Dealing with manic and hypomanic phases has been described as being the biggest clinical challenge in the treatment of bipolar individuals. Most individuals suffering from bipolar disorder would describe a manic phase as being inescapable. Once their mood starts to rise, the initial positive reinforcement of experiencing new sources of energy and creativity develops. Especially when this happens after long periods of depressed mood, it easily develops into a self-reinforcing pattern that seems impossible to stop.
The psychoeducational component of the cognitive behavioural intervention is an important starting point in this stage of problematic mood changes. The individual's awareness of possible consequences and that manic episodes are developing in a way that requires increased external control and medication seems crucial in preventing the negative impact of full-blown manic episodes. Past episodes provide the best source for information.
The early warning signs paradigm, originally developed for relapse prevention in early-onset psychotic disorders, especially schizophrenia, has been adapted for use with people suffering from bipolar disorders (Lam & Wong, 1997). Patients learn to identify prodromal and early symptoms of relapse and develop a range of behavioural techniques to improve their coping skills in order to counteract early symptoms effectively and to avoid their development into a full-blown episode.
In most cases, the change in mood, cognition, and behaviour is a gradual process. This allows time for the clinician and the individual to utilise psychological interventions while he or she is still responsive to cognitive and behavioural techniques. Teaching patients to recognise early symptoms of psychotic relapse and to seek early treatment is associated with important clinical improvements (Perry et al., 1999). Recent advances in the identification and formulation of individualised early warning signs (Lam & Wong, 1997) and the prodromal "relapse signature" (Smith & Tarrier, 1992) allow clinicians to reformulate the process of cycling into mania as an interaction of the individual's life situation, cognitive processing, and general level of coping skills. We can help patients to develop an individualised profile of prodromal changes and to be sensitised to significant mood changes early enough to curtail vicious cycles. This therapeutic step is influenced by the idiosyncratic beliefs that patients associate with changes in mood and that might compromise their coping abilities in the face of prodromal changes. For example, patients who believe that their manic episodes follow a predetermined course no matter what they do, might well be less cautious and responsible in the face of early hypomanic mood changes, and therefore might exacerbate the development of manic symptoms. These maladaptive beliefs underlying the individual's coping strategies and reactions are crucial, especially in the prevention of manic episodes. In utilising cognitive therapy strategies such as cognitive reframing and guided discovery, patients can learn to view new behaviours as an active process in which they execute a choice and that, despite the undeniable attraction of hypomanic impulses, some degree of control may be established.
One of the difficulties described by many patients is that of developing hypervigilance against minor changes in mood and their misinterpretation as onset of a manic episode rather than an accurate reflection of ordinary happiness, a mistake which can lead to inappropriate safety behaviours and avoidance. Within a cognitive behavioural framework, this can be avoided by teaching patients to monitor their mood on an ongoing basis, using individualised mood-monitoring tools that allow patients to look out for several specific prodromal signs in connection with actual environmental stressors and events, in order to avoid the generalisation of mood changes. Patients may also learn to employ coping strategies in response to prodromal changes that are appropriate to the mood changes observed. These coping strategies include activity schedules, the observation of sleep and dietary routines, the practice of relaxation exercises and graded task assignments, time-delay rules and problem-solving techniques in the face of impulsive decision making, and stimulus-control techniques, such as the regulation of alcohol and caffeine consumption, and the reduction of risk-seeking behaviours and stimulating activities. In a review discussing the benefits of cognitive behavioural interventions for individuals suffering bipolar disorder, Jones argues that the indicated mechanisms of change, over and above the known benefits of cognitive therapy, indicate behavioural techniques, such as extended activity scheduling and stabilisation of daily routines and sleep cycles, that predominantly influence circadian rhythm (Jones, 2001).
Disruption and irregularity in circadian rhythms, social events, and activities have been found to impact significantly on mood and can trigger affective episodes in people suffering from bipolar disorders. In support of this effect, the regulation of social interactions and balanced sleep-wake cycles have been found to be effective in preventing relapse and subsyndromal mood swings in bipolar disorders. Bipolar patients are highly sensitive to disruptions in their biological rhythms (Malkoff-Schwartz et al., 1998). The regularity of daily routines and activities, as well as the regularity of sleep-wake cycles, has been identified as a major protective factor (Frank et al., 1999). The psychological factors that influence individuals' ability to maintain stability, such as advance planning, attention to detail, and self-restraint, are the very difficulties that are associated with bipolarity. The therapist must therefore be very cautious in introducing these ideas that might easily be perceived as being overly controlling and meet significant resistance from the patient. One way to evaluate whether positive mood changes are indicative of a hypomanic or manic episode is to engage in calming activities and "time out" as a way of self-assessment of whether it is possible for the patient to remain still and to concentrate for significant periods of time.
The most effective intervention for successful coping with prodromal symptoms and counteracting mood changes is to re-evaluate the experience of past episodes and their consequences, and to engage in a cost-benefit analysis of letting things take their natural course, or to engage in constructive self-monitoring and self-regulating strategies. A useful therapeutic step within this is the acknowledgement of the difficulties in resisting especially hypomanic mood changes and the initial gratification that goes along with it. In this, we need to bear in mind that both appraisals of current symptoms and the memory of past episodes are influenced by mood-congruent biases. It is therefore valuable to use life-charting techniques and diary keeping to encourage patients to process recent changes in the context of past experience and in interaction with other life changes (Basco & Rush, 1996).
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