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Cognitive Therapy for Bipolar Disorders

Dr 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

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

Experience of mania
When you are high, it is tremendous. Shyness goes, the right words and gestures are suddenly there, the power to seduce and captivate others a felt certainty. Feelings of ease, intensity, power, well-being, financial omnipotence and euphoria now pervade ones marrow. But somehow, this changes. The fast ideas are far too fast and there are far too many, overwhelming confusion replaced by fear and concern. You are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of mind It goes on and on and finally there are only other peoples recollections of your behaviour your bizarre, frenetic, aimless behaviour
A patients account from Goodwin & Jamison (1990)

Symptoms of mania

At least one week of persistently euphoric, expansive or irritable mood Inflated self esteem / grandiosity Decreased need for sleep More talkative than usual, pressure of speech Flight of ideas, 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; no impairment

Illustration of subtypes
Unipolar Depression
Mania Hypomania Normal

Bipolar I


Bipolar II
Mania Hypomania Normal

Bipolar I unipolar mania


NB Why no unipolar hypomania?

Important associated symptoms

High levels (>50%) of other clinical problems: anxiety, personality, substance abuse Symptoms during mania also include dysphoria, anxiety, panic and aggression multiple FA studies (Mansell & Pedley, 2008) Subclinical depression, and anxiety, typical even during remission (Judd et al., 2002)

Predictors of Relapse
Stressful interpersonal life events

(Hammen et al., 1992) M&D High expressed emotion hostility, criticism, overprotectiveness (Miklowitz et al., 1988) M&D Disrupted social rhythm events (MalkoffSchwartz et al., 1998) Mania not D Goal-attainment Events (Johnson et al., 2000) Manic symptoms not D

Other important issues

Adherence to medication normative; often ineffective; side effects Poor acceptance of illness normative; stigmatisation Sometimes overacceptance of illness attributing all problems to the bipolar Ambivalent views of hypomanic symptoms Interpersonal processes during therapy

Current Treatments for BP

Medication large majority but high relapse rates despite adequate medication (Solomon et al., 1995) c.60% in 2 years Relapse prevention or psychoeducation (Colom et al., 2003; Perry et al., 1999) = effective Family-focused therapy (Miklowitz et al., 2000; 2007) = effective CBT (Lam et al., 2003; Scott et al., 2006; Ball et al., 2006; Miklowitz et al., 2007) = largely effective

No agreed model Effect sizes smaller than most other disorders

Warning Signs and Coping

Typically attenuated symptoms of mania:

e.g. increased activity, reduced sleep Idiosyncratic examples: e.g. making lots of lists; feeling buzzy all day and night Coping strategies for mania include:

Postponing big decisions Taking a break to unwind Avoiding further stimulation

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?


Have I had them? Have my friends had them? Do they seem normal? Are they on a continuum, i.e. part of a normal distribution? cf. trait anxiety, 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?


100 90 80 70 60 50 40 30 20 10 0 Yes No

Is Bipolar Disorder A Category


or Continuum?

200 180 160 140 120 100 80 60 40 20 0

Num b er o f Experien ces


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.g. 55% 2830 year olds with brief hypomania had no history of depression (Wicki & Angst, 1991)

Self-reported History of Hypomanic Symptoms in a Student Population MDQ

25 20 15 10 5 0
Udachina & Mansell (2007). Cross-validation of the Mood Disorders Questionnaire, the Internal State Scale, and the Hypomanic Personality Scale. Personality and Individual Differences, 42, 1539-1549.

No. of hypomanic symptoms



Resistance to Bipolar Disorder

12 individuals aged 30+, most with a history of SCID diagnosable hypomanic episodes Never sought treatment Seal, Mansell & Mannion (2008). Hypomania and No history of clinical depression What Lies BetweenPsychology and Bipolar Disorder? No diagnosis of bipolar disorder Psychotherapy: Theory, 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

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; dwell on problems

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

But is it more than two vicious cycles?


with Bipolar Disorder do not just have positive beliefs about high moods They are also afraid of embarrassing themselves, relapsing, getting controlled by others.its not all positive Which may lead them to accept low level depression as a safe alternative? And also what stops the cycle?

A Cognitive Model
(Mansell, Morrison, Reid, Lowens & Tai, 2007)

Mood swings are a consequence of multiple, conflicted, extreme, personal appraisals of changes in internal state E.g.

feelings of high energy = imminent success vs. feelings of high energy = mental breakdown Feelings of low energy = safe, relaxing vs. Feelings of low energy = failure, boring

Leads to internal struggle trying to exert extreme control over internal states rather than active, successful ways of pursuing goals

I am excelling and overcoming all my problems Conflicted Beliefs

I am about to make a fool of myself, get controlled by people and relapse

High Energy, Agitated, High Mood

Success! Safety!

Failure! Catastrophe!

INTERNAL STATE De-activated Highly Activated

A Cognitive Model of Bipolar Disorder (Mansell, Morrison, Reid, Lowens & Tai, 2007)

Triggering event Change in internal state

Ascent Behaviours

Appraised as having extreme personal meaning

Descent Behaviours

Beliefs about self, world and others (including procedural beliefs about affect and control) Life Experiences (including current environment & reactions of others)

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, everybody lo ves me


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, 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


Client Example of Conflicting Beliefs about being hyped up

Positive/Coping Negative/Catastrophic When I hype myself up I When I feel hyped up, other people try can overcome all my to control and punish me problems

Three years of age; Castigated for trying to help mother hyped up to save mother Told relapsing when angry from fathers attacks; Tied to post when agitated woke from being Told hope they throw away the key unconscious when in hospital

Demonstration and Practice

Explore conflicting beliefs about internal

states highly personalised Demonstration Practice

Pairs A & B A plays themselves; consider a feeling over which one is ambivalent, e.g. excited, drunk. B asks about internal state & explores both sides equally

The HAPPI Scale

Hypomanic Attitudes and Positive Predictions Inventory Measure of conflicting, extreme, 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., 2008)

Controlled Study
Mansell et al. (in press) Cognitive Therapy & Research

Bipolar relapsed within last 2 years, n = 16 Bipolar no relapse within last 2 years, n = 14 Hypomanic Resistant history of hypomanic episodes but no depression, n = 16 Unipolar - history of depression but not hypomania or mania, n = 22 Non-clinical, n = 22

Controlling for age, education (both ns), and current ISS symptoms; p <.001



Mean HAPPI Score





Bipolar Relapsed (N=16)

Bipolar Recovered (N=14)

Unipolar (N=22)

Non-Clinical Non-Clinical Hypomanic (N=22) (N=16)

HAPPI Predictive Validity

Dodd et al. (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; maintained when clinical measures included (e.g. months since last episode) Activation (e.g. thoughts racing) r = .51, p < .001 Conflict (e.g. irritability) r = .49, p <.001 Depression non-significant, r = .18


Pyramid of Therapy Principles

Change and Recovery Awareness of Formulation Experiential Processing Engagement Safety

Interpersonal issues during assessment & treatment

Autonomy: utilise autonomy; help

prioritise; 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; dont overload Rebellious when high: explore experiences and goals rather than acqueisce; set boundaries

Stage & Goal Setting

Small number; client-led; prioritise Immediate: suicide; mania; current interfering substance abuse; medication non-adherence - 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; improve social & occupational functioning Move towards goals in a way that limits risk of relapse

Delivery Issues

Number and timing of sessions often limitations, but client-led if possible Case studies approx 25 sessions; goal is recovery as defined by client Current Case Series 12 sessions for research Maximise sessions when clients are treatment seeking; taper out over time Challenging during mania patient choice; information on experience & consistency Group work possible workbook available Psychoeducation handout; self-help books

Assessment Recommended Measures

Depression (if not too fluctuating): BDI Mood changes & hypomania - Internal State Scale Bauer et al., 1991; ISS

Subscales: Depression, Conflict, Activation, Well-being Good for plotting variation; user-friendly

Anxiety - Beck Anxiety Inventory; Penn State Worry Questionnaire: PSWQ worry HAPPI validating; measurable; focus of intervention; facilitates cognitive techniques

Clinical Example 1 (Mansell et al., 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; tried to be the perfect mother and continue PhD Stabilised on lithium Goals included understanding bipolar; managing mood swings; preventing relapse; returning to work

Argument with husband Feel Sad; Loss of energy

I will get rejected & humiliated

Isolate self; ruminate

Negative moods are not acceptable; I am worthless if I have no energy Other people do not validate and sooth negative moods; critical; past experience of depression

Start new job Increased energy and excitement Tell people ideas; start new goals; abandon routine; ignore advice to slow down

I can do everything I want; My negative feelings will never return; Other people dont 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

Treatment Stages
Information; mood profiling Formulated vicious cycles of problem

situations Reappraisal e.g. neutral faces perceived as despising; looked for alternative evidence Exposure to internal states while dropping ascent behaviours triggered relevant memories; restructuring

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, sad, 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 dont 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

Case Series (Searson et al., in prep)

5 BP II & 2 BP

I Multiple baseline; 12 sessions; 1,3 & 6m FU Symptoms, cognition & functioning Qualitative feedback

Baseline Post M(SD) M(SD) BDI 21.43 (4.47) 9.0 (6.0)

Month FU Effect Size (d) M(SD) 5.9 (5.2) 3.2

ISS comp.408 (154) 234 (241) 292 (175) 0.7 WSAS HAPPI 18.9 (5.9) 8.3 (7.7) 50.0 (11.1) 28.3 (22.8) 8.4 (7.7) 26.1 (22.0) 1.4 1.4

Functional Impairment across sessions (WSAS)

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.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 wasnt acceptable. I am much more accepting of normal mood and behaviour now. 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 clients own language Helping to realise the real self Non-diagnostic language; use continua

Medicalised views

Personality & identity

Managing Hypomania
Demonstration Practice in pairs

A plays the client have an important project; need energy to fuel creativity; dimly aware of risk B plays participant interrupt to clarify; explore current goals & current perception

Feedback its not easy!

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 Clients 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 dont 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?

Themes Ambivalent Approaches

Monitoring against mania Medication Avoidance of activities that led to states of activation, socialised less Helpful or not, true vs. medicated self, coming off medication: feel better or worse? Excitement vs. stability, overcompensating for the risk of relapse, learned to cope but not recovered Not defining themselves by their illness, not having others define them by their illness: paranoia over being labeled as mentally ill, deciding who to confide in

Whether current wellness is recovery

Sense of identity following diagnosis

Themes Helpful Approaches

Understanding Lifestyle fundamentals Accepting experiences and taking in relevant information Increased balance and stability: sleep, diet, as well as maintaining an overarching structure and routine to personal and occupational activities Openness with others, involvement from others, feedback from others Increase in social activity and interaction, bipolar disorder as social in origin

Support and companionship Social change

Development of the Healthy Self

Clients own terms: middle ground, even

keel, third way, stepping back Help the client to describe it in detail:

Internal state, thoughts, behaviour, social context

Anchor in reality specific period Use Continuum to explore the boundaries Use virtuous cycle to formulate

0 10 20 30 40 50 60 70 80 90 100 /_____/______/______/______/________/
Depressed Down Even Keel Happy Ideal Manic Aware Manic Full-blown

Anxious & Agitated

Its 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

Clients Name of Clients Description State OTT; High Feeling agitated and restless; looking for the next big idea all the time; smiling too much; other people say I am not my normal self; not allowing any negative feelings Feeling happy and optimistic; like when I was on holiday in Australia with family; sharing positive experiences with other people; real self


Normal & Boring Doing everyday tasks; feeling irritable and frustrated with family; anxious and worried Depressed Very low; no energy; want to avoid people; do very little; very self-critical thoughts

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

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, 3, 6 month


Symptoms of bipolar disorder are more extreme expressions of normal experiences Model proposes that extreme, personal, conflicting beliefs maintain and escalate mood swings CBT involves exploring these appraisals, 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

BABCP: CBT Conferences

Relationships and Relating in CBT: Science and Practice

University of Westminster, London Thu 8th April Workshops Fri 9th April Conference University of Manchester Tue 20th July to Fri 23rd July c.20 workshops; CBT science & practice

Annual BABCP Conference


References on the model & therapy

Mansell, W., Morrison, A.P., Reid, G., Lowens, I. & Tai, S. (2007) The interpretation of and responses to changes in internal states: an integrative cognitive model of mood swings and bipolar disorder. Behavioural and Cognitive Psychotherapy, 35, 515-541. [supplementary material is a case study based on the model]. Mansell, W., & Pedley, R. (2008). The ascent into mania: a review of psychological processes associated with manic symptoms. Clinical Psychology Review, 28, 494-520. Mansell, W. (2007) An integrative formulation-based cognitive treatment of bipolar disorders: Application and illustration. Journal of Clinical Psychology, 63, 447-61. Mansell, W. & Lam, D. (2003). Conceptualising a cycle of ascent into mania: A case report. Behavioural and Cognitive Psychotherapy, 31, 363-368. Seal, K., Mansell, W., & Mannion, H. (2008). 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. Psychology and Psychotherapy: Theory, Research and Practice, 81, 33-53.

References on the model & therapy

Mansell, W., & Lam, D. (2006). I wont do what you tell me! Elevated mood and the assessment of advice-taking in euthymic bipolar I disorder. Behaviour Research and Therapy, 44, 1787-1801. Mansell, W. (2006). 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. Behavioural and Cognitive Psychotherapy, 34, 467-476. Mansell, W., Scott, J., & Colom, F. (2005). The nature and treatment of bipolar depression: Implications for psychological investigation. Clinical Psychology Review, 25, 1076-1100. Mansell, W. & Hodson, S. (in press). Imagery and Memories of the Social Self in People with Bipolar Disorders: Empirical Evidence, Phenomenology, Theory and Therapy. In L.Stopa (Ed.), Imagery and the Self in Psychopathology. Routledge. Mansell, W. & Scott, J. (2006). Dysfunctional Beliefs in Bipolar Disorder. In S. Jones & R. Bentall (Eds.), Psychological Approaches to Bipolar Disorder. Mansell, W., Rigby, Z., Tai, S., & Lowe, C. (2008). Factor analysis of the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) and its association with hypomanic symptoms in a student population. Journal of Clinical Psychology, 64, 450-465.