CBT for Bipolar disorder.

Notes for Otago Formal Academic Programme Stage I and II.June 2017Chris Gale

Evidence for efficacy of psychological interventions for bipolar disorderis of low quality (small number of studies, inconsistency of methods andoutcome measures, weak control conditions,elevated risk of bias, limitedblinding, etc.).

All studies to date have investigated psychological interventions asadjunctive to pharmacotherapy.

To understand the literature, it is important to appreciate that there has been almost no research comparing the evidence-based ‘brands’, all have significant shared content, aims and therapeutic process; consequently, existing guidelines refer interchangeably to ‘psychotherapies’ and

specific psychotherapies (CBT, etc.). There is Level I evidence for the effectiveness of structured

psychological interventions as aset (group, individual and family-based)in preventing relapse of any kind, with one metaanalysis suggesting a40% reduction in relapse compared to standard treatment alone . There issome evidence that relapse prevention is most effective forthedepressive pole (Lauder et al., 2010).

RANZCP Guideline Mood Disorder

Dysfunctional Assumptions

Dysfunctional assumptions are unarticulatedrules by which the individual attempts tointegrate and assign value to the raw data ofexperience

These latent rules are activated whenindividuals enter situations that impinge onareas relevant to their vulnerability.

Underlying assumptions are most oftenrelated to knowledge that we ‘feel’ to be truerather than that we ‘know’ to be true

Bipolar (dysfunctional) risk factors?

In Bipolar there is a characteristic reactivity tominor positive mood increase.

High goal attainment beliefs may interact withthe illness and predispose bipolar patients tohave a more severe course of the illness.

These extreme beliefs of high goal attainmentmay lead to extreme striving behaviour andirregular daily routine, which may make thecourse of the illness more chronic anddifficult to treat.

Psychological Models Bipolar.

Three diathesis-stress models are discussedwhich have been influential in psychiatricconceptualizations of bipolar disorder:

Behavioural activation and rewardresponsiveness

Behavioural sensitization and kindling model Circadian disturbance and internal appraisal.

Behavioural Activation System andReward Responsiveness

Hypothesis is that the behavioural activation system (BAS), whichregulates the approach behaviour of the individual in response to signalsof reward or possible goal attainment, plays a central role in thedevelopment of bipolar disorder.

Thus in hypomania/mania BAS activation is reflected in elevated mood,increased goal directed behaviour, reduced need or inclination forsleep,risk taking behaviours, instability and anger/irritability.

It is proposed that dysregulation can be associated with internal biologicfactors and external socio-environmental factors.

From the model it is predicted that if dysregulation is an importantinfluence on mood then high intra-individual variability in mood andmood-related behaviour should be apparent in bipolar disorder.

Kindling ....

Kindling is described as a ‘long lasting, possibly permanent change inneural excitability’.

Electrical kindling describes the production of major motor seizures inanimals using an electrical stimulus, which is usually subthresholdin itseffects, but triggers seizure following repeated intermittent application.

It is suggested that the intermittent presentation of stressors to humansmay also exert a kindling effect with initial episodes requiring substantialstress to be triggered, but later episodes (having been kindled) beingtriggered by much lower levels of stress or insome cases becoming self-generated.

… Behavioural Sensitisation

Behavioural sensitization is the observationof increasingly rapid andsubstantialbehavioural changes in response to repeatedintermittent doses of psychomotor stimulants

Although similar to kindling in many respects,it is thought that different neurotransmitterpathways underlie the two phenomena andthat conditioning forms an importantcomponent in behavioural sensitization inanimals.

...

These models suggest that symbolic aspects of previous triggers ofaffective episodes might over time become conditioned to the point theythemselves can trigger later episodes in the absence of thesubstantivetrigger itself.

Thus, anticipated loss or stress might impact to cause an episode ratherthan actual loss or stress.

There is some evidence that mood disorder episodes are particularlyassociated with significant stress in the early course of the illness

If sensitization occurs through the course of illness it would be expectedthat this pattern should weaken over time as the ability of ‘symbolic’triggers to generate episodes becomes conditioned.

A more rapid onset of mania is observed in later episodes, which wouldbe consistent with earlier presentation of conditioned responses overtime and progressively quicker generation of motor hyperactivity inbehavioural sensitization experiments.

Circadian and social rhythm disturbance

Behavioural stressors of the type observed in learned helplessness arealso associated with circadian disruption and that suchdisruption woulditself be likely to be associated with the kinds of cognitive distortionsassociated with negative affect.

Gesynchronization of rhythms caused by substantial changes to externalenvironment might be associated with mania.

Therefore the combination of disrupted social routines and disruption ofphysiological functioning, such as sleep disruption may together inducea driven hyperactivity.

There are recent findings which indicate that the circadian disturbancesare not restricted in bipolar disorder to individuals in acute episodes.

disturbed circadian activity patterns and sleep disturbances have been reported in remitted bipolarpatients

associations between life events which are disruptive of social rhythms (stability of routine) andsubsequent onset of mania

There is evidence for sleep disturbance in children of bipolar parents Elation in mania may be a secondary effect deriving from the patient’s

normal reaction of ‘explaining’ their increased levels of psychomotoractivity and associated increases in cognitive activity.

Components in therapy?

Psycho-educational. Patients are educated about bipolar illness as a diathesis-stress illness. It isexplained that there is a prominent genetic component in bipolar disorders but that stress canlead to an episode.

Cognitive behavioural skills to cope with prodromes. Clinically, we have observed that somepatients who have a chronic course of frequent relapses find it hard to discriminate normal rangeof mood swings from an episode. The techniques of monitoring and rating mood and relatingmood fluctuations to events in their activity schedules can be a very useful way of teaching thesepatients what their normal mood fluctuations are and how events can affect these.

Importance of routine and sleep. It has been observed that chaos can lead tomore episodes. Sleepand routine appear to be very important for bipolar patients. As the circadian rhythms in humansare attuned to social events and routine, this model suggests the importance of educatingpatients to have a good social routine in order to minimize the disruption of their circadianrhythms. Patients are taught behavioural skills such as activity scheduling as a useful means ofestablishing systematic routines.

Dealing with long-term vulnerabilities. A careful assessment of triggers for past episodes canreveal the individual’s vulnerability to specific themes, such as extreme achievement-drivenbehaviour leading to stress and relapse periodically. Hence, chaotic routine and extreme drivenbehaviour suggest dysfunctional high goal attainment beliefs,which could be a challenge to usingcognitive behavioural techniques.

Insomnia in Bipolar.

Monitor sleep regularly, including time to fall asleep, time awake in the middle of the night, earlymorning awakenings, and daytime naps. Encourage compliance with a simple sleep diary (35) toset a sleep window and evaluate progress between sessions.

Monitor symptoms of depression and mania regularly. Negotiate a safety plan with patient shouldmood grow unstable during treatment. If symptoms of mania emerge after sleep restriction orstimulus control, consider modifying or temporarily suspending the techniques.

Monitor sleepiness regularly using an instrument such as the Epworth Sleepiness Scale. Whensleepiness levels reach clinical significance (a score of 10 on the Epworth scale), discouragepatients from driving or other potentially unsafe behaviors during periods of drowsiness.

Begin by suggesting that the patient adopt a regular sleep schedule across both weekdays andweekends. After 1–2 weeks of this schedule, calculate weekly sleep efficiency with the patient; ifsleep efficiency is below recommended guidelines, consider implementing sleep restriction (8).

Introduce stimulus control and explain the rationale to patient, underscoring the role ofconditioning factors in maintaining insomnia (7, 8). Monitor compliance with stimulus control,along with adverse reaction to stimulus control, in subsequent sessions.

…

Encourage the use of friends, family, and technology to aid in adherence to regularizingbedtime and rise times, sleep restriction, and stimulus control. Setting an alarm as reminderto begin a wind-down period or to wake up at the same time each morning can be helpful forimplementation. Likewise, recruiting the support of family and friends to call or visit in themorning so as to prevent oversleeping, or to respect a “no-call” period in the hour beforebedtime to promote a relaxing wind-down, can be crucial to the success of these strategies.

Encourage a system of regular rewards and positive reinforcement to facilitate behaviorchange. Establish small daily rewards, like a morning trip to the coffee shop, for complyingwith treatment recommendations. Highlight successes in sessions rather than failures. Forexample, if a patient’s weekly sleep diaries reveal that naps were taken on 4 of 7 days,underscore the 3 days on which naps were not taken, perhaps doing a functional analysis ofhow naps were avoided and pointing out positive nighttime sleep parameters (e.g., reducedsleep onset latency or nighttime wakefulness) on nap-free days.

Encourage patients to continue using sleep restriction and stimulus control after treatmenthas ended. Work with patients to review the main components of the tools and anticipatewith patients any setbacks to sleep, along with how stimulus control and sleep restrictioncan be used to prevent the re-emergence of insomnia.

J Clin Psychiatry 2010;71(1):66--72

Meta analysis effects CBT.

e BY, Jiang ZY, Li X, Cao B, Cao LP, Lin Y, Xu GY, Miao GD. Effectiveness of cognitive behavioral therapy in treating bipolar disorder: An updatedmeta-analysis with randomized controlled trials. Psychiatry Clin Neurosci. 2016Aug;70(8):351-61. doi: 10.1111/pcn.12399.

Results

Mean time to relapse. Low threshold 15.6 weeks Medium threshold 27.0 weeks High threshold 32.6 weeks

Hospitalized 10.3 (N=24) of whole sample.

No significant differences between groups.

Summary

CBT useful adjuvant. Psychoeducation. Encourage adherence. Mood monitoring and prodrome identifcation. Sleep and activity regulation. ?challenging dysfunctional belief.

Modest effect size face to face therapy Internet based CBT bipolar minimal efficacy `

References

Katherine A. Kaplan and Allison G. Harvey Behavioral Treatment of Insomnia in Bipolar Disorder American Journal ofPsychiatry 2013 170:7, 716-720

Galvez, Juan F., et al. "Staging Models in Bipolar Disorder." Focus 13.1 (2015): 19-24. Ye BY, Jiang ZY, Li X, Cao B, Cao LP, Lin Y, Xu GY, Miao GD. Effectiveness of cognitive behavioral therapy in treating

bipolar disorder: An updatedmeta-analysis with randomized controlled trials. Psychiatry Clin Neurosci. 2016 Aug;70(8):351-61. doi: 10.1111/pcn.12399.

Hidalgo-Mazzei, Diego, et al. "Internet-based psychological interventions for bipolar disorder: Review of the present andinsights into the future." Journal of affective disorders 188 (2015): 1-13.