Cognitive Behavior Therapy (CBT) — Bipolar 1 Disorder Case Study

Lily Cosgrove
12 min readOct 29, 2016

Introduction

The question what seems to cause fluctuating highs and lows of bipolar disorder is answerable through a study by Dèttore et al. (2015), who note that human thoughts influence the changes in moods. Another study by Björgvinsson et al. (2014) reiterates that having extremely negative feelings may cause what they call “descent behaviors” such as feeling the need to withdraw from friends. Such negative behaviors have an association with depression. On the other hand, extremely positive thoughts and feelings usually result in “ascent behaviors” such as taking of risks, which are in relation with mania. According to West et al. (2014), the best way to treat and deal with such bipolar thought swings is through Cognitive Behavior Therapy. The therapy is definable as a way of capitalizing on the fact that people’s thoughts, emotions, and actions are interconnected and have influence from one individual to another. The therapy, or CBT, is meant to catch, change, and challenge the flawed thoughts, and in the process, help identify and correct behavior patterns that are troublesome. CBT assists patients in teaching them how to respond to agitated situations in a calm manner (Westra et al., 2016). Results of a study by Reigada et al. (2015) indicated that participants who underwent the Cognitive Behavior Theory admitted to feeling better from an emotional perspective, and that they attained a better quality of life.

According to Reigada et al. (2015), the use of structured psychological therapies, which include the CBT and psychoeducation, has been on the rise in the recent years. The CBT is in favor with the psychological treatment of bipolar disorders. Even though programs involving psycho-education have been effective in thwarting depressive and manic episodes, research by Westra et al. (2016) suggests that CBT is more constructive and helpful in the treatment of depression. Therefore, as per Krucik (2015), both the CBT and the psycho-education are useful in bipolar disorders. Other than the fact that CBT is effective in bipolar cases, studies have also indicated that cognitive-behavioral therapy is effectual and can be successful in instances with other psychological and mental health disorders. For example, a study by Lenhard et al. (2016) reveals that those who participate in CBT experience 50 percent fewer days of depression situations over the course of one year, and that less antidepressant enhances in comparison with individuals who only receive a psycho-education. The thesis of this paper is to review a case study of a mother aged 36 years old and has two biological children with one stepdaughter who has been diagnosed with bipolar I disorder.

Objectives of the Case Report

The aim is to apply the cognitive behavior therapy techniques and strategies for treating the bipolar I disorder. The primary goal is to assist the mother in treating her stepdaughter by use of the CBT rather than medication. The therapy is a significant aspect of treating individuals with bipolar disorders. For instance, in this case, the purpose is to assist the stepdaughter in modifying her emotional and behavioral patterns that result in the development of the bipolar I disorder. The daughter, like many other bipolar patients, is to benefit from the CBT. As supported by MacPherson et al. (2016), the best treatment of bipolar I disorder is instances when there is a combination of pharmacotherapy, social support, cognitive therapy, as well as family interventions. Even though antidepressants are effective in bipolar treatments, their side effects involve the provocation of mood swings. Therefore, the objective of the case report is to find diagnostic criteria for the stepdaughter and provide the necessary advice for the mother on how to deal with the girl (Lenhard et al., 2016).

Diagnostic Criteria of Bipolar 1 Disorder

Bipolar disorder is characteristic of at least one episode of mixed depression or manic symptoms whereby the signs and symptoms cause occupational and social distress (Dèttore et al., 2015). As diagnostic criteria for bipolar I disorder, the symptoms should not be accounted as a schizophrenic disorder. At the same time, the manic and mixed episodes should not be mistaken to be schizophrenia; neither should the episodes superimposed on the delusional disorder, schizoaffective disorder, or any other psychotic condition. The manic episodes characterize an extensive, elevated and irritable mood change, which tend to last for about one week or even more. Inflated self-esteem accompanies the manic episodes, psychomotor agitation, and lack of sleep, increased talkativeness, distractibility, and increased risk behaviors (Björgvinsson et al., 2014). However, the signs and symptoms have to be severe to a level that they can cause social impairment in a patient. From the case study, the daughter must be experiencing such severe manic episodes, thus the need for treatment.

Treatment process

As suggested by Reigada et al. (2015), the daughter will have to undergo a Cognitive Behavior Therapy, which involves twelve (12) psychotherapeutic sessions. The courses will aid the daughter to learn ways she can utilize to cope with manic episodes and find out how to change her distorted cognitions. The psychotherapist is to offer the necessary information to the mother such that she might be able to deal with her stepdaughter. That is, the mother should be able to consequently alleviate the girl and help her understand negative behavior patterns. Through the CBT, the mother should teach her daughter coping skills in handling the problem in a correct manner. As noted by Westra et al. (2016), the CBT focuses on both behavior and cognition; thus, the daughter ought to learn maladaptive behavior, which is achievable through behavioral techniques.

West et al. (2014) suggest that psychotherapy should commence after the stepdaughter has achieved the remission phase. During the first few sessions, the therapist builds a rapport with the daughter and guarantees her that maximum confidentiality is maintainable throughout the sessions. It is notable that during the sessions, the mother would not be present, which is to create trust between the therapist and the patient. The next few sessions are to identify the problematic thought patterns, and discuss the patterns with the daughter, as well as with the mother, but differently. From the girl, she will recognize the need to get rid of her problematic behaviors and thoughts, particularly of blaming her stepmother and stepsisters for her woes. It is careful noting and bringing up the issue of being a stepdaughter and her relationship with her sisters. In case the girl has ever had thoughts of committing suicide, perhaps because she is a stepdaughter, the therapist should help her improve on her opinions. It is important that she should not blame her sisters for any of her afflictions, and that she only experiences manic episodes because of her thoughts.

As reiterated by Lee & Harvey (2015), it is worth mentioning the need for the therapist to carry out a meticulous background research on the girl’s social and economic condition, which is to play a significant role in her thought patterns. Such investigations lead to the identification of more stressors in the life of a patient, which tend to create more troubles that are psychological. Once the therapist has identified all patterns, predominantly the negative thoughts, it is vital to discuss these models with the daughter and advice her on how she can work on them. The mother ought to be aware of such affecting background research and advise her on ways she can assist the stepdaughter. It would reach a point when both the mother and the daughter worked together.

However, the therapist should complete this step in a careful and gradual manner. The daughter will need to feel comfortable identifying her negative thoughts, and learn how she can prevent them (Krucik, 2015). The next session is to focus on the cognitive restructuring of the stepdaughter, which involves a systematic identification of her problematic thought patterns. It contributes to the maintenance and onset of symptoms. There is the importance and need for the daughter to understand that her negative thoughts are affecting and enhancing problems such as depression, stress, and manic symptoms. According to Freeman (2016), the best way is for the therapist to address the problematic thoughts one after the other. It is best setting up targets regarding a psychotherapeutic priority. Therefore, cognitive restructuring involves first identifying the problematic ideas before deciding on the strategies to take regarding preventive measures.

Regarding bipolar disorder among toddlers and teenagers, the daughter will be experiencing symptoms such sleep deprivation, frequent anger, racing thoughts, and stress (MacPherson et al., 2016). It is imperative for the therapist to perform follow-up sessions to determine the girl’s level of achievement concerning the psychotherapy analysis. As recommendable by Lenhard et al. (2016), when addressing one particular issue, such as sleep deprivation, the therapist should take the initiative to educate the girl about sleep disruptions and how these are affecting her episodes during the day. Once the girl and the therapist have identified desired hours of sleep, she should be taking those hours seriously, and that she should be thinking hard before going to bed. She should also avoid behaviors that result in a diversion of sleep.

Dèttore et al. (2015) suggest behavioral therapies with the aim of changing the girl’s maladaptive behaviors. One example is teaching the girl muscle relaxant techniques so she may cope well with stress. During the same sessions, the girl should be familiar with anger and stress management. The advantage of tension control is helpful for the daughter in handling stress in the future through problem solving, cognitive restructuring and communication skills. According to Reigada et al. (2015), CBT is useful in case instances where there is an applicable psycho-education session with the client. Thereby, in this scenario, the stepdaughter has to be sensitive to the relationship between physical feelings and mood swings. It is imperious for the patient to undergo training and be able to detect and scrutinize early warning symptoms. Subsequently, the girl needs to gain knowledge of using techniques that control anxiety. Such anxiety-control practices include self-instructions, cognitive distraction, and relaxation and breathing (West et al., 2014).

In last sessions, the girl should become proficient in perceiving distorted thoughts and utilization of cognitive restructuring. Improving self-esteem as a technique helps restrain from future relapses. In addition to the self-esteem recognition, it is equally important that for the client to understand social skills so she can easily relate to other people and friends, both in school and at home (Westra et al., 2016). Some of the social skillsstudy include assertiveness, conversational skills, non-verbal communication, receiving of criticism, as well as asking for favors. For the final session, the therapist has a duty to make a report of the client’s progress concerning mood changes and general improvement with her life. Follow-up checkups are recommendable in scrutinizing her recovery progress.

Other CBT Techniques — for the mother

As the stepmother of the client with bipolar I disorder, it is advisable for the mother to understand and learn about certain CBT techniques that might be useful in assisting her daughter to become well and cope with bipolar episodes. Since she is a stepmother, and she has two other daughters, the situation can be difficult. Therefore, the mother has to win the step daughter’s trust. The following are some of the CBT techniques she needs to learn and understand.

1. Accepting that her stepdaughter has been diagnosed with bipolar I disorder

2. She needs to monitor her stepdaughter’s moods, which possible by use of a journal and a worksheet

3. The mother needs to undergo cognitive restructuring, whereby she will be assisting the girl in correcting her flawed thoughts

4. Learn problem-solving skills such that the mother identifies a problem, create potential solutions, pick a solution, try the solution, and evaluate outcomes

5. Establish a stabilized routine with predictable daily rhythms that make the stepdaughter feel less agitated, thus reduce bipolar episodes

Discussion

According to Björgvinsson et al. (2014), bipolar disorder has become a chronic and debilitating psychiatric condition that affects one percent of the population. The condition is in association with many comorbid mental illnesses and substance abuse difficulties. Furthermore, bipolar disorder is responsible for high mortality rates due to suicide attempts, and ranks as the eighth greatest cause of medical disabilities. Therefore, as reiterated by Lee & Harvey (2015), bipolar treatment needs to be earnest and comprehensive, thus the application of the Cognitive Behavior Therapy. In this example, the cause of the stepdaughter’s bipolar episodes is the circumstance where she lives with two stepsisters and a stepmother. She feels isolated and secluded. However, this is only because of her negative thoughts, hence the need to change her feelings towards her family and herself. The alterations are possible with the presentation of CBT.

The client was having signs and symptoms of racing thoughts, agitations, extreme docility, poor judgments, distractibility, and mood swings. Despite all these warnings, the girl did not involve in substance abuse. The case study encompassed the process of applying the CBT whereby psychotherapy was predominant, and use of medication was limited. From the diagnosis and treatment procedure, the expectation is for CBT to be successful. As illustrated by Freeman (2016), CBT uses cognitive restructuring where negative thoughts are transformable into more realistic and healthier thought patterns. Many thoughts in the girl were identifiable, which then abetted her in becoming aware of her with the aim of preventing future bipolar episodes. As per Krucik (2015), the other important part of the CBT is behavior modification whereby maladaptive and destructive behaviors are removable and replaceable with positive reactions. The teachings and therapist management were helpful for the client to learn anger and stress management techniques. Since the girl is unsocial with her stepsisters and stepmother, the therapist teaches her techniques that enhance social networking and problem-solving techniques, which usually arise in daily interactions with others.

According to Lenhard et al. (2016), the psycho-education of the CBT increases its efficiency in remedying patients with bipolar disorder, which then prevents chances of relapse. CBT is individually operative in improving the life of a client, thus increasing compliance, helping early symptoms, and decreasing manic and depressive symptomatology. During the entire treatment process, the purposes of all psychotherapeutic methods were meant to assist the client to learn and understand her signs and symptoms, hence reduce her levels of anxiety, improve her social skills, and enhance her gain greater control of her moods. MacPherson et al. (2016) remark that current CBT protocols accentuate early intervention approaches to overcome the impacts of manic or hypomanic episodes. The responses are made to overcome the likelihood of social decisions, poor financial and sexual assessments that may transpire in the context of an event.

Conclusion

The aim of the case study was to determine CBT techniques to cater for a girl who lives with two stepsisters and a stepmother. She with bipolar I disorder and the objective was to treat her with the CBT rather than medications. The advice was for a therapist in giving the client appropriate psychotherapeutic sessions, thereby indicating possible solutions for the patient. The treatment also involved the girl’s mother, who was to understand and learn about the girl’s bipolar condition and how best she can offer assistance. From the treatment process, both the mother and the stepdaughter experience instances of learning about the CBT techniques, consequently posing preventive measure for future bipolar episodes. Therefore, as proven by Reigada et al. (2015), psychotherapy is effective for patients with bipolar I disorders, as well as being effectual to patients who do not respond well to medications. In the process, the therapist is required to maintain all the ethics related to counseling and psychotherapy.

West et al. (2014) further restate that the core treatment for bipolar I disorder involves a combination of psychotherapy and medication, whereby CBT is a common type of psychotherapy. According to Lenhard et al. (2016), Cognitive Behavior Therapy is usable in many ways, which include managing signs and symptoms of mental illnesses, preventing relapse, learning valuable coping techniques, and acting as an alternative to medications. As concluded by Westra et al. (2016), given the severity and chronicity of bipolar I disorder, it is imperious for therapists to discharge adequate and empirical interventions on patients diagnosed with bipolar disorder.

References

Björgvinsson T, Kertz S, Bigda-Peyton J, Rosmarin D, Aderka I, Neuhaus E. Effectiveness of Cognitive Behavior Therapy for Severe Mood Disorders in an Acute Psychiatric Naturalistic Setting: A Benchmarking Study. Cognitive Behaviour Therapy [serial online]. July 2014;43(3):209–220. https://goo.gl/rFVsLM

Dèttore, D., Pozza, A., & Andersson, G. (2015). Efficacy of Technology-delivered Cognitive Behavioural Therapy for OCD Versus Control Conditions, and in Comparison with Therapist-Administered CBT: Meta-Analysis of Randomized Controlled Trials. Cognitive Behaviour Therapy, 44(3), 190–211. https://goo.gl/HBw045

Freeman, D. (2016). Cognitive-Behavioral Therapy for Psychotic Disorders | Psychiatric Times. Psychiatrictimes.com. Retrieved from https://goo.gl/0YCMgE

Krucik, G. (2015). Cognitive Behavioral Therapy. Healthline. Retrieved from https://goo.gl/brc8yX

Lee, J. Y., & Harvey, A. G. (2015). The Memory for Therapeutic in bipolar disorder and comorbid insomnia. Journal Of Consulting And Clinical Psychology, 83(1), 92–102. https://goo.gl/ZxddlZ

Lenhard, F., Vigerland, S., Engberg, H., Hallberg, A., Thermaenius, H., & Serlachius, E. (2016). “On My Own, but Not Alone” — Adolescents’ Experiences of Internet-Delivered Cognitive Behavior Therapy for Obsessive-Compulsive Disorder. PLoS ONE, 11(10), 1–14. https://goo.gl/1KYijW

MacPherson, H. A., Weinstein, S. M., Henry, D. B., & West, A. E. (2016). Mediators in the randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy for pediatric bipolar disorder. Behaviour Research & Therapy, 8560–71. https://goo.gl/Bcx7pV

Reigada, L. C., Polokowski, A. R., Walder, D. J., Szigethy, E. M., Benkov, K. J., Bruzzese, J., & Masia Warner, C. (2015). Comorbid Treatment For Pediatric gastrointestinal and anxiety disorders: A pilot study of a flexible health sensitive cognitive-behavioral therapy program. Clinical Practice In Pediatric Psychology, 3(4), 314–326. https://goo.gl/jzpyJK

West, A. E., Weinstein, S. M., & Peters, A. T. (2014). Family and cognitive therapy delivered via 12 manualized sessions effective for bipolar disorder. Brown University Child & Adolescent Psychopharmacology Update, 16(11), 1–8. https://goo.gl/4xT6Ak

Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for a severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal Of Consulting And Clinical Psychology, 84(9), 768–782. https://goo.gl/UQPUA5

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