Academic journal article Journal of Cognitive Psychotherapy

Cognitive-Behavior Therapy for Bipolar I Disorder

Academic journal article Journal of Cognitive Psychotherapy

Cognitive-Behavior Therapy for Bipolar I Disorder

Article excerpt

Although Bipolar I disorder has traditionally been considered a biological illness requiring a biological intervention, research on the course of the illness and the process of treatment suggest that pharmacotherapy alone is insufficient in controlling the symptoms of this disorder. Symptoms include limited patient understanding of the illness and its treatment, poor medication compliance, symptom breakthrough despite good compliance, and impairment in psychosocial functioning. To address these problem areas, a cognitive behavioral therapy (CBT) protocol was developed as an adjunct to pharmacotherapy, with its goal being not only to help remediate symptoms but to arm the patient with the tools that will aid the prevention of relapse. This paper provides a rationale for CBT as a treatment modality in Bipolar I disorder as well as a description of the treatment methods. Preliminary data describing the feasibility of the intervention will be provided along with a case report and suggestions for implementation of the protocol in a general practice setting.

Bipolar I disorder (BPI) is a chronic and severe mental illness characterized by recurring episodes of maior depression and mania. BPI is lifelong once it begins, carries a high risk of suicidality, and often occurs comorbidly with substance abuse. Psychiatric medications are the treatment of choice for controlling episodes of depression and mania, and prophylactic medications are generally indicated to decrease the risk of recurrences. Unfortunately, despite the scientific advances in psychopharmacology for bipolar disorder, medication treatment alone is rarely sufficient to control or prevent symptoms. This article provides a conceptual model of bipolar disorder and makes the case for using cognitive-behavioral therapy (CBT) to supplement, not replace, pharmacological treatment of this chronic illness by addressing symptoms and difficulties not thoroughly remedied with medication. A case example is presented which illustrates the utility of this treatment approach with individuals who suffer from BPI disorder.

Phenomenology of Bipolar Disorder

The diagnosis of BPI can be made once an individual has experienced his or her first episode of mania or a mixed episode. Mania is defined by the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV, American Psychiatric Association, 1996) as a period of expansive, euphoric, or irritable mood lasting 1 week or less, if hospitalization is required to qualify for a diagnosis of mania. There must be 3 additional manic symptoms occurring concurrently with a euphoric mood or 4 additional symptoms, if the mood is irritable to qualify for a diagnosis of mania. These additional symptoms include grandiosity, decreased need for sleep, racing thoughts, psychomotor agitation, increased goal-directed activity, and risky behaviors that have a high risk of negative consequences. To be distinguished from hypomania, mania requires a level of symptom severity that causes functional impairment or requires hospitalization. BPI can also be diagnosed after a mixed episode. During a mixed episode, symptoms of major depression and mania exist concurrently or alternate rapidly. If prior to the manic or mixed episodes the individual experienced episodes of major depression, a diagnosis of major depression may have preceded the diagnosis of BPI. Symptoms can fluctuate with varying intensities. "Recurrences" of depression, mania or hypomania are symptomatic episodes meeting full diagnostic criteria occurring after a period of wellness, defined by DSM-IV as a period of 2 months or more without symptoms. "Relapses" are a return to a fully symptomatic state after a period of some improvement in symptoms that lasted less than 2 months. "Symptom breakthroughs" are the occurrences of symptoms of depression or mania that are mild and do not satisfy full DSM-IV criteria for a new episode of illness.

Cognitive-Behavioral Formulation of Bipolar I Disorder

Figure 1 illustrates the cognitive behavioral model of bipolar disorder. …

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