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Bipolar Disorder (Advances in Psychotherapy

The past 10 years have seen a dramatic increase of interest in psychosocial treatments of bipolar disorder. There is now substantial empirical evidence suggesting the effectiveness of such treatments. However, this accumulated information has not yet been transferred into clinical practice in many settings. Help is now at hand. This compact volume brings to the practitioner a comprehensive, evidence-based approach to the treatment of bipolar disorder that is practical and easily accessible, and can be readily applied in clinical practice. This practitioner's guide begins by describing the main features of bipolar disorder and considerations for differential diagnosis based on DSM-IV and ICD-10 criteria. Following this, current theories and models are described, along with decision trees for evaluating the best treatment options. The volume then guides the reader through a systematic, integrated approach to treatment, based on the best of recent research. The authors describe a structured directive therapy that is also collaborative and client centered. Special considerations, including managing suicide risk, substance misuse, and medication nonadherence, are addressed. The volume is rounded off by the inclusion of clinically oriented tools and sample forms. A comprehensive but compact and practice-orientated presentation of an effective approach to treatment of bipolar disorder, presenting the best from research for clinicians.
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Table of Contents

1.1 Terminology 1.2 Definition 1.2.1 Additional Considerations in the Classification and Diagnosis of Bipolar Disorders 1.2.2 Implications for Clinical Practice 1.3 Epidemiology 1.4 Course and Prognosis 1.5 Differential Diagnosis 1.5.1 Differential Diagnosis of Bipolar Disorders I and II Versus Major Depressive Disorders 1.5.2 Differential Diagnosis of Bipolar I Versus Bipolar II Disorder 1.5.3 Differential Diagnosis of Bipolar I Disorder Versus Psychotic Disorders (Schizoaffective Disorder, Schizophrenia, and Delusional Disorder) 1.5.4 Differential Diagnosis of Bipolar Disorder (Current Episode Manic or Mixed) Versus Substance-Induced Mood Disorder 1.5.5 Differential Diagnosis of Bipolar I and II Disorders Versus Borderline Personality Disorder 1.5.6 Differential Diagnosis of Bipolar Disorders I and II Versus Attention Deficit Disorders 1.5.7 Differential Diagnosis of Bipolar I and II Disorders Versus Antisocial Personality Disorder 1.6 Comorbidities 1.7 Diagnostic Procedures and Documentation 1.7.1 Tools to Assist in the Assessment of Bipolar Disorder: Mania 1.7.2 Tools to Assist in the Assessment of Bipolar Disorder: Depression 1.7.3 Taking a good history 2 Theories and Models of Bipolar Disorder 2.1 Biologically Based Disease Models 2.2 General Psychoeducation and Illness Management Strategies 2.3 The Interpersonal and Social Rhythm Hypothesis: Social Rhythm Disruption as a Potential Catalyst for Bipolar Episodes 2.4 Family-Based Treatment Approaches 2.5 Cognitive-Behavioral Treatment Approaches 2.5.1 Basco and Rush Cognitive-Behavioral treatment of Bipolar Disorder 2.5.2 Lam, Jones, Hayward, and Bright (1999): Identifying Prodromes of Illness 2.5.3 Other Cognitive Behavioral Treatment Strategies with Bipolar Disorder 3 Diagnosis and Treatment Indications 3.1 Decision Tree for Determining Optimal Treatments 3.2 Treatment Options 3.2.1 Treatment Options for Young Adult 3.2.2 Treatment Options for High Risk Presentation 3.2.3 Treatment Options for Repeated Episodes of Mania/Hypomania (see the case of Bill in Section 4.1.5) 3.2.4 Treatment Options for Persistent Subsyndromal Depression and Dysthmia (see the case of Tanya in Section 4.4.2) 4 Treatment 4.1 Methods of Treatment 4.1.1 Biological Approaches to Treatment of Bipolar Disorder 4.1.2 Psychosocial Approaches to Treatment of Bipolar Disorder: General Remarks 4.1.3 Overall Structure of the Course of Therapy 4.1.4 Initial Phase of Treatment: Orientation and Engagement 4.1.5 Middle Phase of Treatment: Skill Building - Filling up the Tool Box 4.1.6 Final Phase: How to Maintain Treatment Gains 4.2 Mechanisms of Action 4.2.1 Targeted Psychoeducation and Illness Management Strategies 4.2.2 Monitoring of Activities and Moods 4.2.3 Social Rhythm Disruption as a Catalyst for Bipolar Episodes 4.2.4 Family-Focused Treatment 4.2.5 Cognitive Behavioral Treatment Approaches 4.3 Efficacy and Prognosis 4.4 Variations and Combinations of Methods 4.4.1 Family-Based Treatment and Family Management 4.4.2. Self-Help Approaches Incorporating the Recovery Model 4.5 Problems in Carrying out the Treatment 4.5.1 Suicide Risk Assessment and Management 4.5.2 Improving Treatment Adherence 4.5.3 Treatment of Patients with Co-Occurring Substance Use Disorders 4.6 Summary 5 Further Reading 6 References 7 Appendix: Tools and Resources


"Patients with bipolar disorder can be very challenging, even to experienced therapists. This guide provides excellent advice for practicing clinicians to more fully understand, accurately diagnose, and effectively treat these patients, using approaches with demonstrated efficacy. Interesting clinical vignettes highlight essential principles and valuable worksheets and self-help resources extend the utility of the guide for clinicians and patients." Judith S. Beck, Ph.D. Director, Beck Institute for Cognitive Therapy and Research Clinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania President, Academy of Cognitive Therapy "The monograph...is a superb, succinct, scientifically accurate and balanced compendium of information about bipolar disorders and their management. The book fills a niche and a genuine need for a practical scientific review of the psychosocial management of this disabling illness. It is scholarly and yet very practical, including appropriate illustrative clinical vignettes and a number of pragmatic suggestions on how best to approach the psychosocial treatment of bipolar depression. It is well organized and useful, focusing on important issues like evaluating suicide risk and managing it, enhancing treatment adherence, controlling and managing co-occurring substance abuse disorders, as well as suggestions on how to improve the lives of both patients, their families and significant others. The organizational framework of Bipolar Disorder is excellent and it is formatted in such a way as to enhance learning. It is especially strong, in outlining and accurately analyzing the key, empirically proven, techniques of psychotherapy for patients with bipolar disorder along with specific suggestions on how these particular techniques can be applied. In my opinion, Bipolar Disorder is a must for clinicians interested in psychotherapeutic management from this illness. It is a very readable little gem, and I recommend it to interested clinicians without reservation." Lewis L. Judd, M.D. This is an exceptionally well-written and comprehensive book on bipolar disorder. The reader will find it an excellent reference for everyday clinical practice. **Purpose** The purpose is to present a series of evidence-based approaches to the treatment of bipolar disorder in an easy-to-read, practical manner. The book successfully discusses the challenges the practitioner faces in day-to-day practice. Considering the ever-changing state of the field, these are worthy objectives that are met by the authors. **Audience** Although written mainly for those psychiatrists and psychologists active in the mental health field, this book will be beneficial for graduate level students and residents. There is a multidisciplinary approach in the mental health field and as such, this book addresses those needs. The authors are highly credible and provide an interesting and enjoyable read. **Features** This is quite possibly the most thorough compact book on bipolar disorder. Case in point, the differential diagnosis of Bipolar I versus Bipolar II, Bipolar I and Bipolar II versus major depression, etc., is terrific. The various theories and models such as family-based and CBT are well covered. Treatment and treatment indications are practical, up-to-date, and cover such pertinent topics as suicide risk assessment and management, treatment adherence, and psychosocial stressors. **Assessment** This is definitely one of the standout books of the year in terms of additive value to the field, comprehensiveness, and applicability to the daily practice of clinicians. Highly recommended. Reviewed by Nicholas Greco IV, M.S., C.A.T.S.M., C.C.R.A.(Abbott Laboratories), published in Doody's Electronic Journal "In recent years, it has become increasingly clear that the longterm prognosis for those with bipolar affective disorder is far more serious then previously thought. Bipolar disorder was first differentiated from dementia praecox or schizophrenia by Kraepelin's meticulous record keeping that showed that some individuals with severe mental illness recovered (Mondimore, 2005). Those who did not recover were given the diagnosis of dementia praecox, and those who did recover were given the diagnosis of manic-depressive illness. The assumption was quickly made that the latter was a disorder with a better prognosis. This belief has persisted until recently. However, the high suicide rate, substance abuse comorbidity, health care costs, and relatively few symptom-free periods in the lifetimes of those with bipolar disorder has changed this perspective. Moreover, bipolar disorder was once thought to be rare (< one percent); however, recent studies have suggested rates as high as four percent. The recommended treatment is pharmacotherapy. However, the available treatment options are still few compared with other mental disorders. Clearly, psychotherapy alone is ineffectual, unlike depression and anxiety disorders where psychotherapy alone is at least as efficacious as pharmacotherapy. Unfortunately, most patients are noncompliant with medication, and most treatments are only partially effective, with breakthrough of mania or depression still being the rule. Consequently, psychotherapy can play an important adjunctive role in the management of this disorder. Robert P. Reiser and Larry W. Thompson are clearly aware of these issues and provide a brief but comprehensive review emphasizing the difficulty of diagnosing and treating this illness. A recurrent problem in the book is identifying the audience. The authors provide comprehensive but brief descriptions of key clinical issues, often with case vignettes, but the information is simply insufficient for the naive clinician to make use of it. Their discussion of diagnosing bipolar disorder illustrates this point. They recognize the difficulty in diagnosing bipolar disorder, noting that patients with this disorder are correctly diagnosed at first Bipolar Disorder by Robert P. Reiser and Larry W. Thompson Seattle, WA: Hogrefe & Huber, 2005. 112 pp. ISBN 0-88937-310-8. $24.95, paperback presentation less then half the time. Misdiagnosis clearly has a clinical impact. Bipolar patients are often misdiagnosed as having depression and treated with antidepressants, which often make the disorder worse. The authors provide the reader with criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994), but they are given verbatim. The authors also provide descriptions of various screening instruments. They provide a case vignette. They systematically go over the differential diagnosis between bipolar disorder and other psychiatric disorders. However, they do not emphasize the concept of bipolar spectrum disorder, which is gaining favor and helps to explain the symptom overlap with other disorders. Their differentials often gloss over key issues. They skip over such difficult issues as distinguishing hypomania and mania, a necessity to distinguishing bipolar II (hypomania, never mania, and major depression) from bipolar I (mania with or without major depression). They suggest using demographic differences between bipolar I and II, which is often not helpful for the individual patient. They distinguish borderline personality disorder from bipolar disorder by noting the enduring characteristics of personality disorders. They fail to note the significant symptom overlap and that others have suggested that borderline personality disorder may be part of the bipolar spectrum. They do note that screening tests alone will not work and that a comprehensive history and information gathering are necessary. Life charts, which are described in detail, are particularly useful. Reiser and Thompson very briefly note that ethnic minorities may be at greater risk of misdiagnosis and suggest that any ethnic differences in prevalence are a result of socioeconomic differences. In fact, this is a gross oversimplification and, in some respects, flat wrong (Lawson, 1996; Strakowski, Shelton, & Kolrener, 1993). Large-scale studies using structured interviews show no racial differences irrespective of socioeconomic status. Studies based on clinical judgment rather than structured interviews show lower rates of bipolar disorder for African Americans, primarily due to the almost twofold greater likelihood of misdiagnosis. Provider factors such as incomplete data or overemphasis on diagnosing psychotic individuals as schizophrenic and patient factors such as delay in treatment seeking and different idioms of distress are more important then socioeconomic status. The failure to provide more information on ethnicity and culture is especially disturbing as the country is rapidly moving to the point where ethnic minorities will make up more than 50 percent of the population. Models of bipolar disorder are discussed, and Reiser and Thompson rightly note that the stress diathesis model both dominates the thinking about the disorder and is a key determinant of many psychological interventions. Presumably, environmental stressors precipitate acute episodes of an illness that is biologically based. The model, however, does not address the reality that chronicity of symptoms, particularly depressive symptoms, dominates the illness. Treatment interventions must not only prevent manic and depressive episodes, they must also address the reality that most patients spend much of their time ill regardless of the therapeutic intervention. Strategies to cope with the chronic dysthymia or dysphoria have simply not been developed. Reiser and Thompson rightly note the importance of the biological model at the present time, particularly in pharmacotherapeutic treatment options. Little discussion is provided on the developing research in the genetics of bipolar disorder. Although the field has progressed such that candidate genes have been identified, they are probably correct in noting that this field of research has yet to influence treatment despite the strong evidence that bipolar disorder has probably the greatest heritability of any psychiatric disorder. This section will not be useful to the prescriber as there are minor errors and the field is fast moving, with limited prescribing guidelines. The authors make a strong argument for the importance of psychotherapeutic interventions, given the limited positive outcomes of pharmacotherapy alone. Their description of psychoeducation and its importance in medication compliance is one of the book's strongest sections. Many bipolar patients simply will not take their medication, regardless of efficacy, treatment guidelines, diagnostic accuracy, or ability to prevent future illness episodes. Psychoeducation as a tool for maintaining adherence and compliance should therefore be indispensable in a comprehensive treatment program. The authors miss an excellent opportunity to discuss the issue of medication side effects, a major factor in compliance. Behavioral interventions to address side effects such as weight gain, a recently recognized feature of most antimanic agents, could play a major role in treatment adherence. The strength of the book is its categorization of psychotherapeutic and psychoeducational approaches, rare in a disorder linked so strongly to a biological conceptualization. The authors make a strong case for the use of adjunctive psychotherapy in bipolar disorder and present an encyclopedic description of various approaches. Clearly, they are not simply interested in presenting a taxonomy of treatment, but unfortunately that is what emerges. They also clearly want this book to function as a treatment manual, providing case reports, step-by-step instructions for diagnosis, and some therapies. An audience of practitioners new to treating this disorder would not be helped by the lack of any attempt to prioritize or provide selection criteria for these treatments. One important problem that dampens enthusiasm is that, although every attempt is made to provide information for the provider with no prior experience, the brevity of much of the information presupposes some knowledge of treatment of the illness. The academician would find the treatment descriptions useful. The uncritical presentation of much of the information and cursory review of the research do not make it helpful to the knowledgeable researcher. The authors cannot be wholly faulted; most of the psychotherapeutic research is designed to demonstrate the validity of the approaches. Psychotherapy studies are often designed to demonstrate the approach studied is value added to pharmacotherapy. The field is simply not at a place yet where therapeutic approaches can be compared and guidelines can be developed. Moreover, Reiser and Thompson note, I think late in the book, that treatment guidelines are currently in flux and limited to pharmacotherapy. Early on, they provide an excellent chapter on comorbidities, which are almost the rule in bipolar disorder. They say little about the use of established psychotherapies in treating comorbidities such as anxiety disorders and substance abuse. This is unfortunate because half of these patients may have comorbid substance abuse; almost a third, comorbid anxiety disorders. This book provides a useful overview of bipolar disorder that encompasses the epidemiology, growing awareness of the impact of the disorder on individual and societal suffering, and the different psychoeducational and psychotherapeutic interventions that have been developed to treat this disorder. The authors have necessarily provided oversimplified and superficial descriptions of key issues and therapeutic approaches for brevity and perhaps to expand the readership. They also provide overviews of the diagnostic process, models of illness, and treatment approaches with useful tools for the experienced clinician. The book's strength is its review of psychotherapy, whose place in treatment guidelines still awaits additional research." Reviewed by William B. Lawson in Contemporary Psychology APA Review of Books PsycCRITIQUES August 30, 2006 Vol. 51 (35), Article 11 1554-0138 (c) 2006 by the American Psychological Association

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