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
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.
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
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.
Online Continuing Education QUESTION
What is Interpersonal and Social Rhythm Therapy? Record the letter of the
correct answer the .