Bipolar Disorder - Guilford Press

1 Chapter 1 Bipolar DisorderWhy Family treatment ? Stewart was admitted to a city hospital for an acute episode of was extremely irritable and euphoric, pressured in his speech,and preoccupied with his campaign for the presidential election,for which he claimed to be a write-in candidate. The admitting physicianimmediately put him on a combination of lithium and antipsychotic med-ications, but his hospitalization lasted only 8 days. For his wife, Susan,this hospitalization seemed too short, given how ill he had been when hewas admitted. In fact, in the weeks after his discharge his symptoms werestill quite evident: He still slept only 4 hours per night, continued to talkof how he could wire the presidential election, became angered easily,had trouble concentrating on conversations, and behaved in an embar-rassing manner in public (talking and laughing too loudly, yelling inap-propriately at waiters in restaurants).

2 His intention to return to his com-puter programming job seemed to Susan like a pipe tried to arrange for outpatient care with the same physicianwho had treated Stewart on an inpatient basis. However, Stewart refusedto see this doctor, arguing heatedly, That was the same guy who lockedme up in those restraints. He finally agreed to a session at a local mentalhealth center with a staff psychiatrist. He did not like this doctor either,describing him as an idiot in a lab coat. Becoming desperate, Susantried to get an appointment with a social worker at the center, only to betold there was a 3-week waiting list for such an appointment. She readeverything she could get her hands on to educate herself about bipolardisorder, but everything pointed to the importance of taking medication3 This is a chapter excerpt from Guilford Disorder , Second Edition: A Family-Focused treatment Approachby David J.

3 Miklowitz. Copyright 2008and being under the regular care of a psychiatrist. She became quiteangry with Stewart: Much of his behavior particularly his unwilling-ness to consult a psychiatrist seemed purposeful and intent upon hurt-ing her. Stewart reacted to her criticisms by upping the ante and threat-ening to leave , Stewart s symptoms did not abate, and the prescriptiongiven to him at the time of his discharge was starting to run out. Heturned his anger upon his wife, arguing that what she was calling hissymptoms of mania were really his personality and that he didn t needthe medication at all. One night, after a heated argument, he revealed thathe had discontinued his medications 3 days earlier to prove to her that hewas healthy. See? he yelled triumphantly. You said I d have a break-down, but here I am! Two days later, Stewart s behavior became increasingly disorga-nized.

4 His condition resembled that which had led him into the hospitalin the first place. That night, he disappeared. Early in the morning, Susanwas telephoned by a police officer, who said that Stewart had beenarrested while trying to break into the downtown Republican electionheadquarters. He was again admitted to the hospital with a recurrence could describe the events that occurred in this case from severaldifferent vantage points. Abiological psychiatristwould argue (1) thatStewart s brain has genetically determined imbalances in catecholaminesor other neurotransmitter or hormone systems, (2) that these must be cor-rected with medication, and (3) that his unwillingness to take medica-tions has made his illness worse. In contrast, a traditionalfamily systems-orientedpractitioner, although perhaps not denying the presence of a bio-logical predisposition, would argue that Stewart s disturbed behaviorcannot be separated from his distressed marital relationship, which isboth a cause and an effect of his symptoms and drug , acommunity mental health-mindedprofessional would viewStewart and Susan s experiences as reflecting inadequacies in the deliveryof mental health services to those who are most needy, and speaking tothe need for better continuity of care between inpatient and outpatientservices, and between different mental health of these views is correct?

5 Aren t they all correct? What modelmight pull these different arguments together? From my perspective as afamily psychoeducationalclinician, I would agree that this patient is indeeddealing with a biologically based Disorder that is likely to recur if nottreated with medication. However, I would also argue that the course ofhis illness is influenced by the stress in his marital relationship, even ifthis relationship did not play a causal role in the original onset of the dis-4 Bipolar Disorder AND FAMILIES order. Likewise, Stewart s wife is suffering, rather severely, from the bur-den of taking care of her ill husband and from the frustration of trying tofind answers. Finally, I would argue that this patient has not accepted thefact that he has a severe, recurrent psychiatric illness, a precondition foragreeing to a medication regimen. Thus, this couple needs to be educatedabout Stewart s illness Bipolar Disorder and taught to communicateabout and solve problems related to the stress it causes for both of also need coaching in how to obtain proper pharmacological careand make the mental health system work for is a book about Bipolar Disorder and families.

6 In it, I recount theproblems experienced by patients and their family members who are try-ing to adapt to this lifelong condition. I also describe how, based on bothmy and others research and clinical experience, they can benefit from apsychoeducational, family-focused treatment (FFT).How Is Bipolar Disorder a Family Problem? Bipolar Disorder is a relapsing and remitting illness. Even patients receiv-ing optimal medication are likely to have multiple recurrences and tohave trouble holding jobs, maintaining relationships, and getting alongwith their significant others (Perlis et al., 2006; Gitlin, Swendsen, Heller, &Hammen, 1995; Coryell et al., 1993).The behavioral and emotional experiences of the person with bipolardisorder affect everyone the patient s parents, spouse, siblings, and chil-dren. In fact, as hospitalizations have become shorter and shorter, and aspatients are discharged in quite unstable clinical states, the burden on thefamily has become considerable (Perlick, Hohenstein, Clarkin, Kaczynski,& Rosenheck, 2005).

7 In this milieu, family members need support, educa-tion, and advice in coping with the ups and downs of their relative s second reason to view Bipolar Disorder as a family problem stemsfrom the effects of the family environment on the course of this years ago, we examined in our research a cohort of hospitalizedbipolar, manic patients whom we followed over a 9-month outpatientperiod (Miklowitz et al., 1988). We found something quite interesting, aswell as clinically useful: A patient who returns from the hospital to astressful family environment is at greater risk for subsequent recurrencesof the Disorder . When recently manic patients returned from the hospitalto high-expressed-emotion (EE) homes (those in which relatives held atti-tudes such as criticism, hostility, or emotional overinvolvement towardthe patient) or to homes characterized by negative, conflictual interac-tional patterns (negativeaffective style[AS]), their chances of relapsingWhy Family treatment ?

8 5were much higher than if they returned to low-conflict, relatively benignhome situations. Further, patients from stressful environments did notfunction as well over time in the social interpersonal domain as those inless stressful , the frequent follow-ups with patients and relativesrequired by this study had the side effect of bringing us in close contactwith the impact of a Bipolar patient s Disorder on his or her family, andvice versa. It became obvious to us that episodes of Bipolar Disorder weremajor life events not only for the patient, but for all who cared about himor her. Patients and relatives frequently turned to us for advice, evenwhen our only role in the case was to conduct follow-up interviews. Itappeared that no one else was available to assist them with their manyproblems related to dealing with the FFT?Our observations in our research and clinical work suggested we take thenext step by developing a family-focused intervention program.

9 This pro-gram, we believed, could be analogous to the psychoeducational pro-grams that had been developed and found successful in delaying relapsesfor patients with schizophrenia (for a review, see Pitschel-Walz, Leucht,B uml, Kissling, & Engel, 2001) and should include the core compo-nents of these approaches: psychoeducation, communication skills train-ing, and problem-solving skills training. However, we felt this programwould need to address some of the unique issues relevant to bipolarpatients in family contexts (described below).This book describes our model for the family treatment of is not a treatment that should stand alone, but, rather, is an impor-tant component of the combined pharmacological and psychosocial treatment ofthe the model and procedures proposed here are imple-mented properly, they provide an organizing framework within whichthe goals of the pharmacological treatment can be more readily close working relationship between the Bipolar patient and his or herclose family members can not only address the multiple psychologicalproblems that emerge in the context of this Disorder , but can also facilitatethe patient s willingness to follow a prescribed medication FFT described in this book has grown out of our experience overthe last 25 years in treating and conducting research with more than 300bipolar patients both youths and adults.

10 These treatments have beencarried out in the context of controlled clinical trials that I and my closecolleagues have directed. In general, these trials have addressed thepostepisode phases of a patient s Bipolar Disorder AND FAMILIESThe Six Objectives of FFTHow might the symptomatic course of Bipolar Disorder be improved byadding a family intervention to medication maintenance? A family pro-gram has to address six important objectives if it is to have a significantimpact on the stressful family relationships accompanying episodes ofthe 1. Assist the Patient and Relatives in Integratingthe Experiences Associated with Episodesof Bipolar DisorderStewart and Susan began the FFT program shortly after his second hospi-talization. They both were quite shaken and confused by what hadoccurred. Susan appeared to be experiencing a posttraumatic stress reac-tion, with intense, free-floating anxiety and fears that Stewart wouldrelapse any minute.