Category Archives: Bipolar Disorder

CBT & Bipolar Disorder

Bipolar Disorder, Treatment Approaches,

認知行為療法 (CBT) 如何幫助躁鬱症（雙極症, bipolar disorder）？

躁鬱症的治療過程中，藥物扮演非常重要的角色。而加入認知行為療法(CBT)，則可以幫助穩定患者的情緒和保持日常的穩定。

是甚麼導致躁鬱症的高低起伏？根據研究，情緒的起伏，受我們的想法影響。該研究發現極度消極負面的想法或過度積極正面的想法都會影響躁鬱症患者的情緒和行為。而學習和練習CBT就可以緩和這些極端，CBT讓患者學習如何捕捉、挑戰、改變錯誤的或極端的思維，同時識別和改變有問題的行為習慣。

六個針對躁鬱症的CBT技巧

  1. 接受“躁鬱症”這個診斷。首先第一步就是明白和理解這個可以對你的症狀做出解釋的疾病。對很多躁鬱症患者來說，這往往很難接受，所以讓他們學會關於躁鬱症的信號、症狀、起因、病程等是很重要的。這讓患者能去尋求幫助，而且也知道他們其實並不孤單。
  2. 監控情緒。這通常是用工作表或日記來紀錄。目的在於更加能夠覺察情緒的導引和改變。
  3. 進行認知重建。這過程專注于通過學習如何更好的識別想法對情緒扮演的角色、如何識別有問題的想法、和如何改變或糾正它們來改變思維的習慣。（有些時候接受該想法，再與想法產生距離化可能比挑戰和改變想法有幫助－似情況而定）。
  4. 頻密進行問題解決。其中的步驟包括如何識別問題，產生可能的解決方案，選擇適合的方案，嘗試它，和評估其結果。問題解決療法可以應用在生活的任何領域，不管是兩性關係、失業、或卡債等。這所有壓力的根源，如果沒有被好好處理解決，都會帶來復發。
  5. 增強社交技巧。有些躁鬱症的患者缺乏社交技巧，這讓他們覺得自己沒辦法控制生活的其中一些部份。學習自信心訓練等技術能幫助處理與他人的關係。
  6. 穩定日常節奏。給生活建立一個規律的日常活動和節奏，這有助于穩定情緒。

而為了最大化躁鬱症的治療，聽從醫生的指示、完成CBT的家庭作業，和不斷繼續學習關於躁鬱症是很重要的。

Is it Depression or Depressive State in Bipolar Disorder?

Basic & General, Bipolar Disorder, Depression

I’ve previously written about patients with Bipolar Disorder taking only anti-depressant medication (see here for Case 1 & Case 2). As presented in these cases, quite often hypomania and mania do not lead to doctor visits, whereas usually people in depressive state will seek help, which then means that anti-depressant medications will more likely to be considered and used initially. But after a period of treatment, just like the teacher in Case 2 who thought she had recovered but all the colleagues and headmistress found her so hyper, and the man in Case 1 who refused to stop anti-depressants as they made him feel so strong, empowering and elated, these drugs could go all wrong without proper follow ups and assessments.

Anti-depressants (SSRI, Selective Serotonin Reuptake Inhibitor) such as Prozac, Lexapro, Luvox, Zoloft are some commonly used medications for anti-depressant. Sometimes they also work for anti-anxiety and treatment for obsessive compulsive disorders. When bipolar is involved, an antidepressant taken without the protection of a mood stabilizer can potentially induce mania or hypomania, and worsen the course of the illness.

So if the family members or the patient suspects that the depression is actually part of a bipolar disorder (based on patient’s presentation and past experience), it’s very important to make aware to the psychiatrist or attending clinician, so that a mood stabiliser can be used first. Even if the mood stabiliser cannot control the depressive state, it can be used in conjunction with anti-depressants, as a “protective shield” from switching to manic stage (though still, no guarantee, only reducing the chance).

Also, it usually takes at least 2 to 3 weeks for mood stabilisers and anti-depressants to kick in, and a much longer period till it becomes fully effective, sometimes seeing no effects may suggest that you need to be patient and in a month or so you will feel very different, while other times it could also suggest that you are not taking the right dosage, and this is to be judged by psychiatric doctor.

N.B. This is written by a psychologist based on her experience working with patients in psychiatric clinic (and some research); if in doubt please consult your doctor. 

本文写的是抑郁症 (depression) 与躁郁症 (bipolar disorder or manic depressive disorder) 里的忧郁的区别. 大部分时候, 狂躁 (manic) 的人都不会寻求医疗帮助, 都是在抑郁的阶段 (depressive state) 去看医生, 这样一来, 医生很可能就会用抗抑郁药物 (anti-depressant). 可是就如 案例 1 里的男人吃了抗抑郁的药不肯停下来, 因为它让他觉得很强大兴奋和 案例 2 里的老师在接受抗抑郁药物一段时间后以为自己好了不再老是悲伤哭泣, 但身边的校长老师都觉得她情绪过度高昂近乎狂躁.

所以如果家人或者病人本身, 根据过去的经验与病人的表现, 怀疑病人目前的忧郁是狂躁的一部分而不是单纯的抑郁病, 就一定要和医生讨论, 可先用情绪稳定剂治疗 (mood stabiliser), 避免单纯的应用抗抑郁药物 (anti-depressants) 而把病人推向狂躁 (mania).

值得一提的是, 大部分抗抑郁药物 (antidepressants) 和情绪稳定剂 (mood stabilisers) 都至少需要两到三个星期才展现效果, 并需要更长时间才更完整地见效. 所以要是一开始完全不觉得情况有改善, 一是你需要更多耐心, 在大概一个月后你的感觉会改善许多, 二是病人的药物分量不够, 这则需要专科医生的判断.

备注: 本文的作者是一名心理学家 (psychologist), 内容是依据与精神科病人工作的经验与研究所写. 如有任何疑问请寻求专业医疗帮助.

Manic Stage

Bipolar Disorder, Clinical Case Studies

She’s a teacher, first came to us being depressed, presented with a complete negative outlook, lacking drives and interests, having crying episodes, and not being able to teach.

After few months of treatments, she recently called up and requested for a letter written to the ministry of education, to say that she’s recovered. During the phone call, she said she’s still regular with med, but now she has no more crying episodes, and her mood is good generally.

Coincidentally one day when she was in school and called up to check whether the report was ready, the school principal walked past her, and requested to speak to me. The principal asked whether the family has contacted us regarding the patient’s condition (negative). She said although patient is no longer crying and depressed now, she has been doing things completely out of order.

The headmistress said patient has organized a basketball competition completely by her own, without the school’s permission but under its name. She also brought a few of her students out for day trip, and only sent them home past midnight. When she meets someone new, she talks a lot, telling a lot of private details about herself. Sometimes she feels tired and will just sleep in the school storeroom. She also refused to go home after the basketball event, stayed at the court and fell asleep there at 3am when she was found by the family. She tries to spend all her time away from home, refusing to go home. She promises to anything and everything others ask her to do, and fail to keep her promises. Others can’t criticize anything about her, she thinks she’s perfect, best of the best, so whoever criticizing her, she becomes very argumentative and defensive, which is why she argued with and shouted at the principals.

The patient displayed some of the very typical symptoms of one who gets into manic phase, especially the part where they feel invincible, perfect, without weakness, and the power to keep going without needing to rest or sleep. One to add is shopping spree, a lot of them turns to spending money when they become manic, feeling like they are always short of something.

A lot of these  during treatment and recovery requires attention from the family or people around them, as the clinician may not always realize that patient has turned manic just within a 20 mins consultation – they may just seem happy, recovered from depression, instead of manic. And indeed, that’s part of some people’s personality. So the family should know where the base line is, and giving feedback to the clinician.

Bipolar Disorder

Bipolar Disorder, Depression, Issues & Debates

His family came for consultation on behalf, as he wouldn’t come no matter what. According to what his family (wife, son & daughter-in-law), he is in such a hypomanic stage, with spending spree, agitated mood, and not sleeping much day nor night.

However, we were surprised to know that the man has been taking anti-depressant himself. The son said that he was depressed few months ago, so he willingly went to the general hospital to see a psychiatrist, and got some anti-depressant medication. He has since then been taking it, and got better from depression.

Now that he’s in such a hypomanic stage, imagine he’s still continuing with the anti-depressant?! He gets even hyper and manic. He doesn’t listen to his family’s advice to stop the anti-depressant, as he feels good taking them, energetic, filled with drives, jovial… (but manic in others’ eyes).

So after consulting us, we’ve given advice to the family that they will have to find a way to stop the man from taking the anti-depressant but to start with our medicine. Few days later it was the date for the man to go for appointment in the general hospital, where he usually just collects medicine as the appointment bookings for the psychiatrist is always full. So when the son accompanied him there (he’d never accompanied his father to the hospital), again the nurse asked them to collect the same medicine as the appointment booking is full. This time, with the advice from us, the son refused. He said the man’s condition is no longer the same, he can’t take the same medication. They sent him to Accident & Emergency department where the man was asked to do blood test. Only with blood test result coming out few hours later, they got to see the psychiatrist doctor.

Here it shows the importance to regularly have follow ups and reviews with psychiatrist doctor rather than continuously collecting and taking medicine (which is very common in most government and some private practices, most likely due to the shortage of clinical staff and doctors). As people don’t usually get depressed all the time with medicine (other than dysthymic disorder which is another case), they do recover, so they shouldn’t really be taking anti-depressant for long term without medical review, even if it is just a maintenance dosage, review is still needed and important.