Peer Reviewed Article Bipolar Disorder and Dysfunctional Family
Curr Dir Psychol Sci. Author manuscript; available in PMC 2008 Jan 9.
Published in final edited grade as:
PMCID: PMC2184903
NIHMSID: NIHMS36688
The Function of the Family unit in the Course and Handling of Bipolar Disorder
David J. Miklowitz
Academy of Colorado
Abstruse
Bipolar disorder is a highly recurrent and debilitating illness. Research has implicated the role of psychosocial stressors, including loftier expressed-emotion (EE) attitudes among family members, in the relapse–remission course of the disorder. This article explores the developmental pathways by which EE attitudes originate and predict relapses of bipolar disorder. Levels of EE are correlated with the illness attributions of caregivers and bidirectional patterns of interaction between caregivers and patients during the postepisode period. Although the primary treatments for bipolar disorder are pharmacological, adjunctive psychosocial interventions have additive effects in relapse prevention. Randomized controlled trials demonstrate that the combination of family-focused therapy (FFT) and pharmacotherapy delays relapses and reduces symptom severity among patients followed over the class of 1 to 2 years. The effectiveness of FFT in delaying recurrences among adolescents with bipolar disorder and in delaying the initial onset of the illness amongst at-take chances children is currently being investigated.
Keywords: family unit-focused treatment, expressed emotion, psychosocial treatment, pharmacotherapy, childhood-onset bipolar disorder
By the twelvemonth 2020, bipolar disorder will be the 6th leading cause of inability worldwide amidst all medical illnesses (Murray & Lopez, 1996). Persons with the disorder vary between the extremes of mania (a highly energized, elated, or irritable land) and low (a deflated, withdrawn, morose, and oftentimes suicidal state). The Diagnostic and Statistical Manual of Mental Disorders (fourth ed., American Psychiatric Association, 1994) defines two master types of bipolar disorder: Bipolar I (at least one episode of mania or mixed disorder) and Bipolar II (episodes of hypomania alternate with astringent periods of depression). Over 2% of the US population has Bipolar I or II disorder, and another 2.4% has the disorder in its various subclinical (or subsyndromal) forms (Merikangas et al., 2007).
The illness is highly recurrent, with 60% of patients experiencing recurrences of mania or depression within 2 years and up to 75% experiencing recurrences within five years. Patients experience pregnant symptoms during approximately half of the weeks of their lives and accept multiple impairments in school, at work, and in relationships (Judd et al., 2002). Upwards to 15% die past suicide, and as many as l% attempt suicide one or more times (Miklowitz & Johnson, 2006).
Mood stabilizers and atypical antipsychotics have a substantial success record in hastening recovery from episodes and decreasing chance of recurrence. Nevertheless, these medications do non fully prevent recurrences of the disorder, nor do they eliminate the significant residual symptoms—notably depression—that many patients feel between episodes.
The family environment is an of import context for understanding the development and maintenance of severe psychopathology (Repetti, Taylor, & Seeman, 2002) and mood disorders in particular (Hooley & Parker, 2006; Miklowitz, 2004). This commodity concerns the role of family unit relationships as run a risk or protective processes in the course of bipolar illness and the office of family unit-focused therapy (FFT) as an adjunct to drug therapy during the postepisode catamenia.
THE Office OF THE Family unit IN THE Course OF BIPOLAR ILLNESS
Current thinking almost the relapse–remission grade of bipolar disorder emphasizes a biopsychosocial model that incorporates the interactive roles of genetic vulnerability, biological predispositions, family or life events stress, and psychological vulnerability. The affliction is clearly heritable, and there is substantial evidence for dysfunction of the neurotransmitter systems (notably dopamine and serotonin) and of the limbic–cortical system. Specifically, elevated activity in the amygdala and diminished activity of the frontal-cortical regions may interfere with the capacity to regulate emotion (for review, run across Miklowitz & Johnson, 2006).
Family stress has been operationalized every bit whether or not the patient resides with relatives characterized by loftier expressed-emotion (EE) attitudes (Brown, Birley, & Wing, 1972). High EE refers to loftier levels of criticism, hostility, and/or emotional overinvolvement from a caregiving relative (typically a parent or spouse) during or immediately following a patient's astute episode of affliction. It is typically assessed through the Camberwell Family Interview, although briefer alternative assessments with acceptable reliability and validity are bachelor (Hooley & Parker, 2006). Patients with schizophrenia, bipolar disorder, or recurrent major depressive disorder who return home to high-EE families post-obit an acute episode are two to three times more probable to relapse in the subsequent 9 months than are patients who return to low-EE families (Barrowclough & Hooley, 2003; Miklowitz, 2004).
A Developmental Psychopathology Arroyo to Expressed Emotion
Inquiry on the mechanisms underlying the association between EE and relapse have addressed two questions: (a) How do caregiving relatives get high-EE? (b) What variables mediate the clan between EE and patients' relapses? A developmental psychopathology framework for understanding the causal and reactive roles of parental EE in mood disorders (Miklowitz, 2004) begins with a child who has temperamental disturbances (e.yard., irritability, low frustration tolerance, mood instability, high anxiety) or compromised cerebral functioning. These early on disturbances partially reflect the child's genetic vulnerability to bipolar, schizophrenic, or other psychiatric disorders. The child is paired with a parent who, by virtue of his or her own neurobiology and social history, reacts to the kid's beliefs with frustration and hostility (expressed equally frequent criticisms of the child) or with guilt and anxiety (expressed in overly protective behaviors). Repeated exposure to criticisms, anxiety, or overinvolvement during the period when a child is developing a sense of identity may contribute to self-doubt, self-criticism, and core beliefs about relationships every bit aversive and conflict-ridden. These schemata for the self may interfere with the kid'due south acquisition of emotional cocky-regulatory skills, as reflected in low, anxiety, assailment, and the inability to tolerate negative states of touch. In turn, his or her negative counterreactions fuel high-EE attitudes and behaviors in parents, which recursively contribute to the child'south emotional and cognitive vulnerabilities. The model in Effigy 1 clarifies how similar recursive processes may maintain high-EE attitudes and contribute to relapse in families in which patients accept already had episodes of bipolar disorder.
Bidirectional relationship between parental expressed emotion (EE) and patients' mood symptoms. The pathway begins with unresolved residual symptoms in the patient (e.g., depression, irritability, mild delusional thinking, withdrawal, hypomania) that contribute to the intensity of the patient'south reactions to caregivers. Escalating negative interactions reduce the threshold for caregivers to react with fear, frustration, and hopelessness; remember and exaggerate negative experiences from prior disease episodes; and make attributions of controllability and negative predictions well-nigh the future (e.g., "She's doing this to hurt me"; "I'll always accept to take care of him"). This "cognitive reactivity" of the caregiver may fuel his or her expression of loftier-EE attitudes toward the patient, resulting in temporary exacerbations of the patient's residual symptoms and a worsening pattern of dyadic interaction. In combination with biological and genetic vulnerability factors, repeated exposure to negative family interactions may contribute to the patient's overall liability to early relapse.
Enquiry on Pathways to EE
Although the pathway in Figure 1 is hypothetical, it is supported past cross-sectional enquiry on the correlates of EE among relatives of psychiatric patients. Notably, high-EE relatives are more likely to attribute the negative behaviors of patients to personal and controllable factors (i.e., personality, lack of effort) than are depression-EE relatives, who are more probable to attribute the behaviors to uncontrollable factors (i.east., illness or external stressors; Barrowclough & Hooley, 2003). Several studies find that high-EE relatives and patients are more than likely than depression-EE relatives and patients to be engaged in negative cycles of exact and nonverbal interaction during the postepisode flow (for review, see Miklowitz, 2004).
A study of family interactions amid patients with schizophrenia is particularly relevant to this hypothesized pathway (Rosenfarb, Goldstein, Mintz, & Nuechterlein, 1995). During the period following a hospitalization for psychosis, patients with schizophrenia from high-EE families showed significantly more odd and disruptive behaviors with parents during laboratory-based family interactions than did patients from low-EE families. High-EE parents were more than likely than depression-EE parents to respond with a criticism to the first unusual idea expressed by the patient with schizophrenia, which increased the probability that the patient would express a second unusual thought. A written report with similar methodology in a small sample of bipolar patients establish that there was a strong correlation (r = .53) between relatives' harsh criticisms and patients' "odd and grandiose thinking" during family interactions, but merely amidst patients who relapsed in the subsequent 9 months (Rosenfarb et al., 2001). The correlation was low (r = .12) among patients who did not subsequently relapse.
The pathways from loftier-EE attitudes in caregivers to relapses among patients may be mediated by patients' biological and psychological vulnerabilities. Hooley, Gruber, Scott, Hiller, and Yurgelun-Todd (2005) examined neural activation (equally measured past functional magnetic resonance imaging) amid college students with and without a history of low while they listened to tapes of their mothers expressing critical, supportive, or neutral statements. In students with a prior history of low, the dorsolateral prefrontal cortex failed to activate in response to maternal criticism, although activation in response to criticism was observed amongst students with no depression history. The dorsolateral prefrontal cortex plays a major role in working memory, problem-solving, affective expression, interpersonal effectiveness, and the witting command of beliefs.
These and other cognitive vulnerabilities of patients may bear upon their processing of critical comments from relatives and may contribute to their overall levels of distress. A longitudinal study found that bipolar patients who reported existence more emotionally distressed by criticisms from relatives had higher low scores and fewer days well during a one-year prospective period than did patients who reported less distress from criticisms (Miklowitz, Wisniewski, Miyahara, Otto, & Sachs, 2005). Patients who become especially distressed by signs of interpersonal rejection from family members may internalize the content of criticisms, which may contribute to their subsequent mood dysregulation.
Thus, high-EE attitudes sally through a complex interplay between historical events, personal variables, attributional styles, and electric current relationship factors. Family interventions should therefore consider (a) the developmental processes past which high-EE attitudes originated, (b) the means in which patients process and react to negative bear on from parents or other caregivers, (c) the cognitive reactivity of relatives, (d) the ability of patients to manage stressful family interactions, and (east) the behaviors of patients that provoke negativity among caregivers.
FAMILY INTERVENTION FOR BIPOLAR DISORDER
Family interventions for bipolar disorder are psychoeducational in orientation, meaning that families (spouses, parents) and patients are taught to recognize the signs and symptoms of bipolar disorder, develop strategies for intervening early with new episodes, and assure consistency with medication regimens (encounter Box 1). The psychoeducational approach recognizes that lack of information about the disorder, along with uncertainties well-nigh the future, fuel patients' deprival of the diagnosis and contribute to caregivers' high-EE attitudes. Thus, in addition to providing prescriptive information, clinicians address the patients' and family members' affective reactions to the disease, its prognosis, and its expected treatments and assist them in developing coping strategies relevant to their private situation.
The first randomized trial of FFT (Miklowitz, George, Richards, Simoneau, & Suddath, 2003) involved 101 bipolar patients (hateful age = 36 years; hateful prior episodes = six.iv) who had had an acute episode of mania or depression in the 3 months prior to the trial. Of the 101 patients, 82 began the trial in the hospital. Patients were randomly assigned as outpatients to FFT and drug therapy or to a comparison crisis-direction treatment consisting of 2 sessions of family unit psychoeducation, crisis-intervention sessions as needed over a period of 9 months, and drug therapy. Over a ii-yr follow-upwards, patients in FFT were more probable to survive the full follow-up without relapsing (52%) than were patients in crisis management (17%) and also had less severe depressive and manic symptoms (Miklowitz et al., 2003; see Fig. ii).
Results of a ii-twelvemonth randomized trial (N = 101) showing that family-focused handling (FFT; northward = 31) and medications improve bipolar patients' mood symptoms more than crisis management (CM; n = 70) and medications. From "A Randomized Report of Family unit-Focused Psychoeducation and Pharmacotherapy in the Outpatient Management of Bipolar Disorder," by D.J. Miklowitz, E.Fifty. George, J.A. Richards, T.L. Simoneau, and R.50. Suddath, 2003, Archives of Full general Psychiatry, 60, p. 909.
A second trial (Rea et al., 2003) compared FFT and pharmacotherapy with an individual psychoeducational therapy of identical duration and intensity (21 sessions over nine months) and equivalent drug therapy. Over a period of 2 to 3 years, patients in FFT had longer periods of stability prior to recurrence than did patients in individual therapy. In the 1- to ii-year menstruation afterwards treatment ended, only 12% of the FFT patients were rehospitalized, compared to lx% of the individual therapy patients.
The multisite Systematic Handling Enhancement Program for Bipolar Disorder assorted the effectiveness of FFT and other psychotherapies to a brief psychosocial intervention across 15 U.South. treatment centers (Miklowitz et al., 2007). Acutely depressed bipolar patients (N = 293) were randomly assigned to one of 3 intensive (30 sessions) psychotherapies with drug therapy—FFT, interpersonal and social-rhythm therapy (therapy focused on interpersonal problem solving and the regulation of daily routines and sleep–wake cycles), or cognitive-behavioral therapy—or to a minimal (3 sessions) "collaborative care" (CC) psychoeducational treatment and drug therapy. Over the course of 1 year, all three intensive psychotherapies were associated with more than rapid recoveries (hateful = 169 days) from bipolar depression in comparing with the recoveries of those assigned to CC (mean = 279 days). The rates of recovery were 64% for patients in intensive treatment (77% for FFT, 65% for interpersonal therapy, 60% for cognitive-behavioral therapy) and 52% for those in CC. Patients in the intensive treatments were also more likely to stay well during whatsoever given study month than were patients in CC. Differences among the iii 30-session treatments were nonsignificant. The Systematic Handling Enhancement Program concluded that intensive therapies developed in academic settings (including FFT) can be successfully exported to community settings in which clinicians take had minimal previous exposure to transmission-based interventions.
TREATMENT MECHANISMS FOR FFT
The Miklowitz et al. (2003) trial identified two variables that mediated the effects of FFT on mania and depression, respectively: improvements in medication adherence and augmentation of positive family unit communication. Patients in FFT were more likely to adhere to lithium or anticonvulsant drug regimens than were patients in crisis management, and adherence was associated with less severe mania symptoms over the course of ii years. Patient–relative interactions were more positively toned afterward FFT than they were after crisis management, and improvements in patient–relative interaction were correlated with improvements in depressive symptoms amid patients over the course of 1 twelvemonth. Negative communication did not change in either treatment condition. Thus, FFT may raise the protective qualities of family relationships rather than directly reducing the frequency of criticisms or aversive patterns of family interaction.
CONCLUSIONS
Episodes of bipolar disorder are strongly associated with family discord, criticism, and conflict. There is increasing evidence that family unit psychoeducational treatments are effective in relapse prevention and symptom control when combined with standard drug treatment.
Much remains to be learned about the subpopulations of patients about likely to benefit from family interventions. It is non clear, for example, whether just patients with high-EE families should be given FFT, and whether patients who exercise not report pregnant family conflicts or who are disengaged from their families would be improve suited to private or grouping approaches. The mediating mechanisms by which family interventions achieve their effects—which may include enhancing medication adherence, family advice and trouble-solving, or the family's ability to recognize and intervene with early alarm signs of recurrence—deserve further examination in randomized trials that measure mediators at systematically controlled intervals.
Longitudinal high-risk studies should clarify which family unit gamble or protective processes operate amidst children who are genetically at risk for bipolar disorder. Specifically, investigators should identify early babyhood temperamental or symptom attributes that deport a resemblance to manic or depressive symptoms (eastward.g., extreme moodiness or impulsiveness), analyze the circumstances under which these attributes evoke criticism or overprotectiveness among parents, and determine which of these children really develop bipolar disorder in adulthood. It volition exist important in such studies to mensurate the psychiatric background of parents, as well equally protective factors (east.one thousand., a supportive secondary parent) that may reduce the likelihood that the kid develops the disorder under weather of high genetic run a risk.
Two uncontrolled treatment trials found that FFT alone or the combination of FFT and cognitive-behavioral therapy helped stabilize the class of bipolar disorder in adolescent and school-anile children, respectively (Miklowitz, Biuckians, & Richards, 2006; Pavuluri et al., 2004). Early preventative interventions involving the family are currently existence developed (Miklowitz et al., 2006). Notably, teaching advice, problem-solving, and emotional self-regulation skills to at-risk children and their parents may help better stress within the family and contribute to delaying the onset of full manic episodes. Early-intervention studies involving high-risk populations should exist a central focus for the side by side generation of research on bipolar disorder.
Acknowledgments
Training of this article was supported in part by National Institute of Mental Health Grant MH073871, a grant from the Robert Sutherland Foundation, and a Kinesthesia Fellowship from the Academy of Colorado'due south Council on Research and Creative Work.
Footnotes
Recommended Reading
Jamison, K.R. (1995). (Run across References)
Johnson, S.50., & Emery, R. (2003). (See References)
Miklowitz, D.J. (2002). (See References)
Miklowitz, D.J. & Goldstein, G.J. (1997). (Run into References)
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