Cognitive Therapy for Bipolar DisordersDr Warren Mansell University of Manchester & BST Early Intervention Service Proposed Plan Your background What is mania, hypomania and bipolar disorder? Warning signs and coping – exercise & overview The hypomanic continuum Simple vicious cycles – demo & practice BREAK An integrative cognitive model Accessing internal states and conflict between beliefs – demo & practice Treatment examples LUNCH Managing hypomania – demo & practice Recovery and the ‘healthy’ self The healthy self – demo & practice BREAK Behavioural experiments – demo & practice (if time) Summary and Questions Acknowledgements 2001-2005 Dominic Lam, Jan Scott 2004 Colleagues at Fulbourn Hospital, Cambridge 2004- Steve Jones, Fiona Lobban 2005- Sara Tai, Richard Bentall, Tony Morrison, Graeme Reid, Ian Lowens, Nick Tarrier, Rebecca Pedley, Gemma Paszek, Peter Taylor, Sarah Jones, Karen Seal, Helena Mannion, Alyson Dodd, Zoe Rigby, Christine Lowe, Rosie Beck, Veneeta Sadhnani, Sarah Hodson, Seth Powell Checking in… Experience with bipolar disorders and mood swings Reading in this area… Current cognitive models used . aimless behaviour…” A patient’s account from Goodwin & Jamison (1990) . But somehow. financial omnipotence and euphoria now pervade one’s marrow. frightened. the power to seduce and captivate others a felt certainty. power.Experience of mania “When you are high. You are irritable. the right words and gestures are suddenly there. uncontrollable. overwhelming confusion replaced by fear and concern. this changes. Shyness goes. well-being. frenetic. angry. it is tremendous. Feelings of ease. and enmeshed totally in the blackest caves of mind… It goes on and on and finally there are only other people’s recollections of your behaviour – your bizarre. The fast ideas are far too fast and there are far too many. intensity. no impairment . thoughts racing Distractibility Increased goal-directed activity Excessive involvement in pleasurable activities that may have high potential for painful consequences Marked impairment or psychosis Hypomania >4 days. expansive or irritable mood Inflated self esteem / grandiosity Decreased need for sleep More talkative than usual.Symptoms of mania At least one week of persistently euphoric. pressure of speech Flight of ideas. Illustration of subtypes Unipolar Depression Mania Hypomania ‘Normal’ Bipolar I Depression Bipolar II Mania Hypomania ‘Normal’ Bipolar I – unipolar mania Depression NB Why no unipolar hypomania? . . personality. 2008) Subclinical depression. anxiety.Important associated symptoms High levels (>50%) of other clinical problems: anxiety. 2002) . and anxiety. panic and aggression – multiple FA studies (Mansell & Pedley. typical even during remission (Judd et al. substance abuse Symptoms during mania also include dysphoria. 2000) – Manic symptoms not D .. 1988) M&D Disrupted social rhythm events (MalkoffSchwartz et al. 1998) – Mania not D Goal-attainment Events (Johnson et al.. criticism. overprotectiveness (Miklowitz et al.. 1992) M&D High ‘expressed emotion’ – hostility.Predictors of Relapse Stressful interpersonal life events (Hammen et al.. side effects Poor acceptance of ‘illness’– normative.Other important issues ‘Adherence’ to medication – normative. stigmatisation Sometimes overacceptance of illness – attributing all problems to ‘the bipolar’ Ambivalent views of hypomanic symptoms Interpersonal processes during therapy . often ineffective. . 2006. 2007) = effective CBT (Lam et al. 2003.. 2000. 1999) = effective Family-focused therapy (Miklowitz et al. Miklowitz et al... 1995) – c.. 2007) = largely effective No agreed model Effect sizes smaller than most other disorders .. Scott et al.Current Treatments for BP Medication – large majority – but high relapse rates despite adequate medication (Solomon et al.60% in 2 years Relapse prevention or psychoeducation (Colom et al.. 2006. Ball et al.. Perry et al. 2003. reduced sleep Idiosyncratic examples: e. ‘feeling buzzy all day and night’ Coping strategies for mania include: Postponing big decisions Taking a break to unwind Avoiding further stimulation .g.g. ‘making lots of lists’.Warning Signs and Coping Typically attenuated symptoms of mania: e. increased activity. Illustration of Risk Factors. Prodromes & Coping Strategies Effective Use of Coping Strategies Prodromes Poor Use of Coping Strategies Mania Fluctuations in mood. thoughts & behaviour Normal Range Stressful events Goal-attainment events Disrupted Routine Stressful relationships Anxiety Examples of risk factors . Exercise 1: Checklist of hypomanic experiences Which are warning signs of mania? Which are ‘normal’? Which are ambiguous? What are the potentials possibilities & pitfalls of identifying these warning signs? How could this be improved? . How do we know if the symptoms of bipolar disorder are ‘normal’? Subjective Have I had them? Have my friends had them? Do they seem ‘normal’? Are they on a continuum. part of a ‘normal’ distribution? cf. trait anxiety.e. i. schizotypy Do people without bipolar disorder experience them? Can a person experience them and function effectively? Can they be explained by within ‘normal’ accounts of cognitive functioning? Objective . 100 90 80 70 60 50 40 30 20 10 0 Yes No Is Bipolar Disorder… A Category Disorder? or Continuum? 200 180 160 140 120 100 80 60 40 20 0 Num b er o f Experien ces 0 2 4 6 8 10 . 55% 2830 year olds with brief hypomania had no history of depression (Wicki & Angst. 1991) .g.Is Bipolar Disorder a Continuum? Bipolar I Disorder: Mania and Depression: 1 in 100 people Bipolar II Disorder: Hypomania and Depression: 6 in 100 people ‘Prodromes’ are mild symptoms Hypomanic symptoms only – e. No. 1539-1549.Self-reported History of Hypomanic Symptoms in a Student Population – MDQ 25 20 15 10 5 0 Udachina & Mansell (2007). 42. the Internal State Scale. Personality and Individual Differences. of hypomanic symptoms 0 2 4 6 8 10 12 . and the Hypomanic Personality Scale. Cross-validation of the Mood Disorders Questionnaire. Resistance to Bipolar Disorder 12 individuals aged 30+. Research and Practice. 81. 33-54 Key findings: High levels of functioning Lower levels of catastrophising about changes in internal states. catastrophising correlated with poorer functioning Reported ‘awareness’ of behaviour and social impact when feeling high . Hypomania and No history of clinical depression What Lies BetweenPsychology and Bipolar Disorder? No diagnosis of bipolar disorder Psychotherapy: Theory. most with a history of SCID diagnosable hypomanic episodes Never sought treatment Seal. Mansell & Mannion (2008). dwell on problems .A Simple Model? Vicious Cycle for Depression THINKING: “I have a brain disease” “There is no point in doing anything” FEELINGS: Low energy Feel Sad BEHAVIOUR: Avoid people Give up everyday activities. A Simple Model? Vicious Cycle for Hypomania? THINKING: FEELINGS: “I can do anything I want” High energy “I can overcome all my problems” Feel High BEHAVIOUR: More active Think of new ideas Do everything faster . Simple Formulation Demonstration Practice Divide into pairs – A & B A describes a recent client B enquires about internal states B enquires about thoughts & appraisals B enquires about behaviours Draw out a possible vicious cycle together . it’s not all positive… Which may lead them to accept low level depression as a safe alternative?… And also… what stops the cycle? .But is it more than two vicious cycles? People with Bipolar Disorder do not just have positive beliefs about high moods They are also afraid of embarrassing themselves. relapsing. getting controlled by others…. 2007) Mood swings are a consequence of multiple. feelings of high energy = imminent success vs. boring Leads to internal struggle trying to exert extreme control over internal states rather than active. feelings of high energy = mental breakdown Feelings of low energy = safe. successful ways of pursuing goals .A Cognitive Model (Mansell. Morrison. conflicted. extreme. personal appraisals of changes in internal state E.g. Lowens & Tai. relaxing vs. Reid. Feelings of low energy = failure. High Mood .“I am excelling and overcoming all my problems” Conflicted Beliefs “I am about to make a fool of myself. Agitated. get controlled by people and relapse” High Energy. Success! Safety! Failure! Catastrophe! INTERNAL STATE De-activated Highly Activated . Morrison. Lowens & Tai.A Cognitive Model of Bipolar Disorder (Mansell. 2007) Triggering event Change in internal state Ascent Behaviours Appraised as having extreme personal meaning Descent Behaviours Beliefs about self. Reid. world and others (including procedural beliefs about affect and control) Life Experiences (including current environment & reactions of others) . everybody lo ves me” HIGH Descent Behaviours Catastrophic High Activation Appraisals “When I am agitated and restless I will have a mental breakdown” “I ha ve no control o ver my thoughts when I feel excited” “When I get exci ted. I make a fool of myself” Unstable Internal State “If I feel more active for a short while.Positive High Activation Appraisals “This energy means I can achieve all my life goals” “My fast thinking shows how witty and intelligent I am” “When I do things so quickly I know I can achieve anything” “When I feel this good. I will have a breakdown” Catastrophic Low Activation Appraisals “I cannot cope feeling low even for a short while” “I must never show negative emotions” “When I am full of energy I can fight back against people who try to control me” “I need to be extremely energetic to cope with feeling so tired and low” Positive Low Activation Appraisals (?) “I need to be in complete control of m y moods to feel safe” “I need to feel as stable as possible” “I can onl y feel safe from losing control when my energy le vels are low” Ascent Behaviours LOW . Tied to post when agitated woke from being Told ‘hope they throw away the key’ unconscious when in hospital . other people try can overcome all my to control and punish me” problems” Three years of age.Client Example of Conflicting Beliefs about being ‘hyped up’ Positive/Coping Negative/Catastrophic “When I hype myself up I “When I feel hyped up. Castigated for trying to help mother ‘hyped up’ to save mother Told relapsing when angry from father’s attacks. g. consider a feeling over which one is ambivalent. e. B asks about internal state & explores both sides equally .Demonstration and Practice Explore conflicting beliefs about internal states – highly personalised Demonstration Practice Pairs – A & B A plays themselves. excited. drunk. 2008) . personal and interpersonal beliefs about internal states Assesses beliefs within the model Elevated in BP vs HC (Mansell. 2006) even when controlling for current symptoms (Mansell & Jones. 2006) Related to history of hypomanic symptoms independently of personality measures (Mansell et al.The HAPPI Scale Hypomanic Attitudes and Positive Predictions Inventory Measure of conflicting.. extreme. (in press) Cognitive Therapy & Research Bipolar – relapsed within last 2 years. n = 22 Non-clinical.history of depression but not hypomania or mania. n = 22 . n = 16 Bipolar – no relapse within last 2 years.Controlled Study Mansell et al. n = 14 Hypomanic Resistant – history of hypomanic episodes but no depression. n = 16 Unipolar . and current ISS symptoms. p <.001 60 Mean HAPPI 50 Mean HAPPI Score 40 30 20 10 0 Bipolar Relapsed (N=16) Bipolar Recovered (N=14) Unipolar (N=22) HAPPIstudy Non-Clinical Non-Clinical Hypomanic (N=22) (N=16) .Controlling for age. education (both ns). maintained when clinical measures included (e. thoughts racing) r = . (submitted) 50 individuals with bipolar disorder Completed measures at baseline Self-reported bipolar symptoms after one month Regression of HAPPI and bipolar symptoms at baseline.001 Depression – non-significant. months since last episode) Activation (e.49. r = .18 .g.g. p < .g. p <.001 Conflict (e.HAPPI – Predictive Validity Dodd et al. irritability) r = .51. Treatment . Pyramid of Therapy Principles Change and Recovery Awareness of Formulation Experiential Processing Engagement Safety . Interpersonal issues during assessment & treatment Autonomy: utilise autonomy. check in with goals Validation: the client may be an undiscovered genius Client change in presentation requires interpersonal flexibility: Compliance when low: provide time for client to make own decision. help prioritise. set boundaries . don’t overload Rebellious when high: explore experiences and goals rather than acqueisce. prioritise Immediate: suicide. current interfering substance abuse.IMPORTANT – but covered elsewhere Overview: allow patients to develop an understanding of their mood. thoughts & behaviour that is normalising and understandable Present: address current symptoms that client wants to deal with (depression/anxiety/irritability/hypomania) using the model Future: Relapse prevention. medication non-adherence .Stage & Goal Setting Small number. improve social & occupational functioning “Move towards goals in a way that limits risk of relapse” . mania. client-led. but client-led if possible Case studies – approx 25 sessions. information on experience & consistency Group work possible – workbook available Psychoeducation – handout.Delivery Issues Number and timing of sessions – often limitations. goal is recovery as defined by client Current Case Series – 12 sessions for research Maximise sessions when clients are treatment seeking. self-help books . taper out over time Challenging during mania – patient choice. measurable. Well-being Good for plotting variation.Beck Anxiety Inventory. user-friendly Anxiety . facilitates cognitive techniques . Activation.Assessment Recommended Measures Depression (if not too fluctuating): BDI Mood changes & hypomania .Internal State Scale – Bauer et al. Penn State Worry Questionnaire: PSWQ – worry HAPPI – validating. Conflict. focus of intervention. 1991.. ISS Subscales: Depression. returning to work . tried to be the ‘perfect mother’ and continue PhD Stabilised on lithium Goals included understanding bipolar.. managing mood swings. 2007) 30 yo mother of twins History of ‘perfect’ childhood later seen as ‘false’. ambivalence of emotion expression First episode of mania was post-natal.Clinical Example 1 (Mansell et al. preventing relapse. critical. ruminate “Negative moods are not acceptable”.Argument with husband Feel Sad. “I am worthless if I have no energy” Other people do not validate and sooth negative moods. past experience of depression . Loss of energy “I will get rejected & humiliated” Isolate self. start new goals. “My negative feelings will never return”. “Other people don’t understand” “When I am very active I can prove myself to everyone” “I must act on an idea as soon as I get it” Some people reward excitable behaviour. others express worry and try to control the situation . ignore advice to slow down “I can do everything I want”.Start new job Increased energy and excitement Tell people ideas. abandon routine. mood profiling Formulated vicious cycles of problem situations Reappraisal – e. restructuring . neutral faces perceived as ‘despising’. looked for alternative evidence Exposure to internal states while dropping ascent behaviours – triggered relevant memories.Treatment Stages Information.g. lively Feel much more happy or tired and excited than people around me Sharing positive experiences with other Irritable for longer than a people few minutes Sleeping over 6 hours per Feel like other people don’t night understand me Being aware of worries but Sleeping less than 6 hours not being caught up in per night for several days them Not taking a break or Able to relax finding time to relax Regular routine of Mind racing activities . sad.Example of Symptom Profile Depression Very low mood Feel exhausted Isolate self Dwell in my mind on ‘why’ I have so many problems Life seems pointless Giving up usual activities Normal Hypomania Feeling happy. 3 & 6m FU Symptoms. 1. in prep) 5 BP II & 2 BP I Multiple baseline..Case Series (Searson et al. cognition & functioning Qualitative feedback . 12 sessions. 0 (11.4 .3 (22.408 (154) 234 (241) 292 (175) 0.Baseline Post M(SD) M(SD) BDI 21.0) 1.4 (7.9 (5.2 ISS comp.2) 3.0) Month FU Effect Size (d) M(SD) 5.9 (5.9) 8.43 (4.7) 26.0 (6.1) 28.1 (22.7 WSAS HAPPI 18.47) 9.7) 50.3 (7.8) 8.4 1. Functional Impairment across sessions (WSAS) . I am much more accepting of ‘normal’ mood and behaviour now.g. “therapy gave me ‘permission’ to exist in different mood states as opposed to my previous attitude/efforts to either be very energetic (high) or quite low – anything in between wasn’t acceptable.Qualitative Feedback Qualitative themes from client feedback: ‘Helpful aspects’ Use of mood profile and formulation Increasing awareness Developing new styles of thinking and behaviour Acceptance of different mood states e.” Positive improvement to goals for 6 participants High levels of therapeutic alliance on CALPAS for sample . Further features of CBT discovered during training… Process issues: Balance of talking between therapist & client Style of asking questions – open & succinct Accessing current thoughts and feelings Block to CBT. use pie charts & continua Using the client’s own language Helping to realise the ‘real self’ Non-diagnostic language. use continua Medicalised views Personality & identity . need energy to fuel creativity.Managing Hypomania Demonstration Practice in pairs A plays the client – have an important project. explore current goals & current perception Feedback – its not easy! . dimly aware of risk B plays participant – interrupt to clarify. Long Term Recovery Overarching goal What does recovery look like? What is involved in long-term recovery? . Mansell & Lam (2003) . Totterdell, Kellet & Mansell (in prep) Example of Client’s Feedback “The CBT has made me aware of my negative thought processes and has given me the coping strategies to combat these thoughts. Something that I have been doing for many years is self criticism. When things don’t go my way I call myself names. Talking about this during the CBT sessions has made me realize that the name calling, fed into my fears and my fears became greater. To break this vicious cycle, I have taught myself to not be so hard on myself. Another point that was mentioned in the CBT sessions was to think about the worst thing that could happen in a given situation that I feared. When I asked myself this question I realized that I could deal with the worst case scenario. Another thing that I discovered through talking in the sessions is that my mood state is partially under my own control, for instance I can improve my mood state through exercise.” Experiences of Recovery Ultimately CBT aims to help people reclaim their lives, fulfil their goals and ‘recover’. But what is this? How do people manage it without CBT? Interview with 13 people with bipolar disorder who have not had depression or mania for 2 years (SCID interview) Followed up for 6 months – still well “What do you think has helped you stay well?” “How are you doing or thinking about things differently now from before?” medicated self.Themes – Ambivalent Approaches Monitoring against mania Medication Avoidance of activities that led to states of activation. learned to cope but not recovered Not defining themselves by their illness. overcompensating for the risk of relapse. socialised less Helpful or not. ‘true’ vs. coming off medication: feel better or worse? ‘Excitement’ vs. deciding who to confide in Whether current wellness is recovery Sense of identity following diagnosis . stability. not having others define them by their illness: paranoia over being ‘labeled’ as mentally ill. Themes – Helpful Approaches Understanding Lifestyle fundamentals Accepting experiences and taking in relevant information Increased balance and stability: sleep. feedback from others Increase in social activity and interaction. as well as maintaining an overarching structure and routine to personal and occupational activities Openness with others. involvement from others. diet. bipolar disorder as social in origin Support and companionship Social change . ‘stepping back’ Help the client to describe it in detail: Internal state. social context Anchor in reality – specific period Use Continuum to explore the boundaries Use virtuous cycle to formulate . thoughts. ‘even keel’. behaviour.Development of the ‘Healthy Self’ Clients’ own terms: ‘middle ground’. ‘third way’. Examples 0 10 20 30 40 50 60 70 80 90 100 /_____/______/______/______/________/ Depressed Down Even Keel Happy Ideal Manic Aware Manic Full-blown Anxious & Agitated “It’s OK to be slightly agitated” “I still have some control” Notice my surroundings Drop ‘ascent behaviours’ Let the mood pass Mood does not escalate and may drop . Client’s Name of Client’s Description State OTT. feeling irritable and frustrated with family. do very little. want to avoid people. very self-critical thoughts . like when I was on holiday in Australia with family. High Feeling agitated and restless. “real self” Happy Normal & Boring Doing everyday tasks. sharing positive experiences with other people. not allowing any negative feelings Feeling happy and optimistic. smiling too much. anxious and worried Depressed Very low. other people say I am not my normal self. no energy. looking for the next big idea all the time. Demonstration Using continuum / mood profile / virtuous cycle / be flexible & client centred Divide in pairs Explore the ‘healthy self’ in detail NB Not prescriptive but optional… . Behavioural Experiment: Practice Ask about feelings when about to engage in an ascent behaviour Identify beliefs about those feelings Develop an experiment to test what would happen if stayed with feeling & dropped ascent behaviours Identify outcome measures to index whether belief is confirmed or disconfirmed Plan logistics of the experiment . 3. 6 month .The Wider Context Dealing with stigma Medication Getting back to work Having children Learning from patients Working with other health professionals Working with families Service user work Follow-up sessions – 1. their origins. impact and facilitating awareness and change in clients Ongoing systemic work to question assumptions about the nature of bipolar disorder Research and treatment evaluation crucial . personal. conflicting beliefs maintain and escalate mood swings CBT involves exploring these appraisals.Summary Symptoms of bipolar disorder are more extreme expressions of normal experiences Model proposes that extreme. London Thu 8th April – Workshops Fri 9th April – Conference University of Manchester Tue 20th July to Fri 23rd July c.com . CBT science & practice Annual BABCP Conference See www.20 workshops.babcpconference.BABCP: CBT Conferences “Relationships and Relating in CBT: Science and Practice” University of Westminster. . Mansell.References on the model & therapy Mansell. & Lam.. D. & Pedley.. 35. G.P. S. Behavioural and Cognitive Psychotherapy. (2008). W. H. Conceptualising a cycle of ascent into mania: A case report. What lies between hypomania and bipolar disorder? A qualitative analysis of twelve non-treatment-seeking people with a history of hypomanic experiences and no history of major depression. Mansell. & Tai. 363-368. (2008). Mansell. Seal. The ascent into mania: a review of psychological processes associated with manic symptoms. (2007) The interpretation of and responses to changes in internal states: an integrative cognitive model of mood swings and bipolar disorder. Research and Practice. W. (2007) An integrative formulation-based cognitive treatment of bipolar disorders: Application and illustration. Clinical Psychology Review. K. Reid.. Psychology and Psychotherapy: Theory. Behavioural and Cognitive Psychotherapy. 515-541. 33-53. W. 81.. W. (2003). Lowens. & Mannion. 494-520. 28. Mansell. Morrison.. W. R. 63. [supplementary material is a case study based on the model].. 31. Journal of Clinical Psychology. A. I. 447-61. F. Jones & R.. (in press). W. W. & Colom. Mansell. (2006). Imagery and Memories of the Social Self in People with Bipolar Disorders: Empirical Evidence. Mansell.References on the model & therapy Mansell. W. W. 450-465. Rigby. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI): A pilot study to select cognitions that are elevated in individuals with bipolar disorder compared to non-clinical controls. J. 64... (2008). Journal of Clinical Psychology. & Hodson. & Lam. & Lowe. Theory and Therapy. 25. Behavioural and Cognitive Psychotherapy. Tai. 34.. C. (2006). 1787-1801. “I won’t do what you tell me!” Elevated mood and the assessment of advice-taking in euthymic bipolar I disorder. Imagery and the Self in Psychopathology. Clinical Psychology Review.Stopa (Ed. Z.). 1076-1100. Dysfunctional Beliefs in Bipolar Disorder. 44. (2005).. Psychological Approaches to Bipolar Disorder. Mansell. Routledge. W. Behaviour Research and Therapy. D. Bentall (Eds. S. . S. Mansell. Scott. J. The nature and treatment of bipolar depression: Implications for psychological investigation. In S. (2006). & Scott. Factor analysis of the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) and its association with hypomanic symptoms in a student population.. Mansell. 467-476. Phenomenology. W.). In L.