What Is Bipolar Disorder And What Keeps It Going?

Bipolar disorder is a mental health condition characterised by episodes of mania or hypomania, during which people experience unusually elevated or irritable mood, increased energy, and changes in their activity levels. Many people also experience episodes of depression, although this is not always the case. These episodes are more pronounced and sustained than ordinary fluctuations in mood and can have a significant impact on daily life, work, and relationships. For clinicians, recognising the symptoms of bipolar disorder is an important first step. A CBT formulation can help identify the psychological and behavioural factors that contribute to mood instability, maintain difficulties, and increase the risk of future episodes.

Research studies have shown that psychological therapies such as cognitive behavioral therapy (CBT) can lower the risk of relapse in bipolar disorder and reduce symptoms of depression and mania. Key maintaining factors include positive bias, sleep disruption, unhelpful beliefs, and behaviors that ‘rebound’.

What is bipolar disorder?

Symptoms of bipolar disorder include:

• Episodes of hypomania or mania, including increased energy or activity, reduced need for sleep, impulsivity, and big ideas.

• Episodes of depression, including tiredness, self-criticism, hopelessness, reduced enjoyment, and loss of interest in activities.

• Mood episodes that continue for several days or weeks.

• Mood changes that negatively affect work, study, relationships, or other areas of life.

• Long periods - sometimes months or years - without a major mood episode.

During hypomania or mania, an individual may feel overly confident or optimistic, experience racing thoughts, feel excited or irritable, sleep less, become more socially or sexually active, pursue more goal-directed activities, and take greater risks. Depressive episodes may involve low self-confidence, a bleak outlook, hopelessness, anxiety, guilt, reduced activity, social withdrawal, changes in sleep or eating, and rumination.

In bipolar I disorder, people experience manic episodes and may become very unwell. They may experience psychotic symptoms or require hospitalization. In bipolar II disorder, people experience hypomanic episodes, which do not last as long or cause as many problems as full mania. People with bipolar II tend to experience more severe and longer depressive episodes than people with bipolar I.

Assessment therefore needs to contextualise changes from the person’s usual functioning over time, rather than considering isolated symptoms alone.

A CBT perspective: What keeps bipolar disorder going?

Particularly when problems are having a significant impact on a client’s life, CBT therapists  tend to prioritise the identification of maintenance cycles and ways to interrupt them, so that clients can experience an improvement in their symptoms and begin making meaningful progress as soon as possible.

Helping clients formulate a model of their experiences is an essential part of CBT for bipolar disorder. The four maintaining processes described below can be used as a focus for discussion or as a template for developing an individualized formulation.

1. Positive bias

The way people think about their abilities and imagine the future can lead to changes in mood. Positively biased thinking may include:

• Overestimating the likelihood that good things will happen.

• Having vivid mental images of things going well in the future.

• Being overly confident in one’s abilities.

In the manic or hypomanic phases of bipolar disorder, positive thinking can go too far and cause problems. For example, it may drive risky or impulsive behaviors such as impulsive spending or hypersexuality. It may also lead someone to ignore advice from friends, family members, or colleagues.

A vicious cycle can develop in which positive beliefs elevate mood and encourage impulsive behavior. As mood becomes higher, thinking becomes increasingly positively biased. A person might interpret one favorable comment about a business idea as proof that it will succeed while discounting less encouraging feedback.

Some people also hold positive beliefs about hypomania itself. Early hypomania may feel enjoyable or productive, leading the person to believe that it will help them work, socialize, or cope. However, as the episode continues, mood may become harder to regulate.

This can contribute to a “boom and bust” pattern. A person has a big idea while manic or hypomanic, but when events do not go as planned, they “crash” and become depressed. Regret, shame, or rumination about actions taken while unwell may then intensify the depressive episode.

2. Sleep disruption

Changes in sleep are the most commonly reported trigger for relapse in bipolar disorder and can also be an early warning sign of a mood episode.

Most people with bipolar disorder experience sleep difficulties such as insomnia, even when their mood is stable. During hypomania or mania, people may sleep very little for several nights, which fuels further mood changes. During depression, they may have difficulty sleeping or sleep excessively.

Socializing, working long hours, traveling, and significant life events can alter normal sleep routines and trigger hypomanic or manic symptoms. Changes to sleep can therefore be both a symptom and a trigger, creating a cycle that keeps an episode going.

Maintaining a stable sleep pattern is important for mood stability, while recognizing that a single poor night’s sleep does not necessarily indicate relapse. Strong beliefs about sleep can themselves become problematic. For example, worrying that one bad night will inevitably cause an episode may increase arousal and make sleep more difficult.

3. Unhelpful beliefs

Some people with bipolar disorder may hold particularly strong beliefs about achievement, success and personal standards. These can include:

• Setting very high standards for themselves.

• Placing a great deal of importance on achievement and success.

• Believing that their worth or other people’s respect depends on how well they perform.

• View mistakes or setbacks as personal failures.

• Being highly self-critical when they fall short of their expectations.

These beliefs can influence both depression and hypomania or mania. High standards and a strong drive to achieve may elevate mood, increase risk-taking, encourage longer working hours, and reduce sleep. This can increase the risk of a hypomanic or manic episode.

The same beliefs can also contribute to depression. When people make mistakes or do not meet their standards, they may ruminate, feel like a failure, and become highly self-critical. High standards can become a losing game: when the person meets them, they raise the bar; when they do not, they criticize themselves and work even harder.

4. Behaviors that rebound

Some behaviours can feel helpful or enjoyable in the short term, but contribute to difficulties in the longer term. People with bipolar disorder may:

• Seek out positive emotions such as excitement, which can sometimes contribute to escalating mood.

• Try to encourage or prolong hypomania because it feels enjoyable or productive.

• Ruminate about positive as well as negative events, which can intensify their emotions.

• Act impulsively or take risks that have unwanted consequences.

Attempts to lift or maintain mood may contribute to escalating hypomanic or manic symptoms. For example, some people may intentionally reduce their sleep or use substances in an attempt to induce hypomania. However, once elevated mood is triggered, it can be difficult to regulate and symptoms may develop into a more serious episode.

Positive rumination (repeatedly thinking about successes or exciting future possibilities) can also intensify positive emotions. In some circumstances, this may contribute to impulsive decision making and risk-taking, with consequences such as debt, relationship conflict, or regret. These experiences may subsequently fuel negative rumination, contributing to low mood and self-criticism.

Eight clinical tips for formulation and treatment

1. Assess depressive and elevated mood episodes across the person’s life, including periods for which they did not seek help.

2. Clarify how each episode differed from the person’s usual mood, behavior, activity, confidence, and sleep.

3. Map individualized triggers, including positive and exciting events as well as adverse events.

4. Treat changes in sleep as both possible symptoms and possible triggers.

5. Explore optimistic predictions, vivid future imagery, and changes in confidence as mood rises.

6. Ask about beliefs concerning the perceived benefits of hypomania.

7. Identify high standards, perfectionism, achievement beliefs, and self-critical responses to mistakes.

8. Examine whether coping strategies provide short-term emotional benefits but create longer-term “boom and bust” cycles.

Frequently asked questions

1. Is bipolar disorder simply a pattern of mood swings?

No. Bipolar mood episodes are different from everyday emotional ups and downs. They involve sustained changes in thinking, emotion, behavior, activity, or sleep that continue for days, weeks or longer. These changes are more pronounced than ordinary fluctuations in mood and may have a significant impact on daily life.

2. What is the difference between mania and hypomania?

The symptoms are similar, but mania is more severe and has a greater impact on daily functioning. Mania can cause serious difficulties with work, relationships and everyday life, and may involve severe impairment, psychotic symptoms, or hospitalization. Hypomania involves noticeable changes in mood, energy and behaviour, but these are generally less disruptive.

3. Can positive events trigger bipolar episodes?

Yes. Difficult events may contribute to depression, while positive or exciting events may contribute to hypomania or mania. Examples include beginning a new job, meeting a new partner, moving home, taking a vacation, or disrupted sleep associated with travel.

4. Why is sleep central to a bipolar formulation?

Sleep disruption is a commonly reported trigger and an early warning sign. Reduced sleep can fuel elevated mood, while depression can involve insomnia or excessive sleep. Worry and rigid rules about sleep can also maintain sleep difficulties.

5. How can CBT help in bipolar disorder?

CBT helps people understand links between thoughts, emotions, and actions; identify triggers and early warning signs; examine unhelpful thoughts and beliefs; evaluate coping strategies; monitor mood; and develop relapse-prevention plans. Psychological therapies are described as adjuncts to medication rather than standalone alternatives.

References

• Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PLOS ONE, 12, e0176849.

• De Prisco, M., Oliva, V., Fico, G., Fornaro, M., de Bartolomeis, A., Serretti, A., et al. (2022). Defining clinical characteristics of emotion dysregulation in bipolar disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 142, 104914.

• Miklowitz, D. J., Efthimiou, O., Furukawa, T. A., Scott, J., McLaren, R., Geddes, J. R., & Cipriani, A. (2021). Adjunctive psychotherapy for bipolar disorder: A systematic review and component network meta-analysis. JAMA Psychiatry, 78(2), 141–150.

• Schönfelder, S., Langer, J., Schneider, E. E., & Wessa, M. (2017). Mania risk is characterized by an aberrant optimistic update bias for positive life events. Journal of Affective Disorders, 218, 313–321.

• Steinan, M. K., Scott, J., Lagerberg, T. V., Melle, I., Andreassen, O. A., Vaaler, A. E., & Morken, G. (2016). Sleep problems in bipolar disorders: More than just insomnia. Acta Psychiatrica Scandinavica, 133(5), 368–377.

• Woods, C., Richardson, T., & Palmer-Cooper, E. (2023). Are dysfunctional attitudes elevated and linked to mood in bipolar disorder? A systematic review and meta-analysis. British Journal of Clinical Psychology, 63(1), 16–53.