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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 92-93

Mindfulness integrated cognitive behavior therapy in bipolar disorder in remission: A case study


1 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Web Publication29-Mar-2018

Correspondence Address:
Ms. Seema P Nambiar
Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Hosur Road, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_28_17

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How to cite this article:
Nambiar SP, Manjula M, Arumugham SS. Mindfulness integrated cognitive behavior therapy in bipolar disorder in remission: A case study. Indian J Soc Psychiatry 2018;34:92-3

How to cite this URL:
Nambiar SP, Manjula M, Arumugham SS. Mindfulness integrated cognitive behavior therapy in bipolar disorder in remission: A case study. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 Jan 21];34:92-3. Available from: https://www.indjsp.org/text.asp?2018/34/1/92/228793



Dear Sir,

Most patients with bipolar disorder (BD) do not fully recover between episodes and continue to have residual symptoms, functional impairment and relational difficulties even if not in a diagnosable episode.[1] Behavioral, cognitive, and mood symptoms are commonly seen during periods of apparent remission. These residual mood symptoms, in particular, depressive symptoms, are highly predictive for recurrence of mood episodes and can also prolong the next episode.[2]

Psychological interventions, especially cognitive behavior therapy (CBT), used as adjunct to pharmacotherapy has been found to be efficacious in improving medication adherence, quality of life, functioning and reducing inter-episodic symptoms and relapse rates in BD.[3] Traditional CBT, however, does not adequately address difficulties in emotion regulation, which are commonly observed in individuals with BD.[4] Integrating core-mindfulness, emotion regulation and distress tolerance skills (as elucidated in Linehan's Dialectical Behaviour Therapy manual) with CBT can possibly improve affect regulation by increasing mindfulness skills, which can lead to symptom reduction and behavior change. The efficacy of mindfulness based cognitive therapy in reducing anxiety and depressive symptoms have been documented in patients with BD in remission.[5] Training in Dialectical Behaviour Therapy skills have shown efficacy in reducing mood symptoms and improving effective control and mindfulness.[6]

In this report, we discuss the successful implementation of mindfulness integrated cognitive behavior therapy for residual mood symptoms in a client with bipolar-II disorder in remission.

The client was a 25-year-old unmarried, unemployed female belonging to a higher socioeconomic status who had discontinued her education (Masters) abroad following a mood episode. The age of onset was 20 years; she had 3 hypomanic and 3 depressive episodes in 5 years (during which 2 suicide attempts were reported). Hypomanic episodes were characterized by decreased need for sleep, racing thoughts, over cheerfulness, overspending (where she would splurge up to 2 lakh rupees in shopping sprees while living alone abroad). After these hypomanic episodes, she would feel anxious and guilty about the financial loss which would then lead to low mood and further attempts to improve it by going on more spending sprees, which lead to a vicious cycle of mood worsening. She had never been hospitalized nor had she received psychological treatment in the past.

She had a family history of psychotic illness in maternal grandmother and alcohol dependence syndrome in a second-degree relative. Personal history of being bullied and teased in school was also noted. She had to discontinue her undergraduate studies in dentistry midway following a mood episode. Premorbidly, her parents described her as introverted, slow to warm up, shy, anxious, and having few friends during childhood. Parents reported that she was sensitive to criticism or disapproval.

Mini-International Neuropsychiatric Interview 7.0 was administered to confirm the diagnosis. She did not have any other Axis-I disorders. Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV revealed traits of avoidant personality disorder. Intake assessment revealed inter-episodic mood (Beck Depression Inventory [BDI]-II = 14) and anxiety (Beck Anxiety Inventory [BAI] = 22) symptoms, coping skill deficits, interpersonal difficulties with parents, emotion dysregulation (Difficulties In Emotion Regulation Scale [DERS] = 130), poor self-esteem, dysfunctional cognitions (Dysfunctional Attitude Scale [DAS] = 80), poor functioning (Functioning Assessment Short Test [FAST] = 11), and poor quality of life (WHO-QOL BREF = 231). When she was referred for psychotherapy, she was stabilized on medication, and no significant medication changes were introduced during psychotherapy.

Client received 12 weekly sessions of outpatient-based psychotherapy over 3 months. She was provided with CBT based on the diathesis-stress model as designed by Lam (2010) integrated with the emotion regulation component of Dialectical Behaviour Therapy.

The first four sessions focused on rapport building through providing a safe, protective, and accepting therapeutic environment for facilitation of ventilation. Psychoeducation on BD, stress-diathesis model and the importance of maintaining bio-socio-occupational routines was explained in order to help her better conceptualize the problem. A mood log was introduced as a homework task. Behavioral activation by means of an activity schedule (with emphasis on pleasure and mastery), regular sleep and daily activity routines were introduced to improve her depressive symptoms. She was socialized to the CBT model and the concept of negative automatic thoughts and thought record exercise was introduced.

In the middle phase, cognitive restructuring of thinking errors such as catastrophization, dichotomous thinking, and minimization was carried out. Further, rumination and other avoidance behaviors in maintaining anxiety were elucidated. She was educated about recognizing symptoms of relapse (differentiating from normal mood fluctuations).

Emotional difficulties with respect to stressors (ongoing strained romantic relationship, stressful life events) were addressed through emotion regulation skills which included exercises to identify and label emotions, mindfulness sitting meditation to deal with difficult thoughts and emotions. Distress tolerance skills such as distracting, self-soothing, urge management, self-validation, opposite to emotion action, and balancing enjoyable activities with responsibilities were taught. The guilt of being dependent on family, discontinuing the course, overspending during hypomanic episodes was also addressed through reattribution. The termination sessions focused on consolidating the gains achieved in therapy, preparing her “for” resuming studies abroad and identifying and addressing future relapses.

At the end of 12 sessions, client reported significant improvement with respect to her mood (BDI = 0, BAI = 4) symptoms, emotion regulation (DERS = 74), dysfunctional attitudes (DAS = 72), functioning (FAST = 1, WHOQOL-BREF = 288). Both client and her parents reported improvement in her coping skills and self-confidence. She started a regular job and felt prepared to go back abroad and rejoin her course.

Components of both CBT and mindfulness seem to have contributed to the improvement in subsyndromal mood and anxiety symptoms and emotion regulation. Psychoeducational nature of CBT, which promotes monitoring and self-regulation, restructuring of dysfunctional cognitions would have largely helped in symptom reduction. Mindfulness would have helped in mood regulation as it teaches early recognition of mood shifts and accepting them rather than avoiding thus preventing escalation of mood symptoms as well as mood activated unhelpful patterns of thinking.[5] In addition, distress tolerance skills would have helped in gaining control over mood regulated action tendencies.[6] Following therapy, the client was able to make significant progress in functioning as well as residual symptoms as implicated in the trials of CBT in BD.[3],[7] The case illustrates the importance of addressing the oft-neglected psychosocial management aspects of BD as an adjunct to pharmacotherapy. Controlled trials would elucidate whether mindfulness provides additional benefits over CBT in this population and if so, which group of symptoms are best targeted by such interventions.

Financial support and sponsorship

Funded by Council of Medical Research.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002;59:530-7.  Back to cited text no. 1
    
2.
Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, et al. Predictors of recurrence in bipolar disorder: Primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry 2006;163:217-24.  Back to cited text no. 2
    
3.
Ball JR, Mitchell PB, Corry JC, Skillecorn A, Smith M, Malhi GS, et al. Arandomized controlled trial of cognitive therapy for bipolar disorder: Focus on long-term change. J Clin Psychiatry 2006;67:277-86.  Back to cited text no. 3
    
4.
Ball J, Corry J, Mitchell P. Mindfulness meditation and bipolar disorder. In D. Einstein ed., Innovations and advances in cognitive behaviour therapy. Australia: Australian Academic Press; 2007. p. 37-42.  Back to cited text no. 4
    
5.
Williams JM, Alatiq Y, Crane C, Barnhofer T, Fennell MJ, Duggan DS, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: Preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord 2008;107:275-9.  Back to cited text no. 5
    
6.
Van Dijk S, Jeffrey J, Katz MR. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. J Affect Disord 2013;145:386-93.  Back to cited text no. 6
    
7.
Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, et al. Arandomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Arch Gen Psychiatry 2003;60:145-52.  Back to cited text no. 7
    




 

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