An IPSRT therapist helps the client create a time line tracking the current and past episodes of depression, mania and hypomania with attention to what preceded the onset, or started the descent into the train wreck outlined above, particularly disruptions in social rhythms.  This history-taking begins the educational process and makes the case for the behavioral changes the therapist will recommend.

As I read, episodes from my own life came to mind.  I used to be a legislator in a national church convention that happens every three years -- extremely stimulating events.  I was on 14-16 hours a day, 11-12 days in a row.  I would be living in strange surroundings, eating restaurant food at irregular hours, on a work schedule invented by the devil.  I always "rose" to the occasion, was energetic, productive, persuasive, effective, charming... hypomanic.  Some of my readers can give an Amen to that statement.  What they didn't know was that I went home from two weeks of brilliance to begin another several months of depression.  The classic bipolar II cycle before it progressed to rapid cycling.

This life review did indeed make the case for me.  There is no IPSRT therapist in my area.  So I moved on to stage two on my own.

Evaluating And Stabilizing Social Rhythms

The challenge begins here.  Having come to suspect that irregular habits contribute to mood disturbances, now we establish just how irregular the client's habits are.

Frank and colleagues developed a chart, the Social Rhythm Metric to track the times that seventeen different events occur each day, getting up, first contact with another person, time to work or school, meals, and so on.  Seventeen.  What time does each happen today.  Every day.  For three weeks.  To start.  If I know my friends with bipolar, we would bail right here.

Then there is a formula to determine the average time of occurrence for each activity, the deviation each day, and the total of all the deviations.  It's more complicated than that.  But I decided to pass on the flow chart.  The client doesn't have to do the math; the therapist does.  I imagine this is where the potential therapist bails.

Never mind.  They figured out which five activities give you the most bang for your buck.  The book recommends the five item version for clients who are not well enough to do track all seventeen.  I hope sometime since the book was published, Frank has changed her interpretation of the resistance to the longer instrument.  Maybe it's not the clients who are too sick to do it.  Maybe it's just an unwieldy instrument.

So I started to track five items.  The shorter instrument also asks how stimulating the activity was on a 0-4 scale.  By the third day, I was in tears and had managed to record no more than two activities each day.  Toward the end of the book, Frank acknowledges that people who have been sick a long time may have cognitive deficits and be able to handle only one or two items.

That's me, cognitive deficits.

Choose A Place To Start

Nevertheless, I moved on to a decision -- get up at more or less the same time every morning.

Of course, getting out of bed anchors other social rhythms, what time I greet my wife, what time I eat breakfast.  At the other end, I have to structure my evening so that I sleep better and long  enough to wake up at the appointed hour.

There are other self care activities/rhythms anchored by getting out of bed.  If I am out of bed before I drink my first cup of coffee, I do my stretches, I say my prayers -- habits that went by the wayside when my out of bed time was disrupted a couple years ago. 

There is significant meaning attached to doing these self care activities that are anchored by getting out of bed -- which affects my mood.

Pretty soon I've got some positive movement in social, psychological and biological realms, my whole person.  My normal baseline, from which I veer violently up and down, is mild depression.  Lately, that seems to have lifted ever so slightly.  We'll see.

See, I didn't need to track five items.

That's Fine For You But My Life Isn't That Regular...

I never said that IPSRT is easy.  But it might help.

In fact, it seems pretty difficult to me.  And Frank acknowledges that.  Treating Bipolar Disorder is written for clinicians.  Her advice to clinicians is to expect resistance, to normalize resistance, and to review, whenever needed, the multiple motivations for the difficult changes that are required.
  • What did the time line indicate?  Is there a connection between loss of social rhythms and onset of episodes?  (If not, then this is not the therapy for you.)  But if there is...
  • What has this illness cost you already?  What will it cost you in the future if you cannot manage your symptoms better?
  • What issues (therapy-type issues) prevent you from making these changes?

We continue with issues, the IP part of IPSRT, next.

flair from facebook
photo of Train wreck at Montparnasse Station, 1895 in public domain

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