| Cognitive behavioural case formulation in bipolar disorder
Elizabeth Tyler and Steven Jones
Bipolar disorder has only recently been studied from a psychological perspective. There is now increasing evidence for the importance of cognitive behavioural therapy in improving functioning and reducing risk of relapse. This chapter briefly describes the rationale for a psychological approach to bipolar disorder before introducing a clinical heuristic as a context within which to appreciate the clinical examples and case formulations that follow. Key features of the assessment and therapy process with bipolar clients will be described. Targets for therapy include the stabilisation of routines and helping clients to deal more adaptively with mood fluctuations. Potential pitfalls in therapy are noted and possible solutions identified.
Bipolar disorder is a severe and chronic mental health problem characterized by recurrent episodes of depression and mania / hypomania. Lifetime prevalence estimates are 1.0% for bipolar disorder I and 1.1% bipolar disorder II (Merikangas et al., 2007). Bipolar disorder I involves periods of severe episodes of mania to depression. Bipolar disorder II involves a milder form of mood elevation (hypomania) with periods of severe depression.
Whilst bipolar disorder is sometimes associated with achievement and artistic creativity (Goodwin and Jamison, 2007; Murray and Johnson, 2010), it is often associated with considerable burden for individuals including elevated rates of anxiety, substance use, suicidality, disability and unemployment (Fajutrao et al., 2009). Bipolar disorder it is now placed within the top 20 most disabling illnesses in the world (Vos et al., 2012) and approximately 20-25 % of individuals will attempt suicide at some point in their lifetime (Merikangas et al., 2011). The estimated cost to the English economy is £5.2 billion per year (McCrone et al., 2008) and in the US Kleinman et al. (2003) estimated total annual costs were $US45.2 billion (1991 values). Bipolar disorder represents a considerable financial burden to society, with many individuals unable to work due to inadequate treatment.
It is only in the last 15-20 years that the importance of psychological, and particularly cognitive behavioural, treatment has been recognised for bipolar disorder (Lam et al., 2010; Basco and Rush, 2007; Johnson and Leahy, 2005; Newman et al., 2001). The assumption that bipolar disorder is primarily a genetic/biological illness, with a relatively benign presentation between episodes, had led to medication with lithium or a similar medication (Scott, 1995; Scott and Colom, 2005; Vieta and Colom, 2004) being seen as the mainstay of treatment for mood stabilization. Consistent with this approach there is clear evidence that Lithium is more effective than placebo in preventing relapse in bipolar disorder (Burgess et al., 2001) and that it is likely to be more effective than more recently investigated mood stabilisers such as carbamazepine and sodium valproate (Kessing et al., 2011; NICE, 2006).
However, medication is not adequate on its own, and lithium is not always beneficial for individuals with bipolar disorder (Goodwin, 2009; Geddes, 2004; Cipriani et al., 2005). A 1990 National Institute of Mental Health (NIMH) report noted that 40% of individuals treated with lithium did not experience a signiﬁcant improvement in clinical state or relapse risk (Prien and Potter, 1990). Furthermore, Denicoff et al. (1997) reported over 30% of patients stopped taking either lithium or carbamazepine within a year due to lack of efficacy. Other reports have concurred that many individuals with bipolar disorder continue to relapse despite prophylactic lithium treatment (Geddes et al., 2004; Burgess et al., 2001).
Since the publication of the NIMH report, which called for the development of eﬀective psychosocial interventions for the treatment of bipolar disorder (Prien and Potter, 1990), there has been rapid development of psychological treatment approaches for this disorder, as will be described below. The National Institute for Health and Care Excellence (NICE) Bipolar Disorder Guideline recommends that individual structured psychological treatment is offered to individuals with a diagnosis of bipolar disorder (NICE, 2006).
The growing recognition of the effectiveness of psychological therapies for bipolar disorder is also reflected in recent launch of the Improving Access to Psychological Therapies (IAPT) for Severe Mental Illness (SMI) project. IAPT-SMI aims to increase public access to a range of NICE approved psychological therapies for psychosis, bipolar disorder and personality disorders.
This chapter will brieﬂy describe the rationale for a psychological approach to bipolar disorder before introducing a clinical heuristic as a context within which to appreciate the clinical examples and case formulations that follow. Key features of the assessment and therapy process with bipolar clients will be described. Potential pitfalls in therapy will be noted and possible solutions identified.
The stress-vulnerability approach to mental health problems assumes that the individual has an inherent vulnerability which is impacted upon by life events and other stressors. The extent of the vulnerability and the amount of stress interact to determine whether and when that individual experiences a period of illness. There is increasing evidence that psychological and social factors have an important impact on the onset and course of bipolar disorder. Numerous studies have now reported that life events are associated with onset, severity and duration of both manic and depressed episodes (Alloy et al., 2005; Johnson and Roberts 1995; Johnson and Miller, 1997). There is also evidence to suggest that stressful life events may be a consequence of bipolar disorder (Hosang et al., 2012), highlighting the importance of developing adaptive coping strategies in response to these events. Furthermore, studies of family atmosphere have indicated that relapses of manic and depressive symptoms are associated with high levels of expressed emotion (Butzlaﬀ and Hooley 1998; Rosenfarb et al., 2001).
In addition to psychosocial factors, there is evidence that bipolar episodes are also associated with disruptions of circadian functioning. Thus, sleep disruption has been noted as a factor in mania in particular (Leibenluft et al., 1996; Wehr et al., 1987), and numerous markers of circadian instability have been reported for individuals with bipolar disorder during episodes (Millar et al., 2004; Teicher 1995; Wolﬀ et al., 1985). There is also evidence that circadian disturbances are present outside periods of acute mood disturbance. Sleep circadian activity disruption has been observed in individuals who are remitted (Jones et al., 2005; Millar et al., 2004; Harvey at al., 2005) and individuals at risk for developing bipolar disorder (Jones et al., 2006; Ankers and Jones, 2009). Additionally, research highlights the importance of cognitive styles in bipolar disorder which can exacerbate the initial disruptions caused by life events or circadian disturbance (Jones et al., 2006; Johnson and Jones 2009). Alloy et al. (2005) suggest that the cognitive styles of individuals with bipolar disorder are distinguished by features which are characteristic of high Behavioural Activation System (BAS) sensitivity, including increased goal striving, perfectionism, self-criticism and autonomy. Jones (2001) further suggests that self-dispositional appraisals of circadian disturbance can exacerbate initial symptoms of both mania and depression (discussed further below).