My article for “Complete Wellbeing” on how psychotherapy can help in the management of Bipolar Disorder. Here is the link to the article.
As per the NIMH [National Institute of Mental Health], the prevalence rate of bipolar disorder is about 1.1% of the population. Around 9 million Indians have this condition, and approximately 51% are left untreated every year.
What is Bipolar Disorder?
According to the Diagnostic and Statistical Manual of Mental Disorders-5 [DSM], bipolar disorder is a serious mental health condition marked by radically opposite states of mood. These moods may occur in phases, also called episodes. The manic episode is typically marked by feelings of grandiosity or heightened self-esteem. People experiencing this phase may seem to be in a “high”. They may be unusually energetic, have little need for sleep, may talk excitedly, get easily distracted, and often recklessly pursue pleasurable activities. In contrast, the depression episode is marked by intense sadness, dejection, lack of energy, apathy and lack of interest in pleasurable activities. Typically, between both episodes, there may not be any symptoms.
A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person and may be associated with good functioning and enhanced productivity. So even when family and friends learn to recognise the mood swings as a possible mental disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can convert to a manic episode or major depression.
Because bipolar disorder tends to run in families, researchers have been searching for specific genes that could be linked to the disorder. Recent research shows that the MLC1 gene could be associated with schizophrenia and bipolar disorder in southern India. [Verma, Mukerji et al, 2005]. External environmental triggers could also set off the disorder or worsen existing symptoms. Stressful life events, substance abuse, seasonal changes, sleep deprivation are all potential triggers for either mania or depression.
What does the treatment involve?
Bipolar Disorder is a Bio-Chemical condition, therefore Psychotherapy is not the first line of treatment. The professional to visit immediately, if one suspects the illness, is a psychiatrist. The psychiatrist will assess the history, symptoms and overall functionality of the person and accordingly prescribe medication. Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They are the cornerstone of treatment, both for mania and depression. Lithium is the oldest and most well-known mood stabilizer [recommended by APA Practice Guidelines]. Psychiatrists may also prescribe benzodiazepines, anti-depressants or anti-psychotic medications based on the persons’ symptom presentation. Adhering to the medication guidelines prescribed by the doctor is crucial to recovery.
Deciding to seek psychotherapy:
Although psychotherapy is not the first line of treatment for bipolar disorder, medication offers only partial relief for patients. Seeking a trained psychologist can make a marked difference towards treatment adherence, relapse prevention, symptom management and leading a better quality of life.
However, visiting a professional only is not enough. Psychotherapy is hard work and is not just about “talking and listening”. The person needs to work within and between sessions to gain insight into their problems, change their activity level, daily schedule, mood, thinking and social relationships. The therapist works with the person to change those negative thinking patterns that reduce their motivation to make these changes. It’s important to note that just meeting a “counsellor” will not provide a solution, unless the professional is managing the illness effectively. One needs to meet an accredited and trained psychotherapist, someone who will actively work to alleviate the symptoms.
What happens in psychotherapy?
Psychotherapy teaches the benefit of adopting a rational stance when faced with difficult situations. The idea is that if one is upset by their problems, they now have two problems:
- The problem
- The upsetness.
In the initial phase of therapy, there will be an assessment. During this phase, the therapist will take an extensive history, including timelines of the episodes. Some information that the therapist will seek:
- Age of onset of the illness
- Progression of symptoms over time
- Description of specific depressive symptoms
- Description of specific symptoms during elevated mood
- Description of sleep patterns and physical energy in each of the different mood phases
- Approximate duration for each of one’s mood phases
- Presence of suicidal thought and accompanying risk factors
- Impact of symptoms upon interpersonal relationships
Sometimes, along with bipolar disorder, the person may also be diagnosed with another condition, eg: a personality disorder. Therefore, the therapist may conduct a psycho-diagnostic evaluation to rule out if there is any other mental illnesses. The therapist will also make a note of the medications the person is taking and monitor the psychiatric intervention, as also recommend any other medical interventions if needed.
The therapist will then provide “psycho-education”, which essentially means educating the client and the family about the illness. This will include explaining the symptom profile, the depression negative triad, brain physiology, the need for both medication and psychotherapy etc. Psychotherapy will also involve some family education, so that the family can learn to recognise symptoms, and how to adopt behavioural strategies to manage the mood episodes.
Psychotherapy will next involve the core phase, i.e. treatment of symptoms. This will include the following:
- Regulating daily schedule
- Keeping mood charts to note daily mood fluctuations
- Restructuring negative thinking
- Promoting adherence with medication regimens
- Reducing risk of suicide
- Identifying triggers that increase the risk for relapse
- Mediating any hospitalizations
- Identifying the prodromal symptoms
The most important benefit of psychotherapy is helping the patient and the family detect “prodromes”. The word prodrome comes from the phrase, “running before”, and refers to the period that precedes a mood episode. In bipolar disorder some environmental triggers may precede a mood episode. These triggers may include seasonal variation, certain stressors [such as disagreement with spouse], work overload etc. Although bipolar moods are not always “predictable”, identifying a certain set of triggers that typically precede a mood episode can prevent episodes from occurring and establish overall smoother management of the illness. The therapist can help the person analyse previous mood episodes, keep daily mood charts and use those logs to identify themes in triggers.
Lastly, psychotherapists will guide their patients and families to seek out the help of support groups for bipolar disorder. Sharing within these groups, where other members report similar experiences, can not only reduce shame and guilt but also offer a different perspective on coping.
Bipolar disorder is a complex condition, with a long and often uncomfortable ride for both the patient and their loved ones. Seeking the right professional help can help the person not only manage their illness well, but also motivate them to seek their highest potential, and live their life with dignity and satisfaction.