Off The Couch #10 Bipolar Disorder Treatment

Did you know that 70% of bipolar cases are caused by interpersonal stress? Dr. Daniel Brown usually consulted with Fred Goodwin (Frederick K. Goodwin) if he had a difficult bipolar case. This interview covers bipolar diagnosis, treatment, psychological factors that cause bipolar disorders, and new types of bipolar disorder treatment for clinical psychologists.

Read the Full Transcript:

Caroline Baltzer: Dan, one of my very favorite things to do in my private practice is work with people of bipolar disorder. I had a lot of different teachers over the years, whom I learned bits and pieces from. But the person that I, without question, learned the most from was you. And your way of teaching it really made me take in not just the knowledge about bipolar disorder but kind of a sense for it, like a smell for it. Because there are things about it that all hang together, and sometimes, it can be hiding in plain sight. Sometimes people will be misdiagnosed for years as having borderline personality, or hard to treat depression. So, it can really require a clinician that has a nose for it to tease it out. And I’ve learned that from you. So, I’m hoping that you’ll tell us something about how you develop that knowledge about bipolar disorder.

Dan Brown: Well, the person that I used to use as an occasional consultant on my cases was Fred Goodwin, the Director, the Principal Investigator of the bipolar project at National Institute of Mental Health for almost 30 years. And if I had a difficult bipolar case, I would ask him how to treat it.

Caroline Baltzer: By difficult, what do you mean?

Dan Brown: One that was not controllable by lithium in those days. And that was before we had the whole range of mood disorder medications that we have available nowadays. In the 1990s, there was a whole unit of serious bipolar patients who were rapid cyclers and didn’t respond to lithium. Fred was open enough to think about non-medication ways of treating them. He was the one that discovered that fish oils, omega-3s, were useful as an alternative treatment for those who were not lithium-responsive. He was the one who tried certain calcium diets, calcium restricted diets. So, he was open to different things. And I would bring him cases, and he would consult with me about the different things that were likely to work when lithium wasn’t working. Then, in my consultations with him, he would often talk about psychological factors. So, I got more interested in the fact that, with the development of lithium as a successful treatment of bipolar disorder, we moved away from the fact that we used to do psychotherapy with bipolar patients.

So, we developed a course on psychotherapy with bipolar patients that focused on at least three areas. The first was the observation that 70% of bipolar episodes are precipitated by interpersonal stress. So, we began to think that, if we treated the interpersonal issues with CCRT or attachment formulations, then that would reduce the risk of having episodes. The second thing was a well-documented finding, at the National Institute of Mental Health, by Goodwin’s research group that, if you look at the genetics of bipolar illness, it’s a defect in the biological clock, which means that sleep-wake cycles are dysregulated, mood and hormonal regulation is dysregulated, and that a good deal of bipolar episodes are precipitated by variable sleep disturbances in diurnal rhythms. So, what emerged was a whole thing called “social rhythm therapy.” If you look at the larger lifestyle of bipolar-vulnerable patients, and you have a stable lifestyle with stable times that they go to sleep and wake up in the morning, and if you work on keeping the rhythms of everyday life stable, regulate those rhythms, pin them down, and anchor them, then that would substantially reduce the risk for bipolar episodes, medication aside.

So, then, the third area was that bipolar patients have variable metacognitive capacity, and whatever metacognitive capacity they have goes down the tubes when they start having an episode. So, they stop taking their medications, and they can’t see what the warning signs are. We found that you could teach them to retain that metacognition by going over their episodes with them post hoc. Then, next time around, they would learn to recognize the warning signs more clearly, and they could retain some metacognitive capacity during episodes, in a way that was at least early on the episodes, protecting them from getting further deteriorated.

Caroline Baltzer: Did you just say that bipolar patients have a predisposition to lower metacognition?

Dan Brown: Not necessarily. It varies per patient. But when they have an episode, it tends to get suspended. So, we began to think that there was a whole domain of psychotherapy that we could reinstitute for bipolar patients, that went beyond just medication management, and that would be an effective preventative approach to bipolar episodes.

Caroline Baltzer: Taking stress off, putting rhythm back in.

Dan Brown: Interpersonal stress, looking at an analysis of episodes, developing a metacognitive capacity to look at the warning signs, to look at the social and diurnal rhythms of life, and to regulate them and stabilize them.

Caroline Baltzer: And helping the patient be more collaborative with their diagnosis instead of getting blind-sighted by it.

Dan Brown: Yes, we would add that too. And then, considering the use of omega-3s as an alternative to some of the mood stabilizers.

Caroline Baltzer: Why is it that omega-3s are a complement to lithium?

Dan Brown: Because it factors in the way in which calcium channeling mechanisms and how lithium works. It is based on the Table of Elements: that lithium is a salt that is the same charge as calcium. It’s based on the old theory of competition: if you plug up the receptor sites with lithium and the calcium channels, then it is not defective. There is some defect in the calcium channel receptors that causes the flooding of bombardment of the neurotransmitters across the synapse. However, the structure of the cell wall is a lipid structure that’s similar to the molecular structure of omega-3s. So, rather than Lithium, based on the old theory of competition, with Omega-3s, you’re actually repairing the cell wall. So, that’s a completely different mechanism.

Caroline Baltzer: So, the lithium is plugging it up but the omega-3s are repairing.

Dan Brown: Yes.

Caroline Baltzer: So, are they used together or as –

Dan Brown: You can use them together or you can use them, depending on the patient, separately. Lithium and other mood stabilizers tend to overshoot the mark for people who have less severe bipolar conditions, like type 2 and type 3 bipolar conditions, and tend to be better for people who have type 1, classic manic-depressive illness. So, omega-3s work better for people with less severe forms of bipolar illness. They don’t overshoot the mark, so the person doesn’t feel snowed by the medication.

Caroline Baltzer: I find it, as a psychologist working with bipolar patients, so important to have knowledge about how the brain works and how the medications work. Because the patients, as you pointed out, sometimes, they’ll go against their treatment plan, their medication, psychopharmacology, because they are feeling pulled by hypomania, or feeling pulled by a rhythm problem, and they can –

Dan Brown: That’s true.

Caroline Baltzer: – be resistant to the medications that ultimately over time– That’s the other thing, that sometimes, it takes a while for them to find their optimum baseline, and they need to understand what’s going on. I feel, as a psychologist, that I need to know about that to help them, almost coach them, as they move towards an optimum baseline. And a lot of psychiatrists that I’ve worked with are surprised at the amount of interest that I take in that part of the treatment, but with those patients –

Dan Brown: There’s no substitute for developing a relationship, which is what you’re talking about, and learning in the relationship what the particular client needs. It’s important.

Caroline Baltzer: Yeah, I think it works better that way.

Dan Brown: I agree with you fully. Well said.

Watch the full clinical interview series:
1. Meet Dr. Daniel P. Brown 
2. Overview of Trauma Treatment
3. Attachment Disturbances 
4. CCRT (Core Conflictual Relationship Themes)
5. Three Pillars Approach (Treatment for Attachment)
6. Teaching Psychology
7. Conversion Disorders 
8. Factitious & Dissociative Disorder
9. Psychological Assessments
10. Bipolar Disorder Treatment
11. Trauma Bonding Maps
12. Conclusion 

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