Does the type of bipolar disorder I have determine the type of treatment I need?
The type of treatment intervention needed is going to be dependent more on the phase of illness you are in. When speaking of pharmacological treatments of bipolar disorder, usually it is bipolar I disorder that is specifically being addressed, although the same medications are utilized in bipolar II disorder. A manic individual is more likely to require hospitalization, while a hypomanic person can be managed in an outpatient setting. If psychotic symptoms are present, your clinician will more likely prescribe an antipsychotic agent. The pattern of episodes is also useful in determining what mood stabilizer is likely to be helpful. Lithium is typically most beneficial for cases considered “classic”- that is, with alternating episodes of depression and mania with euthymic mood in between. For persons with history of mania only without depressive episodes, an anticonvulsant such as Depakote (valproate) is typically prescribed.
Mixed episodes or patterns of rapid cycling usually require the use of Depakote (valproate) or Equetro (carbamazepine). Atypical antipsychotics are often added to a mood stabilizer but can be prescribed alone, although often one medication is not enough, and a second agent is needed for stabilization.
Psychotherapy is a necessary part of treatment for all types of bipolar disorder, but during the manic phase it is likely to be supportive and educational only.
What are the different types of talk therapies and what do they do?
Following your consultation, the clinician will recommend the most appropriate treatment or therapeutic approach for your circumstances. The type of therapy that is useful in part depends on the stage of the illness.
Most therapeutic approaches are going to be useful for bipolar depressive episodes, as it is optimal to be able to minimize or avoid the use of antidepressant medication because of the risk for manic switch. Most individuals are not amenable to therapy in the midst of a manic phase. Patients in this stage usually have quite limited insight, and treatment approaches typically need to be supportive and educationally focused. For bipolar depression or bipolar II disorder, there are many different approaches to consider. Many therapists utilize a combination of therapeutic approaches in their work. Some approaches are: Psychodynamic therapy assumes symptoms, such as in depression, are due to unresolved, unconscious conflicts from childhood. It is based upon the classic psychoanalytic approach developed by Sigmund Freud. The therapist uses the concepts of transference, counter transference, resistance, free association, and dreams in order to help the patient develop insight into patterns in relationships that can then effect change. It is a nondirective therapy. Although classic analytical therapy can last for years, with sessions four to five days per week, psychodynamic therapy may be shorter in duration, with sessions one to three times per week. Controlled research studies examining the efficacy of this type of therapy are minimal, due to the nature of this type of therapy. This treatment approach is often helpful for those with chronic coping difficulties or with personality disorders. This therapy approach does not address bipolar illness specifically. Interpersonal therapy is useful for depression, conceptualizing it in a patient with the three components of symptom formation, social functioning, and personality factors. It focuses on the patient’s social, or interpersonal, functioning, with expected improvement in symptoms. The goal is to improve communication skills and self-esteem. It is a brief and highly structured manual-based psychotherapy. Areas of social functioning that may be addressed are interpersonal disputes, role transitions, grief, and interpersonal deficits. Therapy is focused and brief in duration, typically lasting twelve to sixteen sessions. Research studies have shown it to be an effective treatment for depression.
Interpersonal social rhythm therapy (IPSRT) is a relatively new treatment specifically geared toward the management of bipolar disorder, and it is based on the idea that disruptions in daily routines and problems in interpersonal relationships can cause recurrence of the manic and depressive episodes of bipolar disorder.
During the treatment, therapists help patients understand how changes in daily routines and the quality of their social relationships and their social roles can affect their moods. After identifying situations that can trigger mania or depression, therapists teach the individuals how to better manage stressful events and better maintain positive relationships. In bipolar illness, focusing on improvement of interpersonal relationships can be very important, as these are often adversely impacted by the illness. In addition, the therapy can be used to help regularize daily routines that can help in prevention of manic episodes.
Cognitive-behavioral therapy assumes that symptoms are due to a pattern of negative thinking. It works to help patients identify and change inaccurate perceptions of themselves and situations. It also is brief in duration and manual-based, typically lasting for ten to twenty sessions. It typically involves the use of homework assignments between sessions. Research studies have shown it to be an effective treatment for depression and some anxiety disorders. In bipolar illness, it can be especially helpful for bipolar depression, when use of antidepressant therapy may be deemed risky. See Question 38 for further discussion on cognitive-behavioral therapy.
Scott’s comments:
I discovered after my diagnosis that I had been hiding or shielding my condition (quite well I might add) from my MFCC therapist. I have been in some form of talk therapy since 1988 and my bursts of rage were easily deflected to my wife’s incessant nagging, irrational requests, or lack of sympathy for my ability to hear her due to my state of mind, work distractions, etc. I did a heck of a job keeping this out of the therapists’ office. After my diagnosis, I found that cognitive behavioral therapy did little in my case to assuage the condition. If I take my medication regularly, I’m fine. If I forget, I feel the manic state come on. In my case, it’s very physiological.
Terms:
Transference – the unconscious assignment of feelings and attitudes to a therapist from previous important relationships in one’s life (parents and siblings).
Counter transference – the attitudes, opinions, and behaviors that a therapist attributes to his or her patient, based not on the true nature of the patient but rather on the biased nature of the therapist because the patient reminds the therapist of his or her own past.
Resistance – the tendency to avoid treatment interventions, often unconsciously (e.g., missing appointments, arriving late, forgetting medication).
Efficacy – the ability to produce a desired effect, such as the performance of a drug or therapy in relieving symptoms.
Interpersonal – therapy a form of therapy.
Unlike insight-oriented or dynamic therapy that focuses on developmental relationships, interpersonal therapy focuses strictly on current relationships and conflicts within them.
Interpersonal social rhythm therapy – a form of therapy based on the principles of interpersonal therapy. Specifically geared toward the treatment of bipolar disorder with monitoring of daily activities, including sleep.
Cognitive behavioral therapy – combination of cognitive and behavioral approaches in psychotherapy, during which the therapist focuses on automatic thoughts and behavior of a self-defeating quality in order to make one more conscious of them and replace them with more positive thoughts and behaviors.
How do I choose a therapist and a therapy approach?
Choosing a therapist can be an overwhelming task. One look in the Yellow Pages shows lists of names, and not every therapist is listed there. One factor to consider is that there are many possible credentials of therapists. Some people identify themselves as therapists but do not have credentials that require licensure within their state. In general, a licensed practitioner will have been through a screening process that usually involves testing within their field. Level of training is another consideration. There are master’s levels (social workers), doctorate levels (psychologists), as well as medical doctorate levels (psychiatrists) who do psychotherapy. Clinicians of various credentials may then have further training within a specific area of psychotherapy, such as psychoanalysis. In the treatment of bipolar disorder, you will most likely need medication, thus it may be more fruitful to see a psychiatrist who also performs psychotherapy.
Due to cost considerations, however, this option is not always feasible. Many insurance plans will provide reimbursement for master’s level therapists only, whose fees usually are less than those of psychologists or psychiatrists. If there is a specific treatment modality in mind, one method of finding a therapist is to obtain referrals from professional societies for that specific modality. If modality is not the issue of concern, referrals can be obtained from a primary care physician. You may ask the therapist questions over the phone and arrange a consultation. If you are uncomfortable with the therapist following the consultation, it is important to consider the reasons for your discomfort. Sometimes individual psychological issues are projected onto the therapist immediately and thus are avoided by failing to continue to see the therapist. But certainly there needs to be a fit with the therapist’s style in order to develop a working relationship.
Term:
Projected – the attribution of one’s own unconscious thoughts and feelings to others.
