Interpersonal Psychotherapy

Conditions Treated with Interpersonal Psychotherapy

Interpersonal psychotherapy was initially developed as a brief therapy for depression. Because people with depressive symptoms often experience problems in their interpersonal relationships, IPT is a common treatment option for people experiencing depression. Although the depression itself is not always a direct result of negative relationships, relationship issues tend to be among the most prevalent symptoms during the initial stages of depression. Once addressed, strengthened relationships can serve as an important support network throughout the ensuing recovery process.

In general, interpersonal therapists provide active, non-judgmental treatment in order to help people in therapy successfully handle challenges and improve mental health. Things that might be addressed over the course of treatment can include roles disputes, interpersonal shortcomings, life stage transitions, relational conflict, grief, and other attachment issues. IPT is well researched as an effective treatment for depression and has been modified to treat several other mental health issues. These include:

• Anxiety
• Disordered eating
• Dysthymia
• Substance abuse issues
• Bipolar
• Postpartum depression
• Social phobia
• Post-traumatic stress

Interpersonal Psychotherapy Processes

Within a fairly short amount of time—usually 20 weeks or less—the person in therapy may be able to experience relief from symptoms and begin work on any underlying issues more quickly than is often possible in other forms of therapy. Therapists might utilize various techniques, such as role-playing, to help people in therapy adjust how they relate to their world. An interpersonal therapist will typically focus on the most pressing relational problems in order to support the person wishing to make changes.

IPT is an adaptive form of therapy. It lends itself to modifications that make it suitable for the treatment of several mental health concerns. In addition, IPT can be conducted individually or in a group setting with children, adolescents, and adults.

Effectiveness of Interpersonal Psychotherapy

IPT is recognized as an effective mode of treatment for mental health issues by professional entities like the American Psychological Association (APA) and the National Institutes of Health (NIH). Since its development in the 1970s,  IPT has been determined to be both versatile and effective by multiple studies. Though not effective for every population, it has been shown to provide relief of some depressive symptoms equal to that found in antidepressant medication regimens.

IPT can be administered as a sole form of therapy or in conjunction with medications. The decision whether to receive IPT, medication, or a combination of both is up to the therapist and person in therapy. However, most studies seem to indicate that the combination of medication and interpersonal therapy may be more beneficial than either on its own.

Signs and symptoms

Mania is the defining feature of bipolar disorder,^[8] and can occur with different levels of severity. With milder levels of mania, known as hypomania, individuals appear energetic, excitable, and may be highly productive.^[9] As mania worsens, individuals begin to exhibit erratic and impulsive behavior, often making poor decisions due to unrealistic ideas about the future, and sleep very little.^[9] At the most severe level, manic individuals can experience very distorted beliefs about the universe known as psychosis.^[9] A depressive episode commonly follows an episode of mania.^[9] The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode or vice versa remain poorly understood.^[10]

Manic episodes

Mania is a distinct period of at least one week of elevated or irritable mood, which can take the form of euphoria, and exhibit three or more of the following behaviors (four if irritable):speak in a rapid, uninterruptible manner, are easily distracted, have racing thoughts, display an increase in goal-oriented activities or feel agitated, or exhibit behaviors characterized as impulsive or high-risk such as hypersexuality or excessive money spending.^[8] To meet the definition for a manic episode, these behaviors must impair the individual’s ability to socialize or work.^[8][9] If untreated, a manic episode usually lasts three to six months.^[11]

People with mania may also experience a decreased need for sleep, speak excessively in addition to speaking rapidly, and may have impaired judgment.^[9][12] Manic individuals often have issues with substance abuse due to a combination of thrill-seeking and poor judgment.^[13] At more extreme levels, a person in a manic state can experience psychosis, or a break with reality, a state in which thinking is affected along with mood.^[9] They may feel out of control or unstoppable, or as if they have been “chosen” and are on a special mission, or have other grandiose or delusional ideas.^[14] Approximately 50 percent of those with bipolar disorder experience delusions or hallucinations.^[15] This may lead to violent behaviors and hospitalization in an inpatient psychiatric hospital.^[9][12] The severity of manic symptoms can be measured by rating scales such as the Young Mania Rating Scale.^[12][16]

The onset of a manic (or depressive) episode is often foreshadowed by sleep disturbances.^[17] Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.^[18]

Hypomanic episodes

Hypomania is a milder form of mania defined as at least four days of the same criteria as mania,^[9] but does not cause a significant decrease in the individual’s ability to socialize or work, lacks psychotic features (i.e., delusionsor hallucinations), and does not require psychiatric hospitalization.^[8] Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression.^[19] Hypomanic episodes rarely progress to true manic episodes.^[19] Some hypomanic people show increased creativity^[9] while others are irritable or demonstrate poor judgment. Hypomanic people generally have increased energy and increased activity levels.

Hypomania may feel good to the person who experiences it.^[9] Thus, even when family and friends recognize mood swings, the individual will often deny that anything is wrong.^[20] What might be called a “hypomanic event”, if not accompanied by depressive episodes, is often not deemed as problematic, unless the mood changes are uncontrollable, volatile or mercurial.^[19] Most commonly, symptoms continue for a few weeks to a few months.^[21]

Depressive episodes

Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness;^[22] disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal thoughts.^[22] In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features. These symptoms includedelusions or, less commonly, hallucinations, which are usually frightening and/or intimidating. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.^[23]

The earlier the age of onset, the more likely the first few episodes are to be depressive.^[24] Because a bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having major depression.^[25]

Mixed affective episodes

In the context of bipolar disorder, a mixed state is a condition during which symptoms of both mania and depression occur at the same time.^[26] Individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while at the same time experiencing depressive symptoms such as excessive guilt or feeling suicidal.^[26] Mixed states are considered to be high-risk for suicidal behavior since depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control.^[26] Anxiety disorder occurs more frequently as a comorbidity in mixed bipolar episodes than in non mixed bipolar depression or mania.^[26]Substance abuse (including alcohol) also follows this trend.^[26]

Associated features

Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria. In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities. These include reducedattentional and executive capabilities and impaired memory. How the individual processes the universe also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states.^[18] Some studies have found a significant association between bipolar disorder and creativity.^[27] Those with bipolar disorder may have difficulty in maintaining relationships.^[28] There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder; these disorders include mood abnormalities, full major depressive episodes, and attention deficit hyperactivity disorder (ADHD).^[29]

Comorbid conditions

The diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions including the following: obsessive-compulsive disorder, substance abuse, eating disorders, attention deficit hyperactivity disorder, social phobia, premenstrual syndrome (including premenstrual dysphoric disorder), or panic disorder.^{[13][15][22][30]} A careful longitudinal analysis of symptoms and episodes, enriched if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist.^[31]

Causes

The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear.^[32] Genetic influences are believed to account for 60–80 percent of the risk of developing the disorder indicating a strong hereditary component.^[15] The overall heritability of the bipolar spectrum has been estimated at 0.71.^[33] Twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For bipolar disorder type I, the (probandwise) concordance rates in modern studies have been consistently estimated at around 40 percent in identical twins (same genes), compared to about 5 percent in fraternal twins.^[8][34] A combination of bipolar I, II and cyclothymia produced concordance rates of 42 percent vs. 11 percent, with a relatively lower ratio for bipolar II that likely reflects heterogeneity. There is overlap with unipolar depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67 percent in monozygotic twins and 19 percent in dizygotic.^[35] The relatively low concordance between dizygotic twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.^[33]

Genetic

Genetic studies have suggested that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility with each gene exerting a mild to moderate effect.^[15] The risk of bipolar disorder is nearly ten-fold higher in first degree-relatives of those affected with bipolar disorder when compared to the general population; similarly, the risk of major depressive disorder is three times higher in relatives of those with bipolar disorder when compared to the general population.^[8]

Although the first genetic linkage finding for mania was in 1969,^[36] the linkage studies have been inconsistent.^[8] The largest and most recent genome-wide association study failed to find any particular locus that exerts a large effect reinforcing the idea that no single gene is responsible for bipolar disorder in most cases.^[37]

Findings point strongly to heterogeneity, with different genes being implicated in different families.^[38] Robust and replicable genome-wide significant associations showed several common single nucleotide polymorphisms, including variants within the genesCACNA1C, ODZ4, and NCAN.^[15][37]

Advanced paternal age has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new genetic mutations.^[39]

Physiological

Abnormalities in the structure and/or function of certain brain circuits could underlie bipolar. Meta-analyses of structural MRI studies in bipolar disorder report an increase in the volume of the lateral ventricles, globus pallidusand increase in the rates of deep white matter hyperintensities.^[40][41][42] Functional MRI findings suggest that abnormal modulation between ventral prefrontal and limbic regions, especially the amygdala, are likely contribute to poor emotional regulation and mood symptoms.^[43]

According to the “kindling” hypothesis, when people who are genetically predisposed toward bipolar disorder experience stressful events, the stress threshold at which mood changes occur becomes progressively lower, until the episodes eventually start (and recur) spontaneously. There is evidence supporting an association between early-life stress and dysfunction of the hypothalamic-pituitary-adrenal axis (HPA axis) leading to its over activation, which may play a role in the pathogenesis of bipolar disorder.^[44][45]

Other brain components which have been proposed to play a role are the mitochondria^[32] and a sodium ATPase pump.^[46] Circadian rhythms and melatonin activity also seem to be altered.^[47]

Environmental

Evidence suggests that environmental factors play a significant role in the development and course of bipolar disorder, and that individual psychosocial variables may interact with genetic dispositions.^[48] There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of unipolar depression.^[49] There have been repeated findings that 30–50 percent of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a higher rate of suicide attempts, and more co-occurring disorders such as PTSD.^[50] The total number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child’s own behavior.^[51]

Neurological

Less commonly bipolar disorder, or a bipolar-like disorder, may occur as a result of or in association with a neurological condition or injury. Such conditions and injuries include (but are not limited to) stroke, traumatic brain injury, HIV infection, multiple sclerosis,porphyria, and rarely temporal lobe epilepsy.^[52]

Neuroendocrinological

Dopamine, a known neurotransmitter responsible for mood cycling, has been shown to have increased transmission during the manic phase.^[10][53] The dopamine hypothesis states that the increase in dopamine results in secondary homeostatic down regulation of key systems and receptors such as an increase in dopamine mediated G protein-coupled receptors. This results in decreased dopamine transmission characteristic of the depressive phase.^[10] The depressive phase ends with homeostatic up regulation potentially restarting the cycle over again.^[54]

Glutamate is significantly increased within the left dorsolateral prefrontal cortex during the manic phase of bipolar disorder, and returns to normal levels once the phase is over.^[55] The increase in GABA is possibly caused by a disturbance in early development causing a disturbance of cell migration and the formation of normal lamination, the layering of brain structures commonly associated with the cerebral cortex.^[56]

Prevention

Prevention of bipolar has focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness.^[57] There has been debate regarding the causal relationship between usage of cannabis and bipolar disorder.^[58]