Processing Effects of Cognitive and Emotional Psychotherapy on Bipolar Disorder

BP Disorder

Bipolar disorder, originally called manic depressive disorder, is a severe mood disorder that vacillates between extreme "ups" (mania, hypomania) and "downs" (depression). The effects of having bipolar disorder can be observed across the patients social and occupational functioning. Often the patient is left isolated from work, friends, and family. Medications have become the first-line treatments for bipolar disorder; however, psychotherapy can offer additional benefits in the ongoing treatment of patients with bipolar disorder. This paper discusses the symptoms and treatment of bipolar disorder focusing on cognitive behavioral therapy and emotion focused therapy.

Bipolar Disorder

Description and differentiation

According to the Diagnostic and Statistical Manual of Mental Disorders -- Fourth Edition -- Text Revision (DSM-IV-TR) one's mood is an all-encompassing and sustained feeling tone experienced internally by the person and influences the person's behavior and perception of the world. Affect is the external or outward expression of this inner state (American Psychiatric Association [APA]. 2000). Mood disorders are categorized by a loss of that internal sense of control and a sense of distress. Depressive disorder occurs in the absence of mania or hypomania. When mania or hypomania is involved the person is diagnosed with a variant of bipolar disorder or cyclothymia. A manic episode is defined as a distinctive period of an abnormally persistent and elevated, expansive, or irritable mood lasting for a week (unless the patient is hospitalized) and leads to significant impairment in social or occupational functioning (this can include psychotic episodes; APA, 2000). Hypomania is similar to mania except that the episode is often shorter (but at least four days in duration), there is no psychosis, and the episode does not lead to the same level of social and/or occupational impairment that mania does. Both hypomania and mania result in inflated levels of self-esteem, distractibility, decreased need for sleep, greatly increased mental and physical activity, and an overindulgence in pleasurable or stimulating activities. Bipolar disorder (Bipolar I) is characterized by the presence of one or more manic episodes and sometimes these are interspersed with depressive periods. Bipolar II is characterized by episodes of hypomania and depression (APA, 2000). Cyclothymia is characterized by at least two years of hypomanic symptoms that do not qualify for fit the criteria for mania and depressive symptoms that do not fit the diagnosis of major depression (APA, 2000). For purposes of this paper cyclothymia will not be considered.

Course of the disorder

Bipolar disorder most often starts with a depressive episode and is a reoccurring disorder. Most bipolar sufferers experience both mania and depression, although there are ten to twenty percent of those that are afflicted that with only mania (APA, 2000). Manic episodes typically have a rapid onset (a few hours to a few days), but can develop over longer periods (weeks). Manic episodes can last as long as three months if not treated. Ninety percent of those who experience a manic episode with have another manic episode within two years. As time goes on the period between manic episodes well shorten, but eventually will stabilize. Bipolar I patients have a poorer prognosis than those with other mood disorders and often are expected to take medication for the course of their lifetime (APA, 2000).

Demographic characteristics of those with bipolar disorder

Bipolar disorder occurs equally in men and women (whereas depression occurs more often in woman; APA, 2000). Mania occurs more often in men; when it occurs in women it is more likely to present as a mixed picture (mania and depression). Women are more likely to be rapid cyclers meaning that they are more likely to experience four or more manic episodes in a one year time frame (APA, 2000). The mean age onset for bipolar disorder is 30 years of age (but can occur as early as five or six to older than 50 years old in rare cases). The disorder is more common in divorced and single persons, people without a college degree, and there is a slightly higher prevalence of the disorder found in upper socio-economic groups. Many of these demographic factors may relate to the earlier age of onset for bipolar disorder compared to clinical depression (where the mean age of onset is 40 years of age). These factors can be important when considering the course of treatment.

Etiology

The etiology of bipolar disorder is much more speculative than that of clinical depression. Neurotransmitter dysregulation has long been suspected, but the perspective of focusing on a single neurotransmitter or neurotransmitter system has shifted to one that focuses on studying neurobehavioral systems, neuroregulatory systems, and neural circuits (Goodwin, 2007). Brain imaging techniques have revealed enlarged brain ventricles, cortical atrophy, and widened sulci indicating that these patients have experienced reduced cortical volume loss. Lesions in the subcortical brain matter in bipolar I sufferers is the most consistent finding of these studies (Goodwin, 2007). The findings from these studies suggest a possible cortical pathology is responsible for bipolar disorder. Genetic studies have also been used to support this assumption as there is a high concordance rate for bipolar disorder in monzygotic twins (Goodwin, 2007).

In light of the findings that demonstrate a possible biological etiology for bipolar disorder these findings are still complicated by the notion that many neuro-imaging studies are performed on chronic patients with a history of medication and drug usage and twin studies are complicated by a dearth of adoption studies (Miklowitz, 2008a). However, few would argue the potential for a strong biological influence and contribution on the expression of bipolar disorder compared to many other disorders such as depression and the anxiety disorders. But a strict overarching biological etiology has not been demonstrated by the research. A long-standing clinical observation is that stressful life events precede rather than follow bipolar and almost all other psychiatric disorders (Alloy et al., 2006). One theory is that traumatic stress might change the brain that alter normal brain functioning. Life events such as the death of a loved one or other stressing events increase the risk of developing depression, which precedes mania in the vast majority of bipolar sufferers (Alloy et al., 2006; Miklowitz, 2008a). There are no single personality factors that are consistently associated with the development of bipolar disorder, but stressful life events could conceivably also interact with innate factors to lead to the expression of the disorder. Therefore, in addition to medications one could hypothesize that psychotherapies that assist with cognitive restructuring and reprocessing of events could assist in the treatment of bipolar disorder (Miklowitz, 2008a).

Treatment of Bipolar Disorder

Medications

As mentioned above bipolar disorder is viewed as a chronic condition and even though there are a variety of effective treatments available the use of psychotropic medication is often the first-line treatment option. Interestingly, individuals affected with bipolar disorder will often seek out treatment according to what phase of the disorder they currently experience. For example, someone in an initial depressive stage would seek out treatment for depression which could consist of medication or psychotherapy or both. When the patient is in the manic or hypomanic phase of the disorder they often take on the attitude that they do not need medications and if they are on medication they often stop taking them. During these times referrals from family members, employers, or friends get the patient into treatment or the patient acts in such a manner to get themselves involved in the legal system and treatment referrals are made from that venue. If none of this occurs when the person reaches a depressive phase they will often return or seek out treatment (Goodwin, 2007). In any event, actively manic patients can be very difficult to treat. Bipolar patients are also notoriously prone to self-medicate with drugs or alcohol in attempt to relieve their symptoms.

Medication is almost always a part of the treatment course regime for bipolar disorder. The types of medical interventions commonly prescribed for bipolar disorder include the following (Goldberg, 2004; Goodwin, 2007):

1. Mood stabilizers. This group includes many of the older medications bipolar such as lithium, which are still reliable and are still well-tolerated by many patients. There were the first-line medication treatments for bipolar disorder at one time but now have been they have largely been replaced by the use of the atypical antipsychotics. Mood stabilizers often have side effects such as lethargy, cognitive issues, diarrhea, and others.

2. Atypical antipsychotics. These medications were designed for use with psychotic disorders such as schizophrenia but research indicates that they may provide greater symptom relief for bipolar disorder, but also have more side effects such as tremors, tardive dyskinesia, cognitive problems, sedation, and others.

3. Other medications often include the use of antidepressant medications along with an antipsychotic or mood stabilizer and even an anxiolytic medication.

There is no single approach to treating bipolar disorder with medications and psychiatrists typically have to adapt a trial-and-error approach with individual patients until the best overall combination that works with that particular patient is achieved. The use of medication for treating bipolar disorder is often divided into three broad categories:

1. In the acute treatment phase the focus is on suppressing current symptoms and continues until the patient is considered to be in remission, which occurs when their symptoms have been significantly are reduced and controlled for a significant time period.

2. Continuation treatment is designed to prevent a reoccurrence of the symptoms from the current or from the same depressive or manic episode.

3. Maintenance treatment is designed to prevent a recurrence of symptoms after the last episode has been controlled.

There have been numerous studies that have demonstrated that when treated with medications the relapse rates for bipolar disorder are substantially reduced and the overall improvement of symptoms is quite substantial (e.g., Goldberg, 2004). For these reasons medications will continue to be the first-line treatments for bipolar disorder, but this does not mean than psychotherapy cannot be used to help these patients or to assist with their treatment. For bipolar patients in psychotherapy, being on medications is often viewed as a necessary evil. This is because that many patients experience side-effects from mood stabilizers or atypical antipsychotics and yet have to continue to do the work in therapy (as well as their daily routines) in order to adjust and to move forward. Both patients and therapists need to be cognizant of the complications of medical interventions such as psychotropic drugs when judging their daily levels of functioning and progress in treatment.

Psychotherapy

There are many roles for the uses of psychotherapy in the treatment of bipolar disorder. Some of the roles for psychotherapy would be to psychoeducational, to teach skills for symptom management, to enhance functioning in social and occupational areas, and to keep patients adherent to their medication routines. Other important goals would be to help these patients learn to cope with stress triggers recognizing that certain types of life events and family tensions are potential risk factors that contribute to the expression of the disorder.

Psychoeducation

One of the most distressing issues regarding bipolar disorder is that patients have traditionally expressed their resentment regarding how little information they are given about the disorder that plagues them or the medications that they are prescribed (Goodwin, 2007). Psychoeducational sessions should consist of actual lectures about the disorder, the medications involved, the need for adherence, what to expect side-effect wise, etc. Early studies that used manual-based education programs that teach patients about the signs and symptoms of the disorder and medication management display significantly lower rates of relapses than those that only receive medication management instruction, although the relapse rates in some studies were still high attributing to the chronic nature of the disorder (e.g., Colom et al., 2005). Psychoeducation may also have an effect on the severity of manic symptoms as well. For example, Simon et al. (2005) examined psychoeducation in the context of a multi-component managed care program. The program consisted of patients treated with a case management program (pharmacotherapy, telephone-based monitoring, care planning with a team, and group psychoeducation) compared to patients receiving pharmacotherapy alone. Over a two-year follow-up period had lower mania scores on standard measures and spent less time in manic or hypomanic episodes than the pharmacotherapy group, but there was no effect on depressive symptoms. Thus, it appears that psychoeducation should be an important part of any treatment program for bipolar disorder.

Cognitive Behavioral Therapy

There has been quite a bit of research investigating the use of cognitive behavioral therapy (CBT) used in conjunction with medications for treating bipolar patients. In a review of therapy studies Goodwin (2007) reports that between the years 1960 and 1998 there were more than 30 published studies that investigated the use of combined psychological and pharmacological treatments for bipolar disorder. However, the majority of the studies were not large and had a collective mean sample size of about 25 participants. The bulk of the studies addressed group or family therapies for bipolar disorder with a small number (four) reporting on the results of individual psychotherapy for bipolar disorder. In addition, nearly 20 of these studies were open cohort designs without a control group. In spite of the methodological limitations of many of the studies reviewed the participants in a majority of the studies that received adjunctive psychotherapeutic treatments demonstrated better clinical and social outcomes than the participants undergoing standard treatments comprised of medications (most often mood stabilizers) with some outpatient support. There was also evidence of observer-rated differences between the combined and traditional treatment groups that approached statistical significance. Overall these results motivated later randomized controlled trials using more targeted interventions.

There have since been a large number of studies in several different countries. Many of the trials focus on psychoeducational models and the best researched manualized psychotherapeutic approaches: interpersonal social rhythms therapy, CBT, and family focused therapy (FFT). Some studies have concentrated on techniques drawn from these manualized therapies. Therapies are primarily used to improve awareness, adherence to medications, to instruct the patient in the recognition of prodromal symptoms, and techniques aimed at relapse prevention.

For instance, Lam et al. (2005) compared a CBT/pharmacotherapy group (14 sessions and two booster sessions) with a control (pharmacotherapy) group of bipolar patients who had been in remission for six months but were believed to be at high risk for relapse. At a year follow-up the relapse rated in the CBT group was significantly lower than the control group (44% compared to 75%). The CBT group also demonstrated higher social functioning. However, at the 18-month follow up period the two groups did not differ significantly in regards to relapse rates. As one would expect, the effects of CBT were more salient on depression than on mania. It appears the addition of psychoeducation programs oriented towards symptom management have stronger effects on mania than depression (Butler, Chapman, Forman, & Beck, 2006). Lam et al. (2005) recommended that CBT techniques need to be formulated specifically for bipolar disorder as opposed to using techniques aimed at depression. Therapeutic techniques should address the specific cognitive distortions and cognitive styles associated with mania and hypomania including grandiosity, a pressured sense of time, etc.

A large scale study by Scott et al. (2006) looked a CBT (22 sessions) plus medications vs. A medication only group in the UK recruited across five different sites. There were no differences to relapse; however, a there was a treatment by prior episodes interaction with CBT associated with longer time to relapse for those with 12 or less prior relapses. Thus, CBT may be more effective the earlier in the course of the disorder it is applied.

Miklowitz (2008b) discussed the results of studies of adjunctive therapies for bipolar disorder. Eighteen studies performed between 1984 and 2008 were included in the analysis. The effects of the treatment of different types of modalities varied depending on the clinical condition of patients at the beginning of treatment and the type of symptoms occurring at follow-up. Interpersonal therapy, family therapy, and systematic were most effective in preventing relapses when there were started following an acute episode. CBT and group psychoeducation were most effective when started during recovery of an episode. Individual psychoeducation and systematic care demonstrated greater effectiveness for manic as opposed to depressive symptoms and family therapy and CBT demonstrated the opposite pattern (greater effectiveness for depressive symptoms). Overall Miklowitz found the results to indicate that treatments placing their emphasis on early recognition of symptoms and/or adherence to medications were more effective for mania, whereas those stressing cognitive and interpersonal coping skills have better results on the depressive symptoms.

The results of meta-analytic studies investigating CBT on bipolar disorder have been mixed with some indicating no overall effects (e.g., Lynch, Laws, & McKenna, 2010) and others indicating effects similar to the aforementioned studies (e.g., Butler et al., 2006). However, based on the above discussion several mediating variables would need to be considered. Given these findings we can propose how CBT can be most effective in applying to patients with bipolar disorder.

Early in treatment it is important to provide patients with a model of bipolar disorder and a sound justification for the upcoming treatment procedures. Next the therapist should discuss or instruct the patient in the cognitive-behavioral representation of the interplay between thinking, feeling, and behavior. Patients can then be asked to supplement this information by observing their experiences, testing the CBT model, and identifying the role of their thoughts in influencing their mood. Sessions can be presented in a problem-solving design that begins with a review of the previous learning, developing an agenda for the current session, completion of that list of items focusing on the practice of concepts, and finally ending with homework to enhance skills. This particular format maintains focus on the sequential, goal-oriented, skill development approach advocated in the original CBT literature (e.g., Beck, 1995). To assist making the treatment more palatable the use of metaphors and stories can be used as well.

A good deal of research in clinical and social psychology suggests that compliance with requests is improved when the person's agreement to comply is perceived as their own choice or in line with their opinion (e.g., see Cialdini, 1993). When we take this vast body of research into account we can understand that psychiatrists and therapists might be of more assistance to patients if instead of telling them why medications and other forms of interventions for their disorders are necessary they could get the patient to explain why such ongoing treatment may be of assistance to them. CBT therapists should become adept at this skill. Some utilize a life-history or disorder history graph as a strategy for getting the patient to visualize the impact of their bipolar episodes on their personal lives, goals, and relationships. A life-history timetable or graph requires the patient to construct a timeline of their disorder demonstrating their manic, depressive, and/or hypomanic, episodes and the contexts in their lives surrounding these occurrences. Once this timeline is constructed the information can be used as evidence to help the patient to decide whether the current treatment or an alternative treatment is the soundest strategy to follow. Moreover, the therapist can use the timeline as a clinical tool to help the patient identify triggers, stressors, and other incidents that are associated with the manifestation of their symptoms.

The earlier treatment is attempted in the course of the disorder, the more effective we would expect CBT to be for bipolar disorder. Next, CBT should include aspects of psychoeducation symptom recognition, medication adherence, examining the patient's views concerning their symptoms, and offering counter strategies to assist them deal with their disorder. We can outline five major goals for CBT in the treatment of bipolar disorder based on the aforementioned studies:

1. Treatment adherence. The main goal of CBT for bipolar disorder would be to ensure that the patient remains in their specified treatment plan which most often would include adherence with their pharmacotherapy regime and would also include any other additional forms of treatment. Given the overall high rates of relapse the focus on compliance with the set treatment program presumes that even given the best possible circumstances most patients will find it extremely difficult or will not be able to comply with treatment in light of the fact that treatment is a lifelong commitment. CBT treatment should approach this goal by collaborating with the patient to identify factors that can interfere with compliance to the treatment regime and develop strategies to deal with them. If the patient is not ready to accept their illness, follow through with the treatment, and adhere to their restrictions then CBT cannot help them.

2. Early detection of symptoms that trigger a relapse and a plan for intervention. One of the goals of the CBT treatment would be to alter the long-term course of bipolar disorder in the patient. Every time a patient has a period of depression or mania it can be viewed as an opportunity to learn more about and understand the precipitating factors that signal a recurrence for a the patient. This also allows one develop a plan to deal with future situations. This would entail initial treatment and booster sessions as needed. During such booster sessions following a potential or actual relapse the therapist should determine if the situation was resolved and how much time will be required for discussion of the issue.

3. Lifestyle management. One of the problems with medical treatments for psychiatric disorders is that medication use often leads people with these problems to become passive recipients of medical care opposed to being active participants in their care. By outlining a program of lifestyle management with the patient that includes stress management techniques (and giving the patient freedom to contribute) CBT can assist bipolar patients to become active in the management of their disorder. Some patients with long-standing bipolar disorder will need assistance to develop such skills. Moreover, such a program would allow for the inclusion of family members. Involvement of family in the therapy can be very constructive. It allows the family members a chance to meet with the therapist, learn about the treatment, demystifies the whole process for them, and it encourages family to facilitate in their care.

4. Treating comorbid conditions. Thirty to fifty percent of bipolar patients will also meet the diagnostic criteria for substance abuse, a personality disorder, or other psychiatric condition (APA, 2000). Having a comorbid psychiatric condition is a predictor of poorer responsiveness to medication in bipolar disorder. Many of these comorbid conditions may precede the bipolar diagnosis (Judd et al., 2002). It becomes very important to make assessment an ongoing process in the maintenance of a chronic condition such as bipolar disorder to identify co-occurring complications (especially substance abuse, impulse control issues, and personality disorders). If any such conditions are suspected or uncovered (or are already present) these need to be dealt with in the context of the ongoing treatment. Comorbid conditions will most likely complicate the treatment of bipolar disorder on many levels. It is extremely important for the therapist to adhere to empirically supported methods of intervention in all cases, but in the situation where a patient has bipolar disorder and a comorbid or several comorbid psychiatric diagnoses it becomes crucial to adhere to interventions and strategies with a sound empirical basis.

5. Treatment of depression. In addition to assisting the patient in managing signs and triggers leading to mania CBT can directly confront depressive symptoms via the use of standardized CBT techniques for the treatment of depression. CBT is an empirically validated treatment for depression and studies of CBT use with bipolar patients indicate that it is effective in treating the depressive symptoms associated with bipolar disorder.

By using these guidelines the application of CBT techniques can prove to be a valuable adjunctive treatment to standard pharmacological interventions and other treatments for bipolar disorder.

Family Focused Therapy (FFT)

Emotion-Focused Therapy (EFT) is an empirically supported psychotherapy that has its roots in humanistic psychology, the study of emotions, and attachment theory (Palmer-Olsen, Gold, & Woolley, 2011). EFT views human emotions as crucial to one's experience of self in adaptive and maladaptive situations. Emotional functioning is also seen as the vehicle for therapeutic change via awareness, emotional regulation, and reflection in the context of an empathetically regulated therapeutic relationship.

Family focused therapy is a type of EFT that attempts to affect change by focusing on the relationships within families. Family conflicts may be related to increased cycling in bipolar disorder (Miklowitz & Goldstein, 1997). One way to measure family stress is to measure the level of expressed emotion (EE). EE has been dived into three components (Vaughn & Leff, 1976): critical comments, hostility or personalized criticism, and emotional over involvement or the tendency to be over concerned or overprotective. EE has been demonstrated to be predictive of relapses in schizophrenia (Vaughn & Leff, 1976). It appears that high EE relatives of bipolar patients are more likely to attribute the symptoms of the disorder as under the patient's control, are more negative in problem-solving situations, and engage in arguments behaviors than low EE relatives (Miklowitz & Goldstein, 1997). Arguments are often instigated by the patient, but high EE relatives are more likely to argue back as opposed to avoiding a volatile situation. Miklowitz and Goldstein (1997) developed FFT to deal with these family conflicts. FFT uses family assessments, psychoeducation, mood charts, problem solving skills, and communication enhancement training.

FFT as applied to bipolar disorder has six main objectives that are based on three principal assumptions (Miklowitz & Goldstein, 1997):

1. A bipolar episode represents a family life cycle crises that is not normative.

2. These bipolar episodes (manic or depressive episodes) bring significant disorganization within the family system.

3. Reintegration of the family can occur only with use of new coping strategies that change old ways of interacting.

The six objectives sound much like the objectives in CBT and consist of:

1. Experience integration. Here the goal is to integrate the experiences that are associated with the mood episodes in bipolar disorder.

2. Disease acceptance. It is very important for the patient and the family to accept the probability and vulnerability of the patient to re-experiencing future episodes of bipolar disorder. This does not mean that the patient or family must assume a defeatist attitude, but the goal is to accept the chronic nature of the disorder.

3. Medication compliance. It is very important for the family and the patient to fully accept the fact that they will need to continue taking medication for the stabilization of their mood. The notion that one day they will not need the medication is a potential pitfall that could lead to a serious relapse.

4. Symptom recognition. As mentioned above it is surprising how many people with long-term bipolar disorder are unaware of their symptoms, especially those symptoms that precipitate a relapse. It is extremely important for the family and the patient to be able to distinguish between the individual's normal personality and the symptoms of their bipolar disorder.

5. Stress reduction. Related to number four on this list, stress appears to be a significant contributing factor to relapse in bipolar disorder. Patients and their family need to be able to learn to recognize stressful life events that can help trigger a relapse of their bipolar symptoms as well as learning how to cope with stressful events that can make them vulnerable to relapse.