Cognitive Behavioural Therapy (CBT) For Bipolar Disorder 

Introduction

Bipolar disorder is a mental illness that causes sudden shifts in a person’s mood, energy and activity levels making it difficult to carry out day-to-day tasks.¹

Cognitive behavioural therapy (CBT) is a type of psychological treatment that aims to change thinking and behavioural patterns that contribute to mental illnesses.² CBT can be used to treat a range of mental illnesses, including anxiety, depression and bipolar disorder. Whilst the core principles of CBT remain the same, psychologists and patients work collaboratively to develop the most effective strategy for the individual. 

Understanding bipolar disorder

There are three types of bipolar disorder:

• Bipolar I disorder – The manic episodes last at least 7 days or they are so severe that they require immediate medical attention. Depressive episodes will also occur, usually lasting at least 2 weeks.
• Bipolar disorder II – Depressive episodes and periods of less severe manic episodes, known as hypomanic episodes.
• Cyclothymic disorder – Recurring hypomanic and depressive symptoms that aren’t intense enough to qualify as depressive or hypomanic episodes.

Bipolar disorder is often difficult to diagnose due to it commonly overlapping with other psychiatric disorders.³ Patients suffering from bipolar cannot often recognise their symptoms of mania or hypomania.

The exact reasoning for bipolar disorder development remains unknown but there is research suggesting the interactions of environmental, genetic and neurochemical factors play a role in the aetiology. There is significant research to support the hereditary aspect of bipolar disorder; there have been at least 30 genes identified to increase the risk of developing bipolar disorder.⁴ 

Common symptoms

Manic phase

During a manic episode, symptoms may display as below:

• Exaggerated self-esteem
• Over talkative
• Less need for sleep
• Difficulty concentrating
• Excessive energy
• Engaging in risky behaviour or lack of judgement

If a person is experiencing hypomania, they may display similar symptoms in a less severe form that will not affect their usual life.

Depressive phase

During a depressive episode, symptoms may display as below:

• Depressed mood
• Change in weight
• Difficulty sleeping or sleeping too much
• Agitation
• Loss of energy
• Inability to concentrate
• Feelings of hopelessness and guilt
• General loss of interests 
• Suicidal thoughts

Some patients suffering from bipolar disorder may experience mixed episodes in which they display manic and depressive symptoms at the same time.⁵ This may manifest as thinking and speaking very rapidly, whilst also feeling very anxious and suicidal. These mixed episodes can be difficult to recognise and become very damaging for the individual experiencing them.

Cognitive behavioural therapy

Definition and core principles

Cognitive behavioural therapy was developed in the 1960s and has since gained extensive research and credibility for its efficacy in treating a range of mental illnesses.⁶ It is based on a model analysing the relationship between cognition, emotion and behaviour.

3 core aspects of cognition are emphasised in CBT:

• Automatic thoughts
• Cognitive distortions
• Underlying beliefs

Automatic thoughts are considered a person’s immediate interpretation of events without any premeditation and these thoughts shape a person’s emotional and behavioural response to that event. CBT is based on the ideology that irrational/dysfunctional automatic thoughts play a substantial role in psychological well-being.

Cognitive distortions are considered irrational or negative patterns of thinking which can lead to inappropriately jumping to conclusions. It can also involve catastrophising scenarios before they have happened, which can amplify negative emotions to an unmanageable state.

Underlying beliefs shape the perception of events and are formed through life experiences. They can be understood at two levels:

Core beliefs

They are considered the deepest level of our thinking. An example of a dysfunctional core belief is “the world is a hostile and dangerous place”.

Intermediate beliefs

These beliefs influence the direction of automatic thoughts, and they play a huge role in maintaining anxious or depressive thoughts. They tend to relate to assumptions regarding relationships and situations and they can lead to forming irrational guidelines to follow in life. An example of this is “Not going out will avoid embarrassing myself”.

The theoretical foundation of cognitive behavioural therapy

CBT uses a model known as the ‘cognitive model’ as a structure for understanding an individual’s mental and emotional state. This method of using a set framework to gain an insight into the mechanisms of somebody’s thought processes are referred to as ‘formulations’ and it aids efficiently in developing a mutual understanding of an individual’s experiences and difficulties.⁷

The cognitive model explains how people's thoughts and perceptions influence their behaviour and emotions. It is the core theory of CBT and allows therapists to personalise therapy to receive the most effective outcomes. The model begins with a situation that will lead to an automatic thought. The reaction to this automatic thought is described in terms of emotion, behaviour and physiological response. By identifying these points, a therapist can gain an in-depth understanding of the mechanisms of a patient's thinking.

Application of CBT to bipolar disorder

Given that bipolar disorder causes episodic symptoms with different characteristics, it is a difficult psychological condition to treat with medication alone. CBT for bipolar disorder has been found to have a significant positive contribution to the treatment pathway in four different areas.⁸ The first is easing of symptoms by intervening with depressive thoughts and manic episodes. Drug compliance is a common problem faced when treating bipolar disorder and CBT is effective in increasing compliance, as well as educating patients on the early warning signs of an episode so that they can take action to prevent it from initiating. CBT is also useful in the treatment of comorbid conditions which are commonly seen alongside bipolar disorder.

The evidence for using CBT as a treatment for bipolar disorder is lower compared to depression and psychotic disorder, however, it is effective in the prevention of recurrent episodes.⁹ It is recommended as a second line of treatment following drug intervention. Before receiving CBT, the patient will undergo an assessment interview in which information regarding triggering factors of episodes related to bipolar are discussed. The effect these triggers have on the patients' relationships, responsibilities and work-life will also be established. 

Key components of CBT for bipolar disorder

Psychoeducation 

This is a strategy which is based on educating patients and the patient's family and/or friends about bipolar disorder and teaching them to recognise early warning signs of an episode onset.¹⁰ This aims to improve treatment compliance and a study has seen a significant decrease in new mood episodes and a reduction in the number of symptomatic days, as well as the length of hospitalisation.¹¹ 

Behavioural interventions

Mood tracking

This is a simple method requiring patients to monitor their moods each day and any changes throughout the day, using a tracking calendar. They should note down any significant moods, the amount of sleep they have had and if they have taken their medication. This stage will play a key role in facilitating other behavioural interventions involved in CBT for Bipolar disorder. 

Cognitive restructuring

These schemas are mental frameworks that regulate perception, attention, and information processing.  These cognitive structures are influenced by the environment and they shape behavioural and emotional responses to situations. 

Cognitive restructuring involves altering schemas through reflexive and reflective thinking. Reflexive thinking is a quicker process which involves noticing patterns in thinking and noting them down. Reflective thinking is a longer process involving more data about perceptions and responses to environmental factors, and it should result in a comprehensive output of these thoughts. 

Behavioural activation

This involves creating healthy habits in day-to-day life. Examples of this include: 

• Increasing the amount of sleep you get each night and having a good sleep routine 
• Money management 
• Slowing down important decisions and discouraging impulsive behaviours 
• Regulation of stimulus that might be a trigger for episode onsets 

Challenges and limitations of CBT for bipolar disorder

Although CBT is an evidence-based treatment which is useful in addressing drug compliance, recognition of symptoms and cognitive response to triggers, it has limitations. These include:¹² 

• It may become less effective over time 
• It is less efficient in more severely ill patients 
• It is more effective at treating depressive episodes than manic episodes 
• Not enough people trained in these techniques 

Summary

Bipolar disorder is a mental illness that involves episodes of depression and mania, with a sudden shift between the two. Cognitive behavioural therapy is a recognised, evidence-based form of therapy that uses patient psychoeducation with the aim of giving patients the tools and knowledge to identify the onset of an episode and use techniques learnt during CBT to offset major symptoms. CBT is an efficient tool used alongside drug therapy and it has been found to be very effective in increasing drug compliance. While CBT offers valuable tools for bipolar disorder (BD), challenges exist. These include limited access to treatment, reduced effectiveness with increased episode frequency with severity, and a focus primarily on managing depressive episodes. Having stated these challenges, it can be very helpful in teaching patients to develop healthy habits in day-to-day life to discourage depressive episodes.