Imagery-Focused Cognitive Therapy for Bipolar Disorder

Background: Mood instability, especially mania symptoms in bipolar disorder have proven difficult to curb using pharmacological and psychological treatments. Pharmacological approaches to bipolar disorder have predominated for many years, with all international guidelines recommending that bipolar disorder be managed primarily by medication, such as Lithium (APA, 2002, Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596, 2013; NICE, 2018). However, frequent relapse remains common (Perlis et al., American Journal of Psychiatry 163:217-224, 2006) and the side effect burden of such medications can be high, leading to difficulties with compliance. Psychological treatments may offer particular scope for benefit as they bypass challenges associated with pharmacotherapy. Unfortunately, the evidence-base for the effectiveness of psychological interventions for bipolar disorder remains mixed (Jauhar et al., 2016). Given the limitations of current pharmacological and psychological treatment options for bipolar disorder, it is clear that innovation is urgently needed. A new imagery-focused cognitive therapy (ImCT) has been developed for patients with bipolar disorder and is showing preliminary promising effects on mood instability, anxiety, depression, and mania (van den Berg et al., Journal of Affective Disorders 320:691–700, 2022).

Methodology: We describe imagery-focused cognitive therapy and illustrate the imagery techniques used with a patient with bipolar disorder experiencing mania symptoms. After a micro-formulation, images associated with mania symptoms and anxiety were targeted with metacognitive and imagery rescripting and chair work techniques. Daily measures of mania, depression, and anxiety and weekly questionnaires of mania, depression, anxiety, and mental imagery were collected during 4 weeks baseline, 12 weeks intervention, and 16-weeks follow-up period.

Results: Imagery-focussed cognitive therapy (ImCT) is a helpful and promising new intervention for patients with bipolar disorder, reducing mood instability and levels of depression but might also be a feasible addition to regular treatment for mania. However, using scaffolding techniques and involving both relatives and the multi-disciplinary team remain important. Larger studies need to further explore if this intervention is helpful for patients with bipolar disorder who are (hypo)manic.