Bipolar disorder, also known as manic depression, is a mood disorder that can involve extreme changes in affect, cognition, and behavior. In its extreme form, bipolar disorder can be associated with psychotic symptoms and can require inpatient admission due to disorganization and impulsivity in the manic phase, or due to suicidal ideation or neglect of self-care in the depressive phase. It affects males and females in equal numbers, and has similar rates across all socio-economic groups. Its onset generally occurs during late adolescence or early adulthood, with this having significant implications for the person's developmental trajectory and quality of life. This will be described later in the chapter.

While the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition – Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) should be consulted regarding diagnosis, a brief summary is as follows:

• A major depressive episode is diagnosed through the presence of depressed mood or loss of interest or pleasure for most of the day, nearly every day for two weeks or more. It must also be accompanied by five or more from nine symptoms, including feelings of worthlessness or guilt, insomnia or hypersomnia, psychomotor agitation or retardation, and fatigue.

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In this chapter we discuss the role of family work in interventions with young people with bipolar disorder. We recognize that family work is a specialized area and highly recommend Miklowitz's (2008) Bipolar Disorder: A Family-Focused Treatment Approach (second edition) and Miklowitz and Goldstein's (1997) Bipolar Disorder: A Family-Focused Treatment Approach, which have heavily influenced our intervention. We also acknowledge that some of the family therapy literature describes highly detailed interventions, particularly for communication skills and problem-solving (e.g. Mueser & Glynn, 1999). However, as with the rest of this manual, we place a strong emphasis on “real world” work and the following describes interventions that we have found effective when working with our population.

While for simplicity we have included this as a separate chapter, we suggest that in clinical work, the components described and the philosophy outlined should be interwoven throughout the intervention rather than being provided as a discrete module.

The rationale behind family work

There are a number of reasons for including family and relationship work in a psychological intervention for young people in the early phase of bipolar disorder. Firstly, in our population of young people aged between 15 and 25 years, almost 56% were living with their families, or had returned to the care of their families after developing their first episode (Hasty et al., 2006).

Research indicates that between 70% and 90% of people with bipolar disorder will have more than one episode (Keller et al.,1993; Gitlin et al., 1995; Tacchi & Scott, 2005), with naturalistic studies showing that around 49.8% of people will relapse within a year, and 68% within 2 years (Silverstone et al., 1998; Lam & Wong, 2005). Amongst those who relapse, two-thirds will have multiple relapses, with 9 being the mean number of episodes (Keller et al., 1993; Gitlin et al., 1995). Given these high rates of relapse in bipolar disorder, work on relapse prevention remains an essential aspect of psychological intervention for this population.

It is encouraging that there often appear to be signs or symptoms which occur before a person becomes symptomatic, with early identification of these providing an opportunity to intervene and prevent relapse. There is also evidence that about 75% of people with bipolar disorder are themselves able to reliably identify their prodromal symptoms for both mania and depression (Jackson et al., 2003), even following a first episode (Ward et al., 2003). In their randomized treatment trial, Perry et al. (1995) found that most of the trial participants had identifiable early signs, which began between two and four weeks prior to a manic or depressive relapse.

Diagnostic difficulties in bipolar disorder

There is growing acknowledgement that bipolar disorder may be significantly underdiagnosed (Bowden, 2001). For example, Hirschfeld and colleagues' (2003) survey of over 600 members of the US National Depressive and Manic Depressive Association (now known as the Depression and Bipolar Support Alliance) found that 69% of people with bipolar disorder reported having been misdiagnosed at least once. Furthermore, over one-third of respondents had a latency period of at least 10 years between initially seeking help and receiving the correct diagnosis and treatment. Unfortunately there was little change in rates of misdiagnosis between this survey, in 2003, and when it was previously conducted in 1994.

Underdiagnosis and misdiagnosis in bipolar disorder result in part from its complexity and overlap of symptoms with other disorders. Unipolar depression appears to be the most common misdiagnosis, which is understandable as many individuals have 2 or 3 depressive episodes before they experience the first manic or hypomanic episode. Ghaemi et al. (2000a) reported that around 40% of people with bipolar disorder are initially misdiagnosed with unipolar depression, while Angst (2006) suggested that, using the broadest available criteria, between one-quarter and half of people diagnosed with unipolar depression may in fact meet the criteria for bipolar disorder.

What is bipolar disorder?

Bipolar disorder, also known as manic depression, affects at least 1 or 2 in every 100 people.

Bipolar disorder is a mood disorder involving extreme changes in emotion. While anyone can experience “ups and downs,” bipolar disorder can result in a person at times feeling extremely happy, excitable, and invincible, and at other times feeling irritable, miserable, or even suicidal. Bipolar disorder can also affect the way people think and behave, can affect work, study, and relationships, and can result in hospitalization. It is also a disorder that can keep returning if not treated properly. However, it can also be managed very effectively, with evidence showing that getting help earlier can result in better outcomes.

Diagnosis should only be made by a health professional, but symptoms can include the following:

Symptoms of mania

Feeling “high,” full of energy, or easily annoyed for at least 7 days, and:

• Feeling “driven” to do things, which may feel out of control at times.

• Reckless or impulsive behavior and doing things you usually wouldn't, e.g. spending excessively, being more promiscuous, making decisions without thinking them through, or using drugs or alcohol excessively.

• Finding it very hard to concentrate or focus on one task, and not being able to finish tasks.

• Feeling physically jumpy.

• Talking very fast.

• Feeling like your thoughts are going very fast, or jumping from one subject to another.

• Feeling like you don't need any sleep.

• Increased sexual drive.

• Increased self-confidence.

• Feeling you have special abilities or talents that no-one else has.

When working with many young people with bipolar disorder, managing comorbid disorders – particularly alcohol, substance use, and anxiety disorders – is an integral part of psychological treatment. This is because comorbidity can impact significantly on the effectiveness of other parts of the intervention, including engagement, work with families, psychoeducation, cognitive strategies, social rhythm, the development of sense of self, and relapse prevention. It is also important to note that it may be alcohol or substance use problems that first bring the young person to the attention of mental health services. Therefore, careful assessment can help identify whether the young person may be attempting to “self-medicate” mood difficulties, or whether increased substance or alcohol use is more related to impulsivity or disinhibition.

In clinical practice, work on comorbid difficulties is likely to be integrated throughout the intervention and may not constitute a separate module. The motivational interviewing approach described in this chapter can also be used to assess and enhance motivation to engage in treatment, and to assist with medication adherence. However, as with the preceding chapter on family and relationship work, interventions for comorbid disorders have been included as a separate chapter for ease of reading.

Background to the manual

In recent years there has been growing recognition of the importance of psychological therapies for people with bipolar disorder (Scott & Colom, 2005). While biological and genetic factors appear to play a significant part in the etiology of the disorder (Pekkarinen et al., 1995; Hyman, 1999; Berrettini, 2000), and medication, particularly mood stabilizers, remains the first line of treatment for many clinicians, pharmacological interventions are not universally effective. Numerous reviews have found that even lithium – considered by many to be the “gold standard” of mood stabilizers – is effective in preventing relapse of symptoms for only 32–6% of people with bipolar disorder at 2-year follow-up (Prien et al., 1984; Gelenberg et al., 1989; Silverstone et al., 1998), with up to 87% of people relapsing at 5 years despite good medication adherence (Keller et al., 1993).

The heterogeneity of people with bipolar disorder, its psychosocial impact, and the complexity of the disorder itself led the US National Institute of Mental Health to conclude: “It is clear that pharmacotherapy alone does not meet the needs of many bipolar patients” (Prien & Potter, 1990, p. 419). This view has been echoed by a number of other organizations including the American Psychiatric Association (2002), the British Association for Psychopharmacology, the World Federation of Societies of Biological Psychiatry (Jones et al., 2005a), the Royal Australian and New Zealand College of Psychiatrists (2004), and the United Kingdom's National Institute for Health and Clinical Excellence (2006).

Bipolar disorder can have a significant effect on adolescent development and has traditionally been associated with poor outcomes, both symptomatically and in terms of psychosocial functioning.

There is growing evidence for the effectiveness of psychological interventions for bipolar disorder, particularly individual and family-based cognitive behavioral therapy (CBT). Furthermore, there is emerging evidence that both psychological and pharmacological interventions may be more effective early in the course of the disorder. However, there is currently very little literature describing the unique challenges and opportunities relating to psychological work with a young bipolar population, and there are currently no published clinician manuals relating to this population.

This is the first book to describe a manualized psychological intervention for people in adolescence and early adulthood who are experiencing bipolar disorder. It was developed by clinicians working in a specialist bipolar team at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia, in collaboration with Professor Jan Scott, an eminent researcher in the field of bipolar disorder. EPPIC is a leading clinical and research center for young people experiencing mental health difficulties, and this manual was developed from clinical experience and research evidence gathered by the bipolar team over the past five years.

The manual describes specific issues affecting a young bipolar population and offers clinicians advice on how to manage challenges such as difficulties in engagement, comorbidity, family issues, and developmental factors which impact on the person's adaptation to the disorder.

In this chapter we discuss the issue of insight and ways in which young people may adapt to a diagnosis of bipolar disorder. While some young people minimize or deny their diagnosis, for others, bipolar disorder can significantly impact on their sense of self and identity, and can result in feelings of guilt, shame, loss, and trauma.

After consideration of these issues, we present strategies to help decrease distress, promote adaptive coping, and minimize the impact of the disorder on the person's view of self and their functioning. As with other chapters of this book, the strategies presented in this section are not intended to be delivered in a sequential fashion or as a discrete module. Instead, we encourage clinicians to continue to employ and revisit them where relevant throughout the intervention, recognizing that the young person's insight and needs can change across their phases of recovery and relapse.

Insight

Lack of insight has been described as a common characteristic of bipolar disorder (Pallanti et al., 1999), with some research showing that the degree of insight in bipolar disorder is similar to that of people with schizophrenia (Amador et al., 1994; Pini et al., 2001). Insight has been found to be consistently poorer for people with mania than for people with mixed episodes or unipolar depression (Dell'Osso et al., 2002).

Medication adherence can be a vital component in the treatment of bipolar disorder, as people who are fully adherent are more likely to achieve syndromal recovery than those who are non-adherent or partially adherent (Keck et al., 1998). In addition, adherence with mood stabilizers such as lithium has been found to significantly reduce the likelihood of attempted or completed suicide in people with mood disorders (Muller-Oerlinghausen et al., 1996; Sachs, 2003; Colom et al., 2005).

Conversely, non-adherence with prescribed medication has been found to influence risk of relapse. For example, a review by Colom et al. (2005) noted that rapid discontinuation of lithium was associated with relapse rates of 50% in the 3 months following cessation, compared with less than 10% in people who continued taking prophylactic medication. Furthermore, Strakowski et al. (1998) noted that 60–80% of people admitted to hospital due to a manic episode had been non-adherent in the previous month.

Unfortunately, poor medication adherence is a longstanding problem in bipolar disorder, and continues to represent a significant challenge. In John Cade's (1949) landmark paper, the first case study he reported was a man whose manic symptoms improved significantly with lithium, following which the man returned to work, ceased medication, and relapsed within 6 weeks.