Gerry s experience of bi-polar disorder
Gerry was 21 when he experienced his first episode of mania while at University. After a night out, he was unable to switch off and found it difficult to get to sleep. Over the next couple of days, his friends noticed that he was becoming more and more hyper in that he was very excitable and was speaking really quickly about all sorts of plans and ideas. Gerry’s friends began to get worried on the third day when Gerry came to chat to them about his ideas at 4 in the morning. By the following evening, Gerry was becoming increasingly paranoid and began accusing his flatmates of spying on him. Gerry’s flatmates called his mum who in turn called their GP. Gerry was referred to a psychiatrist and it was agreed he needed an in-patient admission to stabilise his mood. Gerry spent two weeks in hospital where he was treated with medication and his mood stabilised. After a couple of weeks, he felt ready to return to University but things began to get difficult again. He was struggling with motivation and was unable to keep up with the workload. His friends were managing well and he began to feel like the odd one out. Over the next few days, his mood became lower and so he went back to see his GP, who prescribed a course of anti-depressant medication. The period of low mood lasted three to four months and eventually lifted. Over the course of the next four years, Gerry had a further two episodes of mania and one episode of depression and was diagnosed with bi-polar disorder. He was becoming increasingly worried that he might lose his job in sales as he had had a number of periods of absence, and this is the reason he sought psychological help.
When I met with Gerry, he outlined his experiences with mood instability and we discussed his current mood, which was stable. The National Institute of Clinical Excellence (NICE UK) recommend a combination of cognitive behaviour therapy (CBT) and medication for the treatment of bi-polar disorder. I outlined the CBT approach to Gerry and I highlighted the treatment rationale, namely that the aim of treatment is not to eliminate the condition but to help reduce the likelihood of relapse and minimise the impact of an episode should one occur. Gerry understood this and we agreed to meet for 16 sessions of CBT.
Understanding the difficulties
We began by developing a psychological understanding of the difficulties Gerry was experiencing. We discussed predisposing factors (such as a family history), current stressors that increased the likelihood of having an episode of mania or depression (such as a heavy workload in University and relationship problems) and poor coping strategies that further increased the risk of having an episode (such as staying up all night to catch up on work and drinking alcohol to forget about relationship problems). This was important not only because it helped Gerry to understand why he was experiencing these episodes, but also because it identified areas that required attention during therapy.
Liaison with other professionals
Since bi-polar disorder requires a multi-professional approach to manage medication, psychological therapy, mood monitoring and possible in-patient stays, an important aspect of the treatment is close working between professionals. With Gerry’s permission, contact was made with the other professionals involved in his care and a co-ordinated care plan was developed. Once Gerry had developed his relapse prevention plan, this was circulated to the other professionals in his network with his permission.
Gaining insight into the signs and symptoms of a manic or depressive relapse
The next step was to gather information to develop detailed insight into the signs and symptoms of an episode of mania and depression. In order to do this, Gerry had to think about his episodes in detail and list all of the thoughts, feelings, behaviours and physical symptoms he noticed during an episode. In order to make this more comprehensive, Gerry asked his girlfriend and family members for their recollections. Once this was complete, we outlined in detail what a period of wellness looks like and then considered the period in between wellness and an episode, from the first signs that something is changing to the period just before an episode. By doing this, Gerry was able to track a number of behaviours across the mood spectrum. For example, when Gerry was really depressed, he didn’t care at all about his sales targets and often didn’t attend work, when he was well he wanted to achieve the targets which had been set and so worked from 9-5, and when he was going high, he became obsessed with being the best performing salesman on the team, meaning he stayed late most nights and skipped meals to ensure this happened. In this way, Gerry was able to monitor 4-5 activities which would give him insight into his mood at the time. If Gerry noticed that things were changing, he would then be able to take the appropriate action.
Providing a range of skills to manage signs and symptoms of a relapse
Once Gerry had a clear sense of the signs and symptoms of a relapse, we discussed and practiced a range of psychological strategies which he could use to manage these symptoms, including mood monitoring, behavioural activation and deactivation strategies (depending on whether Gerry was going low or high) and cognitive techniques to manage unhelpful thought processes. When Gerry noticed changes in his mood, he was able to use these techniques to manage these changes.
Developing a relapse prevention plan
The next step was to draw all of the information together in a relapse prevention plan. This took the form of a traffic light signal, with green meaning Gerry was well and what he should keep doing to maintain this, amber indicating that things were changing and what he could do to manage these changes and red indicating that he was in an episode and what he could do to manage this. This plan was printed out for Gerry and sent to other professionals involved in his care so that everyone in his network were aware of what Gerry could do at different stages.
At the end of therapy, Gerry reported feeling more confident in his ability to recognise signs of a relapse and more confident in his ability to manage these symptoms should they arise. As a result, he reported feeling more confident and in control of his future.
Attending for top-up sessions
While Gerry had the necessary understanding and skills to manage his condition, at times when he felt at risk of relapse, he requested a top-up session to refresh his skills. Having these top-up sessions meant that Gerry could revise his skills and ensure he was using all of the skills available to him to manage his symptoms.