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In the last section, we presented characteristics of clients who
exhibit the symptoms of a psychosis. These are delusional thoughts; hallucinations;
I have often found, probably like you, that predicting an episode before it
spirals out of control can greatly reduce a bipolar client’s risk of self-harm
and psychotic breakdowns. I feel that in order for a serious manic or depressive
state to be prevented, the client must take an active role in monitoring their behavior. Do you agree?
In this section, we will present
techniques to predict manic and depressive states and to aid clients through these cycles: Listing Symptoms According to Category; Preventative
Maintenance Plan; and Three-Part Breathing Exercise
3 Techniques for Predicting Manic and Depressive States
♦ 1. Technique: Listing Symptoms According to 8 Categories
The first technique I use is "Listing Symptoms According to Category". Chad
was a manic-depressive client of mine whose depressive states became so
overwhelming, he could barely function. To help Chad identify his
more easily, I broke them down into eight categories:
1. Expressions: common expressions that client says prior to or during a
depressive or manic state. Chad wrote, "I’m bored", "What’s
the point?", "I’m
sorry I’m such a burden", and "Things are not right in my life."
2. Thoughts: common thoughts client experiences prior to or during a
depressive or manic state. Chad wrote, "I have no friends", "Is
there is?", "Things will never get better—never", and "Everything
3. Actions: common actions client does prior to or during a depressive or
manic state. Chad wrote, "Listen to old, sad music", "Overanalyze
everything", and "Focus on the past".
4. Physical Signs: common traits client notices prior to or during a
depressive or manic state. Chad wrote, "Wring hands", "Have
sleeping", "Don’t feel animated", and "crying or
5. Sleep: common sleeping patterns client notices prior to or during a
depressive or manic state. Chad wrote, "Sleep through the afternoon",
and "Wake up often during the night".
6. Relations with Others: common behavior towards other people prior to or
during a depressive or manic state. Chad wrote, "Very irritated and snappy," "Have
trouble thinking of anyone but myself",
and "Can’t call
7. Work or School: common thoughts or feelings client exhibits prior to or
during a depressive or manic state. Chad wrote, "Work is boring", "I
seem to do a good job at work," and "Feel unappreciated for work
8. Eating Habits, Alcohol, Drugs, and Medications: common habits and behavior
regarding eating, alcohol, drugs and medication prior to or during a
depressive or manic state. Chad wrote, "Stop taking medications or
sporadically", "Stop eating and notice significant weight loss",
caffeine pills to get some energy."
By simplifying symptoms into these categories, Chad could separate his bipolar
behavior from that of his normal behavior.
♦ 2. Technique: Preventative Maintenance Plan
Now that Chad has identified his depressive symptoms, the second technique I
asked him to complete is a "Preventative Maintenance Plan". I
asked Chad to
brainstorm ideas that he or his wife Sophia could do to help Chad’s
depression from becoming debilitating. Together with his wife, Chad came
with several activities that counteracted his symptoms and kept him from complete depression:
1. "Sophia and I go to a local concert/art gallery/bookstore. Anything
that will stimulate my senses and gets me out of the house."
2. "Play modern, dance related music to keep melancholy at bay. Dance
3. "Sophia forces me to eat at least 2/3 of the food she puts on my plate,
whether I’m hungry or not. She has agreed to make my favorite dishes
begin to eat less."
4. "Do yoga to stimulate energy instead of taking caffeine pills."
5. "Sophia will visit me at work to break up the monotony."
As you can see, Chad’s wife Sophia played a significant role in preventing
his depression from overrunning his life.
Think of your bipolar client.
Would he or she benefit from a "Preventative Maintenance Plan"?
♦ 3. Technique: Three-Part Breathing
In addition to "Listing Symptoms According to Category" and "Preventative
Maintenance Plan", the third technique I suggested Chad use specifically
addressed his sleeping problems. This relaxation technique is known as
three-part breathing exercise and there are several relaxation techniques available for sleepless clients. Review some with your client and figure
out which ones best suit them.
I asked Chad to practice this exercise
before he goes to bed at night to put him into a relaxed state:
Take a deep, diaphragmatic breath. Imagine that your lungs are divided
three parts. Visualize the lowest part of your lungs filling with air. Use
only your diaphragm; your chest should remain relatively still. Imagine
middle part of your lungs filling, and as you visualize the expansion, allow
your rib cage to move slightly forward. Visualize the upper part filling
with air and our lungs becoming completely full. Your shoulders will rise
slightly and move backwards.
Exhale fully and completely. As you
your upper lungs, drop your shoulders slightly. Visualize the air leaving
the middle portion of your lungs, and feel your rib cage contract. Pull
your abdomen to force out the last bit of air from the bottom of your lungs.
Repeat the exercise four times.
I recorded this exercise onto a tape so Chad could easily play it to himself
without having to memorize the entire exercise. I also find it helps
clients to hear their therapist’s voice when there are especially anxious.
In this section, we presented techniques to predict manic and depressive
states and to aid clients through these cycles. These were Listing Symptoms
to Category; Preventative Maintenance Plan; and Three-Part Breathing
In the next section, we will examine conditions that may co-occur with bipolar
disorder: autoimmune disorders, borderline personality disorder, and
cyclothymic disorder. We will also present ways to diagnose these comorbid
conditions along with ways to treat clients with comorbid conditions.
Peer-Reviewed Journal Article References:
Dodd, A. L., Mansell, W., Morrison, A. P., & Tai, S. (2011). Extreme appraisals of internal states and bipolar symptoms: The Hypomanic Attitudes and Positive Predictions Inventory. Psychological Assessment, 23(3), 635–645.
Harvey, A. G., Soehner, A. M., Kaplan, K. A., Hein, K., Lee, J., Kanady, J., Li, D., Rabe-Hesketh, S., Ketter, T. A., Neylan, T. C., & Buysse, D. J. (2015). Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: A pilot randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(3), 564–577.
Ng, T. H., Burke, T. A., Stange, J. P., Walshaw, P. D., Weiss, R. B., Urosevic, S., Abramson, L. Y., & Alloy, L. B. (2017). Personality disorder symptom severity predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum disorder. Journal of Abnormal Psychology, 126(3), 271–284.
What are three techniques to predict manic and depressive states and to aid clients? To select and enter your answer, go to .