Bipolar affective disorders

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medication, both during an acute episode and prophylactically, to prevent or moderate the frequency and severity of subsequent episodes (Scott 1995). However, the onset and course of BP have increasingly been linked both to external stressors and to cognitive and physiological vulnerabilities. Consistent with this is evidence that cognitive behavioural therapy in conjunction with medication may be effective in treating this client group (Lam and Wong 1997; Scott 2001).

It is widely acknowledged that stressful life events play a significant role in

BP patients (for a review see Johnson and Roberts 1995) and that negative family interactions and attitudes predict relapse rates (Miklowitz et al. 1988). These findings have given rise to a number of biosocial models of BP which examine both inherited (and physiological) vulnerability and external stressors: so-called vulnerability–stress models. For example, people are thought to vary in their sensitivity to the effects of life stress on circadian rhythms (e.g. changes in sleep–wake cycle), and also in their ability to recover physiologically from life stress and return to a stable baseline. It has also been noted that BP patients exhibit relatively poor problem-solving skills (Scott et al. 2000), and may therefore experience greater difficulty in dealing emotionally and practically with life stress. This sensitivity to life events is thought to vary during the course of BP, with earlier episodes being more stress-related than later episodes.

Despite this knowledge about BP, it is not clear when and why life events and the subsequent disruption to circadian rhythms result in manic episodes and when they lead to depressive episodes, or indeed why a manic episode might become a depressive one. Beck (1967) suggests mania is a mirror image of depression. In contrast to the negative cognitive triad of depression (see Chapter 10, p. 206) there is a positive cognitive triad consisting of positive cognitive distortions concerning the self, the world, and the future. The self is viewed as lovable, powerful, and in control; the world has many possibilities, and experiences are viewed as being overly positive; and the future is one of unlimited opportunities. During mania, positive experiences are attended to, which in turn strengthens and maintains underlying beliefs and assumptions, influencing cognition, emotion, and behaviour. This framework is useful in clinical assessment and formulation, particularly in explaining how depressive or mania cycles are fuelled by the patient’s thoughts about symptoms.

Studies have shown that people with BP have enduring beliefs regarding dependency, autonomy, and high goal attainment that are similar to those of unipolar depressed patients (Rosenfarb et al. 1998; Lam et al., in press); their beliefs concerning perfectionism and need for approval are also greater than

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those of healthy controls (Scott et al. 2000). However, unlike unipolar depressed patients, beliefs about goal attainment are still apparent during remission from BP (Lam et al., in press). Patients with BP also experience changes in self-esteem that seem to be mood-related (see reviews by Goodwin and Jamison 1990; Hayward et al. 2002).

Different cognitions are active in the manic and depressive cycles. During mania, positive interpretations of symptoms serve to exacerbate intense excitement (‘I am amazing, I can do everything’) and engagement in numerous activities (e.g. taking on more work, throwing all-night parties, etc.), which further disrupt sleep and eating. During depression, negative interpretations such as ‘If I am not achieving people will consider me a failure’ can lead to less engagement and withdrawal (e.g. not seeing friends) and sleep/appetite disturbance. Core beliefs (‘I am special’) and dysfunctional assumptions (‘I need to let people see I am doing well’) are active in maintaining both of these cycles: confirmed assumptions give rise to thoughts that fuel mania (e.g. ‘I am doing well’ and ‘People can see I’m doing really well’), whereas disconfirmed or unmet assumptions promote thoughts and behaviour that maintain depressive cycles (e.g. ‘I have failed—I mustn’t let people see me’). These dysfunctional beliefs and assumptions may also be evident to a lesser extent during remission, when cognitive therapy usually takes place.

With respect to therapeutic interventions, the cognitive model (incorporating biological vulnerability factors) acknowledges a role for medication as well as a role for stress management, by promoting active coping. In particular, patients can learn effective ways to regulate their sleep, eating, and other patterns of activity, thereby compensating for their hypothesized inherited predisposition. Both medication and behavioural interventions (such as activity scheduling) can be employed during the early stages to prevent relapse into mania or depression. Cognitive therapy can also address:

Unhelpful thoughts about symptoms that maintain the depressive and mania cycles

Beliefs and assumptions associated with BP

Beliefs about diagnosis, prognosis, medication, and stigma

As with cognitive therapy for depression, therapists initially work with thoughts about symptoms and go on to work with assumptions and beliefs. The remainder of this chapter will focus on cognitions specific to mania or to a diagnosis of BP. See Chapter 10 for an account of depressive cognitions and associated behavioural experiments.

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relationships, and stigmatization (see Hayward and Bright 1997). BP patients may overgeneralize their personal responsibility for their disorder (e.g. ‘It’s my fault I am ill’), and selectively attend to the good aspects of manic episodes whilst overlooking the risks (e.g. ‘I can catch up with things when I go high’). Moreover, they may underestimate the likely efficacy of medication or the effect of non-compliance (e.g. ‘Why should I take medication when I am well?’) or catastrophize other people’s reactions to them (e.g. ‘No one will want to know me’).

Behavioural experiments

Typical thoughts associated with symptoms of mania

Experiment 11.1: testing the ability to control impulsiveness Experiment 11.2: engaging in pleasant activities without risky behaviour

Table 11.1: other experiments to test thoughts associated with symptoms of mania

Typical beliefs and assumptions associated with bipolar disorder

Experiment 11.3: need for achievement—a survey experiment Experiment 11.4: need for autonomy—a discovery experiment

Table 11.2: other experiments to test typical underlying beliefs and assumptions associated with bipolar disorder

Beliefs about illness, stigma, prognosis, and medication

Experiment 11.5: challenging a sense of hopelessness about prognosis and the future

Experiment 11.6: discovering the extent of stigmatization surrounding BP—a survey experiment

Table 11.3: other experiments to test beliefs about illness, stigma, prognosis, and medication

Typical thoughts associated with symptoms of mania

Experiment 11.1: testing the ability to control impulsiveness

Problem One of David’s early warning signs of mania was spending money on goods he didn’t need. Over a period of a few days he could spend thousands of pounds of money he did not have. During one of his spending sprees he bought a sports car, a house, and booked several expensive holidays. This placed

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pleasurable activities, which had the potential for serious consequences: in particular she would become sexually disinhibited. When she was in this state she found it difficult to hold conversations, her thoughts would race, her speech would speed up, and she became highly distracted, jumping from one thing to another.

Target belief ‘In order to have a good time I have to draw attention to myself.’

Alternative belief ‘I can have a good time without acting on my urges to attract attention to myself.’

Prediction ‘If I go to the party and I don’t do something unusual (e.g. undressing) nobody will notice me. I will not have a good time.’

Details of experiment Jane and her therapist agreed in advance how long she would stay at the party and how much alcohol she would drink (as both these influenced her need to party all night). Once at the party she would sit, rather than stand or dance, and engage in a conversation with the person she was sitting with. If she noticed she was speaking more rapidly, then she would do more listening than talking. She would sit on her hands if she started gesturing with them. Jane decided to assess how good the party had been by comparing it to other parties where she had drawn attention to herself.

Results of experiment Jane was able to sit until it was time to leave the party at the agreed time. She spoke to several people during the night, without doing things she would later regret, such as undressing.

Patient reflection She felt less ‘speedy’, was able to join in conversations, and felt people showed a genuine interest in the real Jane. She did enjoy the party as much as other parties she had been to.

Follow-up experiments Jane continued to practise this approach in other social situations, which provided her with more evidence that she could have a good time without painful consequences.

Tips Most bipolar patients enjoy their early stages of mania and find it difficult to rate their mood. It is helpful to introduce mood monitoring as early as possible in therapy. Patients are then more able to establish at what point on a10 / 10 mood monitoring scale it is desirable for them to implement appropriate strategies to avoid serious consequences.

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Typical beliefs and assumptions associated with biopolar disorder

Experiment 11.3: need for achievement— a survey experiment

Problem Gerald had worked as a highly regarded scientist prior to having episodes of depression and mania. His BP diagnosis, plus physical health problems, had led him to leave this profession. He had not had a paid job since his first hospital admission. Throughout the course of therapy he was pursuing a career as a novelist.

Target belief ‘I haven’t achieved anything worthwhile since my first admission. People will judge me negatively for this.’

Alternative belief ‘People do not judge others simply upon the number of papers they publish. Others may think I have achieved other worthy things in the past three years.’

Prediction In a personal life review and a survey of those who know me well, everyone will disregard the worth of anything except the academic work I did prior to my hospital admission.

Details of experiment First, Gerald and the therapist listed everything that Gerald had achieved in the last three years. The therapist used Socratic questioning and observed Gerald’s style of disregarding his achievements. Gerald and the therapist then drew up some questions that he would ask his wife, brother, and some close friends. These were to be general at first (e.g. ‘What do you think are my greatest achievements in life?’), then more specific (‘Do you think I’ve achieved anything else?’), and finally, specific to the last three years (‘Do you think I’ve achieved anything in the last three years?’)

Results of experiment Friends and family all felt that his achievements not only included his scientific work but also: becoming a father, changing career, and coping with his diagnosis.

Patient reflection Gerald reflected that, despite the experiment, he still felt inclined to disregard these things as achievements. However, he acknowledged that not everyone would judge him purely upon the amount of papers he had published and that it was not helpful for him to continue to do this himself.

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Tips This experiment was followed up with positive data logging to reinforce the change in beliefs about self and others (see Chapter 20 on selfesteem).

Experiment 11.4: need for autonomy— a discovery experiment

Problem Since recovering from a manic phase in hospital, Ingrid felt that she had not resumed any of the household responsibilities. This made her feel useless and dependent upon other family members.

Target belief ‘I am totally dependent upon other family members.’

Alternative belief ‘Everyone in the household helps out. The extent of each person’s tasks varies according to different individuals’ needs at different times.’

Prediction ‘I will discover that other family members will consistently carry out all of the household tasks.’

Operationalize prediction If this prediction is accurate, other family members will consistently carry out all of the household tasks. If the alternative belief is true, there will be variation in who does household tasks from day to day or week to week, and I will do my share.

Details of experiment Each family member kept a log of what they did for a week, in the first instance. The logs were brought into the therapy session and the tasks were tallied.

Results of experiment Ingrid was doing the highest percentage of household tasks.

Patient reflection Ingrid reflected that previously she had taken responsibility for all of the household tasks. She was comparing herself to this standard.

Therapist reflection Before this experiment, Ingrid was so convinced that she was not ‘pulling her weight’ that the experiment was set up with a view to helping her resume some of her share of tasks. In the event, this was not necessary.

Follow-up experiments Ingrid wanted to regain more control over household tasks (as she felt this was her role, whereas her husband was the breadwinner) and gradually increased her tasks to a level that felt manageable and not too stressful.

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Beliefs about illness, stigma, prognosis, and medication

Experiment 11.5: challenging a sense of hopelessness about prognosis and the future

Problem William had a recent diagnosis of BP, which had delayed his career by a year. He had never had the intimate relationship that he desired. Although he was in remission over the course of therapy, there were subclinical fluctuations of depression, marked by thoughts that he had no chance of achieving the things he had hoped for in the future.

Target belief ‘My life is blighted. People with a mental health problem never get the things they strive for (i.e. job, partner, family).’

Alternative belief ‘Many people with a diagnosis of bipolar disorder have jobs, partners, and families. Many also go on to achieve worthwhile things. It is possible that I will too.’

Prediction ‘If I am right, everyone with BP will be unemployed, single, and childless. If the alternative is true there will be the usual variations found in the population.’

Details of experiment Patient and therapist researched and surveyed people with BP as to whether they had careers, partners, and families. The therapist was able to provide some statistics, and the patient found some via the internet and self-help groups.

Results of experiment Both William and the therapist found the normal spread of careers, relationships, and families within a population of people with BP. They also discovered many high-profile people who had a BP diagnosis (e.g. Spike Milligan).

Patient reflection William felt less globally negative about his future.

Follow-up experiments This experiment was followed up with problemsolving strategies to direct his career path, and strategies for meeting more people so as to increase his chances of developing a relationship.

Tips Loneliness is a common feature in people with BP. We have found that cognitive therapy groups and self-help groups can be useful in initially reducing a sense of isolation.

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BP, with periods of mania, depression, and subclinical mood fluctuations. This can affect patients, therapists, and the course of cognitive therapy. Furthermore, the different beliefs that are salient in episodes of hypomania, depression, and euthymia significantly contribute to the way that cognitive therapy can be applied, and the way that behavioural experiments are introduced and utilized. Finally, BP is an enduring disorder and therapists may need to guard against contamination by the sense of hopelessness. All of these difficulties emphasize the importance of a sound therapeutic relationship (Lam et al. 1999). Inexperienced therapists are encouraged to seek good supervision.

Changing presentation

Patients cannot readily engage with cognitive therapy, or any psychotherapy, when they are manic. Furthermore, patients recovering from mania have poor awareness of the benefits of therapy (Dell’Osso et al. 2002). Most cognitive therapy is therefore started during remission, when patients are more clinically stable (Lam et al. 1999; Scott 2002). However, clinically stable BP patients still display mood swings and subclinical fluctuations that are not necessarily the early signs of relapse (Molnar et al. 1988). Some patients react with alarm if they believe that they are getting depressed or, less commonly, that they are getting high (Lam et al. 1999). When this occurs, the patient (and sometimes the therapist) may be unwilling to engage in behavioural experiments that are perceived as risking emotional stability. Careful monitoring of mood and early warning signs can inform when, and at what pace, it is appropriate to proceed with behavioural experiments.

With patients recovering from a depressed mood, it is easy to get caught up in their relief at the improvement in their mood. There is a risk of encouraging patients to resume too many tasks too quickly, or to undertake behavioural experiments too quickly, thereby adding to their stress and tipping them into hypomania. This can be avoided by close monitoring of mood, the use of detailed relapse prevention strategies, such as being aware of the early warning signs and triggers to a potential episode of mania or hypomania, together with an action plan which may include self-monitoring, self-management, and selfmedication. Some patients may welcome the early stages of mania. Inexperienced therapists may feel uncomfortable with helping patients to reduce pleasure seeking and dealing with patients’ resistance to this. The typical cognitive therapist’s role of building up pleasurable activities is replaced by encouraging patients to find alternative (less thrilling) activities in both the short and long term.

Patients becoming high might make over-optimistic assessments of their progress, and opt for early discharge (Scott 2002). The use of coping strategies

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to modify excessive behaviours significantly reduces the rate of manic relapse (Lam et al. 2001), so therapists need to offer prompt help to patients to apply mood-reducing strategies, such as taking additional medication. The changing presentation of BP necessitates therapist flexibility, as it is not always possible to follow a fixed format for this client group (Scott 2002).

Attitudes and beliefs

Common beliefs about social desirability, perfectionism, autonomy, and goal attainment may affect the way patients engage with cognitive therapy. Therapists may therefore need to take longer to engage these patients than those with unipolar depression (Scott et al. 2001) and take longer in preparing for appropriate behavioural experiments. Therapists need to be alert to the tendency of some patients to be ‘good’ patients and strive for the ‘perfect’ cure as an indicator of a broader belief system. Other patients’ beliefs regarding the need to be independent and autonomous may explain why some BP patients have difficulty in acknowledging their negative feelings (Winters and Neale 1985); whilst others may wish to avoid discussing either their manic or depressive episodes (Scott et al. 2001).

By using behavioural experiments, therapists can encourage patients to try out behaviours that challenge the need to please, the need to get things right, the need to achieve, and the need to be independent. These beliefs can have positive as well as negative consequences, so Socratic questioning is used to explore their utility rather than directly refute them. Behavioural experiments are then used to test out alternative, more helpful beliefs. To change longstanding beliefs it may be necessary to carry out a series of behavioural experiments over an extended period.

Enduring disorder

BP is an enduring disorder which can often affect patients for the rest of their lives (Goodwin and Jamison 1990). Therapists need to acknowledge to patients that cognitive therapy does not necessarily aim for cure, but for acceptance, relapse prevention, and psychosocial improvement. It may not be appropriate to challenge distressing thoughts such as ‘I need to take medication for the rest of my life’ or ‘I will have to tell my future employers that I’ve been seriously ill’, since such thoughts may be justified. Also, some manic episodes may have resulted in tragic consequences, including accidents, financial losses, or family breakdown. Therapists can, with sensitivity, help patients appraise their life circumstances realistically, to modify catastrophic or dichotomous thinking such as ‘I’m a failure because I have BP’ or ‘I’m only worth knowing when I’m high; when I’m low I’m worthless’.

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Because of these difficulties, it is important to involve significant others, providing that this is acceptable to the patient. For example, relatives may be able to give information about early warning signs, help with reality testing, provide on-going support for patients coming to terms with their diagnosis, and help conduct behavioural experiments. For some patients, fear of talking to family members about their illness might itself be the subject of a behavioural experiment (for a case example, see Scott 2002). It is also important to help them communicate with other professionals involved in their care.

Related areas

The reader is specifically referred to Chapter 10 on depression for behavioural experiments on this aspect of BP. However, care needs to be taken before applying these strategies with patients with BP, because of the possibility of triggering a manic episode. The reader may also find useful experiments in Chapter 14 on insomnia and Chapter 20 low self-esteem. The following chapter on psychosis has useful experiments to deal with delusional beliefs, in addition to experiments regarding its enduring nature.

Further reading

Basco, M. and Rush, A. (1996). Cognitive behavioral therapy for bipolar disorder. Guilford Press, New York.

Lam, D., Jones, S., Bright, J., and Hayward, P. (1999). Cognitive therapy for bipolar disorder: a therapist’s guide to concepts, methods and practice. Wiley, Chichester.

Scott, J. (2001). Overcoming mood swings: a self-help guide using cognitive behavioural techniques. Robinson, London.

Tales from the Front Line

Singing in the rain

A couple with sexual difficulties, who appeared to behave in a rather cold manner towards each other, was working on improving communication. He was a closet rubber fetishist, and she had said that she no longer found him attractive. However, their demeanour totally changed between two sessions. They had become open and affectionate. In the subsequent session they worked hard with the therapist to try to work out what had made the difference, and how to put the improvement onto a solid foundation. They could find no answers. They put their coats on and left. The therapist watched two rubberised macs, and two pairs of rubber boots disappear into the rain.

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