By Robert Reiser, Ph.D., Fellow & Larry W. Thompson, Ph.D., Founding Fellow, ACT
What is Bipolar Disorder?
Bipolar disorder, also known as Manic Depressive Illness, is a treatable disorder characterized by severe mood swings from intense, manic ‘highs,’ to depressive ‘lows.’ Those who suffer from bipolar disorder fluctuate between these two extremes in an ongoing cycle, and have an impaired ability to function in their personal and professional lives. Bipolar disorder can have a devastating impact on an individual’s relationships, job performance, and overall well-being. Untreated individuals with bipolar disorder are at a significantly higher risk of suicide and attempted suicide. Fortunately, bipolar disorder can be treated through a combination of medication and psychological interventions.
What are the symptoms of Bipolar Disorder?
Individuals with bipolar disorder typically experience extreme fluctuations in mood ranging from severe mania to severe depression. Some individuals experience a more mild form of mania, called ‘hypomania.’ The symptoms of both a manic episode and a depressive episode are described below.
Symptoms of a Manic Episode:
- Increased energy and activity
- 'High,’ euphoric mood
- Extreme irritability
- An inflated sense of self-esteem
- A reduced need for sleep
- A high degree of talkativeness
- Racing thoughts
- Taking on multiple projects at once
More severe Manic Episodes may also include:
- Loss of normal sense of judgment
- Unusual or risky behavior, such as abuse of drugs or alcohol, sexual permissiveness, spending sprees, or other sustained period of behavior that is different from usual
- Disorganized thought processes
Symptoms of a Depressive Episode:
- Depressed mood
- Loss of interest or pleasure
- Significant weight loss, or a decrease or increase in appetite
- Sleeping too much or too little
- Being agitated or slowed down
- Feeling fatigued
- Feeling worthless
- Excessive or inappropriate guilt
- Diminished ability to think or concentrate
- Suicidal thoughts or plans
How is Bipolar Disorder diagnosed?
The most severe form of the disorder, Bipolar I Disorder, is characterized by one or more manic episodes of sufficient severity to cause marked impairment in social and occupational functioning. Some individuals with Bipolar I Disorder experience a ‘mixed’ episode, which includes both manic and depressive symptoms simultaneously. Severe manic or mixed episodes often result in psychiatric hospitalization.
Bipolar II Disorder is characterized by one or more major depressive episodes with at least one mild to moderate manic episode in which the patient’s functioning is not compromised severely enough to cause marked impairment in social or occupational functioning. Although Bipolar II Disorder does not by definition involve an episode of severe mania, it has a high risk of suicide and is often associated with a severe depressive course just as devastating as that experienced in Bipolar I disorder.
If you believe that you or someone you know may be suffering from bipolar disorder or another mental illness, please visit a mental health professional to ensure appropriate diagnosis and treatment.
How common is Bipolar Disorder?
Millions of people, approximately 1% of adults worldwide, have bipolar disorder. Bipolar disorder can also develop in children and adolescents, and is more common among children whose parents have the disorder. Initial studies indicate that heredity plays a role in the development of bipolar disorder, although researchers believe that other environmental factors contribute to causing the illness as well.
Do I need psychological treatment?
Not everyone with Bipolar Disorder requires psychological treatment. If you have difficulty remaining stable and continue to have episodes of depression or mania despite being on medication, you may want to consider receiving cognitive behavioral therapy, which is a form of psychotherapy, or “talk” therapy. Psychotherapy may be necessary especially if you are having suicidal thoughts, are feeling severely hopeless and depressed, or if manic episodes have caused significant problems for you.
In an excellent self-help book, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, Dr. David Miklowitz explains that psychotherapy can help an individual to:
- Improve medication compliance
- Assist in identifying stress-related triggers
- Develop self-management skills and coping strategies
- Help maintain stable “social rhythms” and lifestyle
- Address the long-term impact of the illness on family members, spouses and friends
- Help “make sense” of the illness
- Discuss planning and strategies to keep stable, given vulnerability to future episodes
Help acceptance of a long-term medication regimen
[Adapted in part from Miklowitz (2002), Table pg. 122]
What will Cognitive Behavioral Therapy treatment for Bipolar Disorder be like?
Cognitive behavioral therapy is a form of psychotherapy that teaches people specific cognitive and behavioral skills to help them control and even prevent serious mood swings. Cognitive behavioral therapy involves a structured, systematic approach in which clients are taught specific skills and strategies to address overly positive or negative moods that may escalate into episodes of depression or mania. For example, clients in a manic state typically underestimate the risks and negative consequences of their actions. The therapist works collaboratively to help the client challenge overly positive thoughts like “Everything will turn out fine,” “I feel lucky,” and “I can’t go wrong,” and evaluate possible negative outcomes of the client’s unrealistic thinking patterns. The therapist will also work with the client to reduce impulsive behaviors that have a high risk of harmful consequences. The therapist will help the client to recognize and address environmental stressors such as major life changes, relationship problems, over-stimulation and high-conflict situations that may exacerbate mood swings. Cognitive behavioral therapy strategies may require a great deal of practice, individualized attention and encouragement. However, once clients learn that they can manage mood swings more effectively, their self-esteem and confidence typically improves, and they are more likely to apply their newly learned skills in the future.
Many people use these cognitive skills on a daily basis to cope with the stresses and strains of daily living, but they are often applied so naturally and easily that we may not be aware that we have used them. These mood management skills or techniques can be taught effectively even to clients who have had very serious histories of hospitalization and long-term bipolar illness.
What does research say about Cognitive Behavioral Therapy for Bipolar Disorder?
A number of new approaches to the treatment of bipolar disorder have been developed in the past few years that are designed to supplement standard pharmacotherapy or medication management. The good news is that several of these approaches appear to be quite promising in terms of their ability to reduce the risk of future relapses, and they show potential for prevention and early intervention. According to the National Institute of Mental Health (NIMH):
“For people suffering from a mood disorder, the outlook has never been better. Effective therapies, both pharmacological and behavioral, can help them recover from potentially devastating episodes of depression or mania and prevent possible relapses.”
(Breaking Ground, Breaking Through, The Strategic Plan for Mood Disorders Research of the National Institute of Mental Health (NIMH, 2003), Page 75.)
Research has indicated that only certain psychotherapies, including cognitive behavioral therapy, are particularly helpful and effective in reducing the severity of mood swings and future episodes. In numerous research studies, cognitive behavioral therapy has been demonstrated to be effective for the treatment of bipolar disorder in combination with medication (Chambless, et al. 2001).
What about medication?
Bipolar disorder is a serious illness, typically treated with medication for long-term management of the illness. ‘Mood stabilizers’ are usually prescribed and additional medications may be necessary to control manic or depressive episodes that occur in spite of mood stabilizers or psychotherapy treatment. A careful assessment of the patient is necessary before prescribing medication - especially during depressions - because people with bipolar disorder experience significant periods of both depression and mania, and taking anti-depressant medication may actually induce a manic episode. In addition, many individuals who are bipolar have a history of substance use that makes the diagnosis more difficult to make.
What else should I know about Bipolar Disorder?
Here are some cognitive behavioral therapy strategies that have been found to be helpful in reducing the likelihood of serious mood swings:
1. Learn how to detect subtle changes in your mood, and pay attention to them on a daily basis.
Mood changes almost always occur as a result of specific events in your life, or thoughts that you are having. Being able to identify the connection between moods, events and thoughts is the first step to getting better. Being effective in controlling your mood is somewhat like using a road map to get to your destination. Unless you know your current location on the road map, it will not help you reach your destination. By carefully monitoring and identifying changes in your mood, you will know where you are on your emotional map and this can be the beginning of getting to your destination – mood stability.
2. Learn how to monitor your thoughts carefully.
People who have severe mood swings may tend to have automatic negative or positive thoughts that do not reflect an accurate, adaptive or realistic appraisal of a given situation. For example: John goes to a social gathering of a club he has just joined. No one talks to him, and he begins to feel anxious and a little sad, and soon he is feeling depressed, hopeless and wants to leave the situation. He thinks, “I am being ignored.” “It’s because I don’t know how to talk to people.” “This is why I never have friends.” “I’m totally ineffective.” “No one here likes me. I’m a wallflower.”
John’s negative thoughts may have been distorted and unfounded. His negative thoughts contributed to his negative mood, which in turn made his negative thinking even worse, so that he eventually labeled himself a “wallflower.” These types of negative thoughts may be habitual or automatic for John, and he accepted them as true and accurate with little or no questioning. Had he been more aware of this thought process, he might have questioned some of his negative thoughts. He might have asked himself, “Wait a minute! Where’s the evidence for these thoughts? Maybe they’re not ignoring me. They just don’t know me yet. People who know me don’t ignore me. I do have friends.” Thinking about situations in a different way tends to interrupt negative thinking, sets the stage for a more positive approach to coping with the situation and leads to an improvement in mood.
3. Learn to identify early warning signs.
The best time to address negative or overly positive changes in mood is before your mood shift gains momentum. Often people don’t pay attention to the early changes that could alert them to the upcoming episode. They may begin to notice that there is a problem only after their functioning becomes impaired, and at that point it is more difficult to get control over their thoughts, feelings and behaviors.
4. Have family members or significant trusted others learn to identify your early warning signs.
Other people may be able to detect your mood changes even before you do, which will enable them to give you feedback that a possible episode is about to occur. This also helps family members to remember that the individual’s behavioral difficulties are due to a disorder and not to be taken personally.
5. Develop and write down a personal coping plan.
Begin to keep track of activities that improve or stabilize your mood and develop a written plan to address early changes in mood. For example, loss of sleep is often an early symptom of a more serious manic episode. One part of your plan might be to make an agreement with your doctor to authorize an adjustment in your medications to help you sleep better. Another part of the plan might be to have additional therapy sessions at this point in order to prevent a more severe manic episode.
6. Try to keep a consistent regular schedule.
Go to bed, get up and eat meals at regular times. This increases both physical and emotional stability. Frequently, over-stimulation is associated with increased disorganization and the beginning of a manic episode. Keeping a weekly or monthly plan handy to review every day can also facilitate stability and consistency.
7. Plan a few pleasurable activities into each day.
The experience of pleasant events each day can have a positive effect during times of stress. Pleasant events do not have to be monumental. They can be as simple as having coffee with a friend, or taking time out to experience nature around you for a few minutes. The important thing is that you intentionally plan pleasurable activities into your day and then carry them out. This may also enable you to develop the perspective of being in control of yourself and your life.
Several excellent self-help publications are now available that illustrate how and when to use techniques to manage mood swings:
Dr. Reiser and Dr. Thompson’s “Bipolar Disorder: Advances in Psychotherapy- Evidence-based Practice,” available at www.hhpub.com.
“The Bipolar Disorder Survival Guide- What You and Your Family need to Know” by David J. Miklowitz is particularly useful and well grounded in science and research (available at www.amazon.com).
“Overcoming Mood Swings: A self-help Guide to using Cognitive Behavioral Techniques” by Jan Scott (New York University Press, 2001, available at www.amazon.com).