Holistic approaches to bipolar disorder therapy

Understanding Bipolar Disorder: Symptoms and Triggers

Bipolar disorder refers to a mood disorder with alternating depressive and manic phases, involving abrupt changes in mood, from “normal” to “intense” states of depression and mania (or hypomania, which is similar to mania but not as intense). Its symptoms are known to disrupt normal social and professional functioning, but with proper attention and treatment, many people with the disorder are able to manage their symptoms and live normally. 

A main part of the diagnostic criteria that has to be met for bipolar disorder to be diagnosed is actually shared by major depressive episodes (MDE). Each condition has the same requirements for diagnosis, though they diverge at mania and hypomania, as those criteria are only for bipolar disorder.

Common symptoms of bipolar disorder include: 

• Impulsivity and poor decision-making
• Exaggerated self-confidence and self-assurance
• Needing less sleep than usual
• Oversleeping
• Widely varying moods, from abnormally upbeat to extremely low and depressed mood
• Fatigue
• Inability to concentrate
• Psychosis (for bipolar I)
• Suicidal thoughts

There are two types of bipolar disorder — bipolar I and bipolar II — as well as other closely related disorders. While a person with bipolar I disorder might experience mania and hypomania (in addition to major depression), someone with bipolar II will only have hypomanic episodes. In other words, if someone with bipolar II experiences a manic episode, they would then be diagnosed as bipolar I.

Though bipolar disorder has distinct symptoms, these symptoms can be caused by a variety of disorders and conditions. It’s possible, for example, that a substance abuse problem or medical issue could be playing a major role in changes to your mood. In any event, it’s a good idea to report depressed feelings and out-of-the-norm euphoria to your medical doctor, as addressing any physical concerns will greatly support the counseling and therapy side of recovery and symptom management.

What Triggers a Bipolar Episode?

There are many factors that can trigger a manic, hypomanic, or mixed episode (or depressed mood) in those with bipolar disorder, including:

• Stress (relationship or job especially)
• Substance abuse
• Lack of structure or routine
• Poor self-care, especially lack of sleep
• Inadequate support
• Actual and perceived discrimination
• Isolation

Bipolar I: Criteria and Diagnosis

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an individual must have experienced at least one manic episode in his or her lifetime in order to be diagnosed with bipolar I.

A manic episode is a distinct period in which an individual feels euphoric — perhaps even high — and “on top of the world.” Someone experiencing a manic episode can seem to have limitless energy and enthusiasm, even to the level of it seeming excessive or out-of-place by observers. 

The DSM-5 says this mood must be present for most of the day, almost every day for a period of at least one week, with the addition of three (or more) of the following symptoms (four if the mood is only irritable):

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only three hours of sleep)
• More talkative than usual, or feeling pressure to keep talking
• Subjective experience that thoughts are racing
• Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• Increase in goal-oriented activity or psychomotor agitation (i.e., purposeless, non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, substance abuse, or foolish business investments)

The manic behavior must also be sufficiently severe to cause marked impairment in functioning, sometimes necessitating hospitalization to prevent harm to self or others or involve psychotic features. Finally, the condition cannot be attributable to the physiological effects of a substance, such as a medication (unless it is a result of an antidepressant and persists at a level beyond the physiological effect of that treatment), treatment, or abused drug.

Though those with bipolar I can also experience hypomanic episodes alongside manic episodes and MDEs, hypomanic episodes and MDEs are the signature traits of bipolar II, as people with that type do not experience manic episodes.

Bipolar II: Criteria and Diagnosis

As previously stated, those with bipolar II do not have manic episodes — only hypomanic episodes, which do not significantly impair an individual’s occupational or social function. Since hypomania is less obviously impairing than mania, people with bipolar II disorder often don’t realize something is wrong (though others might notice erratic behavior) or seek a diagnosis until they experience a major depressive episode.

Even though hypomania may be less harmful than mania, bipolar II is not a milder form of bipolar I. People with bipolar II tend to experience depressive episodes for longer periods of time and/or more frequently than those with bipolar I, which can be very debilitating in personal and professional environments. These extended periods of MDE are troubling, especially when the impulsive nature of the disorder is taken into account, since it can contribute to suicide attempts.

According to the DSM-5, a hypomanic episode is characterized by four or more days of abnormally and persistently elevated, expansive, or irritable mood; a change in one’s functioning that is not present when one isn’t symptomatic and noticeable to others (though not severe enough to cause marked impairment or hospitalization); and three (or more) of the following symptoms (four if the mood is only irritable):

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only three hours of sleep)
• More talkative than usual, or feeling pressure to keep talking
• Subjective experience that thoughts are racing
• Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• Increase in goal-oriented activity or psychomotor agitation (i.e., purposeless, non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, substance abuse, or foolish business investments)

Finally, the episode cannot be attributable to the physiological effects of a substance, such as a medication (unless it is a result of an antidepressant and persists at a level beyond the physiological effect of that treatment), treatment, or abused drug.

Cyclothymic Disorder: Criteria and Diagnosis

Cyclothymic disorder is a disorder that is classified alongside bipolar disorders, though its symptoms do not quite align with those of bipolar disorder. It is characterized by the presence of persistent two years of hypomanic symptoms and depression that do not meet the criteria for hypomanic or major depressive episodes and continue for two years with no more than 2 months without symptoms. 

These symptoms also cannot be attributed to other disorders (such as schizophrenia or delusional disorder), a medication, or another medical condition, though they must cause clinically significant levels of distress and impairment of functioning.

With cyclothymic disorder, an individual experiences frequent and chronic mood changes similar to both hypomanic and major depressive episodes without fully qualifying for either.

In other words, cyclothymia is less severe than bipolar I and bipolar II disorder, so much so that someone with the disorder may never realize something is wrong despite the fact that their mood instability might be the cause of occupational or relational dysfunction.

Therapeutic Approaches for Bipolar Disorder

Bipolar disorder is a lifelong issue that can’t ever be fully cured, but there are various forms of treatment that your counselor or therapist can employ, based on the severity of your symptoms. Some examples include:

• Cognitive behavioral therapy (CBT): This approach is one of the most commonly used therapeutic techniques. The main goal is to change negative patterns and behaviors by assessing the ties between one’s emotions, thoughts, and behaviors. By working through the emotions that cause unwanted behavior, one can adjust their behavior and develop new, more helpful patterns. In terms of bipolar disorder, CBT works to help people learn to effectively manage their emotions and find good practices for stabilizing their mood.
• Family therapy/couples therapy: Through this approach, family members are taught effective communication, problem-solving, and conflict-resolution skills. This technique works to bridge the gaps in information and experience between people with bipolar disorder and their family members, guided by a neutral and educated third party that can answer questions and provide clarity for everyone involved.
• Psychoeducation: A term that blends psychology and education. This is intended to educate the individual or their support system about the nature of bipolar disorder. This process of learning is meant to reduce stigma and create a solid support system for people struggling with their bipolar disorder. 

Clinicians can also help their clients create safety plans, which are ways to manage mood and consequent behaviors through increased awareness and identification of causational (or protective) factors, triggers (events that led to the emotional reaction), and warning signs (observable cues for concern) and developing helpful responses that can be implemented until clinical concerns subside.

If you are having a difficult time getting things done due to changes in your mood, it’s time to start a relationship with a licensed, professional counselor or therapist who can give you the attention and care you need.

Cognitive Behavioral Therapy (CBT) for Bipolar Disorder

As stated above, cognitive behavioral therapy is an evidence-based form of treatment that assumes that thoughts, feelings, and behaviors are connected. The idea is that by identifying and changing unhelpful thoughts and behaviors, one can experience more fulfillment in life.

Some examples of common CBT interventions used to treat bipolar disorder are: 

• Cognitive restructuring: Identifying, challenging, and changing negative thought patterns.
• Self-care practices: Learning the best ways you can perform self-care for yourself, including implementing a nutrient-dense diet, adequate and regular sleep, and frequent exercise.
• Relaxation techniques: Ways to relax the mind and body, such as mindfulness, meditation, and calming imagery.
• Reframing: Attempting to take a different perspective in order to see your challenges differently.
• Time-management skills: Techniques to organize time to increase productivity, such as timeboxing.
• Conflict-resolution skills: Strategies to lessen discord between people by teaching them how to come together in times of conflict.
• Frustration tolerance: An ability to remain even-tempered or composed in a difficult situation.
• Coping skills: Techniques that help you deal with a negative or overwhelming issue.
• Recognizing cues: Identification of a situation that triggers an emotional reaction.

These skills are very helpful tools to learn if you struggle with bipolar disorder and need effective ways to manage your emotional states. They aim to increase your self-efficacy, which involves being able to effectively recognize stressors and triggers and regulate yourself accordingly — an important part of managing symptoms of bipolar disorder.

Since bipolar disorder is a lifelong issue, it’s important to understand that your relationship with the disorder cannot be a passive one. Continued treatment is essential to maintaining balance, even if you’ve gone an extended period of time without extreme symptoms.

Can Bipolar Disorder Be Treated With Just Therapy?

Treatment for bipolar disorder is most effective when both psychotherapy and medication are involved. Both have their place and, since symptoms of bipolar disorder can be so severe and difficult to deal with, people may need the intervention of medication before they can manage their symptoms and emotions enough to go through psychotherapy effectively.

The Role of Medication in Bipolar Disorder Treatment

For the best results in managing bipolar symptoms, medication is generally recommended in conjunction with psychotherapy and a more routine lifestyle.

Often times a medical provider will prescribe a mood stabilizer such as lithium to help regulate mood with the intention to decrease manic and depressive episodes. Other bipolar disorder medications include:

• Anticonvulsant medications, such as Depakote, Lamictal, Depakene, and Topamax
• Antipsychotic medications, such as Zyprexa, Risperdal, and Seroquel
• Antidepressant medications, such as Fetzima, Cymbalta, and Effexor

Each of these medications can be used to help regulate the effects of bipolar disorder, minimizing the highs and lows to help you achieve a level of functional balance.

Living With Bipolar Disorder: Action Items

If you (or someone you know) are struggling with bipolar disorder, there are many steps you can take right now to begin seeking relief.

1. Education: While nothing can replace the one-on-one care of counseling therapy, taking the time to learn what bipolar disorder means, what it looks like, and how it feels will help you identify symptoms in your own life. For many people, simply having a definition for what they’re experiencing is extremely helpful in learning to identify and better manage their emotions.
2. Support: Humans are social creatures, so providing support for someone with bipolar disorder or finding someone who can be that support for you is important. Simply sharing a painful experience with someone who has your best interest in mind and offers help, not judgment, can be very beneficial.
3. Be active: Whether it’s going out to a movie or dinner with someone who cares, taking a walk, or starting a daily exercise routine, being active can offer positive distractions from your troubles while also engaging in more pleasure-oriented brain activity. Let your mind relax and simply exist in the present moment.
4. Dwell on hope, not despair: You may feel like all is hopeless, but being intentional –0 whether self-directed or through the support of a friend — about identifying positive growth and opportunities for relief will greatly impact your overall feelings of self-worth and contentedness. 

Bipolar disorder is a clinical issue that might require the assistance of medication (treatment is different for everyone), but there are ways to effectively mitigate your symptoms and live a fulfilling life — relief is possible.

Family Support in Bipolar Disorder Treatment

As stated above, one of the best ways to support a family member with bipolar disorder is to educate yourself. This can include learning about the diagnosis and how it specifically affects the family member with bipolar disorder. 

Through learning about bipolar disorder, you can start to understand how they feel — how their emotions work, how those emotions impact their behavior, and how they differ from your own processes. This knowledge will help you to better understand your loved one’s needs and struggles, allowing you to interact with them accordingly. 

When discussing their disorder and needs, it’s also important to avoid saying anything that sounds shaming. This can feel alienating and cause their symptoms to worsen if they feel like they don’t trust you to react in a supportive way.

However, being a support system for a loved one with bipolar disorder is not without its trials. As much as you want to support that person, it’s also important to make sure you get your own help and support. Some simple ways to ensure you take care of yourself while caring for someone with bipolar disorder are: 

• Self-care: Don’t allow the family member diagnosed with bipolar to occupy all your time and energy. Make time to do things that fulfill and relax you, whether that be a walk, a bath and a face mask, or even just taking time to complete a few forgotten things on your to-do list.
• Clear communication and boundaries: This can involve asserting your needs and boundaries clearly and compassionately while notifying the individual of the consequences of violating your boundaries — especially in committed romantic relationships.
• Personal support: This can include the involvement of nonprofessional support such as friends or family members, or professional support such as talking to a mental health professional or calling/texting the 988 crisis lifeline in the event your family member is experiencing a mental health crisis.

You can still be compassionate, practice forgiveness, and be considerate of their needs while making sure that you are cared for and okay. You can’t help anyone if you can’t function yourself.

Bipolar Disorder Therapy Treatment: Our Experienced Therapists at Thriveworks

You’ve experienced the often-devastating effects of your mood shifts, and so have your loved ones. You don’t want to hurt yourself or those around you, but even when things are normalized, you might not be quite up to the challenges each day presents. 

But it’s OK. You can create the future you want by deciding to invest in yourself in the present moment and contacting a mental health professional about your symptoms. The expert clinicians at Thriveworks are here to help you with your concerns. 

Our therapists can provide you with individualized psychotherapy for your bipolar disorder, or you can get connected with one of our qualified psychiatric nurse practitioners to discuss medication options. Our professionals will work with you to establish goals for treatment and decide on an appropriate treatment plan.

They will help you take the necessary steps toward getting you where you want to be: happy and fulfilled. If you believe you are struggling with uncontrollable mood changes, book a session with a counselor in your area.