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Section 25
Cognitive-Behavioral Therapy for Bipolar Disorder

Question 25 | Test | Table of Contents

The symptoms of depression experienced in bipolar disorder are almost identical to those of major depression, the primary form of unipolar depressive disordeymptoms of the Depression Phase.
They include: • Sad mood • Fatigue or loss of energy • Sleep problems such as insomnia, excessive sleeping, or shallow sleep with frequent awakenings • Appetite changes • Diminished ability to concentrate or to make decisions • Agitation or markedly sedentary behavior • Feelings of guilt, pessimism, helplessness, or low self-esteem • Loss of interest or pleasure in life • Thoughts of, or attempts at, suicide

Distinguishing Between Unipolar and Bipolar Depression.
It is often difficult to differentiate between unipolar and bipolar depression, particularly in bipolar II patients. They may differ in the following ways: • Bipolar depression typically lasts 2 to 3 months--not as long as in major depression (although left untreated some bipolar disorder episodes can last 6 to 12 months or longer). • People with unipolar depression can still experience a variety of other moods, but none meet the criteria for a manic state. • Depressive symptoms in those with bipolar disorder tend to vary. For example, some patients experience increased sleep, gain weight, and feel a heaviness and slowness in their bodies. Other patients with bipolar depression experience impaired sleep, but unlike patients with unipolar depression, they do not feel sleepy the next day. • Bipolar depressive episodes tend to develop more gradually than do those caused by major depression.

Symptoms of the Acute Manic Phase
The acute pure manic phase is always characterized by mood elevation, presented in the following ways: • Exaggerated euphoria (a feeling of great happiness or well being) • Irritability • Both euphoria and irritability. The episode lasts for at least few days but, in some cases, the episode may last weeks or even months and may be severe enough to require hospitalization. Other symptoms must also be present to make a diagnosis. Some mental health professionals use the mnemonic device DIGFAST to identify them. In general, for a diagnosis of mania, a patient must have experienced either euphoria with three DIGFAST symptoms or irritability with four of these symptoms:
• D. Distractibility. This is the most common symptom and it is usually characterized by the inability to pay attention to
any activity for very long.
• I. Insomnia in mania typically means having high energy and requiring less sleep. (This differs from insomnia in depression, in which the patient has low energy plus an inability to sleep.)
• G. Grandiosity. Patients with this symptom have an inflated sense of themselves, which, in severe cases, can be delusional. Close to 60% of all manic patients experience feelings of being all-powerful. Sometimes they feel that they are godlike or have celebrity status.
• F. Flight of ideas. Thoughts literally race.
• A. Activity. The patient may show an increase in intensity in goal-directed activities, which are related to social behavior, sexual activity, work or school.
• S. Speech. The patient may talk excessively.
• T. Thoughtlessness. Excessive involvement in high-risk activities is present (such as unrestrained shopping, promiscuity). Mood disturbance may be severe enough to damage one's job or social functioning or one's relationships with others. Some patients require hospitalization to prevent harm to others or to themselves.

Some patients with bipolar I may experience psychotic symptoms, including thought disorders, hallucinations, and catatonia (a state in which the patient goes into a stupor for long periods, which may give way to short periods of extreme excitement).

Using Cognitive-Behavioral Therapy for Bipolar Disorder.
Typical goals of CBT for bipolar disorder patients include learning how to: • Recognize manic episodes before they become full-blown and change behaviors during an episode • Cope with depression by developing behaviors and thoughts that may help offset the negative mood

Monitoring and Grading Mood. One useful technique is a method that helps the patient predict or recognize an impending episode. This is done using a graph and diary that records and grades the effect of the patient's mental state on energy and physical activity. There are a number of charts for doing this. With one method, the patient makes a time line across the page and a vertical line on the left side of the time line with a range from -5 to +5: • -5 to -1 indicate the depressive phase. Minus five is the most severe depressive state and requires hospitalization. At this score, the patient's psychomotor responses are almost entirely negative. The patient is unable to function, has no appetite, and can barely get out of bed. As the scale moves up to zero, the depressive state lessens, so that -1 indicates a subdued mood with slightly less energy than normal. • Zero is normal. • +1 to +5 indicate the manic phase. For example, +1 indicates a slightly more active and energetic state than normal. Plus five is the most severe manic state, where the patient is incapable of slowing down, experiences impaired thinking and judgment, and sleeps at least 2 hours less than normal. To fill out the graph, the patient takes the following steps: • Using a diary, the patient describes each day, the mood, and its effect on physical activities. • Using this information, the patient makes a mark on the scale that roughly reflects each day's mood and its effect on function. The patient then connects the mark with that of the previous day's state. • The patient also describes any significant emotional or physical events, menstruation, medications, and dosages taken, or any factor that may be relevant in influencing mood or activities. • After several months, the therapist and patient may be able to detect a pattern and possibly identify triggers of bipolar disorder episodes. • Such information helps the patients to make adjustments that might reduce the severity of mood swings. For example, if a predictor for either manic or depressive episodes is insomnia, the doctor might use sleep-inducing methods or medications that might reduce the severity of the emerging mania.

Family Therapy. It is very important that partners, family members, or both be involved in therapy. CBT can help them learn how toaccept the condition, the need for medications, and how to protect themselves and the patient financially during manic episodes. In fact, one study indicated that when a spouse of a patient learned ways of coping with the illness, the partner's chances of sticking to a prescribed treatment improved.

Supporting the Patient. Recommendations for supporting the patient include: • Create a treatment contract as a first step. In this contract, the patient and family agree to specific steps for maintaining emotional stability. If such measures fail, all parties agree on further actions to be taken during an acute episode, including requests for hospitalization. • Be supportive. Unlike relatives of alcoholic patients who may be encouraged to get tough, relatives of bipolar disorder patients must be strongly supportive because of the high risk for suicide with this disorder. Simply listening attentively and being empathic can help. • Get the patient to comply with treatment, even if it means threatening a hospitalization if the patient fails to comply. • Have ready a hotline number or the telephone number of a psychiatrist authorized to commit the patient. The doctor should be willing to facilitate commitment if a patient becomes violent or the family is on the verge of collapse. • Don't feel guilty and don't make the patient feel guilty. Bipolar disorder results from an imbalance of chemicals in the brain and not from anyone's fault.

Support for the Family. Unfortunately, actions that support a bipolar disorder patient may not be intuitive, and they take their toll. Loved ones must also care for themselves or they may also follow a path to severe depression. They should to boost energy and reduce stress through: • Exercise • Meditation • Relaxation techniques • Holidays away from the patient • Involvement in hobbies • Involvement in support groups, Internet resources with chat rooms, and message boards for bipolar disorder caregivers.

Interpersonal and Social Rhythm Therapy. Interpersonal problems (such as family disputes) and disruptions in daily routines or social rhythms (such as loss of sleep or changes in meal times) may make people with bipolar disorder more susceptible to new episodes of their illness. A form of psychosocial treatment called interpersonal and social rhythm therapy (IPSRT) focuses on maintaining a regular schedule of daily activities to reduce these potential triggers and improve emotional stability. Patients also learn how to avoid problems with personal relationships. Preliminary evidence suggests that IPSRT combined with drug therapy works better than medication alone. A 2-year study of patients with bipolar 1 disorder indicated that IPSRT may help prevent new manic episodes.

Lifestyle Factors
Exercise. Exercise is an important part of treatment, particularly in helping manage weight gain. It also helps increase feelings of well-being.
Sleep Management. Good sleep hygiene is particularly important for patients. One study reported that techniques used to enforce healthy sleep helped reduce mood cycling. In the study, patients tried to remain inactive in a dark room for 10 to 14 hours each night for 3 months.
Diet: A healthy diet low in saturated foods and rich in whole grains, fresh fruits, and vegetables is important for anyone. People with bipolar disorder should be sure to maintain a regular healthy diet. They may need to restrict calories if they are on medications that increase weight. Some research indicates that consumption of omega-3 polyunsaturated fatty acids found in oily fish, (such as mackerel, sardines, salmon, and bluefish), may help reduce the symptoms of a variety of psychiatric illnesses, including bipolar disorder. Researchers are investigating the effects of eicosapentaneoic acid (EPA) and docosahexaenoic acid (DHA) supplements for patients who have not responded to other treatments. A preliminary 2002 study found that they may benefit patients with depressive symptoms more than those with mania.

- A.D.A.M.; "Bipolar Disorder"; December 13, 2005.

Personal Reflection Exercise #11
The preceding section contained information about treating bipolar disorder with cognitive behavioral therapy.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Diagnosis and management of bipolar disorders

Goes F. S. (2023). Diagnosis and management of bipolar disorders. BMJ (Clinical research ed.), 381, e073591. https://doi.org/10.1136/bmj-2022-073591


Peer-Reviewed Journal Article References:
Fredman, S. J., Baucom, D. H., Boeding, S. E., & Miklowitz, D. J. (2015). Relatives’ emotional involvement moderates the effects of family therapy for bipolar disorder. Journal of Consulting and Clinical Psychology, 83(1), 81–91.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.

Goldberg, S. G. (2019). Narratives of bipolar disorder: Tensions in definitional thresholds. The Humanistic Psychologist, 47(4), 359–380.

Martins, M. J. R. V., Castilho, P., Carvalho, C. B., Pereira, A. T., Santos, V., Gumley, A., & de Macedo, A. F. (2017). Contextual cognitive-behavioral therapies across the psychosis continuum: A review of evidence for schizophrenia, schizoaffective and bipolar disorders. European Psychologist, 22(2), 83–100. 

Sauer-Zavala, S., Cassiello-Robbins, C., Woods, B. K., Curreri, A., Wilner Tirpak, J., & Rassaby, M. (2020). Countering emotional behaviors in the treatment of borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

QUESTION 25
What is Interpersonal and Social Rhythm Therapy? To select and enter your answer go to Test.

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