Psychological Treatment of Bipolar Disorder
Bipolar disorder is a common and serious psychiatric disorder for which successful treatment is an elusive goal. The combination of grandiosity, hopelessness, and extreme lability make patients reluctant to engage wholeheartedly in treatment, leading to self-destructiveness and, often, suicide. Pharmacologic advances have made symptom reduction more possible than ever, but the psychological concomitants of grandiosity, denial, and the real pleasure of the manic and hypomanic state make long-term medication compliance a rarity. Psychological Treatment of Bipolar Disorder attempts to bring a psychotherapeutic framework back into what has become a psychopharmacologic morass. Although the number of medications available to treat bipolar disorder continues to grow, with the anticonvulsants playing an ever more important role, patient factors frustrate psychiatrists and other therapists. Can this book provide some help?
Well, yes and no. The middle chapters, describing various manual-guided psychotherapies, including cognitive therapy, interpersonal and social rhythm therapy, and the Life Goals Program at Brown University, offer novel and thoughtful additions to the psychotherapeutic armamentarium, never straying from psychopharmacologic compliance but adding depth to the understanding of factors that lead to relapse and to noncompliance. In particular, the chapter on interpersonal and social rhythm therapy, by Ellen Frank and Holly Swartz, develops the important realization that regularization of circadian rhythms is essential to the maintenance of a euthymic state and combines cognitive-behavioral techniques with the keeping of a social rhythm diary to educate the patient about the complex interactions between biological rhythms (for example, diurnal variations in sleep) and social events and stressors (for example, life changes and job stresses). The inclusion of the emphasis on biological rhythms into the psychotherapy is an important development. The authors provide an example of a chart for patients to record the biological and social events in their lives, creating an archive of these interactions, from which the patient can learn important associations that can lead to behavioral change.
The other truly excellent chapter describes the Life Goals Program at Brown University, which is headed by Mark Bauer. In this chapter, Bauer describes what he calls supporting collaborative practice management, in which the patient collaborates with therapists and other patients to manage the illness better and to improve his or her functional outcome. He focuses on the term "manic-depressive illness," which he believes better describes the illness than the newer term, "bipolar disorder." The Life Goals Program encourages the formation of personal goals and strategies for reaching them, including teaching oneself the negative repercussions of one's behavior while manic or depressed. In addition, Bauer recognizes that mere symptom reduction may not have an impact on a patient's functional level, so the program goes beyond achieving remission and looks to living a life that the patient finds fulfilling. It comprises cognitive, behavioral, and group skills and fosters individual accountability and independence.
The rest of the book is not as interesting and useful. The opening section reviews the basic information about bipolar disorder in an extremely inaccessible way. Nothing new is offered, and the citation style of listing all the authors rather than using numbers creates large gaps between material; I found the entire book awkward to read for this reason. Much of the book had little or nothing to do with psychological factors in bipolar disorder, let alone psychological treatment of the disorder. There was almost no mention of the manic defense, a very important concept in managing both phases of the illness and in particular suicidality, despite the fact that an entire chapter is devoted to suicidality. The chapter on psychopharmacology, a curious inclusion given the book's title, is similarly banal. Many of the authors quote themselves extensively. Finally, the research cited is not always the most recent, given that the book was published in 2004.
In sum, Psychological Treatment of Bipolar Disorder offers too little about psychotherapy and too much that is available elsewhere. The chapters "Interpersonal and Social Rhythm Therapy" and "Supporting Collaborative Practice Management" provide a pleasant respite from an otherwise redundant book.
Dr. Tabor is medical director of adult inpatient psychiatry at Kings County Hospital Center and assistant professor in psychiatry at the State University of New York (SUNY)-Downstate Medical Center in Brooklyn.
