ABSTRACT
OBJECTIVES: Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders. METHODS: This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas ¼ AND « bipolar disorder ¼ as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias). RESULTS: Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles. CONCLUSIONS: Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.
Subject(s)
Bipolar Disorder/psychology , Bipolar Disorder/therapy , Adaptation, Psychological , Adult , Clinical Trials as Topic , Female , Humans , Male , Middle Aged , Young AdultABSTRACT
OBJECTIVES: The patient with bipolar disorder and his family are caught in a reciprocal interaction: on one hand, the pathology leads to family sufferings and on the other hand, family behavior affects the disease of the patient and its development. Therefore, it seems of core importance that the psychologist should work with the family on their perception of bipolar disorder, that is to say, on their knowledge and psychological representations of the pathology. The aim of our study is to assess whether the initial perception of bipolar disorder evolves after a therapeutic education program. METHOD: Our research was conducted at the Bipolar Expertise Centre in Bordeaux/Centre Expert Bipolaire in Bordeaux on a sample of 145 participants (78patients and 67 family caregivers). They were all interviewed before and after the therapeutic education program (12 sessions in 6months). The Brief Illness Perception Questionnaire Revised (Moss-Morris, 2002) measures the perception of bipolar disorder and the BP Quizz (Fondation Fondamental) assesses the degree of knowledge of the disorder. RESULTS: Results show that therapeutic education helps families to level up their knowledge about bipolar disorder. Furthermore, representations on bipolar disorder have globally changed so that on average, bipolar disorder is viewed as less threatening by families after 12 sessions of therapeutic education. More precisely, after the program, families have a better understanding and a better insight of the disorder, which is then perceived as being less severe. On the emotional level, anxiety and stress have decreased. So there are an increase of knowledge and a change in perception. CONCLUSION: Our study shows that the therapeutic education program enables families to change their perception of the disease, that is to say, their knowledge but also their representations of the disease, which is a fundamental element according to the models of therapeutic education. Our results point out one of the active processes of therapeutic education at work in the sessions: in the perception of the disease, which is composed of both knowledge and representations of the disease, just a change in representations constitutes a lever for therapeutic education. Therefore, working on representations should be a therapeutic target. As a conclusion, we can say that therapeutic education of families cannot be reduced to an educational dimension which would only consist of gaining knowledge. Then, the right posture of the psychologist is to hold each participant's own development and changing process of representations.
Subject(s)
Bipolar Disorder/psychology , Bipolar Disorder/therapy , Caregivers/psychology , Family Therapy/methods , Patient Education as Topic/methods , Psychotherapy/methods , Adult , Aged , Anxiety/psychology , Emotions , Female , Health Knowledge, Attitudes, Practice , Humans , Male , Middle Aged , Surveys and QuestionnairesABSTRACT
OBJECTIVE: Duration of untreated illness represents a potentially modifiable component of any diagnosis-treatment pathway. In bipolar disorder (BD), this concept has rarely been systematically defined or not been applied to large clinically representative samples. METHOD: In a well-characterized sample of 501 patients with BD, we estimated the duration of untreated bipolar disorder (DUB: the interval between the first major mood episode and first treatment with a mood stabilizer). Associations between DUB and clinical onset and the temporal sequence of key clinical milestones were examined. RESULTS: The mean DUB was 9.6 years (SD 9.7; median 6). The median DUB for those with a hypomanic onset (14.5 years) exceeded that for depressive (13 years) and manic onset (8 years). Early onset BD cases have the longest DUB (P < 0.0001). An extended DUB was associated with more mood episodes (P < 0.0001), more suicidal behaviour (P = 0.0003) and a trend towards greater lifetime mood instability (e.g. rapid cycling, possible antidepressant-induced mania). CONCLUSION: Duration of untreated bipolar disorder (DUB) will only be significantly reduced by more aggressive case finding strategies. Reliable diagnosis (especially for BD-II) and/or instigation of recommended treatments is currently delayed by insufficient awareness of the early, polymorphous presentations of BD, lack of systematic screening and/or failure to follow established guidelines.
Subject(s)
Bipolar Disorder/therapy , Adult , Age of Onset , Bipolar Disorder/diagnosis , Bipolar Disorder/psychology , Delayed Diagnosis/psychology , Delayed Diagnosis/statistics & numerical data , Female , Humans , Male , Time FactorsABSTRACT
BACKGROUND: A strong association has been reported between trait-impulsiveness and bipolar disorder (BD). Much attention has been focused on this association, but subgroup analysis has generated conflicting results, raising questions about the role of trait-impulsiveness in suicidal behavior and substance misuse in bipolar patients. METHOD: We compared Barratt Impulsiveness Scale-10 scores between 385 euthymic bipolar patients and 185 healthy controls. We then investigated possible association between impulsiveness scores and the following clinical characteristics: suicide attempt (SA), lifetime alcohol/cannabis misuse, rapid cycling and mixed episodes. RESULTS: Bipolar patients and healthy controls had significantly different BIS-10 total score and subscores (motor, attentional and nonplanning impulsiveness) (all p values <0.0001). No association was observed between BIS-10 total score, personal history of SA, number of SA, age at first SA and history of violent SA. Higher BIS-10 total scores were associated with alcohol misuse (p=0.005), cannabis misuse (p<0.0001), with an additive effect for these two substances (p=0.005). Higher BIS-10 total scores were also associated with rapid cycling (p=0.006) and history of mixed episodes (p=0.002), with an additive effect of these two variables (p=0.0006). LIMITATIONS: We used only one clinical measurement of impulsiveness and did not carry out cognitive assessment. CONCLUSION: This study demonstrates that trait-impulsiveness may be considered as a dimensional feature associated with BD and with a more severe clinical expression of the disease, characterized by a history of substance misuse, rapid cycling and mixed episodes. We found no association between impulsiveness and SA characteristics in bipolar patients, confirming some previous negative results.
