My nephew suffers with bipolar and is on lithium and an anti-psychotic drug. He feels this drugs “dull his ability to think”. This causes him to come off his drugs which eventually leaves him in a very bad place requiring hospitalization. He believes CBT could help him but hasn’t been given an opportunity to try it, he feels it could help him live a more normal life style. Could you enlighten me please.
Hello and thank you for your question.
I have always been interested in Bipolar disorder since my early days working in the NHS, when someone stated that they did not know anymore what was them and what was the illness, what was them and what was the medication. It became important to me to look at what it means to the individual, and how it can be managed effectively, in order for the person to lead a productive life.
Saying that, I no longer work with people with Bipolar, as I am in private practice, and strongly believe, that to receive the best possible care, that a Team should be used. Why? Well, it allows the person to work with a team of people that understand all aspects of their health, who will be aware of changes in medication, and what psychological work is being done, and how this all works together. This is my own opinion, others may disagree, but it is important to me, to ensure that everyone gets what I would consider to be an effective service.
I should start by saying that as a psychologist, we do not prescribe medication, and all information relating to meds should be discussed with whomever prescribed lithium and and the anti-psychotic drug.
That said, I am very familiar with medications used to treat bipolar disorder, as I previously ran psycho educational groups for people with bipolar, while I was working in the NHS in the UK.
Compliance with meds (ensuring that meds were taken as prescribed) was a pre-requisite of being admitted to, and staying on the psycho educational course. The reason for this, was that, in order to get the best from the group, the medication ensured that they were able to stay well.
I am sure there will be lots of people that are against medication, but meds have their place. Medication options are outlined in the NICE guidelines for the treatment of bipolar. (these are UK guidelines to ensure the quality of health care.)
I would recommend your nephew discuss his medication with whomever prescribed them, as opposed to coming off them alone, as from what I understand from your question, this results in hospitalization.
This is all the more important depending on the type of disorder he has.
Bipolar disorder can sound like a catch all, but it is important to note the differing types of the condition
- Bipolar 1: where a person can experience both mania and severe low mood
- Bipolar 11: you can think of this as a milder form of Bipolar 1
- Rapid Cycling: is where someone has at least four different episodes of mania, or hypomania, and major depression within one year.
As with all medications, there are very good reasons why they should not be stopped abruptly. Many people, if they are having difficulty with side effects or feel that they are doing well, come off medications on their own, which can have adverse consequences.
Will CBT help?
CBT for bipolar disorder, operates a bit differently than say, using it for anxiety. The key areas are;
- Stage 1, psycho-education and symptom history
- Stage 2, cognitive behavioural skills to cope with prodromes (early warning signs)
- Stage 3, self management and dealing with the personal and social cost
An important factor in any treatment is education about the disorder in terms of informing the individual that they may have patterns that are unique to them, that may help them to predict if an episode is about to occur. This will allow them to take action before the episode becomes something major.
The person will normally start to chart or record, signs and signals that seem to occur before an episode.
Taking a symptom history highlights the prodromes (early warning signs) of both mania and depression.
Common prodromes that exist in mania include
- Increased activity
- Elevated mood
- Decreased need for sleep
- Being more talkative, and
- Having an increased sense of self worth
Effective coping strategies include
- Modifying excessive behaviour
- Calming activates
- Ensure to rest and sleep
Common prodromes that exist in depression include
- Depressed mood
- Loss of memory
- Concentration difficulties
Effective coping strategies include
- Getting organised and keeping busy
- Distract from negative thoughts
The diathesis-stress model is introduced and episodes are explained as a result of the interaction between biological factors such as sensitisation effects or circadian rhythms, and stressors, which may include, for example the disruption of routine and specific life events.
You can think of circadian rhythms as being the physical, mental and behavioural changes that we experience every 24 hours, depending on things like, light and darkness. Our body has it’s own rhythms, that influence when we get tired, when we wake up. If these are not working well for us, sleep can get affected (amongst other things.)
The importance of circadian rhythms in relation to Bipolar Disorder, is that staying awake for too long, can act like an anti-depressant. This is important, as when a person is about the enter mania, some research is showing that anti depressants can trigger the episode.
That said, if disruption in sleep, is like an anti-depressant effect, this could mean that the lack of sleep could push the person into mania- this is one of the reasons, identifying these prodromal (or early warning signs) is important.
If the person is able to chart their prodromes to identify, for example, the possible onset of a manic episode, then the coping strategy to employ would be to ensure adequate sleep to avoid the anti-depressant effect of reduced sleep which is common in mania.
Sometimes, it is hard to know the difference between day to day mood swings that we all can get ( I certainly do!) and the mood swings that suggest an episode is about to occur.
Standard CBT tools such as rating and monitoring of moods, help the person differentiate between normal mood fluctuations and the onset of an episode.
Idiosyncratic triggers, can be explored in the therapy sessions. For example, if during the history taking, the individual finds that certain stressful events have been triggers in the past, if possible, these can be avoided in the prodromal stage. If the trigger cannot be avoided, the use of ‘thought monitoring’ detailing how thoughts affect mood can be worked with in order to reduce stress levels.
The final stage includes a review of work to date and continues to build on CBT techniques that the person has been introduced to.
The whole idea of CBT is to help the person recover from episodes, to decrease relapse and to improve quality of life.
You said that he has not been given the opportunity to try CBT yet. As a final point, I would like to say that there are many CBT self help books that he may want to read.
Could start with The Bipolar Workbook
I hope this helps,