The Importance of Routine for Preventing Recurrence in Bipolar Disorder

University of Pittsburgh, Pittsburgh, Pennsylvania, United States
American Journal of Psychiatry (Impact Factor: 12.3). 07/2006; 163(6):981-5. DOI: 10.1176/appi.ajp.163.6.981
Source: PubMed


A 41-year-old divorced woman with a 17-year history of bipolar I disorder is receiving outpatient treatment consisting of lithium pharmacotherapy and psychotherapy. She is currently living with her sons, ages 7 and 9. Her history is notable for several onsets of mania during or immediately following vacation travel. By the time the patient entered treatment with her current therapist, she was vacation phobic. Yet, as the now-single mother of two active young boys, she also recognized how much she would benefit from a change of scenery and some relief from the constant responsibility for her children and her home. Her brother and sister-in-law had offered to send to her a ticket out to the West Coast for a visit. As much as the idea of a vacation with them appealed to her, it also terrified her. When she mentioned the possibility to her psychiatrist, he agreed that there were some risks involved but that if she planned carefully, she might be able to minimize those risks.

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    • "Other researchers have also reported that sleep deficits predict depressive symptoms at a 6-month follow-up but was not predictive of manic episodes (Perlman et al. 2006). Furthermore, several reports demonstrated that interpersonal and social rhythm therapy focusing on regular routines of sleeping, waking, exercise, and social interaction seems to be effective in preventing relapses and improving functioning in bipolar patients (Frank et al. 2006, 2008). Taken together, all these findings highlight that those patients with biological rhythm abnormalities are more likely to experience concurrent depressive symptoms with chronic course and poorer prognosis. "
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    ABSTRACT: Phenomenological research suggests that pure manic and depressive states are less common than mixtures of the two and that the two poles of mood are characterized by opposite ways of experiencing time. In mania, the subjective experience of time is sped up and in depression it is slowed down, perhaps reflecting differences in circadian pathophysiology. The two classic mood states are also quite different in their effect on subjective awareness: manic patients lack insight into their excitation, while depressed patients are quite insightful into their unhappiness. Consequently, insight plays a major role in overdiagnosis of unipolar depression and misdiagnosis of bipolar disorder. The phenomenology of depression also is relevant to types of psychotherapies used to treat it. The depressive realism (DR) model, in contrast to the cognitive distortion model, appears to better apply to many persons with mild to moderate depressive syndromes. I suggest that existential psychotherapy is the necessary corollary of the DR model in those cases. Further, some depressive morbidities may in fact prove, after phenomenological study, to involve other mental states instead of depression. The chronic sub-syndromal depression that is often the long-term consequence of treated bipolar disorder may in fact represent existential despair, rather than depression proper, again suggesting intervention with existential psychotherapeutic methods.
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