This piece will attempt to analyse how the use of Cognitive-Behaviour Therapy has been applied to the treatment of Bipolar Disorder, which is otherwise known as Manic Depression. Major Depressive Disorder, also known as unipolar depression, is classified in DSM-IV in terms of a list of symptoms of which sufferers must experience at least five for a period of two weeks to be classified as having a major depressive episode.
The key symptoms are feeling a depressed mood most of the day, virtually every day, as indicated by self report or observations by others, markedly diminished interest or pleasure in a lot of activities, significant weight loss when not dieting, or weight gain. Other symptoms include decreased or increased appetite nearly every day, insomnia, in other words, the inability to fall asleep, or inability to fall back to sleep after waking in the middle of the night, waking early, or hypersomnia, a desire to stay in bed or large portions of the day, lethargy, fatigue or loss of energy.
Feelings of worthlessness are a primary symptom of depression along with excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, and in significant cases, recurrent thoughts of death or suicide. There are also further diagnostic guidelines included in DSM IV; these are that the condition is not a mixed episode occurring at the same time as a manic episode, also that symptoms cause significant distress or impairment of functioning, though the degree of impairment necessary is not defined.
The condition is not due to substance abuse or a medical condition, and that the depression is not better explained by bereavement, because this reflects the ‘normal’ grieving process and not a psychiatric disorder, also that the symptoms the patient presents could not be better explained by another diagnosis. Finally, DSM IV states that the major depressive episode should not have been accompanied by a manic episode. This diagnostic condition is to separate unipolar from bipolar depression. Bipolar depression in which sufferers experience depressive episodes as described above, but also have periods of mania.
DSM IV defines mania as a distinctive period of unusually and persistently elevated, expansive or irritable mood lasting at least one week. DSM IV contains a symptom checklist for bipolar disorder, which states that a diagnosis can be made when the patient experiences three or more symptoms of inflated self-esteem or grandiosity, decreased need for sleep, is more talkative than usual, has flights of ideas or the subjective feeling of racing thoughts, is easily distractable, displays increased goal-directed activity or psychomotor agitation, for instance, a twitch or wringing the hands.
Other symptoms consist of excessive involvement in pleasurable activities that have a high potential for painful consequences (American Psychiatric Association, 1994), for instance, the patient may spend vast amounts of money without thinking of the consequences (Atkinson, Atkinson, Smith, Bem, Nolem-Hoeksema, 1996). There are also further diagnostic guidelines for bipolar disorder along the same lines as those for unipolar depression, which include that the manic episode should not coincide with a depressive one, in bipolar disorder the depressive and manic episodes occur sequentially not concurrently.
Symptoms cause significant distress or impairment of functioning, though again the degree of impairment necessary is not defined, and that the disorder is not due to substance abuse or a medical condition (American Psychiatric Association, 1994). There are many types of therapy applied to the treatment of depression, though for the purpose of brevity the current piece will focus on the use of Cognitive-Behaviour Therapy (CBT) in the treatment of bipolar depression.
In the mid-1970’s Aaron Beck proposed a model that accounted for symptoms of depression and suggested therapeutic approaches to dealing with these symptoms. Beck theorised that during early life people develop a set of schema, or beliefs, based on experience. In people who suffer from depression, these belief systems, or assumptions, develop from negative early experiences such as the loss of a parent, rejection from parents or peers, or can evolve from the depressed behaviour of a parent.
These negative experiences lead to the development of dysfunctional beliefs about the world, which are triggered by critical incidents in the future. For example, when a relationship ends a depressed person may have feelings that trigger a set of beliefs such as “I am unlovable”, “people will always reject me”, and “I am a worthless person” (Atkinson, et al. 1996). Once the negative schema is activated this leads to a stream of what Beck called Negative Automatic Thoughts (NATs).
NATs are a set of automatic thoughts over which the person has no voluntary control that are intrusive. These thoughts are interpreted as being true by the individual and are not evaluated; therefore, the NATs usually lead to other negative thoughts. It is this pessimistic perception that leads to the symptoms of depression, in other words they disrupt mood, reduce motivation, increase anxiety and arousal, they can disturb cognitive processing especially through misattributions and interpretive biases, and lead to behavioural changes (Beck, 1976).
Beck designed a questionnaire for patients to fill in asking them to report on specific feelings they were experiencing, he called this the Beck Depression Inventory (BDI). The BDI asked respondents to indicate a statement that best describes their recent beliefs about how they feel, how they perceive others feelings and indications as to future prospects. Beck found that using this method gave “a rapid assessment of the severity of the disorder” (Beck, Rush, Shaw, Emery, 1979, p. 89) and provided a “natural lead into some of the patient’s central problems” (ibid. . 89). The Beck Depression Inventory is a therapeutic tool that is still widely used today. A major component of Beck’s theory is the negative cognitive triad, which is a set of far reaching and global views, including pessimistic views of the self, the world and the future. This negative cognitive triad in turn leads to Depressogenic (Negative) Schema which is triggered by negative life events and leading to unfeasible goal-directed schema such as statements like “I must be the best at everything”.
Beck also theorised about another phenomenon he encountered in people with depression which he termed Cognitive Biases (Systematic Logical Errors), these included over-generalisation of negative schema, and personalisation of seemingly innocuous events, which, Beck conjectured, can also lead to depression (Beck, et al. 1979). Cognitive-Behaviour Therapy (CBT) refers to a group of therapies that aim to reduce dysfunctional emotions and behaviour by altering behaviour and by altering thinking patterns, based on the assumption that prior learning is currently having adverse consequences.
The purpose of therapy is to reduce distress or unwanted behaviour by undoing this learning or by providing new, more adaptive learning. Cognitive behavioural therapists believe that a change in symptoms follows a change in thinking, or cognitive change, which is brought about by a variety of possible interventions, including the practice of new behaviours, analysis of faulty thinking patterns, and the teaching of more adaptive cognitions. The primary feature of CBT is challenging negative thoughts and beliefs that have built up.
A key process is in making client’s realise that the thoughts they have are merely thoughts and do not necessarily reflect the true state of affairs (Beck, 1976). CBT for depression includes interventions that focus on publicly observable behaviour. The treatment is conducted in a progressive manner so that the therapist first focuses on overt behaviour change; teaches the client to assess and, when necessary, correct situation-specific distortions in thinking, and finally moves to the identification and modification of more stable depressive schemas and presumed cognitive structures.
A number of procedures are employed as therapeutic tools, including Thought Catching which involves listing intrusive thoughts following a difficult experience so that the therapist and client determine which thoughts are reasonable reflections of reality and which are NATs brought on by the incident. Task Assignments are generated by the client that reflects activities that they are avoiding for whatever reason, like avoiding going out because of fear of rejection (Beck, 1976). The client then makes predictions about what will go wrong should such a task be confronted.
Between sessions the client is encouraged to carry out the task, and in the subsequent session the client and therapist discuss whether their predictions were accurate, though they usually find that they have overvalued the negativity of the task (Beck, Freeman, 1990). Cognitive Rehearsal can be used to help the client develop skills for overcoming problems, for example, if it is possible that a situation is likely to arise in the near future that is similar to the task they have performed, the client is encouraged to think about every detail of this future event.
Whenever they come across a difficulty, it is noted down and set aside so that the client can follow the task through to a positive conclusion; this ensures that the focus is on the positive feelings that this successful completion elicits. The stumbling blocks are then discussed one by one, and the client is encouraged to generate solutions to each one. A particular block can also be dealt with using a task assignment, depending on the nature of the block; this helps clients to practice generating solutions to problems (Beck, et al. 1979).
There are numerous studies on the efficacy of CBT in treating unipolar depression, though there is surprisingly little on the use of this approach in the treatment of bipolar disorder (Zaretsky, Zindel, Gemar, 1999). A meta-analysis that reviewed studies looking at the effect of CBT on depression suggested that CBT alone produces a change in depressed symptoms of around 66%. This is comparable to the efficacy of drug therapy; CBT was shown to be as effective as good as drugs alone, though with none of the side-effects (Williams, 1997).
This finding was reinforced by a study concerning bipolar depressed patients treated with a combination of mood stabilisers and CBT. This method showed a robust treatment response in the absence of antidepressant medication in the participants diagnosed with bipolar disorder. The level of improvement observed in this experiment was analogous to that observed in a control group of case-matched recurrent unipolar patients who were treated with CBT alone.
Conversely, despite improvement in depressive symptoms and negative thinking, no significant changes were observed in underlying dysfunctional attitudes, this suggests that bipolar depressed patients may require a more intensive course of CBT (Zaretsky, et al. 1999). According to these studies into treatment of bipolar disorder, although little in number, the efficacy of CBT is not in doubt, the problems arise when attempting to ascertain how this approach actually works (Zaretsky, et al. 1999).
To conclude, there are clinical reports that people diagnosed with unipolar depression do actually think in the forms indicated herein, for example, in terms of the negative cognitive triad (Beck, 1976). However, Beck’s model has been criticised for merely describing the cognitions that depressives have and not telling us how these negative cognitions come about (Zaretsky, et al. 1999). The paucity of empirical research into the cognitive treatment of bipolar disorder must be resolved in order to understand this important condition more.