Center for Cognitive Therapy
Mark E. Oakley, Ph. D.
The term Bipolar Disorder has traditionally been known as manic-depression. This diagnostic category actually encompasses a broad spectrum of affective symptoms that include depression, agitation, euphoria, impulsiveness, irritability, and in more extreme cases, psychotic ideation.
Those individuals who have met the diagnostic criteria for one or more past manic episodes are classified as having Bipolar I Disorder.
For a person to meet the diagnostic criteria for a Manic Episode, the individual must have exhibited an abnormally euphoric or irritable mood for at least 1 week. During this period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritability) and present to a significant degree (sufficient to cause marked impairment in occupational functioning or in social relationships) :
- inflated self-esteem or grandiosity
- decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
- more talkative than usual or pressure to keep talking
- flight of ideas or subjective experience that thoughts are racing
- deficits in attention/concentration (i.e. Attention too easily drawn to unimportant or irrelevant external stimuli)
- increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (extreme restlessness and not being able to sit still).
- excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees that are later regretted, sexual indiscretions, or foolish business investments)
Those individuals who have past Hypomanic Episodes, defined as having the same aforementioned symptoms that define a Manic Episode but last only at least 4 days and are not severe enough to cause marked impairment in social or occupational functioning, but are significant enough to be observable by others, are characterized as having Bipolar II Disorder.
For those individuals who have exhibited over a period of two years numerous periods of hypomanic and depressive symptoms that do not meet the diagnostic criteria for a Major Depressive Episode, they would be classified as having a Cyclothymic Disorder.
Finally, for those individuals who meet the criteria for both a Manic Episode and for a Major depressive Episode (except for duration) nearly every day for at least a 1-week period, where it is sufficiently severe to cause marked impairment in in occupational or social functioning, they would be classified as having a Mixed Episode.
The natural course of Bipolar Disorder is episodic and frequently entails relapses. It has been historically a recalcitrant syndrome to manage. While medications are considered to be an essential first-order approach to treatment, at least half of the population have been shown to not respond or relapse quickly after an early response to pharmacotherapy (Gitlin, Swensen, Heller, & Hammen, 1995). Fortunately, there has been a surge of recent scientific support for the role of Cognitive-Behavioral approaches to the effective management of this difficult disorder.
In a recent text, “Bipolar Disorder: A Cognitive Therapy Approach by Newman,C.F., Leahy, R.L., Beck, A.T., Reilly-Harrington, N.A. & Gyluai, L., 2002, APA , it was stated:” We believe that we are witnessing the beginning of a promising era in the treatment of bipolar disorder” that has been seen in supportive data from leading researchers on a worldwide basis including clinical research data from the United Kingdom (e.g. Lam, Jones, Hauward, & Bright, 1999; Palmer, Williams, & Adams, 1995 and in the United States (e.g. Basco & Rush, 1996; Hirshfeld et al 1998; Otto, Relly-Harrington, Kogan, Henin, & Knauz, 1999; as well as the line of research conducted at UCLA by Connie Hammen, Ph.D. and Michael Gitlin, M.D.)
Cognitive-Behavioral treatment of Bipolar Disorder is as multi-faceted as the syndrome itself. While it is generally agreed that there are biological and genetic underpinnings to Bipolar Disorder including altered neurotransmitter (brain chemistry) functioning, the Diathesis-Stress model is broadly acknowledged by experts in this field. This model implies that biological factors do not act alone but interact unfavorably with stress. Core elements of treatment draw from the basic cognitive model (A.T. Beck, 1976) that thoughts influence mood with an emphasis upon managing sources of emotional distress that are common and unique to Bipolar Disorder. The goal of therapy is to acquire Cognitive-Behavioral skills that enable individuals to manage Bipolar Disorder in a number of important areas that, where appropriate, include but are not limited to:
- Recognition and early intervention at first signs of significant mood shifts.
- Establish and maintain balanced behavioral routines of sleep, exercise, eating, socializing, and occupational activities.
- Recognition of prodrome or “early warning “ signs of hypomania and mania and applying appropriate cognitive-behavioral strategies.
- Risk assessment/management during manic/hypomanic phases.
- Reduction of impulsivity and recklessness during manic/hypomanic phases.
- Compliance with medication regime.
- Establishing and maintaining healthy interpersonal relationships and support.
- Addressing over-estimation of capabilities, over-reliance on luck, under-estimation of risk & overvaluing of immediate gratification(“I need it right now statements”) during manic/hypomanic phases (Newman, Leahy, Beck, Relly-Harrington & Gyulai, 2002).
- Management of depression, hopelessness and suicide risk as well as any mood shifts during mixed episodes.