_for bipolar disorder心理治疗双相情感障碍（ppt62）课件

Psychotherapy For Psychotherapy For Bipolar DisorderBipolar Disorder Brooke Tompkins Overview Bipolar Diagnoses History and Facts Etiology Cognitive-Behavior Therapy Interpersonal and Social Rhythm Therapy Empirical Support DSM-IV Diagnoses DSM-IV Manic Episode Abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). Three (or more) of the following symptoms have persisted (four if the mood is only irritable): inflated self-esteem decreased need for sleep pressured speech flight of ideas or racing thoughts distractibility increase in goal-directed activity increased involvement in pleasurable activities with a high potential for negative consequences DSM-IV Major Depressive Episode Five (or more) of the following symptoms have been present during the same 2-week period; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. depressed mood most of the day, nearly every day. Note: In children and adolescents, can be irritable mood. lost of interest or pleasure in activities significant weight loss or weight gain insomnia or hypersomnia psychomotor agitation or retardation fatigue or loss of energy feelings of worthlessness diminished ability to think or concentrate suicidal ideation DSM-IV Mixed Episode Symptoms of a Manic Episode and a Major Depressive Episode nearly every day during at least a 1-week period. cause marked impairment DSM-IV Hypomanic Episode Elevated, expansive, or irritable mood, lasting at least 4 days, that is clearly different from the usual non- depressed mood. Three (or more) of the symptoms of a manic episode have persisted (four if the mood is only irritable). The episode is uncharacteristic of the person when not symptomatic. Observable by others. Does not cause marked impairment in social or occupational functioning, and does not necessitate hospitalization. DSM-IV Bipolar Disorder Bipolar Disorder I At least one manic or mixed episode (lasting for at least a week) within his or her lifetime. A depressive episode is not a diagnostic criteria Bipolar Disorder II At least one episode of hypomania at least one episode of depression Rapid Cycling 4 or more episodes in a year Bipolar NOS DSM-IV Cyclothymic Disorder For at least 2 years hypomanic symptoms depressive symptoms Not without symptoms for more than 2 months at a time. Prevalence and Comorbidity Lifetime prevalence: 0.8-1.6% Current point prevalence 18+ (NIMH) = 2.6% Median age of onset: Late adolescence, early 20s Rate among adolescents is increasing (estimate of 1%) Comorbidities 50% with alcohol or substance abuse disorders 60% with anxiety disorders (Panic Disorder Rush et al., 1986) Bech-Rafaelsen Mania Scale (Bech et al., 1979) Young Mania Rating Scale (YMRS; Young et al. 1978) Manic State Rating Scale (Beigel, Murphy, & Bunney, 1971) Assess medication compliance Assess for suicide! Focuses on the cycle of reactions to symptoms that impair functioning, cause psychosocial problems, and increase stress Cognitive Behavior Therapy Cognitive-Behavioral Process Psychoeducation Reactive Symptom Management Symptom Monitoring/Develop Early Warning System Adherence to Treatments Symptom Control (CBT and cognitive strategies) Reducing Stress qGenerally around 12-20 sessions Every Session Collaborative agenda setting Mood and medication assessment Review homework Setting goals and priorities for session Assigning new homework Final summary and feedback Psychoeducation Explain disorder and role of cognition BD runs in families Involves biochemical problems that can cause symptoms such as anger, impulsivity, depression, suicidality, exuberance, hypersexuality, and a false sense of invinciblity “Diathesis-stress” disorder - biological problem interacts with stress Can be dangerous to health, relationships, occupational success, etc. Much due to “cognitive triad” Explain negative explanatory style Can be treated with both medication and psychotherapy Psychoeducation Explain purpose of CBT treatments Learn to adopt constructive outlook on life Problem-solving Improve quality of life Ease of medication adherence Less likelihood of relapse Introduce importance of homework Can assign reading materials for homework Finding Peace of Mind: Treatment Strategies for Depression and Bipolar Disorder Bipolar Disorder Psychoeducation Knowledge of medication and adherence Why medication is used Side effects Mood stabilizing vs. antidepressant Expected outcome Long-term issues with management Why psychotherapy is needed in addition Identify issues to discuss with physicians Provide readings Managing Hypomanic/Manic Symptoms Recognize warning signs Interventions and Rules: Medical solutions first Two-person feedback rule for “great ideas” Limit cash payments To counteract impulsivity: Give car keys or credit cards to someone to keep Rules about staying out late or giving out phone # Avoid alcohol and substance use minimize stimulation 48-hours before acting rule * Treatment Contract Managing Hypomanic/Manic Symptoms Interventions (contd) Imagery about worst-case scenarios Relaxation techniques Diaphragmatic breathing PMR Address wish to stay manic: They will feel more creative, productive, attractive, etc. Remind them that some of the worst events in their life have happened during manic episode Ultimately, decisions will lead to more disruption Symptom Monitoring Identify how day-to-day experiences are related to symptoms of bipolar disorder Ask how illness has affected their lives and home environment Complete Symptom Summary Worksheet List of symptoms Circle what they experience in episode Circle what they experience when normal Homework: Provide copies for patient to add symptoms throughout the week Teach patient to monitor key symptoms, such as changes in mood Review Mood Graph in session, complete for yesterday and today Homework: Keep mood graphs. Remember to always address homework at beginning of the next session Development of Early Warning System Complete Life Chart Reference line that represents a normal/euthymic state Draw episodes of mania, depression, and mixed states on timeline Draw first episode together, they complete the rest Can consult with family members, medical records, etc. Include types and dates of received treatment Development of Early Warning System Develop early warning system Distinguish between “normal” and “abnormal” mood shifts Using Symptom Summary Worksheet and Life Chart Make detailed descriptions of patient in normal and episodic states Descriptions used by patient, family members, can call therapist and review *use mood graphs Treatment Adherence Introduce CBT model of adherence Noncompliance is the norm, not the exception Illness interferes with adherence New conceptualization of adherence: Waxes and wanes over time Difficulties from family, differing opinions, anger at some medications not working, etc. Strategies to reform opinion on illness, medications, and necessity of treatment Compliance Contracts Assessment and Goals Review dosing schedules Review appointment plans Goals for homework assignments Identify Obstacles Intrapersonal Treatment Social system Interpersonal Cognitive Make plan for overcoming obstacles Ask about past successful strategies Make a plan Periodically review and modify if necessary Example Compliance Contract Step 1: Treatment Plan I, patient name, plan to follow the treatment plans listed below: Take 900 mg of lithium at bedtime. Take 4 mg of Ambien to help me sleep. See the doctor every month and call if I think the regimen needs to be changed. Step 2: Compliance Obstacles I anticipate these problems in following my treatment plan: If I continue to gain weight with lithium I may want to stop taking it. The Ambien might stop working and Ill need something stronger. When I get home late Im too tired to go to the kitchen to take my pills. Example Compliance Contract Step 3: Plan for reducing obstacles To overcome these obstacles, I plan to do the following: Join Weight Watchers. Start walking in my neighborhood. Improve sleep by not drinking coffee or other caffeinated beverages after 4 pm. Keep the evening dose at the bedside with a bottle of water. CBT Strategies for Symptom Control - Manic Goal: Testing Reality of Thoughts and Beliefs Discuss typical hypomanic cognitive errors overreliance on luck underestimating risk of danger overestimating capabilities disqualifying negative, minimization of lifes problems overvaluing immediate gratification misinterpreting intentions of others Discuss automatic thoughts and distorted cognitions If difficult to identify, describe general impressions and images until they can identify beliefs, themes, concerns Use Automatic Thought Records CBT Strategies for Symptom Control - Manic Alert them to the impact the thought has on their mood state Use behavioral experiments to test thought Consult with trusted others Examine evidence List evidence for/against Alternative explanations Cognitive restructuring to evaluate thoughts Homework: Keeping Automatic Thought Records. CBT Strategies for Symptom Control - Manic Goal: Modifying Behavioral Symptoms Negative Imagery Activity Scheduling “A” and “B” lists Plan activities ahead of time Can make a Daily Activity Schedule Increasing sitting and listening Sit when they notice they are speaking or moving rapidly in social situations interrupts acceleration of motor activity Focus on listening to others use self-statement prompts if needed “Pay attention. Listen to name of person.” Advantages/disadvantages technique Advantages/Disadvantages Technique Stay at Current JobChange Jobs Advantag es Its close to home *Good secretary *I know everybody *Can make more money Larger office *More independence Get away from boss Disadvant ages Business has been poor *Stuck with current boss *No raise this year Bad neighborhood No room for creativity The work schedule may require weekend work *May have to move family New boss could be a jerk CBT Strategies for Symptom Control - Manic Stimulus Control Knowing what activities to avoid Alcohol or other substances Unsupervised spending of large amounts of money Daredevil hobbies Exaggerated generosity or friendliness with strangers Activities using a lethal weapon Consulting with others Feedback CBT for Symptom Control Manic & Depressive Sleep Enhancement Be consistent Its a nighttime thing Keep your bed a place for sleep Get comfortable Gear down for the night Avoid stimulants that might keep you awake Dont do: Caffeine Internet TV and books Chores Exercise CBT Strategies for Symptom Control - Depression Goal: Testing reality of negative thoughts Identification of Negative Automatic Thoughts Automatic Thought Record “Evidence for/evidence against” technique Alternative Explanations Patient chooses explanation that seems most likely Reframe thoughts of suicide Have them write down reasons to live Homework: Keep Automatic Thought Records. CBT Strategies for Symptom Control - Depression Goal: Increase behavior Discuss behavioral aspects of depression Normalize feeling overwhelmed and overloaded How have they coped with it in the past? Graded Task Assignment List all tasks that require attention Divide tasks into smaller steps Devise plan to guide patient from one step to the next “A” and “B” lists to help choose important tasks CBT Strategies for Symptom Control - Depression Goal: Increase behavior (contd) Increasing Mastery and Pleasure Discuss rationale for activity scheduling: breaks cycle of hopelessness natural antidepressant effects in contact with others increase self-efficacy positive outcomes CBT Strategies for Symptom Control - Depression Adding Positives Select a healthy habit to improve Ex: healthy eating Start one new behavior that gets them closer to goal Ex: eat breakfast in morning Select one problematic behavior to stop Ex: Stop eating late at night Decision-Making Decision Making and Thought Processes Schedule time at end of day to review the day At least 1 hour before bedtime Not in bed Review the day and take notes on events that were troublesome or require more thought Things to do the next day Conversations Disappointments, worries For each item, note what needs to be done to rectify issue At bedtime, instead of ruminating, remind self that day has already been reviewed Decision-Making Decision Making using Advantages/Disadvantages Provides structure Can compare choices relative to one another Consider maximizing advantages of each choice while minimizing disadvantages Problem-Solving Problem identification and definition State problem as clearly as possible Generation of potential solutions List all possible solutions regardless of feasibility Eliminate less desirable or unreasonable choices Order in terms of preference Pros and cons Specify how and when solution is implemented Problem-Solving Implement Solution Implement as planned Evaluate effectiveness Decide whether a revision is needed or a new plan to address problem better Or return to step #2 and select new solution Ask questions to facilitate problem definition Reducing Stress Acute Stress Management Inquire about past coping methods YOU have faith in their ability to cope Relaxation training Stress Control and Problem Solving Cues to stress Internal and external Physical Emotional shifts Input from others Reducing Stress Stress Control and Problem Solving (contd) Proactive Scheduled Assessment Ex: scheduling times to address progress and problems with spouse every 3-6 months Predictable times of change and stress Stress Prevention Activity scheduling Track activities for a week, rank for pleasure and accomplishment Schedule activities high in these areas Important to know limits Lifestyle choices and limit setting Combines IPT for unipolar depression with behavioral strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence. Interpersonal and Social Rhythm Therapy Initial Phase Psychiatric and medical history Events leading up to current and previous episodes Evidence of alterations or disruptions in routine or interpersonal interactions Interpersonal inventory Review of all important past and present relationships Life circumstances Quality of relationships Listen for omissions/disruptions Initial Phase Education on disorder Symptoms Medications Side effects, etc. Role of circadian rhythm and rhythm disruption in disorder Interpersonal and Social Rhythm Therapy, Frank et al. (2000) Social Rhythm Metric (SRM) Record daily activities How stimulating activities were Daily mood Intermediate Phase Social rhythm strategies Review first 3-4 weeks of SRMs to find rhythms that seem unstable Ex: sleep patterns Encourage to work toward stabilization Make goals for recovery/regulating rhythms Graded Range from short-term, intermediate, long-term Also examine larger environmental stressors Learn to adapt to changes in routine At some point, patient will question the need for stability Intermediate Phase Interpersonal strategies Identify problem area (grief, interpersonal role disputes, role transition, interpersonal deficits) Address the problem area Attend to its role in promoting or disrupting social regularity Ex: loss of a loved one causes a disruption in social routine Ex: fights with spouse lead to less sleep Preventative Phase Decreases from weekly to monthly sessions Can last 2 or more years Continue evaluating what works