Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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,
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
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
Depression
Bipolar II
Mania Hypomania Normal
Depression
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
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
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
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:
Normal Range
Stressful events Goal-attainment events Disrupted Routine Stressful relationships Anxiety Examples of risk factors
Subjective
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?
Objective
100 90 80 70 60 50 40 30 20 10 0 Yes No
or Continuum?
10
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)
10
12
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
THINKING: FEELINGS: I can do anything I want High energy I can overcome all my problems Feel High
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
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
Success! Safety!
Failure! Catastrophe!
A Cognitive Model of Bipolar Disorder (Mansell, Morrison, Reid, Lowens & Tai, 2007)
Ascent Behaviours
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
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
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
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
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
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
60
Mean HAPPI
50
40
30
20
10
Unipolar (N=22)
HAPPIstudy
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
Treatment
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
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
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
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
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
I Multiple baseline; 12 sessions; 1,3 & 6m FU Symptoms, cognition & functioning Qualitative feedback
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
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
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
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
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?
keel, third way, stepping back Help the client to describe it in detail:
Anchor in reality specific period Use Continuum to explore the boundaries Use virtuous cycle to formulate
Examples
0 10 20 30 40 50 60 70 80 90 100 /_____/______/______/______/________/
Depressed Down Even Keel Happy Ideal Manic Aware Manic Full-blown
Its OK to be slightly agitated I still have some control Notice my surroundings Drop ascent behaviours Let the mood pass
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
Happy
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
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
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
Summary
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
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
See www.babcpconference.com
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.
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.