IPSRT was developed as a response to the observation that pharmacotherapy, although essential to the treatment of bipolar disorder, is often not enough for patients suffering from
Mood Disorders: A Handbook ofScience and Practice. Edited by M. Power. © 2004 John Wiley & Sons, Ltd. ISBN 0-470-84390-X.
the disorder. Studies of maintenance treatment with mood stabilizers alone demonstrate un-acceptably high rates of recurrence over a 2-3 year period (Gelenberg et al., 1989; Markar & Mander, 1989), and persistence of residual psychosocial difficulties despite syndromal recovery (Goldberg et al., 1995). In order to address these clinical dilemmas, Dr Ellen Frank at the University of Pittsburgh developed a psychotherapy designed both to facilitate full recovery from illness and promote long-term wellness. IPSRT, built on the principles of interpersonal psychotherapy (IPT) for unipolar depression (Klerman et al., 1984) and theories of circadian rhythm biology (Ehlers et al., 1988), has the tripartite goals of supporting medication adherence, minimizing the impact of disruptive life events on social rhythms, and addressing interpersonal difficulties as they arise in the context of a mood disorder. In a broader sense, IPSRT strives to dampen the most extreme oscillations of mood and energy by helping patients to manage provocative social and environmental factors more effectively. IPSRT integrates psychoeducational, interpersonal, and behavioral strategies in order to reduce symptoms, improve functioning, and prevent recurrence of episodes.
The framework of IPSRT rests on three related theoretical constructs:
(1) the "instability model" of bipolar disorder proposed by Goodwin and Jamison (1990)
(2) theories regarding the function of social and environmental cues in promoting/disrupting circadian rhythm integrity (Ehlers et al., 1988; 1993)
(3) the principles of IPT conceptualized by Klerman and Weissman, (Klerman et al., 1984).
We discuss the theoretical underpinnings of each component below.
In their instability model, Goodwin and Jamison (1990) define three interconnected pathways to episode recurrence: taxing life events, medication noncompliance, and social rhythm disruption. Each pathway potentially leads a stable patient towards an episode of depression or mania. Their model suggests that individuals with bipolar disorder are fundamentally (biologically) vulnerable to disruptions in circadian rhythms. Psychosocial stressors, in turn, interact with this biological vulnerability to cause symptoms. For instance, stressful life events (such as the birth of a child) disrupt social rhythms, causing disturbances in circa-dian integrity, which, in turn, may lead to recurrence. Alternately, problematic interpersonal relationships or irregular work schedules contribute to nonadherence to a medication regimen, which, again, may lead to recurrence. Conversely, a patient's ambivalent feelings about medications or intolerable side effects may lead the patient to skip doses or discontinue medication. As medication is decreased, symptoms and rhythm irregularities emerge. As a direct consequence of this model, one would assume that helping patients learn to take their medication regularly, lead more orderly lives, and resolve interpersonal problems more effectively would promote circadian integrity and minimize risk of recurrence. IPSRT focuses on all three of these pathways in an effort to stabilize mood.
Related to the model elaborated by Goodwin and Jamison (above), circadian rhythm researchers have identified reciprocal relationships among circadian rhythms, sleep-wake cycles, and mood. It is well documented, for instance, that sleep reduction can lead to mania in bipolar subjects (Leibenluft et al., 1996; Wehr et al., 1987). Furthermore, sleep deprivation has significant (if transient) antidepressant effects in both unipolar and bipolar depressed subjects (Barbini et al., 1998;Leibenluftetal., 1993; Leibenluft&Suppes, 1999). Ehlers and colleagues (1988), attempting to bridge the biological and psychosocial models of depression, hypothesized that there are specific social cues that entrain biological cycles (Zeitgebers) and others that disrupt them (Zeitstorers). Social Zeitgebers are defined as personal relationships, social demands, or tasks that entrain biological rhythms (for example, meeting school-age children at the bus stop at 3 p.m. each day). They further hypothesized that losing a social Zeitgeber (for example, summer vacation with the attendant loss of the school bus pickup) could trigger an episode by causing the dysregulation of biological rhythms (Ehlers et al., 1993). Another example of a social Zeitgeber is a regular job. Losing a job that may have previously determined sleep/wake times, rest periods, and meal times represents a lost Zeitgeber. In an individual with the genetic predisposition to depression, the physiological and chronobiological disturbances produced by losing the social cues for sleep and meal times could be as important in the genesis of an episode as the psychological distress generated by the event.
In contrast to Zeitgebers, Zeitstorers are defined as physical, chemical, or psychosocial events that disturb the biological clock. For instance, travel across time zones represents a prototypical Zeitstorer. The abrupt change in the timing of light exposure, rest times, and sleep schedule can produce a range of symptoms from mild jet lag to a full-blown affective episode in predisposed individuals. Other examples of potential Zeitstorers include newborn babies, marital separations, work deadlines (especially those that require an individual to stay at work into the night, missing meals and sleep), and rotating shift work. Each of these disruptions has the potential to alter significantly an individual's circadian and sleep-wake rhythms and, in turn, provoke an affective episode. IPSRT was built on the idea that helping patients to regulate social rhythms (modulate Zeitgebers and Zeitstorers) may help vulnerable individuals reduce the risk of developing mood symptoms.
INTERPERSONAL PSYCHOTHERAPY (IPT)
IPT was developed by Klerman and colleagues as a treatment for unipolar depression (Klerman et al., 1984). This treatment is described in detail elsewhere in this textbook (See Chapter 9). Built on the tenets of social psychology and the observations of interpersonal theorists such as Harry Stack Sullivan, IPT focuses on the link between mood and interpersonal life events. IPT postulates that psychosocial and interpersonal factors are associated with the onset and maintenance of mood episodes in individuals biologically predisposed to affective disorders, and that symptoms of mood disorders interfere with the interpersonal coping skills of the afflicted individuals. In IPSRT, therapists use IPT strategies both to resolve interpersonal difficulties and to lessen the impact of stressful interpersonal events on daily routines.
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