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CBT for Bipolar

"How does cognitive behavioral therapy work?The primary goal of CBT is to help you gain a new outlook on your situation. It does this by directly challenging negative thoughts and fears and teaching you to control or get rid of them.
The therapy is generally short-term and directly focused on eliminating or managing specific problems. It involves contributions from you and the therapist.
During a CBT session, you and the therapist will work together to:

1. Determine the problem

This can be mental illness, work or relationship stress, or anything else that’s bothering you.

2. Examine the thoughts, behaviors, and emotions associated with these problems

Once the problems are identified, you will work with the therapist to begin looking at how you’re reacting to those problems.

3. Spot negative or inaccurate thoughts, behaviors, and emotions

There are a number of ways you can perceive or deal with an issue that actually worsens the problem. This can include thinking negatively about yourself, or focusing on the negative aspects of a situation or occurrence.

4. Change your reaction to personal issues

During a session, you and the therapist work together to replace these negative thoughts with more positive or constructive ones. These can include thinking positively about your ability to cope, and attempting to view a situation more objectively."

"6 CBT Techniques for Bipolar Disorder
CBT teaches several important skills that target the core ways bipolar disorder affects you, Rego says. These include:1. Accepting your diagnosis. The first step is to understand and acknowledge that you have a disorder that's responsible for your symptoms. This is often difficult for people with bipolar disorder to accept, so teaching the signs, symptoms, causes, and course of the disorder is essential. It helps people embrace the idea of getting help while also knowing they’re not alone, Rego says.2. Monitoring your mood. This is often done using a worksheet or journal, which is kept up on a daily basis between sessions and then reviewed with your therapist. People are asked to rate their mood daily on a 0-to-10 scale, in which 0 represents “depressed,” 5 stands for “feeling OK,” and 10 is equivalent to “highly irritable or elevated mood.” The purpose is to become more aware of mood triggers and changes.3. Undergoing cognitive restructuring. This process focuses on correcting flawed thought patterns by learning how to become more aware of the role thoughts play in your mood, how to identify problematic thoughts, and how to change or correct them. The therapist teaches the patient how to scrutinize the thoughts by looking for distortions, such as all-or-nothing thinking, and generating more balanced thinking.4. Problem-solving frequently. This step involves learning how to identify a problem, generate potential solutions, select a solution, try it, and evaluate the outcome. Typically first taught in therapy, problem-solving is then practiced between sessions. Problems can be in any domain of life, from relationship distress to unemployment to credit card debt. All of these stressors, if not resolved, can put you at greater risk for a lapse.5. Enhancing your social skills. Some people with bipolar disorder lack certain social skills, which causes them to feel that they aren’t in control of a certain aspect of their lives. Learning skills such as assertiveness can help you manage interpersonal relationships better.6. Stabilizing your routine. Engaging in activities on a regular and predictable basis establishes a rhythm to your day, which helps stabilize your mood. Examples include exercising in the early afternoon, setting a consistent sleep and mealtime schedule, making social plans, and doing chores around the house."

"CBT-IB includes the following elements:
  • Cognitive behavioral therapy for insomnia (CBT-I)
  • Social rhythm therapy
  • Chronotherapy
  • Motivational interviewing (MI)
CBT-I is a triad of sleep hygiene, standard CBT techniques, and sleep restriction therapy; these elements and a remarkable free app supporting their implementation were recently reviewed in my previous article for Psychiatric Times.

Two important differences in the CBT-IB version: sleep restriction is not allowed to be more than 6.5 hours per night, to prevent induction of manic or mixed states; and a regular bedtime is promoted, not “wait to go to bed until you are sleepy.”

Social rhythm therapy includes helping patients develop those regular schedules, especially a regular bedtime and a regular rise time. The latter can be facilitated with a dawn simulator, a form of chronotherapy that is far easier to use than a light box and very inexpensive.

Free apps are available to make a smartphone function as a dawn simulator (although only one dawn simulator has been formally tested, the function is straightforward and ought to generalize across devices, perhaps even the cell phone approach).

CBTI-BP treatment components are described below.

Functional analysis/case formulation and goal setting. Sleep-related behaviors and consequences are assessed before bed (e.g., bedtime routine), during the night (e.g., cell phone left on), on waking (e.g., sleepiness, lethargy) and during the day (e.g., caffeine use). Specific goals are identified.

Motivational interviewing (MI). MI is a method which emphasizes accepting the patient as an individual, avoiding argumentation, giving lectures or ultimatums and focuses on the process of eliciting and shaping language in favor of change (i.e. change talk). MI also includes regular straightforward reviews of perceived pros and cons of change, recognizing that many sleep-incompatible/interfering behaviors are rewarding.

Sleep and circadian education includes definitions, environmental influences (particularly light), circadian and social rhythms (following IPSRT) and the tendency toward delayed sleep phase. Sleep inertia is defined and normalized . We address the role of sleep disturbance in mood regulation and as a prodrome of mood episode relapse.

Behavioral components. 1) Stimulus control , one of the most effective treatment components of CBT-I , focuses on regularizing the sleep-wake cycle and strengthening associations between the bed and sleep , as well as regularizing daytime rhythms (e.g., setting regular meal and wake-up times) . 2) Restricting time in bed is derived from observations that excessive time in bed perpetuates insomnia and increased homeostatic drive improves sleep. We limit time in bed to the actual time slept, and gradually increase it back to an optimal sleep time. In order to avoid sleep deprivation for safety, time in bed is never less than 6.5 hours. 3) Regularizing sleep-wake times. IPSRT principles are utilized to regularize sleep and wake times and avoid naps . These techniques promote consistent sleepiness in the evening and enable patients with a tendency toward eveningness to progressively move their bedtime forward by 20-30 minutes per week (small enough that the circadian system can adapt). 4) Wind-down. Patients need assistance to devise a ‘wind-down’ of 30-60 minutes in which relaxing, sleep-enhancing activities are introduced, in dim light conditions. This helps the circadian phase advance in patients who are evening-types, and maintains entrainment . A central issue is restricting the use of interactive electronic media (internet, cell phones, MP3 players). MI and behavioral experiments are used to facilitate voluntarily choosing an electronic curfew. 5) Wake-up. Individualized wake-up plans draw on IPSRT principles, and include: not hitting snooze, opening the curtains to let sunlight in, and making the bed so the incentive to get back in is reduced.

Cognitive components. 1) Challenging unhelpful beliefs about sleep is important and common in bipolar disorder . They include: ‘the TV helps me fall asleep’ and ‘medication is the only factor that contributes to my feeling drowsy’. Guided discovery and individualized experiments test the validity and utility of the beliefs . 2) Patients with bipolar disorder are anxious about their sleep, in part because they know that sleep loss can herald a mood episode relapse . As anxiety is antithetical to sleep onset , we use individualized strategies to reduce bedtime worry, rumination and vigilance including cognitive therapy, diary writing, or a scheduled ‘worry period’.

Daytime coping. A commonly held belief is that the only way one can feel less tired in the day is to sleep more. Hence, an experiment is devised to allow the patient to experience the energy generating effects of activity and develop a list of ‘energy generating’ and ‘energy sapping’ activities to better manage daytime tiredness.

Relapse prevention. The goal is to consolidate gains and prepare for setbacks using an individualized summary of learning and achievements. The therapist and patient develop a decision tree and menu of options for managing the range of sleep problems that may be experienced during the course of bipolar disorder mood episodes."


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