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<p>Anger and irritability affect 62–75% of patients with bipolar disorder and are associated with mixed features, functional impairment, and elevated suicide risk; however, these symptoms remain inadequately addressed in existing cognitive-behavioral therapy (CBT) protocols. This paper introduces Cognitive-Behavioral Dopaminergic Balance Therapy (CBT-D), a modified CBT intervention that explicitly targets anger and irritability across mood phases. CBT-D is an eight-module protocol integrating cognitive restructuring of phase-specific beliefs, metacognitive awareness training, behavioral activation, and contingency management within a unified arousal-regulation framework. The intervention uses “dopaminergic balance” as a clinical heuristic—a psychoeducational metaphor rather than a biological measure—to help patients understand and regulate activation states. Novel clinical tools include the Dopamine Balance Index (DBI) for daily self-monitoring and the Dopamine-Aware Rage Arrest (DARA) protocol for phase-specific anger management. Cognitive techniques emphasize identification of “phase-contaminated cognitions” and development of cognitive flexibility through structured restructuring adapted to current mood state. The theoretical framework is illustrated by preliminary observations from five outpatients with bipolar I (<i>n</i> = 2) or bipolar II (<i>n</i> = 3) disorder who completed 18–28 sessions of CBT-D, delivered as an adjunct to ongoing pharmacotherapy, over 6–12 months. Using uncontrolled, unblinded clinician assessment, four patients (80%) demonstrated improvement: mean YMRS scores decreased from 18.4 to 10.4, mean BDI-II scores from 24.2 to 12.2, and mean YMRS irritability item scores from 5.6 to 3.6. Treatment engagement was high (92% attendance). One patient showed minimal response, potentially related to medication non-adherence. CBT-D offers a structured cognitive-behavioral framework for addressing the underserved treatment target of anger and irritability in bipolar disorder. These preliminary observations require replication in controlled trials with validated irritability measures and blinded assessment.</p>

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A Cognitive-Behavioral Approach to Anger and Irritability in Bipolar Disorder: Dopaminergic Balance Therapy (CBT-D), A Theoretical Framework and Preliminary Case Series

  • 期刊论文

  • 发表日期：

    2026年6月29日

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  • Jacek Romański

摘要

Anger and irritability affect 62–75% of patients with bipolar disorder and are associated with mixed features, functional impairment, and elevated suicide risk; however, these symptoms remain inadequately addressed in existing cognitive-behavioral therapy (CBT) protocols. This paper introduces Cognitive-Behavioral Dopaminergic Balance Therapy (CBT-D), a modified CBT intervention that explicitly targets anger and irritability across mood phases. CBT-D is an eight-module protocol integrating cognitive restructuring of phase-specific beliefs, metacognitive awareness training, behavioral activation, and contingency management within a unified arousal-regulation framework. The intervention uses “dopaminergic balance” as a clinical heuristic—a psychoeducational metaphor rather than a biological measure—to help patients understand and regulate activation states. Novel clinical tools include the Dopamine Balance Index (DBI) for daily self-monitoring and the Dopamine-Aware Rage Arrest (DARA) protocol for phase-specific anger management. Cognitive techniques emphasize identification of “phase-contaminated cognitions” and development of cognitive flexibility through structured restructuring adapted to current mood state. The theoretical framework is illustrated by preliminary observations from five outpatients with bipolar I (n = 2) or bipolar II (n = 3) disorder who completed 18–28 sessions of CBT-D, delivered as an adjunct to ongoing pharmacotherapy, over 6–12 months. Using uncontrolled, unblinded clinician assessment, four patients (80%) demonstrated improvement: mean YMRS scores decreased from 18.4 to 10.4, mean BDI-II scores from 24.2 to 12.2, and mean YMRS irritability item scores from 5.6 to 3.6. Treatment engagement was high (92% attendance). One patient showed minimal response, potentially related to medication non-adherence. CBT-D offers a structured cognitive-behavioral framework for addressing the underserved treatment target of anger and irritability in bipolar disorder. These preliminary observations require replication in controlled trials with validated irritability measures and blinded assessment.