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Bipolar Adults: Practical Interventions for Hypomanic & Depressive Episodes 
6 CEUs Bipolar Adults: Practical Interventions for Hypomanic & Depressive Episodes

Section 15
Cognitive-Behavioral Therapy:
Applications for the Management of Bipolar Disorder
Part Two

Question 15 | Answer Booklet | Table of Contents | Bipolar CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

Comorbid anxiety in BD
As reported by Angst, within the bipolar spectrum there is significant comorbidity with panic disorder, social phobia, substance abuse, somatization disorder, personality disorder and delinquency. Similarly to unipolar depression, it is important to recognize the presence of comorbid syndromes that may be significant in interfering with the recovery from bipolar illness. Indeed, findings in unipolar depression are consistently demonstrating the presence of anxiety disorders worsens outcome. Although data on the outcome of comorbid BDs:anxiety disorders are not as well established, it is quite possible that similar findings will emerge in BD. The most common clinical situation is comorbid BD with one or more of the anxiety disorders. Therefore, it is imperative to address anxiety symptoms and CBT is particularly well suited to do this because the efficacy of CBT in social phobia, panic disorder and Obsessive Compulsive Disorder (OCD) has already been established. Once the Bipolar illness stabilizes, anxiety symptoms can return to the foreground and contribute greatly to poorer functioning.

An example of a common clinical presentation in BD is difficulty in returning to work. The return to work will be worsened by the presence of a social phobia, perfectionistic traits or both. It is important to determine whether the difficulties in returning to work are related to the lack of confidence, residual depressive symptoms, nostalgia and
reliance on the hypomania for success versus the presence of a social phobia or both. Depending on these issues, CBT interventions targeting symptoms will vary. Anxiety symptoms may to some degree explain the gap between the functional and symptomatic recovery that is often observed in these individuals. Clinically, another manifestation of anxiety often observed is the ‘perfectionism’ or ‘unrelenting standards’ that these individuals display once the mood symptoms have remitted.

Moreover the nature of this illness, especially symptoms of hypomania, may have contributed to overdevelopment of the ‘premorbid’ traits of perfectionism (the person was able to fulfill perfectionistic traits because of the increased energy and creativity associated with mania). Frequently, the diagnosis of BD is perceived as a fault or defect that prevents the individual from reaching his or her goals. Indeed, in the recovery phase, individuals will often report cognitive impairment, cognitive slowing, and difficulties with memory. These symptoms will be attributed to medications, illness or both. As a rule, these symptoms are very poorly tolerated by ‘perfectionistic’ individuals and need to be addressed (not unlike in unipolar depression). It is again up to the therapist and the patient to tease out whether these cognitive symptoms are true cognitive deficits related to the illness, or medications, or both; or the perception of the individual that his or her memory and concentration were much better prior to the diagnosis of the illness. This may be a positively distorted recollection (distorted during a hypomanic state) of premorbid functioning. This is important to address to help individuals adjust expectations during the recovery phase.

Case example
This case was selected to illustrate the numerous difficulties experienced by individuals with BD beyond the acute phase of illness. This case also illustrates the common psychological processes found in patients diagnosed with BD.

Anne is a 46-year-old married mother of three teenage daughters. She was referred for a trial of CBT soon after she had separated from her husband of 17 years. It had been a complicated separation, both in terms of financial issues and emotional issues. She had moved out of the house, without her children, into a newly purchased home close by the family home. The reason for the referral for cognitive therapy was to help her deal with the impact of her illness on her life. She had been diagnosed for 25 years and had refused one hospitalization in her early 20s. She then functioned reasonably well until 5 years ago when her mood became more depressed. Eventually, she started a course of rapid cycling with brief periods of euthymia. Anne had been, for many years, a successful consultant and partner in a business. She had been unable to work for approximately 6 months prior to the referral. Upon presentation her mood was characterized by rapid cycling between depression and hypomania. At the beginning of CBT, she was admitted to hospital for a nonlethal overdose. She nonetheless continued with CBT (sessions were focused on more acute, day to day type of problems). When depressed, she would become very ‘clingy’ and ‘dependent’, socially withdrawn, lacking confidence, hopeless, and would cry frequently. She would have suicidal thoughts, and at times it was difficult to control her mood pharmacologically. She required numerous emergency visits. However, during her hypomanic episodes she would become quite energized with inflated self-esteem, hypersexuality, with a need to be in charge. This was in sharp contrast to her behavior when depressed. Her relationship with her children was complex, in part because of her difficult separation and issues with her husband, but also because of illness-related inconsistency in her ability to care for them. Her family history was positive for mood disorders. Her early life was characterized by parents with high academic standards; both her parents were high achievers and quite successful. She was treated with a combination of mood stabilizers and antianxiety agents, and she also had been off and on antidepressants. She was compliant with treatment.

Following the first assessment regarding suitability for CBT, she identified the following goals for therapy. Most of the goals for therapy were identified in the screening session prior to beginning of treatment. Goals 7 and 8 were identified later, during the maintenance phase (phase III):
1. To learn more about the illness and understand the various components of the disorder.
2. To learn strategies that would help her maintain mood stability and hopefully recognize early onset of episodes.
3. To use non-pharmacological interventions for the management of the disorder.
4. To regain confidence and be able to return to work.
5. To improve her relationship with her children.
6. To deal with her guilt about the impact of the illness on her children.
7. To understand her need for approval. She believes it underlies her emotional neediness during depression and sexual promiscuity during hypomania.
8. To discriminate which symptoms were illness related and which symptoms were ‘personality’related.

As described earlier, the CBT treatment was divided into three phases that took place over approximately a 9-month period.

Phase I
The patient participated in two educational sessions about BD. She learned about the various types of BD, the symptomatology, treatment, and hypotheses regarding the etiology of the illness.

Phase II
This was the skill-training phase. Issues regarding medication and adherence to pharmacological treatment were reviewed, including identifying some of the dysfunctional thoughts interfering with adherence to pharmacological treatment. The patient learned more about depression, its symptoms and the behavioral interventions for depression. She also learned specific cognitive restructuring interventions to challenge the negative thinking associated with depression. She was quite quick at learning these skills challenged her thinking appropriately, and found it quite helpful. An emerging issue during this phase of treatment was to address her guilt regarding her children. She then proceeded to learn more about hypomania and recognize the pattern of her hypomania, this included the following symptoms: becoming more assertive, decreased sleep, hypersexual behavior and somewhat aggressive behavior as well. She came to recognize that these symptoms were affecting her functioning more than anything else, and found that she no longer enjoyed these episodes. She learned to control her sleep with appropriate pharmacological and non-pharmacological interventions. She also learned to decrease stimulation by not exposing herself to possibly dangerous or overstimulating situations, and she became aware of her lack of judgment in choosing men during these times. It is during the first two phases of treatment that she achieved her first three goals and started dealing with goal number six.

Phase III
During this phase of treatment patients return to the goals outlined at the beginning of treatment. They also develop new goals if necessary. Patients learn to prioritize these goals and outline specific and realistic expectations for change. This is when they are given material to read about schemas to familiarize themselves with some of the core beliefs that may interfere with their recovery.  After completing the schema questionnaire Anne identified the following schemas as being maladaptive: 1) defectiveness and unlovability; 2) unrelenting standards; 3) subjugation. She understood that since her early years she had felt incompetent, not able to meet her parents’ expectations (‘pre-illness’ or ‘premorbid’ schemas). She had excelled at school and later on excelled at her job as a consultant but this never successfully compensated for a sense of defectiveness. She described herself as being able to do more than her colleagues, being faster, more creative and productive in her work. She acknowledged that she had learned to depend on the hypomania for her success. She also acknowledged that she had high standards that she could only meet during hypomania (the ‘premorbid’ coping style reinforced by the impact of mania). Once euthymic (or depressed) she felt unable to adjust her standards to a more realistic level. This had led her to make the decision that she would not return to her consulting job (inability to adjust to the illness because of the ‘pre-illness’ schema). The difficulty for the therapist was to determine whether not returning to her previous job was a true disability, or an avoidance behavior, when she realized that she could not rely on the hypomania for success in attaining her unrelenting standards. She also realized that she avoided anything related to work. Furthermore, she stated that she could not even face meeting her colleagues or deal with any paper work related to her employment. She saw herself as a failure and felt very angry. She acknowledged that she was ‘envious’ of people who could adjust their standards but she did not believe she could do this. Therefore, although Anne was euthymic and much improved she remained unable to return to her previous level of functioning.

This is an illustration of the gapbetween symptomatic and functional recovery. At this time, it was not so much the illness which prevented her from returning to her premorbid level of functioning but her early maldapative core beliefs which had been maintained and worsened all these years by the BD. Anne felt caught and understood her dilemma, but she believed (for many weeks) she could not ‘lower’ or adjust her expectations because this would confirm her incompetence. Once treated, she was faced with the belief of being defective and:or ‘disabled’. Eventually, with the help of her father, she was able to meet her colleagues and decided to sell her part of the business. She also decided to do some consulting work which would allow her to work at her own pace. This represented a major adjustment for Anne. She continued to wonder whether she made the decision because she was incompetent or whether this represented a mature, realistic adaptation to the illness.

As for her need for approval (subjugation), she explained that she felt so angry for being unable to reach professional achievements that she attempted to fill the void left by her lack of achievement with relationships with men (this had become the pattern of her hypomanic episodes and had worsened since she had stopped working). Likewise, she agreed with the hypothesis that she became ‘clingy’ and ‘emotionally needy’ during her depression, because she could not tolerate the emptiness left by the absence of hypomania (which made her too aware of her sense of defectiveness). She agreed that future goals were to find a balance between her need for achievement and emotional nurturance.

Once Anne was able to shift her beliefs about achievement and approval, she felt relieved and described ‘a big weight off her shoulders’. She continued to struggle with issues of illness versus personality implying that the decision she made (of selling her business) was not an adjustment to her illness but was because she was ‘incompetent’ and a ‘failure’. Working less also allowed her to spend more time with her children, thereby decreasing her guilt. By the end of treatment, Anne had achieved her goals. Her mood stability had increased and fluctuated less.

This brief literature review and case discussion illustrates the role of CBT in the management of patients with BD. There is no doubt that pharmacological treatment remains the primary intervention in this disorder. However, with the increased recognition of psychosocial deficits, despite aggressive pharmacological treatment, it appears that the role of psychotherapy is increasingly finding its place. Because the burden of this illness is so enormous, these individuals need help to deal with the impact of BD on their lives. The unique characteristics of CBT, described in this brief review, taken with the evidence for efficacy for CBT in unipolar depression, and preliminary outcome data in BD are encouraging, but need further testing. Difficulties in psychotherapy research for BD are significant. Non-compliance to research protocol (inherent to the relapsing nature of the illness) are common. The need to control for pharmacological treatment is complicated by the ‘cycling’ nature of this disorder, which asks clinicians/researchers to often make medication changes during the course of a study. Directions for future research include evaluation of CBT in larger trials, with a stricter patient selection (either BD I or BD II as these disorders evolve differently). At this point, it is not clear whether longer protocols (over 12 weeks) are more efficacious than briefer interventions (minimum effective dose). Optimal ways to deliver psychotherapy need to also be determined, i.e. staging and format of psychotherapy. From a clinical standpoint, it appears that individuals affected with BD experience many significant deficits and losses in all aspects of their lives. This supports longer treatment protocols that would not only address the symptoms of the illness, but address the impact this illness has on family, marriage, and work. This needs to be determined, because implications from a clinical (burden of personal suffering) and health care utilization perspective are enormous. Other areas that need to be researched include determining possible predictors of outcome and response to CBT such as the presence of maladaptive schemas (for example, perfectionism predicting poorer response in unipolar depression. Such research strategies could ultimately determine the effectiveness of CBT in BD patients who differ on a variety of illness and psychosocial variables. Such research will have an enormous impact on the development of CBT for the treatment of BD. Finally, more research is needed to replicate the findings of Reilly-Harrington et al., namely that cognitive vulnerability stress theories of depression may also apply to BD.
- Patelis-Siotis I, Bipolar Disorders, 2001 Feb; Vol. 3
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #8
The preceding section contained information about cognitive-behavioral therapy: applications for the management of bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

According to Patelis-Siotis, what is an important consideration when a BD client with a comorbid anxiety disorder reports cognitive impairment, cognitive slowing, and difficulties with memory during the recovery phase? Record the letter of the correct answer the Answer Booklet

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