Psychiatric Quarterly

https://doi.org/10.1007/s11126-020-09709-6

ORIGINAL PAPER

Enhancing Dialectical Behavior Therapy

for the Treatment of Bipolar Disorder

Alyson DiRocco 1,2 1

& Lisa Liu & Molly Burrets
1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Dialectical behavior therapy (DBT) is a third wave, behavioral therapy that is designed to
target emotion dysregulation. The current study investigated whether DBT could be an
effective treatment intervention for bipolar disorder and how it could be adapted for this
population. Although empirical study of DBT and bipolar disorder is limited, there is
evidence to suggest that DBT is a promising treatment for bipolar disorder. In this study,
adapted DBT products were created for bipolar disorder, and feedback on the products
was elicited from five experts in the field through semi-structured interviews. Interviews
were transcribed and coded for analyses. The findings from the interviews were integrated
into revised products with the intention to be used in the clinical community. Several
experts reported currently using DBT for bipolar disorder treatment. We conclude that a
form of DBT using adapted materials could be a promising intervention for the treatment
of bipolar disorder, although more research is needed to demonstrate efficacy. Future
directions include conducting randomized controlled trials on DBT and bipolar disorder,
as well as testing the created product in clinical practice.

Keywords Bipolar disorder . Dialectical behavior therapy . Bipolar treatment . DBT

Bipolar disorder is a chronic and debilitating mental disorder, characterized by fluctuations in

mood and energy. The lifetime and 12-month prevalence estimates of bipolar disorder in the
United States are 2.1% and 1.4% respectively [26]. Approximately 6.9 million people live with
bipolar disorder in the United States (U.S. [40]). Among those diagnosed with bipolar disorder,
the lifetime suicide risk is estimated to be 15 times greater than for the general population [1, 29].
While the course of bipolar disorder symptoms may be episodic, it is also chronic.
Researchers have observed recurrence of a manic or depressive episode in 37% of their sample

* Alyson DiRocco
adirocco@alliant.edu

1
California School of Professional Psychology, Alliant International University, Los Angeles, CA,
USA
2
Alhambra, CA, USA
 Psychiatric Quarterly

after 1 year, and in 73% of their sample after 5 years, despite participants receiving intense
pharmacological maintenance treatment [10, 11]. Bipolar disorder has been recognized as the
6th leading cause of disability worldwide with estimated costs for the United States at $151
billion in 2009 ([33] as cited in [2]). The high prevalence, risk of suicidality, and relapse rate
among individuals with bipolar disorder make it imperative for professionals in the field of
psychology to develop and utilize treatments that are effective.
Although psychopharmacology is often the first choice for treatment for bipolar disorder,
many patients still experience residual symptoms. Evidence has shown that at least half of
bipolar disorder patients treated with medication alone relapse in a given year [20]. Therefore,
a combination of psychotropic medication with psychotherapy is considered optimal treatment
for bipolar disorder. Psychotherapeutic treatments that are recognized for bipolar disorder
include cognitive behavior therapy (CBT), interpersonal and social rhythm therapy (IPSRT),
family-focused therapy (FFT), and psychoeducation [27]. Efficacy studies have shown that
these treatments are effective in reducing depressive symptoms, number of episode relapses,
and number of hospitalizations [2, 3, 8, 16, 22, 30, 35, 36, 39]. The research has also
demonstrated improvements in medication adherence, time between episodes relapse, and
functioning.
Despite positive results, no single therapy is effective in treating bipolar disorder in its
entirety. For instance, one therapy may be more powerful in treating depressive symptoms,
while another is better at treating manic symptoms. Some treatments work better for patients
that are in remission, whereas others exert more influence during acute episodes. In the
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, 293
outpatients with bipolar I or bipolar II disorder and a current major depressive episode were
randomly assigned to intensive (CBT, IPSRT, FFT) or minimal psychosocial intervention
(collaborative care), both in conjunction with medication [31]. The study was not able to detect
any differences in recovery between the three types of intensive psychotherapies [31].
Recovery rates for patients were 76.9% in FFT, 64.5% in IPSRT, and 60% in CBT [31],
which could imply that the three therapies are equally effective or share similar components.
The STEP-BD study further illustrates that there is need for a comprehensive therapeutic
intervention that can treat bipolar disorder in its entirety.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) was designed to treat parasuicidal individuals struggling
with treatment resistant borderline personality disorder [23]. It has been acknowledged as the
“gold standard of treatment” for borderline personality disorder [32]. Bipolar disorder and
borderline personality disorder share many common features, such as emotion dysregulation,
affective instability, relationship instability, self-damaging behaviors, suicide risk, and impul-
sivity [25]. Many researchers have proposed that since the two diagnoses overlap in
symptomology, they may in fact exist on the same continuum [25, 34, 37]. In fact, the two
diagnoses are often misdiagnosed for one another. Ruggero et al. [38] found 40% of patients
with BPD had previously been misdiagnosed with BD compared to only 10% of patients with
other disorders. Bipolar disorder and borderline personality disorder also co-occur frequently.
Research studies have shown comorbidity rates between 35 to 51.5% [5, 15]. Furthermore,
similar biological vulnerabilities in emotion dysregulation exist between the two disorders
associated with the amygdala and hippocampus, although differing in mechanisms [4, 18, 21,
Psychiatric Quarterly

29]. Additionally, both have evidenced dysfunction in the neurotransmitter levels of serotonin
and dopamine [4, 21, 29]. Due to the similarities in symptomology between borderline
personality disorder and bipolar disorder, DBT could arguably be an effective treatment for
bipolar disorder.
DBT is part of the third wave of cognitive therapy and encompasses a combination of
cognitive and behavioral strategies with eastern mindfulness practices [6, 23]. DBT skills were
developed in order to change emotion dysregulation and maladaptive behaviors, while also
providing acceptance of one’s current emotions, thoughts, and behaviors [23]. The skills are
divided into four core modules: mindfulness, interpersonal effectiveness, emotion regulation,
and distress tolerance [6, 24]. Each module can be helpful in addressing symptoms and skill
deficits for individuals with bipolar disorder.
Mindfulness is a skill that can help individuals with bipolar disorder become more in tune
to their mood shifts as well as learn how to remain in the present moment with their emotions.
By staying present, individuals can become aware of their symptoms and obtain help before
exacerbation to a mood episode [41]. Emotion regulation represents a core dysfunction of
bipolar disorder; therefore, skills from this module can be helpful in regulating mood. The
emotion regulation skills in DBT aim to help individuals understand and identify their own
emotions, decrease the frequency of undesired emotions, and decrease emotional vulnerability
and suffering [24].
Living with a chronic and persistent mental disorder like bipolar disorder can place a strain
on interpersonal relationships, such as isolating from people they care about when
depressed or engaging in risky behaviors that impact friends and family members
[41]. Research has shown low social support predicts higher depression in individuals
with bipolar disorder [28, 29]. The interpersonal effectiveness module helps people
learn how to ask for what they want by asserting themselves, while maintaining
healthy reciprocal relationships [23, 24].
One aspect of bipolar disorder are periods of emotional crises that can lead individuals to
feel their behavior or cognitions are out of their own control [41]. To reduce the intensity of the
emotions, people may engage in behaviors that exacerbate the situation rather than improve it.
The distress tolerance module teaches coping skills for how to tolerate the crisis and reality as
it is, without making it worse [24]. Although the structure of DBT was specifically designed to
target high risk, suicidal individuals, Linehan [24] noted that DBT can adapted for other
populations. Adaptations to DBT have been successful in treating PTSD, eating disorders,
substance use, depression in older adults, cluster B personality disorders, and mood disorders
[24]. However, few research studies have examined its significance in treating bipolar disorder.

Research on DBT for Bipolar Disorder

Four research studies to date have examined the effectiveness of DBT in treating bipolar
disorder [7, 13, 14, 42]. The first pilot study conducted by Goldstein et al. [13], set out to
examine the effectiveness of DBT modified for adolescents (12–18 years old) with bipolar
disorder. In a one-year open trial, ten participants received 36 sessions of 60 minutes duration
that alternated between family skills training and individual therapy [13]. Results showed
improvements in suicidality, non-suicidal self-injury (NSSI), emotion dysregulation, and
depressive symptoms [13]. Nine out of the ten participants finished treatment demonstrating
treatment feasibility, and families and individuals rated treatment satisfaction highly. The study
 Psychiatric Quarterly

concluded that DBT proved to be a promising treatment for adolescents with bipolar disorder
within a highly symptomatic sample [13].
Goldstein and others [14] continued their work by conducting a randomized controlled trial
of DBT versus treatment as usual (TAU) as adjuncts to pharmacotherapy. The team utilized a
2:1 approach with 14 bipolar adolescents in the DBT condition and 6 in TAU. The participants
received 36 sessions over 12 months, switching between individual DBT therapy and
family skills DBT training [14]. Findings revealed that the DBT group attended more
sessions than the TAU group. The DBT group showed improvement in pre- to post-
manic symptoms and emotion dysregulation [14]. Depressive symptoms were less
severe at follow-up and more time was spent euthymic in the DBT group. Lastly,
the DBT group was three times more likely to produce improvements in suicidal
ideation [14]. Overall, the results indicated that DBT may produce greater improve-
ments in treatment adherence and symptomology than TAU.
Van Dijk et al. [42] designed the first study to utilize DBT with adults with bipolar disorder.
The researchers used a randomized, wait list control design with 26 participants to examine the
feasibility and effectiveness of a DBT skills-based psychoeducational group (BDG) on bipolar
disorder. The BDG participated in twelve 90-minute sessions, which provided
psychoeducation on bipolar disorder and DBT skills from the four core modules [42]. After
12 weeks, the DBT-based psychoeducational group (BDG) demonstrated a trend of reduced
depressive symptoms, increase in mindful awareness, and more perceived control over
emotional states. At 6 months follow up, there was also evidence of reduced emergency room
visits and hospitalizations in BDG [42].
Most recently, Eisner et al. [7] wanted to explore the effectiveness of DBT on bipolar
disorder due to its emphasis on emotion regulation, a core deficit of bipolar disorder. The
researchers utilized a stand-alone DBT skills group design pilot study. Thirty-seven partici-
pants with bipolar I disorder were administered twelve, 105-minute group sessions, over
3 months [7]. Findings revealed an 88% satisfaction rate among individuals for the treatment
provided [7]. Increased mindfulness, distress tolerance, and reductions in emotion dysregula-
tion and emotional reactivity were shown in participants from pre-to posttreatment, with these
gains were maintained 3 months later [7]. Depression and mania ratings were unchanged over
the course of the study. However, investigators attributed this result to low levels of depression
and floor effects for mania observed at baseline [7]. Interestingly, increases in mindfulness
were related to improvements in depressive symptoms, but not significantly associated with
reductions in manic symptoms. Additionally, reductions in emotion dysregulation were asso-
ciated with improvements in well-being [7].
Conclusively, results of efficacy research on DBT and bipolar disorder have indicated
promise. Across studies results have included improvements in suicidality, pre to post manic
symptoms, mindful awareness, and high acceptability of treatment. [7, 13, 14, 42]. Findings
also have shown reductions in NSSI, number of hospitalizations, emotion dysregulation, and
depressive symptoms [7, 13, 14, 42].
The present argument is that DBT can be utilized as an effective treatment for bipolar
disorder, due to the similarities between bipolar disorder and borderline personality disorder,
which DBT was inherently designed to treat. The core components of DBT can be applied to
treat the symptoms of bipolar disorder. Despite several psychotherapeutic treatments for
bipolar disorder, none have been effective in treating bipolar disorder in its entirety. Research
conducted on DBT and bipolar disorder shows promising evidence for addressing the limita-
tions of other available treatments.
Psychiatric Quarterly

Design

The goal of this research was to provide evidence that dialectical behavior therapy could serve
as an effective treatment for bipolar disorder through establishing a solid literature base and
creating a DBT adapted handout and worksheet for bipolar disorder for use in the clinical
community. The handout was organized by mood-dependent states, mania or depression, due
to research backing the utility of identifying coping skills by current symptomology. After
reviewing current research on this topic and current treatments available, limitations were
identified. Current interventions for the disorder are inadequate in addressing the totality of
symptoms present in bipolar spectrum disorder.
The current literature proposes several adaptations of DBT for bipolar disorder including
specific skills, choice in modules, structure of treatment, homework assignments, and
psychoeducation of the disorder. DBT skills have been successfully adapted for other disorders
and populations [24]. In fact, in the second edition of the DBT manual, worksheets and
handouts have been designed and included specifically for the treatment of addiction [24].
While the studies conducted on the effectiveness of DBT for bipolar disorder utilized
adaptations of DBT for their research, the researchers did not propose new handouts or
worksheets specifically tailored to bipolar disorder as has been done for addiction and other
disorders. Thus, a new set of DBT skills handouts and worksheet adapted for the treatment of
bipolar disorder is proposed and developed (see Appendix 1). The acronym is titled “CAM-
ERAS.” “CAMERAS” stands for: Check mood, Analyze the pros and cons of goals,
Maximize/Minimize stimulation, Evaluate confidence levels, Relax, Ask for help, and Sleep
monitoring. The set of skills included in “CAMERAS” is divided into two handouts, organized
by mood state, given that appropriate skills chosen in a depressive episode can differ for a
manic episode [13, 14, 41]. “CAMERAS” skills are specifically adapted for bipolar disorder
and were created based on current literature in the field.
The first skill includes a check on the current mood state. For individuals with bipolar
disorder to begin to control their emotions, it is important to first notice when mood shifts are
occurring [7]. Once they are able to detect the emotion present, an emphasis on observing it
nonjudgmentally, describing it objectively, labeling it, and rating its intensity is proposed to
help bring awareness to the emotion. These components are discussed throughout the DBT
emotion regulation and mindfulness modules in order to bring one’s attention and acceptance
to present emotions, which allows room for change thereafter [24]. This skill is integral to
regulating emotional dysfunction in bipolar disorder because if an individual is unable to
recognize signs of a mood episode, then he or she will not be able to perform the appropriate
coping skills.
‘Analyze the pros and cons of goal setting’ is the next skill introduced in “CAMERAS”.
Research has shown that people who experience mania or hypomania have greater activation
in the basal ganglia, and thus show increases in goal engagement and reward seeking [9, 17,
29]. People with bipolar disorder have shown greater excitement from the opportunity to
pursue goals than people without the diagnosis [29]. Johnson and Fulford [17] stated that,
“People with bipolar disorder demonstrate greater emotional reactivity to successes and
rewards, heightened emphasis on goals, increased confidence after successes, and excessive
goal attainment engagement after success” (p. 3). By analyzing the pros and cons of a goal an
individual set for him or herself, he or she can slow down and decide whether it makes sense to
pursue the goal in the current emotional state. For instance, during depressive episodes, an
individual with bipolar disorder may experience avolition, and thus lack motivation for goal
 Psychiatric Quarterly

attainment. This skill will push the depressed individual without any goal motivation to set a
goal for oneself and analyze the possible outcomes. It will illustrate to the person that a goal
that appears daunting may actually have more benefits than drawbacks. Analyzing the pros
and cons of goal setting is similar to the DBT skill of analyzing pros and cons of urges in the
distress tolerance module, but places an emphasis on goals rather than urges [24].
Minimizing or maximizing stimulation is proposed next since it is important to calm or
activate a person experiencing either a manic or depressive state. When experiencing manic
symptoms, reducing the intensity of the surrounding environment and activities can produce
calming effects and slow down racing thoughts [41]. In a depressive episode, this skill would
be maximizing stimulation in order to stop isolation and decrease feelings of sadness and
fatigue. The DBT “PLEASE” skills acknowledges engaging in exercise as a form of a natural
antidepressant if performed routinely [24]. Small steps implemented, such as reducing time
spent lying in bed or starting to socialize with people can enhance stimulation, and thus begin
to improve depressive mood symptoms. The mindfulness module within DBT treatment also
relates to changing stimulation patterns by first bringing into awareness the heightened
intensity or lack thereof in a person’s current environment, in order to then bring about change.
Self-esteem can be significantly affected by the mood symptoms a person with bipolar
disorder is experiencing. Research has shown that a predictor for manic relapses in individuals
with bipolar disorder is a high level of confidence [17, 29]. Studies have also shown that
unrealistically high self-esteem is a characteristic of bipolar disorder in response to successes or
positive mood inductions [17]. Conversely, depression is associated with feelings of worth-
lessness or emptiness, which can lead to the development of low self-esteem [1]. Within this
skill, patients are encouraged to first rate their current self-esteem or confidence level. By
bringing awareness to the rating, an individual may see that he or she is closer to the bipolar
ends of the spectrum rather than in the middle. For mania, confidence can be tied to goal
attainment. Thus, it is important to inquire how successful, or what consequences resulted from
pursuing this goal in the past. In depression, this skill would focus on building self-esteem
through naming past successes, identifying personal strengths, or asking what others who know
the person would say are his or her strengths. The ultimate goal of this skill is to change self-
esteem levels to better regulate mood symptoms. In DBT, similar skills would include being
mindful of current emotions, checking the facts, and analyzing pros and cons [24].
Once stimulation has been modified, relaxation can complement this skill. Activity can be a
prodromal sign of a manic episode and is thought to be the result of a dysfunction in the
behavioral activation system [19]. For individuals with mania or hypomania, progressive
muscle relaxation, along with other relaxation strategies, can help produce calmness, thus
increasing the probability of reducing symptoms [17, 41]. Although thinking about relaxation
could be difficult during a manic episode, incorporating relaxation into one’s daily routine will
increase the chances of the skill becoming available when symptoms begin [41]. On the other
hand, a depressive episode can include psychomotor retardation, lack of energy, or fatigue [1].
For these individuals, decreasing the amount of time relaxing would be important to reduce
depressive symptoms. However, depressive symptoms can also sometimes include psycho-
motor agitation or insomnia, in which case utilizing relaxation strategies could help. Increasing
the amount of pleasurable activities may alleviate sadness. Although low motivation in
depression can stop one from participating in pleasurable activities, it is also true that once
the activity is started it becomes easier and enjoyable [41]. Several DBT skills are associated
with relaxation including, paired muscle relaxation in the distress tolerance module, self-
soothing, body scan meditation, and mindfulness exercises [24].
Psychiatric Quarterly

Possibly the most important skill in “CAMERAS” to utilize is asking for help. Help can be
requested from a family member, caregiver, friend, therapist, or any mental health professional.
It is important to have another person to help monitor prodromal signs of a mood episode or
provide support once the individual experiences symptoms. Family-focused therapy, designed
specifically to improve family functioning in bipolar disorder, has shown positive results in
reducing relapses and improving the course of illness [27, 29, 30, 36]. Other people can assist a
person with bipolar disorder in ways that are helpful to the individual, such as offering
reminders for taking medication, helping monitor mood symptoms, or talking about current
difficulties.
Research has found evidence of a correlation between mood instability and dysfunction of
the sleep/wake cycle in bipolar disorder [8, 10]. IPSRT is a treatment designed to balance
social and sleep routines while also targeting interpersonal problems. Studies on IPSRT have
shown efficacious results in curbing the onset of mood episodes and improving functioning in
bipolar disorder [8, 16]. DBT also emphasizes the importance of maintaining a healthy sleep
schedule in the “PLEASE” skills and sleep hygiene protocol within the emotion regulation
module [24]. For individuals with problems in emotion regulation, such as bipolar disorder,
too little sleep or too much sleep can increase emotional vulnerability, increase relapses,
compromise health, and maintain the underlying cause of mood disorders [24]. Monitoring
sleep by setting a schedule, recording any disruptions in sleep, and exploring new strategies to
fall back asleep once awake will help improve sleeping patterns. Miklowitz [27] concluded
that interventions focusing on predictors, such as sleep/wake cycle disruption, can be effective
in reducing manic symptoms. It is important to find ways to ameliorate manic symptoms as
many interventions are ineffective for prevention of manic relapses [17].
The “CAMERAS” skills aim to establish effective coping strategies for improving emotion
dysregulation and functionality for individuals with bipolar disorder within a DBT framework.
The skills discussed all have equivalents to strategies utilized in the DBT core modules.
However, “CAMERAS” has been specifically designed with the consideration of making
adaptations for bipolar disorder. The hope is that clinicians will utilize “CAMERAS” when
treating their patients with bipolar disorder under dialectical behavior therapy.
To examine the utility of the skill, the present study was conducted to evaluate the
components of “CAMERAS” by eliciting feedback from experts in the field of bipolar
disorder and dialectical behavior therapy.

Methods

Participants

The participants for this research were defined as field consultants. Ten possible field consul-
tants were contacted by email to offer feedback on the clinical product created and provide
professional input on the findings from the literature review. To be eligible for the study, field
consultants needed to hold a doctorate (Psy.D. or Ph.D.) in clinical psychology, or a master’s
degree in counseling, psychology, social work, or other related field with specific training in
DBT, or specialty in working with bipolar disorder. Field consultants were also qualified if
they held an internship or postdoctoral training in DBT or bipolar disorder. Field consultants
were identified by relevant clinical interests, personal colleague connections, and snowball
sampling.
 Psychiatric Quarterly

Out of the ten field consultants, eight responded to recruitment efforts. Five field consul-
tants ultimately participated, one declined participation, and two communicated interest, but
did not sign consent forms. All of the field consultants that participated were female. One held the
title of Psy.D. in clinical psychology, two Ph.D. in clinical psychology, one MSW and RSW, and
one LMFT. Areas of employment included one at a university research institution, three predom-
inantly in private practice, and one in community mental health. Out of the five participants, three
had received intensive training in DBT, two specialized in treating individuals with bipolar
disorder, and one specialized in bipolar disorder research. The elected method of semi-
structured interview varied by participant: one in-person, two via phone call, and two via email.

Procedure

To research the topic and create a functional product, extensive literature searches were
conducted utilizing various databases including EBSCOhost, MEDLINE, PsycINFO,
PubMed, ProQuest, Research Gate, Mendeley, and Google Scholar. Literature searches per-
formed within these databases included search terms such as “Bipolar Disorder and DBT”,
“Psychosocial Treatments and Bipolar Disorder”, “Emotion Dysregulation and Bipolar Dis-
order”, “Dialectical Behavior Therapy”, and “Borderline Personality Disorder and Bipolar
Disorder.” Analyzing the present research studies pertaining to the research question allowed
for the development of a solid theoretical base for utilizing DBT for bipolar disorder, and the
construction of the DBT adapted handouts and worksheet.
Following approval from IRB, potential field consultants were contacted via email with an
official recruitment letter and eligibility criteria form, requesting participation in the study.
After obtaining initial interest, a consent form was sent to and signed by the participant. Once
consent was obtained, the interview was scheduled and the participant was sent the semi-
structured interview questions, the adapted DBT handouts, and the adapted DBT worksheet
(see Appendix 1). The field consultants participated in their elected format of semi-structured
interview with in-person and phone session interviews audio recorded. The interviews were
then transcribed for analysis and the responses were clustered for themes.

Measures

For the implementation of this research, participants were asked a pre-determined set of
questions through a semi-structured interview. The questions pertained to the clinical product
created as an output of this dissertation. Questions that were included were:

1. Do you think DBT could be an appropriate intervention for BD? Why or why not?
2. Do you currently use DBT for treatment of BD? If yes, how or in what way? Are there
ways in which you have adapted DBT for BD?

a. Follow up question: If you are not currently using DBT for bipolar disorder, do you
think other professionals are and is it working? Why or why not?

3. What do you think about the worksheet?

a. What would you propose to change?

b. Could you see your clients benefitting from it?
Psychiatric Quarterly

i. What aspects do you see as beneficial?

ii. Do you feel any aspects are less beneficial?
iii. What may be some challenges for clients to use it?
c. Could you see yourself implementing it? Why or why not?

i. What may be some challenges in implementing it?

4. What do you feel current psychosocial treatments lack for bipolar disorder?

Data Analysis

The data set was comprised of five interviews, which were transcribed for inductive systematic
analysis. The coding phase consisted of the first investigator reading through one interview
and assigning thematic codes for each question. The subsequent interviews were read, then
compared to the generated list of thematic codes. When a common theme existed, the
investigator marked the frequency of the response. If a new theme was present, the theme
was added to the list of codes. The generated thematic codes were reviewed by the second and
third investigator to ensure that themes were mutually exclusive. The themes organized by
question were reported in the results section. Based on the participants’ responses, changes
were incorporated into the final product. Decisions to incorporate changes to the products were
made based on five factors: (1) majority consensus, (2) the rationale was consistent with DBT,
(3) the change was found to be effective for bipolar disorder or DBT in the literature review,
(4) resulted in less judgmental language, or (5) represented symptoms of bipolar disorder.

Results

The intention of utilizing field consultants for the study was to obtain feedback on the created
clinical product. The transcriptions were carefully analyzed, and responses were categorized
by themes. The general findings and patterns of each question will be discussed.

Appropriateness of DBT for the Treatment of Bipolar Disorder

When asked if DBT could be an effective intervention for bipolar disorder, every participant in
the study agreed that it could be viewed as appropriate to use with clients. The majority of
participants reasoned that DBT would be helpful in regulating emotions and mood in bipolar
disorder. For example, one participant stated, “DBT focuses on emotion regulation which is an
important skill when someone experiences emotional extremes. Furthermore, DBT incorporates
interpersonal effectiveness which has been shown to be effective for chronic depression, and
depression is the mood state that individuals with BD spend the most time experiencing over
their lifetime”. Other reasons included DBT’s perceived efficacy when treating patients with
bipolar disorder in vivo and that DBT provides structure to treatment for the clinician and client.

Current Use and Adaptations of DBT

Out of the five field consultants, three reported that they had used DBT to treat bipolar
disorder. Among those who did use DBT for bipolar disorder, the majority reported utilizing
 Psychiatric Quarterly

the original material without disorder-specific adaptations. However, participants that reported
making slight adaptations mentioned their changes would incorporate the knowledge of
bipolar symptoms. For example, they may have utilized mindfulness to increase awareness
of changes in mood state. One participant elaborated that mindfulness helped her clients in
determining whether a manic or depressive mood episode was beginning. Two participants
who reported not having used DBT for the treatment of bipolar disorder provided reasons
including a desire for more published data on its efficacy and already having obtained training
experience in a modality other than DBT. These findings are not surprising given the small
number of studies currently published that explore DBT and bipolar disorder, and the existence
of a number of other evidence-based treatments for bipolar disorder.

Feedback on Worksheets/Products

When asked to share general thoughts about the product, all of the participants provided
positive feedback. The most frequently cited reason for rating it positively was that the
handouts were separated by mood state, or depressive and manic symptoms. Other cited
reasons included the skill of analyzing the pros and cons of goals, and utilizing a mnemonic
device. There was one participant who reported that there may be too much material on the
worksheets.

Proposed Changes

Inquiry about suggested changes or additions to the products elicited a variety of responses.
Over half the participants agreed that there should be an addition of analyzing or observing
current thoughts, urges, or beliefs in the products (see Appendix 2). The rationale was that it
would incorporate the symptom of racing thoughts in bipolar disorder and also bring greater
awareness to factors contributing to the client’s mood. The majority of participants also had
suggestions about changing wording and formatting with the rationale being that the changes
would be more adherent to DBT concepts (see Appendix 1). For example, DBT emphasizes
use of nonjudgmental language. One participant suggested changing the words of “happy
music” as it denotes an evaluation of the music. Therefore, it was changed to “calming music.”
Additionally, two out of five participants proposed the addition of examining risk factors that
might be contributing to the intensity of symptoms. Another theme that emerged was accuracy
of memory pertaining to mood episodes. In other words, clients may have difficulty remem-
bering how they presented when experiencing a mood episode. Other feedback themes
included referring to the DBT manual for relevant skills, adding a letter to oneself, addressing
talkativeness, mood monitoring, medication monitoring, and incorporating mixed episodes.

Benefits of Using the Worksheets/Products

All participants interviewed stated that clients could benefit from using the products. When
prompted to explain which specific aspects participants determined as beneficial, two endorsed
all the material on the products. Participants also indicated that the emphasis on examining
stimulation was helpful. Other aspects viewed as beneficial included three of the categories in
“CAMERAS”: sleep, asking for help, and analyzing goals. Lastly, the use of an acronym and
freedom to choose from several strategies were identified as strengths of the product. No
Psychiatric Quarterly

participant felt any aspect of the products was less beneficial, offering the reason that the
products provide clients with coping skills.

Challenges for Clients

Themes that emerged in terms of challenges for clients to use the products included noncom-
pliance and having to complete the worksheet alone. Three participants mentioned that clients
may not want to do homework or may not want to downregulate their mood if experiencing
increases in confidence or energy. These concerns are also challenges that clinicians face with
any structured treatment that is not novel to DBT. Completing the worksheet alone may be
difficult for clients at first, but it is encouraged in standard DBT for clients to troubleshoot their
difficulties in completion at their next individual session or skills group.

Challenges for Clinicians

In response to the question of whether or not clinicians could see themselves implementing the
products in treatment, four out of five said yes. The participant that said no, stated that the data
available for the use of DBT for bipolar disorder is still being tested and is not yet sufficient for
personal utilization of the treatment. In terms of challenges present for the clinicians to use the
products, two participants said there were none. One participant stated that she might not use
the product because she already has a set format she utilizes for groups. The comment implied
that therapeutic style may interfere with implementation of the products. Having too much
information on the products was a concern for one participant, “I think the challenge might be
that the entire acronym encompasses a lot of interventions, which might be helpful to have all
in one place, but overwhelming to try to implement all at once”. This concern is valid, and the
skills provided on the products could also be utilized individually, thus taught over a number of
sessions. Lastly, lack of efficacy for using the treatment of DBT for bipolar disorder in general
was brought up as a challenge by the same participant who endorsed lack of efficacy for
implementing the product.

Limitations of Current Treatments for Bipolar Disorder

Participants were asked what they felt were limitations of current treatments for bipolar
disorder. While the responses were variable, two prominent themes were lack of
psychoeducation about psychiatry on the clinician’s part, and lack of mindfulness. Bipolar
disorder is a chronic mental illness and the majority of individuals diagnosed use psychotropic
medication. Therefore, the importance of communicating with the psychiatrist, and monitoring
side effects and symptoms is integral for clinicians working with this population to ensure
quality care. Mindfulness was acknowledged as a beneficial tool when working with individ-
uals with bipolar disorder for a number of reasons, and not many available treatments for
bipolar disorder incorporate mindfulness. One participant remarked, “Of course for anybody,
but when it comes to bipolar disorder, for developing that awareness for helping them to stay
on top of symptoms and triggers, to help them prevent full episodes from coming on.”
Mindfulness can help individuals with bipolar disorder become more aware of their mood
changes and promote emotion regulation.
Another theme that emerged in responses was lack of bipolar specificity in treatment, such
as understanding phases of bipolar disorder and lumping individuals in groups with other
 Psychiatric Quarterly

diagnoses like unipolar depression. One participant thought that many treatments for bipolar
disorder do not provide links to resources, such as supportive organizations. Lack of efficacy
was also proposed to exist as a limitation, meaning the current treatments for bipolar disorder
are not reaching enough people. Additionally, one participant mentioned the limitation that
there is weighted emphasis on cognitive appraisal, “They rely a lot on cognitive reappraisal
that may be hard to implement during a hypomanic state”. Lastly, a participant stated that
therapies for bipolar disorder lack an emphasis on interpersonal relationships, which could
potentially affect a person’s mood. Overall, there were several limitations identified in current
treatments for bipolar disorder, many of which are addressed within DBT, such as interper-
sonal skills and an increasing emphasis on acceptance rather than solely cognitive appraisal.

Discussion

Incorporating Changes to Products

Based on the findings, the participants’ feedback was systematically integrated into a product
revision. Decisions to incorporate changes were made based on five factors. The first was if the
proposed adaptation had a majority consensus among participants. In other words, if the
frequency was counted at three or more for the proposed change, then it was included in the
revision of products. Second, changes were included if the rationale was consistent with
dialectical behavior therapy, such that the changes would be relevant to guidelines or as
discussed in DBT literature. Third, if the change related to what has been found to be effective
in DBT or bipolar disorder within this literature review, it was included. Fourth, a proposed
change was accepted if the change resulted in less judgmental language, which is a skill that is
woven throughout DBT. Lastly, changes were incorporated if they mentioned symptoms of
bipolar disorder that were not originally addressed in the worksheet or handouts.
Themes within the analysis of interviews were screened for the presence of the five factors.
A major revision that was incorporated was to add an examination of thoughts and urges,
which was included on the worksheet under “Check Mood”. This change was made for several
reasons. First, it received a majority consensus. Also, flight of ideas is a recognized symptom
of bipolar disorder that could be identified when examining current thoughts. Finally, exam-
ining urges was an item where the rationale was consistent with DBT, as urge surfing is a skill
used within DBT.
A concern with the worksheet that was reported twice, was that individuals with bipolar
disorder might lack memory of their previous mood episodes. The concern was identified with
the phrases, “Do these cues feel similar to the last time you began an episode?” in the “Check
Mood” instructions in the worksheet, and “Notice if these cues feel similar to the last time you
began a mood episode” in the “Check Mood” section of the depressive episode and manic
episode handouts (see Appendix 1). Since this concern did not meet any of the five factors, it
was not eliminated from the worksheet or handouts. However, the language was revised to
account for the possibility that that an individual may have experienced the cues previously but
had not been aware it was within a mood episode. The phrases were changed in the worksheet
to, “Have you had these emotions, sensations, behaviors, thoughts, or urges before? When did
you have them?”, and in both the handouts to “Notice if you have experienced these cues
before” (see Appendix 1). The changes provide room for utilizing awareness, or memory of
symptoms and cues, regardless of whether they occurred in prior mood episodes. Furthermore,
Psychiatric Quarterly

the argument for not eliminating the phrase entirely was because the products are to be used in
addition to the regular DBT skills schedule, not as a stand-alone. Therefore, individuals using
the handouts and worksheets should already be learning how to monitor their mood and other
symptoms within the context of DBT. Skills on the proposed products can be utilized or taught
individually, but it is considered best practice when used in conjunction with a standard
schedule.
Many participants suggested formatting and word changes. Some wording changes were
made in accordance with nonjudgmental language used in DBT. For example, “happy music”
in the relax section of the manic mood episode handout was changed to “calming music,” in
order to remove the evaluation or judgment from the type of music. Also, the word “exacer-
bate” in the stimulation section of the manic mood episode handout was viewed as “unfriend-
ly” to clients and therefore was changed to “increase”. Additionally, other wording changes
were made to be more specific to an individual’s experience of bipolar disorder. For instance,
in the analyze pros and cons of goals section of the manic mood episode handout, an example
of a socially-related goal provided was “wanting to be extremely famous.” A proposed change
was choosing a goal that was presented more frequently in clinical practice, which was
“making several plans with friends.” Appendix 2 is a comprehensive list of all wording
changes.
Additionally, formatting alterations reflected a similar format used in DBT skills, and were
also made to increase cohesiveness, or ease of filling out the worksheet. For example, pros and
cons is used throughout DBT as a skill for analyzing behavior. In DBT, pros and cons are
examined in four columns: pros of behavior, cons of behavior, pros of not doing behavior, and
cons of not doing behavior. Therefore, the worksheet was modified to include four columns for
analyzing a set goal: pros of engaging in goal, cons of engaging in goal, pros of not engaging
in goal, and cons of not engaging in goal. The skill of “Ask for help” was changed to “Ask for
help and feedback” due to the suggestion that another person can be a reliable source in
recognizing a change in symptoms when an individual is actively experiencing a mood
episode. This change is consistent with bipolar disorder literature of family or other support
systems improving outcomes in bipolar disorder.
A section for identifying vulnerability factors was added to the top of the worksheet as it is
consistent with DBT and bipolar disorder literature. Within DBT, the products are proposed to
be categorized underneath the emotion regulation skills of “reducing vulnerability to emotion”
[24]. Additionally, a primary tool used in DBT is behavior chain analysis. In chain analysis,
one of the steps is identifying vulnerability factors. Therefore, examining present vulnerability
factors for an individual with bipolar disorder would be consistent with the DBT literature.
Furthermore, experiencing risk factors in bipolar disorder can increase symptoms to reach a
full-blown episode. For instance, current energy levels, inconsistent medication use, or poor
peer relationships can all be considered vulnerability factors for exacerbation of bipolar
disorder symptoms. Thus, it was important to add a section for examining vulnerability at
the top of the worksheet.
There were additional suggested changes that the authors considered, but were not included
as revisions for specific reasons. One was the suggestion to address mixed episodes. Among
4107 participants who participated in the STEP-BD study conducted by the National Institute
of Mental Health, two-thirds were found to experience subsyndromal manic symptoms during
a bipolar depression episode [12]. While some individuals with bipolar disorder do experience
mixed episodes, it would be difficult to create a worksheet or handout specifically targeting the
mixed symptoms, given that not everyone who experiences mixed episodes presents with the
 Psychiatric Quarterly

same mixed symptoms. Thus, it may be more beneficial to treat the symptoms an individual is
experiencing rather than creating a worksheet for a mixed episode. Individuals could utilize
both sheets when experiencing a mixed episode by selecting what is needed in that moment. A
clinician or the individual could also tailor the handouts or worksheet as needed, if a pattern of
mixed symptoms is identified.
Within the results, another change that was proposed was to add a mood monitoring
worksheet. Mood monitoring involves tracking daily mood ratings (e.g. 1 = depressed to
10 = manic) throughout the week. After consideration, a mood monitoring worksheet will
not be added to the current product with the argument that individuals should be monitoring
their mood with a DBT diary card [24]. The DBT diary card incorporates a range of primary
emotions such as “sad, anger, shame, fear/worry, joy” with ratings from zero to five, which can
incorporate feelings of depression (sad) and mania (joy). Again, the products are made to be
used in conjunction with DBT skills. Finally, a suggestion was made to add medication
monitoring. Instead of adding a medication monitoring chart, the addition of listing out
vulnerability factors at the top of the worksheet incorporates this proposed change, since
failure to take medication as prescribed would represent a vulnerability factor.
Overall, incorporating changes from the analysis of the interviews have enhanced the
clinical utility of the products. The participants who provided feedback on the worksheet
and handouts were considered to be experts in the field on bipolar disorder, dialectical
behavior therapy, or both. Thus, their feedback helps to verify the validity of using the DBT
products for bipolar disorder.

Limitations

There were a few limitations to the present study. One limitation was small sample size. While
ten field consultants were contacted, only five ultimately participated. If the sample size were
larger, it is possible that more distinct trends in responses may have been identified. Addi-
tionally, when incorporating suggested changes due to majority vote, the ratio would have
been greater than or equal to 3:2, which represents a slim majority. The strength or general-
izability of the results would also be greater if there were more participants included. Another
limitation was not recruiting more participants with expertise in both DBT and bipolar
disorder. If there had been more than one field consultant with these qualifications, then the
feedback provided would have been more specific to both aspects. However, since only three
publicly known researchers who utilize DBT for bipolar disorder exist, finding consultants
with both requirements would have been difficult.

Contributions and Implications

The literature on the efficacy of utilizing DBT for bipolar disorder is limited, as currently only
four clinical trials have been conducted, although results have been promising. Therefore,
many clinicians and professionals in the clinical field of psychology are not aware of the
emerging research of using DBT for bipolar disorder. The aim of this research is an attempt to
help close the existing research gap. By developing an adaption for DBT to be used in the
treatment of bipolar disorder, the hope is for clinicians to consider how DBT could be
applicable to bipolar disorder once it is has been empirically validated on this population.
The literature review conducted provides a logical and coherent rationale for making the claim
that DBT could be used as an alternative treatment for bipolar disorder.
Psychiatric Quarterly

It was important to present a review of the research on current treatments for bipolar
disorder, which revealed that while there are many existing evidence-based interventions for
bipolar disorder, no single intervention addressed the entire spectrum of bipolar disorder symp-
toms. Therefore, the review established a need for alternative, more comprehensive treatments.
Comparing bipolar disorder and borderline personality disorder was essential to demonstrate that
a treatment targeting the similarities between the two could be an effective treatment. Further
explaining the components of DBT aided in developing a basic understanding of the proposed
alternative treatment. Lastly, the review identified how DBT could be used in application to
bipolar disorder and what adaptations could be made to increase its effectiveness.
The contribution to the field from this research exists in the creation of the adapted
handouts and worksheets for bipolar disorder. While other researchers have conducted studies
and discussed how they use DBT for bipolar disorder, there have not been any published
adapted worksheets or handouts, or newly created skills. The hope for this research is to inspire
more professionals to think about how DBT could be applied to clients with bipolar disorder,
with the goal of moving towards empirically validating the treatment for this population. In the
future, once the created products from this study have been further validated through research,
the idea would be that clinicians would consider using the products in their clinical work.

Future Directions

The knowledge that has been generated from this study provides rich areas for future research.
The next step in validating the worksheet and the handouts would be to seek additional
feedback from more participants. After the products have been further validated and revised
with a larger sample of participants, clinicians could be trained in how to implement them with
individuals with bipolar disorder. A pilot study could then be created, where the trained
clinicians could use these materials in the treatment for individuals with bipolar disorder and
track the patients’ outcomes. If the pilot study concluded there was efficacy in using the
products for individuals with bipolar disorder, then a randomized controlled study could be
implemented to evaluate the treatment for individuals with bipolar disorder against a control
group. Additionally, research could be conducted on the feasibility of using the products for
clinicians. Clinicians could be asked to implement the products with their clients for a
designated number of weeks and then interviewed on the feasibility.
It is also important that more clinical trials are conducted on the efficacy of using DBT for
bipolar disorder. Currently, with only four studies published, the research is limited in its
scope. In future efficacy trials, researchers might focus on what interventions result in
improvement in both depressive and manic symptoms, or emotion regulation, given that
research indicated that no psychotherapies are effective in targeting both types of symptoms,
and emotion regulation is a core dysfunction of bipolar disorder. Furthermore, a full schedule
of DBT skills could be created for bipolar disorder, as has been done for a multitude of other
diagnoses. Skills such as opposite action, PLEASE, building mastery, coping ahead, identify-
ing core emotions, and others, could be adapted to be more specific to symptoms expressed in
bipolar disorder [24]. Overall, there are many directions that could be taken to further
generalize and apply the knowledge from this research.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of interest.
 Psychiatric Quarterly

Ethical Approval All procedures performed in this study involving human participants were granted exemption
by the Alliant International University Institutional Review Board (ref # 1804106076) and were in accordance
with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards.

Appendix 1

Revised Worksheet and Handouts

Psychiatric Quarterly
Psychiatric Quarterly
Psychiatric Quarterly
Psychiatric Quarterly
Psychiatric Quarterly
 Psychiatric Quarterly

Appendix 2

Table 1 Proposed Changes

Thematic Category Frequency Description Quote/Example

Talkativeness 1 Add other symptoms “Some of this stuff is not addressed

is talkativeness.”
Letter 2 Write a letter to self to “But if not they might have to source
read when in manic/ additional information from people
depressive episode in their lives, but to write a letter
to themselves…”

“I don’t know if there’s any space in

here for in what you’re doing, but
one thing I like to do is have my
client when they’re stable. Write a
letter, I call it a letter to their
depressed self.”
Thoughts 3 A place to analyze “I don’t know if it’s necessary but I
thoughts/beliefs/urges would wonder where are their
thoughts or beliefs being addressed.”

“Yeah not just help but feedback and

then adding that distractibility kind
of racing thoughts. Maybe a place
where they could just write down
all of the thoughts that are in their
mind. And they could objectively
look at them and go you know?”

“I did wonder though, so you’ve got

the describing the emotions
objectively and nonjudgmentally,
you didn’t mention thoughts or
urges in here.”
Refer to 2 Reference other DBT “I mean it’s not necessary, but you
manual skills or worksheets can also point to in sleep, there’s
for more help a sleep protocol.”

“So I also put opposite action here

too so I’m not sure if you’ve got
opposite action somewhere else...”
Opposite 1 Confusion with mnemonic “In general I would be concerned that
device the same acronym is used differently
on the CAMERAS depression
handout vs. the CAMERAS mania
handout (e.g., am I supposed to
minimize or maximize stimulation?)”
Wording and 3 Changing the language “The Analyze pros and cons on the
formatting or wording to make depression sheet is worded in a
more sensitive and confusing way.”
less confusing
“Relax on the depression sheet is
confusing.”

“Under relaxation just a couple more

wordy things the happy music, I
Psychiatric Quarterly

Table 1 (continued)

Thematic Category Frequency Description Quote/Example

think happy and enjoyment is in

that sentence too…”

“Sleep in the depression handout mentions

therapies designed to target sleep
which is not helpful in giving the person
tools they can use in the moment.”

“Under sleep, the only thing that I kind of

I thought might need to be emphasized
a little more if possible is that reduction
in sleep or the lack of sleep it’s a
symptom as well as a trigger.”

“Asking for help and asking for feedback.”

“Under maximize/minimize stimulation

I would have three spaces for possible
ways to increase stimulation and three
for decreasing stimulation.”

“I just question how realistic is it to for

them to feel relaxed if they are in a
manic state. And I wonder if a word like
calmer or more at peace or something
like that might be a better fit?”

“Under the M, I just circled the word

exacerbate. As a not very friendly word
for clients to be working with.”

“I thought why no four columns of the

pros and cons chart (laughs)? Was there
a reason why you just did the two
columns?”

“Analyzing the pros and cons of goals…I

thought, now take this how you will
but I thought maybe a better example
of um a socially related goal, cuz you
said such as wanting to be extremely
famous…”
Mood monitor 2 Create a place to “And there should be a mood monitor
monitor mood schedule as well.”

“So I actually use a worksheet she has in

there, it’s called the mood symptoms
worksheet.”
Memory 2 Clients have difficulty “My clients do not tend to have a memory
remembering of their episodes.”
last mood episodes

Mixed episode 1 Add reference to “Again my only question around that was,
mixed episodes what about mixed episodes, because
you got kind of clear set up in terms
of mania and depression.”
 Psychiatric Quarterly

Table 1 (continued)

Thematic Category Frequency Description Quote/Example

Other risk factors 2 Adding tracking “The other thing that’s not on here is
energy or other identifying risk factors, so, ‘Who
risk factors are the people and the places and the
drugs, and the things that put you
at risk of relapse. And if all the sudden
you’re hanging out with those people,
or you’re doing that drug, or you go
to that place. We know, that you’re
gonna probably cycle up.’”

“We sometimes think shifts in energy,

goals, or confidence may be bigger
than the emotion shifts. Energy is
easier to track than a “mood” or
“emotion” shift.”
Medication 1 Adding tracking “And so, something to say, okay “you
medication piece know write down you took your
medication at this time every day.”
But also allowing for “if you don’t, why?”

Note. Frequencies do not add up to number of participants due to participants including more than one theme or
response to the prompt.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington:
American Psychiatric Association; 2013.
2. Chiang KJ, Tsai JC, Liu D, Lin CH, Chiu HL, Chou KR. Efficacy of cognitive-behavioral therapy in
patients with bipolar disorder: a meta-analysis of randomized controlled trials. PLoS One. 2017;12(5):1–19.
https://doi.org/10.1371/journal.pone.0176849.
3. Colom F, Vieta E, Martínez-Arán A, Reinares M, Goikolea JM, Benabarre A, et al. A randomized trial on
the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is
in remission. Arch Gen Psychiatry. 2003;60(4):402–7. https://doi.org/10.1001/archpsyc.60.4.402.
4. Crowell SE, Beauchaine TP, Linehan MM. A biosocial developmental model of borderline personality:
elaborating and extending Linehan’s theory. Psychol Bull. 2009;135(3):495–510. https://doi.org/10.1037
/a0015616.
5. Deltito J, Martin L, Riefkohl J, Austria B, Kissilenko A, Corless P, et al. Do patients with borderline
personality disorder belong to the bipolar spectrum? J Affect Disord. 2001;67(1–3):221–8.
6. Dimeff L, Linehan MM. Dialectical behavior therapy in a nutshell. Calif Psychol. 2001;34:10–3.
7. Eisner L, Eddie D, Harley R, Jacobo M, Nierenberg AA, Deckersbach T. Dialectical behavior therapy group
skills training for bipolar disorder. Behav Ther. 2017;48(4):557–66. https://doi.org/10.1016/j.
beth.2016.12.006.
8. Frank E, Kupfer DJ, Thase ME, Mallinger AG, Swartz HA, Fagiolini AM, et al. Two-year outcomes for
interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry.
2005;62(9):996–1004. https://doi.org/10.1001/archpsyc.62.9.996.
9. Fulford D, Eisner L, Johnson S. Differentiating risk for mania and borderline personality disorder: the nature
of goal regulation and impulsivity. Psychiatry Res. 2015;227(2–3):347–52. https://doi.org/10.1016/j.
psychres.2015.02.001.
10. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013;381(9878):1672–82. https://doi.
org/10.1016/S0140-6736(13)60857-0.
11. Gitlin MJ, Swendsen J, Heller TL, Hammer C. Relapse and impairment in bipolar disorder. Am J Psychiatr.
1995;152(11):1635–40. https://doi.org/10.1176/ajp.152.11.1635.
Psychiatric Quarterly

12. Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB, et al. Manic symptoms
during depressive episode in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J
Psychiatr. 2009;166(2):173–81. https://doi.org/10.1176/appi.ajp.2008.08050746.
13. Goldstein TR, Axelson DA, Birmaher B, Brent DA. Dialectical behavior therapy for adolescents with
bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry. 2007;46(7):820–30. https://doi.
org/10.1097/chi.0b013e31805c1613.
14. Goldstein TR, Fersch-Podrat RK, Rivera M, Axelson DA, Merranko J, Yu H, et al. Dialectical behavior
therapy for adolescents with bipolar disorder: results from a pilot randomized trial. J Child Adolesc
Psychopharmacol. 2015;25(2):140–9. https://doi.org/10.1089/cap.2013.0145.
15. Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ. Affective instability and
impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res.
2001;35(6):307–12. https://doi.org/10.1016/S0022-3956(01)00038-3.
16. Inder ML, Crowe MT, Luty SE, Carter JD, Moor S, Frampton CM, et al. Randomized, controlled trial of
interpersonal and social rhythm therapy for young people with bipolar disorder. Bipolar Disord. 2015;17(2):
128–38. https://doi.org/10.1111/bdi.12273.
17. Johnson S, Fulford D. Preventing mania: a preliminary examination of the GOALS program. Behav Ther.
2009;40(2):103–13. https://doi.org/10.1016/j.beth.2008.03.002.
18. Johnson SL, Gruber L, Eisner LR. Emotion and bipolar disorder. In: Rottenberg J, Johnson SL, editors.
Emotion and psychopathology: bridging affective and clinical science. Washington, DC: American
Psychological Association; 2007. p. 123–50.
19. Johnson SL, Edge MD, Holmes MK, Carver CS. The behavioral activation system and mania. Annu Rev
Clin Psychol. 2012;8:243–7. https://doi.org/10.1146/annurev-clinpsy-032511-143148.
20. Keller MB, Lavori PW, Coryell W, Endicott J, Mueller TI. Bipolar I: a five year prospective follow-up. J
Nerv Ment Dis. 1993;181(4):238–48.
21. Kuo JR, Linehan MM. Disentangling emotion processes in borderline personality disorder: physiological
and self-reported assessment of biological vulnerability, baseline intensity, and reactivity to emotionally-
evocative stimuli. J Abnorm Psychol. 2009;118(3):531–44. https://doi.org/10.1037/a0016392.
22. Lam DH, Hayward P, Watkins ER, Wright K, Sham P. Relapse prevention in patients with bipolar disorder:
cognitive therapy outcome after 2 years. Am J Psychiatr. 2005;162(2):324–9. https://doi.org/10.1176/appi.
ajp.162.2.324.
23. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford
Press; 1993.
24. Linehan MM. DBT skills training manual. 2nd ed. New York: The Guilford Press; 2015.
25. Magill CA. The boundary between borderline personality disorder and bipolar disorder: current concepts
and challenges. Can J Psychiatr. 2004;49(8):551–6. https://doi.org/10.1177/070674370404900806.
26. Merikangas KR, Akiskal HS, Angst J. Lifetime and 12-months prevalence of bipolar spectrum disorder in
the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64(5):543–52. https://doi.
org/10.1001/archpsyc.64.5.543.
27. Miklowitz DJ. A review of evidence-based psychosocial interventions for bipolar disorder. J Clin
Psychiatry. 2006;67(suppl 11):28–33.
28. Miklowitz DJ, Johnson SL. Social and familial factors in the course of bipolar disorder: basic processes and
relevant interventions. Clin Psychol. 2009;16(2):281–96. https://doi.org/10.1111/j.1468-2850.2009.01166.
x.
29. Miklowitz DJ, Johnson SL. Bipolar Disorder. In: Craighead WE, Miklowitz DJ, Craighead LW, editors.
Psychopathology: history, diagnosis, and empirical foundations. 2nd ed. Hoboken: John Wiley & Sons, Inc.;
2013. p. 364–402.
30. Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath RL. A randomized study of family-focused
psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen
Psychiatry. 2003;60:904–12. https://doi.org/10.1001/archpsyc.60.9.904.
31. Miklowitz DJ, Otto M, Frank E, Reilly-Harrington N, Wisniewski SR, Kogan JN, et al. Psychosocial
treatments for bipolar depression: a 1-year randomized trial from the systematic treatment enhancement
program. Arch Gen Psychiatry. 2007;64(4):419–26. https://doi.org/10.1001/archpsyc.64.4.419.
32. Miller AL. Introduction to a special issue dialectical behavior therapy: evolution and adaptations in the
2 1 ( s t ) c e n t u r y. A m J P s y c h o t h e r. 2 0 1 5 ; 6 9 ( 2 ) : 9 1 – 5 . h t t p s : / / d o i . o r g / 1 0 . 11 7 6 / a p p i .
psychotherapy.2015.69.2.91.
33. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: global burden of
disease study. Lancet. 1997;349(9063):1436–42. https://doi.org/10.1016/S0140-6736(96)07495-8.
34. Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar
spectrum disorders. Compr Psychiatry. 2007;48(2):145–54. https://doi.org/10.1016/j.
comppsych.2006.10.001.
 Psychiatric Quarterly

35. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching
patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ.
1999;318(7177):149–53.
36. Rea MM, Tompson MC, Miklowitz DJ, Goldstein MJ, Hwang S, Mintz J. Family-focused treatment versus
individual treatment for bipolar disorder: results of a randomized clinical trial. J Consult Clin Psychol.
2003;71:482–92. https://doi.org/10.1037/0022-006X.71.3.482.
37. Reich DB, Zanarini MC, Fitzmaurice G. Affective lability in borderline personality disorder. Compr
Psychiatry. 2012;53(3):230–7. https://doi.org/10.1016/j.comppsych.2011.04.003.
38. Ruggero CJ, Zimmerman M, Chelminski I, Young D. Borderline personality disorder and the misdiagnosis
of bipolar disorder. J Psychiatr Res. 2010;44(6):405–8. https://doi.org/10.1016/j.jpsychires.2009.09.011.
39. Scott J, Paykel E, Morriss R, Bentall R, Kinderman P, Johnson T, et al. Cognitive-behavioural therapy for
severe and recurrent bipolar disorders: randomised controlled trial. Br J Psychiatry. 2006;188(4):313–20.
https://doi.org/10.1192/bjp.188.4.313.
40. U.S. Census Bureau (2019). QuickFacts: United States. Retrieved from: https://www.census.
gov/quickfacts/fact/table/US/PST045216
41. Van Dijk S. The dialectical behavior therapy skills workbook for bipolar disorder: using DBT to regain
control of your emotions and your life. Oakland: New Harbinger Publications, Inc.; 2009.
42. Van Dijk S, Jeffrey J, Katz MR. A randomized, controlled, pilot study of dialectical behavior therapy skills
in a psychoeducational group for individuals with bipolar disorder. J Affect Disord. 2013;145(3):386–93.
https://doi.org/10.1016/j.jad.2012.05.05.

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