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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.

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  • Bipolar Diagnoses

  • History and Facts

  • Etiology

  • Cognitive-Behavior Therapy

  • Interpersonal and Social Rhythm Therapy

  • Empirical Support

Dsm iv manic episode
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):

    • 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
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.

    • 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
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
DSM-IV Hypomanic Episode

  • Elevated, expansive, or irritable mood, lasting at least 4 days, that is clearly different from the usual non-depressed 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
DSM-IV Bipolar Disorder

  • Bipolar Disorder I

    • 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

  • Bipolar Disorder II

    • 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
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
Prevalence and Comorbidity

  • Lifetime prevalence:

    • 0.8-1.6%

  • Current point prevalence 18+ (NIMH) = 2.6%

  • Median age of onset:

    • 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
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
Etiology - Biological Basis

  • Heritability as high as 80%

  • First-degree relatives

    • 10% chance of bipolar disorder and unipolar depression

  • Polygenic

    • Involves a combination of several genes

    • New research - genetic vulnerability traits

  • How?

    • Dysregulation of neurotransmitters

    • Difficulties in maintaining homeostasis

    • Symptoms likely under neurobiological stressors (i.e., sleep deprivation)

  • Different brain activity

Etiology diathesis stress
Etiology – “Diathesis-Stress”

  • Biological predisposition + stressful events + subjective perception (“cognitive triad”)

  • Negative life events predict bipolar depression

    • But…combined with a high behavioral activation system - triggers mania

    • Excessive focus on goal attainment stimulates manic episode

Etiology circadian dysregulation
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
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


  • First line of treatment

  • Strongest support:

    • Lithium (1949)– recommended by APA Practice Guidelines

    • ¾ 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
Why Psychotherapy?

  • 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
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
Supported Types of Psychotherapy

  • 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
Differential effects of psychotherapies

Swartz, Frank, & Kupfer, 2006

Assessment of symptoms
Assessment of Symptoms

  • Self-Report

    • Mood Disorders Questionnaire (Hirschfield, 2002)

  • Clinical Evaluation

    • 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
Cognitive –Behavior Therapy

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

Cognitive behavioral process
Cognitive-Behavioral Process

  • 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
Every Session

  • Collaborative agenda setting

  • Mood and medication assessment

  • Review homework

  • Setting goals and priorities for session

  • Assigning new homework

  • Final summary and feedback


  • Explain disorder and role of cognition

    • BD runs in families

      • Involves biochemical problems that can cause symptoms such as anger, impulsivity, depression, suicidality, exuberance, hypersexuality, and a false sense of invinciblity

    • “Diathesis-stress” disorder - biological problem interacts with stress

    • Can be dangerous to health, relationships, occupational success, etc.

    • Much due to “cognitive triad”

      • Explain negative explanatory style

    • Can be treated with both medication and psychotherapy


  • 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


  • 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
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 symptoms1
Managing Hypomanic/Manic Symptoms

  • Interventions (cont’d)

    • 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
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

      • Circle what they experience in episode

      • Circle what they experience when normal

    • Homework: Provide copies for patient to add symptoms throughout the week

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

    • 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
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 system1
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
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
Compliance Contracts

  • Assessment and Goals

    • Review dosing schedules

    • Review appointment plans

    • Goals for homework assignments

  • Identify Obstacles

    • Intrapersonal

    • Treatment

    • Social system

    • Interpersonal

    • Cognitive

  • Make plan for overcoming obstacles

    • Ask about past successful strategies

    • Make a plan

    • Periodically review and modify if necessary

Example compliance contract
Example Compliance Contract

  • Step 1: Treatment Plan

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

      • 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:

      • If I continue to gain weight with lithium I may want to stop taking it.

      • The Ambien might stop working and I’ll need something stronger.

      • When I get home late I’m too tired to go to the kitchen to take my pills.

Example compliance contract1
Example Compliance Contract

  • Step 3: Plan for reducing obstacles

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

      • 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
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 life’s 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 manic1
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 manic2
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

Cbt strategies for symptom control manic3
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
CBT for Symptom Control – Manic & Depressive

  • Sleep Enhancement

    • Be consistent

    • It’s a nighttime thing

    • Keep your bed a place for sleep

    • Get comfortable

    • Gear down for the night

    • Avoid stimulants that might keep you awake

  • Don’t do:

    • Caffeine

    • Internet

    • TV and books

    • Chores

    • Exercise

Cbt strategies for symptom control depression
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

    • Patient chooses explanation that seems most likely

  • Reframe thoughts of suicide

    • Have them write down reasons to live

  • Homework: Keep Automatic Thought Records.

Cbt strategies for symptom control depression1
CBT Strategies for Symptom Control - Depression

  • Goal: Increase behavior

  • Discuss behavioral aspects of depression

    • Normalize feeling overwhelmed and overloaded

      • How have they coped with it in the past?

  • Graded Task Assignment

    • 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 depression2
CBT Strategies for Symptom Control - Depression

  • Goal: Increase behavior (cont’d)

  • 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 depression3
CBT Strategies for Symptom Control - Depression

  • Adding Positives

    • Select a healthy habit to improve

      • Ex: healthy eating

    • Start one new behavior that gets them closer to goal

      • 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

      • At least 1 hour before bedtime

      • Not in bed

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

      • 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 making1

  • 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

    • State problem as clearly as possible

  • Generation of potential solutions

    • 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 solving1

  • Implement Solution

    • 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
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 stress1
Reducing Stress

  • Stress Control and Problem Solving (cont’d)

    • 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.

Interpersonal and Social Rhythm Therapy

Initial phase
Initial Phase strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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 phase1
Initial Phase strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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
Intermediate Phase strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • Social rhythm strategies

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

      • Ex: sleep patterns

    • Encourage to work toward stabilization

    • Make goals for recovery/regulating rhythms

      • 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 phase1
Intermediate Phase strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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
Preventative Phase strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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 strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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
Efficacy of CBT strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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
Efficacy of IPSRT strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • 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 ipsrt1
Efficacy of IPSRT strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence.

  • Frank et al., 2005

    • 175 participants in acute treatment, then maintenance treatment (2 years)

      • ICM + ICM

      • ICM + IPSRT

      • IPSRT + IPSRT

      • IPSRT + ICM

      • All in addition to pharmacotherapy

    • Those in IPSRT acute phase had longer intervals to relapse during 2-year follow-up, regardless of maintenance treatment

      • Also associated with a greater change in stability of routine

    • *Treatment during acute phase has a protective effect against future episodes