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Bipolar disorder is the experience of repeatedly different mood episodes that significantly
disturbed individuals activity level. On some occasions, the individuals will experience an
elevation of mood, energy and activity level; while on another time, the individuals will
experience a lowering of mood, energy and activity (found in all individuals who suffered
from Bipolar Disorder except those who experience elevation only). Bipolar disorder is a
pervasive and chronic disorder which at least moderately impaired individuals daily
functioning. According to Diagnostic and Statistical Manual of Mental Disorder (DSM),
there are four main types of Bipolar Disorder, which are:
1) Bipolar I Disorder
2) Bipolar II Disorder
3) Cyclothymic Disorder
4) Substance/Medication-Induced Bipolar and Related Disorder (DSM-5)
5) Bipolar and Related Disorder due to Another Medical Condition (DSM-5)
6) Bipolar Disorder Not Otherwise Specified (DSM-IV-TR)/Other Specified or
Unspecified Bipolar and Related Disorders (DSM-5)
I. Types of Mood Episodes
1) Diagnostic criteria of Manic Episode in DSM-IV-TR are as below (APA, 2000):
Criteria A: Manic episode is a distinct period during in which individual experience abnormal
and persistent elevated, expansive, or irritable mood. This period must last for at least 1 week
(or less if hospitalization is needed).
Criteria B: The mood disturbance must including at least three following symptoms
(a) inflated self-esteem or grandiosity
(b) decrease need for sleep
(c) pressure of speech
(d) flights of ideas
(e) distractibility
(f) increase involvement in goal-directed activity or psychomotor agitation
(g) excessive involvement in activities that are potentially resulting in painful consequences.
Criteria C: The symptoms do not meet the criteria of Mixed Episode.
Criteria D: The mood disturbances is severe enough to cause marked impairment in social or
occupational functioning, necessity to be hospitalized, or presence of psychotic features.
Criteria E: The symptoms are not due to direct physiological effect of substance or general
medical condition.
2) Diagnostic criteria of Major Depressive Episode in DSM-IV-TR are as below (APA,
Criteria A: The essential feature of Major Depressive Episode is either the presence of
depressed mood or loss of interest or pleasure for at least 2 weeks. While in children and
adolescents, the mood may be irritable rather than sad. During this period, the individual
must also experience at least four additional symptoms such as the following:
(a) changes in appetite and weight not due to dieting


(b) insomnia or hypersomnia almost every day

(c) psychomotor agitation or retardation that is observable
(d) fatigue
(e) feeling worthless or guilty
(f) difficulty thinking, concentrating and making decision
(g) recurrent thoughts of death, suicidal ideations, plans or attempts.
Criteria B: The symptoms do not meet criteria for a Mixed Episode
Criteria C: These symptoms must have either caused significant impairment in social,
occupational and other areas of functioning for individual with moderate or severe symptoms,
or markedly the needs of increased effort in functioning for individual with milder symptoms.
Criteria D: The symptoms are not caused by direct substance or general medical condition.
Criteria E: The symptoms are not better accounted for by Bereavement
3) Diagnostic criteria of Mixed Episodes in DSM-IV-TR are as below (APA, 2000):
Criteria A: Mixed Episode is a combined presence of symptoms in both Manic Episode and
Major Depressive Episode. The duration of symptoms occurrence should be at least one
week. Individual experience alternating moods and other symptoms in both episodes.
Criteria B: The mood disturbance is severe enough to cause obvious impairment in
occupational, social and other areas of functioning, or hospitalization is compulsory to avoid
suicide and harm to others, or with psychotic features.
Criteria C: Presence of symptoms are not physiologically caused by substance and general
medical condition.
(***Mixed Episode in DSM-IV-TR has been replaced with mixed features in DSM-5.)
4) Diagnostic criteria of Hypomanic Episodes in DSM-IV-TR are as below (APA, 2000):
Criteria A: Hypomanic Episode is a distinct period in which individual continuously
experienced elevated, expansive, or irritable mood that last throughout at least 4 consecutive
days. These symptoms are obviously different from the usual non-depressed mood.
Criteria B: During this period, individual experiences at least 3 symptoms (4 if experience
irritable mood only) similar to Manic Episode.
Criteria C: There is significant change in functioning which is not the usual characteristic of
that individual when not symptomatic. Its changes and mood disturbance and observable by
*Criteria D: Manic episode is not sufficiently severe to cause marked impairment in social,
occupational and other areas of functioning, hospitalization, and there is no psychotic
Criteria E: The symptoms are not physiologically caused by substance or general medical
Note:*Main difference from manic episode
II. Types of Bipolar Disorders
1) Bipolar I Disorder
Bipolar I Disorder involves occurrence of at least one Manic Episodes or Mixed Episodes,
and at least one Major Depressive Episode (except for single manic episode type) (APA,
2000). There are six types of Bipolar Disorder I in DSM-IV-TR, which are:
(a) Single Manic Episode
(b) Most Recent Episode Hypomanic
(c) Most Recent Episode Manic
(d) Most Recent Episode Mixed


(e) Most Recent Episode Depressed

(f) Most Recent Episode Unspecified
(***Has been replaced by other specifier stated in )
2) Bipolar II Disorder
(a) It involves occurrence of at least one Hypomanic Episodes and at least one Depressive
Episode within an individual. The diagnostic criteria is similar to Bipolar Disorder I except
that the individual has no history of experiencing Manic or Mixed Episode in first 2 years of
disturbances (APA, 2000).
(b) Bipolar II Disorder has often been regarding as less severe and disabling psychopathology
compared to Bipolar I Disorder due to the less severity of hypomanic episodes. However,
there are several issues that causes individuals with Bipolar II Disorder to have higher
disability as:
(i) Individual with Bipolar II disorder are difficult to be diagnosed due to insufficient number
of assessment tools that are sensitive towards detecting Bipolar II disorder (Miller et al.,
(ii) They are less readily accept that they have Bipolar Disorder. This is because they
recognized the depressive episodes as illness but not considering hypomanic episodes as part
of their illness. This is because it is difficult to differentiate hypomanic magnification of
emotions from ordinary emotional reactions (Orum, 2008), and they enjoy the sense of
mastery and benefits of being fast-pacing and somewhat efficient during hypomanic episodes
(Parker 2008).
(iii) They attempted suicide more frequent, more lethal and more likely to complete suicide
compared to individuals with Bipolar I disorder (Rihmer & Pestality, 1999). This can be
explained by large portion of them live unwell most of their lifetime, mostly suffering from
depressive symptoms (Benazzi, 2001).
3) Cyclothymic Disorder
Its essential feature is chronic, fluctuating mood disturbances involving numerous periods of
hypomanic symptoms and depressive symptoms (APA, 2000). According to DSM-IV-TR,
the diagnostic criteria for Cyclothymic Disorder is as following:
Criteria A: The presence of hypomanic symptoms and depressive symptoms do not meet
criteria for Manic Episode and Major Depressive Episode *(insufficient number, severity,
pervasiveness or duration). These symptoms must present for at least 2 years for adult.
Criteria B: The individual has not been free of symptoms mentioned in Criteria A for more
than 2 months at a time during the 2-year period.*
Criteria C: The symptoms are not better accounted for disorder related to Schizophrenia, and
not physiologically caused by substances and general medical condition.
Criteria D: The symptoms cause clinically marked impairment and distress in individuals
social, occupational and other areas of functioning.
Note: *= main difference from Bipolar I and II Disorder
4) Bipolar Disorder Not Otherwise Specified
While for disorders with bipolar features that do not meet criteria for any specific Bipolar
Disorder, it will be categorized under Bipolar Disorder Not Otherwise Specified in DSM-IVTR (or Other Specified or Unspecified Bipolar and Related Disorders in DSM-5) (APA,
2000, 2012). Examples of the features includes:


(a) Very rapid interchange (over days) between manic symptoms and depressive symptoms.
These symptoms meet threshold criteria, but not minimal duration criteria for Manic,
Hypomanic or Major Depressive Episodes.
(b) Recurrent Hypomanic Episodes without presence of depressive symptoms after or during
the hypomanic episodes.
(c) A Manic or Mixed Episodes overlaid Delusional Disorder, residual Schizophrenia, or
Psychotic Disorder Not Otherwise Specified.
(d) Infrequent presence of hypomanic episodes along with chronic depressive symptoms that
are difficult to be qualified for diagnosis of Cyclothymic Disorder.
(e) Situation in which Bipolar Disorder is present based on clinicians clinical judgment,
however unable to determine whether it is primary, and whether it is due to general medical
condition or induced by substance.
To better illustrate the differences, please refer to diagram below, which is adapted from
International Medical Health Research Organization (IMHRO; 2013).

5) Specifier for Bipolar and Related Disorders

According to DSM-5, the specifiers are as following:
With anxious distress
(a) Presence of at least 2 symptoms in current or most recent
episodes of mania, hypomania & depression:
(i) Feeling tense or keyed up
(ii) Feeling restless that is unusual
(iii) Feeling worry and that cause difficulty concentrating
(iv) Afraid that something awful may happen
(v) Feeling might lose control of oneself
(b) Severity: Mild= 2 symptoms
Moderate= 3 symptoms
Moderate-severe= 4-5 symptoms
Severe= 4-5 symptoms with motor agitation
With mixed feature
(a) In those who are in current or most recent episodes of
hypomanic/manic, it is characterized as presence of full
criteria of manic/hypomanic episode, HOWEVER with at
least 3 symptoms of depressive episodes.
In who are in current or most recent episodes of


With rapid cycling (both

Bipolar I & II disorder)

With melancholic features

With atypical features,

with psychotic features,
with catatonia, with
peripartum onset, with
seasonal pattern.
Remission Specifier

Severity Specifier

depression, it is characterized as presence of full criteria of
depressive disorder, HOWEVER with at least 3 symptoms of
manic/hypomanic episodes.
(b) Mixed symptoms must be observable by others and not
that individuals behavior.
(c) For those who meet both full criteria of mania and
depression at the same time, the diagnosis should be manic
episodes, with mixed features.
(d) Mixed symptoms must not be caused by physiological
effect of substance.
Presence of at least 4 episodes of manic, hypomanic and
major depressive episode which meet full criteria in the past
12 months. The episodes must be separated by a period of
partial or full remissions of at least 2 months OR switch to
the episode that has opposite polarity
(a) At least having one of the following during severe period
of current episode:
(i) anhedonia
(ii) lack of reactivity to usually pleasurable stimuli
(b) At least 3 of the following
(i) Distinct quality of depressed mood characterized by
profound despondency, despair and/or moroseness or empty
(ii) Depression that is normally worse in the morning
(iii) Wake up at least 2 hours earlier before usual awakening.
(iv) Significant psychomotor agitation or retardation
(v) Marked aneroxia or weight loss.
(vi) Excessive or inappropriate guilt.
Please refer to DSM-5 page 151-154 or related websites

(a) In partial remission- symptoms present but not meeting

full criteria in current episodes OR period lasting less than 2
months without symptoms
(b) In full remission- No significant signs or symptoms for
past 2 months.
(a) Mild- number of symptoms just exceed a few that is
required to meet diagnostic criteria, symptoms is distressing
but manageable, result in minor impairment in social or
occupational functioning.
(b) Moderate- number and intensity of symptoms, and/or
functional impairment are between mild and severe.
(c) Severe- number of symptoms is significantly in excess to
make diagnosis, intensity is unmanageable and seriously
distressing, and interfere with social and occupational


6) Bipolar Disorders have concurrent features with other psychopathology, which often cause
misdiagnosis due to features similarity. These psychopathology are:
Types of Bipolar
Features that differentiate both
Disorder that share
similar features
Mood Disorder Due
to General Medical
Substance Induced
Mood Disorder

Bipolar I, II Disorder,
Cyclothymic Disorder

Psychotic Disorder

Bipolar I, II Disorder

Personality Disorder

Cyclothymic Disorder

Bipolar I, II Disorder,
Cyclothymic Disorder

Presence as direct physiological

consequences of a specific general medical
condition (for eg. Hypothyroidism)
Presence as direct physiological
consequences of intoxification with or
withdrawal from substance use, medication
(antidepressant treatment)
Sufficiency of number, duration, and
pervasiveness of manic and depressive
symptoms are less and presence of
psychotic symptoms in psychotic disorders
(can refer to symptoms, previous course,
and family history).
Presence of mood symptoms in Borderline
Personality Disorder are more pervasive
and without period of free from symptoms
even less than 2 months (however
comorbidity can occur).

7) Bipolar Disorder can be present with other features and coexisting with other disorders:
(a) Suicide attempt and ideation
- mostly during depressive episodes and more common in clients with Bipolar II Disorder
(Parker, 2008)
(b) Violent behavior (for eg. child and domestic abuse)
(c) Psychotic features
(d) School truancy, school failure, occupational failure, divorce, or episodic antisocial
(e) Alcohol and other Substance Use Disorders
(f) Anorexia Nervosa, Bulimia Nervosa, Sleep Disorder, Panic
Disorder, and Social Phobia.
(g) Attention-Deficit/ Hyperactivity Disorder, Borderline Personality Disorder
(h) Risk-taking behavior in individual with Bipolar Disorder
8) For Bipolar Disorder, there are differences of gender in manifestation of symptoms. These
(a) Male are more likely to experience Manic Episode as their first episode, while female are
more likely to experience Major Depressive Episode as their first episode.
(b) Male experience equal or higher number of Manic Episodes, while female higher number
of Major Depressive Disorder.
(c) Rapid cycling are more common in female than male.
9) Further information on specific features of Bipolar Disorder
(a) Risk-taking behavior in individual with Bipolar Disorder
(i) Individuals with Bipolar Disorder are always characterized as being impulsive, always


on-the-go, always engaged in goal-directed activities without proper planning and

consideration of consequences and etc, especially when they are manic (Johnson et
al., 2012).
(ii) In fact, there are two subcriteria in DSM under criterion A in manic episode that
describe these behavior (American Psychiatric Association, 2000).
(iii) Interesting result from past research showed that individuals with Bipolar Disorder
are more likely to report themselves as being impulsive compare to healthy
individuals (perhaps the memory of being impulsive is readily available and the selfreport measure is more sensitive in detecting the changes) (Holmes et al, 2009;
Lambardo et al., 2012).
(iv) However, result from past research regarding the risk-taking behavior were
inconsistent with criteria in DSM and generally known in individuals with Bipolar
Disorder, as Holmes et al. (2009) found that only individuals with Bipolar Disorder
and alcohol dependence issues more prone to engage in risk-taking behavior
according to behavior measure, but not generally all individuals with Bipolar
Disorder. Reddy et al. (2014) found that individuals with Bipolar Disorder were not
more prone to risk-taking behavior compared to healthy individuals.
(v) Follow by their study, Reddy et al. (2014) found that the possible explanation is the
whether the individuals with Bipolar Disorder are taking antipsychotic medication. It
was found that in their research that those who took antipsychotic medication were
less likely to engage in risk-taking behavior compared to those who did not take. This
still require further investigation in other research.
(b) Rapid-cycling
(i) 3 types of rapid cycling
- rapid (greater than or equal to four episodes per year)
- ultra-rapid (greater than or equal to four episodes within a month)
- ultradian (cycling within a day; greater than or equal to 4 days within a week)
(ii) Risk factors: younger age of onset, childhood physical and sexual
abuse, non-adherence to medication for existing clients, taking antidepressant
(controversial) (Altshuler et al., Calabrese et al, 2005; 1995; Fristalen et al., 2005;
Leverich et al, 2002 as cited in Goldberg & Berk, 2010).
(iii) Outcome: Poorer prognosis compared to typical cycling clients (Goldberg & Berk,
I. Diagnostic Procedure of Bipolar Disorders
According to Martin (2006), below are the procedure to assess and diagnose Bipolar
1) Initial Assessment
(a) In this part, clinical interviewing regarding clients background and issues will be
conducted by psychiatrist or psychologist.
(b) Relevant information that will be asked including
(i) History of Bipolar Disorder (when it started, duration that it has lasted, the severity,
recurrent or new episodes)
(ii) Treatment history of Bipolar Disorder
(iii) Medical and family history (especially history of having Bipolar Disorder)
(c) Family members or significant others will be interviewed especially if clients are
children or adolescents.


2) Psychological Evaluation
In this phase, psychiatrist and psychologist
(a) will check the presence, severity and duration of symptoms by using clinician-rated
and/or semi-structured interview, self-report or/and other-report measures.
(b) The level of functioning that client has and the pervasiveness of impairment in daily
functioning on social and occupational domain.
(c) Mental Status Exam may be used to obtain information regarding whether clients
Speech, thought pattern and speech have been affected by bipolar disorder.\
(d) Other areas of evaluation including other psychiatric disorder, drug and alcohol use.
This is detect comorbidity, at the same time taking drug and alcohol into
consideration in judging whether these substances affect clients bipolar.
3) Physical examination
In this phase, clinician will refer clients to do physical examination to determine or rule out
that the clients bipolar disorder is due to general medical condition (such as
II. Types of Assessments
As there is no biological marker for Bipolar Disorder, the diagnosis is based on examination
of symptoms and potential medical explanation for those symptoms.
Diagnostic and assessment tools are used to examine the presence and severity of symptoms.
Structured diagnostic tools are needed to enable comorbid conditions to be detected
(Zimmerman & Mattia, 1999 as cited in Miller, et al., 2009). Formal and routine screening on
individual with history of major depression also important as many of them would meet
diagnostic criteria for Bipolar Disorder, which normally be ignored by clinicians (Brickman,
LoPicollo & Johnson, 2002 as cited in Miller, et al., 2009). As a result of improper diagnosis,
serious consequences may occur as antidepressant treatment without mood-stabilizing
medication can generate iatrogenic mania (Ghaemi et al., 2001 as cited in Miller, et al.,
2009). Approaches that are normally used by clinician including:
(a) Clinician-rated interview
(b) Semi-structured interview
(c) Self-report measures
Clinician-rated Interview to Diagnose Bipolar Disorder
1) Youth Mania Rating Scales (YMRS; Young, Biggs, Ziegler, & Meyer, 1978)
YMRS is a semi-structured interview conducted by trained clinician to assessed severity of
manic symptoms. It is the gold standard scale for assessment of Bipolar Disorder (Perlis,
2010). The result is based on observation on patient during 30 minutes of interview and twoday patients self-report of manic symptoms before interview. There are 10 items covering
core symptoms of manic phase (including mood, motor activity) and an item regarding
patient insight in this measure. YMRS does not account for other DSM criteria of mania
(including increases in goal-directed activity). Items of core symptoms (irritability, speech,
thought content, and disruptive/aggressive behavior) are double-weighted as clinicians need
to take patients cooperation during interview into account for observation part. Factor
analysis of YMRS showed three factor, which is thought disturbance, overactive/aggressive
behavior, and elevated mood and psychomotor symptoms (Double, 1990). Baseline score for
mania is YMRS=12. YMRS has high inter-rater reliability (.93) and high correlation with
other mania rating scales (.66 to .92) (Young et al., 1978) (Please refer to Appendix A).


2) Bech-Rafaelsen Mania Rating Scale (MAS; Bech et al., 1979)

MAS is similar to YMRS in its format. It has 11 items as well and cover classic manic
symptoms (with five-point rating scale in which 0 means not present and 4 means
severe). It has excellent internal consistency, interrater reliability and strong correlations
with more lengthy measures of manic symptoms (Licht & Jensen, 1997). It can be used to
assess effectiveness of treatment programme as it can detect changes in symptoms after
intervention (Bech, 2002) (Please refer to Appendix B). The score interpretation is as

no mania
hypomania (mild)
probable mania
definite mania

Semi-Structured Interview to Diagnose Bipolar Disorder

1) Structured Clinical Interview for DSM-IV (SCID; Spitzer, Williams, Gibbon, & First,
SCID is designed to assist diagnosing of Bipolar Disorder base on DSM-IV diagnostic
criteria. It is divided into modules to cover different diagnoses, which allows clinician to
tailor the interview so that relevant diagnoses can be captured. It provides interview probes,
symptom thresholds, and information about exclusion criteria to assist clinician in the process
of diagnosis. In this semi-structured interview, probes that cover core symptoms are ready to
guide clinician to collect symptoms information. Clinical judgments are needed to make
symptoms information more reliable. SCIDs bipolar disorder module has good interrater
reliability (in international multisite trial and 10 major trials) (Williams et al, 1992; Rogers,
Jackson & Cashel, 2001 as cited in Miller, Johnson & Eisner, 2009). SCID demonstrated
adequate to excellent reliability for current and lifetime diagnoses, ranging from .64 to .92
(Williams et al., 1992 as cited in Miller, Johnson & Eisner, 2009). Compared to other
standard clinician interviews, it has higher percentage of agreement with the gold standard
(Basco et al., 2000 as cited in Miller et al., 2009). However, SIDS cannot accurately detect
Bipolar II Disorder compared to expert clinician interview, probably because of of the
subjectivity of definition (limited severity in hypomania episode (Miller et al., 2009) (Please
refer to http:// for the items and more
2) Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978)
SADS is designed to assist diagnosing of Bipolar Disorder base on Research Diagnostic
Criteria (RDC), which are stricter and more likely to yield a diagnosis of Schizoaffective
Disorder if psychotic symptoms are present in individuals. Similar to SCID, SADS contains
interview probes, symptom thresholds, and information about exclusion criteria that assist
clinician. Probes in SADS focus on most recent episode and as well as assist in obtaining a
broad overview of past episodes. SADS has good to excellent reliability for both symptoms
and diagnoses (Andreasen et al., 1981). It has demonstrated good interrater reliability and
good test-retest reliability when it is used to measures adults Bipolar Disorder over 5 to 10
years (Coryell et al., 1995; Rice et al., 1986 as cited in Miller, Johnson & Eisner, 2009).
Within United States, it has demonstrate good validity in capturing diagnoses across different
cultural and ethnic group (Vernon & Roberts, 1982).



Similar with SCID, SADS has demonstrated low reliability in detecting Bipolar II
Disorder. The ability to enhance detectability may be improved by starting measurement with
question about behavioral activation and rise in goal-directed behavioral compared to mood
(Akiskal & Benazzi, 2005). However, it is still waiting to be validated.
SADS also has another subscale (SADS-C), which is used to assess current severity of
manic symptoms. It has a good interrater reliability and strong correlations with other
interview to assess manic severity, such as MAS (with r=.89) (Johnson, Magaro, & Stern,
1986). However, there is no adequate factor analytic support that tested item loading for
SADS-C (Swann et al., 2001) (Online Adult version is not available. Please refer to Endicott
& Spitzer, 1978 original article for more information or by grasping idea through kids version
of SADS via http://
(c) Besides that, it is advised that clinician should consider the following factors during
diagnostic interview to differentiate whether clients are having Bipolar Disorder (especially
Bipolar II) or Unipolar depression. According to PsychiatryTimes (n.d.), clients are more
likely to having Bipolar Disorder compared to Unipolar Depression if below factors exist:
(i) Prepubertal onset of symptoms
(ii) Postpartum symptoms onset
(iii) Brief duration of depressed episodes
(iv) Seasonal pattern
(v) High frequency of depressed episodes
(vi) Multiple antidepressant failures
(vii) Nonresponse, rapid response or/and erratic response to antidepressant treatment
(viii)Dysphoric response to antidepressant treatment, with agitation and insomnia
(xi) Family history of bipolar disorder
(xii) Unstable interpersonal relationship in the past
(xiii) Having vocational problem frequently
(xiv) Responsibility in committing legal issues frequently
(xv) Alcohol and drug abuse
Self-Report Measures that Assess Severity of Bipolar Disorder
1) Bipolar Spectrum Diagnostic Scale (BSDS; Ghaemi et al., 2005)
BSDS is a self-report scale that have 18 items to be checked and one item to be rated. It is
meant to detect the likelihood of respondent to have bipolar disorder. It is sensitive in
detecting the presence of Bipolar Disorder, including Bipolar I and II, with sensitivity=0.75
(Ghaemi et al., 2005). It is able to distinguish unipolar major depressive disorder from bipolar
disorder, with the specificity=0.85 (Ghaemi et al., 2005). The 18 items are descriptive
sentences that describe mood and symptoms of bipolar disorder, while the one item to be
rated is to check how close the descriptive sentences describe the client. One check in each
item is worth 1 point, and addition points will be required to be added to rating on last item
(i.e. Add six points for fits me very well, 4 points for fits me fairly well, and two points
for fits me to some degree) (Please refer to Appendix C for items). The interpretation of
total score is as following:
Highly unlikely
7 12
Low risk
13 19
Moderate risk
20 25
High risk
2) Mood Swing Questionnaire (MSQ; Parker, 2008)



MSQ is a 27-item self-report measure that screens whether client has unipolar depression or
bipolar disorder. The scales divided into 4 phrases: The first phrase tests whether client has
more than 4 symptoms of depression. If they answer yes, they are required to proceed to
question 2, which ask whether client experience mood swing. If they answer yes, they are
required to move to question 3, which ask whether clients experience different hyper in
manic phase compared to euthymic phase. If clients answer yes, they are required to proceed
to question 4 that has 24 items asking the experience of up as 0=no more than usual,
1=somewhat more than usual, and 2=much more than usual. If client score 22 or more, there
is 80% probability that the client has bipolar disorder. It has high level of sensitivity= 0.81
and high level of specificity= 0.91 (Please refer to Appendix D for items).
3) Hypomanic Check List (HCL-32R1; Angst, et al., 2005)
HCL-32R1 is a screening tool to detect hypomanic symptoms in clients with diagnosis of
depression (such as Major Depressive Disorder). The first question is used to assess whether
clients emotional state has effect on answers given in 32 items which consist hypomanic
symptoms and will be presented later. The second question is used to assess clients affective
temperament. The third question consists of 32 items that reflect hypomanic symptoms.
These 32 items can be separated into 2 subscales, which are active/elevated and irritable/risktaking. While question 4 to 7 consists of items ask about how hypomanic symptoms affect
daily life, how significant others react to them and days they spent in high during the past
12 months. If client score 14 or more yes to 32 items in question 3, the client may has
potentially developed bipolar disorder. This require clinician to use clinical judgment to
further consider answers in question 1,2, 4 to 7 in judging whether client has bipolar disorder
(Please refer to Appendix E for items).
4) General Behavior Inventory (GIB; Depue et al., 1981)
GBI is used to identify lifetime diagnoses of Bipolar Disorder, syndromal and also
subsyndrmomal affective tendencies in clinical and nonclinical populations. It has several
version, including brief version and parent-report version for children and adolescent
population. GBI consists 73 items cover lifetime tendencies to experience depressive
symptoms, hypomanic symptoms and biphasic (tendencies for mood states to fluctuate from
extremely high to extremely low). It has high internal reliability (alphas exceeding .90), good
test-retest reliability (exceeding .70), strong predictive validity (through biphasic &
hypomanic items), adequate convergent and discriminant validity across various samples
(Youngstrom, 2007 as cited in Youngstrom, Murray, Johnson & Findling, 2013). The brief
version (with 14 items) has also demonstrated high internal reliability (.83 & .95), strongly
correlated with original version and good construct validity (Youngstrom, Murray, Johnson
& Findling, 2013) (Please refer to Appendix F for items).
5) Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000)
MDQ is a brief self-report screening instrument that consist 3 main questions: first question
which consists 13 items of Bipolar Disorder symptoms, second question which asks whether
individual experiences the symptoms in the same period of time, third question which asks
the extent of the symptoms causing problem to the individual. Positive screening requires an
individual to say YES to at least 7 items in Question 1, YES to Question 2 and
Moderate Problem or Serious Problem in Question 3. MDQ is best at screening Bipolar I
Disorder but not Bipolar II and Not Otherwise Specified Disorder. It has good internal
consistency, good one-month test-retest reliability and good to excellent sensitivity (.73 to
.90) in differentiating bipolar and unipolar disorder in clinical samples (Weber Rouget et al.,
2005). However, this is not the case for community samples. It has good predictive validity in



assessing functioning impairment and suicidal ideation in primary care setting (Das et al.,
2005). Therefore, it is more suitable to be used to screen patient who has existing
psychopathology compared to nonclinical samples (Miller, Johnson & Eisner, 2009) (Please
refer to Appendix G for items).
6) Altman Self-Rating Mania (ASRM) (Altman, Hedeker, Peterson, & Davis, 1997)
ASRM is a 5-item scale measuring mood, self-confidence, sleep disturbance, speech,
and activity level of individual over the past week. The total scores ranging from 0-20, in
which the cut-off score is 5.5. Its advantages are good sensitivity and specificity, and have
adequate internal consistency and concurrent validity with SADS, YMRS and CARS-M
(Young et al., 1978). However, its weakness including covering less symptoms than other
mania scales (Please refer to Appendix H for items).
7) Self-Report Manic Inventory (SRMI; Braunig et al, 1992)
SRMI is a 47-item true-false measures. It assesses symptoms similar to diagnosis criteria of
DSM. It has a good internal consistency and discriminant validity (Braunig et al., 1996 as
cited in Miller et al., 2009). Its advantage is high sensitivity to change. However, it is not
suitable for inpatient due to setting as it was originally designed for outpatient.
8) The Internal State Scale (ISS; Bauer et al., 1991)
ISS is a 17-item scale that differentiate mood state and tracks manic and depressive
symptoms. It has 4 subscales, which are activation (item 6, 8, 10, 12, 13), well-being (item 3,
5, 15), perceived conflict (item 1, 2, 4, 11, 14), and depression index (item 7, 9). However, it
measure arousal more the manic symptoms. It has scoring algorithms for vary substantially
across studies, with different mean and standard deviaton of score distribution (Altman et al.,
2001). It is sensitive to decrement of symptoms, but less sensitive to manic symptoms at the
time of hospitalization (Altman et al., 2001). For depression, the score that is <125 in wellbeing is considered as having depression; while for mania/hypomania. The score that is >125
for well-being and activation<200 is considered as having manic/hypomanic episode (Please
refer to Appendix I for items).
Self-Report Measures that Assess Depressive Episodes in Bipolar Disorder
1) Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960).
HRSD is a 17-item scale observer-rated measurement. The scale cover the aspects of
cognitive, behavioural and somatic aspects of depression. Clinicians are required to enter all
related clinical information when completing the ratings. It has moderate to high inter-rater
reliability (r= 0.57-0.63), high test-retest reliability (r= 0.81), high concurrent validity with
clinician-rated measures such as Montgomerysberg Depression Rating Scale (r=0.69 to
0.90) (Hamilton, 2000 as cited in Cusin, Yang, Yeung & Fava, 2009) (Please refer to Best
Practice Workbook of Depression for the items).
. The score interpretation is as following:
None/minimal depression
8-17 Mild
18-25 Moderate
26+ Severe
2) Beck Depression Inventory-II (Beck, et al., 1996)
BDI-II is a 21-item self-report inventory that measures severity of depression. This inventory
measures 3 aspects of depression, which are somatic, cognitive and behavioral aspects. The



time frame is the last two weeks. It has high internal consistency (Cronbachs = o,84), high
test-retest reliability (r= 0.75), strong correlation with construct-related scales, and was
sensitive to change (Khner, Brger, Keller & Hautzinger, 2007). It is important to measure
clients depression severity if client is in depressive episodes before come out with suitable
treatment plan (Please refer to Best Practice Workbook of Depression for the items). The
score interpretation is as following:
0-13 Asymptomatic
14-19 Mild depression
20-28 Moderate depression
29+ Severe depression
3) The Beck Hopelessness Scale (BHS; Beck et al., 1974).
BHS is a 20-item self-report to measure clients negative attitude and perceptions about the
future. It is reported that hopelessness is better in prediction of suicide compare to depression.
Score more than 9 in this scale indicate suicide ideation (Beck et al., 1985). It has been
reported as having high internal consistency (alpha = .97), good test-retest reliability (r =
.81), and good concurrent validity with scales assessing depressive thoughts such as
automatic thoughts questionnaire (Bouvard, Charles, Gurin. Aimard & Cottraux, 1992). It is
important to measure whether client is high in hopelessness so that proper intervention can be
done to prevent suicide and other possible detrimental consequences when client is in
depressive episodes (Please refer to Best Practice Workbook of Depression for the items).
The score interpretation is as following:
normal range
9-14 moderate
4) The Beck Scale for Suicide Ideation (BSI; Beck & Steer, 1991).
BSI is a 21-item self-report inventory to assess and detect severity of suicide ideation in
clients. It is a screening instrument that indicate suicide ideation rather than predicting
eventual suicide. It has two parts: the first part consists of 19 items that gauge the severity of
suicidal thought, attitudes and plan (with severity range from 0 to 2); while the second part of
questionnaire consists of 2 questions that gauge about clients previous suicide attempt- the
frequency and severity) for further information and are not counted in total score. The first
five items in BSI is a screening items and if let said clients score 0 for item 4 and 5, then they
can skip to item 10, and 21 if they have attempted suicide before. There is no cut-off score for
BSI but any positive response in items should reflect suicide ideation that require clinician
further investigation (Please refer to Best Practice Workbook of Depression for the items).
Assessments that Measure Clients Level of Functioning
1) Bipolar Functional Status Questionnaire (BFSQ; Goldberg et al, 2010)
BFSQ has been developed to assist evaluation of progress and treatment response
exclusively for clients with Bipolar Disorder. It
- Is a clients self-report measures
- Is aimed to provide evaluation that is more holistic based on clients functioning in eight
(a) Cognitive Function
(b) Sleep
(c) Role Functioning



(d) Emotional Functioning

(e) Energy/Vitality
(f) Social Functioning
(g) Personal Management
(h) Sexual Functioning
- Has good psychometric properties: high internal consistency, high test-retest reliability,
strong convergent validity, significant discriminant validity across illness phases (please
refer to Goldberg et al., 2010 original article for items and more information).
2) Family Burden Interview Schedule- Short Form (FBIS/SF; Tessler & Gamache,
- Is a clinician rated measurement, face-to-face or telephone interview
- Interviewees are primary family caregivers of adults aged 18-64
- To measure burden related to caring for relative with mental illness (Bipolar Disorder)
- 65 items, multidimensional approach, has five modules:
(a) assistance with the activities of daily life;
(b) supervision of bothersome or troublesome behaviors;
(c) impact on daily routines;
(d) financial expenditures;
(e) worry on daily routines
- Good psychometric properties: high internal consistency
3) Global Assessment of Functioning (GAF)
GAF is clinician-rated of clients overall functioning level. It is rated based on clinical
judgment after considering impairments clients in psychological, social and
occupational/school functioning (which are not related to physical and environment
limitation). The scale ranges from 0 to 100, in which 0 indicate not enough information,
while 100 indicate superior functioning. By starting from top (100) or bottom (0), clinician
review each category 1 by 1 to see whether it match the clientss symptoms severity or level
of functioning (either 1, depend on the more severe one). Once clinician has reached the
category (let said 50) that best describe clients, compare with the category (let said 40) below
and see whether it is more severe than clients symptoms severity and level of functioning. If
yes, choose that category (50 for example here) and rate from 0-9 (50- 59) to in which 0
indicates lower functioning/more severe and 9 indicates higher functioning/less severe.
4, Clinical Global Impression for Bipolar Disorder- Severity (CGI-BP-S)
CGI is used by psychiatrist to evaluate the effectiveness of medication in reducing clients
symptoms/treatment response based on illness severity (CGIS), global improvement of
change (CGIC), and therapeutic response. Severity of illness is rated range from 1 to 7, in
which 1 indicates normal and 7 indicates amongst the most severely ill patients. It has been
shown to be a robust measure of efficacy in clinical drug trials (Guy, 1976).
Other Supplemental Measurement that Assist Diagnosis and Case Formulation
1) Dysfunctional Attitude Scale (DAS; Revised by Power et al., 1994)
DAS revised version specifically for Bipolar Disorder is a 24-item scale which is used to
measure clients self-evaluation, i.e. whether dysfunctional core belief exist regarding three
areas that are interrelated to symptoms of Bipolar Disorder (both manic and depressive
episode). Three domains that are assessed by this scale is clients dysfunctional belief in
achievement, dependency and self-control. It is important to measure clients dysfunctional



belief especially in gauging vulnerable factors contribute to manic and depressive symptoms,
and in deciding the need to provide cognitive (behaviour) therapy for client (Power et al.,
1994). There is no specific cut-off score for DAS, while higher score indicate higher
dysfunctional belief.
2) Self-Control Behavior Schedule (Rosenbaum, 1980)
SCS is a 36 item self-report measures that assess clients application of cognitions in
controlling physiological and emotional responses due to BD, problem solving skills, coping
with harmful behaviour, ability to delay gratification, belief in own ability in controlling
themselves when facing behavioural issues. The test-retest reliability of SCS is 0.86 (over
four-weeks) with Cronbachs = 0.78 to 0.86. It is important to know that how client cope
with their lives so that appropriate intervention can be conducted to improve their coping
skills. There is no cut off score in SCS, higher score indicate that clients use that particular
coping skills more compared to others or have that kind of belief more.
3) MRC Social Performance Schedule (Hurry et al., 1983)
It is an observer-rated scale based on clients report of their eight areas of social performance:
Household Management, Employment, Management of Money, Child Care, Intimate
Relationship, Non-intimate Relationship, Social Presentation of Self and Coping with
Emergency. Clinician will rate the scale base on the actual behaviour and performances
reported, with 0= fair to no problem, 1= serious problems on occasions but can sometimes
manage quite well, 2=serious problem most of the time and 3= not able to cope at all. There
is different cut off score for different scale. It has demonstrated good interrater agreement and
reliability (Hurry et al., 1983; Lam & Wong, 1997). It is important to measure clients daily
functioning as it assists diagnosis as well as formulation of treatment plan. (please refer to
Appedix J)
C. Predisposing, Precipitating, Perpetuating and Protective Factors
I. Predisposing Factors
1) Family history
Adult relatives of probands with Bipolar Disorder are 10-fold more likely to develop
this disorder compared to relatives of controls (Merikangas & Yu, 2002).
A twin study showed that monozygotic twin 3-fold more likely to develop this
disorder compared to dizygotic twin if another pair of twin has Bipolar Disorder
(Smoller & Gardner-Schuster, 2007 as cited in Yatham & Maj, 2010).
By using Linkage disequilibrium (LD) approaches, researcher has found promising
candidate genes that is related to development of this disorder, including G72 and
brain-derived neurotrophic factor (BDNF) (Yatham & Maj, 2010).
2) Structural Abnormalities in Brain (Yatham & Maj, 2010)
Abnormally reduced volume and grey matter density, synaptic abnormalities,
decrease in neural and glial density in Anterior Cingulate; smaller Dorsolateral
Prefrontal Cortex and Orbitofrontal Cortex were found in patients with Bipolar
Disorder. However, further investigation are needed to determine whether these
abnormalities cause, coexist or as consequences of Bipolar Disorder.
Hypometabolism in prefrontal (especially in dorsolateral and medial orbital regions),
temporal cortex, anterior and posterior cingulate have been found to be related to
presence of Bipolar Disorder. In addition, hypermetabolism in deeper limbic system
yield similar result.



Decrease in anterior cerebral blood flow and metabolism decreases correlate with
severity of Bipolar Disorder.
3) Personality
Rash impulsiveness, which is unplanned impulsive behavior without foresee the
effect, predicts occurrence and vulnerability of BD (Alloy et al., 2010).
Hypersensitivity of Behavioral Activation System (BAS) is vulnerability factor for
BD and predicts the course of BD
- As those who have hypersensitive BAS, their BAS will be excessively activated
when involving in rewards or goal striving and attainment events, which increase
their activity levels that explain why individuals in hypomanic/manic can be very
energetic and restless, and to the extent that their behavior can be unplanned.
- Have higher level of autonomy, perfectionism, self-criticism.
4) Unpleasant and stressful life event (Beck, 1967 as cited in Alloy et al., 2006)
Contribute to the development of faulty core belief and schema
Interact with individuals internal, stable and global attribution style to develop BD.
II. Precipitating Factor
1) Event that has goal striving and attainment value (Johnson et al., 2008)
Trigger those who have hypersensitive BAS.
2) Spring-summer seasonal condition (Lee et al., 2007).
Probably correlated with longer photoperiod
3) High emotion expression communication style in the family (Kim & Miklowitz, 2004 as
cited in Milklowitz, 2008).
Family members are hostile, critical and over-emotionally involved in communication
and interaction.
Client who is from family which has negative affective style (AS; i.e. relatives having
negative emotional-verbal behaviors when interact with client), and high emotional
expressive (EE) are more likely to relapse compared to those who is from less
negative AS and low EE (Miklowitz et al., 1988 as cited in Milklowitz, 2008).).
4) Childbirth (especially will cause relapse in those who have BD before pregnant) (Kumar et
al., 2007)
May be due to disruption of circadian rhythm after giving birth
May be interact with genetic factor (happen higher among pregnant woman who has
family history of BD).
III. Perpetuating factor
1) Self-focused cognitive style (Alloy et al., 2009).
(a) Rumination predicts the frequency of depressive episodes.
(b) Increase private self-consciousness increase the likehood of onset of manic/hypomanic
2) Poor social and family support (Miklowitz et al., 2005).
3) Subsyndromal or persisting symptoms in between episodes (Judd et al., 2008).
Cause poor functioning and thus increase distress level.



4) Stigmatization
Decrease help-seeking attitude (Link, et al, 1987 as cited in Lam et al., 2010).
5) Substance abuse (Salloum & Thase, 2000).
6) Antidepressant medication (Schneck et al., 2008).
Those clients with either bipolar I or II 3.8 times more likely to experience rapid
cycling than those who are not
7) According to Goodwin & Jamisons Instability Model, it is an interaction of
(a) individuals vulnerability to disruptions of circadian rhythm
(b) taxing life events
(b) medication non-compliance
(c) social rhythm disruption, presence of social Zeitstrers (i.e. physical, chemical &
psychosocial cue that disrupt circadian rhythm (Goodwin & Jamison, 1990 as cited in
Swartz et al., 2010)
Taxing life events disrupt the integrity of circadian rhythm. Medication noncompliance increase the vulnerability of those who have previously been diagnosed as
having BD and have individual vulnerability to disruptions of circadian rhythm
(Healey& Williams, 1989 as cited in Swartz et al., 2010).
Cognitive error in misinterpreting energetic feeling (resulting from sleep deprivation)
as personal positive characteristic increase activity engagement and thus further
disrupt the circadian rhythm (and increase the severity of manic episode) (Healey&
Williams, 1989 as cited in Swartz et al., 2010).
IV. Protective Factor
1) Abstinence from alcohol and drug use (NAMI, 2008)
2) Structured schedule (NAMI, 2008)
Regular rest time
Appropriate schedule of recurrent social activities, make use of zeitgebers (i.e. social
cues that entrains circadian rhythm.
3) Strong social support system (NAMI, 2008)
From family, friends, professionals, self-help group
4) Regular exercise (NAMI, 2008)
5) Premorbid high IQ (Zammit et al, 2004)
May protect against development of psychosis in BD.
Base on Practice Guideline for the Treatment of Individuals with Bipolar Disorders, the
general objectives of treatment are as below (APA, 2002):
1) Ensuring the safety of individuals with BD and others surrounding them (ensure that they
bring no harm to self and others).
2) Encouraging and engaging outside providers, family members and support system to



provide supports for individuals with BD.

3) Enhancing clients treatment adherence.
4) Creating awareness of stressors and patterns of activities and rest/sleep.
5) Assisting clients to anticipate, recognize and address the early sign of relapse.
6) Assessing, managing and evaluating functional impairments such as cognitive deficits,
social relationship, occupational, living conditions and medical needs.
7) Educating clients about Bipolar Disorder. Treatment provided aimed at improving
treatment adherence, motivation and mitigating the risk of relapse.
8) Addressing co-occurring behavioral and medical conditions such as substance disorders
Evaluation of achieving objectives will be done based on types of intervention that clients
undergo. However, in general, evaluation will be done on before or during termination phase,
and follow up phase that varied across types of intervention. Domains that will be assessed
for evaluation purpose are:
(a) Presence of symptoms
(b) Severity of symptoms
(c) Duration of symptoms present
(d) Extent of impairment on daily functioning caused by symptoms
(e) Pattern of mood dysregulation
(f) Comorbidity (presence, severity, duration, if applicable)
(g) Suicidal ideation and risk (if applicable)
Bipolar Disorder characterized as disorder involve constantly change in terms of clients
mood. Therefore it is important to have tools that closely assists clinician, clients and their
significant others to monitor their progress after started receiving treatment. Below are two of
the common tools that assist monitoring:
1) NIMH prospective Life-Chart Method (NIMH-LCM-p)
(a) It is a collection of prospective (current) data on course of illness and treatment that client
with BD has received. There are retrospective Life-Chart as well to enable accurate
to be made, prediction of future course of illness and proper intervention.
(b) People who rate.
(i) Patient- for self-monitoring purpose (refer to Appendix K)
(ii) Parent/caregiver
(iii) Clinician
(c) Descriptions.
(i) The version for patient, caregivers and clinician, are basically the same.
(ii) There is a horizontal line across the middle of chart that represent the baseline of BD
(which is neither depressed nor hypomanic or manic- euthymia) and a special column
for date/month (dateline). Above the dateline is where the hypomania and mania
charted, while below the dateline is where the depression charted. This is to enable
client, caregiver and clinician to see the mood fluctuation pattern across the month/ in
the past few year. The severity of the mania and depression are rated base on the
degree that the mood dysregulation causes functional impairment.



(iii) Other information that need to be included are number of mood switch per day
(ultradian) or per month (ultra-rapid), treatment (medication and psychotherapy), life
event that affect the mood/mood changes, and comorbidity symptoms (with impact
rating from -4 to +4, and 0 representing no impact).
(d) Functions.
Enable more precise recall of severity, duration, frequency and patterning in the previous
month and comparisons of mood dysregulation pattern across the day, week, month and
year for
(i) Defining baseline course, monitoring the clinical response to treatment, and further
sustained improvement and disruption of improvement due to breakthrough episodes
(ii) Early detection and intervention of prodromal stage before full
blown of relapse occur.
(iii) Treatment planning for newly observed pattern.
(e) Validity
Convergent validity- significantly and strongly correlated with Youth Mania Rating Scale
(YMRS, Gold standard), Inventory of Depression Symptomatology- clinican rated (IDSC) and Global Assessment of Functioning (GAF) (Denicoff et al., 2000).
(f) Strength and Limitation
Difficult to be used by clients and caregivers, but considered to be worthwhile across
culture due to large amount of functions and advantage that it brings (Honig et al., 2001).
Computerized version (Palmtop computer version) has been devised to resolve
time-consuming issues (Schrer et al., 2002).
2) ChronoRecord software (ChronoRecord Association, 2013)
(a) Similar to NIMH- Life Chart Method, it is a computerized software that assist clients
self-monitoring process.
(b) People who rate. Client
(c) Description
(i) It is a 100-unit visual analog scale that has mood extremes of mania and depression.
(ii) Client was trained before using and during that time, they had set an anchor points
(which was the most depressed and most manic states that they ever experienced
before), described the predominant features of the extreme state. This anchor points
serve as a baseline for them to compare with mood everyday.
(iii) Then, client are required to
- Enter single rating that best describe their overall mood for the previous 24 hour,
at the same time for everyday, without influenced by the previous days rating.
- Review carefully the whole 24-hour period.
- Besides mood, enter medication and treatment taken and the sleep data
(d) Functions.
Enable detailed assessment of frequency and mood dysregulation pattern, which allow
(i) Comparisons of daily mood fluctuations and medications. This helps to monitor the
effectiveness of pharmacotherapy and whether there is nuances of partial response.
(ii) Encourage clients to be active participants in monitoring their own illness (with easy
steps and time-saving method).



(e) Validity
Has convergent validity with Youth Mania Rating Scales (YMRS) and high accuracy in
differentiating hypomania and mania (Bauer et al., 2008).
(f) Strength and Limitation
Able to increase client adherence involve as it is time-saving, more convenient and more
straightforward (Bauer et al., 2004). However, information that is important to be monitor
such as number of episodes in one day (for rapid cycling), impairment to the daily
functioning, special life events that happen on particular that can explain the mood
fluctuation that are crucial for understanding clients mood fluctuation and evaluating
effectiveness of treatment options are not recorded.
Pharmacological Treatment
Prevent mania &
& Lithium

Period to administer
-During acute mania
and maintenance
-For BD I & II



For relatively
severe BD &
behavioral issues
(eg. irritability)

Stabilize mood,
effective in
preventing mania
& depression

Carbamazepine Stabilize mood in

acute mania &
mixed episode




Stabilize mood

-During acute mania

-For BD I
-For BD II with rapid
-During maintenance
-For BD I
-For BD II with
alcohol dependence,
rapid cycling
-During acute mania
& mixed phase

Side effect
Initial: Diarrhea, vertigo,
muscle weakness, dazed
feeling, tremor, polyuria,
polydipsia & etc.
Long term:
goiter, mild memory or
cognitive impairment & etc.
Initial: Increased appetite &
weight gain & etc.
Long term: Liver
dysfunction & etc.

Skin rashes, drowsiness,

headache, insomnia, blur
vision & etc.

-For BD I & II
-During acute mania
& mixed phase

Initial: Dizziness,
drowsiness, gastrointestinal
symptoms & etc.
Long term: kidney
abnormalities, liver
dysfunction & etc.
Headache, insomnia,
dizziness, agitation, and etc.

- For BD I
- During acute
depressive episode

Nausea, agitation,
nervousness & etc.


- For BD II

Somatic Treatment- Electroconvulsive Therapy (ECT)

ECT is a procedure where specific region of brain such as prefrontal cortex, orbitofrontal
cortex, and connections to limbic structures are induced seizure. It will only be used under
condition as below:
(a) Mania is treatment resistant
(b) Severe suicidality
(c) Presence of psychotic symptoms
(d) Catatonia
(e) Food refusal that cause severe nutritional deficiency
(f) History of responding positively to ECT
(g) Risk of ECT is lower than other treatments risk
An active and didactic presentation and education of information about an illness and
ways to manage it. It can be done for individual or in group.
1) Objectives and ingredients of psychoeducation:
To create awareness
(a) Work on denial by introducing medical model to client
towards illness
that can help them to decrease stigma and guilt, which then
enhance their acceptance of treatment.
(b) Work on barriers to effective treatment by providing
information and generate discussion.
To enhance adherence
Educate clients about
(a) Different types of psychotropic medication for BD.
Review brand names of medication, explain differences of
generic and brand names.
(b) That pharmacological treatment is highly customized for
(c) The purpose of each medication and how a drug can serve
more than one purpose.
(d) Side effects of medication, and discuss strategies to deal
with it.
(e) Importance of monitoring serum levels (especially those
who take lithium and also valproate & carbamazepine).
(f) The signs of toxicity with medication (especially lithium).
(g) Drug-drug and drug-food interaction
(h) Appropriate administration of medication (eg. When to
take, dosage).
(i) Effectiveness of other psychotherapy adjunctive to
(j) Ineffectiveness of non-tested treatment (eg. spiritual
To avoid substance misuse Educate clients about
(a) The effect of taking alcohol and street drugs
(b) The effect of harmless substances such as caffeine which
can be misused by clients during subsyndromal and


To detect early warning


To encourage healthy

syndromal depressive stage to compensate their depressive
This is because these types of substances can trigger and
intensify affective disorder episodes.
Educate clients about
(a) Warning signs
(b) Strategies to prevent relapse
(c) Strategies to cope with warning signs and symptoms
Educate clients about
(a) Sleep management (duration, strategies to sleep well).
(b) Organizing daily activities in more structured and regular
*If client has serious issue in regular habits and routine, it is
recommended to introduce Interpersonal and Social Rhythm
Therapy (IPSRT).

2) Psychoeducation is more effective if:

Polarity that client is in
Clients are in manic episodes (Miklowitz, 2008).
Conditions that client is in
It is more effective if delivered during maintenance
phase (for both individual and group)
(Collon & Berk, 2010).
Therapist training
(a) Have clinical experience handling group and BD
clients, trained in social skills and bipolar
psychoeducation (Collon & Berk, 2010)..
(b) If it is in group, more than 1 therapist can be more
effective (Collon & Berk, 2010).
Group size (for group
Optimal size is between 8 to 12 clients (Collon & Berk,
Group participants (for group
(a) Euthymic & stable in the beginning of programme
(b) Balance of gender
(c) Balance of number of BD I & BD II clients if
combination of group is necessary. (This is to avoid BD
II clients from being defensive and denial, and claim
that they are not as severe as BD I clients which lead to
drop out) (Collon & Berk, 2010).
3) Limitation:
(a) Efficacy of psychoeducation will be reduced if clients have greater number of previous
episodes (Colom et al., 2010).
(b) Those who perceive their previous manic episodes as positive took longer time to recover
(Sorensen et al., 2007).
(c) Dropout rate of those who have external locus of control is high as they perceived that
psychoeducation cannot help them (Even et al., 2007).
Interpersonal & Social Rhythm Therapy (IPSRT)
1) It has three types of intervention, in which each intervention rest on different theoretical
constructs and different goals:

Theoretical constructs
Tripartite goals
- Goodwin & Jamisons instability Support medication adherence



Social Rhythm

model (refer to perpetuating factor Minimize impact of disruptions

mentioned in Etiology).
by life events on social rhythm
- Presence of social Zeitstrers in
disrupting circadian rhythm


Psychosocial & interpersonal

factors associated with onset of
mood disorders in biologically
vulnerable person, which then
affect their interpersonal coping

Solve interpersonal difficulties

In IPSRT, life events (for example, daily schedule, interpersonal disputes) are viewed as
source of mood dysregulation and potential triggers of rhythm disruptions.
Therefore, therapist role is to help client adapt to change and find healthy balance between
stability and spontaneity as clients with bipolar disorder may be destabilized when minor
Part 1: Social Rhythm Therapy
This therapy is developed based on the idea that stable daily rhythm improve mood
stability. By promoting regular and rhythm-entraining social Zeitgebers and manage negative
impact of disrupting Zeistrers.
There are three large steps in this therapy, which are
Step 1:
(a) Client will be required to complete the Social Rhythm Metric (SRM) (refer to
Appendix L).
(b) It is a self-report form to record daily activities, whether each occur when client is
alone or with presence of other, and whether the situation involve significant amounts
social stimulation (which is interactive or quiet). Client is also required to report their
mood each day in SRM
(c) Client will be required to complete SRM weekly and the first three to four weeks will
be used as the baseline social rhythm
Step 2:
(a) Then, therapist and client will review the SRM together.
(b) This is to find out:
(i) stable and unstable daily rhythm; (b) clients behavior that negatively affect the
rhythm stability.
Step 3:
(a) Next, therapist will work with client to stabilize the social rhythm through graded and
sequential lifestyle changes.
(b) In this step, client are required to identify and build their
(i) Short term goal (which is started changing small unhealthy behavior, such all
stopping all midnight activities). In order to achieve this, client will be required to
change their social behavior and health-related behavior to ensure he is achieving
the short-term goal (such as only do housework in the morning, stop eating



(ii) Intermediate goal (which is built on short-term gains and establish new social cue,
such as attending gym in the afternoon). The idea here is to help client to establish a
regular time schedule although it requires them to come out from schedule they are
comfortable with, by gradually.
(iii) Long-tern goal (which is encouraged them to find a long-term commitment to
allow them to maintain a more regular schedule, such as choose office work rather
than freelance job so that they have regular working time and the time for other daily
activities can be fixed and structured).
Other factors that therapist will take into consideration when monitoring and help client to
come out with different goals and establishing regular schedule:
(a) Frequency and intensity of clients social interaction (to help them to balance
between social and individual time to avoid being under/overstimulated by social
(b) Connections between mood and activity (to help client to set activities according
to episodes and phases to enable better mood regulation).
Follow-up step:
(a) Throughout the course of treatment, therapist and client will continue reviewing
SRMs. Therapist will work with client in identify social rhythm goals after one goal
has been achieved, and help them to address obstacles to change.
(b) In this therapy, SRMs play the roles as self-monitoring tools for clients (monitor their
mood and activities changes that can indicate relapse), and also to measure and
evaluate therapeutic change.
Part 2: Interpersonal Psychotherapy (IPT)
Step 1:
Therapist will conduct Interpersonal Inventory to explore
(a) important individuals in clients life (either mentioned or not)
(b) quality of relationship in clients current and past life systematically
Step 2:
Therapist comes out with interpersonal case formulations which include
(a) clients diagnosis
(b) type(s) of interpersonal problem and its relations with symptoms exacerbation.
Step 3:
Customize treatment according to types of interpersonal problem, which are described as
the following:

Role Transition


Treatment Focus

Loss of significant
individual in life and related
to symptoms (only when the
person has passed away)
Change in ones social role

Facilitation on mourning process

(encourage expression, help them
recognize distorted memories of
the relationship).
Facilitation in developing more
realistic views of both old and



Grief for the lost of

healthy self

Symbolic loss of self after

having BD

Interpersonal Role

Nonreciprocal expectations
in intimate relationship


Long history of
unsuccessful relationship
and isolation

news roles (resolve idealization of

old role and devaluing of new
role), acquire new skills to master
new roles
Facilitation on mourning of
losses, recognition of own
strengths and encourage setting
new realistic goals.
Facilitation in identification of
dispute, alteration of role
expectation and communication
pattern, development of change
Facilitation in identification of
cause, and building up
interpersonal skills

Integrating Psychoeducation, Social Rhythm Therapy and Interpersonal Therapy

Three types of therapies will be conducted concurrently. However, the emphasis on three
therapies will be different according to the phase of treatment and acuity of clients



(a) Gather information

of clients background
especially interpersonal
disputes and disrupted
daily routines happened
before previous and
current episodes.
(b) Identify triggers
event, vulnerabilities &
interpersonal life.
(c) Use IPSRT
paradigm to assist client
to see relations amongst
their interpersonal
events, social rhythms
& episode onset
Educate the importance Step 2 & 3
of stability, negotiate
how much stability is
possible to minimize
relapse while have
safe spontaneity in
other area to stimulate
themselves in proper


Social Rhythm
Step 1

Interpersonal Therapy
Step 1 & 2
(if client is unstable,
either hypomanic or
manic, case formulation
may not be done,
emphasize more on
psychoeducation first

Step 2 (if unable to

complete in initial
phase) & 3



Maintenance (a) Consolidate treatment gains, optimize interpersonal functioning in

absence of syndromal illness and prevent recurrence.
(b) Crisis intervention if needed.
(c) Educate the importance of maintaining regular social rhythms,
reinforcing importance of practicing skills.
Termination (a) No specific time for termination, depends on individual preferences as
well as therapists clinical judgment.
(b) Should be done very gradually, four to six-monthly sessions for followup before termination.
(c) Review, reflection and encouragement.
(d) Identify important resources if symptoms worsens after termination
Factor influence choice of treatment and effectiveness:
Polarity that client is in
Clients are in depressive episodes (Miklowitz, 2008).
(However, if client is in hypomanic/manic episode,
ensure that they are stable under medication first before
move on).
Conditions that client is in
Best to initiate during acute phase rather than recovery
phase so that can be more effective in delaying relapse
(Miklowitz, 2008).
(a) Effectiveness drops after 2 years from termination (Frank et al., 2008).
(b) IPSRT is more effective for women than men (Frank et al., 2008).

Cognitive Behavioral Therapy

Lam, Jones & Hayward (2010)s programme
1) Main objectives:
(a) Increase compliance to medication
(b) Recognize prodomes
(c) Prepare for and delay relapse
(d) Self-management during relapse and mood fluctuation.
2) In total, 20 sessions in 3 stages.
3) Before getting started, it is important to conduct pre-therapy assessment to gain baseline
data or clients issues that is crucial and/or can be changed by intervention, such as clients
dysfunctional attitude, use of cognitive control of behavior, mood state, performance,
4) Outline of treatment
Education, Development of
Therapeutic Alliance

Illness history

(a) Introduce diathesis-stress model
(b) Explain structured approach &
of agenda in beginning of each
(a) Review clients illness history and



Goal setting

Intermediate Activity Schedule


Thoughts monitoring and


Behavioral experiment

Dysfunctional assumptions

Early warning signs

Medication compliance

use them to educate client regarding
(b) Help client generate chart of
illness history (which will be used as
(a) Emphasize clients active
participation and role of selfmonitoring
(b) Teach client how to monitor
mood, thoughts & activities
throughout and after all sessions.
(a) Help client generate a list of goals,
analyse steps towards goals
(b) Help client identify discuss
obstacles and how to continue goals
despite presence of symptoms.
(a) Teach client to record down their
daily activities and identify factor
that related to mood change (to
identify the antecedent of mood
(b) Help them plan appropriate
activities and regular schedule.
(a) Identify what types of thoughts
(positive and negative) are prominent
in which episodes (manic &
(b) Provide example of challenges,
introduce and review homework
together, as well as obstacles.
(a) Introduce & explain medication
(b) Review and tackle incompliance
reason by having experiment outside
therapy session.
(a) Discuss importance of addressing,
relate thinking with dysfunctional
(b) Demonstrate how to challenge it
and review with client.
(a) Identify information such as
history, activity schedules, mood
ratings, thoughts monitors that may
indicate relapse
(b) Discuss coping strategies.
(a) Discuss about advantages &
disadvantages of medication, costbenefits of medication incompliance,
importance of clients role in


Final (16-20 Review



managing own medication.
(a) Assess extent of client internalize
the cognitive approaches
(b) Discuss its benefits in terms of
relapse prevention.
(a) Review on self-management
practice and issues raised
(b) Emphasize the importance of
sleep, diet and routine.

Consequences of Mental Health


Discuss issues of stigma, guilt and

grief related to their sensation seeking
behavior or resulting from labelling,
and their effects on family
Summarize Main Points of Therapy Help client to develop therapy notes
for future use
5) Homework that has been assigned to client will be review together with them by therapist
in the next session to ensure client practice and able to overcome obstacles that deter them
from practicing (Lam et al., 2010).
6) Termination of CBT is normally scheduled and structured. However, additional session are
allowed depend on therapists judgment and clients ability to follow the flow. Post-treatment
assessment can be done before termination to assist therapists judgment, especially on
assessment that have been done before therapy sessions commence (Lam et al., 2010).
7) Factors influencing the choice of treatment options and treatment effectiveness:
Timing of therapy being introduced
- More effective when client is in depressive
episodes (Miklowitz, 2008)
- Is not effective if client is manic and
overly depressed (Lam et al., 2010)
- More effective if client is in recovery
rather than acute phase (Miklowitz, 2008).
- More effective if client can participate
actively, and at least have average cognitive
competency (and without any impairment)
(Lam et al., 2010).
Medication consumption and adherence
- More effective if client comply to
medication (Lam et al., 2010).
Clients motivation to change and practising - More effective if client have higher
of skills acquired
motivation to change and commitment in
skills practicing (Lam et al., 2010)
8) Other manuals that are available to assist therapist in conducting CBT programme with
client with Bipolar Disorder:
(a) Basco & Rush (1996)
(b) Newman et al. (2001)
Here are the similarities and differences across programme which can assist therapist to
make decision:

Lams programme

Bascos programme



-All deal with BD in maintenance rather than acute phase

- Strongly emphasize on psychoeducation, medication adherence, early
warning signs, employment of cognitive behavioural, interpersonal approach

in Strengths

- Employ classical
cognitive approach
- Emphasize relapse
prevention in

- More explicit &

detailed in
implementation &

- More discussionoriented
- More flexible

9) In addition, CBT also exist in group format that employ similar outline and method as
individual session.
10) Limitation of CBT (Association for Behavioral And Cognitive Therapies, 2013):
(a) Require high commitment and motivation from clients in practicing the skills learned in
the session in their daily life.
(b) Not effective for those who believe that hypomanic is their personal attributes rather than
metal illness (Lam et al., 2005c).
(c) Effectiveness in reducing relapse rate does not last for longer than one year (Lam et al.,
Family-Focused Treatment (FFT; Miklowitz & Goldstein, 1990)
1) Background & Issues
The relationship between client with BD and their family members are often characterized
as emotional inaccessible, rigid, conflictual and disrespectful (Cohen et al., 1954 as cited
in Milklowitz, 2008):
This can be caused by, for example (Kim & Miklowitz, 2004 as cited in Milklowitz,
(a) existing high expressed emotion attitude by the family which can be the risk factor of
predisposing client to BD
(b) client externalizes his behavior when being criticized and triggered by intrusive
statement, which ended up both parties constantly involved in conflict and arguments.
(c) family and client resulting from clients BD issues have communication deviance, in
which the clarity of communication is low and thus trigger disputes.
(d) familys unrealistic expectation on clients recovery and their role in the family
despite BD)
(e) clients unpredictable mood swings that is difficult to be distinguished from
personality and symptoms
(f) possible negative consequences that family need to bear due to clients risk-taking
behavior and impulsivity
According to Miklowitz (2008), these issues were able to precipitate recurrence of BD. As a
result, FFT was developed by Miklowitz & Goldstein (1990) to address abovementioned
2) Target individuals: Client and their family/significant others



3) According to Miklowitz (2008), FFT is suitable for clients who are

(a) Having Bipolar Disorder as their primary diagnosis (if they have other comorbid like
substance dependence).
(b) Acutely-ill
- Regardless of setting that the client is in.
- It is important to tailor educational materials to suit the clients severity and setting
they are in.
(c) Comorbid developmental disabilities or neurological conditions
- Should include them although they have cognitive impairment by tailoring educational
materials to assist them in understanding their own issues with the presence of their
(d) Not complying with medication
- Should emphasize that FFT is not a substitution of pharmacotherapy.
- Need to focus on this part if client does not take medication due to lack of
understandings of the function of medication or use medication incompliance as a
mean to express their anger and rebel towards family members who attempt to control
(e) Presence of family members who have frequent contact with BD client and assume the
role of closely monitoring clients (their family member with BD) health.
4) Issues that therapist need to be aware of before starting (Miklowitz, 2008)
(a) Settings: Home vs. Clinic
(i) Choose home if
- there is a large number of family members involve
- generalization of certain communication skills are more important
(ii) Choose clinic if
- family members worry about stigmatization issue
- avoid family members from having wrong perception that therapist need them
more than they need therapist (encourage assuming of responsibilities and selfinitiated change rather than dependent on therapist to change)
(b) Clinician
Cotherapy team is more effective
- Observation on each family members can be done more thoroughly
- Identification issues or themes that another clinician has missed (cross-check) can be
- Both more and less vocal members can be attended to.
5) Before therapy started, a functional assessment will be conducted to
(a) Support that the diagnosis of Bipolar Disorder is correct.
(b) Obtain systematic psychiatric history, from both patient and their significant others.
(c) Measure familys distress level
(d) To gain information to determine which familys resources and skills, domains of
managing the disorder, communication and solving problem can be enhanced.
6) Important domains that will be covered in functional assessment including:
(a) Diagnostic Interview
(b) Prior Course of Illness (from client and significant others point of view)
(c) Premorbid Functioning



(d) Family Interaction by

(i) Giving scenario/topic and observe how client discuss with their significant others
(ii) From the observation, determine communication assets and deficits that client and
significant others have.
(e) Prior knowledge of Bipolar Disorder
7) Arrangement of stages of FFT according to clients illness phase and summary of what
will be done in each stage (Miklowitz, 2008).
Illness phase Stage
- Developing therapeutic
building &
- Assessment
Stabilization Psychoeducation - Having more
(a) Educate family about
understanding about
(i) symptoms, differential
etiology of BD.
diagnosis, comorbidity,
- Integrating experience
course, treatment, selfwith clients associated with management
mood episodes in BD.
(ii) how genetic &
- Accepting the notion of
biological vulnerability,
vulnerability to future
stress, individual coping
protective factors interact
- Accepting the need for
to cause onset of BD
medication for symptoms
(b) Assist family to
formulate Relapse
- Differentiating clients
Prevention Plan
personality and his/her BD. (i) Help family recall
- Assisting client and his
important information
family in relapse
such as previous periods
of mood instability,
sequence of trigger, early
warning relapse signs,
palliative measures
(ii) Develop a plan which
consists of action in
preventing relapse such as
ways to reduce stress
triggers at home.
Training (CET)

-Decreasing unproductive
interaction among family
-Improving quality of

Adopt role play method

(coaching & shaping):
(i) Teach family about
expressing positive
feelings, active listening,
making positive request
for changes in others
behaviours & provide
constructive feedback
(ii) Give homework to
record familys efforts in


Maintenance Problem solving



- Identifying areas of
- Generating, evaluating &
implementing solutions
- Focusing on behaviour
management strategies

- Evaluate the effect of FFT

- Review course of
- Anticipate future problem
- Evaluate future treatment

Arranging follow up visit

using & generalizing

techniques learned in
home setting.
Assist family members to
(i) Identify & define most
pressing issues with BD
(ii) Generate solution
(iii) Evaluate pros and
cons of solution choices
(iv) All family members
come together to a best
(v) Develop
implementation plan
(vi) Practice problem
(vii) Review whether plan
reflect the objectives and
is effective
Refer to below

By gauging whether
clients and families need
(a) More and different
type of family treatment
(b) Individual therapy
(c) Desire to participate in
support group
Usually 3-6 months after
termination and will
(a) Evaluate clients
clinical status
(b) Check whether client
obtain desired follow-up
(c) Check whether client
need referral
(d) Check the attempt of
client reentering school or
work and whether it is

8) Prior to termination, evaluation of the effect of FFT on client and family will be
conducted. The key domain that clinician will assess including whether they understand and
able to generalize skills learned as listed below:
(a) Nature of BD, factors that trigger recent episode



(b) Clients and familys awareness of risk of full syndromal recurrences and subsyndromal
mood fluctuation.
(c) Role of medication in treating acute episodes of BD.
(d) Preventing recurrences by continuing medication.
(e) Differences between enduring aspects of clients personality, as contrast with sign and
symptoms of BD.
(f) Effective means of identifying and managing stressors.
(g) Employing effective strategies for direct communication, problem solving, conflict
management to maintain cooperative, positive and healthy emotional tone in family
9) Factors influencing the choice of current reatment options and treatment effectiveness:
Polarity that client is in
More effective when clients are in depressive episodes
(Miklowitz, 2008).
Conditions that client is in
Best to initiate from acute phase (Miklowitz, 2008).
10) Limitation:
(a) It requires great commitment from family. Therefore, it may not be feasible especially if
family are financially unstable, significant others have mental disorder/general medical
complication that require attention and assistant from other family members (Scott & Colom,
(b) FFT only effective in improving BD clients who were from dysfunctional family (Miller
et al., 2008).

Third Wave Psychotherapy for Bipolar Disorder: Dialectical Behavior Therapy (DBT;
Linehan, 1993).
1) Goals:
(a) To reduce depressive symptoms
(b) To reduce suicidal ideation
(c) To improve mood regulation (decrease hypersensitivity to emotional stimuli, extreme
emotional intensity and allow moderate return speed to baseline emotion state).
2) Phases, Modalities, Objectives, Topic and Method of Conducting
Modalities and Objectives
Topic and method conducting
Family Skills Training
(a) Psychoeducation
- Family able to manage their
(b) Four standard modules of DBT:
own mood dysregulation before
(i) Mindfulness
they are competent to provide a
(ii) Distress tolerance
better environment for client to
(iii) Emotion regulation
(iv) Interpersonal effectiveness
- Using handouts, exercises and activities
and applying new skills outside session.
Individual Therapy Sessions
(a) Psychoeducation (regarding DBT and
- Client understand Bipolar and Bipolar Disorder)
DBT better and adhere to
(b) Four standard modules of DBT:
(i) Mindfulness
- Clients are able to focus on
(ii) Distress tolerance
current emotion rather than
(iii) Emotion regulation
ruminating the past, control
(iv) Interpersonal effectiveness

emotion better, assertive at the
same time not jeopardize
others, and withstand
difficulties by replacing
problem behavior with
appropriate coping strategies
-Clients are able to solve issues
that trigger or prone them to

Maintenance Family Skills Training

Individual Therapy Sessions

(c) Problem solving strategies
(i) Understand function of behavior by
conducting behavioral chain analyses for
targeted problems.
(ii) Identify alternative solution that is
(iii) Develop techniques that prevent
future problem behaviors
- Goals setting, using diary cards,
handouts, exercises and activities and
applying new skills outside session.
- Consolidate gains by doing revision
- Review skills application

3) Limitation:
Limited evidence to support its efficacy on adults Bipolar Disorder, suitability for polarity
and phase that clients are in (Richardson., 2010).

Third Wave Psychotherapy for Bipolar Disorder: Mindfulness-Based Cognitive

Therapy (MBCT; Tesdale et al.,2000)
1) Goals: To reduce depressive symptoms and suicidal ideation
2) Objective:
(a) Enable client to view negative and suicidal thoughts and feelings as passing events and
minimize important on it.
(b) Enable client to be more open and ready to face difficulties and discomfort
3) Method of conducting:
(a) Mindfulness medication during class.
(b) Assigning homework exercise for client to practice on how to increase their nonjudgmental awareness of bodily sensations, feelings, thoughts, and behavior, and
assimilate awareness skills into daily functioning.
(c) Traditional CBT normally will be incorporated into treatment.
4) More effective when client is in depressive rather than manic episodes (Miklowitz et al.,
5) Limitation:
Inconsistent and limited findings about its effectiveness, suitability for polarity and
phase that clients are in (Richardson., 2010).
Other intervention besides psychotherapy
Wellbeing plans
1) It is important to help client to develop a wellbeing plan to ensure clients are able to
maintain and generalize coping strategies that they have learnt to gear towards remission and
relapse prevention (Orum, 2008).
2) Step 1: Finding motivation
To make this plan to be effective and long lasting, first of all, client should be the main
character who decide the direction of plan, and clinician only play the role of assistance.
Therefore before started, it is important to encourage and motivate client to develop and then



follow the plan. These can be done by discussing the following to create insights and
willingness to change in them:
Content of discussion
Costs of illness
Explore how the illness has negatively affected
- sense of self
- their life
- their relationship
Benefits of illness
Explore how the illness has positively affected
- sense of self
- their life
- their relationship
Imagine life with fewer
Discuss if they are able to learn to manage this illness and
episodes (or with
they can free from episodes for several years, what
successful management)
differences it will bring to
- sense of self
- their life
- their relationship
3) Step 2: Encouraging client to involve others in their plan
- In this step, help them to involve family members, friends or significant others
that they can trust on and have frequent contact with them into development of
treatment plan. This is because they can help clients to develop a realistic plan as
they know their living condition better and they have more insights about clients
symptoms besides clients themselves and clinician. They can also remind client if
they do not adhere to the plan if they are clear about the plan. Therefore, it is
important to involve them start from the development stage (Orum, 2008).
4) Step 3: Making a wellbeing plan
- In this step, client must be the one who speak first and the most. Then only by the
significant others as it should reflect their personal styles and preferences for the
plan to work. Clinician will play the role to correct any misconception and provide
appropriate suggestion for improvement (Orum, 2008).
- Important component to be included in the plan:
(a) Early warning signs of relapse
(b) Risk factors that trigger the relapse
(c) Appropriate method to be used when early warning signs are noticed by client
and their significant others (including how feedbacks should be delivered
especially when thy client does not adhere to plan, what make it difficult to be
accepted and how to overcome the difficulties).
(d) The method that client prefer significant others to use, what are the
consequences that he/she is ready to face (including safety measures that will be
taken and by whom).
(e) Strategies that will be taken and commit to promote quality-of-life (especially
when individuals are in depressive stage, by adopting the principles of positive
psychology: recuperate, master basic management skills, commit to searching
paths return to lifestyle that is engaging, pleasurable and meaningful).
4) Other important factors to be discussed during development of wellness plan (Orum,



(a) Intervene at the earliest possible moment, therefore it is important to identify the very
early warning signs and ways to improve mindfulness on it.
(b) Take into account the strengths and weaknesses of close relationship with the significant
others so that it can strengthen the effectiveness of help from significant others.
(c) The goals should be graded and increase the difficulty bit by bit to maintain motivation
and decrease the likelihood to trigger depressive episode
(d) The plan needs to fit the person so that it increase commitment and thus likelihood of
being effective
(e) Benefits of collaborating with significant others should be discussed and appreciated to
increase client perceived support and commitment in the plan


1) Types of bipolar disorder (Parker, 2008; Yatham & Maj, 2010)

Bipolar I
Bipolar II






2) Polarity of clients disorder (Miklowitz, 2008a)







(Note: IPSRT & CBT will only be effective for clients in manic/hypomanic episode if they
are stable under medication).
3) Phases of disorders that clients are in (i.e acute, maintenance) (Miklowitz, 2008a)







(Note: (i) Psychoeducation (especially group 1 is more effective for clients in maintenance
(ii) IPSRT will only be effective for clients in acute phase if they are stable under
4) Cycling (i.e. rapid and typical)
Pilot study of Cognitive Behavioral Therapy found that CBT was able to reduce
symptoms in clients with rapid cycling (Relly-Harrington et al, 2007).
5) Pregnancy and Postpartum
Pregnancy of clients with is a sensitive period especially if they are in manic or depressive



episodes, as medication can have serious effect on their fetus. Therefore, psychotherapy
and psychoeducation play important roles in controlling symptoms in mother with Bipolar
(a) If client experience depressive episodes before giving birth, psychoeducation and
interpersonal therapy have been found to be effective in reducing depressive symptoms
(Spinelli, 1997 as cited in Frey et al., 2010).
(b) Family-focused therapy may be helpful in educating family regarding bipolar disorders
and assisting communication between pregnant client with family (Frey et al., 2010)
(c) If client experience depressive episodes after giving birth, cognitive behavioral
therapy has been found to be effective in reducing depressive symptoms (Applebly
et al., 1997 as cited in Frey, et al., 2010).

6) Age
(a) Multifamily and individual psychoeducation, family-focused therapy, child and familyfocused CBT have been found to be effective in reducing symptoms and prevent
(Fristad, 2006; Miklowitz & Chang, 2008; West, Henry & Pavuluri, 2007 as cited in
Carlson & Weller, 2008).
(b) To date, there is less study on effectiveness of psychotherapy on elderly patient with
Bipolar Disorder. However, in their study, Nguyen et al. (2007) found that CBT that
specifically adjusted for older adults showed effectiveness in helping them to control
symptom and prevent relapse (Richardson, 2010).
7) Comorbidity
(a) Cognitive Behavioral Therapy has been shown to be effective in treating Bipolar
Disorder that is comorbid with anxiety (El-Mallakh & Hollifield, 2008).
(b) Integrated Group Therapy (IGT) has been found to be effective in addressing Bipolar
Disorder with Substance Abuse, but mostly on substance abuse issues only (Weiss,
8) Risk of suicide
(a) Goldstein et al. (2007) found that Dialectical Behavior Therapy was effective in
reducing suicide ideation in adolescents aged between 14-18 years old.
(b) Miklowitz et al. (2009) found that Mindfulness Behavior Therapy was effective in
decreasing suicide ideation in a group of individuals in middle adulthood.

(a) Patients who took part in Interpersonal and Social Rhythm Therapy (IPSRT) have higher
probability and take shorter time to recover compare to patients who received standard care
(Miklowitz et al., 2007). In another study, patient who participated in IPSRT also showed
longer symptoms-free period and able to regular daily routine better compared to patient who
received intensive care management.
(b) Patient who take part in CBT:
(i) Take longer period for another relapse, lower mania scores, improved behavioural selfcontrol compared to control group (Lam et al., 2005).
(ii) 60% of reduction rate & fewer hospitalization compared to the patients own history
of relapse & hospitalization (Scott et al., 2001).



(iii) In group CBT, clients who have cyclothymic showed significant decrease in
depressive and manic symptoms compared to client in clinical management (CM)
after 1 and 2 years treatment (Fava et al., 2011).
(c) Patients who participated in psychoeducation:
(i) showed improvement in symptoms, functioning and family attitudes after 18 months
among inpatients with mood disorders (Clarkin et al., 1998).
(ii) has their relapse being prevented, less constant rehospitalisation, shorter period of acute
illness (Colom & Berk, 2010).
(d) Participating in Family-Focused Therapy help patients to stabilizing their bipolar mood,
delay recurrences and rehospitalisation, increase adherence to medication and improve
their family relationship functioning (Miklowitz, 2010).
(e) Patients who underwent DBT had significant improvement in regulation of emotions,
symptoms and depression and less likely to engage in suicidal and self-harming behaviour
compared to pre-treatment (Goldstein et al., 2007).
(f) Patients who participated in Mindfulness-Based Cognitive Therapy (MBCT) had their
depressive and anxiety symptoms being reduced (Williams et al., 2008), and reduced in
suicide ideation (Miklowitz et al., 2009).


According to Hirschfeld et al. (2007), indicators of successful therapy is the sustained
remission/recovery, which are:
(a) Scoring in Youth Mania Rating Scales is equal or lower than 8
(b) Scoring in Hamilton Rating Scale for Depression is equal of lower than 7
(c) Scoring in Clinical Global Impression for Bipolar Disorder (severity) is equal or less
than 2.
(d) Global functioning return to the normal level similar to before relapse/having Bipolar
Disorder, and can function normally without assistant from significant others.


1) Wellness plan proposed by Parker (2008) that has been discussed in intervention option
be used to help clients maintain what they have learned from psychotherapy and help
regulate their emotion better.
2) Another method that can be acted as booster programme that encourage independence and
ensure the maintenance is the implementation of Life Goal Collaborative Care Model
(LGCC) (Kilbourne et al., 2008).
3) The self-management programme in LGCC (Bauer et al., 2001) aims to:
(a) Increase their awareness of procedure to manage their physical and mental health
(b) Spark their motivation to change
(c) Form skills and knowledge to manage health condition
(d) Increase self-competency in maintaining and adhering to changes and follow up about
improvement towards achieving goals.
3) In this programme (Bauer et al., 2001), clients will be in group and be taught about



(a) Bipolar disorder

(b) Coping strategies for manic and depressive symptoms through active discussion
(c) How to increase self-efficacy without receiving support from others.
(d) How to engage health care provider effectively in collaborative decision making.
4) To increase and maintain clients motivation in following in the programme and selfmanagement, Motivational Enhancement counseling will be used (Bauer et al., 2001).
5) Another two important components of LGCC is the decision support, which provide
information and guidelines in seeking proper help and support when necessary, and care
management which coordinate healthcare service between clients and providers (Kilbourne
et al., 2008).
6) The ultimate goal of this programme is to encourage independence and responsibility
by clients, at the same let them know there are always someone ready to help them to
overcome the chronicity of Bipolar Disorder.



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