Getting Even:

Cognitive Behaviour Therapy (CBT)

and

Bipolar DisorderNovember 26, 2014

University of British CoumbiaCREST.BD Webinar Series

Presented by:Nasreen Khatri, PhD, CPsych

Rotman Research Institute, BaycrestToronto, Ontario

Learning Objectives

1. Overview of bipolar disorder (BD) (esp depression) in adults

2. Describe the emotional and cognitive impact of depression in BD

3. Summarize clinical impact of Cognitive Behaviour Therapy (CBT) in BD

Background and Review

• BD is a mental disorder characterized by severe mood swings

• Lifetime Prevalence in Canada: 1%

• Lifetime Prevalence of depression: 8%

• Days spent depressed outnumber days spent manic 3 to 1 (Kupka et al, 2007)

Untreated Depression

•Leads too …

• Physical Health problems (diabetes, heart disease, stroke, arthritis)

• Makes current health problems worse

• May double the risk of developing dementia later in l i fe (Saczynski, et al., Neurology, 2010)

BD and Depression

Chronicity

Depression is more like diabetes than a broken ankle

Consequences of Depression

• Depression ranked as the 2nd most burdensome disease in the world in terms of Total Disability based on lifetime prevalence, early age of onset, high chronicity and role impairment

- World Health Organization

Cognitive Symptoms of Depression

• Problems thinking, concentrating or making decisions

• Recurrent thoughts of death (negative bias and guilt)

• (In)attention, executive function

Cognition in mood disorders

• Neuropsychological cognitive measures predict poorer functional outcomes, for example, in terms of return to employment or quality of life

– Jaeger et al. Psychiatry Res 2006;145:39-48.– Martinez-Aran et al. Bipolar Disord

2007;9:103-113.

Cognitive domains affected by depression

• Executive Control

• Affective Processing

• Feedback Sensitivity

• Memory–Clark et al. Annu Rev Neurosci

2009;32:57-74.

Executive Control

• Executive function: higher-level processes involved in the flexible organization of behavior, including working memory, forward planning, and the inhibition of dominant responses.

Cognitive Model of Depression

• A stress-diathesis model which posits that negative thoughts about oneself, others and the future, (cognitive triad),

• Precipitated by a perceived stressor in the environment,

• Activates underlying schemas (i.e., core beliefs, self-knowledge networks) that lead to the development, maintenance and relapse of depression

Stoic Philosophy

Events are Impersonal and Indifferent

“What is a “good” event? What is a “bad” event? There is no

such thing! What is a good person? The one who achieves

tranquility by having formed the habit of asking on every

occasion,”

“What is the right thing to do now?”

- Epictetus (1st Century Roman)

Cognitive Behavior Therapy (CBT)

• Short-term, time-limited, structured therapy

• 15-20 weekly 1-hr sessions

• Focuses on relationship between mood, thoughts and behavior

• Identifies and reframes distorted and negative views of self and the world

CBT

• One of the most validated and empirically supported treatments for depression

• Assumes that psychological disorders involve dysfunctional ways of thinking

• The way an individual feels and behaves is influenced by the way they think and how they structure their experience

• Modifying dysfunctional thinking ⇒ Improvement in symptoms

CBT: The Key Ingredients

• The Cognitive Model (thought influences emotion)

• Good therapeutic alliance

• Structure

• Time-Limited

•  Goal Oriented and Problem Focused

• Collaborative

• Educational

Key Ingredients

• Present and Future Focus

•  Specific Techniques to change thinking, mood and behavior (e.g., thought records)

• Experiential Learning

• Guided Discovery

•  Case Conceptualization

• Skill Acquisition/Homework

Behavioral Techniques

• Activity Monitoring & Scheduling

• Graded Task Assignments

• Exposure to steps on hierarchy

• Relaxation (e.g., controlled breathing, PMR)

• Social Skills Training (e.g., assertiveness)

• Exercise

• Behavioral Experiments to test out thoughts and beliefs

Goals of CBT for Bipolar Disorder

• Psychoeducation

• Medication

• Understanding

• & Adherence

• Mood

• Charting

CBT and BD

• Mood rating and monitoring

• Activity monitoring

• Preventing episodes by knowing and predicting triggers

• Relapse signature

•Healthy lifestyle to manage energy levels (exercise, relaxation training

Mayberg HS. J Clin Invest. 2009; 119(4): 717–725.

CBT for BD

• CBT is successful adjunct treatment for BD (Lam et al, 2003)

Conclusions

• BD presents a complex clinical picture with consequences for the individual, family and society – medication may not be enough

• CBT is an empirically supported treatment for depression in and as an adjunct therapy for bipolar disorder

•CBT empowers indvdiasl with BD to be an active partner in their wellness journey

• Future treatments should focus on relapse prevention, booster sessions, brain imaging and the neural signature of recovery (CIHR grant)