Cognitive-Behavioral Approach to Bipolar Disorder

Description of the Strategy

Cognitive-behavioral therapy (CBT) has evolved over the past 40 years as an alternative to more traditional nondirective and insight-oriented modes of psychotherapy. The family of cognitive and behavioral therapies includes a diverse group of interventions. Although initially conceived as a therapy for unipolar depression, in the past 20 years, CBT has also been applied to the treatment of bipolar disorder as well. [Page 199]Basic CBT principles that are applied to the treatment of unipolar depression can be modified and adapted to the treatment of bipolar disorder. In general, first and foremost, CBT emphasizes a psychoeducational orientation, by which patients learn about the nature of their illness, resulting problems, and the rationale for use of particular treatment strategies. Second, CBT typically employs homework and self-help assignments to provide patients the opportunity to practice therapeutic methods to enhance generalization of positive therapy effects outside of the therapy hour. Third, objective assessment of psychiatric illness is considered an integral part of treatment, and selection of therapeutic strategies derives logically from such assessments. Fourth, therapeutic methods used are generally structured, are directive, and require a high level of therapist activity. Fifth, CBT interventions are built on empirical evidence that validates the theoretical orientation and guides the choice of therapeutic techniques. Specifically, learning theories (i.e., classical, operant, and observational models of learning) and the principles of cognitive psychology are relied on heavily in constructing cognitive-behavioral treatments. Although classic CBT for unipolar depression is most often a time-limited intervention, CBT for bipolar disorder is also useful as a maintenance psychotherapy.

Figure 1 The Classic (linear-processing) Model of CBT

The Cognitive-Behavioral Model

The basic theories of the cognitive model are rooted in a long tradition of viewing cognitions as primary determinants of emotion and behavior. Cognitive therapy (CT) concepts have been traced back as far as the writings of the Greek Stoic philosophers and have been linked to a number of other influences, including the phenomenological school of philosophy, Albert Ellis's rational-emotive therapy, and the contributions of Adler and other neo-Freudians. However, the greatest impetus for the development of cognitively oriented therapy has been the work of Aaron T. Beck. Figure 1 displays the classic CT (linear-processing) model for understanding the relationships between environmental events, cognition, emotion, and behavior. This model is based on the theoretical assumption that environmental stimuli trigger cognitive processes and the ensuing cognitions give the event personal meaning and elicit subsequent physiological and affective arousal. These emotions, in turn, have a potent reciprocal effect on cognitive content and information processing, such that cascades of dysfunctional thoughts and emotions can occur. The individual's behavioral responses to stimuli and thoughts are viewed as both a product and a cause of maladaptive cognitions. Thus, treatment interventions may be targeted at any or all components of the model.

More recently, Beck and others have expanded the model in recognition of other factors that may be involved in the etiology of mood disorders, especially for patients with bipolar disorder, such as genetic predisposition, state-dependent neurobiological changes, and various interpersonal variables. This more complex model, the “integrative” model of CBT (see Figure 2), more accurately describes the phenomenological course for bipolar disorder. In this model, it is hypothesized that the mood state (depressed, manic, mixed, or hypomanic) leads to changes in thinking and feelings. This leads to changes in behavior that then can lead to impaired psychosocial functioning. There is an increase and worsening of psychosocial problems that lead to emotional duress and the biological changes of sleep loss and the other symptoms of the disorder. Now, the positive-feedback loop is complete, as the worsening biological disturbance results in a worsening of the mood state. These influences must be included in the case conceptualization for CBT treatment of patients with bipolar disorder. It must be emphasized that such an expanded cognitive-biological model, which synthesizes cognitive and neurobiological factors in a combined therapy approach, rests upon a foundation of satisfactory maintenance pharmacotherapy. This point highlights the CBT multimodal approach of addressing each of these “nodes” in the web sequentially or simultaneously. Many current researchers are attempting to understand how best to combine and/or sequence CBT and pharmacotherapy. New developments and modifications of CBT technique will be based upon information from contemporary research in basic and cognitive neuroscience as our understanding of the disorder increases.

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