Psychotherapy For

Bipolar Disorder

Brooke Tompkins

Overview

Bipolar Diagnoses
History and Facts
Etiology
Cognitive-Behavior Therapy
Interpersonal and Social Rhythm Therapy
Empirical Support

DSM-IV Diagnoses

DSM-IV Manic Episode

Abnormally and persistently elevated, expansive, or

irritable mood, lasting at least 1 week (or any duration if
hospitalization is necessary).
Three (or more) of the following symptoms have
persisted (four if the mood is only irritable):
1.
2.
3.
4.
5.
6.
7.

inflated self-esteem
decreased need for sleep
pressured speech
flight of ideas or racing thoughts
distractibility
increase in goal-directed activity
increased involvement in pleasurable activities with a high
potential for negative consequences

DSM-IV Major Depressive Episode

Five (or more) of the following symptoms have been

present during the same 2-week period; at least one of
the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
1.
2.
3.
4.
5.
6.
7.
8.
9.

depressed mood most of the day, nearly every day. Note: In

children and adolescents, can be irritable mood.
lost of interest or pleasure in activities
significant weight loss or weight gain
insomnia or hypersomnia
psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness
diminished ability to think or concentrate
suicidal ideation

DSM-IV Mixed Episode

Symptoms of a Manic Episode and a Major Depressive

Episode nearly every day during at least a 1-week period.
cause marked impairment

DSM-IV Hypomanic Episode

Elevated, expansive, or irritable mood, lasting at least 4

days, that is clearly different from the usual nondepressed mood.
Three (or more) of the symptoms of a manic episode
have persisted (four if the mood is only irritable).
The episode is uncharacteristic of the person when not
symptomatic.
Observable by others.
Does not cause marked impairment in social or
occupational functioning, and does not necessitate
hospitalization.

DSM-IV Bipolar Disorder

Bipolar Disorder I

Bipolar Disorder II

At least one manic or mixed episode (lasting for at least a week)

within his or her lifetime.
A depressive episode is not a diagnostic criteria
At least one episode of hypomania
at least one episode of depression

Rapid Cycling 4 or more episodes in a year

Bipolar NOS

DSM-IV Cyclothymic Disorder

For at least 2 years

hypomanic symptoms
depressive symptoms

Not without symptoms for more than 2 months at a

time.

Prevalence and Comorbidity

Lifetime prevalence:

Current point prevalence 18+ (NIMH) = 2.6%

Median age of onset:

0.8-1.6%

Late adolescence, early 20s

Rate among adolescents is increasing (estimate of 1%)

Comorbidities

50% with alcohol or substance abuse disorders

60% with anxiety disorders (Panic Disorder & Social Phobia)
33-50% with personality disorders
Comorbidity is the rule rather than the exception
Associated with poorer course over time

Diagnostic Issues

One-third to one-half of bipolar I disorder patients

experience psychotic symptoms (usually brief - less than
2 weeks)
~ 40% of those with bipolar disorder are first diagnosed
with unipolar depression (2004)

Treated with antidepressants leads to about 25% of these

individuals experiencing iatrogenic manic symptoms

Up to 75% do not adhere to medication regimens

Etiology - Biological Basis

Heritability as high as 80%

First-degree relatives

Polygenic

Involves a combination of several genes

New research - genetic vulnerability traits

How?

10% chance of bipolar disorder and unipolar depression

Dysregulation of neurotransmitters
Difficulties in maintaining homeostasis
Symptoms likely under neurobiological stressors (i.e., sleep
deprivation)

Different brain activity

Etiology Diathesis-Stress

Biological predisposition + stressful events + subjective

perception (cognitive triad)
Negative life events predict bipolar depression

Butcombined with a high behavioral activation system triggers mania

Excessive focus on goal attainment stimulates manic episode

Etiology - Circadian Dysregulation

Biological Rhythms

Seasonal peaks
Suicide

Sleep patterns
Social Rhythm Stability Hypothesis (Frank et al.)

Changes in routine (sleep cycles, appetite, energy, work, etc.) can

cause great stress on the body, especially in more vulnerable
individuals

Then and Now

Most biological of severe psychiatric disorders

Previously thought amenable only to
pharmacotherapy
Psychoanalysis not effective
1980s

Improving pharmacological treatments

Important challenge treating chronic subacute depressive
symptoms
Beginning of research on psychotherapy

Pharmacotherapy

First line of treatment

Strongest support:

Lithium (1949) recommended by APA Practice Guidelines

report side effects, leads to discontinuation and
hospitalization

Mood stabilizers are less effective in reducing

depressive symptoms
Mood stabilizers + antidepressants + antipsychotics
Psychotherapy as adjunct to pharmacotherapy
Know about medications!

Why Psychotherapy?
1.
2.
3.
4.
5.

6.
7.

8.

Provide psychoeducation regarding symptoms

Promote adherence with medication regimens
Address comorbid conditions
Ameliorate stigma and self-esteem consequences
Enhance social and occupational functioning and
adjustment
Reduce risk of suicide
Identify psychosocial triggers that increase the risk for
relapse
Evidence suggests that psychosocial treatments both
reduce and prevent symptoms

Current Treatment Guidelines

American Psychiatric Association, 2002

Initiating mood stabilizing treatment
Add one or more of the following:

Specific psychotherapy
Antidepressant medication

APA Practice Guidelines

Supported Types of Psychotherapy

1.
2.
3.
4.

Interpersonal and Social Rhythm Therapy (IPSRT)

Cognitive-Behavior Therapy (CBT)
Group or Individual Psychoeducation
Family Therapy
All trials of psychotherapy as complementary to
pharmacotherapy (Swartz, Frank, & Kupfer, 2006)
Possible phase-specific treatments

Differential effects of psychotherapies

Effect on recurrence
or relapse?
Therapy Type

Effect on symptoms?

Experienced
Therapists?

Mania

Depression

Mania

Depression

Individual
Psychoeducation

No

Yes

No

Group
Psychoeducation

Yes

No

Yes

Typical Care
Management

No

Yes

No

Cognitive
Therapy

Yes

Yes

Yes

No

Yes

IPSRT

Yes

Yes

Yes

Yes

Yes

Swartz, Frank, & Kupfer, 2006

Assessment of Symptoms

Self-Report

Clinical Evaluation

Mood Disorders Questionnaire (Hirschfield, 2002)

SCID-IV

.61-.64 reliability

.76-.78 reliability when used with medical records

Assessment of Symptom Severity

Inventory for Depressive Symptomatology (IDS-C; Rush et al., 1986)

Bech-Rafaelsen Mania Scale (Bech et al., 1979)

Young Mania Rating Scale (YMRS; Young et al. 1978)

Manic State Rating Scale (Beigel, Murphy, & Bunney, 1971)

Assess medication compliance

Assess for suicide!

Cognitive Behavior Therapy

Focuses on the cycle of reactions to
symptoms that impair functioning, cause
psychosocial problems, and increase stress

Cognitive-Behavioral Process
1.
2.
3.

4.
5.
6.

Psychoeducation
Reactive Symptom Management
Symptom Monitoring/Develop Early Warning
System
Adherence to Treatments
Symptom Control (CBT and cognitive strategies)
Reducing Stress
Generally around 12-20 sessions

Every Session
1.
2.
3.
4.
5.
6.

Collaborative agenda setting

Mood and medication assessment
Review homework
Setting goals and priorities for session
Assigning new homework
Final summary and feedback

Psychoeducation

Explain disorder and role of cognition

BD runs in families

Diathesis-stress disorder - biological problem interacts with

stress
Can be dangerous to health, relationships, occupational success,
etc.
Much due to cognitive triad

Involves biochemical problems that can cause symptoms such as

anger, impulsivity, depression, suicidality, exuberance,
hypersexuality, and a false sense of invinciblity

Explain negative explanatory style

Can be treated with both medication and psychotherapy

Psychoeducation

Explain purpose of CBT treatments

Learn to adopt constructive outlook on life

Problem-solving
Improve quality of life
Ease of medication adherence
Less likelihood of relapse

Introduce importance of homework

Can assign reading materials for homework

Finding Peace of Mind: Treatment Strategies for Depression and
Bipolar Disorder
Bipolar Disorder

Psychoeducation

Knowledge of medication and adherence

Why medication is used

Side effects
Mood stabilizing vs. antidepressant
Expected outcome
Long-term issues with management
Why psychotherapy is needed in addition

Identify issues to discuss with physicians

Provide readings

Managing Hypomanic/Manic Symptoms

Recognize warning signs

Interventions and Rules:

Medical solutions first

Two-person feedback rule for great ideas
Limit cash payments
To counteract impulsivity:

Give car keys or credit cards to someone to keep

Rules about staying out late or giving out phone #
Avoid alcohol and substance use

minimize stimulation
48-hours before acting rule

* Treatment Contract

Managing Hypomanic/Manic Symptoms

Interventions (contd)

Imagery about worst-case scenarios

Relaxation techniques

Diaphragmatic breathing
PMR

Address wish to stay manic:

They will feel more creative, productive, attractive, etc.

Remind them that some of the worst events in their life have
happened during manic episode
Ultimately, decisions will lead to more disruption

Symptom Monitoring

Identify how day-to-day experiences are related to symptoms of

bipolar disorder

Ask how illness has affected their lives and home environment

Complete Symptom Summary Worksheet

List of symptoms

Homework: Provide copies for patient to add symptoms throughout the

week

Teach patient to monitor key symptoms, such as changes in mood

Circle what they experience in episode

Circle what they experience when normal

Review Mood Graph in session, complete for yesterday and today

Homework: Keep mood graphs.

Remember to always address homework at beginning of the next

session

Development of Early Warning System

Complete Life Chart

Reference line that represents a normal/euthymic state

Draw episodes of mania, depression, and mixed states on
timeline
Draw first episode together, they complete the rest

Can consult with family members, medical records, etc.

Include types and dates of received treatment

Development of Early Warning System

Develop early warning system

Distinguish between normal and abnormal mood shifts

Using Symptom Summary Worksheet and Life Chart
Make detailed descriptions of patient in normal and episodic
states
Descriptions used by patient, family members, can call therapist
and review
*use mood graphs

Treatment Adherence

Introduce CBT model of adherence

Noncompliance is the norm, not the exception

Illness interferes with adherence
New conceptualization of adherence:

Waxes and wanes over time

Difficulties from family, differing opinions, anger at some
medications not working, etc.

Strategies to reform opinion on illness, medications, and

necessity of treatment

Compliance Contracts
Assessment and Goals

1.

Review dosing schedules

Review appointment plans
Goals for homework assignments

Identify Obstacles

2.

1.
2.
3.
4.
5.

Intrapersonal
Treatment
Social system
Interpersonal
Cognitive

Make plan for overcoming obstacles

3.

Ask about past successful strategies

Make a plan
Periodically review and modify if necessary

Example Compliance Contract

Step 1: Treatment Plan

I, [patient name], plan to follow the treatment plans listed

below:
1.
2.
3.

Take 900 mg of lithium at bedtime.

Take 4 mg of Ambien to help me sleep.
See the doctor every month and call if I think the regimen needs to
be changed.

Step 2: Compliance Obstacles

I anticipate these problems in following my treatment plan:

1.
2.
3.

If I continue to gain weight with lithium I may want to stop taking it.
The Ambien might stop working and Ill need something stronger.
When I get home late Im too tired to go to the kitchen to take my
pills.

Example Compliance Contract

Step 3: Plan for reducing obstacles

To overcome these obstacles, I plan to do the following:

1.
2.
3.

Join Weight Watchers. Start walking in my neighborhood.

Improve sleep by not drinking coffee or other caffeinated beverages
after 4 pm.
Keep the evening dose at the bedside with a bottle of water.

CBT Strategies for Symptom Control - Manic

Goal: Testing Reality of Thoughts and Beliefs

Discuss typical hypomanic cognitive errors

overreliance on luck
underestimating risk of danger
overestimating capabilities
disqualifying negative, minimization of lifes problems
overvaluing immediate gratification
misinterpreting intentions of others

Discuss automatic thoughts and distorted cognitions

If difficult to identify, describe general impressions and images

until they can identify beliefs, themes, concerns
Use Automatic Thought Records

CBT Strategies for Symptom Control - Manic

Alert them to the impact the thought has on their mood

state
Use behavioral experiments to test thought
Consult with trusted others

Examine evidence
List evidence for/against
Alternative explanations

Cognitive restructuring to evaluate thoughts

Homework: Keeping Automatic Thought Records.

CBT Strategies for Symptom Control - Manic

Goal: Modifying Behavioral Symptoms

Negative Imagery
Activity Scheduling

A and B lists
Plan activities ahead of time
Can make a Daily Activity Schedule

Increasing sitting and listening

Sit when they notice they are speaking or moving rapidly in

social situations interrupts acceleration of motor activity
Focus on listening to others use self-statement prompts if
needed

Pay attention. Listen to [name of person].

Advantages/disadvantages technique

Advantages/Disadvantages Technique
Stay at Current Job
Its close to home

***Can make more money

*Good secretary

Larger office

*I know everybody

**More independence

Advantages

Get away from boss

Business has been poor

Disadvantages

Change Jobs

***Stuck with current boss

The work schedule may

require weekend work

***No raise this year

***May have to move family

Bad neighborhood

New boss could be a jerk

No room for creativity

CBT Strategies for Symptom Control - Manic

Stimulus Control

Knowing what activities to avoid

Alcohol or other substances

Unsupervised spending of large amounts of money
Daredevil hobbies
Exaggerated generosity or friendliness with strangers
Activities using a lethal weapon

Consulting with others

Feedback

CBT for Symptom Control Manic & Depressive

Sleep Enhancement

Be consistent
Its a nighttime thing
Keep your bed a place for sleep
Get comfortable
Gear down for the night
Avoid stimulants that might keep you awake

Dont do:

Caffeine
Internet
TV and books
Chores
Exercise

CBT Strategies for Symptom Control - Depression

Goal: Testing reality of negative thoughts

Identification of Negative Automatic Thoughts
Automatic Thought Record
Evidence for/evidence against technique
Alternative Explanations

Reframe thoughts of suicide

Patient chooses explanation that seems most likely

Have them write down reasons to live

Homework: Keep Automatic Thought Records.

CBT Strategies for Symptom Control - Depression

Goal: Increase behavior

Discuss behavioral aspects of depression

Normalize feeling overwhelmed and overloaded

Graded Task Assignment

How have they coped with it in the past?

List all tasks that require attention

Divide tasks into smaller steps
Devise plan to guide patient from one step to the next

A and B lists to help choose important tasks

CBT Strategies for Symptom Control - Depression

Goal: Increase behavior (contd)
Increasing Mastery and Pleasure

Discuss rationale for activity scheduling:

breaks cycle of hopelessness

natural antidepressant effects
in contact with others
increase self-efficacy
positive outcomes

CBT Strategies for Symptom Control - Depression

Adding Positives
1.

Select a healthy habit to improve

2.

Start one new behavior that gets them closer to goal

3.

Ex: healthy eating

Ex: eat breakfast in morning

Select one problematic behavior to stop

Ex: Stop eating late at night

Decision-Making

Decision Making and Thought Processes

Schedule time at end of day to review the day

Review the day and take notes on events that were troublesome
or require more thought

At least 1 hour before bedtime

Not in bed

Things to do the next day

Conversations
Disappointments, worries

For each item, note what needs to be done to rectify issue

At bedtime, instead of ruminating, remind self that day has
already been reviewed

Decision-Making
Decision Making using Advantages/Disadvantages

Provides structure
Can compare choices relative to one another
Consider maximizing advantages of each choice while
minimizing disadvantages

Problem-Solving
Problem identification and definition

1.

State problem as clearly as possible

Generation of potential solutions

2.

List all possible solutions regardless of feasibility

Eliminate less desirable or unreasonable choices
Order in terms of preference
Pros and cons
Specify how and when solution is implemented

Problem-Solving
Implement Solution

3.

Implement as planned
Evaluate effectiveness
Decide whether a revision is needed or a new plan to address
problem better
Or return to step #2 and select new solution

Ask questions to facilitate problem definition

Reducing Stress

Acute Stress Management

Inquire about past coping methods

YOU have faith in their ability to cope
Relaxation training

Stress Control and Problem Solving

Cues to stress

Internal and external

Physical
Emotional shifts

Input from others

Reducing Stress

Stress Control and Problem Solving (contd)

Proactive Scheduled Assessment

Ex: scheduling times to address progress and problems with spouse

every 3-6 months

Predictable times of change and stress

Stress Prevention

Activity scheduling

Track activities for a week, rank for pleasure and accomplishment

Schedule activities high in these areas
Important to know limits

Lifestyle choices and limit setting

Interpersonal and Social Rhythm Therapy

Combines IPT for unipolar depression with
behavioral strategies designed to regulate
daily routines and psychoeducation to
enhance treatment adherence.

Initial Phase

Psychiatric and medical history

Events leading up to current and previous episodes

Evidence of alterations or disruptions in routine or interpersonal

interactions

Interpersonal inventory

Review of all important past and present relationships

Life circumstances
Quality of relationships
Listen for omissions/disruptions

Initial Phase

Education on disorder

Symptoms
Medications
Side effects, etc.
Role of circadian rhythm and rhythm disruption in disorder
Interpersonal and Social Rhythm Therapy, Frank et al. (2000)

Social Rhythm Metric (SRM)

Record daily activities

How stimulating activities were
Daily mood

Intermediate Phase

Social rhythm strategies

Review first 3-4 weeks of SRMs to find rhythms that seem

unstable

Encourage to work toward stabilization

Make goals for recovery/regulating rhythms

Ex: sleep patterns

Graded
Range from short-term, intermediate, long-term

Also examine larger environmental stressors

Learn to adapt to changes in routine

At some point, patient will question the need for

stability

Intermediate Phase

Interpersonal strategies

Identify problem area (grief, interpersonal role disputes, role

transition, interpersonal deficits)
Address the problem area
Attend to its role in promoting or disrupting social regularity

Ex: loss of a loved one causes a disruption in social routine

Ex: fights with spouse lead to less sleep

Preventative Phase

Decreases from weekly to monthly sessions

Can last 2 or more years
Continue evaluating what works best for patient

Eliminate or change disruptive activities

Seek a stable pattern

Encouragement to address problems as they arise

May require crisis sessions as symptoms or
interpersonal dilemmas arise

Termination

Over 4-6 monthly sessions

Review patient success
Discuss potential vulnerabilities

Identify strategies for management of interpersonal difficulties

and symptom relapses

Encouragement about ability to use strategies

independently

Efficacy of CBT

Lam et al. (2000)

6 months, 12-20 sessions of CBT

Superior to outpatient treatment in reducing episodes and
coping with symptoms

Fava, Bartolucci, Rafanelli, & Mangelli (2001)

CBT added to medication in patients with frequent relapses

Decreased residual symptoms and increase in time to relapse
Follow-up of patients at 2-9 years

Of the 15 patients, only 5 experienced relapse

Swartz, Frank, & Kupfer (2006)

Review of psychotherapies
Effect sizes of 0.32 to 0.45 (highest of all psychotherapies)
Cognitive strategies benefitted depressive symptoms
Behavioral strategies ameliorated manic symptoms

Efficacy of IPSRT

Frank et al., 1997

Compared traditional medication treatment to IPSRT

52 weeks
The 18 in IPSRT showed greater stability in routines
The 20 in medication only group showed no change in routines

Efficacy of IPSRT

Frank et al., 2005

175 participants in acute treatment, then maintenance treatment

(2 years)

Those in IPSRT acute phase had longer intervals to relapse

during 2-year follow-up, regardless of maintenance treatment

ICM + ICM
ICM + IPSRT
IPSRT + IPSRT
IPSRT + ICM
All in addition to pharmacotherapy

Also associated with a greater change in stability of routine

*Treatment during acute phase has a protective effect against

future episodes