The idea has spread that it is a medical disease, that is, of biological origin. And indeed, this concept is correct although perhaps incomplete. Although Bipolar Disorder has as its main cause an imbalance in the biochemistry of the nervous system and its treatment cannot be carried out without medication, this does not mean that psychological strategies are dispensable. Quite the contrary, the evidence supports the idea that combined treatment, pharmacological plus Cognitive Behavioral Therapy, is the one that provides the best and most benefits to patients with this diagnosis.
Bipolar Disorder is a condition that affects between 2 and 6% of the world’s population; the final values depend on how it is defined. When strict criteria are used, obviously the number of people diagnosed decreases. The current trend most accepted today in the scientific world is to consider a “bipolar spectrum”, at one end of which some very defined forms appear, with the most distinctive characteristics of the disorder while at the other end are the less prototypical cases and with the more nonspecific symptomatology. Considering the full spectrum, perhaps up to 6% of the population may suffer from some form of Bipolar Disorder.
Bipolar Disorder is a condition that affects between 2 and 6% of the population in the world.
In all cases, the person who suffers from some form of the diagnosis suffers from mood swings beyond what is normal, healthy and functional; which in general warrants an intervention that can improve her quality of life. The more serious the condition, naturally, the greater the need to intervene. Now, how to intervene? What are the strategies that have shown real effectiveness in managing the symptoms and signs of this disease? Particularly, and given certain characteristics of the disorder, what strategies can also help the social environment of the bipolar patient?
As is widely known, the treatment of Bipolar Disorder has medication as its fundamental pillar. Today pharmacological treatment is highly protocolized. As a first line, mood stabilizers are administered, which are increased or decreased and combined or not with other drugs according to the evolution. In relation to this, one of the first obstacles arises to which Cognitive Behavioral Therapy can provide an answer. Patients often do not take the medication properly, in some cases they even abandon it.
Psychoeducation as a tool in adherence
Psychoeducation consists of providing the patient with correct, scientifically validated and useful information for their treatment, in an understandable language appropriate to their level of education.
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Specifically, as a treatment strategy for Bipolar Disorder, psychoeducation must cover at least a general description of the symptoms, emphasizing the role of oscillations in mood and habits that prevent crises. Along these lines, we will have to transmit information to the patient about the fundamental preventive role that medication and its adequate intake play; In fact, psychoeducation is revealed to be an invaluable strategy in what is known as adherence to medication treatment.
Behavioral contract
The behavioral contract is a tool whose use is recommended in diagnoses where motivation for treatment may fail. It is a very versatile procedure, adaptable not only to the pathology but also on a case-by-case basis. Specifically, and given that Bipolar Disorder is a chronic condition, it is advisable to focus not only on external objectives and incentives, but also on foreseeable obstacles and some alternatives to overcome them. As Bipolar Disorder is a condition with high social impact, a family member is usually involved in drawing up the contract.
Detection of prodromes
Prodromes are, simply put, low intensity signals that announce the possible arrival of an affective, depressive, manic or mixed episode. Among the most characteristic examples are alterations in sleep patterns, changes in activity levels, and fluctuations in the degree of sexual impulsivity. In many cases these are the same symptoms that appear in very marked intensity during affective episodes, but as prodromal symptoms they present in a much milder and more subtle way. Beyond generalities, each patient will have distinctive or idiosyncratic prodromal symptomatology; which is why we are working on training for its detection. Early detection of prodromes allows for early intervention, before crises are established; In this way, affective episodes can be moderated or even aborted.
Rhythm therapy and establishing healthy habits
One of the most influential approaches in the treatment of Bipolar Disorder was developed by Psychiatrist Ellen Frank under the name “Interpersonal and Social Rhythm Therapy.” Emphasizes that given the mood disorders suffered by the patient, it is advisable to establish routines that help regulate activation patterns while focusing especially on the human relationships established by the patient and on adequate training in solution of related problems.
Prodromes are, simply put, low intensity signals that announce the possible arrival of an affective, depressive, manic or mixed episode.
Dr. Ellen Frank’s approach was easily integrated with other lines of treatment and research that can be summarized in a program aimed at helping the patient establish basic routines as well as healthy habits of physical activity, nutrition, recreation and human relationships. Directly, the aforementioned strategies have a strong link with stress management programs that are also applied in the treatment of Bipolar Disorder.
Prevention of excessive behaviors
It is widely known how easily patients with Bipolar Disorder carry out excessive behaviors, such as sexual debauchery, pathological gambling, substance use, binge eating, among others. Consequently, it is vitally important that the patient learns to control her impulsivity.
Among the technical strategies used are the establishment of a daily activity plan, prioritizing some behaviors over others. Thus, we usually write two lists of daily behaviors, one a priority and one not. With this, the patient learns to organize his day, differentiating what he can from what he cannot postpone. This task also helps a lot to limit excess stimulation that comes from one’s own behavior, another of the maximum objectives in treatment.
Given that people with Bipolar Disorder tend to minimize the risks in moments of euphoria and mania or during the prodromes of these episodes, we will have to generate some containment strategies that prevent negative consequences that the patient would later regret. In this sense, we teach the patient to delay the implementation of important decisions that can put their stability at risk and actions whose consequences are difficult to undo. Conveying the idea that “if a decision is correct today, it will also be correct in 2 or 3 days” can prevent actions such as wasting money on crazy businesses or sexual debaucheries that put the stability of a couple at risk.
The change in cognitive content
The bipolar condition favors but does not determine the appearance of certain cognitive contents. Thus, for example, during depressive episodes, thoughts of uselessness, personal devaluation, overestimation of damage, a very pessimistic view of oneself and the environment or even the future are common, which puts the patient at risk of an act of suicide. On the contrary, during episodes of mania or hypomania, cognitions of grandiosity, exaggerated optimism, barely realistic positive expectations, and ideas that generally minimize risk and overvalue one’s own abilities above objective possibilities appear.
We will have to generate some containment strategies that prevent negative consequences that the patient would later regret.
In both cases, Cognitive Therapy strategies are very useful; although its effectiveness is definitely greater in depressive than manic episodes. If cognitive intervention is early, in the prodromal phase of the crisis, its potential for effectiveness increases greatly. It is important to train the patient in the detection, discussion and change of their automatic thoughts when they are euthymic, that is, in an inter-crisis period, so that the tools are more accessible to them at the critical moment.
Addressing cognitive processes
Along with cognitive content, such as thoughts and beliefs, we usually intervene on cognitive processes that take a pathological course during affective episodes. Thus, for example, we carry out exercises so that the patient trains his attentional resources, improves his ability to concentrate and therefore, does not fall into either excess or deficit of stimulation. Training in attentional refocusing as well as exercises and guidelines for managing stimulation are of special importance during the prodromal intervention.
The decision-making process is usually another of the topics frequently addressed. Among the most used strategies for its management are problem-solving training and self-instruction training.
Conclusions
The set of strategies to help a patient with Bipolar Disorder is very broad. The specific selection of which ones will be used depends a lot on the subtype of bipolarity in question and the specific characteristics of the case; As always, idiographic evaluation and functional analysis are the initial step of effective intervention in Cognitive Behavioral Therapy, Bipolar Disorder is no exception.
The treatment of Bipolar Disorder constitutes an archetypal example of the confluence of biological and psychological approaches. And the results of effectiveness studies strongly support this integration. Indeed, the quality of life of a patient with Bipolar Disorder is clearly higher when they are medicated and receive Cognitive Behavioral Therapy. Not only do they experience fewer affective episodes, but when they inevitably appear, they will be of shorter duration and intensity. Perhaps, as in so many other examples, we should stop stating that Bipolar Disorder is a medical disorder and start considering that it is one…