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Cognitive-Behavioral Therapy for Rapid Cycling Bipolar Disorder

N o r e e n A. Reilly-Harrington a n d R o b e r t O. Knauz, Massachusetts General Hospital
a n d H a r v a r d Medical School
This article describes the application of cognitive-behavioral therapy (CBT) to the treatment of rapid cycling bipolar disord~ Between
10 % and 24 % of bipolar patients experience a rapid cycling course, with 4 or more mood episodes occurring per year. Characterized
by nonresponse to standard mood-stabilizing medications, rapid cyclers are particularly in need of effective, adjunctive treatments.
Adjunctive CBT has been shown to improve medication compliance and reduce relapse rates in patients with bipolar disorder. Howev~ no published trials to date have examined the application of CBT to the treatment of rapid cyclers, with only a single case study
existing in the literature. We address challenging clinical problems in the treatment of patients with rapid cycling bipolar disorder
and include strategies for managing frequent mood fluctuations, medication compliance, sleep hygiene, lifestyle regularity, mood elevation, suicidality, and comorbiditv. A case example is included to illustrate the treatment approach.

HIS ARTICLE explores the application of cognitivebehavioral therapy to the treatment of rapid cycling
bipolar disorder. Bipolar disorder is a serious and recurrent mental illness that affects 1% to 2% of the population
(Kessler et al., 1994; Smith & Weissman, 1992). Bipolar
patients with a rapid cycling course experience four or
more depressive, manic, hypomanic, or mixed episodes per
year, as defined by the Diagnostic and Statistical Manual of
Mental Disorders (DSM-I~', American Psychiatric Association, 1994). In fact, individuals with "ultra-rapid cycling"
may experience dramatic m o o d shifts on a weekly or even
daily basis (Kramlinger & Post, 1996). While Emil Kraepelin (1921) initially described the p h e n o m e n o n of frequent cycling in his pioneering work on manic-depressive
illness, the term "rapid cycling" was first coined by Dunner and Fieve (1974). Rapid cycling has since been validated as a distinct course modifier for bipolar disorder
(Bauer et al., t994; Maj, Magliano, Pirozzi, Marasco, &
Guarneri, 1994). Rapid cycling occurs in 10% to 24% of
patients with bipolar disorder (Dunner & Fieve, 1974;
Kukopulos et al., 1980; Maj et al., 1994; Tondo, Baldessarini, Hennen, & Floris, 1998) and while bipolar disorder
is equally common in males and females, rapid cycling is
significantly more common in females (Leibenluft, 1997;
Tondo & Baldessarini, 1998).
Pharmacotherapy has traditionally been the mainstay
of treatment for bipolar disorder. However, limitations to
medication alone are suggested by relapse rates as high as
73% over 5 years, even with adequate maintenance treatment (Giflin, Swendsen, Heller, & Hammen, 1995). In
particular, patients with rapid cycling bipolar disorder are

Cognitive and Behavioral Practice 12, 6 6 - 7 5 , 2005

1077-7229/05/66-7551.00/0
Copyright 2005 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.

considerably less responsive to standard mood-stabilizing

medications for bipolar disorder, such as lithium and carbamazepine (Calabrese et al., 2001; Okuma, 1993). Furthermore, despite the frequent recurrence of depression
in rapid cyclers (Calabrese et al., 2001), the use of antidepressant medication is discouraged due to the risk of
inducing m o o d elevation or exacerbating cycling (Calabrese, Rapport, Kimmel, & Woyshville, 1993; Kilzieh &
Akiskal, 1999). Medication noncompliance further complicates treatment with bipolar patients, with at least 50%
exhibiting poor medication compliance within the first
year of treatment (Keck et al., 1996; Keck et al., 1998).
Furthermore, within a sample of rapid cyclers, Calabrese
et al. (2001) found that comorbid substance abuse and
dependence adversely affected medication compliance.
Thus, the pharmacological management of rapid cycling
bipolar disorder is often complex and challenging. Effective, adjunctive treatments are needed to improve medication compliance and to augment pharmacotherapy in
this population.
In the last several years, a growing n u m b e r of controlled studies have provided encouraging data on the
application of adjunctive cognitive-behavioral treatments
for bipolar disorder. In an early study, Cochran (1984)
randomized 28 bipolar patients to a 6-week adjunctive
cognitive-behavioral therapy protocol or to standard pharmacotherapy alone. The therapy protocol was based on
cognitive therapy principles and focused on modifying
the behaviors and cognitions that interfered with medication compliance. Patients who received the intervention
demonstrated better medication compliance both at posttreatment and at 6-month follow-up. In addition, patients
in the cognitive-behavioral therapy condition were significantly less likely to discontinue medication, to be hospitalized during the study, and to have episodes associated
with medication noncompliance.

CBT for Rapid Cycling

Hirshfeld et al. (1998) reported results from an ongoing controlled trial of an l 1-session group cognitivebehavioral therapy for bipolar disorder. Analyses of data
from the first 30 participants indicated that patients who
completed the adjunctive group treatment had longer
periods of euthymia and fewer new episodes than patents treated with standard pharmacotherapy alone. This
result was maintained at 3-month follow-up.
More recently, Lain et al. (2000) randomized 25 bipolar
patients to adjunctive cognitive-behavioral therapy or to
routine clinical care. Patients in the cognitive-behavioral
therapy condition received up to 20 sessions of cognitivebehavioral therapy over a 6-month period. Ratings completed at 6- and 12-month follow-up indicated that patients
receiving cognitive-behavioral therapy had significantly
fewer mood episodes, better general social functioning,
better ability to respond to early warning signs of episodes,
less hopelessness, and better medication compliance than
patients receiving routine clinical care.
Finally, Scott, Garland, and Moorhead (2001) conducted a randomized, controlled trial in 42 patients with
bipolar disorder who were assigned to either immediate
cognitive therapy for bipolar disorder or to a 6-month
wait-list control condition followed by cognitive therapy.
At 6-month follow-up, patients who received cognitive
therapy showed significantly greater improvements in
symptoms and functioning. In addition, relapse rates were
60% lower in the 18 months after initiating cognitive
therapy, as compared to the 18 months prior to receiving
cognitive therapy, in the 29 patients who eventually received cognitive therapy. Twenty-six patients reported
that cognitive therapy was "highly acceptable" and 23 patients stated that they would recommend it to others with
bipolar disorder.
In addition to the studies detailed above, several other
recent pilot studies and open trials have also shown
promising data on the role of adjunctive cognitive and
cognitive-behavioral therapy for bipolar disorder (Fava,
Bartolucci, Rafanelli, & Mangelli, 2001; Palmer, Williams,
& Adams, 1995; Patelis-Siotis et al., 2001; Zaretsky, Segal,
& Gemar, 1999). Despite all of these encouraging findings, no trials to date have specifically examined the application of cognitive-behavioral therapy to the treatment
of rapid cycling bipolar disorder. Only one published
case report of cognitive-behavioral therapy in a rapid cycling patient currently exists in the literature (Satterfield,
1999).
Using an empirical, single-case study design, Satterfield (1999) conducted 12 months of adjunctive cognitivebehavioral therapy with a rapid cycling patient, focusing
on the prediction, prevention, and treatment of affective
episodes. He reported a significant reduction in the frequency and intensity of mood episodes during the 12
months of treatment as compared to the preceding 14

67

months prior to cognitive-behavioral treatment. Parallel

decreases in hopelessness and anxiety and improvements
in global functioning were also reported. Many of the targets for treatment described by Satterfield, such as psychoeducation, mood monitoring, early detection of episodes,
stress management, activity scheduling, medication compliance, and cognitive restructuring, are consistent with
current treatment manuals and protocols for bipolar disorder (Basco & Rush, 1996; Newman, Leahy, Beck, ReillyHarrington, & Gyulai, 2001; Otto, ReiUy-Harrington, Kogan,
Henin, & Knauz, 1999). This is encouraging and fits with
our own pilot work on the treatment of rapid cycling bipolar disorder (Reilly-Harrington & Knauz, 2000). In this
article, we will elaborate on the specific applications of
cognitive-behavioral strategies to the treatment of rapid
cycling bipolar disorder.

Interventions for Rapid Cycling

Characterized by nonresponse to traditional pharmacotherapy and frequent, unpredictable fluctuations in
mood, rapid cyclers are often considered to be the most
challenging type of bipolar patient (Kilzieh & Akiskal,
1999). Therapists must be particularly flexible, creative,
and adept at detecting and responding to rapidly shifting
moods. While many of the cognitive-behavioral interventions used to treat rapid cyclers overlap with those used to
treat non-rapid-cycling bipolar patients (Newman et al.,
2001; Otto et al., 1999; Otto, Reilly-Harrington, & Sachs,
2003), we will discuss the specific obstacles and considerations in treating this population. In addition to describing the rationale for these r e c o m m e n d e d interventions,
we will illustrate their use in a case example.

Psychoeducation and Medication Compliance

It is vitally important for patients to fully understand
the nature of their bipolar illness and its treatment. Therefore, initial sessions should include information about
rapid cycling bipolar disorder, the role of medications, and
the collaborative nature of cognitive-behavioral therapy
While some patients may be highly informed about their
diagnosis, others may benefit from even basic discussions
of how to recognize the symptoms of mania and depression. Education is essential regarding factors that may
worsen the course of rapid cycling, such as sleep loss, substance abuse, and caffeine. Coming to terms with the idea
of having a recurrent, chronic illness is often an ongoing
issue in treatment, particularly for patients who are relatively new to diagnosis and treatment.
Structure within treatment sessions is particularly important, given the memory and attention deficits reported
in both euthymic and symptomatic bipolar patients (Deckersbach et al., 2002; Deckersbach, Reilly-Harrington, &
Sachs, 2001). Asking patients to take notes in session and

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to review audiotaped sessions inay enhance the organization and learning of session content. Likewise, therapists
may keep sessions on track by regularly setting agendas,
collaboratively prioritizing goals, and providing summary
statements. While such strategies are recommended for
the treatment of all bipolar patients (Newman et al., 2001),
patients with a rapid cycling course may be particularly in
need of such organizational tools.
Therapists working with bipolar patients should familiarize themselves with the m o o d stabilizing, antidepressant, and antipsychotic medications commonly prescribed
for rapid cycling bipolar disorder (see Newman et al.,
2001, for an overview). In order to facilitate medication
compliance, patients should be encouraged to discuss
their beliefs about medication and their concerns about
side effects, such as weight gain. Strategies such as cognitive restructuring and daily thought records (J. S. Beck,
1995) are often useful in modifying negative beliefs (e.g.,
"Taking this medicine means I ' m crazy") that may interfere with compliance. Behavioral strategies and reminders, such as Post-It notes, watch alarms, and pill boxes
may be useful in improving adherence. Rapid communication between care providers and prompt medical and
psychosocial intervention are warranted when the early
warning signs of a mood episode are detected. Such swift
collaboration among care providers is particularly important when treating bipolar patients with rapidly shifting
m o o d states.

Mood Monitoring
Daily mood monitoring (Sachs, 1996) ideally enables
rapid cycling patients to increase their awareness of early"
shifts in mood that may serve as precursors of episodes.
This strategy involves daily graphing of both depressed
and elevated moods, with the goal being to initiate prompt
pharmacological and psychosocial intervention prior to severe episodes. The mood chart also tracks daily compliance
with medications, hours slept, and psychosocial stressors
that may serve as triggers for mood symptoms. Patients
frequently report a greater understanding of the connections between stressors, sleep, medication use, and mood
through using the mood chart. The m o o d chart also prorides an invaluable snapshot of the patient's week and review of it should be included as a regular agenda item at
each session (Otto et al., 1999). Longitudinally, the mood
chart can provide valuable information about the impact
of menstrual cycles and seasonality on mood changes.
The mood chart can be downloaded from the Web site of
the Harvard Bipolar Research Program at Massachusetts
General Hospital (www.manicdepressive.org).

Activity Scheduling and Lifestyle Regularity

The instability of sleep, circadian rhythms, and daily
routines has been linked to m o o d disturbance in theories

of affective disorder (Ehlers, Frank, & Kupfer, 1988; Ehlers,

Kupfer, Frank, & Monk, 1993; Healy & Williams, 1988).
Several studies have examined the effects of sleep-wake
cycles and daily routines or "social rhythms" on mood in
patients with rapid cycling bipolar disorder (Ashman et
al., 1999; Leibenluft, Albert, Rosenthal, & Wehr, 1996).
Leibenluft et al. longitudinally followed 11 rapid cycling
patients over the course of 18 months, with patients completing daily mood and sleep ratings. In their sample of
rapid cyclers, decreased sleep duration was the best predictor of mania or hypomania. Consistent with these findings, Wehr, Sack, and Rosenthal (1987) have proposed
that sleep loss may be a common causal pathway in the
development of mania. Given the connection between
sleep loss and mania, several investigators (Wehr et al.,
1998; Wirz-Justice, Quinto, Cajochen, Werth, & Hock,
1999) have examined the effects of sleep-related interventions in case studies with rapid cycling patients. Such
reports suggest that regularly scheduled periods of nightly
darkness and bed rest may be helpful in stabilizing mood
fluctuations in patients with rapid cycling.
While the stabilization of sleep patterns is an important goal for all individuals with bipolar disorder, it may
be particularly challenging for rapid cyclers, whose daily
routines, including sleep, may be highly irregular. Not
surprisingly, Ashman et al. (1999) found that patients
with rapid cycling bipolar disorder had daily routines or
"social rhythms" that were significantly less rhythmic (i.e.,
regular), than nomaal controls.
Cognitive-behavioral interventions targeting the regulation of sleep and activity levels are especially important
for rapid cycling patients. While decreased sleep is typically associated with mania, hypersomnia is typically associated with depression in patients with bipolar disorder
(Detre et al., 1972). Thus, patients who rapidly cycle between m o o d states may exhibit particularly erratic sleep
patterns. In order to stabilize these sleep patterns, patients are encouraged to adopt good sleep hygiene by establishing regular sleep and wake times, even on weekends, avoiding caffeine, and keeping stressful activities,
such as working or paying bills, out of the bedroom. Sudden sleep disruptions, such as switching to a night shift or
staying up all night to study for exams, should be avoided.
Daytime napping should also be avoided if it interferes
with nightly sleep. Relaxation strategies, such as diaphragmatic breathing and progressive muscle relaxation,
can be used prior to bedtime to ease the transition to
sleep. Since changes in sleep patterns may serve as either
triggers to episodes or as early warning symptoms, they
should be addressed immediately both pharmacologically and behaviorally.
In addition to careful monitoring of sleep regularity, it
is highly advisable for rapid cycling patients to establish
and maintain a regular pattern of activities. Ideally, this

CBT for Rapid Cyding

routine should include a balance of work, social interaction, leisure, and exercise. There is often the tendency
for depressed patients to withdraw and do less, while patients in the manic phase may become overly committed,
starting many new projects and activities. Cognitivebehavioral interventions involving activity scheduling
(J. S. Beck, 1995) may be helpfftl in establishing a regular
routine of activities that are associated with m a s t e r y - - a
sense of accomplishment and pleasure. In non-rapidcycling bipolar patients, there is some evidence that engaging in consistent psychosocial treatment may create
structure and be m o o d stabilizing in and of itself, regardless of the modality (Frank et al., 1999). It is probable, then,
that rapid cycling patients may also benefit from the consistency that regular psychosocial treatment may provide.

Management of Life Stressors

A growing number of studies suggest that negative life
events and environmental stressors contribute to relapse
in patients with bipolar disorder (see Johnson & Roberts,
1995, for a review). Stressors may provoke bipolar mood
episodes through the destabilizing effects of stress on
daily routines of sleep and activity, thus disrupting critical
biological rhythms (Ehlers et al., 1988; Healy & Williams,
1988). Stressors leading to sleep disruption may be more
likely to induce mania than depression. Consistent with
this, Malkoff-Schwartz et al. (1998) found that manic patients had significantly more pre-onset life events leading
to sleep disruption than did depressed bipolars. Thus, as
discussed above, one of the goals of cognitive-behavioral
therapy for rapid cycling is to stabilize patterns of sleep
and activity. Activity management is a particularly important focus when patients are confronted with stressful
events. For example, it is vitally important for the patient
who is laid off from his job to maintain a consistent sleepwake cycle and pattern of daily activity.
Problem-solving is also an important component of
CBT for rapid cycling bipolar disorder and patients are
encouraged to develop and evaluate potential alternatives for managing stressful life situations. It is highly advisable for patients to evaluate the types of stressors that
characteristically provoke episodes and to problem solve
in advance regarding potential solutions and alternative
coping mechanisms. For example, a patient who characteristically becomes depressed following criticism from
her boss can plan in advance that she will take specific
steps to buffer herself against the effects of this criticism
in the future: increase assertive communication with
boss, evaluate negative automatic thoughts using thought
record, call a friend to discuss concerns, take a brisk walk,
utilize relaxation strategies, treat self to something special (e.g., a movie) to distract self from ruminative
thoughts. Such advance problem-solving may help to reduce the impact of stressors, lessen the likelihood of full-

blown episodes, and interrupt a rapid cycling course of

bipolar disorder.
Family stress also appears to affect relapse in patients
with bipolar disorder. Specifically, high levels of expressed
emotion (criticism, hostility, or emotional overinvolvement) on the part of family members have been shown to
increase vulnerability to episodes. For example, Miklowitz,
Goldstein, Nuechterlein, Snyder, and Mintz (1988) reported that bipolar patients who were discharged from
the hospital into family environments characterized by
high levels of expressed emotion were five times more
likely to relapse within 9 months of discharge than patients discharged into environments characterized by low
expressed emotion. Thus, interventions geared toward
improving communication patterns among family members may be incorporated into the context of cognitivebehavioral therapy for rapid cycling bipolar disorder. We
typically invite family members to attend several therapy
sessions, with the goal of providing information about bipolar disorder, problem-solving regarding current stressors,
and involving the family in the patient's treatment contract, which will be described below.

Cognitive Restructuring and Core Belief Work

Several studies have found that cognitive styles interact with intervening life events to prospectively predict
manic and depressive symptom changes in patients with bipolar spectrum disorders (Alloy, Reilly-Harrington, Fresco,
Whitehouse, & Zechmeister, 1999; Reilly-Harrington, Alloy, Fresco, & Whitehouse, 1999). These studies have provided support for the applicability of the cognitive vulnerability stress theories of unipolar depression (e.g., Beck's
T h e o r y - - A . T. Beck, 1967; Hopelessness T h e o r y - Abramson, Metalsky, & Alloy, 1989), in which maladaptive
cognitive styles act as risk factors for affective episodes in
combination with negative life events, to the bipolar spectrum. Therefore, one of the goals of cognitive-behavioral
therapy for rapid cycling bipolar disorder is to modify
maladaptive cognitive styles and dysfunctional attitudes
that provide risk for relapse. Standard cognitive restructuring techniques, such as thought records (J. S. Beck,
1995), are utilized to teach bipolar patients to respond
more adaptively to negative thoughts. Most importantly,
patients and therapists work together to identify recurrent themes and core beliefs, such as "I'm unlovable" or
"I'm incompetent," that are formed early in life, may be
triggered by negative events, and serve to prolong or
worsen episodes.
Rapid cycling patients and their therapists may find
themselves shifting gears on a weekly basis from responding to depressive thoughts to restructuring hyperpositive,
hypomanic thoughts. Similar techniques, such as thought
records, can be used to respond to elevated thoughts,
such as "I can afford it" or "Everybody finds me attractive."

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As described below, cognitive-behavioral interventions
for managing m o o d elevation are often geared at preventing the damage and embarrassment that can result
from manic behavior.

Management of Mood Elevation

Detection of the earliest warning signs of m a n i a / h y p o mania is critical in breaking the pattern of repeated episodes in rapid cycling patients. While it is often quite difficult to engage a severely manic patient in cognitive
restructuring, it is certainly possible to intervene with a patient whose m o o d is mildly elevated. Thus, it is vitally important for patients to be aware of their subtle, early symptoms indicative of elevated m o o d (e.g., feeling slightly
more verbose, awakening an h o u r earlier than usual,
thinking about making new plans, feeling slightly flirtatious, etc.). In a phase of mild m o o d elevation, patients
can take several precautionary steps to ensure that their
m o o d does not launch into mania. These steps include:
maintaining compliance with medication, maintaining
regular sleep/wake cycle, contacting psychiatrist for pharmacological assistance in the event that falling or staying
asleep is difficult, avoiding alcohol and drugs, reducing
stimulation, and avoiding highly stressful or confrontative
situations. In order to reduce the impulsive risk associated
with elevated mood, we r e c o m m e n d that patients leave
credit cards at home, resist engaging in conversations with
strangers, and avoid driving if speeding or "road rage"
have occurred during previous episodes. Newman et al.
(2001) outline several rules for bipolar patients that are
particularly useful in interrupting impulsive decisionmaking. These include a "Two Person Feedback" rule, in
which patients are instructed to check new plans or ideas
with two trusted friends before acting on them, and a "48
Hours Before Acting" rule, in which patients are instructed to wait 2 full days and get 2 full nights of sleep before making major decisions. Many of these strategies are
described in further detail in Newman et al. (2001) and
are particularly appealing to patients who have suffered
devastating consequences from previous manic episodes.
It is important to recognize that mania can be quite seductive and patients new to a bipolar diagnosis may have
greater difficulty accepting the premise that mania is
harmful. With patients such as this, it is vitally important
to avoid lecturing on the costs of mania. Rather, it is m u c h
more powerful to utilize Socratic questioning and to
guide patients in evaluating the advantages and disadvantages of m o o d episodes. We have also f o u n d it helpful for
patients to attend bipolar support group meetings and to
hear about the downsides of mania from other patients.

Management of Depression and Stdddality

Frequent, severe depression has been described as the
"hallmark" of rapid cycling and the primary u n m e t treat-

m e n t need for rapid cycling patients (Calabrese et al.,

2001). From a pharmacological perspective, patients with
rapid cycling bipolar disorder are considerably less responsive to standard m o o d stabilizers, and antidepressant use is discouraged due to the risk of inducing m o o d
elevation.
Furthermore, the rates of suicide in patients with bipolar disorder are astounding. Goodwin and Jamison
(1990) report that lifetime completed suicide rates for
patients with bipolar disorder are 19%, with 25% to 50%
of bipolar patients attempting suicide at least once. Brown,
Beck, Steer, and Grisham (2000) report that the diagnosis of bipolar disorder carries the highest risk of completed
suicide, with four times the risk of suicide as c o m p a r e d to
other psychiatric diagnoses. Little research has directly
c o m p a r e d the suicide rates of rapid cycling and nonrapid-cycling patients, with one study finding no significant difference in suicide attempts in rapid cycling versus
non-rapid-cycling patients (Wu & Dunner, 1993).
Clearly there is the n e e d for effective, adjunctive treatm e n t for depression and suicide prevention in bipolar
disorder, particularly in patients with rapid cycling bipolar disorder. Cognitive and behavioral interventions
described in detail by Newman et al. (2001) andJ. S. Beck
(1995) are r e c o m m e n d e d to treat depressive symptoms
and reduce suicidal risk. The treatment contract described below may also be used to reduce the risk of suicide by involving the patient's support network.

Treatment Contracting
O u r treatment of rapid cycling bipolar disorder involves the use of a written treatment contract in which
the patient, while euthymic, formulates a plan for detecting, c o p i n g with, a n d preventing future episodes of
mania and depression (Otto, Reilly-Harrington, Kogan,
& Winett, 2003; Reilly-Harrington, Kogan, Otto, & Sachs,
2002). First, the patient selects a support network to include in the treatment contract. The support network
may consist of treatment providers, trusted family members, friends, or even coworkers, with whom the patient
has regular contact. In the contract, the patient specifies
the early warning signs of m o o d episodes and instructs
their support network to take specific actions in the event
of noting m o o d symptoms. The following are some examples of directions that a patient might give their support
network:
Encourage me to contact my doctor if you notice that I am
becoming manic.
Remove my credit cards i f I am spending impulsively.
Keep in touch with me if I appear hopeless and suicidal

Support members are typically asked to attend several

therapy sessions in which the contract is reviewed and
questions are answered about bipolar disorder and its

CBT for Rapid Cycling

treatment. Finally, the contract is signed by all parties and
the support members become agents of the patient's
plan, not people imposing restrictions on the patient.
The contract ideally- enables patients to maintain control
over their illness during episodes in which their judgm e n t or functioning might be compromised. The likelihood of swift attention to early warning signs of episodes is also likely to increase when open communication
exists a m o n g patient, treatment providers, and support
network.
Treatment of Comorbidity
High rates of comorbid substance abuse and anxiety
disorders have been reported in patients with bipolar disorder (Perugi, Toni, & Akiskal, 1999). McElroy et al.
(2001) reported that 42% of their bipolar sample met criteria for a comorbid anxiety disorder and 42% met criteria for a comorbid substance use disorder. The presence
of comorbid anxiety has been associated with poorer outcomes and longer times to remission in patients with bipolar disorder (Feske et al., 2000). Moreover, comorbid
substance abuse and dependence has been shown to adversely affect medication compliance in patients with
rapid cycling bipolar disorder (Calabrese et al., 2001).
Therefore, the treatment of comorbidity is an important
area of focus in our treatment of rapid cycling. In our
small, ongoing, open pilot study of rapid cycling bipolar
disorder, we have found particularly high rates of comorbid anxiety disorders, with 7 out of 9 patients currently meeting criteria for a comorbid anxiety disorder,
including panic disorder, generalized anxiety disorder, and
obsessive-compulsive disorder.
Structure of Treatment
The treatment utilized in our ongoing open pilot
study of rapid cycling bipolar disorder is based on Newman et al. (2001) and Otto et al. (1999) and consists of
four flexible core modules. The first module focuses on
medication compliance and psychoeducation about rapid
cycling bipolar disorder. In this module, patients are
taught to monitor and respond to daily m o o d fluctuations, manage medication side effects, and maintain adequate sleep hygiene. The second module targets crisismanagement skills and coping strategies for dealing with
depressive and manic m o o d shifts, including suicidal and
high-risk manic behaviors. In this module, patients construct the treatment contract, in which they specify a plan
for detecting, coping with, and preventing future episodes. The third module targets specific cognitive restructuring skills for identifying and responding to depressive and manic thoughts and beliefs. Finally, a fourth
module focuses on cognitive-behavioral skills for managing comorbid disorders, including anxiety disorders and
substance abuse.

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In summary, therapists working with rapid cycling patients must be particularly flexible, creative, and adept at
detecting and responding to rapidly shifting moods. Thus,
these modules represent core areas of focus, but may be
adapted flexibly for each patient.
Case Example

Jason is a 42-year-old disabled professional who is separated from his wife and has no children. Upon intake
evaluation, he was diagnosed with bipolar I disorder,
most recent episode depressed, rapid cycling type; alcohol dependence in sustained partial remission; and opioid dependence in sustained full remission. Further elucidation of the diagnoses revealed that he had had six
m o o d episodes in the previous 12 months consisting of
two major depressive episodes and four hypomanic episodes. Jason had not had a full-blown manic episode in
over 15 years, but described previous episodes in which
he had destroyed property in fits of irritable mania. His
recent bouts of depression included hypersomnia, decreased interest, feelings of worthlessness, low energy,
decreased concentration, and passive suicidal ideation
with no plan or intent. Behaviorally, Jason stated that his
depressive episodes included spending "long periods of
time in bed, feeling miserable about myself and about
how little I am achieving." His hypomanic symptoms included increased irritability, increased distractibility, mild
racing thoughts, increased activity, increased spending,
and decreased need for sleep.Jason stated that his hypomanic episodes were rarely pleasurable as he engaged in
more arguments with his friends and family and felt
wired but could accomplish little.
Jason also had comorbid Axis I diagnoses of alcohol
and opioid dependence. Both were in various stages of
remission upon intake. He had a 13-year history of drug
and alcohol dependence with increasingly greater lengths
of sobriety after each relapse. He had not used alcohol
for 9 months and had not used opioids in 3 years. Largely,
his substance use coincided with his m o o d episodes. He
often would use opioids to control his sleep-wake cycle,
and be would use alcohol to modulate his feelings of low
self-esteem and poor self-image. His last relapse consisted
of a 2-week binge on alcohol during a major depressive
episode. He subsequently checked himself into a 28-day
rehab and then moved to a sober halfway house. He moved
to his own apartment about 3 months prior to our intake
evaluation.
Jason also had several psychosocial stressors, or "loose
ends," as he often described them. The first involved his
marriage of the past 5 years. This was Jason's third marriage, and he and his wife had been separated for the past
3 years after a relapse on opioids. They had a contentious
relationship with long periods of no communication

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p u n c t u a t e d by high levels of negative emotions. Overall,
J a s o n stated this his wife " b l a m e d h i m for everything that
went wrong" a n d he s p e n t his time "acting as if she is
right a n d d o i n g what [he] can to get h e r forgiveness."
J a s o n also h a d a s e c o n d significant stressor. H e h a d b e e n
d e e m e d disabled for the past 3 years, yet he wanted to return to his previous career. H e h a d lost the ability to perform his j o b d u e to his use o f substances on his j o b a n d
the suspension o f his license. As he stated, "I j u s t d o n ' t
see how I can be anyone unless I get my j o b a n d my wife
back j u s t like it was before."
At the start o f treatment, Jason was recovering from a
m a j o r depressive episode a n d was b e g i n n i n g to cycle into
a h y p o m a n i c episode. H e n o t e d that his sleep was becoming increasingly erratic, going from h y p e r s o m n i a to a decreased n e e d for sleep followed by a n o t h e r p e r i o d o f hypersomnia. D u r i n g the p e r i o d s of d e c r e a s e d sleep, Jason
would notice that he was irritable a n d would b e c o m e
m o r e easily distracted.
F r o m the onset o f treatment, his symptoms were compelling a n d n e e d e d i m m e d i a t e attention. After the intake
evaluation, it was a p p a r e n t that the first session n e e d e d to
include a psychoeducational a p p r o a c h regarding his sleep
patterns a n d an i m m e d i a t e discussion a b o u t the role o f
sleep loss a n d h y p o m a n i c symptoms. T h e first step involved discussing his sleep p r o b l e m s with his psychopharmacologist. It was a p p a r e n t that o n e o f his sleep aids, a
tricyclic antidepressant, may have b e e n p u t t i n g h i m to
sleep in the short-run, b u t may have b e e n exacerbating
his m o o d cycling in the l o n g run, c o n t r i b u t i n g to a decreased n e e d for sleep the following night. H e was immediately switched to a sleep aid that was less likely to exace r b a t e his m o o d cycling. D u r i n g the first session, we
discussed p r o p e r sleep hygiene a n d i m m e d i a t e l y employed several behavioral changes to regulate his sleep
cycle. These strategies i n c l u d e d avoiding daytime napping, waking a n d sleeping at r e g u l a r times, decreasing
the a m o u n t of stimuli j u s t before b e d t i m e (e.g., avoiding
r e a d i n g h o r r o r novels in b e d ) , avoiding caffeine after
12:00 n o o n (ideally, r a p i d cycling patients s h o u l d avoid
caffeine use entirely), a n d buying a s e c o n d alarm to h e l p
h i m arise in the m o r n i n g . T h o u g h it is difficult to determ i n e which o f the p h a r m a c o l o g i c a l o r behavioral interventions was the most i m p o r t a n t , it was a p p a r e n t that by
the s e c o n d session Jason's sleep was m o r e r e g u l a r and,
subsequently, his m o o d h a d stabilized.
Sessions 2 to 6 c o n t i n u e d with a psychoeducational
a n d behavioral focus. We b e g a n with the use o f m o o d
charting, which involved having Jason c h a r t his highest
a n d lowest m o o d each day. H e was also asked to m a r k
how m a n y hours he h a d slept o n a nightly basis a n d what
m e d i c a t i o n s he h a d taken for his symptoms. Using a daily
m o o d chart allowed Jason to take a step back from his
m o o d symptoms in o r d e r to identify patterns o f behavior,

to begin a g e n e r a l discussion of the c o n n e c t i o n between

events in his life a n d his feelings, a n d to feel m o r e in control o f his illness.
T h e use o f m o o d c h a r t i n g also segued into m o r e specific discussions a r o u n d his b i p o l a r disorder. It is important to note that the use o f p s y c h o e d u c a t i o n was g e a r e d
toward Jason's level o f u n d e r s t a n d i n g a r o u n d his illness.
H e was a highly intelligent p e r s o n who was well r e a d on
his psychiatric diagnoses. Simply going over the symptoms of b i p o l a r d i s o r d e r would have likely belittled his
intelligence a n d d a m a g e d the t h e r a p e u t i c alliance. Instead, the focus was on his knowledge of his m o o d symptoms a n d any gaps in u n d e r s t a n d i n g that he may have
had. In fact, given his intelligence, he was given j o u r n a l
articles describing behavioral a n d cognitive a p p r o a c h e s
to his m o o d symptoms. We h a d m a n y active discussions
a r o u n d these articles that s e e m e d to m a k e him feel m o r e
in charge of his t r e a t m e n t a n d m o r e on the "cutting
edge" o f research. It s e e m e d m o r e i m p o r t a n t to make
Jason feel e n g a g e d in his t r e a t m e n t than to simply lecture
him on the signs a n d symptoms o f his disorder.
In a d d i t i o n to psychoeducation, activity scheduling
b e c a m e a key behavioral intervention d u r i n g the first six
sessions. Jason often oscillated between trying to d o too
m u c h d u r i n g his h y p o m a n i a s a n d then "crashing a n d
burning." D u r i n g depressive episodes, he would ruminate a b o u t how he was a failure because he was u n a b l e to
"do anything." T h e goal was to find a m a n a g e a b l e p a t t e r n
o f activities. However, it was clear that activity scheduling
was stirring u p automatic thoughts o f b e i n g a "failure"
a n d that "everything was his fault." It was a p p a r e n t that
these i n t e r f e r i n g thoughts n e e d e d to be a d d r e s s e d m o r e
thoroughly. Otherwise, for all its g o o d intentions, therapy would simply be a r e p e t i t i o n o f his l i f e - - s c h e d u l i n g
too m a n y activities to avoid feelings o f failure a n d incomp e t e n c e a n d then "crashing a n d b u r n i n g " a n d confirming his beliefs a b o u t himself by d o i n g no activities. T h e
pace o f his activity scheduling also s e e m e d to mimic his
r a p i d cycling m o o d symptoms; too many activities o n e
week a n d t h e n too little o r n o n e the following week. We
d e c i d e d to use the "one" rule. H e a g r e e d to do o n e thing
well over the next week instead o f focusing on all his activities at once. In this case,Jason a g r e e d to get back to a
r e g u l a r exercise r o u t i n e b u t to d o only o n e exercise, running. We also b e g a n to challenge his automatic thoughts.
However, it was a p p a r e n t that Jason was e m p l o y i n g the
same zeal in o u r discussions o f cognitive strategies as he
h a d with his activity s c h e d u l i n g - - f o r example, n e e d i n g
to c o m p l e t e the t h o u g h t r e c o r d perfectly o r it (or he)
would be worthless. Therefore, we b e g a n modifying these
perfectionistic beliefs r e g a r d i n g h o m e w o r k assignments.
F r o m Session 6 until the e n d of o u r 12 m o n t h s of
treatment, we e x a m i n e d Jason's m o o d symptoms from
b o t h behavioral a n d cognitive perspectives. It b e c a m e

CBT for Rapid Cycling

clear that his automatic thoughts were driven a r o u n d a
strong desire to c o r r e c t his life's p r o b l e m s d u e to his bip o l a r d i s o r d e r a n d his substance d e p e n d e n c e . In b o t h
cases, the p a t i e n t d e s c r i b e d horrific j o u r n e y s on the
"roller coaster" o f his symptoms. H e d e s c r i b e d periods o f
e x t r e m e lows sometimes i m m e d i a t e l y followed by irritable highs, a n d he also discussed l o n g stretches o f substance use a n d t h e n p e r i o d s o f sobriety. In all instances, it
was a persistent battle o f e x t r e m e illness a n d disability followed by a r e t u r n to a high level o f functioning. Each subs e q u e n t d o w n t u r n r e s u r r e c t e d his beliefs that h e was a
failure a n d a loser because h e c o u l d n o t k e e p his m o o d s
stable a n d he could n o t m a i n t a i n sobriety.
T h o u g h it was obvious that his feelings o f failure a n d
i n c o m p e t e n c e were there l o n g b e f o r e his first m o o d episode, we d e c i d e d to r e m a i n focused o n the here-and-now,
a n d we b e g a n to challenge his beliefs a b o u t his illness
a n d his sobriety. We e x a m i n e d what researchers know
a b o u t the course of his disorders, b u t we also b e g a n to
challenge his beliefs a b o u t himself a n d what he was cap a b l e o f controlling. We discussed the d i l e m m a that was
i n h e r e n t with b o t h disorders (i.e., your m o o d episodes or
urges to use may be c o m p l e t e l y o u t o f y o u r control, b u t it
is your obligation to d o anything in y o u r p o w e r to maintain as m u c h c o n t r o l as possible). We reviewed his past
experiences, at times with painful e m o t i o n s tied to his
n u m e r o u s low points. We also e x a m i n e d a n d c h a l l e n g e d
his automatic thoughts a r o u n d daily activities a n d curr e n t experiences. T h o u g h t records proved useful for exa m i n i n g his daily life, a n d these usually led to d e e p e r discussions a b o u t his past experiences a n d his beliefs.
D e e p e r discussions often l e d to a n o t h e r e r r o n e o u s belief a b o u t his illness. H e believed that if h e c o u l d mainrain his sobriety a n d stay o u t o f a m o o d episode, t h e n he
would be "cured." It was a p p a r e n t that J a s o n h a d a difficult time accepting his diagnoses o f b i p o l a r d i s o r d e r a n d
substance d e p e n d e n c e . Given the course o f his illnesses,
he was able, m a n y times, to r e t u r n to a stable, euthymic
p e r i o d o f high functioning. His strong desire to r e t u r n to
his s e p a r a t e d wife a n d his desire to r e t u r n to his c a r e e r
were indicative of this wish to make it all b e t t e r a n d be
"cured." Instead o f going after this e r r o n e o u s wish to be
c u r e d o f his b i p o l a r d i s o r d e r t h r o u g h a rational discourse
o f the chronicity o f the illness, we d e c i d e d to dig d e e p e r
a n d b e g a n i n t r o d u c i n g the n o t i o n o f core beliefs. It was
a p p a r e n t from his discussion o f his early c h i l d h o o d that
he was raised in a r a t h e r harsh, hypercritical environment. H e d e s c r i b e d difficult experiences, for example,
showing his parents a nearly straight-A r e p o r t card only
to be q u e s t i o n e d a b o u t the "one A-minus." Currently, his
parents barely spoke to h i m b u t disclosed that when he
r e t u r n e d to a " n o r m a l life" o f a c a r e e r a n d a wife, they
would come back into his life. Again, we b e g a n to m a k e
often painful c o n n e c t i o n s of this style o f p a r e n t i n g a n d

how it may have c o n t r i b u t e d to a core belief o f feeling unlovable a n d how those tentacles r e a c h e d to his feelings o f
failure, his b i p o l a r disorder, a n d his c u r r e n t functioning.
His b i p o l a r d i s o r d e r a n d his substance d e p e n d e n c e fit
too well into this belief system a n d often f u e l e d depressive episodes a n d urges to use. (During o n e session,Jason
c o n n e c t e d that his nightly urges to use were r e l a t e d to his
ruminative thinking a r o u n d his daily activities a n d his
self-deprecating list o f everything he d i d n o t finish that
day.)
Cognitive behavioral t h e r a p y with J a s o n was p h a s e d
o u t after 12 m o n t h s o f weekly visits. His desire n o t to have
a c h r o n i c illness was normalized, a n d t h o u g h this wish
never faded, we discussed how he c o u l d m a n a g e this
y e a r n i n g to "be normal." We a g r e e d to s u s p e n d treatm e n t when it b e c a m e a p p a r e n t that his symptoms h a d
stabilized a n d h e was n o l o n g e r " r a p i d cycling" (i.e.,
h a d d r o p p e d to two m o o d episodes in the previous 12
m o n t h s ) . We a g r e e d to s u s p e n d t r e a t m e n t to solidify his
gains a n d to have a sense o f success in treatment. H e d i d
believe u p o n t e r m i n a t i o n that he still h a d b i p o l a r disorder, b u t felt p r o u d that he was controlling what he
could of his m o o d symptoms a n d that he was "taking away
the label o f r a p i d cycling." H e also asked if he c o u l d return to t r e a t m e n t when he d e c i d e d to r e t u r n to work o r if
his m o o d symptoms b e c a m e m o r e severe. H e p r e d i c t e d ,
p r o b a b l y accurately, that his core beliefs "would r o a r
loudly" when he d e c i d e d to r e e n t e r the workforce.
O f note, Jason d i d have o n e h y p o m a n i c episode a n d
one brief, m i l d depressive e p i s o d e d u r i n g o u r 12 m o n t h s
o f treatment. In b o t h instances, we utilized a behavioral,
"crisis m o d e " o f treatment, focusing on safety, p r o b l e m
solving, a n d risk m a n a g e m e n t . After these two m o o d episodes h a d e n d e d , we t h e n used these e x p e r i e n c e s to furt h e r o u r discussion o f the interface o f his cognitions, his
feelings, a n d his m o o d episodes. Also o f n o t e is o u r interm i t t e n t discussion o f his substance use a n d his attend a n c e at AA s u p p o r t g r o u p meetings. T h o u g h we d i d n o t
c o n d u c t o u t r i g h t substance abuse counseling, to i g n o r e
that potentially devastating c o m o r b i d c o n d i t i o n would
have b e e n fatal to the t r e a t m e n t outcome. We focused on
his urges to use a n d continually r e t u r n e d to behavioral
interventions a n d cognitive restructuring. We also h a d
several discussions on how to h a n d l e his relationship with
his wife a n d his parents without f u r t h e r e x a c e r b a t i n g the
situation. We u s e d crisis m a n a g e m e n t techniques such as
distraction, behavioral rehearsal, a n d self-soothing skills.
T h e key p o i n t was to m a k e the situations less stressful if
they could n o t be avoided.
Given the n a t u r e o f r a p i d cycling b i p o l a r disorder, it
w o u l d b e difficult to review every i n t e r v e n t i o n that was
used with Jason. However, the key p o i n t is that a therapist
needs to be flexible, creative, a n d e m p a t h e t i c to g u i d e
their patients to greater c o n t r o l o f their m o o d symptoms.

73

74

Reilly-Harrington & K n a u z

A vast a r s e n a l o f b e h a v i o r a l a n d c o g n i t i v e s t r a t e g i e s is
n e e d e d to h e l p t a m e t h e m o o d e p i s o d e s .

Conclusions
While nearly a quarter of bipolar patients may meet
c r i t e r i a f o r r a p i d cycling, this c h a l l e n g i n g p o p u l a t i o n h a s
b e e n e x c l u d e d f r o m p r e v i o u s trials o f c o g n i t i v e - b e h a v i o r a l t h e r a p y f o r b i p o l a r d i s o r d e r . H o w e v e r , C B T offers
n u m e r o u s s t r a t e g i e s to i m p r o v e f u n c t i o n i n g a n d r e d u c e
relapse in these patients. We are in the process of cond u c t i n g a small, o p e n trial o f C B T f o r r a p i d cyclers a n d
p l a n to c o n d u c t a l a r g e r r a n d o m i z e d c o n t r o l l e d trial i n
t h e n e a r f u t u r e . W e a r e h o p e f u l t h a t this article will g e n erate a greater clinical and research interest in treating
p a t i e n t s w i t h a r a p i d cycling c o u r s e o f b i p o l a r d i s o r d e r .

References
Abramson, L. Y, Metalsky, G. I., Alloy, L. B. (1989). Hopelessness
depression. A theory-based subtype of depression. Psychological
Review, 96, 358-372.
Alloy, L. B., Reilly-Harrington, N. A., Fresco, D. M., Whitehouse, W. G.,
& Zechmeister, J. S. (1999). Cognitive styles and life events in subsyndromal unipolar and bipolar disorders: Stability and prospective prediction of depressive and hy-pomanic mood swings.Journal
of Cognitive Psychotherapy: An International Quarterly, 13, 21-40.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental discrtvlers (4th ed.). Washington, DC: Author.
Ashman, S. B., Monk, T. H., Kupfer, D.J., Clark, C. H., Myers, E S.,
Frank, E., & Leibenluft, E. (1999). Relationship between social
rhythms and mood in patients with rapid cycling bipolar disorder.
Psychiatry Research, 86, 1-8.
Basco, M. R., & Rush, A.J. (1996). Cognitive-behavioral therapy for bipolar
disorder.. New York: The Guilford Press.
Bauer, M. S., Calabrese, J., Dunner, D. L., Post, R., Whybrow, E C.,
Gyulai, L., Tay, L. K., Younkin, S. R., Bynum, D., Lavori, E, & Price,
R. A. (1994). Multisite data reanalysis of the validity of rapid
cycling as a course modifier for bipolar disorder in DSM-FE. American Journal of Psychiatry, 151, 506-515.
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical
aspects. NewYork: Harper & Row.
Beck, J. s. (1995). Cognitive therapy: Basics and beyond. New York: The
Guilford Press.
Brown, G. K., Beck, A. T., Steei, R. A., & Grisham,J. 1L (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective
study. Journal of Consulting and Clinical Psychology, 68, 371-377.
Calabrese, J. R., Rapport, D. J., Kimmel, S. E., & Woyshville, M.J.
(1993). Rapid-cycling bipolar disorder and its treatment with valproate. Canadian Journal of Psychiatry, 38, 45-51.
Calabrese,J. R., Shelton, M. D., Bowden, C. L., Rapport, D.J., Suppes,
T., Shirley, E. R., Kimmel, S. E., & Caban, S. J. (2001). Bipolar
rapid cycling: Focus on depression as its hallmark.Journal of Clinical Psychiatry, 62, 34-41.
Cochran, S. (1984). Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders.Journal of Consulting
and Clinical Psychology, 52, 873-878.
Deckersbach, T., Reilly-Harrington, N., Clark, L., Goodwin, L., Savage,
C. R., Dougherty, D. D., Rauch, S., & Sachs, G. (2002). Characteristics and functional anatomy of episodic m e m o ~ impairment in
bipolar disorder. Biological Psychiatry, 51, 88S.
Deckersbach, T., Reilly-Harrington, N., & Sachs, G. (2001). Episodic
memory dysfunction in bipolar disorder. Bipolar Disorders, 3(Suppl.
1), 33.
Detre, T., Himmelhoch,J., Swartzburg, M., Anderson, C. M, Byck, R.,

& Kupfer, D.J. (1972). Hypersomnia and manic-depressive disease. American Journal of Psychiatry, 128, 1303-1305.
Dunner, D. L., & Fieve, R. R. (1974). Clinical factors in lithium carbonate prophylaxis failure. Archives of General Psychiatry, 30, 229-233.
Ehlers, C. L., Frank, E., & Kupfer, D.J. (1988). Social zeitgebers and
biological rhythms. Archives of General Psychiatry, 45, 948-952.
Ehlers, C. L., Kupfer, D.J., Frank, E., & Monk, T. H. (1993). Biological
rhythms and depression: The role of zeitgebers and zeitstorers.
Depression, 1, 285-293.
Fava, G. A., Bartolucci, G., Rafanelli, C., & Mangelli, L. (2001). Cognitive-behavioral management of patients with bipolar disorder who
relapsed while on lithium prophylaxis. Journal of Clinical Psychiatry, 62, 556-559.
Feske, U., Frank, E., Mallinger, A. G., Houck, E R., Fagiolini, A., Shear,
M. K., Grochocinski, V.J., & Kupfer, D.J. (2000). Anxiety as a correlate of response to the acute treatment of bipolar I disorder.
American Journal of Psychiatry, 157, 956-962.
Frank, E., Swartz, H. A., Mallinger, A. G., Thase, M. E., Weaver, E. V., &
Kupfer, D.J. (1999). Adjunctive psychotherapy for bipolar disorder: Effects of changing treatment modali~ Journal of Abnormal
Psychology, 108, 579-587.
Gitlin, M.J., Swendsen,J., Heller, T. L., & Hammen, C. (1995). Relapse
and impairment in bipolar disorder. American Journal of Psychiatry,
152, 1635-1640.
Goodwin, E tC, & Jamison, K. R. (1990). Manic-depressive iUness. New
York: Oxford University Press.
Healy, D., & Williams, J. M. G. (1988). Dysrhythmia, dysphoria, and
depression: The interaction between learned helplessness and circadian dysrhythmia in the pathogenesis of depression. Psychological Bulletin, 103, 163-178.
Hirshfeld, D. R., Gould, R. A., Reilly-Harrington, N. A., Morabito, C.,
Guille, C., Fredman, S.J., & Sachs, G. (1998, November). Cognitivebehavioral group therapy for bipolar disorder: A controlled trial Paper
presented at the 32nd annual meeting of the Association for
Advancement of Behavior Therapy, Washington, DC.
Johnson, S. L., & Roberts, J. E. (1995). Life events and bipolar disorder: Implications from biological theories. Psychological Bulletin,
117, 434-449.
Keck, E E., McElroy, S. L., Strakowski, S. M., Stanton, S. R, Kizel; D. L.,
Balistreri, T. M., Bennett, J. A., Tugrul, K. C., & West, S. A. (1996).
Factors associated with pharmacologic noncompliance in patients
with mania.Journal of Clinical Psychiatry, 5 Z 292-297.
Keck, R E., McElroy, S. L., Strakowski, S. M., West, S. A., Sax, K. W.,
Hawkins, J. M., Bourne, M. L., & Haggard, E (1998). 12-month
outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry,
155, 646-652.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes M.,
Eshleman S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime
and 12-month prevalence of DSM-III-R psychiatric disorders in
the United States: Results from the National Comorbidity Survey.
Archives of General Psychiatry, 51, 8-19.
Kilzieh, N., & Akiskal, H. S. (1999). Rapid-cycling bipolar disorder: An
overview of research and clinical experience. ThePsvchiatric Clinics
of North America, 22, 585-607.
Kraepelin, E. (1921). Manic-depressive insanity and paranoia (R. M.
Barclay, trans.). In R. M. Barclay (Ed.), Textbook of psychiatry. Edinburgh, Scotland: E & S Livingstone.
Kramlingel; K. G., & Post, R. M. (1996). Uhra-rapid and ultradian
cycling in bipolar affective illness. British Journal of Psychiatry, 168,
314-323.
Lain, D. H., Bright, J.,Jones, S., Hayward, R, Schuck, N., Chisholm, D.,
& Sham, E (2000). Cognitive therapy for bipolar disorder: A pilot
study of relapse prevention. Cognitive Therapy and Research, 24,
503-520.
Leibenluft, E., Albert, E S., Rosenthal, N. E., & Wehr, T. A. (1996).
Relationship between sleep and mood in patients with rapidcycling bipolar disorder. Psychiatry Research, 63, 161-168.
Maj, M., Magliano, L., Pirozzi, R., Marasco, C., & Guarneri, M. (1994).
Validity of rapid cycling as a course specifier for bipolar disorder.
American Journal of Psychiatry, 151, 1015-1019.
Malkoff-Schwartz, S. E, Frank, E., Anderson, B., Sherrill, J. T., Siegel,

CBT for Rapid C y c l i n g

L., Patterson, D., & Kupfer, D.J. (1998). Stressful life events and
social rhythm disruption in the onset of manic and depressive
bipolar episodes: A preliminary investigation. Archives of General
Psychiatry, 55, 702-707.
McElroy, S. L., Atshuler, L. L., Suppes, T., Keck, R E., Frye, M.A., Denicoff, I~ D., Nolen, W. A., Kupka, R. W., Leverich, G. S., Rochussen,
J. R., Rush, A.J., & Post, R. M. (2001). Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients
with bipolar disorder. American Journal of Psychiatry, 158, 420-426.
Miklowitz, D. R., Goldstein, M.J., NuechteHein, K. H., Snyder, K. S., &
Mintz, J. (1988). Family factors and the course of bipolar affective
disorder. Archives of General Psychiatry, 45, 225-231.
Newman, C. E, Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., &
Gyulal, L. (2001). Bipolar disorder: A cognitive therapy approach.
Washington, DC: American Psychological Association.
Okuma, T. (1993). Effects of carbamazepine mad lithium on affective
disorders. Neurop~ehobiology, 27, 138-145.
Otto, M. W., Reilly-Harrington, N., Kogan, J. N., Henin, A., & Knauz,
R. O. (1999). Cognitive-behaviortherapyfor bipolar discmter: Treatment
manual. Unpublished manual, Massachusetts General Hospital,
Boston.
Otto, M. W., Reilly-Harrington, N. A., Kogan,J. N., & Winett, C. (2003).
Treatment contracting in cognitive-behavior therapy. Cognitive
and Behavioral Practice, 10, 199- 203.
Otto, M. W., Reilly-Harrington, N., & Sachs, G. (2003). Psychoeducational and cognitive-behavioral strategies in the management of
bipolar disorder.Journal of Affective Disordo~, 73, 171-181.
Palmer, A. G., Williams, H., & Adams, M. (1995). CBT in a group format for bipolar affective disorder. Behavioral and Cognitive Psychetherapy, 23, 153-168.
Patelis-Siotis, I., Young, L. T., Robb, J. C., Marriott. M., Bieling, R J.,
Cox, L. C., &Joffe, R. T. (2001). Group cognitive-behavioral therapy for bipolar disorder: A feasibility and effectiveness study. Journal of Affective Disorde~x, 65, 145-153.
Perugi, G., Toni, C., & Akiskal, H. S. (1999). Anxious-bipolar comorbidity: Diagnostic and treatment challenges. Psychiatric Clinics of
North America, 22, 565-583.
Reilly-Harrington, N. A., Allo~ L. B., Fresco, D. M., & Whitehouse,
W.G. (1999). Cognitive styles and life events interact to predict
bipolar and unipolar symptomatology. Journal of AbnormalPsychology, 108, 567-578.
Reilly-Harrington, N. A., & Knauz, R. O. (2000, November). Specialized

ness. Paper presented at the annual meeting of the Association for

Advancement of Behavior Therapy, New Orleans, Louisiana.
Reilly-Harrington, N. A., Kogan,J. N., Otto, M. W., & Sachs, G. S. (2002).
Treatment contracting in bipolar disonCen.Manuscript under review.
Sachs, G. S. (1996). Mood chart. Unpublished assessment measure, The
Harvard Bipolar Research Program, Massachusetts General Hospital, Boston.
Satterfield, J. M. (1999). Adjunctive cognitive-behavioral therapy for
rapid-cycling bipolar disorder: An empirical case study. Psychiatry,
62, 357-369.
Scott, J , Garland, A., & Moorhead, S. (2001). A pilot study of cognitive
therapy in bipolar disorders. PsychologicalMedicine, 31, 459-467.
Smith, A. L., & Weissman, M. M. (1992). Epidemiology. In E. S. Paykel
(Ed.), Handbook ofaffective disorders.NewYork: Churchill Livingstone.
Tondo, L., & Baldessarini, R.J. (1998). Rapid cycling in women and
men with bipolar manic depressive disorders. A~nericanJournal of
Psychiatry, 155, 1434-1436.
Tondo, L., Baldessarini, R.J., Hennen,J., & Floris, G. (1998). Lithium
maintenance treatment of depression and mania in bipolar I and
bipolar II disorder. American Journal of Psychiatry, 155, 638-645.
Wehr, T. A., Sack, D. A., & Rosenthal, N. A. (1987). Sleep reduction as
a final common pathway in the genesis of mania. American Journal
of Psychiatry, 144, 201-204.
Wehr, T. A., Turner, E. H., Shimada, J. M., Lowe, C. H., Barker, C., &
Leibenluft, E. (1998). Treatment of a rapidly cycling bipolar
patient by using extended bed rest and darkness to stabilize the
timing and duration of sleep. BiologicalPsychiatry, 43, 822-828.
Wirz-Justice, A., Quinto, C., Cajochen, C., Werth, E., & Hock, C. (1999).
A rapid~rycling bipolar patient treated with long nights, bedrest,
and light. Biological Psychiatry, 45, 1075-1077.
Wu, L. H., & Dunner, D. L. (1993). Suicide attempts in rapid cycling
bipolar disorder patients.Journal of Affective Disorders, 29, 57-61.
Zaretsky, A. E., Segal, Z. V., & Gemar, M. (1999). Cognitive therapy for
bipolar depression: A pilot study. CanadianJournalofPsychiatry, 44,
491-494.

strategiesfor the cognitive-behavioral treatment of rapid cycling bipolar ill-

This article was accepted under the editorship of Atone Marie Albano.

Address correspondence to Noreen A. Reilly-Harrington, Ph.D.,

Harvard Bipolar Research Program/Massachusetts General Hospital,
50 Staniford Street, Suite 580, Boston, MA 02114; e-mail: nhreilly@
partners.org.

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