Therapy for Mood Disorders
Chris Aiken, MD Instructor, Wake Forest University Dept of Psychiatry Director, Mood Treatment Center Editor-in-Chief, The Carlat Psychiatry Report
Depression and Mood Disorder Certification Training
PESI, 2020
Disclaimer Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards. Conflicts of Interest Book royalties, WW Norton, PESI
Mood Spectrum
Mania Mixed States Depression
“Manic-depression … is an illness that is biological in its origins, yet one that feels psychological in the experience of it.”
—Kay Redfield Jamison, An Unquiet Mind, 1996
Therapy changes the brain and body in ways that medications do not
Moods are not emotions
Mood disorders are not emotional illnesses
Emotions are adaptive responses to life.
There is no such thing as a diseased emotion.
Mood disorders affect the connections between
the brain’s emotional center and action center.
What is a Mood Disorder?
Allen Francis, Chair of DSM-IV
Homeostasis The tendency of the body to seek and
maintain a condition of balance
Negative feedback maintains homeostasis
Psychiatric illness is a break in homeostasis1
1Allen Francis, Saving Normal, 2013
Positive feedback Disrupts homeostasis, so reserved for rare but critical events: Ovulation Childbirth Blood clotting
Broken feedback loops Alcohol, drugs, or binge eating without satiety
Panic attacks Phobia of panic More anxiety More panic
Avoidance Reduced anxiety More avoidance More depression/anxiety
Action Success More action Less sleep More hypomania
Therapy Implications Early intervention in depression and mania can
prevent full episodes.
OEA: Acting the opposite of the emotion.
Empowers clients, destigmatizes.
CBT lead to longer remission when it increased flexible thinking rather than positive thinking1.
1Teasdale et al., 2001
Questions?
The Mood Spectrum
1900’s manic depression
Emile Kraepelin, MD, 1856-1926
1900’s manic depression 1960 bipolar vs. depression 2013 mood spectrum
Jules Angst, MD, 1926-present
major depression depression with mixed features depression with short-duration hypomania cyclothymic disorder bipolar II disorder bipolar I disorder
Depression and bipolar are part of “a continuum, with variable expressions of vulnerability to hypomania or mania” —David Kupfer, Chair of DSM-5, 2013
Diagnosis Rate of Bipolar I, II and Cyclothymia
General Population 3-5% of total population
Primary Care 20-30% of mood/anxiety patients
Outpatient Psychiatry 30-50% of mood/anxiety patients
On average, people with bipolar wait 10 years and visit to 3 different providers before being correctly diagnosed.1
1Hirschfeld RM, J Clin Psychiatry, 2001.
Diagnosis: Youth Rate of Bipolar I, II and Cyclothymia
Adolescents 1-3% of teens
Children of bipolar 15-30% (or 50% if 2 BP parents)
Conversion in adulthood
20-40% of depressed teens
Stages of Bipolar
0: Genetic risk factors only 1: Prodromal (subsyndromal) symptoms + genes 2: First onset of hypomania or mania 3: Recurrence (>90% recur within 5 years) 4: Treatment resistance and disability develop after too many episodes
Ü Family therapy Ü Meds + therapy Ü Meds, therapy, cognitive rehab
Bipolar diagnoses rose in children 2000-2005
Family history matters
When children have a few hypomanic symptoms, which ones will develop full bipolar? A family history of bipolar nearly doubled the risk of conversion to the full disorder.
Hafeman et al, Am J Psychiatry, 2017 Birhamer et al, 2009
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No family history BP Family history BP
Conversion to bipolar in youth with subsyndromal hypomania
Diagnostic Tools Bipolarity Index
Self rated scales Mood Disorder Questionnaire Bipolar Spectrum Diagnostic Scale Hypomanic Check List
Bipolar II Unipolar Depression Early Onset (age 15-20) Later Onset (age 30-40)
Recurrent depressions (40-60% of lifespan) 50-60% recur
Hypomania present, but rare (10% of lifespan) No hypomania
More comorbidities Fewer comorbidities
Likely to worsen with, or not respond to, antidepressants Improves with antidepressants
Female : Male = 1:1 Female : Male = 3:1
Strong genetic factors Less genetic
Depression Mania Julie Fast, BP Hope, 2017
Sunny hypomania Greater drive and energy
Socializing
Less shy, less inhibited
More plans and ideas
Motivated
Happy, euphoric
Physically active
Faster thoughts, more jokes
Talkative
Laughter, good humored
Less need for sleep
Confident
(Akiskal et al., 2003)
Euphoric mania or hypomania
Clear separation of mania, depression, and normal self
Rare mixed states and rapid cycling
Healthy personality with few comorbid conditions
Very responsive to lithium
Classic Bipolar
Dysphoric mania/hypomania
Mixed states, rapid cycling, rare recovery
Comorbid: anxiety, bulimia, OCD, borderline personality
Higher rates of trauma, head injury, substance abuse
Responds better to: seizure meds and atypical antipsychotics
Atypical Bipolar
Sunny hypomania Dark (mixed) hypomania Greater drive and energy Irritable, impatient
Socializing Excess traveling, imprudent driving
Less shy, less inhibited Unwise or impulsive decisions
More plans and ideas Heightened sex drive
Motivated Distracted
Happy, euphoric Excessive spending
Physically active High anxiety
Faster thoughts, more jokes Urges to self-medicate
Talkative Verbal aggression
Laughter, good humored Disregard for authority
Less need for sleep Careless of responsibilities
Confident Suicidality, self harm
(Akiskal et al., 2003)
“Tired and Wired”
“Driven but don’t know what to do”
“Irritable, agitated, impatient, frustrated”
Anxiety, panic, non-delusional paranoia
Craves urgent relief (substances, benzos, self-cutting)
Distracted, “like a ping-pong, mind won’t shut off”
Sleep reversal; over- and under-sleeping
More physical symptoms and medication side effects
Elevated risk of suicide
Mixed State Misery
Questions?
“Irregular energy levels” with “intense, variable moods,” where depression predominates but is interspersed by brief periods of “elation... dejection, anxiety, or impulsive anger”
Borderline Personality Disorder Affective Temperaments
Dysthymic Hyperthymic
Irritable Cyclothymic
“The psychiatrist’s aim is to bring out what is positive and desirable in the patient’s temperament” –H. Akiskal
Temperament Mood linked to Features
Depressive Depression Self-critical, “glass half-empty,” avoidant, worried, hard-working, realistic
Hyperthymic Hypomania Energetic, confident, extroverted, charismatic, impatient, hot-headed, impulsive
Irritable Mixed states Quick tempered, skeptical, suspicious, dissatisfied, assertive
Cyclothymic Rapid cycling of all moods
Traits from the other three temperaments cycle frequently, from energized to sluggish, extroverted to withdrawn, and passionate to disinterested. This cycling leads to anxiety, insecurity, and instability in relationships and work – but also to creativity, empathy, intuition, and spontaneity.
Temperament Mood linked to Features
Depressive Depression Self-critical, “glass half-empty,” avoidant, worried, hard-working, realistic
Hyperthymic Hypomania Energetic, confident, extroverted, charismatic, impatient, hot-headed, impulsive
Irritable Mixed states Quick tempered, skeptical, suspicious, dissatisfied, assertive
Cyclothymic Rapid cycling of all moods
Traits from the other three temperaments cycle frequently, from energized to sluggish, extroverted to withdrawn, and passionate to disinterested. This cycling leads to anxiety, insecurity, and instability in relationships and work – but also to creativity, empathy, intuition, and spontaneity.
Temperament Mood linked to Features
Depressive Depression Self-critical, “glass half-empty,” avoidant, worried, hard-working, realistic
Hyperthymic Hypomania Energetic, confident, extroverted, charismatic, impatient, hot-headed, impulsive
Irritable Mixed states Quick tempered, skeptical, suspicious, dissatisfied, assertive
Cyclothymic Rapid cycling of all moods
Traits from the other three temperaments cycle frequently, from energized to sluggish, extroverted to withdrawn, and passionate to disinterested. This cycling leads to anxiety, insecurity, and instability in relationships and work – but also to creativity, empathy, intuition, and spontaneity.
Temperament Mood linked to Features
Depressive Depression Self-critical, “glass half-empty,” avoidant, worried, hard-working, realistic
Hyperthymic Hypomania Energetic, confident, extroverted, charismatic, impatient, hot-headed, impulsive
Irritable Mixed states Quick tempered, skeptical, suspicious, dissatisfied, assertive
Cyclothymic Rapid cycling of all moods
Traits from the other three temperaments cycle frequently, from energized to sluggish, extroverted to withdrawn, and passionate to disinterested. This cycling leads to anxiety, insecurity, and instability in relationships and work – but also to creativity, empathy, intuition, and spontaneity.
Depressive Dysthymic (DSM-IV) Persistent depressive disorder (DSM-5)
Paul Giamatti, Sideways, 2004
Limitation Strength
Self-doubting, non-assertive
Anxious, worried
Indecisive, avoidant
Sensitive to rejection
Little pleasure in life
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried
Indecisive, avoidant
Sensitive to rejection
Little pleasure in life
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant
Sensitive to rejection
Little pleasure in life
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant Cautious, prudent
Sensitive to rejection
Little pleasure in life
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant Cautious, prudent
Sensitive to rejection Empathic, considerate, sensitive to other’s pain
Little pleasure in life
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant Cautious, prudent
Sensitive to rejection Empathic, considerate, sensitive to other’s pain
Little pleasure in life Hard-working, conscientious, ethical
Non-spontaneous, difficulty adjusting to change
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant Cautious, prudent
Sensitive to rejection Empathic, considerate, sensitive to other’s pain
Little pleasure in life Hard-working, conscientious, ethical
Non-spontaneous, difficulty adjusting to change Dependable, consistent, fair-minded
Low energy, high need for sleep (>9 hours/day)
Depressive
Limitation Strength
Self-doubting, non-assertive Humble, thoughtful
Anxious, worried Realistic
Indecisive, avoidant Cautious, prudent
Sensitive to rejection Empathic, considerate, sensitive to other’s pain
Little pleasure in life Hard-working, conscientious, ethical
Non-spontaneous, difficulty adjusting to change Dependable, consistent, fair-minded
Low energy, high need for sleep (>9 hours/day) Patient, persistent
Depressive
Hyperthymic
Franklin Roosevelt
Limitation Strength
Arrogant, self-assured, egotistical
Risk-taking, impulsive, reckless
Controlling, overbearing, domineering, meddlesome
Overindulges in food, drink, or sex
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless
Controlling, overbearing, domineering, meddlesome
Overindulges in food, drink, or sex
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome
Overindulges in food, drink, or sex
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Friendly, extraverted
Though warm and engaging, can also be insensitive and unempathetic
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Friendly, extraverted
Though warm and engaging, can also be insensitive and unempathetic
Thick-skinned, able to take insults in stride like “water off a duck’s back”
Lacking in self-reflection, which makes it hard to learn from mistakes
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Friendly, extraverted
Though warm and engaging, can also be insensitive and unempathetic
Thick-skinned, able to take insults in stride like “water off a duck’s back”
Lacking in self-reflection, which makes it hard to learn from mistakes
Easy going, comfortable, not bogged down by self-conscious worries
Impatient
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Friendly, extraverted
Though warm and engaging, can also be insensitive and unempathetic
Thick-skinned, able to take insults in stride like “water off a duck’s back”
Lacking in self-reflection, which makes it hard to learn from mistakes
Easy going, comfortable, not bogged down by self-conscious worries
Impatient Active, energetic, lots of interests
Decreased need for sleep (<6 hours/day)
Hyperthymic
Limitation Strength
Arrogant, self-assured, egotistical Confident, decisive, a natural leader
Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful
Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others
Overindulges in food, drink, or sex Lover of life, spreads joy to others
Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept
Spontaneous, fully engaged in the moment
Talks over people, socializes to the point that it’s exhausting to others
Friendly, extraverted
Though warm and engaging, can also be insensitive and unempathetic
Thick-skinned, able to take insults in stride like “water off a duck’s back”
Lacking in self-reflection, which makes it hard to learn from mistakes
Easy going, comfortable, not bogged down by self-conscious worries
Impatient Active, energetic, lots of interests
Decreased need for sleep (<6 hours/day) Can turn into insomnia in middle age
Hyperthymic
Hyperthymic in Therapy
Moderation to balance hedonism.
Realistic assessment to balance impulsivity.
Interpersonal skills: Empathy, listening, patience, humility.
Irritable
Clint Eastwood, Gran Torino, 2008 Archie Bunker
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Limitation Strength
Irritable, hot-headed, quick to anger Assertive
Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific
Jealous Protective, loyal to their inner circle
Conflicts in relationships, social isolation
Able to take important stands that others are
not comfortable making, original, iconoclastic,
independent
Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real
problems
Irritable
Cyclothymic
Jessica Lange, Blue Sky, 1994
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Limitation Strength
Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative
Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people
Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately
Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry
Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine
Tend to seek professional help when needed and make good use of therapy
Falls in and out of love too easily, impulsive starts and ends relationships
Able to rebuild their social network when things break down
Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”
Able to put on a mask when needed, to “fake it ‘til they make it”
Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes
At other times, have the healthy skepticism that comes with experience
Cyclothymic
Therapeutic Relationship Approach Therapeutic Stance Therapeutic Pitfalls
Dysthymic Respect them
Realism Encourage open communication Encourage assertion
Dominating, anger, hostility Withdrawing, defeated Cheerleading, overly-positive Missing indirect expressions of anger
Hyperthymic Mirror them Practical focus on the future Action-oriented Tell it like it is Strong-spine
Missing pathology Losing control of sessions Power struggles Boundary violations
Irritable On their side Firm but compassionate Open, honest, genuine Clearly state boundaries Don’t sweat the small stuff
Argument Withdrawing (“got something to hide”) Attacking Reacting personally to attack
Cyclothymic Believe in them Define roles clearly Use active, genuine body language Speak direct, and sometimes directive
Judgmental Overly strict Overly permissive
Therapeutic Relationship Approach Therapeutic Stance Therapeutic Pitfalls
Dysthymic Respect them
Realism Encourage open communication Encourage assertion
Dominating, anger, hostility Withdrawing, defeated Cheerleading, overly-positive Missing indirect expressions of anger
Hyperthymic Mirror them Practical focus on the future Action-oriented Tell it like it is Strong-spine
Missing pathology Losing control of sessions Power struggles Boundary violations
Irritable On their side Firm but compassionate Open, honest, genuine Clearly state boundaries Don’t sweat the small stuff
Argument Withdrawing (“got something to hide”) Attacking Reacting personally to attack
Cyclothymic Believe in them Define roles clearly Use active, genuine body language Speak direct, and sometimes directive
Judgmental Overly strict Overly permissive
Therapeutic Relationship Approach Therapeutic Stance Therapeutic Pitfalls
Dysthymic Respect them
Realism Encourage open communication Encourage assertion
Dominating, anger, hostility Withdrawing, defeated Cheerleading, overly-positive Missing indirect expressions of anger
Hyperthymic Mirror them Practical focus on the future Action-oriented Tell it like it is Strong-spine
Missing pathology Losing control of sessions Power struggles Boundary violations
Irritable On their side Firm but compassionate Open, honest, genuine Clearly state boundaries Don’t sweat the small stuff
Argument Withdrawing (“got something to hide”) Attacking Reacting personally to attack
Cyclothymic Believe in them Define roles clearly Use active, genuine body language Speak direct, and sometimes directive
Judgmental Overly strict Overly permissive
Therapeutic Relationship Approach Therapeutic Stance Therapeutic Pitfalls
Dysthymic Respect them
Realism Encourage open communication Encourage assertion
Dominating, anger, hostility Withdrawing, defeated Cheerleading, overly-positive Missing indirect expressions of anger
Hyperthymic Mirror them Practical focus on the future Action-oriented Tell it like it is Strong-spine
Missing pathology Losing control of sessions Power struggles Boundary violations
Irritable On their side Firm but compassionate Open, honest, genuine Clearly state boundaries Don’t sweat the small stuff
Argument Withdrawing (“got something to hide”) Attacking Reacting personally to attack
Cyclothymic Believe in them Define roles clearly Use active, genuine body language Speak direct, and sometimes directive
Judgmental Overly strict Overly permissive
Cycloid Personality
Original term for borderline personality in the working drafts of DSM-III “Irregular energy levels” with “intense, variable moods,” where depression predominates but is interspersed by brief periods of “elation... dejection, anxiety, or impulsive anger” —T. Millon
“The theory I present is… in many ways similar to that of Millon’s [Cycloid Personality]” —Marsha Linehan, Cognitive-Behavioral Treatment of Borderline Personality Disorder
Common Traits in Cyclothymia and Borderline
high neuroticism, low agreeableness
harm avoidance + novelty seeking
anxiety + impulsivity
Borderline traits can result from the overlap of cyclothymic temperament and bipolar II
impulsive
self harm
irritable
Sunny hypomania Dark (mixed) hypomania Greater drive and energy Irritable, impatient
Socializing Excess traveling, imprudent driving
Less shy, less inhibited Unwise or impulsive decisions
More plans and ideas Heightened sex drive
Motivated Distracted
Happy, euphoric Excessive spending
Physically active High anxiety
Faster thoughts, more jokes Urges to self-medicate
Talkative Verbal aggression
Laughter, good humored Disregard for authority
Less need for sleep Careless of responsibilities
Confident Suicidality, self harm
(Akiskal et al., 2003)
38% of people with bipolar II have cyclothymia Akiskal et al., 2003
38% of people with bipolar II have borderline personality disorder Fornaro et al., 2016
Borderline Personality Disorder Cyclothymic Disorder H
IGH
OV
ER
LAP
Affective instability due to marked reactivity of mood (e.g., intense episodic depression, irritability, or anxiety lasting hours to days)
Rapid mood swings that cycle between depression, irritability, anxiety, and excitation over days to weeks
Unstable relationships that shift from idealization to devaluation (splitting)
Relationships that vacillate from glowing adoration to hateful paranoia
Unstable identity Insecure identity. Frequent changes in beliefs, religions, and social groups
Impulsivity Impulsivity
Intense anger Intense anger
Borderline Personality Disorder Cyclothymic Disorder H
IGH
OV
ER
LAP
Affective instability due to marked reactivity of mood (e.g., intense episodic depression, irritability, or anxiety lasting hours to days)
Rapid mood swings that cycle between depression, irritability, anxiety, and excitation over days to weeks
Unstable relationships that shift from idealization to devaluation (splitting)
Relationships that vacillate from glowing adoration to hateful paranoia
Unstable identity Insecure identity. Frequent changes in beliefs, religions, and social groups
Impulsivity Impulsivity
Intense anger Intense anger
SO
ME
O
VE
RLA
P Frantic efforts to avoid real or imagined
abandonment Intense romantic attachments and sensitivity to rejection
Recurrent suicidal behavior, gestures, threats, and self-injury
Elevated risk of suicide and self-injury
Borderline Personality Disorder Cyclothymic Disorder H
IGH
OV
ER
LAP
Affective instability due to marked reactivity of mood (e.g., intense episodic depression, irritability, or anxiety lasting hours to days)
Rapid mood swings that cycle between depression, irritability, anxiety, and excitation over days to weeks
Unstable relationships that shift from idealization to devaluation (splitting)
Relationships that vacillate from glowing adoration to hateful paranoia
Unstable identity Insecure identity. Frequent changes in beliefs, religions, and social groups
Impulsivity Impulsivity
Intense anger Intense anger
SO
ME
O
VE
RLA
P Frantic efforts to avoid real or imagined
abandonment Intense romantic attachments and sensitivity to rejection
Recurrent suicidal behavior, gestures, threats, and self-injury
Elevated risk of suicide and self-injury
LES
S O
VE
RLA
P Chronic feelings of emptiness May occur if there is a significant history of trauma or
neglect
Transient, stress-related paranoid ideation or severe dissociative symptoms
Paranoia can occur during severe mood episodes, and dissociation may be part of the picture if there is a significant trauma history
PTSD Bipolar Trauma: 100% Trauma exposure is 2-3x higher in bipolar2
Interpersonal trauma in bipolar: 30-60%3
PTSD in bipolar: 16%4
Intrusive distressing memories Pressured, intrusive negative thoughts
Nightmares Nightmares more common (REM sleep)
Flashbacks --
Distress with triggers Amygdala hypersensitivity
Avoidance of triggers, memories, emotions Dislikes thinking about painful events
Inability to fully recall trauma
Persistent negative beliefs, distorted cognitions, negative emotions, low activity, detachment from others
Prominent in depression (50% of lifetime)
Irritable, reckless, self-destructive, hypervigilant, startle, poor sleep/concentration
Prominent in mixed states
1Kilpatrick DG, J Trauma Stress, 2013. 2Yuval N, Bipolar Disord, 2008. 3Mauritz MW, Eur J Psychotraumatol, 2013. 4Otto, Bipolar Disord, 2004
ADHD Bipolar hypomania Fidgets, gets up, runs about Hyperactive mood
(irritability common) Euphoric or irritable mood
n/a Inflated self-esteem
(insomnia common from restlessness) Decreased need for sleep
Talks excessively, interrupts others More talkative
Thoughts are easily distracted Flight of ideas
n/a Racing thoughts
Easily distracted Distractibility
“On the go,” “Driven by a motor” Goal-directed activity or motor agitation
(impulsivity part of hyperactive syndrome) Impulsivity
Generalized Anxiety Bipolar Excessive worry about every things Common in depression
Difficulty controlling the worry Rumination common in depression and mania
Restless, keyed up, or on edge Hyper, agitated
Easily fatigued Atypical depression = fatigue
Difficulty concentrating Part of mania and depression
Irritability Part of mania
Muscle tension Motor agitation in mania and depression
Sleep disturbance Part of mania and depression
Anxiety sensitivity is higher in hypomania than depression1
20-50% of people with bipolar have an anxiety disorder at some point2
1Otto M, J Affect Disord, 2005. 2Deckersbach T, Am J Psychiatry, 2014.
1Otto M, J Affect Disord, 2005. 2Deckersbach T, Am J Psychiatry, 2014. Deckersbach T, Am J Psychiatry, 2014.
People with bipolar responded better to psychotherapy if they had anxiety.
CBT Family focused therapy
Social Rhythm (IPSRT)
Psycho- Education
CBT-insomnia-
bipolar
Functional Remed-iation
Psychoeducation Y Y Y Y Y Y Relapse prevention Y Y Y Y Y Mood monitoring Y Y Y Y Y Med adherence Y Y Y Y Y Regular sleep Y Y Y Y Y Communic. skills Y Y Y
Six Effective Therapies for Bipolar
Questions?
The Therapeutic Relationship
Common Themes in Bipolar
Denial of the illness Stigma Developmental delays and emotional immaturity Uneven career or creative life; loss of roles in society Financial problems Burden on the family Risky sexual behavior Marriage, pregnancy, genetics Tempestuous relationships, lovelife, divorce Effects of medications on temperament Fears of return of illness episodes Grieving over years lost due to bipolarity and its complications Self-regulation and regulation of self-esteem —Adapted from Hagop Akiskal, Care of the Bipolar Patient, 2011
Therapy Stance Friendly advisor who works to understand the client’s entire life and educate them on relationships. Role model for relationship skills such as consideration, healthy assertion, gratitude, and understanding. “Cool under stress,” “Not overreact to disappointment,” “Think before acting.” Adapt stance to current mood state.
Judy Beck, CBT for Personality Disorders
“Encouraging grandiosity diminishes it. The best reaction to a grandiose comment is to say: ‘How wonderful! I wish I could feel more that way myself.’" —Ghaemi and Havens, American Journal of Psychotherapy, 2005
Manic Siding
Nassir Ghaemi
Dysthymic To establish trust, be realistic, sensible, and skeptical. Caution with optimism.
Countertransference Therapeutic defeat in chronic depression can lead to…
Anger (assigning lots of homework, challenging) Withdrawal (passive, daydreaming)
Sign: dreading the appointment
Illness Role Depression is an illness.
People lighten their loads and reduce expectations when ill.
You are not responsible for the depression, but you are responsible for doing your part in recovery. (from Interpersonal Therapy for Depression)
Fully whole vs. wholly bipolar “I don’t think my therapist gets it that I have bipolar. He expects me to do things that I just can’t, and acts like I’m not trying hard enough.” “No offense but I really don’t want to hear anymore about bipolar. I want to move beyond that and need a therapist who can help me find myself again.”
Past vs. Future “My therapist only wanted to talk about my father, and that just made me more depressed so I quit.” “I have a lot of baggage and really want a therapist who can help me work through that so I don’t repeat the past.”
Advice vs. Listening “I don’t need someone to nod and say ‘I understand.’ I need some guidance here!” “There’s no one I can talk to about these problems, and have a lot to get off my chest. I’m not looking for simple advice. I need someone who can take the time to understand me.”
Questions?
Cognition
“Functional impairment often persists even in the face of full symptomatic recovery.”
—Goodwin & Jamison, Manic Depressive Illness, 2007
The Cognitive Pole “I lost my sense of competence... Word retrieval was difficult and slow... Clarity of thought, memory and concentration had all left me. I was slowly fading away. [After recovering] I still don’t have full days — I’m only functional mornings to midafternoons.”
—Linda Logan New York Times Magazine 2013
Cognitive Problems
Attention “I’m distracted, can’t follow a movie.”
Memory “I forget what I went in the room for.” “Can’t think of words.” “I repeat conversations… embarrasing!”
Executive “I’m overwhelmed and don’t know where to start.” “I’m impulsive.” “I’m always late.” “My boss is so unfair, she keeps changing the rules on me.”
Social “I don’t trust anyone” “People are always criticizing me.”
Group therapy 21 weekly 1.5 hour sessions
Interactive Clients roll-play and do exercises together
Homework Reading, practicing, word games, puzzles. Can include web-training: www.cognifit.com www.brainhq.com www.rehacom.us
Functional Remediation
What to Tell Clients Cognitive problems affect 30-60% of people with bipolar and often persist after the episode resolves. They are the result of too many past episodes. It is not progressing to dementia.
Medications rarely cause significant cognitive impairment. They can help prevent cognitive problems, but rarely treat them. Aerobic exercise, Mediterannean diet, and skill-building are the best treatments.
Allow extra time Schedule breaks
(5 min/hr) Change tasks Schedule difficult tasks
for times when concentration is optimal
Minimize distractions
Attention
Attention Drink water Build in simple rewards
(chocolate, favorite websites) Summarize as you read Find something personally
relevant in the material
Memory MEMORY AIDS Calendars Apps Alarms DAILY JOURNAL To do list Appointments Important events
ORGANIZE Keep related things in
the same place at home
MEMORY TRICKS Chunk information into
smaller pieces Associate names with
people you know, physical traits, or funny rhymes
Calendars Top Picks Simple Elephant Planner and Panda Planner. Designed with mental health in mind, these include mood-boosting features like a gratitude journal. Simple, affordable options Blue Sky, At-A-Glance® Classic, professional look Moleskin, Lemome, and Ink+Volt
Panda Planner
Task Completion BREAK IT DOWN Break complex tasks into
smaller steps Prioritize each step
TIME MANAGEMENT Practice estimating how it
will take to complete each step
Problem Solving SLOW DOWN
DESCRIBE THE PROBLEM What causes it or makes it persist? Who are the people involved? What is the desired outcome?
BRAINSTORM SOLUTIONS
EDIT, RANK & IMPLEMENT Most likely to work Least likely to backfire Easiest to implement
No solution is too ridiculous
A video
game for ADHD?
Wii Sports
Questions?
Top Causes of Depression
Initial response to stress = Try harder.
Chronic stress (e.g. 6 months) without success = Depression.
Stress + Time
Loss + humiliation = depression
Loss + threat = anxiety
Kendler KS et al, Arch Gen Psychiatry. 2003 Aug;60(8):789-96 Aslund C et al, Eur Child Adolesc Psychiatry. 2007 Aug;16(5):298-304
Like weeds, even minor physical and mental symptoms tend to grow back into full episodes.
Residual symptoms
Antidepressants do not work in depressed mice who are kept in isolation.
Isolation
Aerobic exercise prevents depression 4-times better than an antidepressant.
Depression tends to return 2-4 months after stopping exercise.
Inactivity
BMI > 30 predicts poor response to antidepressants, in part due to inflammation.
Weight
Poor diet is contributes to 30% of the depression risk in large epidemiologic studies
Poor diet
The body’s response to injury and infection
Found in 30% of depression, 50% of treatment-resistant depression
Inflammation
Inflammation Risks Early childhood trauma
Recent significant stress
Treatment resistant depression
Anxiety, depression, neurotic traits
Chronic medical illness
Obesity (BMI ≥ 30), Western diet
Smoking, sedentary lifestyle
Recent chemotherapy or radiation
Recent bodily injury or surgery
Elevated CRP > 3
Chronic pain
Sleep apnea
Thyroid illness
Head injury
Other health problems
Insomnia is a top risk factor of depression or mania.
Anxiety disorders often turn into depression, e.g. by age 30.
Both are risk factors for suicide.
Insomnia and Anxiety
High activity at night, and low in the evening, was associated with depression, bipolar, and cognitive problems 3 years later in a study of 91,000 people
Nocturnal Activity
Lyall LM et al, The Lancet Psychiatry, 2018
Associated with: Depression Sexual dysfunction Obesity GI and Heart disease
Night Shift
Routinely working over 11 hours a day doubles the risk of depression
Long Hours
30 min one-way and longer associated with: Depression Insomnia Obesity Marital stress Chronic pain
Commutes
St-Louis E et al (2014), Transportation Research Part F: Traffic Psychology and Behaviour, 26, 160–170.
Depression in fall or winter
Mixed states or mania in spring
Can worsen around equinox when the light changes rapidly. Or when the amount of light is lowest (Dec-Jan).
Depression in March when daylight savings shifts morning light later.
Seasonality
Sudden changes in sleep, wake times, or timing of daily routines
Rapid changes in outdoor light (Spring or Fall Equinox)
Traveling across more than 2 times zones
Childbirth (for women and men)
Medications: antidepressants, stimulants, steroids, testosterone, weight loss medications
Top Mood Destabilizers
Questions?
“The most noxious assumption that [clinicians] can fulfill is the feeling by patients that we represent the “system,” the status quo of power and privilege. We will label the patient as sick, and then send them through a rigamarole of diagnosis and treatment that will end up with his extrusion as a “patient,” often without an active and productive role in society or a strong sense of self-worth.” —Ghaemi and Havens, American Journal of Psychotherapy, 2005
On Diagnosis
Fragile Circadian Rhythm Disorder
A day in the (ideal)
life
Sound alarms wake us from deep sleep 90% of the time, causing sleep inertia.
This groggy state lasts 15 minutes in most people, but up to 4 hours during depression.
Sleep Inertia
Phillips HF3520/60 $100
TURNS ON Gradually over 30 minutes
IMPROVES Alertness Energy Depression
Dawn Simulator
EXAMPLES Philips morning wake-up
LightenUp (best price)
Apps (Rise & Shine, Lichtwecker )
Seasonal Affective Disorder (SAD) Positive in 8/10 small controlled trials (total n=446) 7/10 of those are placebo-controlled
Other Conditions Sleep inertia SAD in recovered alcoholics Sleep quality in normal adults (cross-over study, n=100) Attention, alertness, and working memory in adolescents and sleep deprived adults (pb-control)
Dawn Simulation
$20 at windhovermfg.com
Products
www.moodtreatmentcenter.com/products
Wake up at the same time each morning (within 15 minutes).
Get out of bed immediately upon waking.
Make the bed so it’s harder to get back in.
Start the day with energizing activity.
Brisk Awakening
Melodic Music Reduces Sleep Inertia
McFarlane SJ et al, PLOS One 2020
Do these upon awakening: Page turners: the more you do them, the more you want to do them
Aromatherapy (citrus, mint, rosemary)
Morning playlist (e.g. dance or exercise music)
Step outside, move around
Cold water
Energizing Activity
Top activities that stabilize mood (zeitgebers*)
Time out of bed Time starting work or chores Time of significant interaction with others Time of dinner
Do these at the same time each day (give or take 15 minutes) *German for “Time givers”
Social Rhythm Therapy
IPSRT: Interpersonal Social Rhythm Therapy
“Awake” = Feet on the Floor
Social Rhythm Chart
Rate the People Factor
0= Alone
1= Others present but not involved
2= Others actively involved
3= Others very stimulating
Social Rhythm Therapy
Avoid overstimulation at night
Bright lights
Crowds
Arguments
Intense conversation
Goal-directed activity
Exciting projects
Is it energizing? Move it to morning
Opposite action for Mania Schedule down time
Stay on one task at a time
Mindfulness
Rhythmic breathing
Limit overstimulation, texting, social media
Avoid stimulant drugs, caffeine
3-Volley rule for arguments
Delay making decisions (wait 3 days or ask 2 people)
Dim lights
Sleep
5 Month Educational Group Therapy for Bipolar
Delle Chiaie R et al, n=20, RCT, 2013
Cortisol Before Cortisol After
Questions?
45 minutes every other day of light aerobics (raise heart rate by 10 bpm)
Brisk Walking
Exercise works as well as an antidepressant, but prevents depression 4-times better. It also improves memory, which antidepressants do not.
Dance Play with kids or animals Cycling or stationary bike Treadmill in front of TV Swimming Active video games
(Wii Sports, Just Dance, Island Run) Happy walk at home video Or even better... In a forest
Creative Aerobics
Island Run
An hour a day in "farming" activity, from gardening to agriculture, was associated with a 50% lower risk of depression
12% of the improvement was related to physical activity, but none was related to age, gender, weight, smoking, drinking, physical health, isolation, education, income, or length of day.
Asai Y et al, J Affect Disord. 2018, 1;241:235-240
How Nature Heals Low threat signals Phytoncides improve immunity Negative air ions lift depression
Sundown Dim the lights Dim the screens (f.lux app)
30 min before bed
Electronic free zone Darkness or warm, yellow light Colder temperature Meditative activity Stretching, muscle relaxation Calming music Lavender, Jasmine
Evening Wind Down
Obesity Diabetes Cancer (breast, prostate) Cardiovascular disease Neurologic diseases Gastrointestinal ulcers Adverse reproductive outcomes
Light at Night (LAN)
Delays, reduces melatonin Impairs neuroplasticity, shrinks dendrites Impairs sleep, cognition, learning Creates night-owls (phase delay)
Light at Night (LAN)
Obayashi K et al, Am J Epidemiol. 2018
Bedroom light above 5 lux associated with double the risk of depression after 2 years. The brighter the light, the greater the risk. (Obayashi, 2018, Longitudinal study of 863 older adults)
Even dim light...
Full moon 0.3 Twilight 5-10 Dark public area 20-50 Living room 50 Dark overcast day 100 Office lighting 320-500 Sunrise/set 400 Overcast day 1,000 Full daylight 10,000-25,000 Direct sunlight 32,000–100,000
Lux
Dark Therapy
Mania (controlled trial) Rapid cycling (case series) Shift-work syndromes (case series) Insomnia (controlled trial, deepened sleep) Next-day cognition
Dark Therapy Treats
Dark therapy improved mania in hospitalized patients. Effect size = 1.8 (3-times greater than most meds). Patients recovered without sleeping more.
Henricksen et al. Bipolar Disorders, 2016
6pm to 8am Virtual darkness (blue-light filters) when out
of bed Total darkness (or eye mask) when in bed Can start later if improved after a week or if
symptoms are mild (Shifting later by 1 hour every 2-3 days) (2 hours before bed is ideal for prevention)
Protocal pm
am
Glasses
Uvex Skyper 3S1933X $7-10 on Amazon
Uvex Ultraspec 2000, S0360X , $7 on Amazon
Lowbluelights.com $70-80
Kayumov et al. J Clin Endocrinol Metabolism, 2005
Melatonin Rises with Dim Light or Blue-Light Filtering Glasses
Blackout curtains (such as ShiftShade, or buy blackout fabric, attach with pins or Velcro)
Aluminum foil against window Electric tape over LED lights Sleep in basement Low blue nightlights: Maxxima MLN-16 Amber LED Night Light Plug SCS Nite-Nite Light Bulb or Sleep-Ready Light lowbluelights.com, somnilight.com Apps: f.lux, Apple Nightshift mode, Kindle Candle
Black out
Computers Windows: f.Lux
Mac: Candlelight by Oliver Denman
Smartphones, Tablets
Apple Nightshift mode
Kindle BlueShade
Android Twilight and Blue Light Filter app
Blue Light Filters
Try and see what works: Weightless, by Marconi Union
Binaural beats (5-7 Hz, theta)
Regular rhythm, bass tones, tranquil melodies, slow tempo (60-80 BPM; songbpm.com)
Classical, celtic, Gregorian chant, New Age, Indian or Chinese Classical, electronic
Familiar songs without lyrics
White noise and pink noise (nature sounds)
Music for Sleep
Top Tools for Bipolar
1. Regimented sleep
2. Reducing alcohol
3. Exercise
4. Lamotrigine (Lamictal)
5. Sunlight
6. Mindfulness
7. Psychotherapy
8. Self-tracking & journaling
9. Reducing caffeine
10. Lithium CureTogether, online survey, 2012
bipolar CBT-i
Harvey et al, 2015
bipolar CBT-i
Harvey et al, 2015
Questions?
CBT Insomnia (CBT-i)
Free app: CBT-I Coach
Doubles the rate of response to antidepressants.
In bipolar disorder, reduced the rate of mood problems 8-fold after six months.
“Jump starts” therapy for PTSD
Lowers inflammation
Apps (CBT-i Coach)
Mood Benefits of CBT-i
Ashworth 2015, Taylor 2007, Harvey 2015
Two forces drive sleep: Sleep Drive:
Increases the longer you’re awake.
Circadian Drive:
Cycles with sunlight and wake times.
Sleep: A 24-hour Cycle
The problem: Sleep-drive is more powerful than sleep
medicine, but one force can override it: Anxiety.
Anxiety about sleep delays sleep drive, causing people to get tired at the wrong times.
Trying to sleep can override sleep-drive because the effort involved activates stress hormones.
Anxiety Disrupts Sleep Drive
Solutions: Only go to bed when you are tired; don’t force it.
If you can’t sleep after 20 minutes, get out of bed. Keep the lights low and do boring or meditative things.
Allow sleep deprivation; it will increase your sleep drive.
While following this strategy, you may worry that limiting your time in bed will cause you to be sleep deprived. That’s true, but remember you are already suffering sleep deprivation from insomnia so either way you will have trouble. With this strategy, the trouble will gradually get better.
Anxiety Disrupts Sleep Drive
The Problem: Oversleeping prevents the circadian clock from setting correctly, resulting in more insomnia.
Solution: Arise out of bed the same time each day regardless of how much you slept.
“CBT-i will help harness your sleep drive and align your circadian rhythm. CBT-i is more effective, and longer lasting, than sleep medicine, but it takes longer to work. You may be more anxious, and more sleep deprived, in the first phase.”
Awake at regular times. Out of bed during the day; only use bed for
sleep and intimacy. Avoid daytime napping. Avoid caffeine after 2pm. Wind-down time in 30 minutes before bed. Only go to bed when tired. If unable to sleep after about 20 minutes
(don’t watch the clock), get up and sit in the dark doing nothing until tired again.
First Aid: Sleep Hygeine
For each day, record how much time you spent in bed awake vs. asleep
At the end of the week, add up the total time asleep and divide by 7 for average time asleep.
Add 30 min to that average time asleep. Over the next week, you can only spend that much time in bed. Choose a regular wake time that fits with it.
Do not restrict time in bed to < 5 hours (or <6.5 hours if bipolar).
Advanced: Bed Restriction
CBT-i Examples
Daytime Napping Napped during the day 4:00 pm to 6:00 pm.
Evening: awake in bed from 11:00 pm to 1:00 am, then slept to 7:00 am. Total sleep = 8 hours. Time awake in bed = 2 hours.
Can’t fall asleep (initiation insomnia) To bed at 10:00 pm, toss and turn for 3.5 hours and fell asleep around 1:30 am.
Sleep through the night and wake up at 9:00 am
Total sleep = 7.5 hours. Time awake in bed = 3.5 hours.
Waking up at night (middle insomnia) To bed at 10:00 pm and fall asleep within 15 minutes.
Woke up twice during the night, each time losing about 30 minutes of sleep.
Awoke a third time at 5:00 am and stayed in bed for 3.5 hours before getting up at 8:30 am.
Total sleep = 6 hours. Time awake in bed = 4.5 hours.
After about a week, or once improvement occurs, you can adjust your allowed time in bed nightly rather than weekly using this formula:
Sleep efficieny = (time asleep) / (time in bed) * 100.
Below 80%: subtract 15 minutes from time in bed.
80-85%: keep time in bed the same.
Above 85%, add 15 minutes to time in bed.
Nightly adjustment
After age 50, people tend to go to bed earlier and wake up earlier.
Waking in the middle of the night is more common.
Sleep becomes more fragmented after age 60, so that people may effectively sleep in two shifts. In that case napping can be normal and health, e.g. 30-90min nap at a regular time (before 5pm). This needs to be individualized – best to add napping in after improvement with basic CBT-i to see whether it destabilizes the sleep cycle.
Modifications for Older Age
Modifications for Bipolar 1. Don’t restrict time in bed by <6.5 hours.
2. Address rewarding aspects of sleep-interfering behaviors.
3. Greater emphasis on circadian rhythms.
4. Morning: light, brisk wake-up, energizing activity.
5. Evening: dim light. Dark therapy if manic.
6. Addresses night-owl nature of bipolar (phase-delay) by gradually moving sleep-time 20-30min earlier each night.
7. Validate the realistic fear that lack of sleep could trigger a mood episode.
8. Use mood chart and connect sleep problems to mood problems.
Yearning for freedom from time constraints may impair adherence to sleep hygeine –Hagop Akiskal
Modifications for Night Owls Adolescents and bipolar clients tend to stay up late and wake up late….
1. Move the wake-up time up by 30-60 minutes each day, while keeping time allowed in bed the same.
2. If society allows, clients are welcome to keep their night-owl routine.
Questions?
Temperature & Sleep Drop in temperature signals
sleep. A Rise signals wake.
A very hot bath (not a shower) 1-2 hours before bed (102-104°F) for 20-30 min causes core body temperature to fall.
Sleep in a colder room (60-65°F)
For morning, program thermostat to increase temp.
Bath Safety Falls and drowning: Avoid alcohol, sleep meds, sedatives.
Blood pressure drops: Stay hydrated. Caution with pulmonary hypertension, emphysema, heart disease, renal disease, elderly, dizziness.
Skin burns, infection, breakdown: Avoid if active skin disease, neuropathy or numbness, any infections. Avoid > 30 min or temp ≥ 110°F.
Fertility: Avoid in pregnant women and men attempting to conceive (sperm count).
Questions?
End Day One
Therapy for Mood Disorders
Chris Aiken, MD Instructor, Wake Forest University Dept of Psychiatry Director, Mood Treatment Center Editor-in-Chief, The Carlat Psychiatry Report
Depression and Mood Disorder Certification Training
PESI, 2020
Social World
Mood disorders alter the perception of facial expressions, even when mood is stable.
=
S/S Gene The short-arm of the serotonin transporter This gene is associated with amygdala hypersensitivity to fearful faces (and fear in general). It also predicts higher rates of depression after stress.
Dark Blue: 2 short arms. Light Blue: 1 short, 1 long. Yellow: 2 long
Family Focused Therapy Free manual: www.semel.ucla.edu/champ
Reduce: Hostility, critical comments, scrutinizing mood, over-involvement Increase: Warmth, optimism, positive comments Communication: Reflective listening Regular family meetings Education: Family learns signs of illness so they can better focus on the person Plan for emergencies
Expressed Emotions
Critical comments Specific negative comments about the client
Expressed Emotions
Critical comments Specific negative comments about the client
Hostility
A belief that the client can control their symptoms
but chooses not to.
The client is seen as the cause of all the family’s problems.
Expressed Emotions
Critical comments Specific negative comments about the client
Hostility
A belief that the client can control the symptoms of their
disorder but chooses not to.
The client is seen as the cause of all the family’s problems.
Over-involvement Over-protectiveness, enmeshment, poor boundaries,
self-sacrifice, excessive praise or blame
Priebe et al, 1989 8 times more likely
Bipolar relapse in families with high EE…
Families with high EE benefit from communication skills
All received similar family therapy with education, but only the FFT group learned communication skills:
1. Active listening 2. Making requests for changes
in others’ behaviors 3. Offering positive feedback or
constructive criticism about specific behaviors.
4. Problem-solving
Taught through role playing and homework assignments
Milkowitz D et al, JAACAP 2009
Warm, optimistic and positive expressions help.
Angry, hostile, and critical expressions worsen outcomes,
Structured time to give feedback and problem-solve difficult topics.
When criticism is given randomly, it feels like it’s happening 24/7
Weekly meeting
“It is often the mother who carries the brunt of the illness’ burden. Such mothers themselves often go through periods of despair, hope and denial about their adult bipolar children.
This is often a lonely despair, about which kin not living with the family are ignorant of or indifferent to; at worst, such kin may even display critical and angry attitudes towards the caregiving mother (i.e. “You are a bad mother - you are not taking care of your sick child”), or even worse (“Your child's illness is due to you having abandoned her”).
Such criticism toward the mother is also routinely verbalized by the bipolar offspring, but unlike that of kin, may cycle into effusive expression of love and gratitude in a state-dependent fashion.”
—Hagop Akiskal, Care of the Bipolar Patient, 2011
On Mothers
Adult Children with bipolar living in the home If they can do something independently, allow them to.
Seize the day: Don’t avoid opportunities (e.g. college) because of fear of relapse or failing.
Set up realistic expectations with enforceable consequences for living in the home, much like you would with a tenant.
Living at home may be contingent on going to treatment, but not necessarily on taking medication.
Emergency plan
Crisis Plan
Anticipate problems Violence, suicidal behavior, substance abuse, overspending, and
fights that impact children in the home.
Plan Solutions Wellness Recovery Action Plan (WRAP) or Crisis Plan
www.dbsalliance.org/pdfs/wellness_toolbox/crisis_plan.pdf
Allow family to come to appointment or contact providers
Lock away guns, credit cards, extra medication
Temporarily live apart
Partial hospitalization or hospitalization
Young Children what to tell children of parents with mood disorders If over 12, talk about the disorder in specifics.
Otherwise use general terms and compare to physical illness.
Emphasize that their parent loves them.
Tell them it is not their fault.
Empower them: give specific things to do to help the family.
Encourage them to ask questions and talk about how they feel.
Strengthen sources of support outside the home.
Questions?
CBASP Cognitive Behavioral Analysis System of Psychotherapy Easier book: CBASP: A Distinctive Treatment for Persistent Depressive Disorder
CBASP is one of few therapies with efficacy.... > in chronic depression > as antidepressant augmentation
In a large study of chronically depressed people with early childhood abuse or neglect, CBASP was effect while antidepressant (nefazodone) was not.
CBASP: The Data
James McCullough , PhD, Founder of CBASP
CBASP for Chronic Depression
Keller MB et al. New Eng Med. 2000;342:1462-70. (n=681)
Theory of Chronic Depression Childhood maltreatment may have fostered survival skills
that were effective then but not now
Disengaged from their environment
Don’t respond to feedback, can’t learn
Locked in a primitive world-view that blurs the linear sequence of cause and effect
We Overestimate Their Logical Capacity
Reality is the way it is because “I believe it”
Monologue speech. They don’t talk with us. They talk at us. Empathic, bidirectional speech is absent
Ego centric. All roads leads to the client. You don’t exist for the client in any way that could change their behavior
Global thinking. Always, everyone, forever, never, nothing…
CBASP: Strategies Problem-solve desired vs. actual outcomes through
interpersonal exercises.
Pragmatic focus on transference distortions.
Increase client’s awareness of their effect on others.
Which relationships left a mark on you? For each one, how did they react when you...
Asserted your needs?
Expressed negative emotions?
Made mistakes?
Sought to be close to them?
Interpersonal Inventory
CBASP: Interpersonal History
Sought Intimacy Failed, made mistakes Expressed Emotional
Needs Expressed Negative
Affect
Father He goes away He beat me Ignores my feelings He tells me to suck it
up
Mother Uses me to do things for
her Ignores it unless it
effects her Tells me not to be
emotional Gets angry at me
What was the mark each person had on your life?
Disciplined Personal Involvement
Reveal your reaction to the client to help them learn how they effect others.
Hot Spot: when client would expect you to be rejecting, dominating, hostile, or withdrawn… act the opposite way and call attention to the difference.
Use yourself as a tool for the client to learn verbal and non-verbal empathy and give and take.
Interpersonal Discrimination
The way it was then
with my parent
The way it is now
with my therapist
Fearful
Unsafe
Unchanging
Hopeless
Helpless
Safe
Helpful
Hopeful
Empowering
Avoidance Approach
Tell a story about a recent personal interaction. What happened? What did you do? What was said? What were your emotions and perceptions? What did it mean to you?
The story should have a beginning, middle, and end.
What was the actual outcome?
How did you want it to turn out?
How did your perceptions and actions influence the outcome and how could you improve on that?
Situational Analysis
If you don’t like the way you feel, then you must change your behavior
Questions?
Behavioral Activation Easier book: Behavioral Activation by Jonathan Kanter (CBT Distinctive Features)
Behavioral Activation WORKS As well as CBT, and more effective than CBT for severe depreession
WHAT IT IT’S NOT Lists of activities Purely behavioral
WHAT IT IS Identifying avoidance Gradually overcoming anxiety Values-based action
Jacobsen N et al, 1996
BA outperforms CBT in severe depression
Dimidjian S et al, 2006
Remission rates greater with BA in severe depression
Dimidjian S et al, 2006
23% Medication (ADM)
36% Cog Therapy (CT)
56% Behav Activ (BA)
DEPRESSION CAUSES...
Passivity: “Things happen to me,” without a sense of one’s role
Avoidance of unpleasant feelings (anxiety)
Tendency to interpret others as rejecting or critical
Erosion of pleasure, meaning, and values BA HELPS PEOPLE ENGAGE WITH....
Moment-by-moment awareness of actions and choices
Values they can live by
Purposeful action
Behavioral Activation
Behavior is everything a person does...
Actions: Approach, avoidance
Private behaviors: Thinking, feeling
There is no judgment about will or intention
Behavioral Activation
Positive reinforcement Adding a reward makes the behavior more likely
Negative reinforcement Removing something aversive makes the behavior more likely
Punishment Adding something aversive makes the behavior less
Extinction Removing a reward makes the behavior less likely
Reinforcers
Positive Reinforcement
Adding something rewarding (a text message)
makes his cell phone use more likely to happen
Removing something aversive (parents)
makes the behavior more likely to happen
“I can’t stand my parents” Negative Reinforcement
Adding something aversive (wrist pain)
Punishment
makes the behavior less likely to happen
Removing a reward (cell phone)
Extinction
makes the behavior less likely to happen
“I enjoy it.”
“It’s a responsibility I have to take care of.”
“It’s a step towards something better in my future.”
“It’s part of my beliefs and values.”
“I was avoiding uncomfortable feelings or a difficult situation”
Common Reinforcers
Behavior is everything a person does...
Behavior: What are they doing?
Antecedent: What is going on, what’s the context, when they do it?
Consequence: What happens after they do it?
Behavioral Activation
The ABC’s of CBT and BA
Cognitive
Antecedent Invited to a dinner, anxious
Belief “I’m not likeable”
Consequence More depressed, stay at home
Behavioral
Antecedent Invited to a dinner, anxious
Behavior Stay at home
Consequence Reduced anxiety
Target for change What reinforces Behavior
Diverse and stable rewards
DEPRESSION RESULTS FROM LACK OF CONTACT WITH
Increase contact with diverse, stable, meaningful rewards
THE GOAL
Devotion to a single pursuit with unstable reward, e.g.
Artistic fame
Creating ideas
Composing
Collaborating
Public performance
Mastery of instrument
Recording & Technology
Marketing
Depression is an adaptive response to loss of rewards
Problem solve
Elicit support
Signal retreat
so as to avoid conflict and further loss
ORIENT THE CLIENT
Take history
Link behavioral model to history
Explain nature of sessions
Depressive behaviors are normal, understandable responses
Goal is to learn to take action even in the face of negative thoughts and difficult feelings.
Often this means to act the opposite of your feelings and knowingly approach unwanted experiences
This is a skill; the therapist is a supportive coach.
Opening Session
ORIENT YOURSELF
There are no failures – goal is understanding. It’s rare for clients to complete homework 100%
Your interest is in understanding behavior – what the client does – and what makes it more or less likely. Not their intentions or will power.
Your interest is in the function of their thoughts – what their thoughts lead to – not in their validity or content.
Opening Session
CALENDAR WEEK 1
“The heart of this therapy is in understanding what you do each day and how that affects your mood and life. To help me get a better picture of that, I’d like you to record as much as possible of what you do each over the next week. Include things that seem like “nothing” – if you are sitting and worrying write that. Don’t try to make it look better than it is. I want to know how badly this depression is for you.”
Any form of calendar that gets the information will do.
Optional: Rate mood 0-10 throughout day
First assignment
Always Decide on a time and place for activation assignments
REVIEW CALENDAR
Positively reinforce any completed effort
Look for times of low activity, avoidance, approach
ACTIVITY ASSIGNMENTS
Develop list of approach activities with client, have them rate by difficulty, and schedule in upcoming week.
Choose activities collaboratively – What is easiest? Are basic daily routines missing? What is most likely to be rewarding, especially with diverse and stable rewards.
Anticipate difficulties in completing assignments.
You’ll be interested in how the assignment goes – whether they do it or not – you’ll want to know the details
Session 2
Antidepressant Activity
1. Time flies
2. Un-self-conscious
3. Challenging enough
4. Sensory involvement
5. Clear goals, quick feedback
6. Slightly addictive
7. For the love of the game
8. A higher cause
Mindful Media
1. Limit screen time
2. Use it as a reward
3. Watch with intention
4. Get absorbed, but avoid binge watching
5. Move around and laugh a little
Mindless Media
1. Social comparisons
2. An unruly social media circle
3. Advertisements
4. Gratuitous violence
5. Daily news
6. Reality TV
7. Binge watching
FUNCTIONAL ASSESSMENT OF ASSIGNMENTS
If successful, continue to build activations
If not successful, problem-solve
Ask about the context/triggers, the immediate result, and the long-term result. How did it work? How did it affect their mood?
Session 3+
Forgot Stimulus control:
Post-it notes in place that’s relevant to the action.
Smartphone, family or friends for reminders.
Skill deficit Non-social skills
Courses, learning, practice
Social skills
Borrow skills modules from other therapies, e.g. DBT
Skill deficit 1. Break it down into simpler steps
2. Practice and prepare
3. Focus on the process, not the outcome
4. Imagine how you’ll feel when it’s done
External consequences
How would family or friends respond if you did this?
Contract with others and client together to change reaction.
Internal consequences
Experiential avoidance is default reason if no other comes up. If client is vague about reasons, they may be avoiding in session.
These activations will take longer work.
Internal consequences Distress tolerance
Mindfulness
Sensory-based skills (music, aromatherapy, deep breathing)
Values
Values-based action is easier to sustain in absence of rewards
Marriage, dating, intimate relationships
Parenting
Other family relationships
Job, meaningful work
Education, training, life-long learning
Recreation, hobbies
Creative and artistic expression
Spirituality
Citizenship, community, activism, altruism
Health, nutrition, self-care
Life organization, time management, discipline, finances
Values
“What is important to you?”
“What used to give your life purpose?”
“Do these goals reflect any one else’s values?”
“Would these goals still be important to you if no one else was aware of your success or failure?” “Would you be happy – or unhappy – if you
achieved this goal?”
“Would this goal still be important if it did not lead to certain outcomes, such as praise, success, promotion, money?”
Core Values
“What goals would you like to work towards in treatment?”
“In what ways would you like things to be different?”
“What would you most like to change about your circumstances?”
“What things have you stopped doing since you became depressed that you would like to resume?”
“Are there any things you have started doing since you became depressed that you would like to change?”
“What would you be doing differently if you were not depressed?
Goal Questions
Functional goals are…
Specific: concrete, broken into steps
Measurable: pursuing something, rather than avoiding something
Achievable: within their control
Realistic: adjust if not
Time-limited: time-line with outcome
Goal conflict
“I want people to do things the right way…”
“I don’t want to disagree with people”
S.M.A.R.T. Goals
Putting values into practice
Reminders
Pictures, quotes in relevant places
Morning walk Start the day by reflecting on values
Rumination
Staying in bed
Staying at home
Avoiding conflict
Avoiding risk, challenge, and responsibility
Putting off jobs
Avoiding people
Avoiding promotion at work
Avoiding evaluation or judgment by others (e.g. tests, exams, interviews)
Abstract thinking
Distraction
Analyzing events over and over for certainty and control
Reassurance seeking
Complaining
Emotional avoidance (blocking or suppressing emotions)
Avoidance Behaviors
Direct action
Asking people for help and support
Being assertive
Taking risks
Trying new things
Making decisions and plans
Taking responsibility
Expressing feelings to others
Social contact
Scheduling activities
Testing things out by trial and error in the world
Problem solving
Learning and developing skills
Allowing oneself to experience feelings
Staying with details of memories
Approach Behaviors
Warm, supportive, validating, patient, understanding
Bring the abstract into the concrete
Address in-session behaviors that are relevant to activation: Avoidance, non-assertiveness
Therapist as reinforcement: e.g. If client completes assignment, they can use session time to talk about what they want; otherwise will talk about assignment
Act natural. Natural reinforcers are more generalizable. Avoid artificial praise.
Therapeutic Relationship
What are you feeling right now?
I see that you are struggling with your emotions at this
experience rather than fighting it and, without judgment, tell me what you are feeling.
Where do you feel it? In your chest? Behind your eyes? In your shoulders?
Take your time with this and mindfully explore this feeling for me if you are able. I will be here for you and I am open to anything you may experience.
─ JW Kanter et al, Behavioral Activation, 2009
How does therapy reinforce activation? Can it continue in its absence?
Gradually space out sessions, shorten their duration
Prepare for future risk periods, like major life changes, holidays and other disruptors of routines, and early signs of depression
Ending Therapy
Activation Guide Skills
Awareness of environment
Self-assessment
Self-activation
Tools
List early warning signs, activities, values, obstacles and ways to overcome them
Questions?
Rumination Focused Cognitive Behavioral Therapy
Recognize the Types
Dwelling, brooding, worry, obsessing, pondering, over-analyzing, stewing, “stinkin’ thinking”
“Yes, but…”
Rumination about rumination
Rumination about therapy
Co-rumination with the therapist
Rumination
Risk factors
Unreachable goals
Poorly defined goals
Goals that are hard to let go of
Inadequate skills to reach goals
Rumination
A gap that won’t close
Validate!
Thoughts that lead to a decision or plan
Specifics, like “What? Where? When?”, rather than abstract or general terms
Answerable questions
“How” rather than “Why”
Helpful Rumination
but I never walk backwards
I walk slowly
Stephen Spielberg’s
Scary Whispers
Stop Ruminating!
Habit Reversal Recognize early signs and risks
Intervene early with actions that are incompatible with rumination
Identify rewards of rumination
Goal is to reduce frequency, not eliminate it
Environmental risks…
Early in the morning
Late at night
When alone, tired, bored, or unoccupied
Pain, tension, or physical symptoms
Feeling pressured or disorganized
Withdrawing when upset (often to the bedroom)
Early Signs
Internal thoughts:
The self: mental and physical symptoms
The past: upsetting events, unresolved conflicts
The future: catastrophizing, worry
Social: other people’s intentions
Early Signs
Tracking Like a treasure hunt… “What new cues of rumination did you discover?”
Choose two situations with opposite outcomes; one a success and one a failure. For each one…
What? Include goals, events, actions, feelings, physical state, outcome
Where? Location, setting
When? Time, day, what came before the situation
How? Step by step how the event unfolded, your approach during the situation
Who was involved?
Functional Analysis
Avoidance
> Thinking about a problem rather than confronting it
> Anticipating rejection rather than facing the risk
> Avoiding painful details by abstracting
Feels like you’re solving or understanding a problem
Rehearse future events, worry to prevent errors
Revenge fantasies in angry rumination
The Rewards of Rumination
Anti-Ruminators
Conversation
Sports, board games, puzzles
Comedy, entertainment
Researching
Spiritual or religious activity
Music or dance
Art project, cooking, or knitting
A warm bath
Exercise, walking, biking
A pager-turner
Engaging activity
Behavioral Activation Quiets the Default Mode Network
RCT of 5 session of BA in adolescents, n=40, Yokoyamaa et al, 2018
Before After
A 90-minute walk in the woods reduced rumination more than a walk in the city
RCT of 38 healthy adults (Bratman GM et al, 2015)
Drop in Rumination Drop in Default Mode
After a Forest Walk
Take your time…
One thing at a time
Reduce demands
Allow adequate time to complete things
Simplify
Deliberately attending to the present in a friendly, nonjudgmental way.
Notice ruminative thoughts without trying to change, run from, or get caught up in them.
Mindfulness
The awareness of what is, at the level of direct and immediate experience, separate from concepts, category, and expectation.
-Dimidjian and Linehan
Allowing ourselves to be moved by suffering,
and experiencing the motivation to help.
Compassion
Do you relate to your struggle with…
Self-criticism, attack, shame, thinking you’re a problem,
Physical reactions of threat (fight/flight)….OR
Supporting, reassuring, encouraging yourself
Wisdom, kindness, courage
Acceptance and tolerance
Create a compassionate voice and script: “This too shall pass,” “I’m doing the best I can.”
Compassion
Recall painful memories in full sensory detail.
Watch for abstraction and rumination, which are ways to avoid the experience.
Allow self to be moved by the memory, letting go of the desire to change or avoid it.
Immersion in Memories
Questions?
CBT for Suicidality
CBT for Suicide Prevention (CBT-SP)
CBT-SP reduces suicide attempts by 50%*
10-16 sessions after a suicide attempt
Suicidal behavior is an understandable reaction given their
circumstances and frame of reference, but one that is
ultimately disadvantagous to the client
*metaanalysis of 10 controlled studies, 1,241 patients (Gøtzsche, 2017)
Key Ingredients
1. Attention to drop-out: Engage client quickly
2. Hope
3. Problem-solving: Suicidal patients jump quickly to a most
extreme solution
4. Social supports
5. Emotion regulation (self soothing)
6. Impulsivity
7. Hope box, Coping cards, Safety plan
8. Imaginal exposure to practice new learning
Structure of Sessions
1. Set agenda
2. Check symptoms (mood, suicidal ideation, etc)
3. Monitor substance use
4. Monitor adherence to psych meds and physical health care
5. Build bridges between past sessions with a particular focus on
beliefs related to the suicide attempt
6. Make capsule summaries
7. Elicit feedback throughout the session
8. Assign homework
Therapeutic Relationship
Flexibility
Empathic, validating, while at the same time
keeping the focus on the problem at hand
Prioritize Autonomy
Client cannot change their life if they aren’t in the drivers seat.
Put them there explicitly.
“I cannot prevent you from suicide,”
but acknowledge reality of involuntary commitment
Early Phase
Early Phase Goals
1. Engage client
2. Have them tell their story about the suicide attempt
3. Assess risk collaboratively
4. Safety plan for emergencies
5. Orient to CBT model
6. Collaboratively develop a cognitive conceptualization of the
suicide attempt, problem list, and goals (skills, life stressors)
7. Convey hope
Engage the patient
1. Simply scheduling an appointment is usually inadequate
2. Reminder calls
3. Discuss factors that would prevent them from attending
4. Discuss ways you’ll reach them if no-show
5. Conduct no-show sessions by phone
Tell the story
1. Thoughts, feelings, mental images, and events leading up
to the attempt
2. Empathy. Listen. Bear witness. They should feel heard.
3. May be first time they’ve shared the full details with another
Safety plan for crises
1. Clients cannot think straight when suicidal
2. Collaboratively develop list of strategies for emergency
3. At a minimum, include phone numbers of
Supportive people
Therapist and on-call providers
24-hour emergency psychiatric center
Other services that handle emergency calls
National Suicide Prevention Lifeline, 1-800-273-TALK
Coming soon: Dial 988
Cognitive model
1. Teach about how interpretations
influence feelings, and behavior.
2. Homework (skill based, or book
Choosing to Live)
3. Chain analysis of attempt
Stressors
Skill deficits and problems with
processing information
Dysfunctional core beliefs
Problem solving
What problem(s) lead to the attempt?
Can the attempt be reframed as an effort to solve that problem?
To escape from pain that seems unbearable and unending
To change something in their environment
Make a full problem list, divide into solvable and unsolvable
“Help clients adopt a more flexible approach to problem-solving and
modify beliefs that their problems are unsolvable or unbearable”
Hope
Hope in the face of adversity is more functional than hopelessness
No cheer-leading, Pollyanna, however
Middle Phase
Coping cards
Side 1: Automatic reaction
When stressed, slow down and notice your thoughts,
feelings, or impulsive. Write on front of card.
Side 2: Adaptive response
Work in session to develop an alternative to side 1
Coping Cards
Side 1
“This is hopeless
and will never get
better”
Side 2
“I have solved
problems that looked
unsolvable at first
before, like when I
moved here with no
one and found friends”
“Getting hopeless
does not help, I need
to talk with someone
who can help me get a
more objective view”
“Although I am overwhelmed now, I know this is temporary”
Hope Kit
1. A memory aid of reasons to live and adaptive strategies
developed in session
2. A box with items in it, e.g. pictures of family or pets, sentimental
gifts or objects, an award from school, a letter from a friend,
passage from a spiritual text, a prayer card, and a coping card
3. Put it in a conspicuous or easy to find place
“Many clients
report that the
Hope Kit is the
most
meaningful part
of cognitive
therapy.”
Virtual Hope Box
1. Relax: Breathing, muscle relaxation, guided
meditations
2. Distract: Puzzles, word games, solitaire
3. Inspire: 100 inspirational quotes
4. Coping: Cards, and activity planner
5. Phone contact list
6. Favorite songs
Though practical and portable, it lacks the
sentimental touch of real objects.
But it’s got music.
Distress Tolerance Skills
1. Self soothing
2. Exercise
3. Progressive Muscle Relaxation
4. Breathing exercises
5. Recall positive memories or pleasant scenes
6. Distraction techniques (Count 7 things in the room)
7. Aromatherapy, hot bath
8. Apps: Stress Free, Panic Relief, Breath2Relax
Aromatherapy
Calming scents
Lavender
Jasmine
Chamomile
Sweet marjoram
Frankincense
Bergamot
Impulsivity
1. Suicidal impulses come and go in waves
2. Goal is to wait them out
3. Safe-guard environment to make action more difficult
4. Hierarchy of strategies for impulsive times
Call or visit a friend
Engage in a task (clean, sing along with music, start a puzzle)
Sleep
Call therapist
5. Short-term solutions for impulsivity. Long-term solutions for life.
Long term goals
1. What have they been meaning
to do with their life?
2. Homework
Create a list of these and write
down why each is important
Social supports
1. Who is most caring in your life or willing to help?
2. Clients often believe no one cares, so use detailed questions or
family meeting to identify sources of support.
3. Are institutional supports in place?
Primary care physician, social services, church
Ending Therapy
Imaginal exposure of past attempt
1. Recall events leading up to past attempt with all senses.
Relive the pain and distress they experienced
2. Then… imagine using coping strategies instead of suicide
3. Important to explain rationale (consolidating learning) and warn
that they may have intense emotional reactions to the imaginal
exposure
Imaginal exposure with relapse prevention drill
1. Imagine future situation that might lead to suicide
2. See if they can use alternative coping in that situation
3. When they do, praise client but offer additional challenges to see
if they can continue to respond adaptively
Afterwards, debrief, check in.
Explore any suicidal ideation activated by the task.
Client remains in the session until all such thoughts have subsided.
Moving on
1. Discuss how the future will look
2. Support realistic expectations
Life has ups and downs, but that’s not the same as relapse
Modifications for adolescents
1. Psychoeducation for family on nature of depression, suicide
attempts, and treatment. Address problematic beliefs.
2. Family check-ins (5–15 minutes) are optional, but most session
time is for client.
3. Longer sessions with family to encourage their support and teach
Problem-solving skills
Emotion-regulation
Communication skills
Behavioral activation as a family
Modifications for adolescents
1. “No questions asked” turn in policy to get rid of pills/razors/etc.
2. Make a plan with relatives for room checks
3. Create a “safe space” in bedroom
(i.e., removing any upsetting pictures, posters, music, etc.)
Step 1: Look for Solutions
A crisis is a major stress that can’t be readily fixed or easily ignored, but there may be aspects that can be solved or worked on for part of each day
Step 2: Distress Tolerance
Improve the moment with distractions, ACCEPTS
Step 3: Avoid making it worse
If you can’t make it better, shift your goal – avoid making it worse
Irregular sleep, inactivity, poor diet, intoxication, self-harm, heated arguments, and other destructive behaviors
Crisis Survival
Questions?
Diet
Vegetables Daily servings ≥ 6
One servings = ½ cup
Aim for variety of colors. Include green leafy vegetable or tomatoes in at least one of those servings.
Frozen is fine. Mushrooms count. Limit potatoes to one serving a day unless it’s a sweet potato.
Fruit Daily servings ≥ 3
One servings = ½ cup
Include berries in at least one of those servings.
Dried fruit fine but watch for added sugar.
Limit fruit juice to no more than one of those servings.
Nuts, seeds, olives
Daily servings ≥ 1
One servings = ¼ cup nuts or seeds, ½ cup olives
Minimize salt.
Peanut butter and other spreadable nuts count, but look for low sugar options.
100% whole grains
Daily servings ≥ 5-8
One serving = 1 slice bread ½ cup cooked rice or pasta ¼ cup oats or muesli
Bread, brown rice, whole wheat pasta, oatmeal, muesli cereal, whole wheat crackers, quinoa.
The bran and germ has the healthy stuff: Antioxidants, B vitamins, fiber, and other nutrients
Not that! Eat this
Not that! Eat this
Not that! Eat this
Home Popcorn Ingredients
1/3 cup popcorn
3 tab extra virgin olive oil
Directions
Place olive oil in heavy bottom pot on high heat. Add 3 kernels of popcorn. When they pop, add the rest.
Cover and turn off heat for 30 seconds.
Turn head back to high and shake pot every few seconds. Lift the cover slightly ever 15 seconds to let out steam.
When popping slows, turn off heat and add popcorn salt or seasonings to taste.
Fish Weekly servings ≥ 2
One serving = 3 oz cooked.
“Fresh” fish is often defrosted, so frozen is a wise buy.
Costco’s frozen Kirkland Atlantic salmon preferred by chefs.
Beans
Weekly servings ≥ 4
One serving = ½ cup beans, or 1/3 cup hummus or tofu.
Edamame, humus, tofu, and falafel count.
Extra Virgin Olive Oil Daily servings = 3 tab
Olive oil is low in saturated fats, and extra virgin has brain-healthy antioxidants.
EV olive oil burns ≥ 325-400°F. For high-temperature cooking, use regular olive oil (465°F), safflower oil (510°F), or avocado oil (520°F)
“Extra virgin olive oil [is] the most stable oil when heated, followed closely by coconut oil and other virgin oils such as avocado and high oleic acid seed oils.” -Guillaume C, 2018
Phenols and antioxidants protect it from breaking down when heated. Reusing olive oil can increase the trans fats.
Guillaume C., et al, Acta Scientific Nutritional Health 2.6 (2018): 02-11.
g g
Safety line 25%
Low polar compounds
High oxidative stability
Lean red meat Max weekly servings = 3-4
One serving = 3 oz.
Poultry Max weekly servings = 2-3
One serving = 3 oz.
Milk, cheese, yogurt Max daily servings = 3-4
One serving: Milk: 1 cup milk (250 mL)
Yogurt: 200 grams
Hard cheese: 40 grams
Soft cheese: 120 grams
Eggs Max weekly servings = 6
Less if high cholesterol
Eat in Moderation
Questions?
Processed foods Fried foods Fast foods Sweets Sodas White bread/pasta Deli meats Bacon, beef jerky Butter, condiments
Max weekly servings = 3
One serving = 120 cal.
Eat less of
Purchasing tips
Highly processed foods:
Packaged meals, hotdogs, cold cuts, bacon, sausage, soda, chips, microwave popcorn, candy, frozen desserts, sugary breakfast cereals, energy bars, bottled drinks, Frappuccinos, pre-mixed baking items, margarine, and premade sauces.
Choose packaged foods with
Fewer chemical ingredients Lower salt Lower added sugars
Limit added sugars to
Women: 25g a day Men: 36g a day
Coffee or Tea?
Dong X et al, 2015
3 cups of tea a day lowers risk of depression by 37%
11 studies, 23,000 people
Green, black and white tea from the Camellia sinensis plant.
Brain benefits from Epigallocatechin gallate, catechins, flavonoids, polyphenols, and L-theanine. Risks: Renal stones, cancer if throat burn
Grosso et al, 2016
Depression risk falls with moderate coffee use, but rises with more than 1-2 mugs a day
12 studies, 347,000 people
Risks: Insomnia, dependence, tremor, anxiety, reflux, diarrhea, headaches, high blood pressure (but protects against heart/liver disease & diabetes)
Max cups/day of caffeinated beverages for brain health
Beverage Max metric cups/day
Brewed Coffee 2
Latte or mocha 2.5
Espresso 0.5
Instant Coffee 5
Brewed black tea 6
Brewed green tea 10
Bottled tea 8
Cola 6
Energy drink 1.5
Energy shot 0.3
Alcohol ≤ 1.5 standard drinks/day:
6.8 ounces wine
2 bottles beer
1 bottle high gravity beer
2 ounces spirits
5 ounces sherry or port
Red wine is best
Fish Oil (1-2,000mg of DHA + EPA, EPA should be at least 60% of total)
Salmon (10 oz/week farm-raised) Trout, herring, caviar, anchovies, mussels,
Albacore (white) tuna, anchovy Walnuts, flax seed, edamame, kiwi
Omega-3
Risks: Bleeding if taken before surgery
Turmeric MENTAL BENEFITS Depression: 1,000mg daily with curcumin BCM-95
6 controlled trials; in one it was equal to fluoxetine (Prozac) Particularly for middle-age and older adults Cognition May prevent dementia
PHYSICAL BENEFITS Arthritis Anti-inflammatory Anti-cancer Diabetes, high cholesterol RISKS: Kidney stones 1 teaspoon a day in young adult study
Cinnamon Protects the brain’s memory center
(hippocampus) and may improve cognition Improves diabetes, cholesterol Dose 1/8 to 1.5 teaspoon daily Ceylon cinnamon safer than the more
common Cassia type (for liver)
1 teaspoon a day in young adult study
Dark Chocolate Brain and heart benefits for a few
ounces per day of at least 70% cocoa
May prevent diabetes, weight gain, and improve cholesterol
CocoaVia, a flavanol extract of dark chocolate, improved age-related memory loss (by 30 years) and protected hippocampal cells (dose 900mg daily, equal to 8 bars of dark chocolate per day)
Based on cross-sectional study of 13,000 adults Average intake: ½ ounce of > 45% cocoa Controlled for physical activity, smoking, alcohol, and total sugar and caloric intake, gender, marital status, education, income, weight, and presence of chronic medical problems.
Jackson SE et al, 2019
Risk of Depression by Chocolate Intake
Probiotics Improved anxiety,
depression, cognition, mania in dozens of studies, but only about half are positive
Also aid weight loss, irritable bowel syndrome, and fatty liver
Diet and Mania
High fructose corn syrup caused manic-depressive behavior and bipolar brain-changes in rats
In humans it impairs memory
Diet and Mania Beef jerky associated with 3-fold increase in mania in 2018. Animal studies pinned this down to nitrates in the meat that caused bipolar-like changes in the brain.
Unknown if bacon, hot dogs, and deli meats will do the same.
Cookbooks America’s Test Kitchen. The
Complete Mediterranean Cookbook (2016).
Christy Ellingsworth and Murdoc Khaleghi M.D. The Everything Guide to the MIND Diet (2016)
Maggie Moon, MS, RDN. The MIND Diet (2016)
Rebecca Katz. The Healthy Mind Cookbook (2015)
Leslie Korn. The Good Mood Kitchen (2017)
Free: moodtreatmentcenter.com/antidepressantcookbook.pdf
Measure Start Diet Off On Off Diet
Questions?
Natural Supplements
Omega 3 Fish oil, 30% of the brain
Improves flexibility of brain cell membranes
Treats: depression, bipolar, irritability, borderline, emotional features of ADHD. Prevents psychosis and dementia.
Dosage 1-3,000mg daily, with EPA = at least 1.5 times DHA amount
Omega 3 Physical Benefits: Reduce cholesterol, blood pressure, and inflammation.
Lower the risk of cancer, stroke, osteoporosis, psoriasis, inflammatory bowel disease, macular degeneration, and asthma.
Recommended products at www.moodtreatmentcenter.com click Brochures
Vayarin, Vayacog FDA approved for emotional symptoms of ADHD (Vayrin) and cognitive decline (Vaycog).
Combines omega-3 (EPA+DHA) with another component of brain membranes: Phosphatidylserine.
N-Acetylcysteine (NAC) Main antioxidant in the brain.
Improves low-grade depression in bipolar and schizophrenia.
Treats trichotillomania (compulsive hair pulling), skin picking, self-cutting, and nail biting, OCD.
Addictions (e.g., marijuana, cocaine, nicotine, gambling).
Dementia.
Dose 2,000mg daily.
Recommended products at www.moodtreatmentcenter.com click Brochures
L-Methylfolate (Deplin) FDA approved to augment antidepressants.
Works preferentially in obesity, inflammation, elderly, and people with MTHFR c-677t gene.
Small study showed efficacy in bipolar depression.
Involved in production of neurotransmitters.
Vitamins Folate 2mg daily with vitamin B12 400–600 mg daily. Prevents depression, improves SSRI efficacy.
Vitamin D for unipolar and bipolar.
SAM-e Natural methyl-donor, involved in serotonin, dopamine, norepinephrine.
Best-studied natural supplement for depression; worked as well as a tricyclic antidepressant.
Dose 400–1,600 mg daily.
Can trigger mania.
Lavender (Silexan) Prescription medicine in Germany.
Improved Generalized Anxiety Disorder better than paroxetine (Paxil).
Recommended products at www.moodtreatmentcenter.com click Brochures
Chamomile Improves anxiety and sleep.
Dose 220mg/day, with 1.2% apigenin
Recommended products at www.moodtreatmentcenter.com click Brochures
Melatonin Naturally increases in darkness and shuts off
with bright/blue light.
Mild benefits in sleep, 0.2-5 mg at night, can use SR version.
Can take with zinc 11.25mg and magnesium 225mg, which enhance natural release.
Sustained release melatonin
Reliable Brands Time release: Natrol Melatonin, Sam’s Club
Member’s Mark, REMFresh, Source Naturals time release. Instant release: Swanson’s natural
Dr. Wurtman’s combines instant release and sustained release
Melatonin
Dr. Wurtman’s Melatonin
Melatonin Useful in elderly, shift-work, and jet-lag.
Prevents weight gain on antipsychotics (3-5mg/night), migraines, and possibly tinnitus.
Possible treatment for depression (e.g. taken with buspirone, as melatonin agonists: ramelteon or agomelatine).
Other For Unipolar: Chromium picolinate (600 mcg daily)
Saffron (30 mg daily)
Creatine (5 grams daily; effect when used with an SSRI antidepressant in women)
Acetyl-L-carnitine 1,000–3,00 daily
St. John’s Wort (Hypericum perforatum) 900–1,800 mg daily
Rhodiola rosea (200–400 mg daily)
For Bipolar: Inositol
Magnesium
EMPowerPlus
Some natural treatments for unipolar can worsen mood in bipolar.
Lightbox Treats depression as well as an antidepressant.
Can work in summer as well.
Typically started early in morning (use AutoMEQ test at cet.org to optimize timing) for 30-60min per day.
For bipolar can start at noon.
Need to sit close to it, and box should be above head.
Can be combined with Wake Therapy and lithium (triple chronotherapy).
Uplift Daylight XL and Recommended products at www.moodtreatmentcenter.com click Brochures
Negative Air Ions Prevalent in beaches, waterfalls, humid forests.
Depleted by air conditioning and dehumidifiers.
Filters dust, smoke, pollen, and mold spores.
Treats depression in 5 controlled studies1
Possibly safe/effective in mania2
1Perez, BMC Psychiatry, 2013. 2Giannini, Psychol Rep, 2007
Negative Air Ionizer Sit beside it 30min in morning, or have it
auto-turn on/off 90min before awakening.
Some models produce unhealthy ozone.
Can be used 24/7.
Instructions at cet.org
Wein Room Air Purifier $75 on Amazon.
Questions?
Medication
Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia
Causes of Premature Death in Bipolar
Heart disease Stroke Cancer Diabetes mellitus Chronic obstructive pulmonary disease (COPD) Pneumonia and influenza Accidental injuries Suicide
Top Ten Updates 1. Medication increases lifespan in mood
disorders, ADHD, and schizophrenia. 2. Lithium lowers rate of suicide attempts,
completion, and suicidal thinking.1
1Based on data from 100,000 people. Goodwin & Jamison, Manic Depressive Illness, 2007.
Top Ten Updates 3. Lithium prevents dementia and has other
health benefits, lowering the risk of: Dementia Cancer Heart disease Stroke Neurologic illnesses Protects telomeres in the genes Enhances growth in the brain
Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia. 2. Lithium prevents dementia and has other health benefits 3. Lithium lowers rate of suicide attempts, completion, and suicidal thinking 4. Latuda (lurisidone) and Vryalar (cariprazine) FDA-approved for bipolar
depression. 5. Ingrezza and Austedo are first FDA-approved treatment for tardive dyskinesia. 6. New antidepressant vortioxetine (Trintellix) improves cognition and lacks
sexual side effects.
Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia. 2. Lithium prevents dementia and has other health benefits 3. Lithium lowers rate of suicide attempts, completion, and suicidal thinking 4. Latuda (lurisidone) FDA-approved for bipolar depression. Vryalar (cariprazine)
may be next. 5. Ingrezza is first FDA-approved treatment for tardive dyskinesia. 6. New antidepressant vortioxetine (Trintellix) improves cognition and lacks
sexual side effects 7. Don’t take with food (slows them down): Sleep meds and Adderall-XR 8. Warning placed on Abilify (aripiprazole) for gambling risk 9. Trazodone associated with suicidal risk 10. Varenicline (Chantix) relative safe for smoking cessation in psychiatric patients
Therapy and Meds 1. Benzodiazepines may slow learning if taken during CBT or exposure
therapy. 2. Cycloserine (an older antibiotic that’s hard to find) speeds learning if
taken before exposure exercises. 3. Benzodiazepines (and alcohol) increase risk of PTSD if taken after a
trauma. 4. Hydrocortisone (a steroid) and possibly propranolol (blood-pressure
med) reduce risk of PTSD if given after a trauma.
Antidepressants Buproprion (wellbutrin), fluoxetine (prozac), ?emsam patch (MAOI).
Mood stabilizers Lamotrigine (lamictal), carbamazepine, ?lithium.
Atypical Antipsychotics Best: Ziprasidone (geodon) best. Worst: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), clozapine (clozaril).
Low Weight Gain
Antidepressants Buproprion (wellbutrin), fluoxetine (prozac), emsam patch (MAOI) SNRIs: Desvenlafaxine (pristiq), duloxetine (cymbalta), levomilnacipran (fetzima), milnacipran (savella), venlafaxine (effexor).
Mood stabilizers Lamotrigine (lamictal), lithium.
Atypical Antipsychotics Low risk: Aripiprazole (abilify), brexpiprazole (rexulti), paliperidone (invega), lurisidone (latuda), cariprazine (vraylar). Higher risk: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), ziprasidone (geodon), clozapine (clozaril).
Low Fatigue
Antidepressants Buproprion (wellbutrin), mirtazapine (remeron), vortioxetine (trintellix), vilazodone (viibryd), ?emsam patch (MAOI).
Mood stabilizers Lamotrigine (lamictal).
Atypical Antipsychotics need data Low risk: Aripiprazole (abilify), brexpiprazole (rexulti), paliperidone (invega), lurisidone (latuda), cariprazine (vraylar). Higher risk: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), ziprasidone (geodon), clozapine (clozaril).
Low Sexual Side Effects
Antidepressants Buproprion (wellbutrin), vortioxetine (trintellix) improve cognition. Most others are neutral.
Mood stabilizers Lamotrigine (lamictal) best.
Also lacking weight gain, sexual dysfunction, cognitive problems: Pramipexole (mirapex) treats restless leg syndrome and both bipolar and unipolar depression. It can cause fatigue. Modafinil (provigil/nuvigil) treats fatigue, ADHD, and partially helps both bipolar and unipolar depression.
Low Cognitive Effects
The main reason people with bipolar stop meds is not because they miss the mania; it’s because they don’t think they are working. Chance of bipolar episodes returning: 95% in next 5 years after stopping Chance of unipolar depression returning:
Prevention is necessary. Meds are one tool in prevention.
Can I Stop Meds?
Past depressions Chance of relapse
1 50% 2 70% 3 90%
One at a time.
Slowly; at least 2 weeks. 2-6 months may be better.
Only after symptom-free for 6-12 months (depending on diagnosis).
Preferably after making lifestyle changes to prevent depression.
How to Stop Meds
It takes 7-10 years for a med to go generic, and another year for the cost to drop. Generics have the same blood levels as brands, plus or minus 10%. Generics with release coatings (SR, CR, XR) may have more issues. Solutions for Medication Costs
Price check if paying out-of-pocket: Costco or www.goodrx.com Assistance if uninsured: www.pparx.org, www.togetherrxacces.com, www.rxassist.org
Meds and Cost
Lean-forward for caps
Swallowing Meds
Read more at www.moodtreatmentcenter.com/brochures.htm. Source: Schiele JT, Annals of Family Medicine, 2014.
Squeeze bottle for tabs
Questions?
Mood and Technology
Mood Charting MoodLog Look for apps that measure mood or energy, not emotions Automatic trackers: The Future
Sleep Monitors Monitor Breathing Temperature Movements Sound
Versions Apps: Sleep Cycle, SleepBot, Sleep Time FitBit, Jawbone ResMED S+
Mental Health Apps Mindfulness Headspace ($), Insight Timer, Smiling Mind, iMindfulness ($), and Mindfulness Daily Breath2Relax
Behavioral Activation Ginsberg, Moodivate ($), Happify ($), and Activities Mood Tracker Intellicare CBT App Suite
Sleep CBT-i Coach (free)
Stress Management Stress Free and Virtual Hope Box DBT Diary Card and Skills Coach
Questions?
Strengths
“Many bipolar patients have considerable psychological assets, such as personal charm, affective warmth, creative bent and a high drive to fight for or advance various causes.
These assets can often he capitalized in attempts to reconstruct lives that have been shattered because of impulsiveness and poor social judgment.”
—Hagop Akiskal, Care of the Bipolar Patient, 2011 “Work on two fronts, one for treating their illness and one for encouraging their strengths.” —L. Havens and N. Ghaemi
Strengths
Artistic sensitivity, intellectual curiosity, creativity, love of variety, flexible thinking, and a nonjudgmental attitude.
Associated with better response to psychotherapy1.
Openness
1Bagby, 2008. Carrie Fisher, Actor & Author, 1956-2016
Warmth, assertiveness, expressive, leadership. People with bipolar tend to have more friends than those with unipolar1. In the military, those whose relatives have bipolar are more likely to be in leadership positions.
Extraversion
1Poradowska-Trzos, 2007.
Lyndon Johnson, 1908-1973.
Both higher and lower IQ are more common in bipolar1. Greater creativity and verbal abilities2,3.
Intelligence
1Meyer, 2015. 2Kyaga, 2011. 3MacCabe, 2010 Ernest Hemmingway, 1899-1961
People with bipolar may recover faster after a trauma1.
Resilience
1Galvez, 2011. Winston Churchill, 1874-1965
People with depression tend to see the world (and themselves) more accurately. Empathy may be a strength when not in an episode. Three leaders who were suicidal in their early 30s: Abraham Lincoln, Martin Luther King, Jr., and Mahatma Gandhi.
Depressive Realism
Questions?