Monday, April 18, 2011

Treating Bipolar Disorder Part III -- The Interpersonal Therapy Part

Lately I have been reviewing Treating Bipolar Disorder by Ellen Frank -- the recommendation of a friend who is researching hypomania.  Part I described the basis of Interpersonal Social Rhythms Therapy (IPSRT) in circadian rhythms that control the many physiological symptoms of mood disorders.  Part II outlined the Social Zeitgeber Theory and described the early stages of the therapy process, history taking and stabilizing social rhythms.  Today I pick up with the later stages, interpersonal therapy and maintenance.

Interpersonal Social Rhythms Therapy came to Ellen Frank in an epiphany on her birthday, July 14, 1990.  Personally, I like that.  I especially like that it was the day that she participated in a conference for people with bipolar, and listened to them.

Frank and her colleagues were already using interpersonal therapy for people with recurrent unipolar depression.  Their theory was that certain life events, particularly losses could result in lost social zeitgebers, (timekeepers), with subsequent disruption of circadian rhythms, leading to eventual relapse into another episode of depression.

IPSRT took up from there as an adaptation specifically for people with bipolar disorder, integrating the work on issues (as in, you've got issues) with greater focus on behavioral changes to achieve and maintain daily rhythms, time of rising, time of first human contact, work, main meal, etc.  The purpose of IPSRT is to help people achieve stability and then to avoid relapses into either depression or mania/hypomania. 

Why Do People Relapse?

IPSRT builds on Goodwin and Jamison's work in their classic Manic-Depressive Illness, which argues that instability is the fundamental dysfunction in manic depressive illness.  Goodwin and Jamison identify three interrelated reasons why relapse occurs for those who have been successfully treated with medication (lithium): noncompliance with medication regime; disruptions in social rhythms; and stressful life events.  IPSRT addresses all three. 

How Interpersonal Therapy Helps

The friend who brought Frank's work to my attention wonders if the interpersonal part of this mash-up (IP+SRT) is integral to the results, or if they do IP just because that is what they were already doing.  I wondered that, too.

Frank answers most succinctly in a 1994 article for the journal, The Behavior Therapist.  (And I thank her for sending me a copy.)  There she identifies the interpersonal work specifically with the third reason for relapse, stressful life events:

By addressing interpersonal problem areas in the patient's life, IP/SRT attempts to reduce the number and severity of interpersonally-based stressors the patient experiences.  We believe that reduction of interpersonal stress was important for three reasons.  First, stressful life events can have a direct effect on circadian integrity through increased autonomic arousal.  Second, many life events lead to marked changes in routine which, in turn, affect circadian rhythms.  Finally, the psychological meaning of such events frequently has the capacity to affect mood directly.

The interpersonal issues on which they focused for treating unipolar depression included unresolved grief, social role transitions, interpersonal role disputes and interpersonal deficits.  Grief for the formerly healthy self was added in their modification for for bipolar disorder.

Where To Begin

The therapist and client contract together on which issue to address in therapy, usually the one that most clearly contributed to the most recent relapse.  A tour through each issue can illustrate how closely integrated the theory and therapy indeed are.  Some of what follows is from Frank.  Some is my own take on the matter.

Unresolved Grief -- Even normal grief makes people with bipolar disorder vulnerable to a mood episode.  A death in the family brings with it all kinds of stresses.  Pick your own favorite family craziness.  Plus travel, finances, interacting with unfamiliar professionals, unresolved spiritual issues... There is a reason why funeral home directors speak in that gentle voice.  They know how close to the edge you are, and don't want to set you off.  It's called funeral parlor mania.  Add to stress the disruption of schedules, temporary for some and long term for those whose daily lives were most closely linked with the deceased.  In the chaos of events and emotions, self care, including medication can be neglected or forgotten.  Stressful life events, disruptions in social rhythms, noncompliance with medication regime -- there you have the Goodwin/Jamison relapse trifecta.

If the person with bipolar has not worked through a past grief, like, went off the deep end during the original event, he/she can return to the chaos at an anniversary or when confronted with some trigger.  Reload, repeat, relapse.

Grief For The Lost Healthy Self -- It's a real whack upside the head to be diagnosed with a serious mental illness that will be with you for the rest of your life.  Frank says it helps to acknowledge what has been lost, like meaningful work, accomplishment, recognition -- my glorious career with its circadian rhythm wrecking lifestyle.  Framing the issue in terms of grief helps people move on to acceptance of a new sense of self.  Self-expectations, concepts of healthy and ideal have to be redefined to include good judgment about self care.

I have to take her word on this.  Among the stages of grief, I have moved past stunned, and am stuck on royally pissed.  I can see that more realistic expectations could reduce stress, and that acceptance could morph into motivation to search for and stick with the program that works, including limits on those late night sessions that solve the problems of the world.  But I suspect a large part of Frank's agenda, wanting me to get to acceptance, includes acceptance of medications I don't want to take.  And I go back to royally pissed.  Notice, we have stress, schedule and meds again, all addressed in one stop shopping for resolving grief for the lost healthy self.

Interpersonal Disputes -- Perhaps because a central feature of both hypomania and depression is irritability, and because a characteristic of the "bipolar temperament" is a certain tendency toward an attitude of entitlement, interpersonal disputes tend to be common in this patient population.

Well.  The bipolar temperament and attitude of entitlement will take a whole post to unravel.  Later.

Irritability -- yes, we know that story.  Irritability is not only a symptom, it is also a side effect of medication.  How blessed is the patient whose doctor and/or therapist will explore the second possibility and not take it personally; for that bipolar II patient might get to a correct diagnosis sooner and suffer fewer years of antidepressant trials.

But one does need to save ones attitude of entitlement for the doctor's office.  When we inflict our symptomology on family, friends, coworkers, bosses, we end up in interpersonal disputes.  Therapy can teach reasonable expectations and alternate means of communicating distress.  Again, the goal is to lower stress, preventing its increased autonomic arousal and potential for circadian disruption, loss of sleep or appetite, or even being kicked out the door.  Nothing like getting fired or divorced to disrupt your rhythm and move you to your next interpersonal therapy issue:

Role Transitions -- Whether positive, negative or neutral, marriage, divorce, new parenthood, birth of child or kids leaving home, new job or retirement, new house, new town, change is difficult for people with bipolar.  We just have a hard time with change, whether it hits our relationships, social rhythms or self image.

Which is a bite, because bipolar is all about change.  The therapist's focus will be on management of symptoms, helping the client to plan transitions, possibly set limits on expectations that come with the new role or even rethink choices to decrease stress and overstimulation.

Interpersonal Deficits -- Are you chronically dissatisfied, burned all your bridges or afraid that you have in previous manic episodes?  Interpersonal deficits is one of those global issues, more difficult to tease out and to treat.  Frank recommends that it get postponed until later in treatment, and has less to say about it.  I suspect this issue includes the slush category for when therapy just gets stuck.  Interventions include a more general approach to the conflict issue, addressing patterns of interpersonal conflict, building new interests and relationships to replace those that have been lost, and exploring whether broken relationships might indeed be reconciled.

Perpetual dissatisfaction does keep that autonomic arousal system aroused and prevents the stability/rhythms that good relationships offer.  Social isolation might decrease stress.  That would be why some of us do it.  But again, it costs us the stability and the stress buffer that positive relationships offer. 

Why The Mash-Up

So interpersonal issues cause stress.  They have the potential to screw up your circadian rhythms.  They mess with your mood.  And they can interfere with the program.

The major reason for interpersonal therapy is to support the program, meds and schedule, and to intervene in whatever would mess with the program.

Living Healthy With A Chronic Disease

I was concerned about a young friend whose marital conflicts are reported with several Facebook updates every day.  I just don't get people who fight with their spouses on Facebook.  Anyway.  The emotional whip-lash between perfect and doom got so extreme that one day I picked up the phone and told her I was worried for her.  Actually, scared.  I don't let suicidal language pass by.  I reminded her of her previous diagnosis of bipolar.  Oh no, that was years ago.  I haven't taken medication for a long time.  It didn't help anyway.

Sigh.  The girl doesn't have health insurance.  Where she lives, she doesn't have access to psychiatrists nor community mental health nor support groups.  All she has is Facebook messages from friends who are not qualified to say what her diagnosis is.  I am not qualified to say what her diagnosis is, nor how it should be treated.  And my amateur armchair diagnosis goes to a different section of the DSM anyway.

But if it's bipolar, it won't go away.  That the meds stopped working has nothing to do with it.  That's what meds do.  They stop working.  They never were able to prevent relapse, only postpone it.

It is not helpful when doctors tell us that if we don't take our meds for the rest of our life, we will get sick again.  They imply a promise that the meds won't keep.  We probably will get sick again.  The meds help.  They do not cure.  When we relapse, we quit taking them, because they didn't live up to the sales job.

If you have bipolar, you have to take care of it every day, or it will get the best of you.  Every day for the rest of your life.

Now if you do that, you can have a life.  It may or may not be the life you planned on.  But it can be a good life.  And a hellava lot better than if you don't take care of it.

Meds alone do not solve the problem.  This is what Ellen Frank heard over and over on July 14, 1990, when she listened more than she talked at a conference for people with bipolar.  And she decided to find something that would do better.

Those who have been at this for a long time say that #1 is lifestyle.  #2 is support.  #3 is meds.  IPSRT is about helping you learn a lifestyle that will maximize the success of treatment.  And NIMH agrees.  People who take meds do better if they also do IPSRT than if they do just meds alone.

Maintenance Treatment For Bipolar Disorder 

The last part of IPSRT is sticking with it.  

Once you've got a workable program, have a better handle on what would interfere with the program and know how to adapt to changing circumstances, appointments become less frequent, every two weeks, once a month, once a quarter, whenever something major comes up.

Things do come up.  Not all of them are events.  The fundamental dysfunction in manic depressive illness is instability.  You go up, you come down.  You do your best to create and maintain what stability you can.  Then you monitor your moods, your energy level, your sleep, the volume of your voice, the rapidity of your thoughts, the number of projects you take on, looking for evidence that things are slipping.

The IPSRT therapist and client learn to recognize the warning signs of an impending episode, and then to respond.  Interventions might include ratcheting up or down the level of stimulation one is experiencing.  Maybe you need to get out of the house more.  Maybe you need less time with your chronically hypomanic buddy.  Maybe the book you are reading at night is too stimulating, and a different author will solve your sleep issue.  Or maybe you could use a few nights of "rescue" medication for sleep to nip that incipient hypomania in the bud.  Maybe your regular meds need adjusting.

The earlier the intervention, the more successful.  It's all about the right balance, knowing how far you can move off center and how to get back. 

Hope For Living With Bipolar Disorder

If your meds don't work well enough or if they don't work at all, there are more tools in the tool box.  I love this book.

So after a break next week, I will finish up with a little nitpicking and my overall recommendations regarding Treating Bipolar Disorder, by Ellen Frank.


photo of book cover from amazon.com
flair from facebook
photo of jenga blocks by Jason7825, used under the GNU Free Documentation License
photo of roller coaster by WillMcC, used under the GNU Free Documentation License
photo of dirty dishes by Mysid and in the public domain

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