Maria Reinares, Eduard Vieta - Integrative Psychotherapy For Bipolar Disorders-Cambridge University Press (2020)
Maria Reinares, Eduard Vieta - Integrative Psychotherapy For Bipolar Disorders-Cambridge University Press (2020)
Maria Reinares, Eduard Vieta - Integrative Psychotherapy For Bipolar Disorders-Cambridge University Press (2020)
Psychotherapy for
Bipolar Disorders
An Integrative Approach
Edited by
María Reinares, PhD
Bipolar and Depressive Disorders Unit of the Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, Barcelona, Spain
www.cambridge.org
Information on this title: www.cambridge.org/9781108460095
DOI: 10.1017/9781108589802
© Cambridge University Press 2020
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
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permission of Cambridge University Press.
First published 2020
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Library of Congress Cataloging-in-Publication Data
Names: Reinares, María, editor. | Martínez-Arán, Anabel, editor. | Vieta, Eduard, editor.
Title: Psychotherapy for bipolar disorders: An integrative approach / edited by María Reinares, Anabel Martínez-
Arán, Eduard Vieta.
Description: Cambridge, United Kingdom ; New York, NY : Cambridge University
Press, 2019. | Includes bibliographical references and index.
Identifiers: LCCN 2019015918 (print) | LCCN 2019016847 (ebook) | ISBN 9781108460095 |
ISBN 9781108460095 (pbk. : alk. paper)
Subjects: | MESH: Bipolar Disorder – therapy | Psychotherapy – methods
Classification: LCC RC516 (ebook) | LCC RC516 (print) | NLM WM 171.7 | DDC 616.89/5–dc23
LC record available at https://lccn.loc.gov/2019015918
ISBN 978-1-108-46009-5 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
This study has been funded by Instituto de Salud Carlos III through the project “PI17/00914” (Co- funded by
European Regional Development Fund/European Social Fund) “Investing in your future”.
.................................................................................................................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
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Contents
List of Collaborators vii
Preface ix
2.3 Mindfulness 39
Part 1 An Introduction to 2.3.1 Distinctive Aspects of
Treatments Mindfulness 40
2.3.2 Mindfulness Module in the
1.1 Introduction to Bipolar Integrative Approach 48
Disorders 1
2.4 Cognitive and Functional
1.2 Adjunctive Psychological Remediation 49
Treatments in Adults with Bipolar 2.4.1 Distinctive Aspects of
Disorders 6 Functional Remediation for
Patients with Bipolar
Part 2 The Foundations of an Disorders 54
2.4.2 Cognitive and Functional
Integrative Approach to Bipolar Enhancement Module in the
Disorders Integrative Approach 59
2.1 Psychoeducation for Patients and
Family Members 15 Part 3 An Integrative Approach
2.1.1 Distinctive Aspects of to Bipolar Disorders
Psychoeducation for
Patients with Bipolar 3.1 Introduction to the Integrative
Disorders 17 Approach 61
2.1.2 Distinctive Aspects of Family
3.2 Contents of the Integrative
Psychoeducation for
Approach 64
Patients with Bipolar
3.2.1 Bipolar Disorder: Causes and
Disorders 23
Triggers 64
2.1.3 Psychoeducational Module
3.2.2 Symptoms of Bipolar
in the Integrative
Disorder: Early Detection of
Approach 29
Warning Signs and Early
2.2 Promotion of a Healthy Action 66
Lifestyle 30 3.2.3 Treatment of Bipolar
2.2.1 Characteristics of Disorder and Therapeutic
a Programme Promoting Adherence 70
a Healthy Lifestyle in Those 3.2.4 Regularity of Habits and a
with Bipolar Disorder 31 Healthy Lifestyle 73
2.2.2 Promotion of a Healthy 3.2.5 Psychoeducation Directed at
Lifestyle Module in the Family Members: Family and
Integrative Approach 38 Bipolar Disorder 82
vi Contents
Collaborators
vii
Preface
Pharmacological treatment is essential for the management of bipolar disorder. However,
supplementing this treatment with certain psychological treatments has been shown to
improve the prognosis of the illness and therefore the well-being of people suffering from it.
The integrative approach proposed in this book is based on the need to cover different
areas that may be affected by bipolar disorder, by means of a brief intervention that can
therefore be generalised to clinical practice. It intends to include broader therapeutic
objectives that make it possible to work on the prevention of relapses without losing sight
of other important issues for people suffering from the disease, such as those related to daily
functioning, cognition (attention, memory, executive functions), the presence of mild
symptoms that often persist between episodes, physical health, well-being and quality of
life. To this end, it incorporates therapeutic components of broader psychological
approaches that the Barcelona Bipolar and Depressive Disorders Unit developed and
whose efficacy has been evaluated separately, such as psychoeducation, family intervention
and functional remediation. In addition, it places emphasis on the promotion of a healthy
lifestyle and also includes a module of mindfulness-based cognitive therapy. This book is
born, therefore, from the authors’ clinical practice, teaching and research on bipolar
disorder, undertaken over the course of more than two decades and involving patients
and relatives as active participants in the therapeutic process.
The book consists of two well-differentiated sections divided into three parts. The first
section (Parts 1 and 2) is addressed to mental health professionals. It includes an introduc-
tion to bipolar disorder and presents the main efficacy studies in psychological interven-
tions. Then, each of the programmes on which the integrative approach is based is described
in detail; this allows the pillars on which this integrative therapy is based to be contextua-
lised. The second section (Part 3), informative and accessible to all types of readers,
including those with bipolar disorder and their families and caregivers, presents the con-
tents of each of the 12 sessions of the integrative approach.
Although it has not been easy to select the main components of the different treatments,
we are confident that this approach will help guide professionals and reduce the suffering
that bipolar disorder generates in patients and families, facilitating strategies to better
manage the illness and mitigate its possible consequences. The reality of the disease is too
complex to fragment it, hence the importance of an integrative approach that connects
different aspects from a biopsychosocial perspective.
ix
1.1
What Is Bipolar Disorder?
Bipolar disorder, previously known as manic-depressive syndrome, is a chronic and recur-
rent mental illness that affects the mechanisms that regulate mood and may result in a high
level of personal, familial, social and economic burden.
It is estimated that bipolar disorders affect approximately 2.4% of the global population
(Merikangas et al. 2011). The illness onset typically occurs during young adulthood,
although the diagnosis is often delayed, worsening the long-term prognosis (Altamura
et al. 2015). Therefore, an early diagnosis is crucial to establishing an appropriate treatment
plan as soon as possible.
To date, the diagnosis of the disease is based on purely clinical criteria. The defining
symptoms for mental illnesses are detailed in the Diagnostic and Statistical Manual of
Mental Disorders (DSM), published by the American Psychiatric Association, and in the
International Classification of Diseases (ICD), produced by the World Health Organization.
Through psychiatric interviews, clinicians can assess whether the criteria for behaviour
changes specific to the disease are met.
Patients with bipolar disorder can show manic, hypomanic and depressive episodes,
alternating with symptom-free periods (euthymia). However, some patients complain of
persistent residual symptoms (Baldessarini et al. 2010) that, although they do not meet the
clinical criteria necessary to be considered a relapse, have a negative impact on cognition
(processes such as attention, memory and executive functions which involve planning,
organisation and decision making, among other tasks), psychosocial functioning and
quality of life (Bonnin et al. 2012; Morton et al. 2018).
Both manic and hypomanic episodes are characterised by a distinct period of abnor-
mally and persistently elevated or irritable mood together with hyperactivity, high energy,
increased self-esteem, grandiosity, increased talkativeness, decreased need for sleep, becom-
ing easily distracted, flight of ideas, increased goal-directed activity or psychomotor agita-
tion and excessive involvement in activities that have a high potential for painful
consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions or unwise
business investments). Hypomania is less intense than mania and its impact on psychosocial
functioning is therefore lower and, in contrast to what can happen in mania or even
depression, does not imply psychotic symptoms (delusions and/or hallucinations), nor
does it require hospitalisation.
Regarding depressive episodes, a common feature is the presence of lowered mood or
a loss of interest or pleasure, together with decreased energy, sadness, feelings of worth-
lessness or excessive guilt, psychomotor agitation or retardation, decreased ability to think
1
10:05:08
002
2 An Introduction to Treatments
Cingulate gyrus
Anterior group of Parahippocampal
thalamic nuclei gyrus
Hypothalamus Hippocampus
Mammillary body
Amygdaloid body
10:05:08
002
Introduction to Bipolar Disorders 3
10:05:08
002
4 An Introduction to Treatments
functioning (Samalin et al. 2016). Therefore, the longer the time without relapses, the better
the prognosis becomes. Some studies have reported that a higher number of previous
episodes was associated with greater deficits in cognition (Lopez-Jaramillo et al. 2010;
Sanchez-Morla et al. 2018) and psychosocial functioning (Rosa et al. 2012), highlighting
the relevance of relapse prevention. Psychosocial functioning seems to be directly influ-
enced by both clinical variables (e.g. number of episodes, subsyndromal depressive symp-
toms) and cognitive deficits (Reinares et al. 2013; Sanchez-Moreno et al. 2018; Sole et al.
2018). Psychosocial functioning and cognitive enhancement have become new targets in the
treatment of bipolar disorders, because a high proportion of patients show difficulties
outside of the acute phases. In fact, many patients, especially those with a more severe
course of the disease, complain of difficulties in attention, memory and executive functions
(Martinez-Aran et al. 2004) as well as psychosocial difficulties (Sole et al. 2018) even while in
remission.
Stress can act as a trigger of affective relapses (Lex et al. 2017). The social environment in
the form of childhood adversities or trauma and stressful life events in adulthood (Gilman
et al. 2014), as well as a negative family atmosphere (Reinares et al. 2016), plays a crucial role
in the course of bipolar disorder.
The illness is associated with high mortality rates (Hayes et al. 2015) not only because of
a high suicide risk (Nordentoft et al. 2011), which can be drastically reduced with an early
diagnosis and good treatment, but also because of the high probability of comorbidity, that
is, of presenting other psychiatric and/or medical illnesses that often accompany bipolar
disorder (Crump et al. 2013). Substance abuse is particularly common in those with bipolar
disorders and can negatively affect the course of the illness (Messer et al. 2017). Therefore,
there is increasing awareness of the need to promote physical health through the develop-
ment of regular physical exercise, healthy eating habits and a healthy lifestyle, including the
regularity of sleep (which is crucial in bipolar disorder), good stress management and
avoidance of substance abuse, all aspects that could also reduce the risk of relapses.
Following other branches of medicine, in which the use of clinical staging has been
established (i.e. oncology) to determine the extent and severity of a disease, there have been
suggestions that clinical staging could be applied to bipolar disorders, based on emerging
data about the potentially deteriorating nature of the illness if not treated early and correctly
(Berk et al. 2017). For this reason, early diagnosis and appropriate treatment are of
fundamental importance. Clinical staging defines not only the extent of progression of
a disorder at a particular point in time, but also the point at which a person is currently on
the continuum of the course of a disease. Several staging models have been proposed with
the aim of guiding prognosis and helping clinicians to choose the treatment that is better
adapted to the patient’s needs (Salagre et al. 2018). However, more research is still needed in
this area.
10:05:08
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Introduction to Bipolar Disorders 5
treating a person with bipolar disorder should use ‘trifocal’ lenses, that is, do not lose sight
of near, intermediate and distant vision when selecting the treatment. At the same time, it
is important that the pharmacological treatment is well tolerated, with few short- and
long-term side effects. Because of the chronic and recurrent nature of bipolar disorder,
most experts advocate for a focus on maintenance from the first episode. The choice of
maintenance pharmacological treatment will be determined by the patient’s clinical
history and response to previous treatments.
Following clinical guidelines, mood stabilisers alone or in combination with antipsy-
chotics, or in specific cases with antidepressants, represent the main pharmacological
treatment (Goodwin et al. 2016; Yatham et al. 2018). If a manic or depressive predominant
polarity can be established throughout the course of the illness (defined as at least twice as
many episodes of one pole over the other), it could also contribute to guiding the treatment
choice (Popovic et al. 2012).
Psychological interventions also play a crucial role as adjunctive treatment in bipolar
disorder, especially when used in patients who are stable or exhibit mild symptoms, as
different studies have proved (Reinares et al. 2014). To date, the evidence of psychological
approaches in the acute phases of the disease is limited, for obvious reasons in the case of
mania but more surprisingly in that of depression. The latter may be due to the tendency,
based on an erroneous assumption, to extrapolate the results of unipolar depression
(experienced by people who have depression only, without hypomanic or manic episodes)
to patients with bipolar depression (depression alternating with episodes of hypomania
and/or mania). Although there are areas of overlap between both forms of depression, some
differences have also been found: bipolar depression is characterised by earlier age of onset,
psychomotor inhibition, higher risk of psychotic symptoms and more atypical depressive
symptoms such as excessive sleepiness or increased appetite. The impact of antidepressants
is also different, being clear for unipolar patients and unclear and sometimes self-defeating
for bipolar patients (Pacchiarotti et al. 2013), increasing the risks of mood shift into
hypomania/mania or rapid cycling (the presence of four or more distinct episodes of
depression, mania, or hypomania during a 1-year period). Regarding psychotherapy,
although a few studies focused on bipolar depression have shown promising findings
(Miklowitz et al. 2007), most data about the efficacy of psychological treatments come
from samples of patients in euthymia or with mild symptoms. The main evidence-based
studies and new approaches are discussed in the next section.
The advantages of combining pharmacological and psychological approaches would
contribute to decreasing the burden of bipolar disorder by ensuring the achievement of
syndromal recovery from the acute phase and maintaining it through relapse prevention,
and also symptomatic and functional recovery, which is crucial for the quality of life and
well-being of patients and the people close to them.
10:05:08
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Chapter
Adjunctive Psychological
Ideally, the needs, characteristics of the subjects and course of the illness should guide
the design or selection of the treatment in the context of personalised patient care.
6
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Adjunctive Psychological Treatments in Adults with Bipolar Disorders 7
Unfortunately, and despite the recommendation of clinical guidelines (Goodwin et al. 2016;
Yatham et al. 2018), some studies report that only a minority of individuals with bipolar
disorder receive adjunctive psychotherapy (Barbato et al. 2016; Sylvia et al. 2015).
10:06:56
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8 An Introduction to Treatments
Psychoeducation
Psychoeducation provides education and coping skills training to those suffering from the
illness in order to enhance their resources for relapse prevention and empower them to
participate actively in the illness management.
One of the first rigorous studies in the area of psychoeducation consisted of 7–12 individual
sessions for teaching patients to identify early symptoms and seek prompt treatment. This
specific component of psychoeducation proved useful to increase the time to the first manic
relapse, social functioning and employment at 18 months; however, the intervention did not
prevent depression (Perry et al. 1999). In a group format, the efficacy of adjunctive psycho-
education was shown with a sample of 120 euthymic bipolar patients randomised to receive 21
sessions of group psychoeducation or non-specific group meetings. The psychoeducational
programme consisted of five modules focused on illness awareness, the early detection of new
episodes, medication adherence, substance abuse avoidance, regular habits and stress manage-
ment. Psychoeducation reduced the percentage of, number of and time to recurrences and
hospitalisations per patient, with benefits observed not only at 2-year follow-up (Colom et al.
2003) but also at five years (Colom et al. 2009) when, together with the long-lasting prophy-
lactic effects, subjects who received psychoeducation had been acutely ill for shorter periods. In
addition, the cost efficacy of group psychoeducation was proved by reducing the number of
hospitalisations and emergency visits (Scott et al. 2009). However, the clinical benefits of the
intervention were especially evident in patients with a lower number of previous episodes
(Colom et al. 2010). In a 12-month study with a similar design but shorter treatment length (16
sessions), de Barros et al. (2013) found no differences between groups in mood symptoms,
psychosocial functioning and quality of life. The authors suggested that characteristics of the
sample could have explained the findings, as patients with a more advanced stage of disease
might have a worse response to psychoeducation. Similarly, a multicentre randomised con-
trolled trial conducted at eight community sites in England compared 21 two-hour weekly
sessions of either structured group psychoeducation or unstructured peer support for patients
with remitted bipolar disorder (Morriss et al. 2016). No differences were found at 96 weeks in
terms of patients with new episodes or time to next bipolar episode. However, when the results
were analysed in detail, psychoeducation was most beneficial in participants with one to seven
previous bipolar episodes, highlighting again the need to provide psychoeducation early in the
course of the illness. In Canada, Parikh and collaborators (2012) reported similar clinical
improvements when 6 sessions of group psychoeducation were compared with 20 sessions of
individual CBT. Using a shorter programme (8 sessions) and including patients with few
previous episodes (median of 4), Chen et al. (2018) conducted a study in China that showed the
benefits (fewer recurrences in mania in particular, lower rates of rehospitalisation, fewer
symptoms and better functioning) of group psychoeducation compared with regular free
discussions for inpatients with bipolar I disorder who were in remission from a manic episode.
It is worth mentioning that psychoeducation is also a core element of some approaches
involving different components or care packages, some of which have shown positive results
on relapse prevention (Castle et al. 2010), manic symptoms (Bauer et al. 2006; Simon et al.
2006), social role function and quality of life (Bauer et al. 2006).
Family Intervention
The illness affects not only patients but also their relatives, who suffer the consequences of
the episodes and usually become the main caregivers. Many studies support the negative
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Adjunctive Psychological Treatments in Adults with Bipolar Disorders 9
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10 An Introduction to Treatments
follow-up and four treatment options, depending on the treatment (IPSRT or intensive
clinical management consisting of education) to which each patient was assigned in the
acute and maintenance phases. No differences were found in terms of time to remission, nor
in the proportion of patients achieving remission. However, patients who received IPSRT in
the acute treatment phase survived longer without an episode and showed higher regularity
of social rhythms. Regularity during acute treatment was associated with a reduced like-
lihood of recurrence during the maintenance phase. Subjects who initially received IPSRT
showed more rapid improvement in occupational functioning but no differences at the end
of the follow-up (Frank et al. 2008). Similarly, more rapid improvement of mood symptoms
but a comparable response rate were found by Swartz et al. (2017) in a study of patients with
bipolar II disorder in a depressive episode randomly assigned to 20 individual sessions of
IPSRT plus quetiapine (to a maximum of 300 mg/day) or IPSRT plus placebo in identical-
appearing capsules. IPSRT plus quetiapine assignment was associated with a significantly
higher body mass index over time and rates of a dry mouth. Patients randomly assigned to
their preferred treatment were 4.5 times more likely to respond. Finally, Inder and others
(2015) randomised a group of 100 participants with bipolar disorder to IPSRT or specialist
supportive care. After treatment, both groups had improved depressive symptoms, social
functioning and manic symptoms. The reduction in symptoms was maintained at 3-year
follow-up for both conditions (Inder et al. 2017).
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Adjunctive Psychological Treatments in Adults with Bipolar Disorders 11
framework, with the main aim of improving functional outcomes in bipolar disorder. In
Spain, Torrent and other authors (2013) carried out a randomised trial that involved several
centres, with a total of 239 euthymic patients with functional impairment. The sample was
divided into three subgroups according to treatment: 21 sessions of group functional
remediation, 21 sessions of group psychoeducation, or treatment as usual. The functional
remediation programme resulted in improving patients’ psychosocial functioning, but no
significant effect of treatment group on the clinical (manic and depressive symptoms) or
neurocognitive variables was found at the end of the intervention (6 months). However, at
1-year follow-up, the benefits of functioning were maintained and an improvement in
verbal memory was obtained (Bonnin et al. 2016). This approach represents a useful option
for the high proportion of patients with problems of poor functioning.
10:06:56
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12 An Introduction to Treatments
two broad categories according to their main platform of delivery: web-based interventions
(e.g. ORBIT, MoodSwings, Beating Bipolar, Bipolar Education Program, Recovery Road,
Living with Bipolar, iCBT, MoodChart, MyRecoveryPlan) and mobile-based interventions
(e.g. MONARCA, PRISM, SIMPLe). Most of the evidence concerning bipolar disorders
comes from web-based programmes which, however, do not provide objective monitoring
but are aimed more at delivering interventions and remotely monitoring symptoms. In
mobile technology, there is the possibility of continuously capturing objective behavioural
data and complementing self-reported measures, while at the same time delivering inter-
ventions outside clinical settings. Finally, even though these platforms are appealing, they
share challenging issues such as retention and engagement, suggesting they should use
a feasible and acceptable method of delivery. As in face-to-face psychological treatments,
future studies should clarify which components of the programmes are crucial in relation to
obtaining expected results. Another issue is finding a balance between the degree of patient
self-management and the level of clinician involvement. Many studies are at a preliminary
stage, making it difficult at present to draw firm conclusions about the effectiveness of
psychological interventions using Internet-supported technologies for bipolar disorders.
Meanwhile, we cannot dismiss their utility as a complement of current treatments.
Recently, through the combination of objective measures (actigraphy and ecological
momentary assessment) and subjective measures through the traditional clinical method,
Merikangas and collaborators (2018) observed a close relationship between parameters such
as motor activity, energy, mood and sleep hours. The findings suggest the importance of
active and passive tracking of multiple regulatory systems and the need to integrate all these
aspects in order to achieve a more effective therapeutic approach.
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Adjunctive Psychological Treatments in Adults with Bipolar Disorders 13
bipolar disorder highlighted the feasibility and utility of the intervention using psychosocial
functioning as a main outcome, but the lack of a control group means it is not yet possible to
draw conclusions about its efficacy (Haffner et al. 2018).
Lifestyle Interventions. Although maintaining a healthy lifestyle is important in bipolar
disorder and is usually a component of different approaches, research on diet and exercise
has recently begun, and treatments particularly aiming at improving healthy habits are still
scarce in this population (Bauer et al. 2016). Most randomised controlled trials have been
carried out with mixed samples of patients with severe mental illness, including unipolar
depression, schizophrenia and bipolar disorder (De Rosa et al. 2017). One randomised
controlled trial conducted in a sample of patients with bipolar disorder used a 20-week
cognitive-behavioural intervention consisting of three modules: nutrition, exercise and
wellness (Sylvia et al. 2013). Over the course of the treatment, participants showed improve-
ments in exercise, nutritional habits, depressive symptoms and overall functioning.
Previously, with a 5-month intervention of 11 group sessions and weekly fitness training,
another randomised controlled trial reported a reduction in body mass index, particularly in
female patients (Gillhoff et al. 2010). A positive impact on weight loss was found in
a behavioural intervention in a mixed sample that also included bipolar patients (Daumit
et al. 2013). Results from open trials of exercise as an adjunctive intervention for bipolar
disorder have reported that more physical exercise means fewer depressive symptoms,
better quality of life and increased functioning, as well as less psychiatric comorbidity
(Melo et al. 2016).
10:06:56
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Part 2 The Foundations of an Integrative Approach to Bipolar Disorders
Chapter
Bipolar disorder is a chronic mental illness with dramatic changes in mood. The illness leads to
a high level of personal, familial, social and economic burdens. As previously stated, although
medication is essential in bipolar disorder, in the past two decades there has been a growing
interest in the development of adjunctive psychological interventions in order to enhance aspects
that medication alone cannot reach and to account for the heterogeneity of areas of intervention.
As was reviewed in the section on evidence-based adjunctive psychological treatments,
the efficacy of specific psychological interventions has been proven not only in short- but
also long-term follow-up for some treatments; many interventions share components, but
vary in the emphasis given to them (Reinares et al. 2014). The main outcomes also differ,
with most psychological treatments focusing on the prevention of episodes of mood swings.
Recently, however, the importance of improving other areas affected by the disease, such as
cognition, psychosocial functioning, physical health, persistent symptoms, well-being and
quality of life, is being underlined.
The duration of the therapies, usually approximately 20 sessions, is an important aspect
to consider, especially for many psychological treatments that have been shown to be
effective: group psychoeducation of patients, some family intervention programmes (e.g.
family-focused treatment), cognitive-behavioural therapy, interpersonal and social rhythm
therapy, and functional remediation. It is necessary to generalise intervention programmes
developed in specialised centres to the usual clinical practice. This requires the design and
evaluation of potentially effective treatments that must be brief and feasible enough to be
implemented more widely. In the same way, making the inclusion criteria more flexible
would make it possible to cover a greater number of patients and would be more repre-
sentative of the population with bipolar disorder.
An integrative intervention is therefore required that combines the main components of
different approaches to cover broader therapeutic objectives, to improve the prognosis of
the disease in both clinical and functional aspects, as well as the well-being and quality of life
of those who suffer from the illness. Because of its characteristics and its potential lower cost,
this intervention could be easily applicable to routine clinical practice.
The integrative approach incorporates therapeutic components of other broader treat-
ments that the Barcelona Bipolar and Depressive Disorders Unit has developed and whose
effectiveness has been evaluated separately, such as psychoeducation, family intervention and
functional rehabilitation. In addition, an important emphasis is given to the promotion of
a healthy lifestyle, and a module focused on mindfulness-based cognitive therapy is included.
This section, Part 2, describes the treatments previously mentioned that represent the
foundation on which the development of the integrative approach is based. In Part 3, the
contents of each of the 12 sessions of the brief integrative approach are outlined and discussed.
15
08:57:34
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16 The Foundations of an Integrative Approach to Bipolar Disorders
Every illness represents in some way a threat and increases the sense of vulnerability. The
diagnosis of a chronic and recurrent mental disorder influences a person’s self-image and has
a strong impact on all members of the family. In the adjustment to the diagnosis, each
individual usually undergoes a process in which a variety of beliefs and emotions may arise
that will have to be dealt with, in parallel to education about and acceptance of the disorder. It
is common for denial to appear first, attributing what has happened to external factors. There
is also a tendency for the patient to deny the chronic nature of the disorder, refusing the
possibility that another episode may occur. The onset of the disease can often be accompanied
by a marked sense of loss, experienced both by the person receiving the diagnosis and by his or
her relatives: the loss of the healthy self together with an increase in the feeling of vulnerability,
real losses as a consequence of the episodes (work is impaired, social difficulties arise, ruptures
occur, family are affected, financial problems ensue, etc.) or perceived loss, sometimes
erroneously, of expectations about the person him- or herself or about the future. There
may be a tendency for the person to define her- or himself by the disorder (‘I am bipolar’)
rather than being able to distinguish between illness and identity (‘I have a bipolar disorder’)
which goes far beyond any diagnosis. Added to this, there is the marked stigma that still
surrounds mental illness and that leads many people to hide the disorder even from those in
their closest circles for fear of rejection or embarrassment. Statements such as, ‘People with
bipolar disorder are violent and unpredictable’, ‘Bipolar disorder is always disabling’,
‘Individuals with bipolar disorder have a double personality’ are unfortunately very common.
They reflect the myths and ignorance that still exist about mental illness, and as such should be
reviewed and corrected. All these aspects of reactions to diagnosis are potentially modifiable
and should therefore be considered in the therapeutic approach and throughout whatever
may be required in the process of acceptance of bipolar disorder.
In medical illnesses such as diabetes, asthma or high blood pressure, the need for
education about the factors that can improve the course of illness seems self-evident. The
same should be true for mental disorders. The knowledge and acceptance of bipolar disorder,
as well as the optimisation of strategies for its management, will not only contribute to
increasing the sense of control and self-efficacy but will also positively influence the course
of the disorder, which is the primary goal of any treatment. Although all types of interventions
with some educational component are often erroneously included within the psychoeduca-
tional approach, a distinction must be made between merely transmitting general information
and those treatments that incorporate theoretical and practical skills training in order to allow
the subjects to take an active role in the therapeutic process.
Psychoeducation can have a crucial impact on both disease awareness and therapeutic
adherence, and consequently on the prognosis of bipolar disorder. In addition, aspects such as
early detection of warning signs and other factors such as maintaining healthy and regular
habits and managing stress are essential pillars for the prevention of relapses, as different
studies discussed previously have shown. Therefore, it is essential that patients and their
families receive support, education about the disease and training in coping strategies that
have a positive impact on the course of the disorder and consequently improve their well-
being and quality of life.
Several psychoeducation manuals have been developed for clinicians working with
patients with bipolar disorder (Bauer & McBride 2003; Colom & Vieta 2006) or with the
family, the latter in different formats such as family-focused treatment directed at the
whole family unit (Miklowitz & Goldstein 2007) or caregiver-focused psychoeducation
(Reinares et al. 2015).
08:57:34
004
Psychoeducation for Patients and Family Members 17
Two psychoeducation programmes, one for patients and one for relatives, are presented
in the following sections. Both have inspired the psychoeducational module of the integra-
tive approach presented in Part 3 of this book.
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18 The Foundations of an Integrative Approach to Bipolar Disorders
The process of learning about the disease should begin the moment it is diagnosed and
from that point constantly expanded, allowing the patient’s and the therapist’s under-
standings to be in alignment. However, psychoeducational intervention as a specific treat-
ment, as will be discussed later, has been implemented in a group format and tested in
subjects who were on medication and whose mood was stabilised at the time of the
intervention. This makes it possible to highlight a fundamental objective of the treatment:
the prevention of relapses.
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Psychoeducation for Patients and Family Members 19
1. Introduction
18. Regularity of habits 2. What is bipolar disorder?
19. Stress-management techniques 3. Causal and triggering factors
20. Problem-solving techniques 4. Mania and hypomania
21. Final session 5. Depression and
mixed symptoms
Awareness of 6. Course and outcome
the disorder
Regular Drug
habits and adherence
stress
management Psychoeducation 7. Mood stabilisers
for bipolar 8. Antimanic agents
disorder 9. Antidepressants
10. Serum levels of mood
15. Early detection
Early stabilisers
of (hypo)mania Avoid
detection of 11. Pregnancy and genetic
16. Early detection substance
new counselling
of depression abuse
episodes 12. Other treatments
17. What to do when
13. Risks of medication
a new phase is
14. Alcohol and illegal drugs withdrawal
detected
Figure 2.1 Sessions of the group psychoeducational programme for bipolar disorders (Barcelona Bipolar and
Depressive Disorders Unit).
are reviewed in this module, highlighting the (often underestimated) pathological character of
hypomania and aspects related to the course of the illness.
A useful exercise for this block of sessions consists of drawing a graph with the evolution
of the illness during the past approximately 8–10 years. On a horizontal line reflecting the
state of euthymia over time, the different types of episodes experienced are represented
(with elevations for hypomania, more accentuated elevations for mania and reductions
illustrating depressions) as shown in Figure 2.2. At the same time, it is helpful to write down
the dates corresponding to the relapses, possible triggers (if there were any), the conse-
quences of the episodes and the treatment received.
This exercise allows the subject to detect specific patterns (e.g. if there is a seasonal
pattern – coinciding with certain seasons of the year – or if the relapses have occurred after
potential triggers such as drug use), as well as to be more aware of the chronic and recurrent
nature of bipolar disorder, and not to underestimate the risks associated with relapses
(hospitalisations, breakups, socio-occupational problems, overspending, etc.).
2. Drug Adherence
Pharmacological treatment is essential for bipolar disorder, and its abandonment or poor
adherence is a clear predictor of relapses, with all the complications that these entail
(hospitalisations, cognitive deficits, problems with work and social functioning, increased
risk of suicide, etc.). The fact that almost all people who suffer from bipolar disorder have
thought, throughout their lives, of abandoning the treatment, and that approximately half
of them have done so on some occasion – even in periods of euthymia – justifies the
importance of having sessions on adherence. The patients are informed about the different
pharmacological treatments for the disorder and their therapeutic and adverse effects. Doubts
and fears are addressed and erroneous beliefs about the treatment corrected (i.e. ‘People with
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20 The Foundations of an Integrative Approach to Bipolar Disorders
Euthymia
Depression
bipolar disorder lack lithium in their blood’, ‘Pharmacological treatment creates addiction’,
‘Medication prevents experiencing emotions’, ‘Memory problems are exclusively caused by
pharmacological treatment’). Identifying the factors that influenced poor adherence in the
past, and what the consequences of poor adherence were, can help prevent it from happening
again. Explaining the phases that a drug goes through before being introduced to the market
and familiarising patients with the scientific method generates greater confidence. It can also
be useful to later state which non-pharmacological approaches have – and which have not –
shown efficacy in bipolar disorder. In this module, medication and other recommendations
related to pregnancy are also addressed, always highlighting the importance of advance
planning and psychiatric counselling.
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Psychoeducation for Patients and Family Members 21
are recommended to avoid completely, the negative effects of alcohol should be discussed.
Instructions should also be given regarding the consumption of caffeinated beverages such
as coffee or other stimulant drinks. These should be avoided in the afternoon and evening
because of their potential negative impact on sleep (which can act as a trigger for relapses),
and eliminated altogether in the case of hypomanic/manic symptoms and episodes.
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22 The Foundations of an Integrative Approach to Bipolar Disorders
Non-specific Concrete
08:57:34
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Psychoeducation for Patients and Family Members 23
The application is based on the idea that every day the person will answer test questions about
mood state, hours of sleep, energy level, irritability and medication taken. After doing so, he or
she receives a personalised psychoeducational message. In the event that the answers to the daily
test detect warning signs, a more exhaustive test is activated, which is otherwise systematically
presented on a weekly basis. If a risk of decompensation is suspected, the patient is advised to
contact his or her doctor of reference or go to the emergency services. Simultaneously, the
application allows users to do things such as programme warnings at established times for taking
medication, to incorporate information on prodromal symptoms of relapse in order for the
device to warn of its possible appearance, to record stressful events and to share the mood graph
with other people. Regular use of the application is reinforced by medals and trophies as a way of
boosting motivation.
The application is continuously being tested to scientifically evaluate its efficacy and safety
(https://simplebipolarproject.org/). To date, it has shown high levels of feasibility, adherence –
especially in the first months – and satisfaction (Hidalgo-Mazzei et al. 2016, 2018) as well as
having a positive impact on adherence to medication and circadian rhythms (Hidalgo-Mazzei
et al. 2017). Translations from Spanish to other languages are currently under way, which will
allow this resource to be offered more widely to users. Work is also being done to complement the
subjective data, introduced by the person with the disorder, with objective data (sleep, activity
level, Internet browsing, etc.) captured through mobile phones or through smartbands.
Through the use of smartphones, other applications such as MONARCA (MONitoring,
treAtment and pRediCtion of bipolAr disorder episodes) (Faurholt-Jepsen et al. 2014, 2015)
and PRISM (Personalized Real-time Intervention for Stabilising Mood) (Depp et al. 2015)
have also been developed for those with bipolar disorder.
The integrative approach proposed in Part 3 of this book provides patients with
information on SIMPLe and other applications, as well as links related to the contents of
the programme with the aim of reinforcing each module worked on during the intervention.
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24 The Foundations of an Integrative Approach to Bipolar Disorders
DENIAL HYPERVIGILANCE
emotional over-involvement (e.g. ‘I am constantly looking out for her; if she is not nearby,
I cannot relax’) has a negative influence on the course of the illness. However, the clinician
must be cautious in the way this information is transmitted to relatives and avoid any kind of
blaming but still emphasise a reality: the relationship between the person with the illness and
the family is reciprocal. Family psychoeducation aims to reinforce favourable attitudes and, in
the case of group intervention, to take advantage of this context to model and encourage
behaviours that may reduce the level of stress and improve the family atmosphere.
Not only the person diagnosed with bipolar disorder but also the family members may
find it difficult to accept and understand the nature of the disease. A continuum could be
established whose extremes are at one end denial and at the other hypervigilance (Reinares
et al. 2015). Each of these attitudes elicits consequences that could affect the course of the
illness (Figure 2.3). Sometimes different members of the family may adopt different positions
(e.g. a father who denies the illness and a mother who adopts an overprotective attitude) and
this also becomes a source of conflict to be addressed. A whole range of emotions can be
placed along the continuum, such as frustration, a feeling of loss, sadness, fear for the future,
anxiety and guilt, among others. Some family members have also reported positive aspects of
their role as caregivers, such as the enhancement of feelings of love, pride and compassion.
Given the close relationship between attributions, attitudes and behaviours, it is impor-
tant to identify and work on the beliefs that different members of the family may have about
the illness in order to correct them in a way that leads to more beneficial behaviours for
themselves, the family environment and the course of the disorder. Carer emotional
reactions and behaviours will be completely different depending on their appraisals. For
example, it has been observed that if a family member is highly critical, there may be
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Psychoeducation for Patients and Family Members 25
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26 The Foundations of an Integrative Approach to Bipolar Disorders
✓ A joint intervention involving all parties ✓ Allows the identification and exchange of
allows different views to be experiences among equals.
contemplated. ✓ Facilitates expression, normalisation and
✓ Observe (and work on) the interaction handling of emotions, without fear of
between the different members. offending the patient.
✓ More personalised approach and ✓ Allows the modelling of more adaptive
objectives. coping strategies.
✓ Work on more intimate aspects that they ✓ Increases the variety of solutions to
perhaps do not want to reveal in a group. problems.
✓ It may prevent the relatives of recently ✓ Increases support, social networks and the
diagnosed patients from being alarmed importance of self-care.
by cases of greater severity. ✓ Increases acceptance, illness awareness
✓ Resource for those who do not want to and destigmatisation.
attend a group. ✓ More economical.
✓ More flexible schedule.
intensity that facilitates the assimilation of information and the resolution of problems. At the
same time, it allows the longitudinal perspective in the management of bipolar disorder to be
emphasised, highlighting the importance of prevention. Otherwise, there is a risk of focusing
the intervention on the search for immediate solutions derived from the period of crisis or of it
becoming a resource for emotional venting.
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Psychoeducation for Patients and Family Members 27
Figure 2.4 Sessions of the group psychoeducational programme delivered to family caregivers of patients with
bipolar disorder (Barcelona Bipolar Depressive Disorders Unit).
disorder, but also the role that certain environmental factors play in the course of the
illness. Therefore, the biological vulnerability to future episodes is highlighted together
with the potential negative impact on the illness of triggering factors such as poor
pharmacological adherence, drug abuse, unhealthy lifestyle/irregular habits and stress.
It is encouraging for family members to know that, despite the chronicity of the
disease, certain attitudes and behaviours can reduce the risk of relapse. The role of the
family in relation to bipolar disorder is underlined, always from a constructive point
of view. Family caregivers often become experts; their experience complemented with
the knowledge and training we can offer should improve management of the illness.
The feelings of guilt expressed by some relatives have to be dealt with, as well as
attitudes of denial, criticism, overprotection or hypervigilance that can lead to con-
flicts and affect the illness as well as every member of the family. The idea is to help
relatives understand and accept the illness.
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28 The Foundations of an Integrative Approach to Bipolar Disorders
Promote autonomy
Promote preventive factors
Self-care of family members
Euthymia
Prodromal phase
Figure 2.5 The need to adapt strategies and positions according to each phase of the illness.
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Psychoeducation for Patients and Family Members 29
Expression and
Mood state → interpretation of
messages
08:57:34
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Chapter
Promotion of a Healthy Lifestyle
2.2
What we do throughout life contributes to accelerating or to slowing down the ageing
process. Although we tend to remember the importance of taking care of ourselves when we
feel ill, good health should be considered a long-term investment. A sedentary lifestyle,
obesity, tobacco, consumption of alcohol and other substances, and stress, among others,
are factors that negatively affect our cells, accelerating the deterioration of tissues in our
body. Good health means staying active physically, intellectually and socially, as well as
carrying out healthy and regular habits, including a balanced diet and varied physical
exercise. Fortunately, control of these factors is in our hands. If we manage to transform
healthy behaviours into habits, the effort to maintain them will be less and will be rewarded
by the motivation and perceived benefits for health and quality of life.
Disability-adjusted life years (DALY) is a measure of global disease burden, expressed
as the number of years lost due to illness, disability or premature death. It was developed
in the 1990s as a measure to compare the overall health and life expectancy of different
countries. Bipolar disorder is one of the mental illnesses that generates the highest level of
burden (Murray et al. 2012). People with severe mental disorders have mortality rates two
times higher than that of the general population; in bipolar disorder, life expectancy is
9 years lower than the rest of the population (Crump et al. 2013). In addition, people living
with bipolar disorder present more risk of obesity, hyperglycaemia and metabolic syn-
drome, all related to risk factors such as lack of physical exercise, unbalanced diet,
consumption/abuse of tobacco and alcohol that could be modified through changes in
lifestyle.
Low levels of physical exercise have been associated with poorer quality of life, worse
overall functioning and more depressive symptoms. In contrast, regular exercise improves
cardiorespiratory function and reduces the risk of premature death, in addition to having
a positive impact on weight control and cholesterol levels. However, a recent study reported
that approximately half of people with mental disorders did not meet the recommendation
of at least 150 minutes of physical activity per week, with subjects with bipolar disorder
being more likely to have a sedentary lifestyle (Vancampfort et al. 2017). Some of the
barriers identified have to do with illness and medication. In terms of eating habits, many
people with the disease tend to eat a large amount of saturated fatty acids and large amounts
of sugar (simple carbohydrates). This food consumption pattern is associated with diseases
such as type II diabetes, dyslipidaemia, obesity, hypertension and cardiovascular diseases.
Beyond the genetic predisposition, most of the behaviours associated with these diseases are
modifiable (sedentary lifestyle, inadequate nutrition, smoking, etc.) through the implemen-
tation of good dietary habits. Diets high in fruits, vegetables, fish and whole grains are
associated with a decreased risk of depression (Lai et al. 2014). A study in patients diagnosed
30
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Promotion of a Healthy Lifestyle 31
with bipolar disorder found that obesity was linked to a worsened course of the disease
(Fagiolini et al. 2003).
Helping patients persist with small changes can lead to substantial positive impacts over
time; to get to that point, however, it is important that the person accepts that change is
needed, finds the motivation to change and overcomes obstacles in the way of making
change (Nierenberg et al. 2015). There are few randomised clinical trials studying the
efficacy of interventions based on healthy lifestyles exclusively in the bipolar population.
Sylvia and collaborators (2013) pointed out the benefits of a cognitive-behavioural inter-
vention consisting of three modules: nutrition, exercise and well-being. After the treatment,
participants showed improvement in exercise, nutritional habits, depressive symptoms and
overall functioning. Previously, another study had proved the efficacy of an intervention on
healthy lifestyle, nutrition and physical exercise on muscle mass index. It was found that
women with bipolar disorder improved body composition after receiving this intervention
(Gillhoff et al. 2010).
In recent years, health professionals have become increasingly interested in motivating
their patients to adopt healthy lifestyles, becoming more physically active and eating
a balanced diet as a strategy to prevent disability and improve quality of life. In addition,
in bipolar disorder, negative life events and stress may trigger relapses (Lex et al. 2017).
Conversely, use of drugs negatively affects the course of the disease (Messer et al. 2017;
Starzer et al. 2018). Therefore, regular healthy habits (sleeping an average of 8 hours, eating
a healthy diet, avoiding abuse of drugs), controlling the level of stress and being active
physically, intellectually and socially are basic ingredients for good health. Hence, the
factors explained in what follows will be of fundamental importance for people suffering
from this disease. Assuming the responsibility of controlling these factors can reduce the
risks and improve the prognosis of the illness, in addition to increasing physical–
psychological well-being and quality of life. For this reason, the integrative approach
dedicates a session to promoting healthy lifestyles, which is presented in Part 3.
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32 The Foundations of an Integrative Approach to Bipolar Disorders
2. Dietary Habits
Eating properly is essential for good health. The body needs certain substances (nutrients)
to create and maintain the tissues and to get the energy needed to perform vital functions.
A healthy diet should be balanced, varied and sufficient, taking into account the character-
istics and lifestyle of the individual. A healthy diet provides the necessary amounts of energy
and nutrients and minimises the risk of diseases associated with unbalanced consumption,
in addition to contributing to the delay in the ageing process.
Variety, balance and moderation in the quantity consumed are basic principles con-
tributing to healthy eating, and this helps maintain body weight. Taste preferences and
dietary habits have a lot to do with our learned behaviours. In recent years, eating styles in
developed countries have changed considerably, promoting the consumption of fats,
sugars and animal proteins and a lower consumption of fibre. A sedentary lifestyle
together with poor dietary habits can lead to an imbalance between calories consumed
and calories spent, promoting overweight and obesity because of the excessive accumula-
tion of body fat. Besides the physical limitations and the impact of obesity on body image
and self-esteem, other important consequences are derived from increasing weight,
including an increased risk of cardiovascular disease, diabetes, musculoskeletal disorders,
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Promotion of a Healthy Lifestyle 33
hypertension, dyslipidaemia, dyspnoea, sleep apnoea, gallbladder disease and some can-
cers. Obesity, therefore, increases the risk of premature death. One of the most commonly
used parameters to measure obesity is the body mass index (BMI) that is calculated by
dividing the weight in kilograms of the person by their height in metres squared (kg/m2).
According to the World Health Organization, a normal BMI in adults is between 18.5 and
24.9, a BMI of over 25 corresponds to overweight and one above 30 indicates obesity.
It is never too late to promote a healthier diet; however, it is best to establish new habits
when the patient is euthymic. Referral to a specialist should be considered if the goal is
weight loss or to treat hypertension, diabetes or other endocrine problems. However, if
there is motivation to improve eating habits, the following tips may be useful. The ideal diet
pattern is similar to the traditional Mediterranean diet which is characterised, among other
aspects, by a high consumption of cereals, fruits, vegetables, nuts, legumes and olive oil (as
the main source of fat); a moderate consumption of fish, chicken and dairy products; and
a low consumption of red meat. Regular consumption of water is also important, because it
maintains body temperature and is essential for metabolic functions and the elimination of
toxins.
Besides following the recommendations in Table 2.4, the advice in Table 2.5 can be also
applied.
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34 The Foundations of an Integrative Approach to Bipolar Disorders
Overeating can be sometimes triggered by emotions. When this happens, eating is used
as a tool to reduce anxiety by consuming high-calorie, sugary and fatty foods. ‘Emotional
hunger’ implies that the person eats because of the emotions rather than real hunger. It is
important to identify and address this. Some examples include eating when stressed (at
work, at school), eating as a response to emotions (sadness, anger, anxiety, boredom,
feelings of loneliness or emptiness) or to improve mood (using the food as a crutch), eating
with the feeling of loss of control, and even continuing eating despite feeling full. Eating
with full consciousness helps to pinpoint why emotional eating is occurring when it does.
Treating emotional hunger is important in identifying the triggers that cause it, and to break
the relationship established between the triggers and the food intake, which could end up in
binge eating.
In the case of bipolar disorder, changes in mood may also involve alterations in
appetite that affect the usual eating pattern. Frequently, hyperactivity, common in hypo-
manic/manic episodes, leads to skipping meals and depression is accompanied by
a reduced intake of food, with the consequent loss of weight, or by excessive intake
(hyperphagia). The latter is a characteristic trait in atypical depressions. This, together
with the potential effect on weight gain of some pharmacological agents for illness
management (Table 2.6), reinforces the importance of promoting healthy habits in this
population. In addition, if any unhealthy behavioural pattern is detected, an appropriate
referral should be made for treatment. It is also important to explore fears about weight
gain or possible side effects of the medication in order to agree on the most appropriate
treatment and establish guidelines that limit, as far as possible, the adverse effects of the
medication.
The following should be considered in relation to bipolar disorder: (a) follow a healthy
and regular food pattern, avoiding excessively restrictive diets that generate hunger and
may increase levels of anxiety; (b) there are no ‘prohibited’ foods, unless antidepressants
(monoamine oxidase inhibitors (MAOIs)) are prescribed, in which case the appropriate
diet for these medications should be followed; (c) if lithium is prescribed, a low-sodium or
sodium-free diet should not be abruptly initiated because it could interfere with lithium
blood levels.
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Promotion of a Healthy Lifestyle 35
A group of scientists from the University of Barcelona validated the Barcelona Bipolar
Disorders Eating Scale (Torrent et al. 2008). It consists of a brief, hetero-applied (administered
by the clinician) instrument, whose 10 items revolve around the regularity of eating habits,
the influence of mood over eating, bingeing behaviour, mechanisms regulating satiety, the
tendency to eat compulsively and a craving for carbohydrates. It allows a quick and effective
evaluation of the intensity and frequency of eating dysfunctions, guiding clinicians on those
aspects that require more attention.
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36 The Foundations of an Integrative Approach to Bipolar Disorders
– Physical exercise can be a very powerful tool during depressive phases. It is helpful to
determine which activities are positive for the patient, because they can serve as
a resource to modulate mood and increase feelings of well-being.
Brisk walking to increase heart rate. Walk to work or to the store instead of going by car
Strength exercises, such as weight or motorcycle.
training, squats. Climb the stairs instead of using the lift (elevator).
Aerobic exercises: running, cycling, Park the car farther from the destination.
swimming, attending gym classes. Get off the underground or bus a couple of stops
Activities such as yoga, tai-chi or dance. before the final destination.
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Promotion of a Healthy Lifestyle 37
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38 The Foundations of an Integrative Approach to Bipolar Disorders
interpreting the situation and the assessment a person makes of his or her capacity to face
the demands, which in turn determines emotions and reactions. Therefore, being aware of
negative automatic thoughts (dichotomous thinking, catastrophism, jumping to conclu-
sions, selective attention ignoring other aspects of the event, etc.) and being able to question
them and look for more realistic and evidence-based alternatives, can place someone in
another position in the same situation.
At the behavioural level, training in assertiveness, communication skills and problem
solving can contribute to a greater perception of self-efficacy in certain potentially stressful
situations. In the same way, good planning, prioritisation and time management can
facilitate the resolution of the demands that may arise, without forgetting to incorporate
rewarding moments and rest into an agenda, as well as enhancing the social life that is
a fundamental aspect for well-being.
There are also several strategies that contribute to reducing physiological activation or
muscle tension associated with stress. Among the best known are controlled diaphragmatic
breathing and Jacobson’s progressive muscular relaxation training.
Sometimes, the strategy is more directed at improving emotional regulation than at
changing the focus of the situation or the resolution of the problem. In parallel, poor
regulation of emotion can interfere in the resolution of problems, as it can lead to impulsive
responses. Being less reactive to certain thoughts, emotions and physical sensations puts
the situation in a more favourable light. In this context, mindfulness training, defined as
deliberately paying attention, in the present moment and without judging, to how the
experience unfolds from moment to moment, is important (Kabat-Zinn 1994). This
approach will be discussed in more detail in the next section, and training will be offered
throughout three sessions in the integrative approach in Part 3.
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Chapter
Mindfulness
2.3
Stress is part of life. As discussed previously, some degree of stress can be stimulating to
achieve certain goals. However, when the level of stress is maintained, the effects can be
detrimental to health. Stress depends not only on the objective situation, but especially on
factors related to how we interpret the situation and the resources we believe we have to deal
with it. Faced with a stressful situation, the body undergoes a series of physiological
reactions that involve the activation of the hypothalamic–pituitary–adrenal axis and the
autonomic nervous system. What happens in the stress response is that a real or imagined
problem causes the cerebral cortex to send an alarm to the hypothalamus, which then
stimulates part of the nervous system to make a series of changes in the body. These include
changes in the heart and breathing rates, muscle tension, metabolism and blood pressure,
among others. The adrenal glands secrete corticoids which shut down processes such as
digestion, growth, tissue repair and the responses of the immune system.
We can be victims of stress and its consequences for physical and mental health or we can
learn to better manage those factors that increase our levels of stress with techniques such as
cognitive restructuring, diaphragmatic breathing, muscle relaxation and mindfulness, which
may contribute to restoring our bodies to their baseline states. Assertiveness, effective
problem solving and good time management can also contribute to reducing some tensions.
Therefore, there are several strategies we have to manage stress, most of them related to the
components that contribute to its appearance and maintenance, as explained at the end of the
previous section.
In bipolar disorder, stress can act as a triggering factor for relapses. Faced with this
reality, we can adopt an attitude of helplessness and passivity or a more constructive attitude
that places us in an active position towards strategies that allow us to handle the stress better.
As Kabat-Zinn states in his book Wherever You Go, There You Are: ‘You can’t stop the
waves, but you can learn to surf’ (Kabat-Zinn 1994, p. 31).
Mindfulness is an approach that has gradually gained strength as a treatment or
complement to many interventions aimed at reducing stress and the anxious and depressive
symptomatology that often accompanies it. Mindfulness is a mental training technique
originating from Eastern contemplative traditions, specifically Buddhism. However, med-
itation practices and mindfulness skills can be used in a completely secular way. At the heart
of mindfulness training is the recognition that it is not the thoughts or emotions experi-
enced that cause suffering; rather, it is the unskilful attempts at dealing with them.
Together with the relevance of improving stress management to reduce the risk of
relapses in bipolar disorder, many patients present subsyndromic anxious and depressive
symptoms that could be reduced with mindfulness training; the training also seems to
improve emotional regulation and attentional performance (Bojic & Becerra 2017; Lovas &
39
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40 The Foundations of an Integrative Approach to Bipolar Disorders
08:52:03
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Mindfulness 41
– ‘Automatic pilot’ → stop, take a look and consciously choose the response.
– ‘Monkey mind’ or wandering and distracted mind → focus attention intentionally.
– Mental time travel to the past and the future → focus attention on the present, on the ‘here
and now’.
– To judge → observe with curiosity, openness and acceptance.
– Focus on the content → focus on the process.
– Endeavour that things ‘should’ be different → allow things to be as they are.
– Thoughts as realities → thoughts as mental events.
– Avoidance and resistance → ‘turn towards’, openness and awareness.
– Fight or resignation → acceptance.
– Clinging and controlling → be able to ‘let go’.
– ‘Doing’ mode → ‘being’ mode.
– Striving and goal-oriented → non-goal attainment or specific state to be achieved, letting go
of outcome and expectation.
– Identification with what is observed (getting caught up in the mind with thoughts, emotions)
→ identification with the observer without ‘getting lost’ in what is observed (like a scientist).
– Critical attitude, ‘should’ statements → loving and compassionate attitude towards others and
oneself.
– Reactive responses or impulsive problem solving → intentionally choose the most skilful
response, problem solving in a less reactive way and from a broader perspective.
happening. Most of the time when we are practising, we have to continually renew our
intention to pay attention, over and over again. We have to bring the mind back from its
wanderings and pay attention to the breath, the body. It is at the exact moment when you
have noticed the mind wandering and you deliberately decide to re-focus that you are being
mindful. These features are summarised in Table 2.8.
If we are more conscious, reduce experiential avoidance and increase the ability to
distance ourselves and observe with curiosity, we can better regulate the tendency to
ruminate, increase the flexibility of attention and decrease the tendency to judge, selecting
the responses in a less reactive way. Mindfulness training will therefore allow us to respond
to situations with greater freedom of choice and without being carried away by automatic
reactions.
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42 The Foundations of an Integrative Approach to Bipolar Disorders
when their mood is deteriorating, and using techniques that would take up limited resources
in channels of information processing that normally sustain ruminative thought–affect
cycles. MBCT combines elements of mindfulness meditation practice, alongside cognitive
techniques to allow individuals to work with and see more clearly patterns of thinking that
may be unhelpful or unskilful. However, the emphasis is not directly on the content of the
thoughts but rather on changing the relationship established with them (as well as with
emotions and physical sensations), which in turn generates a change of perspective. The
idea is to observe the thoughts as external events and to be aware of the way we relate to
them. It means moving from a focus on content to a focus on process.
The usual approach is through an intervention of 8 weeks’ duration, with 2 hours per
week accompanied by various types of practice. Throughout the training, the following
aspects are worked on:
✓ Recognise the tendency to be on automatic pilot and explore what happens when we are
more aware and intentionally focus our attention on what is happening. Some of the
practices that allow the person to work on these aspects are meditation of the body,
breathing, and the ‘raisin exercise’ (this illustrates how paying attention intentionally,
without judgement, to the way we eat, for example, can transform the experience).
✓ Emphasise the difference between thinking about a sensation versus experiencing it
through our senses. For this, the body scan as a practice that emphasises shifting
attention to the various parts of the body is a useful way of training in the practice of
observing without judging.
✓ Learn that thoughts and emotions are transitory, similar to sounds. A posture of
observing how they come and go is promoted, considering them as external events,
adopting an attitude of curiosity, kindness and acceptance. It is important to clarify that
acceptance should not be understood as resignation. It does not imply renouncing
changing things in the future, but rather not resisting the way things are in the here and
now. Acceptance allows us to be fully aware of the difficulties and to give ourselves time,
if appropriate, to respond skilfully and not automatically. Sometimes doing nothing,
allowing the experience to pass, can be the most skilful response. For this, meditation on
sounds, thoughts and emotions can be useful.
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Mindfulness 43
3. Emotion regulation:
• Reappraisal – approaching ongoing emotional reactions in a different way (non-
judgementally, with acceptance). Associated brain areas: (dorsal) prefrontal cortex.
• Exposure, extinction and reconsolidation – exposing oneself to whatever is present in
the field of awareness; letting oneself be affected by it; refraining from internal
reactivity. Associated brain areas: ventro-medial prefrontal cortex, hippocampus and
amygdala.
4. Change in perspective on the self: detachment from identifications with a static sense of
self. Associated brain areas: medial prefrontal cortex, posterior cingulate cortex, insula,
temporo-parietal junction.
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44 The Foundations of an Integrative Approach to Bipolar Disorders
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Mindfulness 45
yourself with the entire body of water so that you become steady and calm below the surface
even when it is turbulent on the outside; a train that passes by; actors on a stage. For other
practices (e.g. that of walking), it can be interesting to use the metaphor of exploring
everything as a child would who is performing the behaviour for the first time or as an
alien for whom everything is new, that is, with the beginner’s mind. Another resource used
to illustrate the nature of mindfulness is poetry (e.g. ‘The Guest House,’ by Rumi).
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46 The Foundations of an Integrative Approach to Bipolar Disorders
to take each moment as it comes – pleasant or unpleasant, good or bad – and then work with
that because it is what is present now.
Both formal and informal practices allow the person to:
✓ Be aware of the mind’s tendency to wander.
✓ Be aware that he or she often operates on ‘automatic pilot’.
✓ Train the mind to focus and pay attention.
✓ Be more aware of real experience, which makes it easier to make better decisions.
✓ Realise how the mind works (clinging to what it considers pleasant, fleeing from what is
unpleasant, establishing judgements, associations between thoughts and certain
emotions, reactions, etc.) and thus allowing the person to change the way he or she
relates to these mental events.
✓ Note how paying attention to the experience changes its nature.
✓ Be more aware of negative thoughts and moods, allowing the person to handle them
better and generating greater control over the behaviour.
✓ See how thoughts, emotions and physical sensations are transitory, and not take them as
‘absolute truths’ that require an immediate response. This will allow the person to select
more appropriate responses.
✓ Reduce avoidance of experience through sustained exposure.
✓ Reduce rumination or repetitive thinking.
✓ Understand that both the breath (observing how it flows naturally, without attempting
to force it) and the focus on the body are crucial, as they are used as a link to the present
moment.
• Regarding breathing:
◦ It allows us to anchor our attention ‘here and now’.
◦ It is present 24 hours a day.
◦ It does not produce attachment.
◦ It contributes to increasing the awareness of our body, where the breath can be
observed (nostrils, chest, belly).
◦ It is linked to emotional states and can facilitate their regulation, as well as the
control of rumination or repetitive thoughts.
◦ It represents a bridge between the automatic and the voluntary.
• Regarding the body:
◦ It provides another perspective from which to contemplate the experience,
a different point of view from which to relate to thoughts and emotions.
◦ Emotions have bodily components, and bodily sensations can influence and in
turn be affected by thoughts, emotions and behaviours.
◦ Sensations are an indicator of mood; therefore, paying attention to the body gives
us information about our emotional state and can help to better regulate
emotions.
◦ It allows us to train the mind using the body and allows attention to be diverted
from the ‘mind’ to the body.
◦ Paying attention to sensations of which we have not been aware modifies our
experience.
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Mindfulness 47
◦ Bringing awareness to the body can guide us to introduce beneficial aspects – for
example, intentionally changing posture or facial expression helps to change one
of the components of the ‘mental modality’ that keeps us trapped in a certain
emotional state.
◦ Body awareness facilitates the exposure and management of pain or physical
discomfort, allowing us to accept the fear of pain or associated discomfort. If it
emerges, it must be observed with curiosity and openness, as well as the chain of
associated thoughts and emotions. However, it should be borne in mind that
people with negative emotions about their body may perceive this exercise as more
aversive. It is important to empathise and validate these sensations, but encourage
people to perform the exercise with a curious and kind attitude, open to whatever
comes up, or address the issue in a deeper way if necessary.
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48 The Foundations of an Integrative Approach to Bipolar Disorders
✓ More awareness of first warning signs of relapses and activating appropriate strategies.
✓ Better ability to recognise stress and acting accordingly to reduce its harmful effects.
✓ Preventive factor.
✓ Improving communication with family and friends, also concerning issues related to the
illness.
✓ Training attention networks for improved focus and concentration.
✓ Better management of anxiety.
✓ Improved management of depressive subsyndromic symptoms.
✓ Reducing the rumination that often accompanies depressive symptomatology.
✓ Improvement of emotional self-regulation.
✓ Substitution of automatic responses (impulsivity, reactivity) by more adaptive strategies.
✓ Feeling more compassionate towards oneself and others.
✓ Being more connected with the present moment.
✓ Increasing the sensation of well-being.
Murray and collaborators (2017) suggest the relevance and clinical implications that
regulation of attention and emotions, body awareness and change in one’s perspective
have on bipolar disorder. They highlight how these aspects can potentially affect the
improvement of neurocognition and socio-occupational functioning; the detection and
management of prodromes; emotional, cognitive and behavioural regulation; the avoidance
of progression to relapses; the management of comorbidities and symptoms such as anxiety;
the improvement of quality of life; and the reduction of self-stigma. Some of these themes
emerged in a qualitative study in which participants with bipolar disorder highlighted the
benefits of the following aspects: focusing on what is present; awareness of mood state/
change; acceptance; mindfulness practice in different mood states; reduction/stabilisation of
negative affect; relating differently to negative thoughts; and reduction of the impact of
mood state (Chadwick et al. 2011).
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Chapter
Cognitive and Functional
2.4
Remediation
Cognitive functions encompass the mental processes that take place in the brain, in the
central nervous system, related to thinking, decision making, planning, paying attention,
remembering. In recent years, the increasing prevalence of dementia in the general popula-
tion has led to a growing interest in stimulating cognitive functions. This greater awareness
of the importance of preserving and improving our cognitive functions has been accom-
panied by a proliferation of brain training programmes, especially with the expansion of
new technologies. Even so, neuropsychological rehabilitation and its application in different
pathologies have been in use for more than a century. While different assessments and
treatment procedures for brain injury began to be developed in the 1970s, neuropsycholo-
gical evaluations acquired a relevant status in the world of psychiatry in the late twentieth
century, with a particular focus on schizophrenia. Currently, the study of cognitive func-
tioning has been extended to other psychiatric illnesses, especially affective disorders such as
bipolar disorder and depression.
Research in the field of bipolar disorder started later, as the illness was traditionally
considered to be more cognitively and functionally preserved. However, evidence has
shown that both cognitive and functional impairments are also intrinsic characteristics of
bipolar disorder, although to a lesser extent than in schizophrenia. Importantly, dysfunction
may even be present in euthymic patients. Bipolar disorder is considered a highly disabling
illness in some cases, placing a great burden on both patients and the health system, ranking
among the top 20 causes of disability in the world (Vos et al. 2012).
49
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50 The Foundations of an Integrative Approach to Bipolar Disorders
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Cognitive and Functional Remediation 51
understand and predict the behaviour of others, as well as draw inferences from what we
perceive in others and make decisions based on this information. Social cognition encom-
passes different dimensions such as the recognition of emotions, empathy and theory of
mind. The latter refers to the ability to infer both one’s own feelings and those of others from
data perceived during social interactions. Although available evidence is scarce, it suggests
that patients suffering from bipolar disorder may present deficits in theory of mind, even
when they are remitted (Bora et al. 2016).
Psychiatric and
medical
Hormonal factors comorbidity
and stress (especially
substance abuse
and anxiety)
Number of episodes
(especially manic Pharmacological
episodes) and treatment
chronicity (years of
illness)
Subclinical Cognitive
Sleep disorders
symptoms difficulties
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52 The Foundations of an Integrative Approach to Bipolar Disorders
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Cognitive and Functional Remediation 53
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54 The Foundations of an Integrative Approach to Bipolar Disorders
Effective pharmacotherapy
and psychoeducation to avoid
Strategies multiple episodes
to prevent or to
mitigate
Control comorbidities
cognitive
Treat subclinical symptomatology
impairment
Although cognitive remediation has been proposed as an effective treatment tool in the
field of psychiatric illnesses, it was not until 2010 that a clear definition concerning this type
of intervention was given by the Cognitive Remediation Experts Workshop. This group of
experts defined cognitive remediation as an intervention based on behavioural training,
aimed at improving cognitive processes (attention, memory, executive functions, social
cognition or metacognition) with the aim of achieving a durable and generalised improve-
ment (Wykes & Spaulding 2011). Other authors, however, define cognitive remediation as
a treatment to improve neurocognitive functioning, involving a learning process and
attempts to influence psychosocial functioning (Penadés & Gastó 2010). Therefore, cogni-
tive remediation is not just a specific intervention isolated from cognitive processes.
The functional remediation programme, a therapeutic intervention designed by the
Barcelona Bipolar and Depressive Disorders Unit to treat the cognitive and functional impair-
ment associated with bipolar disorder, is explained in more detail in the following section.
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Cognitive and Functional Remediation 55
– Educational and metacognitive components about cognitive deficits associated with the
disorder and its impact on daily functioning.
– A neurocognitive–behavioural approach that includes modelling techniques, role-playing,
self-instructions, positive reinforcement and metacognition.
– That it is aimed not only at cognitive improvement but also at psychosocial functioning.
– Training in strategies to improve performance in attention, memory and executive functions
domains.
– Training of impaired functions and implementation of compensatory strategies.
– Learning ecological neurocognitive strategies and techniques to be transferred to daily life.
– Training in communication skills and stress reduction techniques for managing stressful
situations and enhancing autonomy.
– Involving the family in facilitating the implementation and practice of the techniques learned
by participants.
characteristics and specific needs of this population. The basis of functional remediation is
to achieve a real transfer of the new neurocognitive skills or learned strategies to daily life in
the context of a highly ecological approach with practical exercises. This programme is
based on the neurocognitive–behavioural model that addresses neurocognition and psy-
chosocial aspects (Table 2.12).
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56 The Foundations of an Integrative Approach to Bipolar Disorders
↓ Stress, Attention
↑ communication
↑ autonomy
Functional
remediation
12. Self-instructions and
self-monitoring Memory
13. Programming and Executive
organising activities functions
14. Programming
activities, establishing 6. What is memory? Strategies for improving it
priorities and time 7. Memory: Diary and other external aids
management 8. Internal strategies
15. Problem-solving 9. Other mnemonic strategies
technique 10. Reading and remembering
16. Solving problems 11. Puzzle: retrieving information from the past
Figure 2.9 Sessions of the group functional remediation programme for bipolar disorders (Barcelona Bipolar and
Depressive Disorders Unit).
1. Education
The first module contains three sessions devoted to providing basic information on neuro-
cognitive processes. The main objective of these sessions is to explain the nature of the
relationship between disease progression and neurocognitive dysfunction. Not all patients
are aware of their cognitive difficulties and repercussions in their daily functioning. Two
sessions deal with educating or training participants in neurocognitive impairment asso-
ciated with the illness and those factors influencing their cognitive performance. In addi-
tion, there is a brief explanation concerning some positive factors (e.g. diet, physical
exercise, sleep regularity) and negative factors (e.g. number of relapses, substance abuse,
poor treatment adherence) that may interfere with neurocognitive performance and func-
tioning, and over which patients may exert a certain amount of control. Dysfunctional
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Cognitive and Functional Remediation 57
beliefs and prejudices related to patients’ neurocognitive deficits may make them feel
anxious or embarrassed. In this regard, some myths (e.g.‘ The medication causes the
cognitive deficits’, ‘There is greater intellectual capacity during an episode of mania’) are
discussed to help with the process of destigmatisation. Although the intervention is
addressed to patients, the first session is offered to family members in order to explain the
objectives of the intervention and clarify any questions related to neurocognitive deficits
and their implications in patients’ daily lives. In this family session, it is recommended that
relatives encourage the patient to attend the sessions and to do the homework, boosting
their autonomy whenever possible.
2. Attention
Training in neurocognitive functions begins in the second module with two sessions
devoted to training different types of attention: selective, sustained and divided atten-
tion. After a brief introduction to what attention means and which aspects of daily life
are compromised by deficits in this area (e.g. losing the thread of a conversation, not
remembering the name of an interlocutor, difficulties in following a film plot), several
strategies to cope with attentional difficulties are provided and practised by means of
different exercises to consolidate their use. Some of the guidelines explained involve
taking breaks during attention-straining tasks, limiting tasks rather than attempting to
multitask several activities, avoiding starting new activities before others are completed,
eliminating distractions in the environment, and so on. Within this block, participants
are also trained to regulate attentional capacity through the use of self-instruction,
a resource based on internal language to guide self-behaviour (e.g. when faced with
a task, patients will look for external clues to detect whether attention has been lost by
using phrases such as ‘Am I paying attention to what I’m doing?’, ‘I’ve lost my train of
thought . . . I’m going to refocus on what I was doing’). Patients are also encouraged to
train their attentional capacity by means of a word search, looking for differences
between two images, mental calculation tasks, Sudoku, and so on. The objective is to
propose a wide range of strategies, so that each patient can adopt those which personally
work best for him or her.
3. Memory
One of the main complaints made by patients with bipolar disorder as well as one of the
most replicated deficits in the scientific literature is memory; hence, this module includes
a greater number of sessions. Participants are trained in internal strategies to enhance the
process of encoding to help retrieval memory, that is, to learn to adequately organise new
information so that access to information will be more effective. This group of techniques
(such as association, categorisation and visual imagery) promotes more profound proces-
sing to make new information more meaningful. These mnemonic techniques are practised
with different exercises, with the objective being to later transfer them to patients’ daily
routines. Because memory difficulties often involve problems with remembering the names
of people, some techniques to improve this are provided. Patients are also trained in the use
of external aids that refer to instruments or tools to reduce the impact of cognitive deficits
on daily life and compensate impaired functions (e.g. diary, clock alarms, information and
communication technologies (ICTs), calendar). The objective is not only to enhance or
optimise the use of external aids but also to destigmatise their use. Special emphasis is
placed on the use of a diary (notebook, smartphone), because it will improve patients’
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58 The Foundations of an Integrative Approach to Bipolar Disorders
independence and involve mental effort, which may help to enhance the encoding and
retrieval of information. Some strategies that allow the reconstruction of information from
the past, such as better organising memories with well-classified, ordered and labelled
photos, recordings, and videos of important events, are also provided. Finally, one session
within this block is dedicated to reacquiring the reading habit, lost by a significant propor-
tion of patients given their difficulties in their ability to maintain concentration or to
remember what was previously read. Patients are encouraged to read a specified number
of chapters of a book every week, and to respond to a series of questions to evaluate their
level of understanding. Patients also must choose a piece of news in the newspaper and track
it every week.
4. Executive Functions
This module includes five sessions focused on executive functions, those functions that
allow us to constantly adapt to changes required by the environment. Activities within
this module promote the use of several strategies to enhance planning to meet goals,
programme day-to-day activities, focus on time management, and adapt to unforeseen
events, alongside training in problem-solving techniques. This takes place in an ecolo-
gical setting to achieve a real transfer of these strategies to daily life functioning.
Problem-solving training will translate into greater efficacy in coping with problems,
as well as reducing stress and negative thoughts (‘I can’t do anything’, ‘This has no
solution’, ‘I’m not able to manage this situation’). After the different steps of the
problem-solving technique have been explained, the method is practised using an
example. Then, participants are encouraged to train using their own problems in situ
with the aim of familiarising themselves with the method and learning to use
a procedure that works for them to increase their skills to solve problems that may
arise in their daily lives.
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Cognitive and Functional Remediation 59
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Part 3 An Integrative Approach to Bipolar Disorders
Chapter
Introduction to the Integrative
3.1 Approach
61
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62 An Integrative Approach to Bipolar Disorders
or screen as audiovisual support for the presentation of slides in the cognitive enhance-
ment module.
It is recommended that the groups be balanced, being homogeneous enough to create
a feeling of identification but with a certain heterogeneity that is enriching. Generally, the
sessions are structured by dedicating the first few minutes to holding an informal
conversation in which possible incidents and doubts that may have arisen from the last
encounter are discussed, and practical exercises (if any) are reviewed or the practice is
introduced (e.g. in the sessions about mindfulness and those that follow). Subsequently,
the topic of the day is addressed, covering the main objectives of each session with
flexibility while encouraging participation and discussion. The formulation of questions
that guide the contents, rounds and the use of exercises will encourage the participation
of every member of the group, always in a context of acceptance of the degree of
involvement and the amount of time that everyone needs. After each session,
a summary of the topic worked on is delivered; this material is presented in this section.
If an individual format is used, then the objectives and contents can be personalised
and perhaps worked on in more than one session if necessary.
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Introduction to the Integrative Approach 63
potentially toxic atmosphere can be reduced if the objectives and rules of the group are
made clear from the beginning and are shared by the participants. If an adequate
evaluation has been made, if realistic expectations have been established, if the rules of
the group have been clearly stated and if a positive atmosphere of acceptance and respect
is generated, then the group will coalesce in a climate of safety.
It is important that, whether the sessions are carried out in an individual or group
format, the therapist encourages the participants to perform exercises at home that allow
them to deepen the practice, intensifying its effects. For this reason, after each thematic
block it is advisable to provide websites, mobile phone applications, readings and other
resources that complement what has been worked on in the sessions. Given the rapid
progress in this area, the therapist should update this information regularly.
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Chapter
Contents of the Integrative
3.2
Approach
The following sections present the material worked on in each of the sessions, adapted
for delivery to the participants. As mentioned, each thematic block will be complemented
with additional information (constantly updated) in the form of mobile applications,
links, audios and literature so that members can go deeper into the practice of the
components on which they have worked.
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Contents of the Integrative Approach 65
Mania
Hypomania
Euthymia
Depression
Bipolar disorder does not change the personality of the individual who suffers from
it. Although during episodes of depression or euphoria the symptoms may suggest that
the personality has indeed changed, when the episode remits, it will be possible to verify
that the personality remains unchanged. Therefore, bipolar disorder is not an alteration
of character or personality. We should not say, ‘I am bipolar’ but instead ‘I have a bipolar
disorder’. Bipolar disorder is a disease, not a way of being.
The disease has a biological basis and is genetically transmitted. Although the cause
of bipolar disorder is genetic, there are a number of environmental factors that can
precipitate relapses and thus influence the course of the disease. The occurrence of
episodes is determined by the interaction between genetic vulnerability, biological
factors and environmental factors:
➢ The fact that the cause of this disease is genetic means that in individuals with bipolar
disorder there is probably a family history of similar forms of the illness, but it is also
possible for individuals with no family history of bipolar disorder to manifest the
disease.
➢ Regarding biological factors involved in the disease, neurotransmitters (e.g.
dopamine, serotonin, noradrenaline, acetylcholine) are the substances responsible for
transporting information in the brain. Abnormalities in neurotransmitter systems
have been associated with mood episodes; medication makes it possible to regulate
such dysfunction. Hormonal functioning, among others, also seems to play an
important role in the disorder. The mood oscillations that can be caused by the
alteration of thyroid hormones should be noted, as should the increased risk of relapse
in the postpartum period if the person is without medication because of the significant
hormonal changes that occur.
➢ Environmental factors are not the cause of bipolar disorder, but can positively or
negatively influence the course of the illness. Among the most common relapse
triggers are the following:
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66 An Integrative Approach to Bipolar Disorders
Mania
Manic episodes are characterised by a distinct period of abnormally and persistently
elevated, expansive or irritable mood, and by an increase in activity and energy over
a period of time that can range from a week to several months.
Symptoms of mania:
– Increased activity.
– Elevated mood.
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Contents of the Integrative Approach 67
Hypomania
Hypomanic episodes are characterised by a minimum period of 4 days wherein the mood
is persistently elevated, expansive or irritable, and is accompanied by an increase in levels
of activity or energy. It is clearly recognisable as different from a person’s regular mood
and functioning. The symptoms of hypomania are similar to those of mania but are less
intense. In contrast to mania, in hypomania the change in functioning is not severe
enough to cause marked impairment in social or occupational functioning, or to require
hospitalisation, and there are no psychotic symptoms.
Depression
Depressive episodes are characterised by a period of at least 2 weeks in which the person
shows a depressed mood or a loss of interest or pleasure in nearly all activities.
Some of the following symptoms must also be present:
– Depressed mood. Feelings of sadness, emptiness, hopelessness, depression, or crying
for no apparent reason.
– Fatigue or loss of energy.
– Diminished ability to think or concentrate.
– Indecisiveness.
– Loss of interest.
– Changes in sleep patterns (insomnia or hypersomnia).
– Significant changes in appetite/weight.
– Irritability.
– Feelings of worthlessness or excessive or inappropriate guilt.
– Recurrent thoughts of death.
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68 An Integrative Approach to Bipolar Disorders
Mixed Features
In some cases, both hypomania/mania and depressive episodes may have mixed features,
described as the simultaneous presence of symptoms of an episode of both depression
and mania.
Identification of Prodromes
The first signals of an episode are called prodromes. Just as the discomfort and suffering
typical of depression usually signal a need for help, during a manic episode the person
may not recognise that he or she is ill. In both cases, it is very important to identify the
onset of new episodes as early as possible, allowing us to act quickly and therefore avoid
relapses and the consequences of mood episodes (e.g. hospitalisations, social and occu-
pational difficulties). The sooner we detect the first warning signs, the more likely it is
that we can avoid the progression of symptoms, preventing the episode or, if it does
occur, making it less intense and less disruptive and so requiring less medication to treat
it. In addition, it is not uncommon for a depressive episode to occur after mania, so the
prevention of hypomania/mania will also reduce this possible risk, and vice versa.
Drawing up a list of prodromes, if possible with the help of a family member, is
extremely useful. The following factors should be taken into account:
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Contents of the Integrative Approach 69
A signal in isolation is not in itself a cause for alarm, but if more than two of these
signals are presented repeatedly over the course of 2 or 3 days, it would be advisable to
contact the clinician. The pharmacological treatment can be reviewed and a series of
behavioural guidelines can be adjusted in order to prevent these early signs from
becoming symptoms with greater consequences. Just as physical symptoms may signal
that a person may be coming down with the flu and would activate a plan to counteract
or deal with the consequences, there are guidelines that can be useful when warning
signs are detected in bipolar disorder. In addition, it is always advisable to have a trusted
person available who knows us and the disease well.
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70 An Integrative Approach to Bipolar Disorders
Mood Stabilisers
Mood stabilisers are medications that help to calm and smooth mood swings. They are
used to avoid the occurrence of new episodes and, in the case of relapse, to minimise the
severity of the symptoms as well as their duration. Patients need to take mood regulators
over many years, in most cases for life.
➢ One of the most common mood stabilisers is lithium, which has also proven useful in
the prevention of suicide. Lithium’s therapeutic effects (like its toxic effects) are related
to its concentration levels in the blood, the reason it is important to have regular blood
tests to harness its positive effects and avoid the risk of intoxication. The most
common side effects associated with lithium are changes in digestive rhythms, tremor,
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Contents of the Integrative Approach 71
increased thirst, greater need to urinate and modest weight gain due to retention of
liquids. Effects on kidneys and thyroid function are rare but must be checked with
regular analysis. Those circumstances that favour marked changes in body water
volume (e.g. sauna, low-sodium diet, diuretics) can alter blood lithium levels. Lithium
(as well as other medications discussed in this section) can interact with other drugs;
therefore, the physician should be consulted before incorporating a new medication.
➢ Anticonvulsants (antiepileptic or antiseizure drugs) can act as mood stabilisers. They
include carbamazepine, oxcarbazepine, valproate and lamotrigine. The latter has
properties that prevent depression.
Antipsychotics/Antimanic Drugs
In bipolar disorder, antipsychotics are used mainly to treat manic or hypomanic epi-
sodes. They are very effective at eliminating psychotic symptoms (delusions and hallu-
cinations), agitation, irritability, acceleration and other symptoms of elated mood.
➢ Among classic antipsychotics, one of the most commonly prescribed is
haloperidol. Clozapine is also useful in manic/hypomanic episodes. Newer
antipsychotics include risperidone, olanzapine, quetiapine, aripiprazole,
ziprasidone, paliperidone, cariprazine, lurasidone, and asenapine, which are often
used for preventive purposes. Some antipsychotics, such as olanzapine and
quetiapine, appear to be useful as mood stabilisers. The most common side effects
of antipsychotics are weight gain, decreased blood pressure, sexual dysfunction
and some muscle stiffness, but these vary widely from drug to drug.
Antidepressants
For patients with bipolar disorder, the use of antidepressants can increase the risk of
a hypomanic/manic episode or even rapid cycling (presence of at least four episodes in
a year). For this reason, caution must be exercised with their prescription and they must
never be administered as a sole treatment, but rather in combination with mood stabilisers
and always under the supervision of a psychiatrist. It is important to bear in mind that it
usually takes antidepressants 2 to 4 weeks to improve mood. Side effects, however, can
manifest at the beginning of treatment (e.g. nausea and effects on sexual functioning).
➢ Fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram,
venlafaxine, duloxetine and desvenlafaxine are among the most prescribed
antidepressants. Other antidepressants include mirtazapine, trazodone, bupropion
and vortioxetine.
Other Treatments
➢ Benzodiazepines: anxiolytics or hypnotics, always under medical supervision, can be
useful when anxiety is elevated or insomnia is experienced. In any case, they are not
used as the sole treatment of a manic episode.
➢ Electroconvulsive therapy (ECT): this is an effective and safe treatment that can be
used in cases resistant to pharmacological treatment or in which a rapid therapeutic
response is required. The most common side effects are headaches and memory
impairment during treatment.
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72 An Integrative Approach to Bipolar Disorders
➢ Alternative therapies: these are treatments not approved by the scientific community
and so not considered standard care, because they have not been scientifically tested to
demonstrate their efficacy, safety and tolerance. The danger of alternative therapies
depends on their intentionality: those who choose to replace conventional treatment
face a high risk of relapse.
➢ Psychological therapies: although pharmacological treatment is essential for bipolar
disorders, psychotherapy can also be beneficial, but should always be instituted as
a complement to medication. Psychoeducation, family intervention and, to some
extent, interpersonal and social rhythms therapy, and cognitive-behavioural therapy
are those that have proved to be, so far, effective in bipolar disorder. They all allow the
person to understand the illness more deeply and incorporate training strategies and
resources to handle it better (promoting protective factors and reducing risk factors)
and to face stressful situations, thus reducing the risk of relapse. Some studies have
shown that a combined treatment of medication along with these types of
psychological therapies improves the course of bipolar disorder, both short and long
term.
Treatment Adherence
Although pharmacological treatment is essential in keeping the mood stable, more than
50% of people with bipolar disorder do not comply with their agreed-on plan of
treatment. Poor adherence can involve abandoning the treatment, making errors in
dosing (e.g. skipping doses, not adhering to the schedule for dosing) or even neglecting
proactive factors such as maintaining a healthy lifestyle.
There are many reasons for poor treatment adherence: lack of awareness of the illness or
denial, real or feared side effects, feeling that the mood is ‘controlled’ by drugs, missing
periods of euphoria, prejudices about the medication by the individual or those around them,
social stigma, forgetting the scheduled dose. Identifying these reasons is the first step in
dealing with adherence. Although no medication is exempt from side effects, these should
not be reasons for abandoning treatment because the consequences of doing so are usually
worse than the cost of maintaining it. Consulting with the psychiatrist about discomfort and
fears allows for ways to be found to mitigate side effects, or to assess the possibility of
modifying the dose or changing the treatment if necessary. Jointly analysing the pros and
cons that result from the interruption of medication is essential, as well as seeking strategies
to avoid forgetting to take the medication (e.g. pill boxes, alarms). Some people argue that the
medication does not matter, because they have relapsed even while taking it. However,
although the possibility of suffering an episode will never disappear, this probability will be
lower in patients who take the medication correctly, and if under these conditions a relapse is
suffered, they will be less frequent and severe and of shorter duration.
Stopping Treatment is the Most Common Trigger of Relapses. Other consequences
include hospitalisations, increased suicidal risk, cognitive deterioration, problems in
social and occupational functioning and economic losses. Assuming the need for sus-
tained treatment and acting accordingly will reduce the frequency and intensity of
relapses, and eventually will mean greater autonomy and less medication, while prevent-
ing the disease from interfering with the decisions and lives of the patient and the people
around them.
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Pharmacological treatments are not ‘drugs’; they do not create dependency, they do not change
personality and they do not avoid experiencing emotions, but prevent these emotions from
reaching pathological levels.
Sleeping Patterns
Lack of sleep can lead to feeling more irritable and tired and affect concentration; in
addition, it may interfere with performance in other areas of health and functioning.
The following sleep hygiene guidelines can contribute to better rest:
– Use the bed only to sleep and not to eat, study, watch television, use the computer or
other tasks that involve stimulation. You can read before falling asleep, as long as it is
not related to academic or work issues.
– Avoid solving problems and planning activities while you are in bed.
– Maintain an environment that favours sleep: ventilate the room during the day, and at
night maintain an adequate temperature. Avoid light and noise.
– Try to have dinner at least 2 hours before going to bed, avoiding heavy dinners (fatty
dishes), and eat a moderate amount to avoid going to bed feeling hungry or overfull.
– Do not consume stimulants or substances that contain caffeine/theine after
approximately 4 p.m.
– Do not consume chocolate, large amounts of sugar or excess liquids.
– Engage in regular physical exercise, preferably in the morning. If you exercise in the
afternoon do it at least 3 hours before going to sleep to avoid being overstimulated,
unless it is light exercise.
– Avoid prolonged naps (no more than 30 minutes).
– Keep a regular sleep schedule, always going to bed and getting up at a similar time.
– Turn off the television, computer and mobile phone 2 hours before going to
sleep.
– Before bedtime, include the promotion of relaxation (deceleration activities) such as
lowering the intensity of light, listening to quiet music, having a warm shower,
drinking a glass of hot milk or an infusion of tea without theine.
– If you cannot fall asleep, remain in a comfortable position with your eyes closed. If this
is not possible, get out of bed and relax somewhere else, returning to bed when you
start feeling sleepy.
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74 An Integrative Approach to Bipolar Disorders
– Do not use luminous bedside table clocks to avoid controlling the passage of time or
seeing how long it takes you to fall asleep, as this contributes to increasing anxiety.
– Do not have an argument before going to bed.
In bipolar disorder, a disturbance in sleep patterns can act as a trigger of an episode (e.g.
a decrease in the hours of sleep can precipitate a manic episode) or as a symptom (e.g.
during mania, one experiences a reduced need to sleep and sleeps fewer hours).
Therefore, regularity in sleep patterns can be used as a preventive tool and not only
as an aspect to be treated in case of relapse. Controlling sleep hours can also help to
manage the disease.
Nutrition
A balanced diet provides the nutrients and energy necessary for the body to carry
out day-to-day activities, maintain vital functions and move around in the environment.
Energy is balanced between intake, ‘energy in’ (food calories taken into the body through
food and drink) and ‘energy out’ (calories being used in the body for our daily activity
requirements).
Developing healthy eating habits to reach an adequate energy balance is not as
restrictive as many people think. The essential steps are based on introducing foods
derived from nature – that is, foods that are minimally processed – and increasing the
intake of vegetables, fruits, lean meats, vegetable protein, whole grains and limiting the
consumption of prepackaged and processed foods. Healthy eating means eating varied
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Carbohydrates
-Whole-grain rice,
Vegetables quinoa Healthy
-Wheat pasta
Fruits -Broccoli, cabbage, -Potato, sweet potato fats
cauliflower -Oat flakes
-Spinach, lettuce -Wholemeal bread
-Celery, carrot -Corn
-Courgette, tomato
-Aubergine, cucumber
-Pumpkin
-Mushrooms
Animal or vegetable
-Onion, leeks
-Asparagus protein:
-Artichoke -Lean meat (poultry)
-Lamb’s lettuce -Whitefish, bluefish
-Pepper -Tofu, tempeh
-Legumes
meals with portions appropriate to maintaining a good energy balance and a healthy
mind. Nutrients protect health and prevent or delay certain diseases associated with
unbalanced consumption and ageing itself.
Tips for healthy eating
1. Control portion sizes. We tend to overestimate how much we need to eat.
Controlling portion sizes does not mean eating a little of everything, but rather
choosing wisely what is put on the plate. Figure 3.2 is a suggestion of how to
distribute food on a plate: half the plate consists of vegetables, one-quarter is
carbohydrates, and one-quarter is protein, either vegetable or animal. A small
amount of healthy fats and fruits rounds out the meal.
Green, leafy vegetables should play a major role in a meal. Different varieties
of vegetables, both raw and cooked, can be offered to add variety.
Carbohydrates must be complex (not refined, but whole grain), because they
provide the most nutrients. It is also important to alternate and try different options
(e.g. quinoa, brown rice, potatoes, sweet potatoes, wholemeal bread, oatmeal flakes).
Try to keep a balance between vegetable and animal proteins, prioritising
vegetables whenever possible (e.g. legumes, tofu, tempeh, seitan, soy, peas, eda-
mame). For animal proteins, choose the leanest meats (e.g. chicken and turkey
without skin, lean beef, sirloin steak, pork loin). It is recommended to consume
a minimum of three to four servings of fish per week and increase the frequency
of oily fish (which contains healthy fats). Use low-fat cooking techniques (e.g. griddle,
oven, en papillote, steam). Rather than using salt to add flavour to dishes, experiment
with different herbs and spices (e.g. curry, rosemary, pepper, paprika, oregano,
turmeric, nutmeg, cloves), so cooking also becomes an exercise in creativity.
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76 An Integrative Approach to Bipolar Disorders
The servings shown in Figure 3.2 are approximate and may vary depending on
energy needs. In addition, although they do not appear integrated in the dish, fruits
and healthy fats are no less important and are essential for good bodily functioning.
Part of the portion size of the vegetables could be replaced with fruit. Fruit,
preferably seasonal fruit, can be a between-meals snack (mid-morning or mid-
afternoon). Examples of healthy fats include extra virgin olive oil, avocados, nuts
or nut butters (e.g. tahini, natural peanut butter), Greek yogurt, dark chocolate (85%
minimum purity), seeds (e.g. chia, sunflower, flaxseed), olives and eggs. It is impor-
tant that healthy fats are present in meals but take care to limit them because they are
high in calories. Use a tablespoon (equivalent to a portion size) to avoid excess.
2. Limit sugar intake. Try to limit eating white bread, pasta and non-wholemeal
grains. Almost all precooked and processed foods (e.g. biscuits, pastries, cereals,
bread, pizzas, sauces, sausages, snacks) have added sugars to make them tastier.
3. Limit or avoid altogether sugary beverages. A can of a sugary soda represents
approximately 140 kcal. The problem is not so much the number of calories but
the nutritional deficiency that this product represents, as it mainly provides
refined sugar and no source of nutrients. Juices and smoothies can be good
choices, but it is preferable to eat whole fruits because they provide fibre and
satisfy more with a smaller amount. Coffee and tea are considered healthy drinks
as long as they don’t contain a lot of added sugar (or the amount of sugar is
minimised as much as possible) and a high consumption pattern is avoided.
4. Stay hydrated. It is recommended that we drink between 1.5 and 2 litres of water
per day. Make sure to have a bottle of water within reach and take small sips
throughout the day, even if you do not feel thirsty.
5. Apply the 80/20 rule. Some experts talk about applying this rule for a flexible diet.
It consists of healthy eating for 80% of the time and reserving 20% for treats
(or not-so-healthy foods). Nutrition is not a matter of perfection but of finding
a balance that can be maintained over time. This rule means that if you make
a total of 21 meals a week (3 meals a day), you can reserve 3–4 ‘free’ meals when
you are with friends or family without having to worry about the food you
consume during these social gatherings. At the end of the day, it is about doing
what best suits your needs and lifestyle.
6. Plan your meals. Planning your meals in advance (the day before or making
a weekly menu) can help you to better organise the shopping list and prevent you
from eating unhealthily when you do not know what to eat due to tiredness or lack
of time. A balanced diet should aim to nourish the body rather than counting
calories. Moreover, not all sources of calories cause the same effect in the body.
The way the body metabolises a doughnut as opposed to a chicken sandwich, for
example, is completely different: varying hormonal and metabolic responses are
generated that end up affecting the sensation of hunger and satiety after eating
them. It’s about choosing the foods we eat wisely, the more natural and less
processed the better. If we are used to eating a lot of processed food, making
this change will not be easy, but it is not impossible. Introducing changes in
a gradual way could be the key to success. After all, the palate (and our brain) is
educated. The appetite for unhealthy products will progressively diminish as soon
as you start eating healthily and nourishing your body and mind.
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7. Sit at the table to eat and pay attention to the sensations and feelings (hunger,
if you feel it, taste, colours, smells, texture), as well as related emotions and
thoughts.
– Follow healthy and regular food pattern consumption. Excessively restrictive diets are
not recommended, because they can increase anxiety levels.
– There are no ‘forbidden’ foods, the exception being for those who take monoamine
oxidase inhibitors (MAOIs; antidepressants), who require a specific diet.
– Patients taking lithium should not abruptly initiate a low-sodium (low-salt) or asodic (no
salt at all) diet, as it could interfere with blood lithium levels. Saunas involve an excess of
sweating and could also modify lithium levels.
– A few studies suggest that intake of omega-3 fatty acids, in addition to pharmacological
treatment, could contribute to improving mood stability.
– It is recommended that you discuss any alteration in eating patterns openly with your
psychiatrist, including ‘binge eating’ (compulsively eating a large amount of food,
usually carbohydrates, sweets or snacks, to calm anxiety or discomfort).
– Talk with your doctor about your fears of weight gain or possible side effects resulting
from pharmacological treatment, in order to agree on the most appropriate treatment or
to establish some guidelines to compensate for the side effects.
Physical Exercise
Moderate physical exercise represents a great benefit not only for physical health but
also for psychological well-being. Therefore, performing moderate physical exercise
periodically could decrease the risk of depressive relapse and improve well-being. It is
also a way to reduce stress, and improve memory and sleep regulation. Physical exercise
promotes changes in the brain that include neural growth, decrease in inflammation and
release of endorphins, and increases the feeling of calm and well-being.
It is never too late to start building a stronger body and to benefit from the effects
derived from physical exercise. Very few health problems preclude any kind of physical
activity at all; if you have any problem, it is better to talk with a doctor in order to find
a suitable routine. Physical exercise should not be considered a chore (no need to feel
exhausted or stiff after every session at the gym) but rather part of a healthy lifestyle.
Keeping a healthy body is a must since it can positively influence psychological health.
You can build a strong body and mind with daily activities such as walking, swimming,
cycling, caring for the garden or cleaning the house. Research shows that a moderate level
of exercise is the best option.
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In addition to this commitment to physical activity, the following are some tips for an
active life:
1. Walk whenever you can. Replace the car or public transport and bike or walk to work,
to an appointment, shopping. If this is not possible, you can park farther away or get
off the bus one or two stops before your destination.
2. Avoid lifts (elevators) whenever you can and use the stairs.
3. Increase your tasks at home or in the garden.
4. When you watch television, during advertisements take the opportunity to move or
stretch, so it becomes a less sedentary activity.
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– Cocaine can trigger an episode of any kind, with rapid cycling, anxiety, aggressiveness,
psychotic symptoms and sleep disturbances, and causes cognitive impairment.
– Hallucinogens and designer drugs, even if consumed only once, may lead to
hospitalisation. They can cause psychotic symptoms that can persist over a long period
and cause flash-back phenomena (repetition of symptoms weeks or months after
consumption).
– Tobacco is harmful to health because it increases the risk of some types of cancer,
affects the cardiovascular system and increases the risk of heart attack and stroke as
well as respiratory diseases. Although it does not directly affect the course of bipolar
disorder, interrupting its consumption has many benefits. A sudden attempt to quit
tobacco can generate an increase in anxiety, so withdrawal should supervised. In
bipolar disorder, drugs such as bupropion and varenicline, which are commonly used
to facilitate smoking cessation, are not recommended. Because bupropion is an
antidepressant, there is a risk of entering a hypomanic/manic phase or precipitating
rapid cycling. Varenicline can also produce relapses. Quitting smoking is best begun
in a period of stability (after some months of euthymia), with the help and
supervision of a therapist, and through the use of replacement therapies (chewing
gum or nicotine patches) to avoid the withdrawal syndrome that can lead to anxiety
and irritability.
– Stimulant substances such as coffee can interfere with the hours of sleep and thus
influence the course of bipolar disorder. Therefore, it is best to curtail coffee or tea
consumption beginning in the afternoon. During hypomania or mania, it should be
completely avoided. Other drinks that are strongly discouraged are the so-called energy
drinks (e.g. Red Bull), which contain taurine, a stimulant.
– Benzodiazepines (e.g. alprazolam, diazepam, lorazepam) are the only medications that
can create dependence if they are misused or abused. Therefore, it is important to
follow a doctor’s or psychiatrist’s instructions. Never self-medicate.
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Although we tend to associate stressful situations with negative events, there are positive
events that can also be stressful (e.g. a wedding, a promotion at work). It has been seen
that the sign of the episode (mania, depression) does not necessarily correspond to the
type of stressor.
Some of the stressful situations that we experience are a result of the duties and
activities we carry out. However, in stress management the interpretation of the
situation, including the perception of the demands and the resources/skills we have
to face it also play an important role. Stress can affect physical, cognitive, emotional
and behavioural levels. However, there are interpersonal differences in the response to
stress, which makes some people perceive a situation as more stressful than would
others.
Facing a stressful situation should involve objective and rational thoughts,
and a greater sense of control. Therefore, training in assertiveness, commu-
nication skills and the resolution of problems can contribute to a greater per-
ception of self-efficacy given a potentially stressful event. These techniques can
also be part of an integrative programme that includes coping strategies centred
on the problem and coping strategies focused on emotion. There are also strate-
gies that contribute to reducing mental and physiological activation, as explained
below.
One of the most commonly used techniques is Jacobson’s progressive muscle
relaxation, which consists of contraction and subsequent relaxation of each
muscle, paying attention to the different sensations that occur throughout the
exercise.
Controlled or diaphragmatic breathing consists of taking a deep breath in through
the nose, inhaling it into the lower area of the lungs, pausing briefly and finally releasing
it slowly through the mouth.
Mindfulness, defined as deliberately paying attention in the present moment without
judging, and focusing on how the experience develops from moment to moment, can be
useful training. It can be carried out by combining formal with informal practice (the
latter to be incorporated in everyday situations), as will be explained in subsequent
sessions.
The best action is prevention of stress. Often, the level of stress can be reduced
with good planning and establishing priorities, in addition to incorporating into
our day-to-day lives rewarding moments and rest, physical exercise and a supportive
social network that provides us with satisfactory relationships. Dedicating time to the
practice of these strategies is important.
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– Abuse of drugs.
– Stress.
Controlling, as far as possible, these factors, encouraging good therapeutic adherence,
promoting the regularity of habits and a healthy lifestyle, and controlling the level of
stress, among others, will contribute to reducing their negative impact on the course of
the disease.
The family environment can act either as a protector or as a trigger for relapses.
Bipolar illness can clearly affect family functioning; likewise, family functioning can
influence the course of the illness. In the process of acceptance of the disorder, certain
resistances can surface, which can lead to denial of the illness (e.g. attempts to explain
the disorder as the personality of the patient, as a consequence of circumstances).
Attributing voluntary control of symptoms to the patient can result in criticism, blame
and conflict. At the opposite extreme, fear of relapses can lead to overprotection and
hypervigilance that in turn can produce an interpretation of the patient’s emotions,
behaviours or reactions as if they were solely products of the illness – that is, seeing
normal emotions or wishes as pathological. Although both positions may be under-
standable, in order to improve the course of the illness and one’s own well-being, the
acceptance of the disorder is fundamental, avoiding both denial and hypervigilance. The
family must learn to adjust expectations and behaviours according to the phase of
the illness, encouraging autonomy in times of stability.
Pharmacological treatment is essential for bipolar disorder. There are very effective
treatments that, together with a series of behavioural guidelines, will contribute to
improving the course of the illness and, as a consequence, family, social and work
functioning, also increasing the quality of life. Taking medication correctly is the best
way to avoid relapses. The family’s attitude towards the treatment can play a crucial
role. It is important for the family to develop an understanding of the situation that
strengthens medication adherence, avoiding negative comments about medication and
side effects. If the treatment is effective, some side effects should be tolerated, especially in
cases where other medications have not worked. It is important to remember that the
medication is not addictive, it doesn’t produce dependency or tolerance, and it has been
evaluated and tested very thoroughly so that the side effects have been determined not to
harm the patient’s health. Sometimes, fears and misconceptions about a treatment can
manifest in negative attitudes and behaviours. If there are doubts about the treatment,
the family should always consult the clinician. Medication should not become a subject of
family conflict. The level of involvement will vary depending on where the patient is in
the course of the illness. Greater control in the case of decompensation is understand-
able. However, if the person is stable, hypervigilant behaviours or excessive control can
be counterproductive; in this case, if there is illness awareness, the patient should be
responsible for taking the medication, and autonomy should be encouraged.
In bipolar disorder it is necessary to distinguish maintenance treatment (mood
stabilisers) from the treatment of the acute phases of mania (antipsychotics) and depres-
sion (in severe cases, antidepressants can be used). Mood stabilisers help to even out
mood swings. In general, people with bipolar disorder should take mood stabilisers
throughout their lives to prevent further episodes, and in the event of a relapse, to reduce
both severity and duration. The most commonly used mood stabilisers are lithium,
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84 An Integrative Approach to Bipolar Disorders
carbamazepine, valproate and lamotrigine. The therapeutic effects of lithium (as well as
its toxic effects) are related to its blood concentration levels, hence the importance of
carrying out periodic blood analyses (lithaemias). Some antipsychotics, such as olanza-
pine and quetiapine, appear to be useful as mood stabilisers.
Psychotherapy can also be beneficial in bipolar disorder but should always be used
as a complement to pharmacological treatment. Not all therapies are equally effective.
Most of the effective psychological therapies for bipolar disorder, such as psychoeduca-
tion, allow the person to know the disease in greater depth and to learn coping strategies
to manage the illness better, thus reducing the risk of relapses.
Acceptance and understanding of the disease and its management must be accom-
panied by caregivers’ self-care, as it is essential that family members take care of
themselves.
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• Thinking continuously about past or future events, without enjoying the present.
• Considering thoughts as something true and real, rather than as mental events that
may or may not correspond to reality.
• Relating to experience through thought rather than directly experiencing it. This
leads us to judge what happens to us as good or bad, pleasant or unpleasant and,
consequently, to attach to the experiences that we judge as pleasant and wanting
to avoid or escape from those that are unpleasant, instead of observing them
and learning from them.
• Desiring things to be different from the way they are, instead of allowing them to be as
they are.
• Being tough and critical with ourselves, instead of kind and compassionate.
Summarising:
➢ We tend to live on ‘autopilot’ instead of experiencing our lives in a conscious and
deliberate way. Automatic pilot refers to the tendency to behave like automata,
without focusing attention on or being aware of what is really happening from
moment to moment. As a consequence, we can become ineffective in our tasks
and not apply important information gained from experience, also affecting
decision making.
Some examples:
– Missing a bus stop because we are thinking about what we are going to prepare for
dinner.
– Eating a snack without paying attention to the smell, taste and texture.
– Taking a shower while reflecting on a work meeting we have to attend.
– Forgetting to take a medication because we are focused on a topic that worries us.
– Breaking things, having accidents or forgetting activities that we needed to perform
because of carelessness or distraction.
– Driving without being aware of where we are.
– Avoiding a situation because of a past negative experience that we cannot stop
thinking about.
– Criticising ourselves for having made a comment that is deemed inappropriate.
– Resorting to drugs or eating compulsively when we feel discomfort.
– Hearing someone but without listening carefully to what he or she says.
Mindfulness training allows us to be more aware of each moment, accept the experience
and respond to situations with greater freedom of choice, without letting ourselves be
carried away by automatic reactions.
Mindfulness does not mean relaxation. Although sometimes mindfulness exercises can
result in relaxation, it is not the goal of the practice. The practice is not oriented to
achieve or ‘get to’ a certain state; each practice is valuable in itself.
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86 An Integrative Approach to Bipolar Disorders
Mindfulness does not mean leaving the mind blank, but observing what is happen-
ing in each moment, and when the mind wanders, bringing attention back to the here
and now.
Throughout the day it is useful to ask ourselves, Where is my mind now?
Long-established mental patterns become habits. Mindfulness training allows us to
become aware of our mental modality. Negative thoughts can provoke and maintain
feelings of sadness. The training will allow us, for example, not to let ourselves be
absorbed by rumination (allowing things to become a vicious cycle) that often con-
tributes to accentuating feelings of sadness or personal ineffectiveness. In addition,
being more aware of negative thoughts and moods will allow us to manage them better
and have more control over their behaviour. Paying attention with an attitude of
curiosity and kindness can reduce the reactions we all have to certain thoughts,
sensations and emotions, which increases their duration and intensity. It allows us
to observe them objectively, as transitory events like clouds passing through the sky.
It increases, therefore, our ability to accept and experience sensations, thoughts and
emotions without being trapped in them. This process makes us more aware of the
alternatives that are presented to us, facilitating less impulsive decision making.
What does it mean to be in direct experience?
Being in direct experience means paying attention to the experience as it is, without
expectation.
How can we get to observe our thoughts without ‘hooking up’ to them?
We can observe them with curiosity, letting them arise and taking note of them and
what they promote (‘pleasant’, ‘unpleasant’, ‘neutral’), as if we were an external and
objective observer, a kind of scientist.
What is our goal?
Our goal is to embrace the experience, without getting attached to it or running away
from it – become aware. Try to live the experience as if it were the first time, with the
eyes of a beginner. Leaving ‘autopilot’ allows us to be more aware and less reactive,
which will improve our choices and decision making. This approach simply allows the
presence of physical sensations, thoughts and emotions that sometimes are difficult for
us, adopting an attitude of acceptance and kindness towards them. It is not about
resigning ourselves but accepting things as they are in the present and giving us time to
choose the most skilful response to them. It is an alternative to avoiding unpleasant,
difficult or painful thoughts, emotions and bodily sensations. We welcome whatever
comes, without judging.
How can we achieve it?
Through practice, this is fundamental. We can distinguish two types of practice:
• Formal practice. Formal practice is that which is done in a regulated way, adopting
a specific posture and reserving a specific time each day to perform it (e.g. with the
help of an audio as a guide). To facilitate formal practice, look for a quiet place, have
comfortable clothes and a light blanket if necessary, and reserve a fixed time each day
to carry it out.
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• Informal practice. Informal practice consists of performing our daily activities with
full attention, which implies a different way of facing everyday experiences. For
example, we brush our teeth paying attention to every movement, the sensation of
water in the mouth, the taste of the toothpaste.
Both formal and informal practices are important. In both, the mind will tend to wander. It
is then a matter of detecting that and redirecting attention to the present moment. Although
this process always involves an effort, the more we practise the more skilful we will become.
We will enhance the practice both inside and outside the sessions. We will work
together in the modification of mental patterns that were installed so long ago that they
have ended up becoming habits. All new learning for change requires some effort, time
and dedication. Therefore, it is essential for us to carry out daily exercises that allow us to
learn about the habits of our mind and to modify them. The practice will allow us to be
more aware of the present moment, detecting automatic responses and the tendency of the
mind to wander and judge. If we observe carefully, the perceived experience can change.
The difficulties that may arise (distractions, boredom, drowsiness, self-criticism) can be
opportunities to observe, ‘realise’ and use in practice.
What benefits can the practice of mindfulness offer us?
Several studies point out the benefits of the repeated and regular practice of mindfulness
on the reduction of anxious and depressive symptomatology, on the management of
stress, emotional regulation, the ability to concentrate and, in general, on physical and
mental well-being. In addition, we will be more aware of changes in our mood states,
which can facilitate the detection of the first signs of alarm and the introduction of the
most appropriate responses.
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88 An Integrative Approach to Bipolar Disorders
and leaving, trajectory of the air through the body, changes in the thorax or abdomen
when we breathe in and out. It is about observing our breathing with an attitude of
curiosity.
• Fundamental instruction. To return to the notion of anchorage, when we have
lost ourselves (if thoughts, emotions or physical sensations appear that distract
us), sometimes it helps to briefly label the mental phenomena (e.g. thought,
emotion, sensation, noise, or more specifically ‘anticipation’, ‘comparison’). It
is therefore useful to identify distractions and redirect our attention to
breathing.
• Attitude. It is important to maintain a compassionate, caring attitude towards the
mind and towards ourselves. The mind wanders continuously, and is like a restless
animal. (Would we get angry with a small child who becomes distracted? Would we
understand that a little dog moves from one side of the room to the other,
continuously exploring the surroundings? Why don’t we do the same with
ourselves?)
It is irrelevant how many thoughts there are (the goal is not to have the mind blank).
What is relevant are the following:
1. The time it takes you to return: we can’t avoid leaving, but we try to return
immediately.
2. How we return: it is key that it be with kindness, without criticising or getting angry,
redirecting our attention again and again to the present moment.
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sensations that you experience in each moment, as an external observer, to redirect your
attention to the present, with a kind attitude. It’s not about enjoying it; you just have to
do it!
The generalisation of the practice: 3 minutes of breathing
Once you have practised breathing as outlined in the previous session, a generalisation
exercise is necessary to apply what you are learning to a wide range of everyday
situations. This exercise consists of three steps:
1. Detach from autopilot and become aware of the present moment by asking yourself,
‘Where am I?’ and ‘What is my experience now?’ Observe, without judging, your
thoughts, emotions and bodily sensations.
2. Focus your attention on your breath, unifying the scattered thoughts in your mind to
direct them towards an objective: breathing. Note the physical sensations and
movements that accompany it.
3. Expand your attention to integrate your breathing and your whole body, being aware
of your sensations, posture and facial expression. If you become aware of any feelings
of discomfort, tension or resistance, focus on them, bringing the breath to that
sensation with each inhalation and expelling it with each exhalation.
For example, if we fall and break an arm, we will suffer an inevitable (primary) pain. If
we also start to dwell on that and think, ‘What bad luck I have, this sort of thing always
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happens to me’, ‘Why me?’, ‘How useless I am’, ‘This should not have happened to me’,
‘I’m clumsy’, then our pain will increase, this suffering being secondary and avoidable.
The crucial message here is that we can learn to free ourselves from the suffering created
by ourselves.
The mindfulness-based approach allows us to ‘be with’ the problems without the
need to solve them immediately. The goal is not to try to control the thoughts. The
simplest way to ‘let go’ is to stop trying to make things different. As a result, we will be
less reactive and will be better at solving problems that require a solution.
What could we do, for example, when a strong emotion appears? A first step would be
to acknowledge its presence, for example, before thinking, ‘I’m tired of being talked to in
that way’ to realise, ‘The emotion of anger is already here’ and next, ‘I’m afraid of the
possibility of getting confused in that situation’ to recognise and articulate, ‘The emotion
of fear is here’. Identifying and labelling emotions help us not to completely identify with
them.
Accepting the experience simply means allowing space for what is happening. Being
more aware of what is happening at each moment puts us in a more objective position
from which to respond to difficult situations or negative moods, giving us the time and
space necessary for decision making.
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3. Taking note of the thoughts allows us to consider them more objectively and,
consequently, find them less overwhelming. In addition, the interval between having
the thought and writing it or labelling it mentally (‘This is the voice of depression’,
‘Here is the criticism again’, ‘This is a dichotomous thought’) also gives us time to be
able to respond in a different way.
4. Recognise the close relationship between thoughts, emotions and associated physical
sensations, as well as the impulse to act, being aware that our thoughts are only one
link in a chain.
5. It may be useful to look at them again deliberately, from a more objective
perspective based on evidence.
Emotions
Emotions are a vehicular factor between perception and behaviour. A perception gen-
erates an emotion that will guide our action. The problem arises when we ignore the
emotions or we allow ourselves to be invaded by them, leading us to act in a reactive or
impulsive way. Being aware of the body’s expression and behavioural responses related to
emotions (fear, sadness, anger, joy) as well as to the function they have and the time in
which associated thoughts are located could be an interesting exercise.
Since in bipolar disorder the emotions can become ‘pathological’, it is good to be able
to apply full awareness to the emotion to recognise it when it arises, and to assess whether
the associated behaviour is the most appropriate. We know that some behaviours can be
more or less beneficial at certain points in the illness and therefore we will be able to
introduce them if we are able to recognise certain emotional states in time to deal with
them.
Emotional regulation, or the ability to handle emotions appropriately, is taught
through becoming aware of the emotion and regulating our behaviour according to the
context and requirements of the situation. First, we recognise the emotion by giving it
a name (fear, anger, sadness, joy), accepting it without judging, noticing the impact it has
on the body (e.g. breathing, muscular tension), noticing the impulse to react that it
produces and being aware of the consequences that would result, and then being able to
put it into perspective and decide on the most skilful response (e.g. paying attention to
breathing or to other stimuli, cognitive restructuring, adopting certain behaviours). We
can try to distance ourselves from emotion and become a compassionate observer (the
metaphor of a mother holding her crying child can be useful). It is worth remembering
that we are more than an emotion, that emotions can have an adaptive value and that
they are changing and transitory.
In summary, mindfulness training (and that implies a lot of practice) can, among
other things, make us more aware of our changes of state (mental, mood, body, etc.) and
also of the first warning signs of a possible relapse, to allow us to recognise stress more
quickly and to look for strategies to better manage it, to facilitate greater emotional
regulation and strategies for the reduction of anxiety, to train our capacity of attention
and concentration, to be more compassionate with ourselves, to improve our responses
(so that they are less automatic) and decision making, to enjoy the present moment more
and to increase our well-being.
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1. Attention
Some useful guidelines that may help to improve our attention capacity include the
following:
a. Reduce external distractions to let you focus on what is important to you.
b. Commit to paying attention for a period of time (e.g. 20 minutes). You can use
a clock or an alarm.
c. Give yourself a reasonable and realistic amount of time to complete an activity. This
may mean modifying some of your expectations.
d. Redirect your attention, going from a more global view to the most specific and
relevant details when you observe places or people. The formulation of mental
questions about what you are observing may be a useful resource to use to redirect
your attention.
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96 An Integrative Approach to Bipolar Disorders
e. Plan rest periods (breaks) during an activity (e.g. 5–10 minutes of rest every 20–30
minutes of activity).
f. Change tasks at certain pre-established times to avoid monotony and boredom.
g. Take notes.
h. Establish routines to avoid situations that involve more than one simultaneous task.
i. Use ‘self-instructions’ to redirect your attention when faced with a task. This resource
is based on the use of internal language as a behaviour mediator, allowing us to
regulate our activity or, in this case, focus our attention. For example, before starting
an activity you can ask yourself, ‘What do I have to do?’; while you are engaged in the
task, you will look for external clues to detect whether you have been distracted and
thinking of something else: ‘Am I paying attention to what I am doing?’, ‘I have lost my
train of thought . . . I am going to focus again on what I was doing’.
j. Reflective listening: try to participate in conversations with reflective listening, for
example, asking questions to clarify doubts or to confirm data. This will help you to
focus your attention and, consequently, better retain the information.
Tasks to train attentional capacity include word searches, Sudoku, ‘spot the difference’,
crossword puzzles, mental calculation (e.g. calculating change owed for a purchase when
shopping) and other hobbies such as online games. There are several online cognitive
training programmes available, including mobile applications, some of which have been
shown to activate and strengthen cognitive abilities through the enhancement of brain
functioning. Board games are also useful and fun.
Moreover, as has been covered in previous sessions, the practice of mindfulness
techniques may be useful in making you better at focusing your attention on what you
are doing or experiencing in the present moment.
Reading is a habit that enhances attention and concentration. For people who have lost
the reading habit and would like to resume it or for those who have never been enthusiastic
readers, start reading gradually. For instance, start with simple works and read for short
periods at different times under optimal conditions (e.g. when well rested). As practice
progresses, you will be able to spend longer periods of time and choose more complex
readings.
The ‘three-step method of reading’ will be useful to facilitate reading comprehen-
sion and the acquisition of information:
1. First, read without underlining or taking notes.
2. Go back and underline the most important aspects (ask yourself what has happened,
where, when, how, who is involved and why; this will help you detect the most relevant
information).
3. Review, reading the information that has just been underlined.
This method may be useful for reading short texts, news articles, magazine articles or
readings related to an academic/educational or work context.
2. Memory
Some authors have compared the way memory processes work with the functioning of
a library, which can hold thousands of units of information, in which memories must
be well classified and coded to retrieve them easily (Figure 3.3). At the librarian’s desk,
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4. Recall/Retrieval
• Retrieve saved
information to be
used at present
1. Sensory 2. Short-term
store 3. Long-term store
memory
• Working memory • Storage
• Information entry
• Sensory register • Coding
(visual,auditory, ...) • Sort and classify
information
Loss of
information
the data to be stored arrive (short-term memory), so it is very important to label and
code them correctly to access them easily (coding process). At that moment, perhaps
some papers or books are lost or discarded (information that is lost or rejected in the
short-term memory). Books already stored and well coded on the shelves (long-term
memory) may also arrive on the desk when it is necessary to retrieve certain informa-
tion (memory or stored information). Well-classified and stored data will be easier to
recover. However, sometimes books or documents are badly classified or mis-shelved
in the library, which makes access to them difficult (data or memories that we have but
cannot retrieve). Memory functioning has also been compared to the functioning of
a computer.
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There are both internal and external strategies that can help us to remember things in
our daily lives. Everyone should evaluate which strategies and techniques work best for
him or her.
External aids are resources that offer many advantages since training is much
simpler than that required by other memorisation strategies, such as those that are
internal.
a. Daily planner: the use of a daily planner may help you to retain information about
appointments, future plans or activities and important dates to remember. A planner
can also work as a notebook, as it can contain a number of separate sections designed
to respond to different issues (e.g. note sections, urgent items, monthly planning).
Good use of the planner implies an activity and mental effort that can help increase the
ability to code and retrieve the information later.
Important aspects to take into account for optimal management of the planner:
– Take the planner with you to note down what is necessary.
– Consult it daily. Review it every day at the same time to check what activities are
outstanding. At the end of the day, check it again to plan the next day and note
what is pending.
– Develop an easy notation system to allow quick access to information.
– Be concrete and concise when writing down tasks.
– Write down the most important appointments and activities of the day, even if
you think you have committed them to memory.
– Devise a personal coding system to help you quickly visualise whether or not you
have completed the tasks listed in the planner (e.g. cross out, underline with
a highlighter or tick when the task has been completed) or their level of urgency
(e.g. put an exclamation mark (!)).
Information that may be recorded:
– Data that can guide you on a personal, temporal and/or spatial level. For
instance, write down a personal or important news event that happened that day.
– Tasks, appointments or activities to be carried out during the day. It is important
to be specific when noting the tasks. You can write down the steps required to
perform tasks or resources that are needed to complete them.
– Detailed lists of things or tasks (e.g. shopping list).
– Calendar. Many planners include an annual calendar. Crossing out the day that
has ended helps temporal orientation.
– Birthdays of relatives and friends.
– Other data to be recorded are those relating to taking medication to keep track of
therapeutic adherence, a simple registry of mood (with a numerical scale from 1
to 10) and hours of sleep per night. It helps detect changes in your usual pattern
that could be ‘warning signs’ to consider in case of an eventual relapse.
b. Computers and mobile devices: these devices have programmes or applications
comparable to the planner and they are very useful for everyday organisation. In
addition, they incorporate alarm systems that may be programmed to alert you when
an activity is scheduled and also allow you to repeat an alarm periodically.
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c. Alarms: they are useful to remind you of non-immediate activities to do, for example
taking medication, going to a meeting or attending a medical appointment, or as
a timer (e.g. when baking something in the oven).
d. Weekly or monthly calendar: it is very useful to have a calendar in a very visible place
in the house to write down appointments or important dates to avoid forgetting them
and to be able to plan the week or month in advance.
e. Lists: apart from paper and pencil lists, new technologies allow you to use the note
system to create lists, and some applications have even been developed specifically
for it.
f. Sticky notes: these are coloured note pads with a self-adhesive backing. Writing on
these notes and putting them in visible places (mirror, wall, diary) can be useful as
a reminder that you have to do a specific activity, such as call the dentist or buy
batteries. It will be important to date them and throw them away once the task has
been completed to avoid confusion. It is not recommended that these be used as the
only reminder system or as a usual procedure since it will be easy to lose or accumulate
them without their having been checked.
g. Pillboxes: these are useful not only to remember to take the medication properly, but
also to check that it has been taken in case of doubt.
h. Other external strategies to use to remember certain outstanding activities may be to
ask someone you trust to remind you to do something (doing so should be used for
a specific occasion but not as a general rule) and the use of symbolic reminders such
as moving a ring or your watch from one hand to the other.
i. Personal diary: this can help you remember things you have already done (significant
events or experiences that have happened during the day) and can become part of your
autobiography. As with the daily planner, the codification and retrieval of information
are reinforced by writing down experiences in the personal diary. The use of certain
social networks (e.g. Instagram, Facebook) may also be useful for storing and later
retrieving information about events that were published previously. In addition, access
to photographs, reading comments on details or anecdotes can help you remember
a trip, an excursion, the name of a restaurant you liked, a celebration.
Internal strategies include mnemonic rules to carry out a better process of information
encoding. They consist of organising or associating the new information, attempting to
give it more profound meaning. Thus, information will acquire a structure with more
significance, which will facilitate retrieval. The use of these strategies improves with
repeated practice. There are several internal strategies, but the following focus on what
may be more useful for daily functioning:
a. Chunking: our capacity to remember information in the short term is limited, being
reduced to an average of around seven information units. Therefore, it may be useful
to chunk or split the information into smaller and more manageable units when you
have to remember a large amount of data (e.g. an ID or driver’s licence number,
telephone numbers).
b. Association: this strategy consists of linking new information with something that is
already known, therefore connecting, joining or linking one element with another.
For example, if you have to remember a list of words, you can look for phonetic
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associations (words that begin with the same letter or similar letters) or semantic
associations (concepts that usually go together). The association can be useful to
organise objects at home and find them easily: set a place for each object (medicines,
documents, tools, keys, purse, glasses, etc.) and put them in places related to their use.
Another strategy related to association is the story-telling technique, which consists
of inventing a simple story using the information (words) to be memorised, giving it
a certain meaning through the use of verbal mediators (links) that facilitate
associations.
c. Visual imagery: using imagination to generate mental images that facilitate or enrich
the association between concepts can greatly help us retain information (e.g. if you
have to buy bread, eggs and milk, it may be useful to imagine a scene in which you are
dipping bread in a fried egg that is served with a large glass of milk to remember this
small shopping list).
d. Categorisation: this strategy consists of grouping the information into blocks
according to a common characteristic. Identifying the common characteristic of the
data provides a meaning and facilitates the storage of the information, which will
make it easier to remember later. For example, it can be useful to make a shopping list
in which items will be grouped according to a category (hygiene, dairy products,
preserves, meat, fish, etc.); to pack a bag for a trip; or to organise the kitchen cabinets
or the drawers of a wardrobe.
e. Remembering names: pay attention to the name of the person you wish to
remember from the first contact and repeat his or her name several times during
the conversation. In addition, it will be helpful to associate the name with the
name of a relative/known person, or with the name of a famous person, or with
some feature that characterises him or her. The name could be associated with
mental images.
f. Other internal strategies are the use of acronyms, a mnemonic technique that
consists of generating words, or pseudo words, as an abbreviation using the initials
or first syllables of the key words to remember; the technique of repetition, which
consists of mentally repeating the information to be retained, in which we are forced
to focus on that information, increasing the possibility of memorising it; and the use
of rhythm and rhyming, for example, adding a melody to the material to be
remembered will facilitate the possibility of accessing the stored information (e.g.
multiplication tables).
Practical exercise
Organise the following clothing in a closet using a strategy to help you with the categorisa-
tion technique:
Shoes Jacket Coat Belt
Handkerchief Blouse Sweater Sweatshirt
Anorak Sneakers Pyjamas Boots
T-shirt Skirt Socks Shoes
Are you able to remember all the elements after finishing the exercise? Organising the
elements according to common characteristics should facilitate later recall.
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Web and mobile apps are used to train cognitive functions and to practise different
exercises – word search, Sudoku, crossword puzzles, mental calculation, looking for differ-
ences. Board games are also suggested.
1. Plan of Activities
Carrying out a complex task with a specific objective implies the following:
a. Defining the main task to be performed.
b. Determining the necessary steps to carry out the task.
c. Establishing the order of execution of the steps to be carried out.
d. Implementing the action plan.
e. Monitoring the plan and introducing changes in case of unforeseen events.
The following are some general tips that may also be useful:
– Divide tasks into several steps or different components.
– Give yourself simple and clear instructions to help structure and progress
properly in the task execution. Using internal strategies such as self-instructions
helps self-regulation. As mentioned in the previous session, self-instructions help
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to focus attention, but they are also helpful in inhibiting impulsive acts (‘Think
before you act’, etc.) and promoting the achievement of objectives (stop: ‘What
am I doing?’; define: ‘What is the main objective?’; list: ‘What steps do I need to
take?’; learn: ‘Do I know all the steps to follow?’; check: ‘Am I doing everything
I have planned to do?’).
– Know and use available external resources that can facilitate the execution of the
task (e.g. if you want to visit a place where you have not been before, it may be
useful to consult a map in advance or use navigation applications such as Google
Maps).
2. Time Management
A good estimation and management of time will be an essential requirement for
programming and organising all kinds of activities. This concept refers to the ability to
judge, in an appropriate way, the time needed to carry out different activities and to
regulate behaviour according to time restriction. Therefore, it will be necessary to do the
following:
– Estimate time needed to perform each task, taking into account not only the resources
needed to carry them out but also the unforeseen events that may arise and force us to
modify the planned order of activities.
– Plan tasks in advance. Establish and follow a temporary schedule,
avoiding leaving tasks until the last minute since doing so contributes to the
stress level.
– Establish priorities. Prioritise activities according to their level of urgency and the
deadline. Discriminate between what is important in your life and what is not
a priority. For this reason, it is advisable to draw up a list or an action plan establishing
the priority level for each task.
– Specify the order of activities. In addition to the urgency, the order established to
carry out tasks may be influenced by other factors, such as proximity, availability of
resources or means of transport, using the same route already planned, among
others.
– Be flexible and know how to introduce changes to the usual routine and make some
adjustments to the distribution of activities whenever necessary. It is recommended
that you have an alternative plan to ensure that you can complete the activity in case
of unforeseen events.
– Delegate responsibilities if the situation permits and you feel overwhelmed. It
may be useful to consider delegating the execution of some of the planned tasks
to others.
– It is advisable to plan short breaks between activities to avoid unnecessary mental
blocks or burdens.
The use of a record sheet such as the one here will be useful to plan the order of activities
as well as managing time on any given day (or week).
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Record sheet
Practical exercise
Peter is an administrative assistant for three people at his office. At 4 p.m. he has to have
a room ready for a meeting, which implies preparing the material for 10 attendees, setting up
the computer and projector, receiving the catering company at 3 p.m. and supervising that
everything is ready just half an hour before the meeting. In addition, first thing in the
morning, at 9 a.m., the three bosses ask him to do several tasks at the same time. One
boss asks him to make a restaurant booking for next Wednesday at 8 p.m. for four people.
The second one asks him to make 10 copies of a series of documents for the afternoon
meeting, and the third asks him to go to his office immediately to take some notes to write
a letter that he will then have to type up, print, have signed by his boss and take to the post
office to be sent priority to arrive by tomorrow morning at the latest.
Peter’s work schedule is from 9 a.m. to 5 p.m. Please organise the tasks that Peter has to do
in the office using the Record Sheet for the time management and planning activities and
recommendations that have been previously discussed during the session, taking into
account both time and resources needed to carry out each of the tasks.
Other exercises to practise the use of guidelines for planning activities and time manage-
ment include the following:
– Plan a weekend in the mountains.
– Plan a trip.
– Organise a surprise birthday party or a barbecue with friends.
Haste makes us prioritise what is urgent, always resolving those issues first and
pushing back what is actually important. That can be very stressful. Important issues
should not be allowed to become urgent, as they will usually require a certain amount of
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time to be resolved. Urgency does not make an issue more important. It is fundamental
to know how to differentiate between these two dimensions: important/not important
(it is or it is not related to my objectives) and urgent/not urgent (it requires or does not
require immediate attention). The Eisenhower matrix includes these two dimensions of
planning and time management. It may be a useful tool to use to increase our produc-
tivity or make us more effective in our daily lives, especially at work.
Eisenhower matrix
Important Do Plan
Schedule a time to do it on
Do it now calendar, decide when to
do it
Not important Delegate Don’t do
Who can do it for you? Do it later or eliminate
The so-called time thieves are another aspect to bear in mind regarding time
management. The phrase refers to certain behaviours, habits, people or things that
make us waste time. Some of these are generated externally, but others are created by
ourselves. The first step is to know what they are in order to detect which of them are
present and avoid interfering with our daily lives. Common ‘time thieves’ include the
following: (1) personal disorganisation; (2) having confusing or unclear goals that will
lead to a need to expend more effort; (3) not making decisions; (4) not knowing how to
say NO; (5) inability to delegate; (6) procrastination, especially postponing those tasks we
do not like or that we find boring; (7) bad communication; (8) interruptions by other
people; (9) certain meetings in which there is no explicit agenda or objectives; and (10)
emails and the Internet, social networks (e.g. Facebook, Instagram) and instant messa-
ging (e.g. WhatsApp, Telegram). We should look for strategies to use to avoid some of
these time thieves. For example, we can mute the mobile phone when we are involved in
an important task, and it is also highly recommended that you uninstall notifications of
certain social networks or instant messaging applications since they constitute
a significant source of interruptions. Concerning email, designate a moment during
the day and fix a specific time limit to deal with reading and answering email.
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important decisions when symptoms of the illness are present, and it is better to wait for
periods of mood stability that favour objectivity and freedom in decision making.
The way we interpret a given situation (insurmountable threat versus challenge) and
perceive the resources we have to face it (feeling capable versus thinking that we do not
have sufficient skills) conditions the emotional reactions and the way we face it.
Problem-solving skills training can strengthen our competence in selection of effec-
tive decision making, which can contribute to reducing the level of stress (and therefore
its potential influence on relapses). In order to learn the technique, it is convenient to
start with a problem that does not generate much difficulty, and then be able to generalise
the process to more complex problems.
Problem-solving training consists of the following steps:
1. Defining the problem.
It is essential to define the problem in a specific way, as this will allow us to clarify
what the objective is that we want to achieve. A bad approach or an overly general or
unspecific focus on the problem can make its resolution more difficult. For this
reason, it is useful to describe the problem in detail, specifying who, what, where,
when and how. The more objective the description is, the better.
2. Finding possible solutions.
A richer result is produced when alternatives are many and varied, no matter how
far-fetched or absurd they may seem! It is about encouraging what we call ‘brain-
storming’; in this step nobody is judging or evaluating suggested solutions yet. The
more potential solutions we list, and the more diverse they are, the more likely it is that
some of them may be adequate. However, we will carry out this analysis later. Here we
have to be guided by the principles of quantity, variety and postponement of judgement.
3. Analysing the advantages and disadvantages of the possible solutions.
The adequacy of each solution to solve the problem will be analysed, evaluating its
consequences. It may be useful to use (a) the two-column technique, noting the pros
and cons of each option, and then (b) scoring each solution according to the previous
analysis, taking into account the probability that the solution will solve the problem,
the time and effort required, the short- and long-term effects, the associated risks, and
so on.
Solution 1
Advantages Disadvantages
Solution 2
Advantages Disadvantages
Solution 3
Advantages Disadvantages
...
Score (0–10):
Solution 1:
Solution 2:
Solution 3:
...
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others; the right to change our mind; the right to ask for what we want; the right to reject
petitions without feeling guilty, among others.
When the interlocutor is very insistent or manipulative, some techniques include the
following:
– Viable agreement: give each person enough room to manoeuvre in order to arrive at
a solution that is as convenient as possible for all parties.
– Broken record: repeat clearly your point, over and over again, staying calm.
– Fogging: agree with some parts of what the other person raises.
– Assertive postponement: useful when you don’t know what to answer at that moment.
Mood affects the way we send messages and interpret the ones we receive, thus
influencing communication. The existence of symptoms typical of depression, such as
feelings of worthlessness or excessive self-criticism, or the lack of self-criticism and
suspicion that can occur in manic episodes or when mixed symptoms are present, can
introduce a distortion in the interpretation of messages received and affect the way the
person expresses him- or herself. When a person’s emotional levels interfere with
interaction, it is advisable to stop the discussion and resume it when the emotional
intensity has diminished. It is not a question of not talking about what concerns us, but of
selecting the moment and the way in which we communicate.
Training in communication skills facilitates efficient and direct transmission and
reception of thoughts, feelings and desires. It can therefore have an impact on
problem solving and stress reduction.
Some guidelines can help improve interpersonal communication:
– Pay attention to both verbal and non-verbal communication; the latter includes facial
expression, gaze, posture, and so on. Paralinguistic or modulating components (e.g.
tone, volume, speed) also play a fundamental role.
– If symptoms from an episode are still present, it is preferable to postpone important
decisions.
– If complaints or disagreements emerge, try being specific and do not generalise,
focusing on the behaviour and not on the person (‘It annoyed me that you didn’t tidy
the room’, instead of ‘You are an irresponsible person’). This makes it easier to find
solutions and avoids the other person feeling attacked and therefore becoming
defensive.
– Transmit clear and precise messages that cannot lead to misinterpretations (avoid
vague terms, repeat the message, etc.).
– Listen well and pay attention, letting the other person express the message he or she
wants to transmit without interruptions. Refrain from telling ‘your story’ when the
other needs to express him- or herself.
– Don’t invalidate what the other is feeling with ‘that’s nothing’ comments.
– Avoid value judgements and attributions. Replace ‘mind reading’ with direct
questions and avoid incorrect interpretations.
– Be flexible; keep your mind open to the ideas and suggestions of others.
– Focus on the present and speak in first person (‘I need . . . ‘).
– Deal with one problem at a time. Raise problems as they arise, avoiding resentment
and irony.
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108 An Integrative Approach to Bipolar Disorders
– Avoid distractions (e.g. tablet, mobile phone) as much as possible, as they can interfere
with communication. Select an appropriate time and place for discussions.
– If there is an issue that is difficult to address, you can turn to a trusted person or
a specialist.
Communication Skills
➢ Active listening
▪ Look at the person speaking and pay attention to what he or she is saying.
▪ Ask questions, clarify (avoid constant interruptions).
▪ Check that you have understood what you have heard.
– Summarise the message and ensure all is understood.
➢ Refusing requests
▪ Analyse the situation without rushing to make sure you have understood what the
person is asking for, or ask for clarification or time to think about the answer if you
need it.
▪ Look at the person and express your negative response in a friendly and clear way.
Saying no is a right (if you want, you can give reasons, not excuses).
– You can directly say no, give a brief explanation or use techniques like the ‘sandwich’
(say something positive before and after refusing the request: ‘Thanks for telling me,
I can’t help you today, but we can meet tomorrow’), or the ‘broken record’ if the other
person insists after hearing your negative response (repeat ‘I’m sorry but no’ without
having to justify your answer).
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➢ Facing criticism
▪ Wait until the criticism is over before speaking.
▪ If necessary, ask for details to better understand the other’s point of view.
▪ Assess whether there is something positive or constructive in the criticism.
▪ Apologise or agree if you believe that the criticism is totally or partially justified. If not,
accept that the other person may have been bothered by a particular behaviour and
explain your position without putting yourself on the defensive.
08:44:38
009
Appendix 1 The Group Rules (if the group
format is used)
Over a period of 12 weeks, we will form shows a lack of respect for those on the
a group that will meet every [define waiting list, and limits the
a specific day and time slot that covers 90 understanding and benefit to be taken
minutes]. From an integrative approach the from the programme content. Any
aim is to contribute to a better understand- absence must be duly explained and
ing and acceptance of bipolar disorder, as justified. If absence occurs for more
well as to train in strategies to improve dis- than three sessions, participants will be
ease management, control stress and reduce withdrawn from the programme,
the impact of the disorder. except in the case of a justified reason,
In order to facilitate the optimal func- in which case an assessment will be
tioning of the group and to get the most out made for participation in subsequent
of your participation in these sessions, we groups.
have defined the following rules: ✓ Punctuality. The group sessions take
✓ Respect. All of the group’s participants place on the same day of the week at the
must respect the other members and same time. It is important to respect the
their opinions, even when disagreeing. schedule; arriving late to the sessions
We don’t allow demeaning, facetious or interrupts their progress, affects
sarcastic comments towards others in everyone else in the group and prevents
the group. We can laugh together, but the person from taking full advantage of
never laugh at another individual. It is the programme.
essential to respect the others’ turn to ✓ Participation. It is not compulsory to
speak, listening to them and avoiding contribute in sessions, but it is
frequent interruptions. advisable. We recommend active
✓ Confidentiality. A person’s health participation in sessions – answering
condition constitutes part of his or her questions, discussing doubts, sharing
private life. The members of the group experiences – but all participants are
must be bound not to share private free to choose the degree of disclosure
information outside of the members of and participation that they wish to
the group. However, what we as show.
therapists say and the material from ✓ Distractors. It is essential to keep your
each session can be openly discussed mobile phone silent during sessions.
and shared with friends, relatives and In case of any doubts or problems you
acquaintances, as it is all general can contact the group therapists. Our con-
information related to bipolar disorder. tact details are the following [names, emails,
✓ Attendance. It is important to attend phone numbers].
all programme sessions. Not doing so
110
10:16:38
010
Appendix 2 Level of Satisfaction with the
Intervention
We would like to know your opinion ☹ ☺
regarding the integrative approach in _________________________________
which you have participated. 0 1 2 3 4 5 6 7 8 9 10
Evaluation
Positive ☐ Neutral ☐ Negative ☐ What contributions or positive aspects
would you highlight?
Degree of satisfaction
Between 0 and 10, taking into account that Can you think of any suggestions or areas
0 is not at all satisfied and 10 is very for improvement?
satisfied.
111
10:16:32
011
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Cambridge University Press
978-1-108-46009-5 — Psychotherapy for Bipolar Disorders
Edited by Eduard Vieta , Maria Reinares , Anabel Martínez-Arán
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