Dialectical behavior therapy (DBT) can help mood regulation in those with bipolar disorder

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Researchers have conducted a new trial to identify how an existing psychological therapy can be adapted to help people cope with and manage frequent Bipolar mood swings.

A subgroup of those with Bipolar Spectrum Disorders experience ongoing mood fluctuations outside of full episodes. These shifts in mood can sometimes make it difficult to live life to the full, and can be a source of difficulties in relationships with others.

There are currently few therapy options available for people living with dramatic weekly, daily or even hourly mood swings.

The ThRIVe-B programme, carried out by researchers at the University of Exeter, involved taking an existing psychological therapy for another group of people that aims to help with emotion regulation, known as Dialectical Behaviour Therapy (DPT), and adapting it for people who have these frequent Bipolar mood swings.

DPT teaches skills both in acceptance of situations and emotional responses and is currently offered to people who have a diagnosis of Emotionally Unstable Personality Disorder.

“We have psychological therapies that can be helpful for people with Bipolar but there’s less available for people who have very frequent and ongoing mood swings within Bipolar” said lead author Dr Kim Wright, of the University of Exeter.

“We wanted to see how acceptable the therapy would be to the people who received it and do a test run to identify what changes need to be made before conducting a larger trial.”

The study took place in Devon and Cumbria and 43 participants were placed randomly into two groups.

Half of the participants received the new therapy. The other half continued with their usual NHS care.

The therapy lasted for around six months and participants were interviewed at various stages and asked to complete questionnaires when the study started and three, six, nine and 15 months later.

Participants were invited to reflect upon their behavioural response to extreme mood and activation states day-to-day and modify this where necessary.

In DPT this is achieved by building mindful awareness skills and through giving participants a framework through which to appraise their emotional responses and to develop alternative ways of relating to and managing these.

The therapy involved attending 16 group sessions and also some individual sessions with a therapist.

To support this, there was home practice as well as handouts and a ThrIVe-B smartphone app where participants could rate their mood.

“Because of the small numbers of people tested, the trial was never intended to evaluate the benefit of the treatment itself. Instead the study aimed to evaluate feasibility and acceptability of this therapy” Dr Wright explained.

“Overall, the study shows that there is demand from people with Bipolar for a psychological therapy addressing ongoing mood instability, and that a larger trial of a therapy like this is feasible.

“Our next steps will be to refine the therapy in line with what we learned from this study, such as simplifying content and considering individual rather than group delivery.”


THE CAPACITY TO REGULATE emotion through conscious and unconscious psychological and physiological processes is essential for effective psychosocial functioning (Gross, 2002; Thompson, 1994). Growing evidence suggests that this capacity may be compromised in bipolar disorder (e.g., Green, Cahill, & Mahli, 2007; Johnson, Gruber, & Eisner, 2007; Murphy et al., 1999; Phillips, Ladouceur, &Drevets, 2008).

Difficulties regulating emotion may be exacerbated by the tendencies of individuals with bipolar disorder to experience more intense emotional responses compared to those without bipolar disorder (Johnson et al., 2007), and to interpret neutral stimuli as negative (Gur et al., 1992; McClure, Pope, Hoberman, Pine, & Liebenluft, 2003). Although specific neurological mechanisms have yet to be elucidated, compared to controls, individuals with bipolar disorder have shown greater limbic system activation in response to emotional stimuli (Phillips et al., 2008) and while appraising emotional material(Chenetal.,2006),and they have demonstrated greater difficulty inhibiting emotional responses (Murphy et al., 1999).

Additionally, there is a growing and robust literature that suggests bipolar disorder involves maladaptive exaggerated responses to emotional stimuli and diminished use of adaptive responses to regulate strong emotions (Johnson, Tharp, Peckham, & McMaster, 2016; Phillips et al., 2008).

Notably, following treatment for a mood episode, most patients with bipolar disorder continue to experience persistent subthreshold mood symptoms (Fagiolini et al., 2005; Keck et al., 1998), which put them at greater risk for the recurrence of subsequent mood episodes (Perlis et al., 2006). While pharmacotherapy can be effective for maintaining mood stability, for most patients, medication fails to achieve sustained, full symptom remission (Keck et al., 1996). For this reason, adjunctive psychosocial group interventions such as psychoeducation and mindfulness-based cognitive therapy have been used to complement pharmacotherapy for individuals with bipolar disorder. However, deficits in emotion regulation, a core component of this disorder, are not directly addressed in these interventions.

Dialectical behavior therapy (DBT) is an empirically supported treatment for borderline personality disorder that specifically targets emotion dysregulation. In DBT, emotion dysregulation is understood as a consequence of emotional vulnerability coupled with inadequate, or maladaptive, affective modulation strategies (Linehan, 1993a).

Emotional vulnerability is characterized as high negative affect at baseline, sensitivity to emotional stimuli, and intense emotional responding to stressors, usually with a slow return to affective baseline. DBT teaches mindfulness as well as interpersonal effectiveness, emotion regulation, and distress tolerance skills to improve emotion regulation, reduce vulnerability to negative emotions, and reduce maladaptive coping behaviors associated with strong emotions (McMain, Korman, & Dimeff, 2001).

Because of DBT’s well-established utility for addressing emotion regulation challenges in borderline personality disorder, it has been suggested that DBT might also be used to target emotion regulation problems in bipolar disorder (Goldstein, Axelson, Birmaher, & Brent, 2007). In a preliminary trial of adolescent-focused DBT(Miller, Rathus, & Linehan, 2006) adapted for bipolar disorder, Goldstein and colleagues (2007) determined that incorporating family group skills training (conducted with individual family units), and individual DBT therapy could be successfully delivered to adolescents with bipolar disorder.

The authors found that those receiving DBT were more adherent to treatment and experienced greater reductions in depressive symptoms when this intervention was delivered as an adjunct to pharmacotherapy. Later, in a randomized trial of DBT versus treatment as usual(TAU) for adolescents with bipolar disorder, Goldstein and colleagues (2015) found that those receiving DBT attended significantly more therapy sessions over the course of treatment than did adolescents receiving TAU. Study participants receiving individual DBT +family group skills training demonstrated significantly less severe depressive symptoms, as well as improvements from pre- to posttreatment in manic symptoms and emotion dysregulation compared to participants receiving TAU. Additionally, those receiving DBT were also nearly three times more likely to demonstrate reductions in suicidal ideation.

Standard DBT, as it was originally designed and tested, consists of four components: individual therapy, group skills training, between-session coaching, and a consultation team for DBT therapists. Standard DBT has been well studied and found to be effective for treating a range of psychiatric disorders. However, due to feasibility and resource challenges commonly faced by treatment outlets, there is a growing trend toward offering stand-alone DBT skills groups to complement TAU (Neacsiu, Eberle, Kramer, Weissmann, & Linehan, 2014).

Such DBT skills groups have been found to reduce negative affect, emotion dysregulation, aggression, and impulsivity across psychiatric presentations including borderline personality disorder, depression, bipolar disorder, attention-deficit disorder, problem drinking, incarcerated women with histories of trauma, while also reducing number of hospitalizations, and improving social adjustment and global functioning (see Valentine, Bankoff, Poulin, Reidler & Pantalone, 2015, for review).

To date, however, only one study has examined DBT skills group training as an adjunct treatment for adults with bipolar disorder. Concurrent to the present investigation, Van Dijk and colleagues (2013) ran a small, 12-week randomized controlled trial of DBT skills group that combined psychoeducation for bipolar disorder and DBT skills training in addition to TAU compared to wait-listed controls receiving TAU only. DBT + TAU resulted in a trend toward greater reductions in depression symptoms, compared to TAU only.

Additionally, DBT group skills training led to greater mindful awareness and lower fear of and need for control over emotional states. Participants receiving DBT group skills training also had fewer emergency room visits and mental health-related admissions in the 6 months following treatment.

Using an open-trial design intended to test proof of concept, we explored the feasibility and efficacy of a brief DBT skills group for adults with bipolar disorder with residual mood symptoms. To gauge treatment efficacy, we assessed changes in mood and well-being, as well as associations between psychosocial change and measures of skill acquisition that correspond to the modules taught in the DBT.

We hypothesized that participants receiving 12 weeks of DBT group skills training would show decreases in mood symptoms and improvements in global well-being, and that these improvements would be associated with increases in mindfulness, emotion regulation, and distress tolerance.

reference link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145450/


Original Research: Closed access.
“Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme)” by Kim Wright et al. International Journal of Bipolar Disorder

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