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Clinical Case Conference   |    
Integrating Pharmacotherapy and Psychotherapy in the Treatment of a Bipolar Patient
Carl Salzman, M.D.
Am J Psychiatry 1998;155:686-688.

Most contemporary psychiatric literature describing the long-term treatment of bipolar illness emphasizes the benefit of pharmaco~therapy. Although reference may be made to the need for concomitant psychotherapy (13), the techniques and problems in integrating these two therapeutic approaches are seldom discussed. The following case report, describing the treatment of a woman with bipolar disorder, illustrates problems common to the management of bipolar disorder and the usefulness of psychotherapy in the following aspects of treatment: 1) establishing a therapeutic alliance, 2) helping the patient overcome denial of illness, 3) addressing issues in transference and countertransference, 4) balancing therapeutic drug doses and side effects, and 5) encouraging significant others to provide ongoing mental status information.

Bipolar patients, especially when manic, frequently deny that they are ill. The importance of recognizing denial as a pathologic coping strategy in mania was emphasized in the early psychoanalytic literature, by Deutsch in 1933 (cited by Lewin [4, p. 46]) and by Lewin in 1950 (4, pp. 51–55, 58–60). Goodwin and Jamison (5), however, emphasized that denial may be a normal response to serious illness for the manic-depressive patient.

Clinicians may experience considerable frustration in trying to convince a manic patient that mood-stabilizing medication is necessary. When medication must be given to a denying patient, the first task is to establish a therapeutic alliance. As illustrated by the following case, a patient may initially hear the diagnosis as a demand to comply with social norms and only gradually come to trust the clinician's judgment regarding the presence of a treatable illness. Once there is agreement about the presence of an illness, patient and clinician can then embark on what may be a long, complex treatment collaboration.

When she first came to see me, "Ms. Upmann" was a 60-year-old married executive of considerable experience and success who had always been energetic, attractive, and popular. She was married to an eminent financier, had two well-adjusted married children, and had a career that fostered independence from her husband. Together they shared a rich social and interpersonal life. There was a family history of mood disorder in her maternal grandparents and one sister, but the patient's own parents were not noticeably troubled by affective disturbance. Indeed, they were loving, sometimes overly doting parents who encouraged their daughter's intellectual life and commercial success. In childhood, Ms. Upmann had been closer to her father, who often communicated the pleasure that her future professional success would bring him. These expectations, although warmly received, were in conflict with the young Ms. Upmann's own wish to be an artist, an aspiration apparently based on considerable talent.

Despite her cyclothymic temperament and occasional severe mood swings, Ms. Upmann did not come to psychiatric attention until her mid-40s. At that time, she grew progressively frenetic and unable to concentrate, sleep, or relax. Her normally rapid rate of speech increased, and she became inappropriately jocular and flirtatious at work. Her first psychiatrist diagnosed bipolar mood disorder and prescribed a course of lithium, which diminished her hypomania and stabilized her mood. After several years of taking lithium, however, she began to experience severe side effects and ultimately discontinued treatment.

When we first met, Ms. Upmann was in an unmedicated hypomanic state, walking regally and rapidly, frequently whistling or singing, and stopping to chat at any open office door. She was deeply skeptical about resuming lithium treatment. When I suggested that her mood was somewhat elevated beyond the usual range, she cited contradictory evidence from fellow passengers on a recent transcontinental flight: "Oh, people on the plane told me they had enjoyed the flight so much. They hoped to fly with me again." When her husband commented to her that wearing a diamond tiara to the supermarket was inappropriate, she countered brightly by saying, "I should move to Hollywood; everybody dresses that way there." Ms. Upmann's refusal to see herself as sick was reinforced by references to previous lithium side effects; she noted wryly that there seemed little point in taking an unnecessary drug just to produce nausea, diarrhea, and weight gain.

In the face of denial, it is important not to debate the patient regarding the presence of psychopathology or the need for medications. Empathic and exploratory discussions of more traditional psychotherapeutic themes (childhood, relationships with parents, and recent life events) may help establish the beginning of a mutual confidence within which the subject of medications may be broached at subsequent meetings.

Ms. Upmann and I gradually recognized that her denial of illness and grandiosity not only were evidence of hypomania but resonated with themes in her relationship to her father. It was he who took pride in her energy, who insisted that she not "settle" for the life of a housewife (which was then common even for intelligent, well-educated women), and who encouraged her intellectual efforts. He would have been very proud of her professional success. Thus, it was not surprising that psychiatrists were greeted with contempt when her treasured character traits of ebullience, energy, and feistiness were diagnosed as an illness. Therefore, in contrast to previous clinicians, I decided to acknowledge her hypomanic qualities as a potential strength, to be harnessed and controlled for creative purposes. I openly enjoyed her outspoken manner and sense of humor, and I promised to work with her toward the best possible balance between therapeutic benefits and negative effects of medication.

The importance of a mutually respectful therapeutic alliance cannot be underestimated in the treatment of the bipolar patient. Jamison (6) eloquently noted the characteristics of her psychiatrist that sustained her through the many difficult periods of her pharmacologic mood stabilization. She emphasized his caring, steadiness, and availability as qualities that actually helped her life when medication alone was insufficient.

Only with a solid therapeutic alliance can a patient share the two burdens of bipolar illness; first, the need to give up a seductively grandiose sense of self; second, to learn to live with less than perfect therapeutic results (5). One technique that can foster growth of an alliance and simultaneously facilitate psychotropic drug treatment is the creation of a mood chart. The usefulness of this technique has been demonstrated in early longitudinal descriptions of bipolar illness and has been recommended as a general therapeutic technique (5).

Ms. Upmann and I decided to create a daily mood chart when it became apparent that despite lithium treatment, her moods continued to fluctuate. We began to plot her moods during each appointment. As we examined the curve of her mood oscillations and noted their correlation with drug doses, side effects, and life stresses, the collaborative bond between us strengthened. When hypomanic, Ms. Upmann delighted in this "scientific scrutiny" of her condition; during depressive phases, the chart offered her hope that a positive outcome was possible based on evidence of prior improvement.

At the beginning of pharmacologic treatment of a bipolar patient, frequent dose adjustments may be necessary. Side effects of lithium and other mood stabilizers may be unpleasant and surprising for a first-time user. Antidepressants may cause agitation, even when administered in conjunction with a mood stabilizer.

Ms. Upmann and I struggled to find a medication regimen that would control her moods without producing deleterious side effects. Although lithium usually terminated hypomania, she invariably became dysphoric and wished to discontinue the lithium treatment. Carbamazepine produced an immediate rash, and valproate caused unacceptable gastrointestinal side effects. There were periods when Ms. Upmann's hypomania had to be controlled with low doses of haloperidol (2–4 mg/day) or occasional clonazepam at bedtime. When depressed, Ms. Upmann benefited from modest doses of nortriptyline, but she twice suffered hypomania. Fluoxetine was ineffective, and bupropion, either alone or in combination with lithium, precipitated hypomania followed by a rapid descent into profound depression.

Ms. Upmann and I decided to try an MAO inhibitor. It had been reported (7) that tranylcypromine might be particularly useful in treating bipolar depressions, as compared with tricyclic antidepressants. Because of prior dysphoric responses to mood stabilizers, Ms. Upmann refused a concurrent mood stabilizer. Therefore, we began with only 5 mg/day of tranylcypromine and very slowly increased the dose. At 30 mg/day, with 25 µg/day of thyroxine added, Ms. Upmann's depression remitted. We then reduced the tranylcypromine dose to 10 or 20 mg/day, depending on her mood. With these low doses, without a mood stabilizer, she entered a 2-year period of relative stability.

Bipolar patients, especially when manic, are often poor judges of their own mood and behavior. Although a lack of self-awareness may be attributed to denial, it is useful to recall that moods sometimes shift slowly, and it may be difficult for both patient and clinician to distinguish between the lifting of depression and emergent hypomania. When patients are not accurate reporters of their mental state, clinicians may need to rely on other sources of information, often family members. Typically, a spouse may be asked to report early warning signs of a mood shift, such as changes in sleep pattern, increased spending, or long and frequent telephone calls, which may signal the need for medication adjustments.

Although the use of another person to observe and report changing mood may be welcomed by some patients who are aware of their own impaired self-judgment, there are others for whom the use of an external reporter is fraught with problems. The latter proved true in Ms. Upmann's case.

Ms. Upmann was often unable to detect her elevations in mood, although they were readily apparent to her husband. Rather than perceiving herself as hypomanic, she would invariably conclude that he was "depressed." In a sense, she was correct: Mr. Upmann did become unhappy as her inappropriate manic behavior escalated. She also correctly perceived that Mr. Upmann preferred her in a state of mild depression, since there was less cause for worry. His wife did not wear a diamond tiara to the supermarket when depressed.

As a consequence, the three of us began to meet in an effort to establish an acceptable "early mood warning system," so that medication doses could be adjusted before mood swings escalated. Mr. Upmann and I found this arrangement quite promising. Ms. Upmann's perspective, however, was distinctly different. In her hypomanic state she interpreted our concern about her mood elevation as an attempt to suppress her cherished energy and affability. She concluded that her husband and I wanted her to remain mildly depressed. I recognized that unless I paid careful attention to her concerns, our carefully constructed alliance might begin to erode.

It is not surprising that potentially serious transference and countertransference reactions may develop in the combined psychotherapeutic-psychopharmacologic treatment of a bipolar patient. Janowsky et al. (8) commented on the "friendly, bright, cheerful, and entertaining manic patient who can flatter others. . . . What is temporarily overlooked is the fact that the manic patient may reverse his stance, taking away as well as giving, and making another feel demeaned and degraded." These authors cited the case of an initially positive therapeutic alliance that gradually disintegrated as "the therapist felt increasingly impotent." Alienation of family members as well as therapists by a manic patient also occurs. "In contrast to the depressive phase, where the spouse feels venerated, he often becomes the villain or the `bad parent' during the manic phase, seen as a hostile, unperceptive opponent" (8). Marriages are frequently threatened.

Ms. Upmann's newfound mood stability was, for her, a compromise. Although she was able to work, attain pleasure, and feel some reassurance about a stable future, like most manic patients she regretted the loss of her elevated moods, her energy, her wit, and her social exuberance. Furthermore, she was not happy with either her husband or me. Ms. Upmann accused us (men) of reinforcing her subservient female role, one that her father would never have endorsed. Like many male professionals, I was now perceived as a hypocrite: manifestly supporting her rights as a woman but covertly subverting them. She became angry, sarcastic, and intensely critical.

Now the alliance soured, to be replaced by disappointment, hostility, and denigration. I was not only ridiculed as a "drug-manipulating mechanic" like previous psychiatrists, I was also branded as an incompetent, not very bright therapist. In her most hostile manic phase, she commented that I was "stupid, vapid, and insipid—ID, get it, psychiatrist?" She insisted that I was only interested in her as a case to further my own career or to improve my relationship with her eminent husband. I was further accused of being depressed like her husband, threatened by her affability, and intent on keeping her depressed in order to avoid recognition of my own monochromatic and banal existence. ("The trouble with all you psychiatrists is that you are depressed and can't stand to see someone who is happy.")

Ms. Upmann did not err entirely in her analysis of my feelings about her. She was certainly very frustrating to work with, as on many occasions she thwarted all therapeutic efforts. I also felt especially irritated by her political analysis of my "male role" in suppressing her personal and professional assertiveness. At first, I tried to deny her accusations and blame her anger at me on her hypomania. Gradually, however, I understood how I was recapitulating her father's control over her independence. Helping Ms. Upmann connect some of her anger toward me with earlier feelings toward her father enabled us to acknowledge the contradictory currents of love and anger elicited by the important men in her life. These shared realizations helped diminish her anger and my frustration.

Although negative transference and countertransference may threaten the therapeutic alliance, it may be incorrect to ascribe all frustration and anger only to the patient's mood dysregulation. The clinician must constantly assess transference shifts in a broad psychodynamic context while determining the necessity for medication adjustments. Sometimes an appropriate interpretation may obviate the need for medication changes or, alternatively, may facilitate necessary dosage changes with a minimum of misunderstanding.

As sometimes happens with bipolar patients, an event outside the treatment may change the patient's symptoms and the nature of the therapeutic work.

After nearly 2 years of her mood stability, Ms. Upmann's husband developed a serious illness. As his attention shifted to his own health needs, Ms. Upmann had to confront a marital role reversal: of the two, she now was the healthier mate, and he the sicker. As he was no longer able to report her moods, her conviction that he and I were conspiring to control her evaporated, and she became an accurate self-observer and diligent patient.

In the context of his illness, the psychotherapy focus shifted back to discussing ambivalence about her father, her husband, and me. She angrily recalled that her father had supported her intellectual efforts but not her artistic aspirations, and her husband may have similarly exerted control over her career. She felt constrained from expressing anger at her husband because of his illness, and she felt a similar constraint with me because she was grateful for her mood stability. Despite my attempts to discuss these themes with her, she insisted that they could be more easily discussed with a female clinician. After considerable debate I referred her to an older female psychiatrist. She promised to continue taking medications and terminated treatment with me, while undepressed and having a stable mood, with a great expectation of continued psychotherapeutic progress.

Bipolar illness is optimally perceived from both biological and psychodynamic perspectives. Although likely to be driven by neurobiologic mechanisms, it is also shaped by an individual's particular history. Clinical experience suggests that combined treatment is often essential for maximum therapeutic benefit. From the pharmaco~therapy perspective, psychotherapy may diminish denial of illness and establish a therapeutic alliance, which is essential to a patient's active participation in medication treatment. The use of a simple mood chart may be extremely helpful in further maintaining this alliance. From the psychotherapy perspective, pharmacotherapy may control the symptoms and offer temperamental stability, which, in turn, allows the clinician to address psychodynamic issues interfering with the patient's adaptive skills.

Transference problems abound in the combined treatment of a bipolar patient. Manipulative, entertaining, and adoring, bipolar patients are not always interested in gaining insight into their grandiosity (a characteristic they share with patients who have narcissistic personality disorder) (8, 9). Fueled by manic energy and enthusiasm, a positive transference may define the clinician as direct heir to an idealized parent. But this affective valence can rapidly shift from love to hate when the patient becomes depressed or when the clinician attempts to confront denial. Obtaining historical or concurrent information on affective status from someone other than the patient, although sometimes essential, may also activate transference difficulties. In some cases, the use of an informant who is the same sex as the clinician may threaten the thera~peutic alliance with a patient of the opposite sex.

Clinicians who work with manic patients must also be sensitive to their own countertransference feelings, which are almost certain to arise. They may become angry or frustrated or develop the urge to overmedicate the patient or terminate treatment (9). The possible relevance of gender roles, important in any therapeutic relationship, may exacerbate countertransference feelings. Although a detailed discussion of gender-related problems is outside the scope of this case presentation, male clinicians must remain particularly sensitive to the potential for a struggle to develop between a male clinician and female bipolar patient.

Received Oct. 27, 1997; revision received Feb. 20, 1998; accepted Feb. 27, 1998. From the Consolidated Department of Psychiatry, Harvard Medical School and Massachusetts Mental Health Center. Address reprint requests to Dr. Salzman, Massachusetts Mental Health Center, 74 Fenwood Rd., Boston, MA 02115; csalzman@warren.med.harvard.edu (e-mail). The author thanks Drs. Judith P. Salzman, Robert Michels, and Joseph J. Schildkraut for their suggestions during the preparation of this case report.

American Psychiatric Association: Practice Guideline for the Treatment of Patients With Bipolar Disorder. Am J Psychiatry 1994; 151(Dec suppl)
Bipolar disorders, in Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association, vol 3. Washington, DC, APA, 1989, pp 1925–1940
Expert Consensus Guideline Series: Treatment of Bipolar Disorder. J Clin Psychiatry 1996; 57(suppl 12A):2–88
Lewin BD: The Psychoanalysis of Elation. New York, WW Norton, 1950
Goodwin FK, Jamison KR: Manic-Depressive Illness. New York, Oxford University Press, 1990, pp 727–734
Jamison KR: An Unquiet Mind. New York, Alfred A Knopf, 1995
Himmelhoch JM, Thase ME, Mallinger AG, Fuchs CZ: Tranylcypromine versus imipramine in manic depression, in 1989 Annual Meeting New Research Program and Abstracts. Washington, DC, American Psychiatric Association, 1989, p 78
Janowsky DS, Leth M, Epstein RS: Playing the manic game: interpersonal maneuvers of the acutely manic patient. Arch Gen Psychiatry  1970; 22:252–261
Kahn D: The dichotomy of drugs and psychotherapy. Psychiatr Clin North Am  1990; 13:197–208


American Psychiatric Association: Practice Guideline for the Treatment of Patients With Bipolar Disorder. Am J Psychiatry 1994; 151(Dec suppl)
Bipolar disorders, in Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association, vol 3. Washington, DC, APA, 1989, pp 1925–1940
Expert Consensus Guideline Series: Treatment of Bipolar Disorder. J Clin Psychiatry 1996; 57(suppl 12A):2–88
Lewin BD: The Psychoanalysis of Elation. New York, WW Norton, 1950
Goodwin FK, Jamison KR: Manic-Depressive Illness. New York, Oxford University Press, 1990, pp 727–734
Jamison KR: An Unquiet Mind. New York, Alfred A Knopf, 1995
Himmelhoch JM, Thase ME, Mallinger AG, Fuchs CZ: Tranylcypromine versus imipramine in manic depression, in 1989 Annual Meeting New Research Program and Abstracts. Washington, DC, American Psychiatric Association, 1989, p 78
Janowsky DS, Leth M, Epstein RS: Playing the manic game: interpersonal maneuvers of the acutely manic patient. Arch Gen Psychiatry  1970; 22:252–261
Kahn D: The dichotomy of drugs and psychotherapy. Psychiatr Clin North Am  1990; 13:197–208

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