Psychotherapy Brown Bag

The relationship between antiepileptic drugs and suicide attempts in bipolar disorder

by Joye C. Anestis

Ok, prepare yourself for this one...the article was hard for me to get through, making it even harder to translate into non-scientific jargon.  Medical journals, as opposed to psychology journals, like to make things difficult. 

Bipolar disorder is a difficult illness to live with.  Among the many difficulties faced by those with this illness is usually a lifetime of medication management.  Psychotherapy has been shown to be a useful adjunct to pharmacotherapy, but pharmacological treatment is considered the front-line for bipolar disorder. The most common is lithium, but some alternative medications have been identified as useful in managing bipolar disorder.  Specifically, antiepileptic medications are commonly prescribed (on a side note, antiepileptic meds are also commonly prescribed for borderline personality disorder).  As you can guess from their name, this class of drugs was originally developed to control seizures in individuals with epilepsy but they also have mood stabilizing effects. 

Recently, the Food & Drug Administration (FDA) has questioned the safety of these drugs in regard to suicidality.  They conducted a meta-analysis of placebo-controlled trials of 11 antiepileptic drugs (AEDs)  - importantly, this meta-analysis examined AED use for any reason, not just psychiatric ones.  Results revealed that 0.43% of those treated with AEDs reported suicidal behavior or ideation compared to 0.22% of patients in placebo groups.  On January 31, 2008, the FDA issued an alert to healthcare providers about an increase risk for suicidal behavior and ideation with AEDs, and on July 10, 2008, the FDA's scientific advisory committee voted that there was a significant association between suicide and AEDs but voted against a black box warning similar to the one found on antidepressant labels(click here for the FDAs webpage on this topic).

Obviously, increased risk of suicide is always concerning, especially when the risk concerns a population already at elevated risk of suicidality.  Without treatment, an estimated 10 per 1000 individuals with bipolar disorder complete suicide annually and 40 per 1000 attempt suicide (Baldessarini et al., 2006).  Risk of completed suicide and suicide attempt in bipolar disorder are 100-fold and 10-fold higher, respectively, than the risk of the general population.  So it's important to determine if AEDs specifically affect suicide risk in bipolar disorder...it would be troubling to discover that the primary treatment for an illness made those taking it less safe! 

A new study by Gibbons, Hur, Brown, & Mann (2009) in Archives of General Psychiatry investigated this very topic and attempted to correct some of the methodological problems found in the FDAs study and other studies on this topic.  Gibbons et al. obtained data from a large database of longitudinal medical claims data, representing over 47 million people.  All individuals with a diagnosis of bipolar disorder who were enrolled in the same healthcare plan for 1 year before and after the index diagnosis data were included  (i.e., they included everyone with the diagnoses continuous data pre- and post-treatment data).  47,918 patient met these criteria, and 1,226 of them had at least one suicide attempt.  Analyses were restricted to AED monotherapy, which they defined as taking only 1 of the 11 AEDs in the year following diagnosis and not taking lithium.  Other psychiatric medications were included as covariates in the analyses, including concomitant antidepressant, other antiepileptic, antipsychotic use or lithium monotherapy - meaning they could statistically remove the effects from these other treatments in order to examine findings for just the AEDs.  For comparison groups, the researchers identified a group of patients who received none of the 11 AEDs or lithium in the year following diagnosis and a group of patients who received no central nervous system (CNS) medication.

Interestingly, the results explicitly contradict the FDA warnings.  Gibbons et al. did a lot of complicated analyses, and I've reported just the primary ones below.  Please refer back to the original article for more details.  But overall they found:

• After treatment, there was no significant difference in suicide attempt rates for those treated with an AED and those received no AED or lithium.
• When each individual AED was examined, similar findings appeared with 2 exceptions, topiramate and carbamazepine, which had significantly greater post-treatment risk than no treatment.
• A small but significant increase was found with lithium compared with no treatment.  Overall, AEDs were associated with lower suicide attempts than lithium.
• When they did within-subjects comparisons, rate of suicide attempt was significantly greater prior to any AED treatment than after.  Similar reductions were found for the individual AEDs and lithium, except for topiramate and carbamazepine.  Also, interestingly, the pretreatment suicide attempt rate was significantly higher for the group that ultimately received an AED than the no-treatment suicide attempt rate, indicating the the AED group was potentially more impaired prior to treatment.
• Suicide attempt rate for patients not treated with any CNS drug was significantly higher than those who received an AED only.
• Sensitivity analyses revealed that these effects were maintained for the duration of treatment.  They were also found when looking at single attempters and multiple attempters.

So, in sum, it appears that AEDs are not associated with increased suicide attempt risk in folks with bipolar disorder.  Certainly, a number of limitations exist in the present study, including the use of medical claims data which likely underreport suicide attempts, no information on completed suicides (just attempts), no data on intensity of treatment, lack of random assignment to treatment, reliance on diagnoses from the database and not from structured interviews, no consideration of treatment adherence, and the fact that patients could have had a concomitant illness (such as epilepsy) for which the AED was prescribed.  Despite all of this, it is remarkable that the AED group had such higher rates of suicide attempts prior to treatment and still achieved lower rates post-treatment, compared to the control groups.  Hopefully, the FDA will consider these findings, and any future data that may emerge on this topic, as they issue warnings.  

For more information on suicide and bipolar disorder, check out our online bookstore.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Borderline personality disorder and bipolar spectrum disorders: How are they different?

by Michael D. Anestis, M.S.

Borderline personality disorder (BPD) and bipolar spectrum disorders (e.g., bipolar I, bipolar II, cyclothymia) have both been fairly common topics on PBB.  Both disorders are characterized by fluctuating emotions and problematic behaviors and both exhibit highly elevated suicide rates.  That being said, ever since BPD was added to the DSM, there have been a number of individuals who have questioned whether it simply represents another form of bipolar disorder.  Although many researchers have demonstrated that there are profound differences in important variables such as family histories, treatment responses, and longitudinal course between BPD and bipolar spectrum disorders and subsequently concluded that they are distinct from one another (e.g., Paris, 2004), others have pointed to individual similarities, such as the fact that both show relatively positive responses to mood stabilizing medications as justification for assuming that they are the same underlying phenomenon (e.g., Smith, Muir, & Blackwood, 2004).  Today, I would like to give a clear definition of each of these disorders and provide a solid - although by no means comprehensive - summary of the evidence for these positions.

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The following descriptions detail the diagnostic criteria for each of the disorders in question:

Borderline Personality Disorder

In order to meet diagnostic criteria for BPD, a client must exhibit five of the following nine symptoms and this pattern must represent a pervasive pattern in that individual's life (APA, 2000).  Note that, while personality disorders can fluctuate with respect to how severe they are from time to time, they are theorized to be much more stable and consistent than are symptoms of Axis I disorder (e.g., depression).

1. Frantic efforts to avoid real or imagined abandonment
2. Unstable interpersonal relationships characterized by fluctuations between adoring and devaluing significant others
3. Identity disturbance (e.g., who the person is depends upon who they are around)
4. Impulsivity in at least two areas (e.g., binge eating, spending money, risky sexual behavior, aggression, substance use) *do not include self-injury in this symptom*
5. Recurrent suicidal behavior or non-suicidal self-injury (NSSI)
6. Affective instability or extreme emotional reactivity - usually lasting only a few hours for any given mood and rarely more than a day
7. Chronic feelings of emptiness
8. Inappropriate, intense anger and/or difficulty controlling anger
9. Temporary stress-induced paranoia or dissociation

Bipolar I

1. Presence or history of a full manic episode

Note that a depressive episode is not required for this diagnosis.  Once an individual has had a full manic episode, they meet criteria for bipolar I.  Depressive episodes are common, but not required for the diagnosis.

Bipolar II

1. Presence or history of at least one major depressive episode
2. Presence or history of at least one hypomanic episode

Note that there are other requirements regarding the timing of the onset of various phases that are not included in this description but are available through the DSM-IV-TR, which can be found at Psychiatry Online.  Also note that, while it is possible to go from having a bipolar II diagnosis to a bipolar I diagnosis, the opposite pattern is not possible.

Cyclothymia

1. Prominent and persistent disturbance in mood characterized by either a depressed mood or an elevated, expansive, irritable mood.  In other words, fluctuations between sub-threshold depression and hypomania.

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So, looking over all of these criteria, BPD and bipolar spectrum disorders clearly share an element of mood difficulties and behavioral problems.  This, quite obviously, makes for a bit of a confusing picture.  That being said, the confusion is easily clarified through a better understanding of the words "mania" and "hypomania." 

A full manic episode, as defined by the DSM, involves a "distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week." 

A hypomanic episode is defined as "a distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least four days, that is clearly different from the usual non-depressed mood."

In other words, whereas BPD is characterized by moods that shift from moment to moment, with a particular mood rarely lasting more than a few hours, bipolar spectrum disorders are characterized by mood phases, each of which tends to last at least a week (or four days in the case of hypomania).  So, while an individual with BPD might experience emotions that are unpredictable from one moment to the next, an individual with a bipolar spectrum disorder is unlikely to repeatedly jump from elated to depressed in such a short period of time.  Both situations involve an emotional roller coaster, but for BPD, the ups and downs are more frequent.

Another important distinction to make is the difference between happiness and mania or hypomania. Individuals who are manic often report a decreased need for sleep.  They believe they are capable of accomplishing incredible things without any training (e.g., suddenly writing the Great American Novel or uncovering previously unknown principles of physics) and take on projects at odd hours that, once the episode ends, seem bizarre even to the person him or herself (e.g., painting the outside of a house in the middle of the night).  While the individual is manic, he or she typically enjoys the experience; however, once the episode ends and the consequences are more apparent, the entire experience seems much more aversive.  For individuals with BPD, there is no real parallel.  They certainly engage in problematic, impulsive behaviors, but these are most often utilized in response to negative emotions and represent an effort to regulate emotions (see our previous articles on non-suicidal self-injury for an example).

Although I hope these descriptions have been helpful, I do not believe that on their own they represent sufficient evidence to support the idea that BPD and bipolar spectrum disorders are distinct from one another.  Empirical evidence is much more compelling.  That being said, what does the research tell us?

In 2006, Franco Benazzi examined the similarities between BPD symptoms and Bipolar II symptoms in an outpatient psychiatric private practice.  Diagnoses were assessed through structured clinical interviews, thereby ensuring maximum validity and reliability in diagnostics.  Benazzi (2006) found that, while the emotional symptoms of BPD mirrored those of bipolar II, the impulsive behaviors in BPD showed no relationship to bipolar II.  

Also in 2006, John Gunderson and colleagues found that, while a greater number of individuals with BPD also had a bipolar spectrum disorder (19.4%) than did individuals with other personality disorders and a higher percentage of individuals with BPD experienced now onsets of bipolar spectrum disorders (8.2%) relative to individuals with other personality disorders over the subsequent four year, the actual association between BPD and bipolar spectrum disorders was modest at best.  In other words, many mental illnesses frequently co-occur, but this does not make them the same thing or even necessarily variants of one another. 

In 2007, Paris, Gunderson, and Weinberg reviewed the literature to determine whether or not BPD should be subsumed under the bipolar disorder category.  Like other studies already mentioned, they found that, while there is some overlap in important characteristics, the relationship between the two is neither consistent nor specific.  Individuals, to some degree, respond differently to different treatments, and the differences in the nature of their mood and behavior problems are substantial.

So, not only can distinctions be made by simply looking at the diagnostic criteria outline in the DSM, but empirical research has come to support the idea that these two phenomena are, in fact, distinct from one another.

Some of you might be wondering whether this distinction is really all that important.  In other words, does it matter that BPD and bipolar spectrum disorders are distinct from one another.  To some degree, I can see the argument that this is just an academic issue - the kind of thing that nerds like myself care about deeply but which matter little to people who do not spend much of their lives treating clients and reading psychology journals.  That being said, let me take a quick moment to explain why I think this is important.  As I have said in other articles on the topic of diagnoses, a proper understanding of mental illness is vital.  Different diagnoses respond differently to different treatments.  Although BPD shows relatively strong responses to mood stabilizing medications and there is preliminary evidence that dialectical behavior therapy (DBT) can be helpful in the treatment of bipolar disorder (Goldstein, Axelson, Birmaher, & Brent, 2007), these disorders do, in fact, respond differently to different treatments.  As a result, assuming that they are the same can cloud treatment decisions.  Additionally, if we made mistakes about the basic nature of a disorder, we are less likely to get the details correct.  In other words, if we can not even fully grasp the fundamental nature of a diagnosis, we are highly unlikely to develop a precise understanding of the more complex components and, as a result, we are unlikely to develop better treatments in the future.  Accuracy is important.  Just as a repeated small error on your paycheck can add up over an extended period of time to cost you a lot of money, errors on abstract concepts like this can keep both researchers and clinicians from maximizing their potential and can set our understanding of mental illness back extensively.

If you would like to learn more about borderline personality disorder and bipolar spectrum disorders, we recommend the following resources, all of which are available through our online store:

• Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan

• Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan

• Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda Dimeff and Kelly Koerner

• Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition by Monica Ramirez Basco and John Rush

• Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy by Ellen Frank

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Negative family interactions impact relapse rates in bipolar disorder: Defining "expressed emotion" and attempting to reduce its occurrence

by Michael D. Anestis, M.S.

Few people would disagree that living with bipolar disorder is extremely difficult.  Even though most individuals experience manic episodes as exhilarating while they last, the repercussions of these episodes tend to result in extremely negative emotions and significant problems once the mania recedes.  Additionally, the depressive episodes experienced by many bipolar individuals can be debilitating and dangerous.  That being said, less attention is generally paid to the fact that living with somebody else who has bipolar disorder is also a difficult experience.  For the spouses and families of an individual with bipolar disorder, the consequences of bipolar symptoms can be painful, costly, and disheartening.  Some individuals are able to maintain a positive outlook in such situations and remain close to their ailing loved one.  Others, however, find such outcomes more difficult to attain.

One of the most important variables to consider when discussing the relationship between a mentally ill individual and his or her loved ones is expressed emotion (EE).  EE is defined as critical, hostile, or emotionally overinvolved attitudes towards and interactions with a relative diagnosed with a mental illness (Hooley, Rosen, & Richters, 1995).  This definition is admittedly broad; however, a substantial amount of research has been conducted on EE and results have consistently indicated that high levels of EE predict poorer outcomes for a host of mental illnesses, including schizophrenia and mood disorders (Barrowclough & Hooley, 2003; Butzlaff & Hooley, 1998).  In other words, the more critical family members are towards a mentally ill relative, the more likely that individual is to relapse and exhibit a negative outcome. 

With respect to bipolar disorder, EE has been shown to be unrelated to manic relapse, but significantly related to depressive relapse.  In fact, even when controlling for symptom severity, high levels of EE predicted a five-fold increase in the likelihood of depression relapse in individuals with bipolar disorder (Yan, Hammen, Cohen, Daley, & Henry, 2004).  So, while EE does not appear to have any impact on manic episodes, high levels of EE in family members predicts subsequent relapses of depression for individuals with bipolar disorder.

In 2008, Lori Eisner and Sheri Johnson of the University of Miami published a study in Behavior Therapy that looked at the utility of an intervention aimed at reducing EE in individuals with a family member diagnosed with bipolar disorder.  They noted that, despite the negative outcomes associated with EE, it persists in large part due to prominent misconceptions regarding the nature of mental illness in general and disorders such as bipolar disorder in particular.  Individuals with high levels of EE tend to believe that the symptoms of mental illness are within the control of the mentally ill individuals (Barrowclough, Johnston, & Tarrier, 1994) and, as such, become highly angered when their loved one fails to prevent him or herself from exhibiting those symptoms.  This viewpoint leads the high EE individual to make frequent judgmental, critical comments to the loved one and to become emotionally overinvolved in their loved one's life. 

Eisner and Johnson further noted that prior attempts to develop interventions based on psychoeducation have succeeded in increasing relatives' understanding of mental illness, but have failed to actually reduce EE (Fristad et al., 2003; Simoneau et al., 1999).  As such, their goal was to create an alternative approach that not only emphasized psychoeducation, but also sought to diminish EE directly by teaching high EE individuals acceptance skills capable of disarming the intense surges of emotions that likely lead to critical comments and interactions.  The authors based this component of their intervention on Christensen and Jacobson's (2000) integrative behavioral couple therapy (IBCT), which works to reduce bitter interactions between romantic couples.

The study sample consisted of 42 adults from 32 different families.  All participants had at least one relative who had a lifetime history of at least one full manic episode as determined through a semi-structured diagnostic interview (SCID-IV; First, Spitzer, Gibbon, & Williams, 1997).  Participants had the option of attending one full-day seminar (9am - 4pm) or two evening seminars (5:30pm - 9pm).  Only the family members themselves attended the workshop(s).  The family members with a history of manic episodes did not attend, as prior research has indicated that this can have negative effects on participants' willingness to openly share information and engage in the treatment (Reilly, Rorbaugh, & Lackner, 1988).  The intervention itself consisted of modules focusing on the following material:

• Providing education on the nature of bipolar disorder
• Helping family members understand and contextualize the responses of their relatives
• Addressing the impact of criticism on the course of bipolar disorder
• Defining acceptance and discussing its relevance to bipolar disorder
• Discussing ways to implement acceptance in their lives and practicing these skills in session

The rationale for this study was strong and the intervention itself seemed promising; however, the results were not consistent with what the authors anticipated.  In the end, the clients were very happy with the intervention and exhibited an increased knowledge regarding bipolar disorder.  The intervention was less successful in its other aims though, as levels of anger and criticism did not decrease post-treatment.  Unfortunately, this is consistent with prior work and seems to indicate that EE is very difficult to change.  Obviously, given the strong negative impact of EE on the course of bipolar disorder and other mental illnesses, it is pivotal that other researchers and clinicians work to develop empirically supported interventions capable of actually reducing EE.  Given that the entire treatment consisted of either one full day or two half-day sessions, the brevity of the intervention may have had an impact on the outcome.  Perhaps if the intervention included brief follow-up sessions in which the participants could problem solve regarding areas in which they have had a difficult time integrating material into their daily lives, the treatment would be more effective.

So what does all of this mean?  First of all, the anger, frustration, and sense of being overwhelmed experienced by individuals with relatives diagnosed with bipolar disorder is entirely understandable.  The research on EE is not blaming family members for their loved ones' illnesses nor are they saying that they are not entitled to their feelings.  Instead, the research on EE simply tells us that frequent critical, harsh interactions with individuals diagnosed with mental illnesses can have a highly negative impact on outcomes.  Consequently, maintaining the viewpoint that mentally ill individuals have complete control over their symptoms seems counterproductive and unlikely to result in desired outcomes.  Whether or not an individual wants harsh criticism to be effective in changing behaviors, the evidence indicates that it is not.  The acceptance-based approach tested by Eisner and Johnson (2008) seems philosophically appealing; however, the results of their study indicated that is not an effective solution either, at least as the intervention is currently packaged. 

If you would like to learn more about expressed emotion or other relevant topics, we encourage you to consult our online store, which provides a long list of resources based on rigorous scientific studies.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

When feeling good can be bad: The influence of positive emotions on symptom severity in bipolar spectrum disorders

by Michael D. Anestis, M.S.

For most individuals with a bipolar spectrum disorder (e.g., bipolar I, bipolar II, cyclothymia), life is experienced as a series of shifts between three phases: depression, mania/hypomania, and euthymia, a period during which the individual is relatively symptom free.  The question however, is not necessarily what an individual with a bipolar spectrum disorder's symptoms will be, but rather how to predict when those symptoms become more likely to emerge.  In a study recently published in the journal Bipolar Disorders, June Gruber and colleagues (2009) attempted to provide some clarity on this topic.

Building off prior work they had conducted in this area, the authors wanted to examine the role of positive emotions in predicting depressive and manic symptoms in a sample of individuals diagnosed with but recovered from a bipolar spectrum disorder (BD) relative to a sample of nonclinical controls (NC).  Prior studies using both self-report measures and physiological measures (e.g., vagal tone) have demonstrated that individuals with BD exhibit higher average levels of positive emotionality (Johnson, Gruber, & Eisner, 2007; Johnson, Ruggero, & Carver, 2005; Sutton & Johnson, 2002).  In this particular study, however, the authors sought to expand upon this point by looking at specific positive emotions as predictors.

Gruber and colleagues (2009) noted that, in prior work examining the relationship between positive emotions and BD, researchers had only considered "happiness" and "positivity," broad constructs that do not differentiate between the potentially varied roles of different positive affective states.  As such, the authors decided to examine four specific positive emotions with a history of prior research (pride, compassion, happiness/joy, and amusement) and three specific positive emotions with less of a research history (love, awe, and contentment).  The authors only had a priori hypotheses (predictions made prior to the analysis of data) for the specific emotions that had previously been subject to research, as there was no evidence upon which to base any predictions for the other three.

Given prior findings, the authors anticipated that the recovered BD participants would report higher levels of trait joy and pride at baseline relative to NC participants.  In addition to the data collected at baseline, the authors also assessed participants at a six-month follow-up, thus allowing them to examine if levels of particular positive emotions at baseline predicted changes in depression and mania symptoms six months later.  The authors anticipated that higher levels of joy, pride, and amusement would predicted increases in symptoms of mania.  On the other hand, the authors anticipated that higher levels of compassion would predict decreased mania and depression symptoms.

In total, the BD participants included 55 individuals who had been diagnosed with bipolar I (n = 27), bipolar II (n = 21), or bipolar disorder not otherwise specified (n = 7).  39 of these individuals also took part in the six month follow-up examination.  All of these individuals were recovered, meaning that they had been euthymic for a period of at least two months.  The rationale for using only recovered participants was to determine whether increased positive emotionality was a trait-like, stable characteristic of individuals with BD or if it simply represented a fleeting symptom of manic phases.  The NC group included 32 individuals with no prior history of any mental illnesses.  Impressively, the authors utilized two semi-structured clinical interviews based on DSM-IV-TR criteria for each participant in order to reach diagnostic decisions.  This is a level of rigor that is rare in any psychological study and vastly increases the reliability of their information.  Given the findings we reported in an earlier PBB article on misdiagnosing bipolar disorder, this was particularly important for the authors' chosen topic.  

The results for this study were fairly impressive, particularly with respect to the analyses predicting changes in symptoms at six month follow-up.  Surprisingly, however, the baseline findings comparing trait levels of positive emotions between BD and NC individuals did not always support the authors' hypotheses.  BD individuals actually reported lower levels of joy than did NC individuals and did not differ from NC individuals on levels of pride. 

At six month follow-up, the data yielded much more informative findings.  High levels of joy and amusement predicted increased symptoms of mania whereas high levels of compassion predicted decreased mania severity.  Additionally, amusement predicted increased depression severity whereas pride predicted decreased depression severity.  Importantly, only two BD individuals had actually relapsed at the six-month follow-up time, so the authors were not measuring whether these emotions predicted the onset of a full manic or depressive phase.  Instead, they were examining whether they could predict shifts in the levels of various symptoms, independent of whether or not such shifts would be considered clinically significant.  An important consideration in these longitudinal findings is the sample size of the study.  Because only 39 individuals took part in both Time 1 and Time 2, the authors' ability to actually test their hypotheses and find significant effects was limited, which could have resulted in type II (false negative) errors. 

Ultimately, this study tells us several things.  First, although the baseline findings did not conform to the author's hypotheses, they offered the first look at how individuals with BD might differ from others on trait levels of positive emotions.  Future studies on this topic will be helpful in clarifying the matter.  Additionally, and perhaps more importantly, the authors demonstrated that, in recovered BD individuals, a heightened presence of certain positive emotions can be either helpful (compassion for mania and pride for depression) or harmful (joy and amusement for mania and amusement for depression).  The point is not that recovered BD individuals should not feel positive emotions, but rather, when such individuals exhibit extremely high levels of particular positive emotions, care should be taken to adjust that individual's environment so as to reduce risk of relapse.  An example of such an adjustment would be an increased focus on social rhythms.  Positive emotions are, by nature, a good thing.  For particular individuals, however, extremely high levels of positive emotions might reflect a vulnerability to symptoms of BD and care must be taken to ensure that, when risk emerges, necessary resources are available to help prevent the onset of a manic or depressive phase.

If you would like to learn more about bipolar spectrum disorders, we recommend checking out the "Real World of Bipolar" blog.  

Additionally, we recommend the following products, all of which are available through our online store:

The Bipolar Disorder Survival Guide: What You and Your Family Need to Know

The Bipolar Teen: What You Can Do to Help Your Child and Your Family

Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition

Bipolar Disorder, Second Edition: A Family-Focused Treatment Approach

Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Misdiagnosing bipolar disorder: How we arrive at diagnoses impacts the accuracy of our conclusions

by Michael D. Anestis, M.S.

At the beginning of each semester, I open my Abnormal Psychology course with a unit discussing how and why to integrate a systematic approach to diagnosis and a data-driven approach to treatment.  Inevitably, while my students see the utility in this approach and come to appreciate it as the semester progresses, they are relatively bored by this topic early on, eagerly awaiting the portion of the course devoted to specific disorders and treatments.  Admittedly, I find this portion of my class a bit dry as well, but feel that it is necessary.  Well, my students for next semester are likely to roll their eyes a little more emphatically now because I just found a new study that addresses this idea quite well and, as such, my reading list just evolved.  A preemptive apology to my students!

In this particular study, conducted by Bruchmuller and Meyer (2009) and published in the Journal of Affective Disorders, the authors examined whether providing irrelevant information would influence the diagnostic decision making of therapists when the client clearly meets criteria for bipolar disorder.  The authors provided a strong rationale for conducting this particular study.  According to prior research, approximately 73% of individuals diagnosed with bipolar disorder report having been given at least one misdiagnosis prior to being diagnosed as having bipolar.  On average, they received 3.5 misdiagnoses and saw five clinicians prior to receiving the proper diagnosis.  In some cases, it took as long as ten years to arrive at the proper diagnostic conclusion (Lisch et al., 1994).  This is particularly problematic given the data indicating that individuals with undiagnosed bipolar disorder have elevated rates of suicide (Shi et al., 2004).  Additionally, because many individuals with undiagnosed bipolar disorder are mistakenly diagnosed with depression, treatment at times involves the prescription of antidepressant medication, which has been shown to worsen the course of bipolar disorder (e.g., induced manic episodes; Altshuler et al., 1995).  Given these findings, it appears pivotal for clinicians to correctly identify the diagnostic condition presented by the client in order to ensure the proper treatment and the best outcome.

There are, admittedly, a multitude of factors that can lead to confusion on the part of a clinician in diagnosing a client with bipolar disorder.  First, bipolar clients quite often present during the course of a depressive episode, thus naturally leading the clinician to assume this is the primary problem.  Additionally, individuals in the midst of hypomanic or manic episodes are often not motivated to seek treatment, as this portion of the illness often feels good to the client at the time and, as such, is not seen as a problem.  These factors, however, are not justifiable reasons for misdiagnosis, as a proper diagnosis should be arrived at through a systematic assessment that includes probing for symptoms that are not necessarily mentioned upon arrival by the client but which correspond to disorders specified in the DSM-IV-TR (or ICD-10 outside the United States).  In other words, diagnosis isn't about simply asking the client what brings them to see you, but rather evaluating the data they provide through answers to structured questions based upon the diagnostic criteria for a range of mental illnesses.

The authors point out that, in making day-to-day decisions, we rarely consider all available data.  Instead, we rely upon heuristics and beliefs to influence our conclusions.  Quite often, this is a helpful approach, enabling us to manage an infinite number of stimuli and to make quick decisions and appropriate responses.  In diagnostics, however, this is highly problematic, as indicated by the findings mentioned above.

This particular study investigated two specific ways in which the diagnosis of bipolar disorder can be influenced.  One way was through the inclusion of irrelevant information - in this case, mentioning that the client had recently fallen in love, which had left him feeling extremely positive in recent weeks.  The second way was by including a symptom that is often connected with bipolar disorder, a decreased need for sleep.  Participating therapists received one vignette and were asked to indicate what they believed to be the proper diagnosis for that particular client.  In each vignette, the fictional client endorsed a sufficient number of symptoms to meet criteria for bipolar disorder in both the DSM-IV-TR and the ICD-10 (except one vignette, in which the fictional client met criteria for depression).  Of the five vignettes, four described an individual meeting criteria for bipolar disorder.  They differed from one another as follows:

1. Endorsed lack of sleep and a new romantic relationship
2. Endorsed lack of sleep but no new romantic relationship
3. Did not endorse lack of sleep but did endorse a new romantic relationship
4. Did not endorse lack of sleep or a new romantic relationship

Again, remember, all of the vignettes in these four conditions described individuals who met the diagnostic criteria for bipolar disorder.  They simply differed on whether they described a new romantic connection and the lack of sleep symptom of bipolar disorder.

The authors' findings were stunning.  In the bipolar vignettes, only 38% of the fictional clients were diagnosed with bipolar disorder.  53% were mistakenly diagnosed with depression.  No such difficulties were found in diagnosing the fictional clients in the depression vignette, indicating that the problem is at least somewhat unique to bipolar disorder.  Vignettes that included a description of lack of sleep were significantly more likely to result in a bipolar diagnosis than were vignettes that did not include such a description.  Given that all of the clients actually met criteria for bipolar disorder, this difference is fairly troubling, as it seems to indicate that the therapists were making their diagnostic decision based upon the presence or absence of one particular symptom rather than considering all the potential presentations for bipolar disorder.  There was no main effect for relationship (e.g., whether or not the fictional client endorsed a new romantic connection did not, on its own, influence diagnostic decision making); however, relationship status interacted with sleep information such that individuals who endorsed a lack of sleep but had a new romantic connection were significantly less likely to receive a bipolar diagnosis than were individuals who endorsed a lack of sleep but no new romantic connection.  At first glance, this might seem reasonable, but the authors noted two reasons why such an interpretation would be mistaken:

1. Individuals in a hypomanic or manic episode often experience high levels of sociability, hypersexuality, and need for intimacy, which might make them more likely to endorse having "fallen in love."  As such, this particular new relationship is just as likely to reflect the presence of mania or hypomania as it is to justify a decreased need for sleep.
2. Even if a new romantic relationship is somehow seen as a justification for dismissing a lack of sleep, all of the fictional clients met criteria for bipolar disorder regardless of whether or not the sleep criteria was included.  In other words, the extra symptom, which many therapists think of as a trademark of bipolar, was actually superfluous in this case and should have therefore had no impact on diagnostic decision making

The authors reported one more important finding.  The theoretical orientation of the therapist significantly predicted whether or not the correct diagnosis was given.  In this case, cognitive behavioral therapists were significantly more likely to identify the fictional client as meeting criteria for bipolar disorder than were psychodynamic therapists.

As I read this article, it occurred to me that some readers may respond by questioning the utility of diagnoses altogether.  A complete retort to that line of reasoning is beyond the scope of this article, but I will provide a quick and overly simplistic response in case this is on your mind as you're reading these results.  First, while many individuals who feel this way indicate that they feel as though diagnoses simply represent labels that force people into a box, this is in fact far from the case.  Diagnoses can help clients realize that they are not alone in their symptoms or freaks for having them, but rather one of many individuals who have encountered these symptoms, for which we have empirically supported treatments.  Our July 2009 featured article will, in fact, provide data that supports the utility of proper diagnostic feedback.  Second, different diagnoses respond differently to different treatments.  As such, without an effective diagnosis, we are significantly less likely to engage in the most effective approach to treatment. 

There are several limitations to this study and the authors properly note many of these weaknesses. The primary one I would like to mention though is the use of vignettes for diagnostic decision making.  A proper diagnostic assessment involves the administration of semi-structured diagnostic interviews (see our assessment tools page for more information on such tools).  As such, asking clinicians to reach a diagnostic decision after merely reading a story is a bit problematic.  Unfortunately, there is not much that can be done to resolve this particular problem, as it would be extremely difficult to run a study with enough participants to effectively test these hypotheses using such a diagnostic interviews.  As a result, the best we can hope for may be to see these results replicated multiple times by independent researchers, thus increasing our confidence that they represent a generalizable phenomenon.

Overall, what does this study tell us?  Quite a bit, actually.  First, as clinicians, we tend to selectively attend to particular information in such a way that leads us to discount relevant data in diagnostic decision making.  When we do this, we're likely to misdiagnose clients.  Although the symptoms as described in the DSM-IV-TR and the ICD-10 are imperfect, they provide us with our best framework within to work and, as such, fidelity to that diagnostic system is crucial.  Second, it highlights the need for a standardized approach to diagnostics.  This point overlaps a bit with the first, but the central idea is that, by having one unified approach that involves a systematic assessment of all available data, we can decrease the degree to which personal bias on the part of the therapist or incomplete information provided by the client upon first arriving at the clinic will influence diagnosis.  The need for this was emphasized further by the finding that theoretical orientation significantly predicted misdiagnosis.  How the therapist thinks about mental illness is fairly irrelevant, as the interaction between therapist and client is not about satisfying the therapist's intellectual needs.  The point of this interaction is the effective identification and treatment of symptoms so as to improve the life of the client and prevent relapse.  If how we think about mental illness is influencing our diagnostic decision making abilities, our thought process is flawed.

In the coming month, leading up to our July featured article, I intend to touch on other issues relevant to the diagnostic process and the utility of diagnoses in general.  In the meantime, we at Psychotherapy Brown Bag would love to hear your thoughts not only on this particular study, but also on these issues in general.

If you would like to learn more about these issues, a wide variety of resources in our online store could prove useful.  The store is divided into books for professionals (which is further divided by topic) and books for nonprofessionals, but this division is somewhat arbitrary and most resources in the latter are also listed in the former.  Feel free to contact us with suggestions for other resources we might consider including in the store.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Social rhythms in bipolar disorder: How daily behavioral patterns can increase vulnerability to both mania and depression

by Michael D. Anestis, M.S.

My dog got sick last night.  Why do I point this out in an article on PBB?  Quite simple, really.  As a result of my poor dog's illness, I did not get much sleep last night and, consequently, I'm experiencing a bit of a bad mood.  I suspect every person reading this article can relate to what I am feeling in this moment - a night of bad sleep leading to a morning characterized by irritability or other negative emotions.  Generally speaking, this passes within a couple hours and we forget all about it later in the day.  On a similar note, think about the last time you were extremely hungry and unable to find food.  Maybe you were rushed in the morning, missed breakfast, and went to work without time to stop and get a quick bite to eat.  Here again, I suspect everyone reading this article can think back to a time when this happened and remember feeling as though they were ready to bite the head off of the next person who asked them to do something.  Before long, these feelings fade as well, and the rest of the day typically goes smoothly.
    Researchers refer to our day-to-day routine, particularly with respect to basic processes such as eating and sleeping, as social rhythms.  Disruptions in these rhythms can cause anyone to experience a bad mood, but they are particularly problematic for individuals suffering from bipolar spectrum disorders (e.g., bipolar I, bipolar II, cyclothymia).  Research on social rhythms first gained prominence through the work of Ehlers and colleagues (1988), who published a theory referred to as the social zeitgeber theory of mood disorders.  If you are like me, you are currently thinking, "what the heck is a zeitgeber?"  Fair enough.  Zeitgebers are environmental "time setters," or cues that help regulate our circadian clock.  The simplest zeitgeber is the rising and setting of the sun, which for centuries has cued individuals to fall asleep and wake up.  Given that light is now readily available, humans now rely on a variety of other such cues.  Amazingly, simple day-to-day activities such as the timing of our meals or even our nightly schedule of television programming can have profound effects on our circadian clock (Frank, 2007).  Importantly, researchers have found that, in individuals with bipolar disorder, simple disruptions in social rhythms can prompt episodes of depression and particularly mania and prolong episodes that have already begun (Malkoff-Schwartz et al., 1998; Malkoff-Schwartz et al., 2000).  Shen, Alloy, Abramson and Sylvia (2008) found that individuals diagnosed with cyclothymia or bipolar II disorder engaged in fewer regular activities than did individuals with no mood disorder and that poor social rhythms predicted a quicker onset of mood episodes.  Ashman and colleagues (1999) found that individuals with rapid cycling bipolar disorder (four or more cycles of depression and mania/hypomania) demonstrated particularly dysregulated patterns of activity in the morning.  These findings seems to indicate that disruptions in our daily routine can make anyone vulnerable to a bad mood, but such disruptions in the lives of individuals with a bipolar spectrum disorder are particularly problematic and can lead to the onset and increased duration of both depressive and manic (or hypomanic) episodes.
    So what can be done about this?  Thankfully, an empirically supported treatment for social rhythms that can be used in conjunction with appropriate pharmacological treatment has been developed.  Interpersonal and Social Rhythms Therapy (IPSRT; Frank et al., 1994) aims to address three primary paths to relapse frequently seen in individuals with bipolar spectrum disorders:

1. Poor medication adherence
2. Stressful life events
3. Disruptions in social rhythms

IPSRT involves several components.  Clients are given medication adherence training in order to decrease the likelihood that they will cease using the mood stabilizing medications that have been shown to be, by far, the most effective means for stabilizing the dangerous mood patterns that characterize bipolar spectrum disorders, particularly bipolar I (Craighead, Miklowitz, Frank, & Vajk, 2002).  Additionally, clients are given a form on which they are taught to explore their feelings about their symptoms.  In doing this, clients are given a chance to grieve what Frank and colleagues have referred to as "the lost healthy self" in order to help them accept their current life situation and develop new perspectives and goals.  Such shifts in perspective often lead to a significant reduction in interpersonal and social role stress, which in turn can help reduce unhealthy fluctuations in social rhythms.  The goals of IPSRT can thus be summarized as ensuring the regular use of prescribed mood stabilizing medication, increasing acceptance of symptoms, developing goals based upon current life situations, and maintaining a stable, healthy pattern of eating and sleeping.
    In clinical trials, IPSRT in conjunction with proper pharmacological care has been shown to significantly increase the time between episodes of both mania and depression in individuals with bipolar I disorder (Frank et al., 2005).  In other words, when incorporated into treatment with medication, IPSRT increases the amount of time that individuals with bipolar spend symptom free.  Additionally, in bipolar I and bipolar II individuals experiencing depressive episodes, IPSRT resulted in a quicker remittance of symptoms (Miklowitz et al., 2007).  Perhaps the greatest measure of the effectiveness of a therapeutic intervention is its ability to reduce the most problematic outcomes associated with a particular ailment.  In this case, IPSRT has been shown to significantly reduce suicide attempts in individuals with bipolar disorder (Rucci et al., 2002).  IPSRT can be used both as an acute treatment for individuals currently in the midst of a depressive or manic episode or as a prophylactic treatment for individuals who are currently between episodes and seeking to maximize the amount of time spent without symptoms.  For individuals with bipolar I disorder (full manic episodes), IPSRT is best used in conjunction with mood stabilizing medication.  For individuals with bipolar II (hypomanic episodes, full depressive episodes), IPSRT can be used as a stand alone treatment if severity is not particularly extreme (Frank, 2007). 
    IPSRT consists of the following four phases, explained in more detail in Frank (2007).

Initial phase

• Obtain detailed history about the degree to which disruptions in social rhythms and interpersonal interactions have been involved in mood episodes.  This provides a rationale for treatment.
• Select area from the four interpersonal psychotherapy (IPT) modules that will be the focus of therapy (grief, role transitions, role disputes, interpersonal deficits).
• Typically lasts 3-5 sessions

Intermediate phase

• Develop healthy, regular social rhythms (e.g., sleep and eating schedule)
• Address the primary interpersonal area of concern selected during the initial phase of treatment

Continuation phase (or maintenance phase)

• Increase client's confidence that he can utilize these skills in his daily life, even when faced with life stress
• At this point, sessions are reduced from weekly to bi-monthly and, eventually, monthly.

Final phase

• Sessions are further reduced in frequency as termination becomes the goal

    The idea that regular sleep and eating patterns can impact our mood is not earth shattering news, although the empirical research examining this process certainly expands upon this point dramatically.  What is especially important to consider along these lines, however, is that individuals who are vulnerable to mood disorders must pay particularly close attention to the regularity of their schedules in order to reduce the likelihood of a mood episode.  Fortunately, as outlined above, empirically supported treatments are available that emphasize this point and train individuals to develop regular schedules that can be maintained even in times of stress.

For more information on IPSRT, we recommend the following products, all of which are available through our online store:
Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)

For more information on bipolar disorder, we recommend the following products, all of which are available through our online store:
Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition
Managing Bipolar Disorder: A Cognitive Behavior Treatment Program Workbook (Treatments That Work)

For more information on interpersonal psychotherapy, we recommend the following products, all of which are available through our online store:
Comprehensive Guide To Interpersonal Psychotherapy
Clinician's Quick Guide to Interpersonal Psychotherapy
Mastering Depression through Interpersonal Psychotherapy: Patient Workbook (Treatments That Work)
Mastering Depression through Interpersonal Psychotherapy: Monitoring Forms (Treatments That Work)

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University