Elsevier

Biological Psychiatry

Volume 48, Issue 6, 15 September 2000, Pages 593-604
Biological Psychiatry

Therapeutic approach
Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder

https://doi.org/10.1016/S0006-3223(00)00969-0Get rights and content

Abstract

Interpersonal and social rhythm therapy is an individual psychotherapy designed specifically for the treatment for bipolar disorder. Interpersonal and social rhythm therapy grew from a chronobiological model of bipolar disorder postulating that individuals with bipolar disorder have a genetic predisposition to circadian rhythm and sleep–wake cycle abnormalities that may be responsible, in part, for the symptomatic manifestations of the illness. In our model, life events (both negative and positive) may cause disruptions in patients’ social rhythms that, in turn, perturb circadian rhythms and sleep–wake cycles and lead to the development of bipolar symptoms. Administered in concert with medications, interpersonal and social rhythm therapy combines the basic principles of interpersonal psychotherapy with behavioral techniques to help patients regularize their daily routines, diminish interpersonal problems, and adhere to medication regimens. It modulates both biological and psychosocial factors to mitigate patients’ circadian and sleep–wake cycle vulnerabilities, improve overall functioning, and better manage the potential chaos of bipolar disorder symptomatology.

Introduction

During the second half of the 20th century, new treatments for bipolar disorder focused primarily on somatic therapies. The discovery of lithium carbonate as a treatment for “psychotic excitement” by Cade in 1949 Johnson et al 2000, Cade 1949 and advances in research supporting the heritability of bipolar disorder led investigators to conceptualize bipolar disorder as a purely biological process amenable to pharmacotherapy alone. Furthermore, clinical lore mistakenly led practitioners to believe that most patients with bipolar disorder recover fully from mania or depression, remain asymptomatic between episodes, and experience no decline in functional status over time. Psychotherapy for bipolar disorder was considered superfluous and was largely neglected as a treatment strategy for many years (Benson 1975). Beginning in the 1980s, however, reports appeared in the literature suggesting that outcomes with lithium alone were suboptimal. Cumulative data suggest that pharmacotherapy alone fails to prevent recurrence in 50 to 70% of patients over a 2- to 3-year period Markar and Mander 1989, Prien et al 1984 and that overall functioning of bipolar patients remains low even after the resolution of fully syndromal episodes Coryell et al 1993, Goldberg et al 1995. Researchers and clinicians became increasingly cognizant that the chronic course of bipolar disorder may, in the absence of appropriate interventions, lead to unremitting symptoms and a downward psychosocial spiral.

As depicted in Figure 1, the course of recurrent unipolar disorder, although often debilitating, is unidirectional and relatively easy to describe: patients become depressed, recover, have a period of remission, and then may or may not become depressed again at some point in the future (Kupfer 1991). Although a small percentage of the population experiences refractory depression, most patients, in the absence of significant comorbidity, eventually respond to treatment and achieve a euthymic state. By contrast, the course of bipolar disorder is typically hectic and variable. A “roller coaster” for both patients and clinicians, extreme highs and lows intermingle with mixed states and subsyndromal symptom flurries to create hybrid symptom states that defy easy labels. As depicted in Figure 2, hypomania can surge into a fully syndromal mania and then plummet into a debilitating major depression. A fall from mania can lead to endless months of major depression, with brief excursions into minor depression providing only relative relief from unrelenting dysphoria, anergia, and hypersomnia. Treatments for those intolerable depressions may send a patient’s mood back into the manic range, only to plunge back down into depression. Although we distinguish between the treatment of acute symptomatology (labeled Preliminary Phase in Figure 2) and prophylactic treatment following remission (labeled Preventative Phase), we recognize that these distinctions are often arbitrary and inaccurate. In fact, patients in a nonacute phase of treatment often experience on-going symptom fluctuations. Depressive symptoms, in particular, seem especially difficult to eradicate completely (Hlastala et al 1997). Thus, the holy grail of sustained euthymia in bipolar disorder may remain an elusive goal in the absence of sophisticated treatments that address both the biological and psychological aspects of this disorder.

Goodwin and Jamison’s definitive textbook on bipolar disorder (Goodwin and Jamison 1990) acknowledges the important interplay between biological and psychosocial factors in determining the course of bipolar disorder. Recognizing the primacy of biology, they hypothesized that “the genetic defect in manic depressive illness involves the circadian pacemaker or systems that modulate it” (Goodwin and Jamison 1990, 589) but then further postulated that psychosocial factors will interact with biology to create three probable pathways to recurrence of bipolar illness: 1) stressful life events; 2) disruptions in social rhythms; and 3) medication nonadherence. As envisioned by Goodwin and Jamison, these routes to illness are interconnected. Their model suggests that individuals with bipolar disorder are fundamentally vulnerable to disruptions in circadian rhythms. Psychosocial stressors then interact with this biological vulnerability to cause symptoms. For instance, stressful life events disrupt social rhythms, which causes disturbances in circadian integrity, which, in turn, may lead to recurrence. Alternately, problematic interpersonal relationships or disordered schedules contribute to a patient’s difficulty adhering to a medication regimen which, again, may lead to recurrence. As a direct consequence of this model, one would assume that helping patients learn to take their medication regularly, lead more orderly lives, and resolve interpersonal problems more effectively would promote circadian integrity and minimize risk of recurrence.

As depicted in Figure 2, bipolar illness is a disorderly disorder. Characterized by erratic sleep–wake cycles and dramatic symptom fluctuations, the clinical course is unpredictable and rarely static. Needless to say, treating this “moving target” creates many interesting—and sometimes problematic—challenges. For instance, lithium monotherapy is still considered the “gold standard” of pharmacotherapy for bipolar disorder. As patients move through the various phases of the disorder, however, most psychiatrists find themselves treating patients with a range of mood stabilizers in combination with neuroleptics, sedative-hypnotics, and antidepressants (Sachs et al 2000). Efforts to simplify regimens are often thwarted by unsatisfactory treatment response, resulting in years of complex polypharmacy. Vacillating symptomatology, impaired psychosocial functioning, and problematic medication side effects converge to create unique clinical challenges for both patients and health care professionals. Considering the complexities of this illness, it is not surprising that pharmacotherapy alone does not address the multiple needs of patients with bipolar disorder. Although there are many excellent review papers discussing extant psychosocial approaches to bipolar disorder Colom et al 1998, Johnson et al 2000, Miklowitz and Frank 1999, there are surprisingly few data supporting their efficacy Craighead et al 1998, Swartz and Frank in press, Reynolds CF et al 1999. The absence of well-designed, empirically tested psychotherapies in the literature led us to develop and test a model of individual psychotherapy that would be used in conjunction with medication to enhance functioning and diminish recurrences in patients with bipolar I disorder.

Section snippets

Theoretical context for interpersonal and social rhythm therapy

Interpersonal and social rhythm therapy (IPSRT) is a treatment that is specifically designed for patients with bipolar disorder. As elaborated below, the genesis of IPSRT rests in a psycho-chronobiological theory of affective illness that we articulated in a series of papers in the 1980s and early 1990s Ehlers et al 1988, Ehlers et al 1993, Monk et al 1991, Monk et al 1990. Its design was also strongly influenced by the instability model of bipolar disorder proposed by Goodwin and Jamison (1990)

Interpersonal psychotherapy of depression

Interpersonal psychotherapy (IPT) is a time-limited, focused psychotherapy developed in the 1970s by Klerman, Weissman, and colleagues for the treatment of unipolar depression (Klerman et al 1984). Unlike many other psychotherapies, IPT is designed to treat a specific disorder (depression) and has been systematically evaluated in several randomized, controlled research trials. IPT was envisioned as an acute (12–16 weeks) treatment for depression but has also been tested in an 8-month

Interpersonal and social rhythm therapy: treatment description

Interpersonal and social rhythm therapy is a manual-based psychotherapy (E. Frank et al, unpublished data, 1999) focusing on 1) the link between mood and life events, 2) the importance of maintaining regular daily rhythms as elucidated by the SRM, 3) the identification and management of potential precipitants of rhythm dysregulation with special attention to interpersonal triggers, 4) the facilitation of mourning the lost healthy self, and 5) the identification and management of affective

Empirical data supporting the efficacy of IPSRT

We are currently conducting an on-going randomized clinical trial at the University of Pittsburgh testing the efficacy of IPSRT as an adjunctive maintenance treatment for bipolar I disorder (Maintenance Therapies in Bipolar Disorder; MH29618, E. Frank, PI). After giving written, informed consent, acutely ill bipolar patients are treated with medication and randomly assigned to either IPSRT or intensive clinical management (CM). Once stabilized, patients are reassigned to either IPSRT or CM (in

Conclusion

Among medical treatments, psychotherapies have the dubious distinction of being among the least well tested and most “cultish” prescriptions offered to patients. Although the field is beginning to redress this wrong, IPSRT is among only a handful of psychotherapies utilizing techniques derived from sound scientific theory, the efficacy of which will be evaluated in a randomized controlled trial This rational treatment rests firmly on the circadian rhythm theory of bipolar disorder and our

Acknowledgements

Supported in part by National Institute of Mental Health Grants Nos. MH-30915 (DJK), MH-29618 (EF), and MH-60473 (HAS).

Aspects of this work were presented at the conference “Bipolar Disorder: From Preclinical to Clinical, Facing the New Millennium,” January 19–21, 2000, Scottsdale, Arizona. The conference was sponsored by the Society of Biological Psychiatry through an unrestricted educational grant provided by Eli Lilly and Company.

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