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

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1 CBT for Bipolar disorder. Notes for Otago Formal Academic Programme Stage I and II. June 2017 Chris Gale

2 Evidence for efficacy of psychological interventions for bipolar disorder is of low quality (small number of studies, inconsistency of methods and outcome measures, weak control conditions,elevated risk of bias, limited blinding, etc.). All studies to date have investigated psychological interventions as adjunctive 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 a 40% reduction in relapse compared to standard treatment alone. There is some evidence that relapse prevention is most effective for thedepressive pole (Lauder et al., 2010). RANZCP Guideline Mood Disorder

3 Dysfunctional Assumptions Dysfunctional assumptions are unarticulated rules by which the individual attempts to integrate and assign value to the raw data of experience These latent rules are activated when individuals enter situations that impinge on areas relevant to their vulnerability. Underlying assumptions are most often related to knowledge that we feel to be true rather than that we know to be true

4 Bipolar (dysfunctional) risk factors? In Bipolar there is a characteristic reactivity to minor positive mood increase. High goal attainment beliefs may interact with the illness and predispose bipolar patients to have a more severe course of the illness. These extreme beliefs of high goal attainment may lead to extreme striving behaviour and irregular daily routine, which may make the course of the illness more chronic and difficult to treat.

5 Psychological Models Bipolar. Three diathesis-stress models are discussed which have been influential in psychiatric conceptualizations of bipolar disorder: Behavioural activation and reward responsiveness Behavioural sensitization and kindling model Circadian disturbance and internal appraisal.

6 Behavioural Activation System and Reward Responsiveness Hypothesis is that the behavioural activation system (BAS), which regulates the approach behaviour of the individual in response to signals of reward or possible goal attainment, plays a central role in the development 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 biologic factors and external socio-environmental factors. From the model it is predicted that if dysregulation is an important influence on mood then high intra-individual variability in mood and mood-related behaviour should be apparent in bipolar disorder.

7 Kindling... Kindling is described as a long lasting, possibly permanent change in neural excitability. Electrical kindling describes the production of major motor seizures in animals using an electrical stimulus, which is usually subthresholdin its effects, but triggers seizure following repeated intermittent application. It is suggested that the intermittent presentation of stressors to humans may also exert a kindling effect with initial episodes requiring substantial stress to be triggered, but later episodes (having been kindled) being triggered by much lower levels of stress or insome cases becoming selfgenerated.

8 Behavioural Sensitisation Behavioural sensitization is the observation of increasingly rapid andsubstantial behavioural changes in response to repeated intermittent doses of psychomotor stimulants Although similar to kindling in many respects, it is thought that different neurotransmitter pathways underlie the two phenomena and that conditioning forms an important component in behavioural sensitization in animals.

9 ... These models suggest that symbolic aspects of previous triggers of affective episodes might over time become conditioned to the point they themselves can trigger later episodes in the absence of thesubstantive trigger itself. Thus, anticipated loss or stress might impact to cause an episode rather than actual loss or stress. There is some evidence that mood disorder episodes are particularly associated with significant stress in the early course of the illness If sensitization occurs through the course of illness it would be expected that 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 would be consistent with earlier presentation of conditioned responses over time and progressively quicker generation of motor hyperactivity in behavioural sensitization experiments.

10 Circadian and social rhythm disturbance Behavioural stressors of the type observed in learned helplessness are also associated with circadian disruption and that suchdisruption would itself be likely to be associated with the kinds of cognitive distortions associated with negative affect. Gesynchronization of rhythms caused by substantial changes to external environment might be associated with mania. Therefore the combination of disrupted social routines and disruption of physiological functioning, such as sleep disruption may together induce a driven hyperactivity. There are recent findings which indicate that the circadian disturbances are not restricted in bipolar disorder to individuals in acute episodes. disturbed circadian activity patterns and sleep disturbances have been reported in remitted bipolar patients associations between life events which are disruptive of social rhythms (stability of routine) and subsequent 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 psychomotor activity and associated increases in cognitive activity.

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13 Components in therapy? Psycho-educational. Patients are educated about bipolar illness as a diathesis-stress illness. It is explained that there is a prominent genetic component in bipolar disorders but that stress can lead to an episode. Cognitive behavioural skills to cope with prodromes. Clinically, we have observed that some patients who have a chronic course of frequent relapses find it hard to discriminate normal range of mood swings from an episode. The techniques of monitoring and rating mood and relating mood fluctuations to events in their activity schedules can be a very useful way of teaching these patients 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. Sleep and routine appear to be very important for bipolar patients. As the circadian rhythms in humans are attuned to social events and routine, this model suggests the importance of educating patients to have a good social routine in order to minimize the disruption of their circadian rhythms. Patients are taught behavioural skills such as activity scheduling as a useful means of establishing systematic routines. Dealing with long-term vulnerabilities. A careful assessment of triggers for past episodes can reveal the individual s vulnerability to specific themes, such as extreme achievement-driven behaviour leading to stress and relapse periodically. Hence, chaotic routine and extreme driven behaviour suggest dysfunctional high goal attainment beliefs,which could be a challenge to using cognitive behavioural techniques.

14 Insomnia in Bipolar. Monitor sleep regularly, including time to fall asleep, time awake in the middle of the night, early morning awakenings, and daytime naps. Encourage compliance with a simple sleep diary (35) to set a sleep window and evaluate progress between sessions. Monitor symptoms of depression and mania regularly. Negotiate a safety plan with patient should mood grow unstable during treatment. If symptoms of mania emerge after sleep restriction or stimulus control, consider modifying or temporarily suspending the techniques. Monitor sleepiness regularly using an instrument such as the Epworth Sleepiness Scale. When sleepiness levels reach clinical significance (a score of 10 on the Epworth scale), discourage patients 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 and weekends. After 1 2 weeks of this schedule, calculate weekly sleep efficiency with the patient; if sleep efficiency is below recommended guidelines, consider implementing sleep restriction (8). Introduce stimulus control and explain the rationale to patient, underscoring the role of conditioning factors in maintaining insomnia (7, 8). Monitor compliance with stimulus control, along with adverse reaction to stimulus control, in subsequent sessions.

15 Encourage the use of friends, family, and technology to aid in adherence to regularizing bedtime and rise times, sleep restriction, and stimulus control. Setting an alarm as reminder to begin a wind-down period or to wake up at the same time each morning can be helpful for implementation. Likewise, recruiting the support of family and friends to call or visit in the morning so as to prevent oversleeping, or to respect a no-call period in the hour before bedtime 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 behavior change. Establish small daily rewards, like a morning trip to the coffee shop, for complying with treatment recommendations. Highlight successes in sessions rather than failures. For example, 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 of how naps were avoided and pointing out positive nighttime sleep parameters (e.g., reduced sleep onset latency or nighttime wakefulness) on nap-free days. Encourage patients to continue using sleep restriction and stimulus control after treatment has ended. Work with patients to review the main components of the tools and anticipate with patients any setbacks to sleep, along with how stimulus control and sleep restriction can be used to prevent the re-emergence of insomnia.

16 Meta analysis effects CBT. J Clin Psychiatry 2010;71(1):66--72

17 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 updated meta-analysis with randomized controlled trials. Psychiatry Clin Neurosci Aug;70(8): doi: /pcn

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24 Results Mean time to relapse. Hospitalized Low threshold 15.6 weeks Medium threshold 27.0 weeks High threshold 32.6 weeks 10.3 (N=24) of whole sample. No significant differences between groups.

25 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 `

26 References Katherine A. Kaplan and Allison G. Harvey Behavioral Treatment of Insomnia in Bipolar Disorder American Journal of Psychiatry :7, Galvez, Juan F., et al. "Staging Models in Bipolar Disorder." Focus 13.1 (2015): 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 Aug;70(8): doi: /pcn Hidalgo-Mazzei, Diego, et al. "Internet-based psychological interventions for bipolar disorder: Review of the present and insights into the future." Journal of affective disorders 188 (2015): 1-13.