Increases in manic symptoms after life events involving goal attainment

Mood reactivity to daily events in patients with remitted bipolar disorder

Information about mood reactions to naturally occurring stress in remitted bipolar patients may help elucidate the mechanism by which stressors influence the propensity to manic or depressive relapse in these patients. Using the experience sampling method (ESM), we therefore investigated negative and positive mood states and their reactivity to daily hassles and uplifts in 38 outpatients with remitted bipolar disorder and 38 healthy volunteers. Multilevel regression analyses confirmed that mean levels of negative affect (NA) were higher and positive affect (PA) lower in bipolar patients. Reactivity of NA and PA to hassles and uplifts in bipolar patients was similar to controls and was unrelated to the number of previous episodes. Bipolar patients with subsyndromal depressive symptoms, however, showed particularly large NA responses to daily hassles, which they also rated as more stressful. Subsyndromal depressive symptoms in patients with remitted bipolar disorder thus appear to increase sensitivity to everyday stressors.

Sense of hyper-positive self, goal-attainment beliefs and coping strategies in bipolar I disorder

BACKGROUND

There is some evidence that cognitive therapy (CT) is beneficial in reducing relapses in bipolar disorder. However, not all bipolar patients benefit from it. A previous study found that a group of non-responders to CT shared common characteristics: they value some of the high goal-attainment beliefs and characteristics associated with being in a state of mild hypomania - a high 'sense of hyper-positive self' (SHPS). To promote of our understanding of this group of patients, the present study investigated the relationship between SHPS, preferred internal state, dysfunctional attitudes and coping with hypothetical manic prodromal scenarios.

METHOD

Fifty-four bipolar I patients filled in self-report questionnaires that assess preferred mood state, coping with scenarios, dysfunctional attitudes and SHPS.

RESULTS

The Sense of Hyper-positive Self Scale Ideal score (SHPSS-Ideal) predicted patients' preferred internal state of mania. Coping with hypothetical scenarios was predicted by Dysfunctional Attitude Scale (DAS) goal-attainment scores: the higher the goal-attainment score, the higher the participant's tendency to identify with self-descriptors linked to hypomania and to engage in stimulating behaviours that may escalate the prodromal stage to mania.

CONCLUSIONS

Clinicians should check and modify goal-attainment beliefs, particularly of those who exhibit features of SHPS. These patients' tendency to identify with hypomanic traits as self-descriptors should be dealt with by psychological techniques such as cognitive restructuring.

Vulnerability Factors for Bipolar Disorders as Predictors of Attributions in Ability-Based and Chance-Based Tests

The role of attributional style in bipolar disorder has received empirical support. Research suggests that a pattern of global, stable, and possibly internal attributions for positive events might even trigger mania. We tested whether hypothesized risk factors for bipolar disorder are associated with such attributions after feedback of success in an ability- and chance-based test. University students (n = 115) completed the Behavioral Inhibition and Behavioral Activation Scales (BIS/BAS) and the Hypomanic Personality Scale (HPS) to assess risk for bipolar disorder. In addition, participants were interviewed using the Structured Clinical Interview. All participants performed an ability-based (intelligence) test and a chance-based (dice-throwing) test, and success was induced by providing positive feedback regardless of their actual test performance. Attributions of perceived success were assessed after each test. Results showed that high scores on the BAS scale were generally predictive of self-serving attributions in the ability-based test, while scores on the HPS predicted a more global and self-serving attributional style in the chance-based test. Current depression, lifetime affective disorder, BIS, or the dysregulation of the BAS did not consistently predict attributions on either test. Despite some methodological limitations, results suggest that anticipated or experienced success in skill-related contexts triggers self-serving attributions in individuals scoring high on the BAS scale, while perceived positive outcome in chance-related, more unrealistic contexts triggers similar attributions in individuals scoring high on the HPS. Future research has to examine whether these overly positive attributions after positive, chance-related situations are a stable characteristic with respect to vulnerability to mania.

Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder

OBJECTIVE

The aim of the current study was to evaluate family functioning, social support, and functional impairment as predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder. This study builds upon the extant literature by evaluating these putative psychosocial risk factors simultaneously to determine whether they account for unique variance in clinical outcomes.

METHOD

Patients (N = 92) were recruited from hospital settings during an acute mood episode to participate in pharmacologic or combined family and pharmacologic interventions. The Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, Family Assessment Device, Interpersonal Support Evaluation List, and UCLA Social Attainment Survey were administered at acute phase treatment completion and again at 1-year follow-up. Controlling for mood symptom severity at acute phase treatment completion, multiple regression analyses were used to examine longitudinal associations between the psychosocial variables and subsequent depressive and manic symptoms.

RESULTS

None of the aforementioned psychosocial variables predicted manic symptomatology, and social support alone emerged as a unique predictor of depression at the 1-year follow-up. Effects of social support were moderated by recovery status, such that the strength of association between social support and subsequent depression was stronger for those who had not fully recovered during the acute phase of treatment than for those who had.

CONCLUSIONS

Low levels of social support at acute phase treatment completion, especially in concert with residual symptomatology, may place individuals with bipolar I disorder at risk for subsequent depressive symptoms. These data suggest that maintenance therapies focused on improving level of social support might be especially important to consider in the management of bipolar depression, and add to a growing literature focused on unique vs shared effects of psychosocial risk factors for poor illness course in bipolar disorder.

Cognitive correlates of mania risk: are responses to success, positive moods, and manic symptoms distinct or overlapping?

Several measures of cognitive style have been shown to be elevated among persons diagnosed with bipolar disorder and those at risk for bipolar disorder. Several of these scales capture responses to positive affect, success, and hypomanic symptoms. We had two goals: (a) to use factor analyses to assess whether the constructs within these scales were statistically independent and (b) to examine whether the factors identified uniquely related to mania risk. A cross-national sample of 638 participants completed measures of cognitive style, including the Responses to Positive Affect scale, the Positive Overgeneralization Scale, and the Hypomanic Interpretations Questionnaire. To assess whether these measures might simply reflect more impulsive reactions to positive mood states, participants also completed the Barratt Impulsivity Scale. To measure risk of mania, participants completed the Hypomanic Personality Scale (HPS). Factor analyses suggested seven factors of cognitive style and impulsivity. Four factors uniquely correlated with HPS. That is, risk for mania related to higher scores on separable factors of acting before thinking, being overly positive in interpreting manic symptoms, being overly confident in response to success, and tendencies to dampen positive affect. Current findings suggest the need to consider multifaceted aspects of cognition in refining psychological treatments of bipolar disorder.

On the Role of Goal Dysregulation in the Treatment of Bipolar Disorder

Nusslock, Abramson, Harmon-Jones, Alloy, and Coan (this issue) propose that current psychosocial treatments for bipolar disorder be supplemented with interventions focused on altering goal dysregulation pathways. While innovations to existing treatment manuals are always welcome, there are several reasons why this suggestion may require further consideration. We highlight issues pertaining to the status of cognitive-behavioral therapy for bipolar disorder, the distinction between education and psychoeducation, the nature of familial expressed emotion, differences between clinical and analog samples, and the larger question of how to assess mechanisms in psychosocial treatment studies. We also raise the question of whether an optimistic goal orientation can be a protective factor in patients' long-term coping with bipolar disorder.

Psychosocial Interventions for Bipolar Disorder: Perspective from the Behavioral Approach System (BAS) Dysregulation Theory

Research has emerged providing consistent support for the behavioral approach system (BAS) dysregulation theory of bipolar disorder. The objective of the current article is to examine the extent to which findings from the BAS dysregulation theory can inform psychosocial interventions for bipolar disorder. Towards this end, we first provide an overview of the BAS dysregulation theory. Second, we review extant research on psychosocial interventions for bipolar disorder. And, third, we discuss means by which research and theory in line with the BAS dysregulation model can inform psychosocial interventions for bipolar disorder. Particular attention is given to the clinical implications of research suggesting that bipolar disorder is characterized by high drive/incentive motivation, ambitious goal-setting, and perfectionism in the achievement domain.

Behavioral approach system (BAS)-relevant cognitive styles and bipolar spectrum disorders: concurrent and prospective associations

The authors examined concurrent and prospective associations of behavioral approach system (BAS)-relevant and non-BAS-relevant cognitive styles with bipolar spectrum disorders. Controlling for depressive and hypomanic/manic symptoms, 195 individuals with bipolar spectrum disorders scored higher than 194 demographically similar normal controls on BAS sensitivity and BAS-relevant cognitive dimensions of performance concerns, autonomy, and self-criticism, but not on behavioral inhibition system sensitivity and non-BAS-relevant dimensions of approval seeking, sociotropy, and dependency. Moreover, group differences on autonomy fully mediated the association between higher BAS sensitivity and bipolar status. In addition, only BAS-related cognitive dimensions predicted the likelihood of onset of depressive and hypomanic/manic episodes among the bipolar individuals over a 3.2-year follow-up, controlling for initial symptoms and past history of mood episodes. Higher autonomy and self-criticism predicted a greater likelihood of hypomanic/manic episodes, and higher autonomy predicted a lower likelihood of major depressive episodes. In addition, autonomy mediated the associations between BAS sensitivity and prospective hypomanic/manic episodes. These findings suggest that individuals with bipolar spectrum disorders may exhibit a unique profile of BAS-relevant cognitive styles that influence the course of their mood episodes.

On the specificity of positive emotional dysfunction in psychopathology: evidence from the mood and anxiety disorders and schizophrenia/schizotypy

We review recent research to establish that the associations between positive emotional experience and major forms of psychopathology show considerable specificity. Although indicators of low positive affect are consistently related to both social anxiety/social phobia and schizophrenia/schizotypy, they are more strongly linked to depression, thereby displaying relative specificity. Moreover, low positive affect actually shows greater specificity than the diagnostic criteria for depression and is most strongly related to those symptoms (anhedonia, dysphoria, lassitude, suicidality) that are specific to the disorder. With regard to social phobia, findings suggest that low positive affect is more strongly related to the generalized subtype than to the non-generalized performance subtype. Analyses of schizophrenia/schizotypy indicate that although low positive affect is consistently associated with the negative symptoms (e.g., constricted affect, social aloofness), it is only weakly related to positive symptoms (e.g., magical thinking, perceptual aberrations, suspiciousness). Other data suggest that schizophrenia is associated with an anticipatory pleasure deficit, such that individuals with the disorder engage in rewarding activities less frequently because they do not expect to derive pleasure from them. Finally, we summarize evidence indicating that elevated positive affect is both a risk factor for bipolar disorder and a concomitant of manic symptoms.

Principal Components Analysis of the Hypomanic Attitudes and Positive Predictions Inventory and Associations with Measures of Personality, Cognitive Style and Analogue Symptoms in a Student Sample

Background: An integrative cognitive model proposed that ascribing extreme personal appraisals to changes in internal state is key to the development of the symptoms of bipolar disorder. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) was developed to measure these appraisals. Aims: The aim of the current study was to validate an expanded 61-item version of the HAPPI. Method: In a largely female student sample (N = 134), principal components analysis (PCA) was performed on the HAPPI. Associations between the HAPPI and analogue bipolar symptoms after 3 months were examined. Results: PCA of the HAPPI revealed six categories of belief: Self Activation, Self-and-Other Critical, Catastrophic, Extreme Appraisals of Social Approval, Appraisals of Extreme Agitation, and Loss of Control. The HAPPI predicted all analogue measures of hypomanic symptoms after 3 months when controlling for baseline symptoms. In a more stringent test incorporating other psychological measures, the HAPPI was independently associated only with activation (e.g. thoughts racing) at 3 months. Dependent dysfunctional attitudes predicted greater conflict (e.g. irritability), depression and reduced well-being, hypomanic personality predicted self-reported diagnostic bipolar symptoms, and behavioural dysregulation predicted depression. Conclusions: Extreme beliefs about internal states show a modest independent association with prospective analogue bipolar symptoms, alongside other psychological factors. Further work will be required to improve the factor structure of the HAPPI and study its validity in clinical samples.

Preventing mania: a preliminary examination of the GOALS Program

There is strong evidence of a relationship between goal dysregulation and mania. Building on these findings, we examined the feasibility of developing a mania prevention treatment program designed to improve goal regulation skills for those with bipolar disorder. Here, we describe the process of developing a manual, delivering the intervention to a series of cases, and then conducting a small open uncontrolled trial. All participants met diagnostic criteria for bipolar I disorder based on the Structured Clinical Interview for DSM-IV and were not currently experiencing episodes of depression or mania. Ten participants (8 female, mean age = 46.7 years) were enrolled in the GOALS program and completed an average of 13.2 weekly sessions. Participants were administered the Bech-Rafaelson Mania Scale (BRMS) and the Modified Hamilton Rating Scale for Depression at baseline and termination. Some participants completed self-report scales including the Altman Self-Rating Mania Scale, the Beck Depression Inventory, and the Willingly Approached Set of Statistically Unrealistic Pursuits at baseline and termination. In addition, participants were administered a consumer satisfaction questionnaire at termination. At termination, all 10 participants found the program highly relevant and helpful. Most importantly, even though levels of mania were low initially, mean levels of manic symptoms on the BRMS decreased significantly from baseline to termination, and all 10 participants were within a healthy range (BRMS <7) at termination. Although the lack of control group or follow-up data limits this study, preliminary evidence suggests that it is feasible to identify treatment targets by drawing from the basic research literature in bipolar disorder. Findings await replication and more careful testing within a randomized controlled trial.

Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions

This article reviews the role of social factors, notably life events and family relationships, in the course of bipolar illness in adults and youth. We also discuss psychological variables that help explain the vulnerability of bipolar patients to social environments, including personality factors (e.g., neuroticism), reward sensitivity, and difficulty with the accurate perception of facial emotions. Bipolar patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment events may be one pathway to mania. Negative life events predict depressive symptoms, as do levels of familial expressed emotion. Psychosocial interventions can speed recoveries from episodes and delay recurrences over 1-2 year intervals. Future research should examine the nature of vulnerability/stress interactions at different phases of development, and the role of psychosocial interventions in altering these processes.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.

Psychological processes in bipolar affective disorder: negative cognitive style and reward processing

BACKGROUND

Psychological processes in bipolar disorder are of both clinical and theoretical importance.

AIMS

To examine depressogenic psychological processes and reward responsivity in relation to different mood episodes (mania, depression, remission) and bipolar symptomatology.

METHOD

One hundred and seven individuals with bipolar disorder (34 in a manic/hypomanic or mixed affective state; 30 in a depressed state and 43 who were euthymic) and 41 healthy controls were interviewed with Structured Clinical Interview for DSM-IV and completed a battery of self-rated and experimental measures assessing negative cognitive styles, coping response to negative affect, self-esteem stability and reward responsiveness.

RESULTS

Individuals in all episodes differed from controls on most depression-related and reward responsivity measures. However, correlational analyses revealed clear relationships between negative cognitive styles and depressive symptoms, and reward responsivity and manic symptoms.

CONCLUSIONS

Separate psychological processes are implicated in depression and mania, but cognitive vulnerability to depression is evident even in patients who are euthymic.

Positive and Negative Affect in Individuals at High and Low Risk for Bipolar Disorders

Introduction: Affective disorders are thought to be associated primarily with changes in positive affect (PA) and secondarily with changes in negative affect (NA). Based upon a dysregulation model, we assumed that people at risk for bipolar disorders show stronger emotional reactions – especially with reference to PA – in certain situations (e.g., facing success). Methods: Seventy-two male students completed the Hypomanic Personality Scale and were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The high-risk persons (n = 16) and controls (n = 56) completed an intelligence test and received success feedback. Afterward they played with dice. Affect was repeatedly assessed. Results: High-risk individuals generally reported more PA than controls but no significant interaction with time emerged. Different aspects of PA, however, showed different time courses. Conclusion: Despite methodological limitations, the results are in line with prior research showing that individuals at risk for bipolar disorder often report elevated levels of PA. It is unclear, however, if the available measures are the most appropriate because PA might be a multidimensional concept with its facets being differently affected by time and experimental or environmental changes.

Carbon dioxide induces erratic respiratory responses in bipolar disorder

BACKGROUND

CO(2) respiration stimulates both anxiety and dyspnea ("air hunger") and has long been used to study panic vulnerability and respiratory control. High comorbidity with panic attacks suggests individuals with bipolar disorder may also mount a heightened anxiety response to CO(2). Moreover, problems in the arousal and modulation of appetites are central to the clinical syndromes of mania and depression; hence CO(2) may arouse an abnormal respiratory response to "air hunger".

METHODS

72 individuals (34 bipolar I, 25 depressive and bipolar spectrum, 13 with no major affective diagnosis) breathed air and air with 5% CO(2) via facemask for up to 15 min each; subjective and respiratory responses were recorded.

RESULTS

Nearly half the subjects diverged from the typical response to a fixed, mildly hypercapneic environment, which is to increase breathing acutely, and then maintain a hyperpneic plateau. The best predictors of an abnormal pattern were bipolar diagnosis and anxiety from air alone. 25 individuals had a panic response; panic responses from CO(2) were more likely in subjects with bipolar I compared to other subjects, however the best predictors of a panic response overall were anxiety from air alone and prior history of panic attacks.

LIMITATIONS

Heterogeneous sample, liberal definition of panic attack.

CONCLUSION

Carbon dioxide produces abnormal respiratory and heightened anxiety responses among individuals with bipolar and depressive disorders. These may be due to deficits in emotional conditioning related to fear and appetite. Although preliminary, this work suggests a potentially useful test of a specific functional deficit in bipolar disorder.

Implementing clinical guidelines for bipolar disorder

PURPOSE

To critically review the evidence concerning the implementation of clinical guidelines for bipolar disorder.

METHODS

A Medline search was made of the literature on the implementation of guidelines in bipolar disorder and mental health. The implementation of non-pharmacological treatments from the 2006 NICE Guideline for Bipolar Disorder was then used as a case example. May's model of normalization of complex interventions was then applied to the NICE guideline recommendations for bipolar disorder.

RESULTS

The effective local implementation of guidelines requires a detailed understanding of local barriers to their implementation. Some recommendations in the NICE Guideline on advanced directives and management of anxiety disorder in bipolar disorder appear to follow the existing trends in practice and are more likely to be implemented. Interventions concerning the psychological management of bipolar depression and maintenance psychological treatments are going to be the most difficult to implement because of shortages of skilled staff, the absence of specific training and supervision, the requirements for staff to adopt practices that are quite different from what they are used to, and some uncertainty about whether these interventions are effective in the most severe patients.

CONCLUSIONS

Without a detailed local understanding of the barriers to implementation and the resources and will to overcome them, there is likely to be a considerable local variation in the implementation of guidelines for bipolar disorder. Recommendations that require little change to working practices and resources are most likely to be implemented.

Hypomania: a depressive inhibition override defense mechanism

OBJECTIVE

Evolutionary perspectives on bipolar disorders can further our understanding of the origins of these conditions, and assist clinicians in distinguishing normal from abnormal states. Hypomania is unique amongst bipolar conditions in that it seems to have beneficial aspects and can be difficult to diagnose, in contrast to full-blown mania and depression. A theoretical perspective regarding the evolution of hypomania as a defense mechanism is presented.

METHOD

Literature review focused on the fitness reducing aspects of depression and the fitness enhancing aspects of hypomania/mania.

RESULTS

Of all the adversity inherent in depression, inhibition of physical and mental activity-depressive inhibition-has the most detrimental consequences, and throughout our evolution would have significantly reduced fitness. It is proposed that hypomania evolved as a depressive inhibition override defense mechanism, typically operating in a short-term time frame, to restore physical and mental activity to fitness sustaining or enhancing levels. Over-activity and not mood enhancement enabled hypomania to function as a defense mechanism against the fitness reducing state of depressive inhibition. Contributing to depressive inhibition are the Behavioral Activation System (BAS) and the Behavioral Inhibition System (BIS), two basic motivational systems. Depressive inhibition consists to some extent of low BAS and high BIS. As human intelligence evolved cognitions inhibiting BAS and activating BIS became amplified, resulting in intensified depressive inhibition.

LIMITATIONS

A theoretical perspective.

CONCLUSIONS

Given its ability to override depressive inhibition hypomania might be viewed as a natural treatment as opposed to a problem to treat, producing maximal improvement in areas where functioning has suffered the most while typically enhancing social behavior.

Bipolar disorder as maladaptive arousal: a behavioral model and evidence

Bipolar disorder can be understood as a disorder of behavioral regulation. Manic and depressed individuals are impaired in the titration of appetitive arousal, possibly at the level of neuronal plasticity. An experiment in which fixed 5% CO2 stimulates respiration and blocks satiety tests the regulation of appetitive arousal. In preliminary analysis of data from 35 individuals (24 with bipolar disorder) individuals with bipolar disorder were more likely to fail to find a stable state of respiratory adjustment to CO2. If confirmed, the unstable respiratory response to CO2 may prove useful as a bipolar-disorder endophenotype.

Euthymic patients with bipolar disorder show decreased reward learning in a probabilistic reward task

BACKGROUND

Bipolar disorder (BPD) features cycling mood states ranging from depression to mania with intermittent phases of euthymia. Bipolar disorder subjects often show excessive goal-directed and pleasure-seeking behavior during manic episodes and reduced hedonic capacity during depressive episodes, indicating that BPD might involve altered reward processing. Our goal was to test the hypothesis that BPD is characterized by impairments in adjusting behavior as a function of prior reinforcement history, particularly in the presence of residual anhedonic symptoms.

METHODS

Eighteen medicated BPD subjects and 25 demographically matched comparison subjects performed a probabilistic reward task. To identify putative dysfunctions in reward processing irrespective of mood state, primary analyses focused on euthymic BPD subjects (n = 13). With signal-detection methodologies, response bias toward a more frequently rewarded stimulus was used to objectively assess the participants' propensity to modulate behavior as a function of reinforcement history.

RESULTS

Relative to comparison subjects, euthymic BPD subjects showed a reduced and delayed acquisition of response bias toward the more frequently rewarded stimulus, which was partially due to increased sensitivity to single rewards of the disadvantageous stimulus. Analyses considering the entire BPD sample revealed that reduced reward learning correlated with self-reported anhedonic symptoms, even after adjusting for residual manic and anxious symptoms and general distress.

CONCLUSIONS

The present study provides preliminary evidence indicating that BPD, even during euthymic states, is characterized by dysfunctional reward learning in situations requiring integration of reinforcement information over time and thus offers initial insights about the potential source of dysfunctional reward processing in this disorder.

Development of the treatment attitudes questionnaire in bipolar disorder

Despite the success of pharmacotherapy in the management of bipolar disorder, as many as one-half of those in treatment discontinue their medication over time. Currently, no self-report measure is available that predicts treatment engagement in bipolar disorder. The goal of the current study was to develop a measure of awareness of symptoms and attitudes toward treatment among those with bipolar disorder. Sixty-six participants diagnosed with bipolar I disorder on the SCID completed the Treatment Attitudes Questionnaire (TAQ) and were then followed for up to 2 years to assess symptom levels. Medication data were available for 37 participants. Analyses of the TAQ were conducted to examine reliability, predictors of subscales, and how well scores predicted medication and symptom levels over time. Results indicate that previous episodes of depression, but not episodes of mania, correlated with increased scores on the Insight and the Enjoyment of Mania subscales. Scores on the Nonbiological Attributions subscale predicted lower levels of lithium as well as increased depressive symptoms over time. Although the current study includes limited measurement of treatment engagement and a small sample size, this easily administered scale may help treatment planning for those with bipolar disorder.

Life events as predictors of mania and depression in bipolar I disorder

To date, few prospective studies of life events and bipolar disorder are available, and even fewer have separately examined the role of life events in depression and mania. The goal of this study was to prospectively examine the role of negative and goal-attainment life events as predictors of the course of bipolar disorder. One hundred twenty-five individuals with bipolar I disorder were interviewed monthly for an average of 27 months. Negative and goal-attainment life events were assessed with the Life Events and Difficulties Schedule. Changes in symptoms were evaluated using the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Scale. The clearest results were obtained for goal-attainment life events, which predicted increases in manic symptoms over time. Negative life events predicted increases in depressive symptoms within regression models but were not predictive within multilevel modeling of changes in depressive symptoms. Given different patterns for goal attainment and negative life events, it appears important to consider specific forms of life events in models of bipolar disorder.

Dysregulation of the behavioral approach system (BAS) in bipolar spectrum disorders: review of theory and evidence

In recent years, a call for increased research on bipolar disorder has been answered with methodologically diverse studies exploring goal striving, life events, cognitive style, decision-making, and neurobiological abnormalities in bipolar disorder. In order to further this spurt of research and to systematize our understanding of bipolar disorder, an integrative perspective is warranted. The behavioral approach system (BAS) dysregulation theory, proposed by Richard Depue and colleagues, provides such an integrated model for understanding psychosocial and biological aspects of bipolar disorder. In this paper, we review studies on life events, cognitive style and other psychosocial and neurobiological factors to examine whether the BAS dysregulation theory is supported by existing data. Then, we draw on recent advances in the study of emotion and motivation, and propose an expansion of the BAS dysregulation model of bipolar spectrum disorders to foster further biopsychosocial investigations of bipolar disorder. This expanded model provides greater specificity in predictions, especially about the nature of BAS dysregulation, environmental factors and psychological processes (e.g., appraisal processes) featured in a causal chain culminating in bipolar symptoms. Finally, we discuss the implications of the expanded BAS model for the course of bipolar spectrum disorders.

Effect of bipolar disorder on left frontal cortical responses to goals differing in valence and task difficulty

BACKGROUND

The behavioral activation system (BAS) dysregulation theory of bipolar disorder predicts that bipolar individuals will show an excessive increase in approach motivation during reward striving. Building on past research showing that the left frontal cortical region is involved in approach motivation, we predicted that individuals with bipolar disorder would evidence increased relative left frontal cortical activity in response to goal striving, particularly in response to positive challenges.

METHODS

Right-handed individuals (age 18-24) with a bipolar spectrum diagnosis (n = 41) and individuals with no major affective psychopathology (n = 53) were presented with cues indicating that, on a given trial, an easy, medium, or hard anagram (scrambled word) would be presented in 7 seconds and that they would receive money or avoid losing money for the correct solution (10 anagrams of each of the 6 types). During this preparation period, electroencephalogram (EEG) alpha power was measured and hemispheric asymmetry indexes were computed.

RESULTS

Compared with the nonbipolar individuals, individuals with bipolar disorder showed greater relative left frontal cortical activation in preparation for the hard/win trials. Whereas nonbipolar individuals showed a decrease in left frontal cortical activation from medium to hard win trials, bipolar individuals did not. In addition, among bipolar individuals, current self-reported activation related to greater left frontal activation to the hard/win trials.

CONCLUSIONS

These results provide support for an integrative biopsychosocial model of bipolar disorder, BAS dysregulation theory, and suggest that relative left frontal activity, which may be involved in mania, is triggered by challenging and potentially rewarding events.

A review of potential cognitive and environmental risk markers in children of bipolar parents

Although there is clear evidence that bipolar disorder runs in families, the mechanisms by which this illness is transmitted across generations are poorly understood. In particular, there has been limited consideration of nature of the psychosocial risk factors that might be present in offspring of bipolar parents and of how these factors might increase the likelihood of transition to illness. Recent research has begun to explore psychosocial factors in both healthy and diagnosed children of bipolar parents. This review explores the findings that have been obtained to date in terms of personality, cognitive functioning, life events and family factors. Three potential theoretical frameworks are then considered which might prove fruitful for facilitating theoretically driven empirical studies in this important area. Implications for future research and therapy are noted.

Effects of trauma on bipolar disorder: the mediational role of interpersonal difficulties and alcohol dependence

OBJECTIVES

This study examined: (i) the prevalence of trauma in a bipolar disorder (BD) sample, and (ii) how trauma histories mediated by interpersonal difficulties and alcohol dependence impact on the severity of BD. The prevalence of posttraumatic stress disorder (PTSD) and its relationship to outcomes in BD were also examined.

METHODS

Sixty participants were recruited from a geographically well-defined mental health service in Northern Ireland. Self-reported trauma histories, PTSD, interpersonal difficulties and alcohol dependence and were examined in relation to illness severity.

RESULTS

A high prevalence of trauma was found. Trauma predicted the frequency of hospital admissions (R(2) = 0.08), quality of life (R(2) = 0.23) and inter-episode depressive symptoms (R(2) = 0.13). Interpersonal difficulties, but not alcohol dependence, appeared to play an important role in mediating these adverse effects. While only 8% of the sample met criteria for active PTSD, this comorbid disorder was associated with BD severity.

CONCLUSIONS

This study indicates that awareness of trauma is important in understanding individual differences in bipolar presentations. The theoretical and clinical implications of evidence that trauma is related to more adverse outcomes in BD are discussed. The finding that interpersonal difficulties mediate the relationship between trauma and BD severity is novel. The need for adjunctive evidence-based treatments targeting interpersonal difficulties is considered.

Behavioral Approach System and Behavioral Inhibition System sensitivities and bipolar spectrum disorders: prospective prediction of bipolar mood episodes

OBJECTIVES

Research has found that bipolar spectrum disorders are associated with Behavioral Approach System (BAS) hypersensitivity and both unipolar and bipolar depression are associated with high Behavioral Inhibition System (BIS) sensitivity, but prospective studies of these relationships are lacking. We tested whether BAS and BIS sensitivities prospectively predicted the time to new onsets of major depressive and hypomanic and manic episodes in bipolar spectrum individuals.

METHODS

We followed 136 bipolar II or cyclothymic and 157 demographically matched normal control individuals prospectively for an average of 33 months. Participants completed the BIS/BAS scales and symptom measures at Time 1 and semi-structured diagnostic interviews every four months of follow-up.

RESULTS

The bipolar spectrum group exhibited higher Time 1 BAS, but not BIS, scores than the normal controls, controlling for Time 1 symptoms. Among bipolar spectrum participants, high BAS sensitivity prospectively predicted a shorter time to onset of hypomanic and manic episodes, whereas high BIS sensitivity predicted less survival time to major depressive episodes, controlling for initial symptoms.

CONCLUSIONS

Consistent with the BAS hypersensitivity model of bipolar disorder, a highly responsive BAS provides vulnerability to onsets of (hypo)manic episodes. In addition, a highly sensitive BIS increases risk for major depressive episodes.

A temporal difference account of avoidance learning

Aversive processing plays a central role in human phobic fears and may also be important in some symptoms of psychosis. We developed a temporal-difference model of the conditioned avoidance response, an important experimental model for aversive learning which is also a central pharmacological model of psychosis. In the model, dopamine neurons reported outcomes that were better than the learner expected, typically coming from reaching safety states, and thus controlled the acquisition of a suitable policy. The model accounts for normal conditioned avoidance learning, the persistence of responding in extinction, and critical effects of dopamine blockade, notably that subjects experiencing shocks under dopamine blockade, and hence failing to avoid them, nevertheless develop avoidance responses when both shocks and dopamine blockade are subsequently removed. These postulated roles of dopamine in aversive learning can thus account for many of the effects of dopaminergic modulation seen in laboratory models of psychopathological processes.

Unique association of approach motivation and mania vulnerability

Bipolar disorder involves experiences of both mania and depression over time, and measures of mania-risk and depression-risk therefore tend to be correlated, making it difficult to disentangle the shared versus unique aspects of mania and depression vulnerability. In theory, strong approach motivation is uniquely linked with mania risk, but this relation tends to be obscured unless co-occurring depression risk is statistically controlled. In this study, 461 college students completed the General Behaviour Inventory (GBI)-a validated questionnaire of bipolar disorder vulnerability-and they reported their degree of approach motivation in response to four vignettes that varied in relative incentive versus threat strength. After controlling for the effect of depression vulnerability, mania vulnerability was associated with approach motivation, particularly in response to more threatening scenarios, and this association remained significant even when controlling for dispositional threat and incentive responsiveness, current symptoms, mood, self-esteem, and optimism. The results are consistent with models that regard heightened approach motivation as a unique aspect of mania vulnerability.

An electrophysiological endophenotype of hypomanic and hyperthymic personality

BACKGROUND

Hyperthymic Temperament (HYT) and a closely related trait, Hypomanic Personality (HYP), have both been related to bipolar affective disorder (BAD). Intensity dependence of auditory evoked potentials (IAEP) is a suggested inverse indicator of serotonergic neurotransmission and has been found to be elevated in BAD. Therefore the present study explored for the first time whether subclinical variance of HYT/HYP is also associated with IAEP in a healthy sample. As several traits from biological personality research are correlated with HYT/HYP and also with BAD, the specificity of results against these traits was further analyzed by calculating multiple regression analyses.

METHODS

Evoked potentials were recorded from a sample (N=87) homogenous for confounding variables influencing IAEP. For this reason, only 19 to 27-year-old non-smoker psychiatrically healthy male students were included.

RESULTS

Significant correlations were found between IAEP and both HYP and HYT. Including Sensation or Novelty Seeking and Extraversion in Regression Analyses did not weaken the associations of HYP with IAEP much, but did affect those of HYT. However, these competing biological personality traits were hardly able to predict IAEP themselves. Impulsivity, though, was able to reduce the predictive power of HYP and HYT and to explain unique IAEP-variance. This was even more the case for Behavioral-Activation-System-Sensitivity (BAS) subscale Fun Seeking clearly dominating all regression analyses.

LIMITATIONS

Homogeneity of sample.

CONCLUSIONS

The impact of BAS is in agreement with the assumption that heightened BAS-sensitivity is an underlying biological cause for HYP/HYT and for BAD. Future studies on BAD should include BAS and Impulsivity besides HYP/HYT to further explore uniqueness of the latter and to develop questionnaires based on those items of a hyperthymic-hypomanic-impulsive-funseeking item pool, which possess the most external validity.

Response styles to depressed mood in bipolar affective disorder

BACKGROUND

It has been hypothesised that dysfunctional strategies for avoiding depression play an important role in the pathway to mania. Support for this hypothesis comes from studies demonstrating that remitted and manic bipolar patients show similar cognitive biases to currently depressed patients.

METHOD

Manic patients, depressed bipolar patients, remitted bipolar patients and healthy controls were compared on an expanded version of Nolen-Hoeksema's [Nolen-Hoeksema, S., 1991. Responses to depression and their effects on the duration of depressed mood. Journal of Abnormal Psychology, 100, 569-582.] Response Styles Questionnaire, measuring strategies for coping with depression.

RESULTS

Manic patients reported greater use of active-coping and risk-taking compared to the depressed, remitted and healthy controls. Bipolar remitted patients reported greater rumination.

CONCLUSIONS

The findings are consistent with the hypothesis that mania is associated with dysfunctional strategies for regulating negative emotion.

Positive Mood Induction and Facial Affect Recognition among Students at Risk for Mania

Previous research has suggested that bipolar disorder is characterized by a state-dependent decrease in the ability to recognize facial affect during mania. It remains unclear, though, whether people who are only vulnerable to the disorder show these changes in facial affect recognition. It is also unclear whether minor shifts in mood affect the recognition of facial emotion. Thus, this study examined the effects of positive mood induction on the facial affect recognition of undergraduates vulnerable to mania. Fifty-two undergraduates completed the Hypomanic Personality Scale, and also completed a measure of their ability to recognize affect in pictures of faces. After receiving false success feedback on another task to induce a positive mood, they completed the facial affect recognition measure again. Although we expected to find a relationship between higher Hypomanic Personality Scale (HPS) scores and an impaired ability to recognize negative facial affect after a positive mood induction, this was not found. Rather, there was a significant interaction between HPS scores and happiness level, such that individuals with higher scores on the HPS who also reported higher levels of happiness were particularly adept at identifying subtle facial expressions of happiness. This finding expands a growing literature linking manic tendencies to sensitivity to positive stimuli and demonstrates that this sensitivity may have bearing on interpersonal interactions.

Life stress and the course of early-onset bipolar disorder

BACKGROUND

Studies of adult bipolar patients and adolescents with major depression indicate that life stress and mood symptoms are temporally and causally related to one another. This study examined whether levels of life stress predict levels of mood symptoms among bipolar adolescents participating in a treatment development study of family-focused psychoeducation and pharmacotherapy.

METHODS

Bipolar adolescents (n=38) who reported a period of acute mood symptoms within the prior 3 months were recruited for a 1-year study of life stress. Clinician-administered evaluations were completed with adolescents and parents at 3-month intervals for up to 12 months, using the UCLA Life Stress Interview and the K-SADS Mania and Depression Rating Scales.

RESULTS

Chronic stress in family, romantic and peer relationships was associated with less improvement in mood symptoms over the study year. The frequency of severe, independent life events also predicted less improvement in mood symptoms. Higher levels of chronic stress in family and romantic relationships, and higher severity of independent events, were more strongly associated with mood symptoms among older adolescents. Results were independent of adolescents' psychosocial treatment regimens.

LIMITATIONS

The majority of adolescents received family-focused psychoeducational treatment and all were being treated with psychotropic medication. The influence of life stress on mood symptoms may have been attenuated by intensive intervention.

CONCLUSIONS

Stress is linked to changes in mood symptoms among bipolar adolescents, although correlations between life events and symptoms vary with age. Chronic stress in family, romantic, and peer relationships are important targets for psychosocial intervention.

Life events and juvenile bipolar disorder: conceptual issues and early findings

There is increasing interest in the psychosocial variables that might predict the course of child and adolescent bipolar disorder. In the literature on adult bipolar disorder, life events have been shown to be a major predictor of symptoms. In this review, we focus on studies of how life events influence the course of child and adolescent bipolar disorder. To begin, we review methodological considerations in life events research, and briefly summarize the findings regarding life events in adult bipolar disorder. Then, we discuss available studies on life events as a predictor of the course of juvenile bipolar disorder. We conclude with suggested directions for future research.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

Responses to Positive Affect: A Self-Report Measure of Rumination and Dampening

Rumination in response to dysphoric moods has been linked to the onset and maintenance of depressive symptoms; however, responses to positive moods have received less attention despite the theoretical roles of both positive and negative affect in mood disorders. The purpose of the present study was to develop a self-report measure of ruminative and dampening Responses to Positive Affect (RPA), which we called the RPA Questionnaire. In two psychometric studies, the three subscales of the RPA (Dampening, Self-focused positive rumination, and Emotion-focused positive rumination) demonstrated acceptable structural validity, internal consistency, and preliminary evidence of convergent and incremental validity with concurrent measures of self-esteem, depressive rumination, and depressive and manic symptoms among undergraduates. The present results suggest that future research on mood disorders would benefit from measuring responses to both negative and positive moods.

Role of treatment alliance in the clinical management of bipolar disorder: stronger alliances prospectively predict fewer manic symptoms

The strength of the treatment alliance between patients and their clinicians may play a unique role in the management of bipolar disorder. However, few empirical studies have examined the alliance in bipolar disorder or its effects on patient outcomes. This study investigates variables associated with a strong treatment alliance in bipolar disorder, and the prospective effects of treatment alliance on patients' mood symptoms and treatment attitudes. Participants were 58 longitudinally followed individuals with Bipolar I disorder. We found that alliance ratings covaried with depressive symptoms, such that alliance strength increased as depressive symptoms decreased, and stronger alliances were associated with more social support. Tests of temporal association indicated that stronger alliances predicted fewer manic symptoms 6 months later. Stronger alliances also predicted less negative attitudes about medication and less of a sense of stigma about bipolar disorder. Thus, a strong treatment alliance may help to reduce manic symptoms over time. It may be that a strong treatment alliance encourages patients' greater acceptance of bipolar disorder and psychopharmacological interventions, and thus contributes to improved medication adherence and clinical outcomes. Considered in sum, these findings suggest that the treatment alliance is an integral component of the long-term management of bipolar disorder.

An update on the role of psychotherapy in the management of bipolar disorder

Recent studies have examined the value of combining structured forms of psychotherapy with medication maintenance for patients with bipolar disorder. These studies have been influenced by the growing body of literature on stress in the elicitation of manic and depressive episodes. Randomized trials published within the past 5 years indicate positive benefits of cognitive-behavioral therapy, interpersonal and social rhythm therapy, family-focused therapy, and group psychoeducation as adjuncts to mood stabilizers in delaying recurrences, stabilizing symptoms, and improving medication adherence. Open trials of family interventions for pediatric-onset bipolar patients also have yielded promising results. Questions remain about the relative advantages of one psychosocial approach over the others, whether there are subgroups of patients who respond to each type of intervention, the impact of psychotherapy on role functioning, mediators of treatment effects, and the potential utility of early intervention as a means of delaying the onset and/or severity of the disorder.

Adapting interpersonal and social rhythm therapy to the developmental needs of adolescents with bipolar disorder

Interpersonal and social rhythm therapy (IPSRT) is a manual-based adjunctive psychotherapy specific to the treatment of bipolar disorder. This paper reviews the theoretical rationale and empirical evidence for the efficacy of IPSRT in combination with pharmacotherapy for adults with bipolar I disorder. We then provide an overview of the developmental modifications being made to IPSRT to increase its relevance to adolescents with bipolar disorder.

Extreme Goal Setting and Vulnerability to Mania Among Undiagnosed Young Adults

During euthymia people with bipolar disorder and their unaffected family members accomplish more than the general population. People with bipolar disorder, or those who are at risk for it, also set higher goals in laboratory tasks than other people. The work reported here examines whether persons vulnerable to mania set elevated goals in their lives. In two studies, a measure of lifetime vulnerability to mania was related to traits bearing on incentive sensitivity, and also to endorsement of high ambitions for fame, wealth, and political influence (assessed by a new measure). Relations were weaker to ambitions for other kinds of extreme goals. The effects were independent of current symptoms of mania and depression and lifetime depression. There was also evidence that incentive sensitivity and elevated aspirations made independent contributions to variance in the measure of manic risk. Discussion focuses on the implications of high goal setting for understanding goal dysregulation and mania.