doi: 10.1111/j.1467-8721.2007.00502.x.
The Role of the Family in the Course and Treatment of Bipolar Disorder
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- PMID:18185847
- PMCID: PMC2184903
- DOI: 10.1111/j.1467-8721.2007.00502.x
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The Role of the Family in the Course and Treatment of Bipolar Disorder
David J Miklowitz. Curr Dir Psychol Sci.2007 Aug.
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Abstract
Bipolar disorder is a highly recurrent and debilitating illness. Research has implicated the role of psychosocial stressors, including high 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 course 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 among at-risk children is currently being investigated.
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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’s 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 illness episodes; and make attributions of controllability and negative predictions about the future (e.g., “She’s doing this to hurt me”; “I’ll always have to take care of him”). This “cognitive reactivity” of the caregiver may fuel his or her expression of high-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.
Results of a 2-year randomized trial (N = 101) showing that family-focused treatment (FFT;n = 31) and medications improve bipolar patients’ mood symptoms more than crisis management (CM;n = 70) and medications. From “A Randomized Study of Family-Focused Psychoeducation and Pharmacotherapy in the Outpatient Management of Bipolar Disorder,” by D.J. Miklowitz, E.L. George, J.A. Richards, T.L. Simoneau, and R.L. Suddath, 2003,Archives of General Psychiatry, 60, p. 909.
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