Amy is a 31-year-old single woman with a 10-year history of bipolar disorder. Recent plasma levels of her current primary mood stabilizer, sodium divalproex, were perplex-ingly low. In IPSRT, the therapist reviewed with Amy the parameters of therapeutic blood levels and then pointed out that the two most recent blood tests fell below the therapeutic range. The therapist reminded Amy about the risk of nonadherence to pharmacotherapy, and gently asked her whether she had any insight into her uncharacteristically low blood levels. Amy burst into tears, revealing that her boyfriend had threatened to leave her because of her 30-pound weight gain over the past year, which he attributed to sodium divalproex. The therapist acknowledged that weight gain can be a troubling side effect of many of the medications used to treat bipolar disorder. Together, they reviewed Amy's currently prescribed medications, which, in addition to the divalproex, included olan-zapine and citalopram. Given the complex medication regimen currently prescribed for Amy, the therapist suggested that the weight gain might not be attributable solely to the divalproex. They discussed other options besides abruptly discontinuing her medication, such as consulting with her psychiatrist to discuss alternatives and pursuing an exercise regimen. In addition to helping Amy understand the importance of raising this issue specifically with her psychiatrist, the therapist discussed with Amy how her weight gain had affected her relationship. They reviewed the importance of educating her boyfriend about her medications, explored other areas of conflict in the relationship, and discussed the negative impact of the weight gain on Amy's sex life with her boyfriend (related to her shame about her changing body).
Social rhythm therapy is based on the theory that stable daily rhythms lead to enhanced stability of mood. This component of treatment focuses on developing strategies to promote regular, rhythm-entraining, social Zeitgebers and manage the negative impact of disrupting Zeistorers. Each week, patients are asked to complete an instrument, the Social Rhythm Metric (SRM), that helps them optimize their daily rhythms. This 17-item self-report form asks patients to record daily activities (that is, time out of bed, first contact with another person, meal times, and bedtime), whether each occurred alone or with others present, and whether or not they involved significant amounts of social stimulation (that is, quiet versus interactive). Patients are also asked to rate their moods each day. A shorter version of the SRM (five items) has also been validated and may be more easily implemented than the longer form in most clinical settings (Monk et al., 2002).
In the beginning stages of treatment, the patient is asked to complete the SRM weekly. The first 3-4 weeks of SRMs are used to establish the patient's baseline social rhythms. The therapist and patient jointly review the SRMs, identifying both stable and unstable daily rhythms. For instance, is the patient going to bed at a reasonable hour during the week but then staying out late on the weekends? Does the patient's mood dip on days when she or he skips meals? By examining the SRMs, the therapist and patient can begin to identify behaviors that negatively influence the patient's rhythm stability.
Once baseline SRMs are collected and patterns of regularity/irregularity identified, the therapist and patient begin working towards rhythm stability through graded, sequential lifestyle changes. The therapist and patient identify short-term, intermediate, and long-term goals to bring social rhythms gradually into a tighter, less variable range. For example, a short-term goal may be going to bed at a fixed time for a period of 1 week. In order to achieve that goal, the patient may need to make changes in his or her social behaviors (for example, curtailing late-night social activities) and health-related behaviors (for example, working with the psychiatrist to move all sedating medications to bedtime). Intermediate goals may include sleeping 8 hours a night with no naps during the day or decrease the number of hours spent at work. In order to accomplish these goals, the patient will build on short-terms gains but also institute some new social cues (such as signing up for afternoon classes to decrease napping). The therapist emphasizes the importance of establishing a regular schedule, even if the schedule most comfortable to the patient is phase shifted. For instance, many patients with bipolar disorder prefer to establish regular routines that include a late bedtime (such as 2 a.m.) and a later awakening time (such as 10 a.m.). The therapist helps patients understand that virtually any regular schedule is acceptable as long as they are able to meet their social obligations and to sleep for an adequate duration in a single time block (for most individuals, 7-9 hours). Long-term goals may consist of encouraging patients to find a job which allows them to keep a more regular schedule (for example, a job in a movie theater that does not begin until noon). In an effort to regulate rhythms, the therapist will also monitor the frequency and intensity of social interactions and identify connections between mood and activity level. If a patient is depressed, the therapist may encourage the patient to participate in more stimulating activities; if hypomanic, the patient will be encouraged to minimize overstimulation.
During the course of treatment, the therapist continues to review SRMs. The weekly SRM provides the therapist with the opportunity to review progress toward identified social rhythm goals and address impediments to change. In addition, the SRM is used to help the patient self-monitor for evidence of an exacerbation of the mood disorder. When a patient begins to slip into an episode of mania or depression, changes in sleep and activity levels may be detected on the SRM before the patient is aware of a shift in mood. Thus, the SRM is used as both a measure of therapeutic change and an ancillary mechanism for monitoring symptoms.
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