Increases in manic symptoms after life events involving goal attainment

Are dysfunctional attitudes elevated and linked to mood in bipolar disorder? A systematic review and meta-analysis

OBJECTIVES

Dysfunctional attitudes (DA) are higher in depression; however, less is understood about their role in bipolar disorder (BD). This paper aimed to explore the presence of DA in BD in comparison to clinical and non-clinical groups. Also explored were the associations between DA and mood states of depression, mania or euthymia in BD.

METHODS

A systematic review and meta-analysis were conducted. A total of 47 articles were included in the systematic review of which 23 were included in the meta-analysis. The quality of each study was rated.

RESULTS

The meta-analysis showed significantly higher DA in BD than healthy controls (d = .70). However, no difference was observed between BD and unipolar participants (d = -.16). When reviewing mood state within BD, a significant mean difference was found between DA scores for euthymic and depressed participants (d = -.71), with those who were depressed scoring higher. Three studies found that psychological therapies significantly reduce DA in BD (d = -.38).

CONCLUSIONS

These findings imply not only that DA are both a characteristic of BD that is not as prevalent in healthy populations but also that a depressed mood state is associated with increased severity. This implies that DA could possibly go 'offline' when mood symptoms are not present. Psychological therapies appear to reduce DA in BD. Implications for future research as well as practice-based implications are expanded on in the discussion.

Circadian, Reward, and Emotion Systems in Teens prospective longitudinal study: protocol overview of an integrative reward-circadian rhythm model of first onset of bipolar spectrum disorder in adolescence

BACKGROUND

Bipolar spectrum disorders (BSDs) are associated with a heightened sensitivity to rewards and elevated reward-related brain function in cortico-striatal circuitry. A separate literature documents social and circadian rhythm disruption in BSDs. Recently, integrated reward-circadian models of BSDs have been proposed. These models draw on work indicating that the two systems influence each other and interact to affect mood functioning. When dysregulated, reward and circadian system signaling may combine to form a positive feedback loop, whereby dysregulation in one system exacerbates dysregulation in the other. Project CREST (Circadian, Reward, and Emotion Systems in Teens) provides a first systematic test of reward-circadian dysregulation as a synergistic and dynamic vulnerability for first onset of BSD and increases in bipolar symptoms during adolescence.

METHODS

This NIMH-funded R01 study is a 3-year prospective, longitudinal investigation of approximately 320 community adolescents from the broader Philadelphia area, United States of America. Eligible participants must be 13-16 years old, fluent in English, and without a prior BSD or hypomanic episode. They are being selected along the entire dimension of self-reported reward responsiveness, with oversampling at the high tail of the dimension in order to increase the likelihood of BSD onsets. At Times 1-6, every 6 months, participants will complete assessments of reward-relevant and social rhythm disruption life events and self-report and diagnostic assessments of bipolar symptoms and episodes. Yearly, at Times 1, 3, and 5, participants also will complete self-report measures of circadian chronotype (morningness-eveningness) and social rhythm regularity, a salivary dim light melatonin onset (DLMO) procedure to assess circadian phase, self-report, behavioral, and neural (fMRI) assessments of monetary and social reward responsiveness, and a 7-day ecological momentary assessment (EMA) period. During each EMA period, participants will complete continuous measures of sleep/wake and activity (actigraphy), a daily sleep diary, and three within-day (morning, afternoon, evening) measures of life events coded for reward-relevance and social rhythm disruption, monetary and social reward responsiveness, positive and negative affect, and hypo/manic and depressive symptoms. The fMRI scan will occur on the day before and the DLMO procedure will occur on the first evening of the 7-day EMA period.

DISCUSSION

This study is an innovative integration of research on multi-organ systems involved in reward and circadian signaling in understanding first onset of BSD in adolescence. It has the potential to facilitate novel pharmacological, neural, and behavioral interventions to treat, and ideally prevent, bipolar conditions.

Positive irrational beliefs are associated with hypomanic personality

Primary irrational beliefs, such as demanding about attaining personal goals, are a common trans-diagnostic factor involved in many emotional disorders. Although Bipolar Disorder (BPD) is a severe emotional disorder, little is known about the role of primary irrational beliefs in the risk of BPD. Given that the risk for mania is related to responses to positive rather than adverse events, we developed a measure of irrational beliefs in response to cues of positive events. This is the first study that examines the relationship between positive primary irrational beliefs and the risk of BPD. 119 participants completed an online survey including measures for the risk of BPD, irrational beliefs, positive irrational beliefs, mania-related cognitions, and mood measures (depressive and manic mood). Results revealed significant associations between the risk of BPD and positive primary irrational beliefs, irrational beliefs, positive generalization, and mood. Regression analyses revealed that positive primary irrational beliefs, such as demanding to attain significant goals in response to cues for positive events, uniquely predict the risk for BPD independently of mood, mania-related cognitions and irrational beliefs. These findings encourage the treatment approaches focused on restructuring primary irrational beliefs in response to positive situations to reduce the risk of BPD.

Social and environmental variables as predictors of mania: a review of longitudinal research findings

Considerable evidence suggests that psychosocial variables can shape the course of bipolar disorder. Here, though, we focus on the more specific idea that the social environment can predict the course of mania. We systematically review evidence from longitudinal studies concerning how social support, family interactions, traumatic life events, and recent life events relate to the age of onset, the frequency of episode recurrence, and the severity of manic symptoms. Although we find some evidence that the course of mania can be worsened by social environmental factors, the links are specific. Among social variables, some studies indicate that conflict and hostility are predictive, but more general social relationship qualities have not been found to predict mania. Some research indicates that childhood trauma, and recent life events involving goal attainment or sleep disruption can predict mania. Taken together, the profile of variables involving recent exposure that are most predictive include those that are activating, reward-related, or sleep-disrupting, which fits with general psychological hypotheses of behavioral activation and sleep disruption as important for mania. We discuss gaps in the literature, and we note future directions for research, including the need for more integrative, longitudinal research on a fuller range of social and biological risk variables.

Risk for bipolar spectrum disorders associated with positive urgency and orbitofrontal cortical grey matter volume

Bipolar spectrum disorders (BSDs) are associated with reward hypersensitivity, impulsivity, and structural abnormalities within the brain's reward system. Using a behavioral high-risk study design based on reward sensitivity, this paper had two primary objectives: 1) investigate whether elevated positive urgency, the tendency to act rashly when experiencing extreme positive affect, is a risk for or correlate of BSDs, and 2) examine the nature of the relationship between positive urgency and grey matter volume in fronto-striatal reward regions, among individuals at differential risk for BSD. Young adults (ages 18-28) screened to be moderately reward sensitive (MReward; N = 42), highly reward sensitive (HReward; N = 48), or highly reward sensitive with a lifetime BSD (HReward + BSD; N = 32) completed a structural MRI scan and the positive urgency subscale of the UPPS-P scale. Positive urgency scores varied with BSD risk (MReward < HReward < HReward + BSD; ps≤0.05), and positive urgency interacted with BSD risk group in predicting lateral OFC volume (p <.001). Specifically, the MReward group showed a negative relationship between positive urgency and lateral OFC volume. By contrast, there was no relationship between positive urgency and lateral OFC grey matter volume among the HReward and HReward + BSD groups. The results suggest that heightened trait positive urgency is a pre-existing vulnerability for BSD that worsens with illness onset, and there is a distinct relationship between positive urgency and lateral OFC volume among individuals at high versus low risk for BSD. These findings have implications for understanding the expression and development of impulsivity in BSDs.

Dynamic interplay between life events and course of psychotic disorders: 10-year longitudinal study following first admission

BACKGROUND

Life events (LEs) are a risk factor for first onset and relapse of psychotic disorders. However, the impact of LEs on specific symptoms - namely reality distortion, disorganization, negative symptoms, depression, and mania - remains unclear. Moreover, the differential effects of negative v. positive LEs are poorly understood.

METHODS

The present study utilizes an epidemiologic cohort of patients (N = 428) ascertained at first-admission for psychosis and followed for a decade thereafter. Symptoms were assessed at 6-, 24-, 48-, and 120-month follow-ups.

RESULTS

We examined symptom change within-person and found that negative events in the previous 6 months predicted an increase in reality distortion (β = 0.07), disorganized (β = 0.07), manic (β = 0.08), and depressive symptoms (β = 0.06), and a decrease in negative symptoms (β = -0.08). Conversely, positive LEs predicted fewer reality distortion (β = -0.04), disorganized (β = -0.04), and negative (β = -0.13) symptoms, and were unrelated to mood symptoms. A between-person approach to the same hypotheses confirmed that negative LEs predicted change in all symptoms, while positive LEs predicted change only in negative symptoms. In contrast, symptoms rarely predicted future LEs.

CONCLUSIONS

These findings confirm that LEs have an effect on symptoms, and thus contribute to the burden of psychotic disorders. That LEs increase positive symptoms and decrease negative symptoms suggest at least two different mechanisms underlying the relationship between LEs and symptoms. Our findings underscore the need for increased symptom monitoring following negative LEs, as symptoms may worsen during that time.

Evidence-Informed Approach to De-Prescribing of Atypical Antipsychotics (AAP) in the Management of Behavioral Expressions (BE) in Advanced Neurocognitive Disorders (NCD): Results of a Retrospective Study

The LuBAIR™ Paradigm is a novel approach to ascribe meaning to behavioral expressions in advanced neurocognitive disorders when the reliability of a clinical assessment is limited. The meaning ascribed to each behavioral category was used to identify those which are likely to respond to the use of atypical antipsychotics, in their management. De-prescribing was attempted on patients who qualified to enter this retrospective study. De-prescribing was defined as successful if individuals were completely withdrawn from AAP and remained off them for 60 days, without the re-emergence of behaviors. The LuBAIR™ Inventory was filled on two occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. MANOVA, Chi-Square paired t-test statistical analyses were used to detect the differences in the behavioral categories between the two cohorts. Cohen d was used to measure effect size. Patients who did not have Mis-Identification and Goal-Directed Expressions were more likely to successfully de-prescribe: X2 (1, N = 40) = 29.119 p < 0.0001 and X2 (1, N = 40) = 32.374, p < 0.0001, respectively. Alternatively, the same behavioral categories were more likely to be present in patients who failed de-prescribing: MANOVA and paired t-test (p < 0.0001). Atypical antipsychotics, in their role as an antipsychotic and mood stabilizer, may be used to manage Mis-Identification and Goal-Directed Expressions, respectively.

Dysfunctional cognition in individuals with an increased risk for mania

Background

There is still a lack of knowledge about attitudes and cognitions that are related to bipolar disorder. Theoretically, it was proposed that exaggerated beliefs about the self, relationships, the need for excitement, and goal-related activities might lead to mania in vulnerable individuals, however, the few studies that examined this hypothesis provided mixed results. One of the unresolved issues is if such a cognitive style is associated with current mood symptoms or with different stages of the illness, i.e. at-risk versus diagnosed bipolar disorder. Therefore, the present study aimed at evaluating depression and mania-related cognitive style in individuals at-risk for mania.

Method

In an online survey, we collected data of 255 students of the University of Klagenfurt, Austria. All participants completed the Hypomanic Personality Scale (HPS), the Cognition Checklist for Mania – Revised (CCL-M-R), the Dysfunctional Attitude Scale (DAS), the Beck Depression Inventory (BDI), and the Internal State Scale (ISS).

Results

In a hierarchical regression, HPS was positively related to scores of all subscales of the CCL-M-R. The HPS did not significantly predict scores of the DAS. Current manic and depressive symptoms significantly contributed to the models.

Conclusion

The present results suggest that a trait-like risk for mania is associated with mania-related but not depression-related cognitions.

Individuals at-risk for mania show mania-specific rather than depression-specific thinking patters.

Current subclinical mood symptoms are related to mood-congruent attitudes and cognitions.

Emotional awareness, affective dysregulation, and bipolar spectrum psychopathology: A path analysis

Affective dysregulation is present in those with subsyndromal symptoms of hypomania and mania and prospectively predicts the development of bipolar spectrum disorders. A crucial, understudied area related to the experience and regulation of emotion in this population is emotional awareness - emotional clarity (Clarity) and attention to emotion (Attention). We examined whether scores on the Hypomanic Personality Scale (HPS) were associated with deficits in emotional awareness and whether these deficits were associated with heightened intensity and instability of negative (NA) and positive affect (PA). Young adults (n=233), oversampled for high HPS scores completed self-reports and 14 days of experience sampling assessing high and low arousal NA and PA. HPS scores were associated with low Clarity and unassociated with Attention. High HPS scores were associated with greater high and low arousal NA intensity and instability only for those at low and mean levels of Attention. In contrast, there was a significant indirect association between HPS scores and intensity of high and low arousal NA and PA, as well as instability of high arousal NA, through low Clarity. Results highlighted that individual differences exist in the extent to which facets of emotional awareness differentially link scores on the HPS to emotional outcomes.

Prolonged functional cerebral asymmetry as a consequence of dysfunctional parvocellular paraventricular hypothalamic nucleus signaling: An integrative model for the pathophysiology of bipolar disorder

Approximately 45 million people worldwide are diagnosed with bipolar disorder (BD). While there are many known risk factors and models of the pathologic processes influencing BD, the exact neurologic underpinnings of BD are unknown. We attempt to integrate the existing literature and create a unifying hypothesis regarding the pathophysiology of BD with the hope that a concrete model may potentially facilitate more specific diagnosis, prevention, and treatment of BD in the future. We hypothesize that dysfunctional signaling from the parvocellular neurons of the paraventricular hypothalamic nucleus (PVN) results in the clinical presentation of BD. Functional damage to this nucleus and its signaling pathways may be mediated by myriad factors (e.g. immune dysregulation and auto-immune processes, polygenetic variation, dysfunctional interhemispheric connections, and impaired or overactivated hypothalamic axes) which could help explain the wide variety of clinical presentations along the BD spectrum. The neurons of the PVN regulate ultradian rhythms, which are observed in cyclic variations in healthy individuals, and mediate changes in functional hemispheric lateralization. Theoretically, dysfunctional PVN signaling results in prolonged functional hemispheric dominance. In this model, prolonged right hemispheric dominance leads to depressive symptoms, whereas left hemispheric dominance correlated to the clinical picture of mania. Subsequently, physiologic processes that increase signaling through the PVN (hypothalamic-pituitaryadrenal axis, hypothalamic- pituitary-gonadal axis, and hypothalamic-pituitary-thyroid axis activity, suprachiasmatic nucleus pathways) as well as, neuro-endocrine induced excito-toxicity, auto-immune and inflammatory flairs may induce mood episodes in susceptible individuals. Potentially, ultradian rhythms slowing with age, in combination with changes in hypothalamic axes and maturation of neural circuitry, accounts for BD clinically presenting more frequently in young adulthood than later in life.

Behavioral activation system (BAS) dysregulation and bipolar spectrum psychopathology in daily life: An online-diary study

Dysregulation of the behavioral activation system (BAS) has been theorized to be a core factor underlying mood swings in bipolar disorder (BD). However, few studies have directly addressed BAS dysregulation and more research is needed to understand its dynamic expression in daily life. The aim of this study was to directly assess BAS dysregulation, and to examine its moderating effect on the relationship between life events and bipolar spectrum symptoms via multilevel modeling. Korean young adults (n = 100) were screened using the Hypomanic Personality Scale (HPS) from a large sample (N = 1,591). They completed online diaries for 7 consecutive days including the Daily Events Record as well as bipolar spectrum symptoms. BAS-activating and/or -deactivating scores were allocated to each reported life event by an expert consensus rating. Cross-level interaction analysis showed that the occurrence of BA life events contributed to a steeper increase in bipolar spectrum symptoms, particularly for individuals with high BAS dysregulation. The present study suggests that BAS dysregulation is a unique construct that deserves further exploration in BD.

Mania Following Bereavement: State of the Art and Clinical Evidence

Bereavement is the state of loss, determined in most of the cases by the death of a close person. It is probably the greatest sorrow that can occur in an individual life. Grief is a normal, healthy response to loss, evolving through stages in the process of mourning. In some cases, bereavement may lead to the outburst of manic episode: despite literature data being scarce, reports have explored this important clinical entity, variously called as "funeral mania" or "bereavement mania". We systematically reviewed the literature exploring the possible relationships between bereavement and the onset of a manic episode, both first or recurrent pre-existing episode, besides describing a case report on a manic episode in the aftermath of a loss event, with an accurate evaluation of prior mild mood spectrum instability, supporting the role of loss-events as potential risk factor for bipolar illness progression. This article tries summarizing existing evidence on the debate whether clinicians should consider mania as a possible bereavement reaction.

A prospective study of bipolar disorder vulnerability in relation to behavioural activation, behavioural inhibition and dysregulation of the Behavioural Activation System

Background:

The weak regulation, or “dysregulation”, of the Behavioural Activation System (BAS) is implicated in the development and recurrence of bipolar disorder. However, there has been a lack of prospective studies investigating the predictive role of BAS dysregulation in relation to bipolar-vulnerability. Furthermore, no studies have tested the prospective predictive utility of the DYS self-report measure of BAS dysregulation in an analogue sample. The goal of the current study was to redress this gap.

Methods:

Participants (n = 127) completed baseline self-report measures of mood symptoms (Internal States Scale [ISS]), the Hypomanic Personality Scale (HPS), behavioural activation, inhibition and dysregulation of BAS (BIS/BAS and DYS), and at six months, the Mood Disorders Questionnaire (MDQ).

Results:

Linear regression analysis indicated a significant main effect of BAS Dysregulation, and a significant interaction between BIS and BAS Fun Seeking, on prospective MDQ scores whilst controlling for baseline mood symptoms and HPS scores. The interaction effect indicated that the relationship between high BAS Fun Seeking and follow-up MDQ scores was strongest when BIS scores were high, whilst the lowest MDQ scores were observed for a combination of low BAS Fun Seeking and high BIS. However, DYS scores were the stronger predictor of MDQ scores compared to the BAS Fun Seeking and BIS interaction.

Conclusions:

Bipolar-vulnerability is prospectively associated with heightened BAS Dysregulation, as measured by the DYS subscale, similar to prior findings in clinical samples. Further research investigating the longer-term associations between BAS Dysregulation with the development of clinically significant bipolar mood symptoms is required.

Reward sensitivity and the course of bipolar disorder: A survival analysis in a treatment seeking sample

OBJECTIVES

Reward sensitivity is suggested to be an influence on the onset and reoccurrence of bipolar disorder (BD) in observational longitudinal studies. The current study examined whether reward sensitivity predicted the recurrence of mood episodes in a treatment seeking sample. We also explored if reward sensitivity moderated treatment outcomes of psychosocial treatment.

METHODS

Seventy-six euthymic adult patients with BD were randomly assigned to either Cognitive Behavioral Therapy (CBT) or Supportive Therapy (ST) and followed up for 2 years after completing therapy (Meyer and Hautzinger, 2012). The primary outcome measure was recurrence of mood episodes. The final multivariate Cox regression models included potential covariates, therapy conditions, BAS reward sensitivity, and the interaction between BAS and therapy conditions.

RESULTS

BAS emerged as the only significant predictor of time till recurrence of mania, but not depression, but the overall model did not reach significance. There was no interaction between treatment and BAS reward sensitivity. Interestingly, a diagnosis of BD II predicted time till recurrence of depression.

CONCLUSION

The main result regarding BAS partially confirms prior studies linking BAS and mania, but power and the specific sample seeking psychosocial treatment might have reduced the effect.

A positive emotion regulation intervention for bipolar I disorder: Treatment development and initial outcomes

OBJECTIVE

Dysfunction in positive affect is a defining symptom of bipolar I disorder (BD), both during and between mood episodes. We hypothesize that helping people with BD learn skills to create balance in their affective experiences by engaging in strategies that increase low activation positive emotion (LAP; e.g., relaxation) could help to improve well-being during periods of symptom remission. We discuss the development and preliminary outcomes of a positive emotion regulation (PER) group treatment for people with BD, designed as a supplement to pharmacological treatment.

METHOD

The Learning Affective Understanding for a Rich Emotional Life (LAUREL) intervention is a group-based intervention covering 10 empirically supported skills designed to increase LAP. Sixteen people with BD enrolled in the LAUREL intervention and twelve completed baseline and post-intervention assessments.

RESULTS

Participants who completed the study (n = 12) attended the majority of groups (87.96%) and reported practicing skills, on average, 16 times a week. We were unable to detect significant differences in mania symptoms following engagement in this PER intervention. Finally, participants reported increases in several areas associated with well-being post-intervention, including mindfulness, reappraisal, and self-compassion.

CONCLUSION

This study provides a theoretical framework and preliminary support for a PER intervention for BD.

Impulsivity and Behavior-Dependent Life Events Mediate the Relationship of Reward Sensitivity and Depression, but Not Hypomania, Among at-Risk Adolescents

Both reward sensitivity and impulsivity are related to the development and course of bipolar spectrum disorders (BSDs) and have been implicated in other disorders and negative functional outcomes such as substance abuse, obesity, suicidal behaviors, and risk-taking. Furthermore, according to the transactional component of the Behavioral Approach System (BAS)/reward hypersensitivity theory of BSDs, people with reward hypersensitivity should experience more BAS-relevant events, and thus, are more vulnerable to mood symptoms and episodes via stress generation. Impulsivity may exacerbate stress generation in individuals at risk for BSDs based on exhibiting reward hypersensitivity. The current study examined whether impulsivity explained the generation of stress and subsequent mood symptoms beyond what is explained by reward sensitivity alone. Participants were 131 Moderate BAS and 216 High BAS sensitivity adolescents (M = 18.43 years, SD = 1.40), who completed baseline measures of reward sensitivity and impulsivity, as well as follow-up measures of life events and mood symptoms. Results from linear regression analyses indicated that higher baseline impulsivity predicted behavior-dependent, but not behavior-independent, life events. Furthermore, path analyses suggested that the effect of BAS group on depression symptoms at next follow-up was partly explained via the indirect effect of impulsivity and negative behavior-dependent life events. We did not find these effects for behavior-independent or positive-dependent events or for prediction of hypomanic symptoms. The findings suggest that impulsivity may account for stress generation of negative events that precede depression.

Identity in bipolar disorder: Self-worth and achievement

This article considers self and self-concept in bipolar disorder. Bipolar disorder, defined on the basis of manic symptoms, is a highly debilitating psychopathology. It is heavily grounded in biology but symptom course is still very responsive to psychological and social forces in the lives of persons who have the disorder. This review assumes an overall view of the self that is typical of personality psychology: self as traits, self as goals and aspirations, and ongoing efforts to attain those goals. In this review, we will discuss two different facets of self and identity in bipolar disorder. First, we review a body of goal pursuit literature suggesting that persons with bipolar disorder endorse heightened ambitions for attaining goals and recognition from others. Second, we will review multiple findings which suggest that among persons with bipolar disorder, self-worth depends on measurable success in an extreme way. We will consider how the intersection of these two themes may lead to unique identity challenges for people with bipolar disorder, drawing from self-report, behavioral, and neuroscience findings to critically examine this viewpoint.

The Behavioral Approach System (BAS) Model of Vulnerability to Bipolar Disorder: Evidence of a Continuum in BAS Sensitivity across Adolescence

Behavioral Approach System (BAS) sensitivity has been implicated in the development of a variety of different psychiatric disorders. Prominent among these in the empirical literature are bipolar spectrum disorders (BSDs). Given that adolescence represents a critical developmental stage of risk for the onset of BSDs, it is important to clarify the latent structure of BAS sensitivity in this period of development. A statistical approach especially well-suited for delineating the latent structure of BAS sensitivity is taxometric analysis, which is designed to evaluate whether the latent structure of a construct is taxonic (i.e., categorical) or dimensional (i.e., continuous) in nature. The current study applied three mathematically non-redundant taxometric procedures (i.e., MAMBAC, MAXEIG, and L-Mode) to a large community sample of adolescents (n = 12,494) who completed two separate measures of BAS sensitivity: the BIS/BAS Scales Carver and White (Journal of Personality and Social Psychology, 67, 319-333. 1994) and the Sensitivity to Reward and Sensitivity to Punishment Questionnaire (Torrubia et al. Personality and Individual Differences, 31, 837-862. 2001). Given the significant developmental changes in reward sensitivity that occur across adolescence, the current investigation aimed to provide a fine-grained evaluation of the data by performing taxometric analyses at an age-by-age level (14-19 years; n for each age ≥ 883). Results derived from taxometric procedures, across all ages tested, were highly consistent, providing strong evidence that BAS sensitivity is best conceptualized as dimensional in nature. Thus, the findings suggest that BAS-related vulnerability to BSDs exists along a continuum of severity, with no natural cut-point qualitatively differentiating high- and low-risk adolescents. Clinical and research implications for the assessment of BSD-related vulnerability are discussed.

Electrocardiographic and Electrooculographic Responses to External Emotions and Their Transitions in Bipolar I and II Disorders

Bipolar disorder has two main types, bipolar I (BD I) and II (BD II), which present different affective states and personality characteristics, they might present different modes of emotional regulation. We hypothesized that the electrocardiogram and electrooculogram to external emotions are different in BD I and BD II. We asked 69 BD I and 54 BD II patients, and 139 healthy volunteers to undergo these tests in response to disgust, erotica, fear, happiness, neutral, and sadness, and their transitions. Their affective states were also measured. The heart rate in BD I was significantly higher under background fear after target neutral. The eyeball movement was quicker in BD I under target happiness after background disgust; in BD I under target sadness after background disgust; and in BD I under background disgust after target neutral. Some electrocardiographic and electrooculographic changes were correlated with affective states in patients. BD I and BD II had different physiological responses to external emotions and their transitions, indicating different pathophysiologies and suggesting different emotional-therapies for BD I and BD II.

Combining cognitive therapy with medication in bipolar disorder

Although mood stabilisers have substantially improved the treatment of bipolar disorder, recent studies suggest that treatment with lithium is not as effective as originally claimed. Furthermore, patients still have high rates of relapse even when prescribed medication. Recent research has shown that poor coping strategies in response to bipolar prodromes and disruptions of sleep and social routines increase the risk of relapse. Combining a psychosocial approach with medication may improve the rate of relapse prevention. Cognitive therapy teaches patients better self-monitoring and coping skills and is therefore an appropriate means of minimising psychosocial risk factors for relapse. Recent randomised controlled trials suggest that combined medication and cognitive therapy significantly reduce bipolar relapse compared with medication alone.

Social inhibition, sense of belonging and vulnerability to internalizing problems

BACKGROUND

The aim of this study was to provide a conceptual test of how social inhibition, sense of belonging and internalizing problems are related, and whether sense of belonging moderates or mediates the relation between social inhibition and internalizing problems.

METHODS

Data were used from two waves of the Dutch internet cohort LISS (Longitudinal Internet Studies of the Social Sciences; N = 511, M age = 52.09 years). Social inhibition was measured using the DS14 in 2012, sense of belonging (i.e., feeling cut off and having people to really talk to) was measured with the General Social Exclusion Index in 2012 and internalizing problems with the MHI-5 in 2015.

RESULTS

Social inhibition was related to a lower sense of belonging and more internalizing problems. A low sense of belonging was related to more internalizing problems. Results indicated no moderation. However, evidence was found for partial mediation. That is, feeling cut off and having people to really talk to explained part of the link between social inhibition and internalizing problems. All analyses were controlled for sex, age and income.

LIMITATIONS

The items used to measure sense of belonging only cover part of the construct. The study was not fully prospective, as such, no conclusions can be drawn regarding causality.

CONCLUSIONS

Low sense of belonging is a key factor to consider when aiming at understanding individual differences in internalizing psychopathology related to social inhibition.

Disrupted cortico-limbic connectivity during reward processing in remitted bipolar I disorder

OBJECTIVES

Bipolar disorder (BD) is associated with elevated reward sensitivity and persistent positive affect, yet the neural mechanisms underlying these patterns are not well understood. In the present study, we examined putative disruptions in communication within a well-known cortico-limbic reward circuit during reward processing as a potential contributing mechanism to these symptoms.

METHODS

The present investigation employed a within- and between-subjects design utilizing a monetary and social incentive delay task among adults with bipolar disorder type I (BD; N = 24) and a healthy non-psychiatric control group (HC; N = 25) during functional magnetic resonance imaging (fMRI). Participants in the BD group were remitted at the time of testing.

RESULTS

Functional connectivity analyses revealed increased connectivity between the ventral striatum (VS) seed region and orbitofrontal cortex (OFC) as well as the amygdala during processing of reward receipt in the BD group. After omission of expected rewards, the BD group showed decreased functional connectivity between the VS and a medial frontopolar cortex (mFPC) region associated with consideration of behavioral alternatives. Follow-up analyses within the BD group showed that increased VS-OFC connectivity after reward receipt, and decreased VS-mFPC connected after reward omission, were associated with higher levels of subthreshold mania symptoms.

CONCLUSIONS

Results point toward potential mechanisms implicated in elevated reward sensitivity in BD. Enhanced VS-OFC connectivity after reward receipt may be involved in elevated valuation of rewards whereas blunted VS-mFPC connectivity after reward omission may reflect a failure to consider behavioral alternatives to reward pursuit.

Creativity and Mood Disorder: A Systematic Review and Meta-Analysis

Although the belief that creativity is related to psychopathology is prevalent, empirical evidence is limited. Research findings relating to mood disorder in particular are mixed, possibly as a result of differing research approaches (e.g., assessing the creativity of individuals with versus without mood disorder opposed to the prevalence of mood disorder in creative versus noncreative individuals). Therefore, a systematic review and meta-analysis were conducted to investigate prior research examining the link between mood disorder and creativity from three distinct research approaches. Multilevel random effects models were used to calculate the overall effect size for studies that assessed (a) creativity in a clinical versus nonclinical sample ( k = 13), (b) mood disorder in a creative versus noncreative sample ( k = 10), and (c) the correlation between dimensional measures of creativity and mood disorder symptoms ( k = 15). Potential moderators were examined using meta-regression and subgroup analyses, as significant heterogeneity was detected among the effects in all three analyses. Results reveal a differential strength and pattern of effects across the three analyses, suggesting that the relationship between creativity and mood disorder differs according to the research approach. The theoretical implications of results and potential mechanisms responsible for the relationship between creativity and mood disorder are discussed.

Schizophrenia: Reaction to Positive Life Events

Negative life events can exacerbate symptoms in schizophrenia, but there is no literature on the effect on psychotic symptoms of positive life events. The purpose of this review was to scan the literature that studies how the joy that accompanies positive life events can be dampened and dismissed or, alternatively, savored and maintained, and how this contrast applies to schizophrenia. A literature search elicited 53 articles relevant to schizophrenia. Schizophrenia was found to be linked with difficulties in the processing of reward, in feeling that one was deserving of a reward, in sharing news of positive events, in knowing with whom to share, in knowing how to elicit a positive response from listeners when communicating good news, and in ensuring that positive feelings endure. There was no evidence that positive life events reduce psychosis symptoms but teaching the various skills of how to capitalize on good fortune can nevertheless improve the quality of life of individuals with schizophrenia.

Reward processing and mood-related symptoms: An RDoC and translational neuroscience perspective

BACKGROUND

Two objectives of the NIMH Research Domain Criteria (RDoC) initiative are to identify (a) mechanisms that are common to multiple psychiatric disorders, and (b) mechanisms that are unique to specific psychiatric symptoms, and that reflect markers of differential risk for these symptoms. With respect to these objectives, a brain-behavior dimension that has received considerable attention and that is directly relevant to the Positive Valence Systems domain of the RDoC initiative involves reward processing.

METHODS

The present review paper first examines the relationship between reward processing and mood-related symptoms from an RDoC perspective. We then place this work in a larger context by examining the relationship between reward processing abnormalities and psychiatric symptoms defined broadly, including mood-related symptoms, schizophrenia, and addiction.

RESULTS

Our review suggests that reward hyposensitivity relates to a subtype of anhedonia characterized by motivational deficits in unipolar depression, and reward hypersensitivity relates to a cluster of hypo/manic symptoms characterized by excessive approach motivation in the context of bipolar disorder. Integrating this perspective with research on reward processing abnormalities in schizophrenia and addiction, we further argue that the principles of equifinality and multifinality may be preferable to a transdiagnostic perspective for conceptualizing the relationship between reward processing and psychiatric symptoms defined broadly.

CONCLUSION

We propose that vulnerability to either motivational anhedonia or approach-related hypo/manic symptoms involve extreme and opposite profiles of reward processing. We further propose that an equifinality and multifinality perspective may serve as a useful framework for future research on reward processing abnormalities and psychiatric symptoms.

What can daily life assessment tell us about the bipolar spectrum?

Evidence suggests that bipolar psychopathology is better characterized as a spectrum than by categorical diagnoses. The examination of symptoms and impairment associated with bipolar spectrum psychopathology is important and can be enhanced by methods that examine affect, thoughts, and behavior in daily life. The present study extended findings that provide validation of a continuum of bipolar psychopathology in daily life. Young adults (n=294) completed the Hypomanic Personality Scale (HPS) and experience sampling using smartphones. Participants were signaled eight times daily for one week to complete surveys in their normal daily environment. Bipolar spectrum psychopathology was characterized by increased positive and negative affect, confidence, racing thoughts, energy, and impulsivity in daily life. The HPS moderated the association of stress with trouble concentrating, irritability with dysphoria and impulsivity, and confidence with feeling like one's emotions were out of control. This study demonstrated that bipolar spectrum psychopathology is associated with disruptions in affect, thoughts, and behaviors and provided further evidence for a continuum of bipolar psychopathology. ESM is a promising method for examining dynamic constructs such as bipolar spectrum psychopathology and has the potential to be a strong research and clinical tool.

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Environmental factors, life events, and trauma in the course of bipolar disorder

The etiology and clinical course of bipolar disorder are considered to be determined by genetic and environmental factors. Although the kindling hypothesis emphasizes the impact of environmental factors on initial onset, their connection to the outcome and clinical course have been poorly established. Hence, there have been numerous research efforts to investigate the impact of environmental factors on the clinical course of illness. Our aim is to outline recent research on the impact of environmental determinants on the clinical course of bipolar disorder. We carried out a computer-aided search to find publications on an association between environmental factors, life events, and the clinical course of bipolar disorder. Publications in the reference lists of suitable papers have also been taken into consideration. We performed a narrative overview on all eligible publications. The available body of data supports an association between environmental factors and the clinical course of bipolar disorder. These factors comprise prenatal, early-life, and entire lifespan aspects. Given varying sample sizes and several methodological limitations, the reported quality and extent of the association between environmental factors and the clinical course of bipolar disorder should be interpreted with utmost caution. Systematic longitudinal long-term follow-up trials are needed to obtain a clearer and more robust picture.

Eye Tracking of Attention to Emotion in Bipolar I Disorder: Links to Emotion Regulation and Anxiety Comorbidity

Research has yielded mixed findings regarding whether bipolar disorder is related to attentional bias for emotionally-relevant stimuli, yet little research has utilized advances in eye-tracking technology to study attention in this population. The current study used a free-viewing eye-tracking paradigm to test whether people with remitted bipolar disorder show preferential attention to positive faces, and to test if comorbid anxiety or emotion regulation strategies are related to attention bias. Twenty-nine adults with bipolar I disorder and 28 control participants viewed images of emotionally valenced faces while their gaze was tracked, and participants completed self-report measures of emotion regulation. Contrary to hypotheses, people with bipolar disorder did not differ from control participants in attention to positive stimuli, and both anxiety comorbidity and emotion regulation were unrelated to attentional indices. Unlike some findings in unipolar depression, these results suggest that attention to valenced faces may not be characteristic of remitted bipolar disorder.

Role of Reward Sensitivity and Processing in Major Depressive and Bipolar Spectrum Disorders

Since Costello's (1972) seminal Behavior Therapy article on loss of reinforcers or reinforcer effectiveness in depression, the role of reward sensitivity and processing in both depression and bipolar disorder has become a central area of investigation. In this article, we review the evidence for a model of reward sensitivity in mood disorders, with unipolar depression characterized by reward hyposensitivity and bipolar disorders by reward hypersensitivity. We address whether aberrant reward sensitivity and processing are correlates of, mood-independent traits of, vulnerabilities for, and/or predictors of the course of depression and bipolar spectrum disorders, covering evidence from self-report, behavioral, neurophysiological, and neural levels of analysis. We conclude that substantial evidence documents that blunted reward sensitivity and processing are involved in unipolar depression and heightened reward sensitivity and processing are characteristic of hypomania/mania. We further conclude that aberrant reward sensitivity has a trait component, but more research is needed to clearly demonstrate that reward hyposensitivity and hypersensitivity are vulnerabilities for depression and bipolar disorder, respectively. Moreover, additional research is needed to determine whether bipolar depression is similar to unipolar depression and characterized by reward hyposensitivity, or whether like bipolar hypomania/mania, it involves reward hypersensitivity.

Assessment and Treatment of Bipolar Spectrum Disorders in Emerging Adulthood: Applying the Behavioral Approach System Hypersensitivity Model

Bipolar disorder is associated with a host of negative physical and interpersonal outcomes including suicide. Emerging adulthood is an age of risk for the onset of bipolar spectrum disorders (BSD) and there has been increased effort to focus on early identification and subsequent intervention for BSDs during this developmental period. Recent research on the behavioral approach system (BAS) hypersensitivity model of bipolar disorder may have implications for the assessment and treatment of BSD in emerging adulthood. We summarize relevant findings on the BAS hypersensitivity model that support the use of reward sensitivity in the early identification of BSDs and suggest evidence-based strategies for clinical work with emerging adults with bipolar spectrum disorders.

Spontaneous Eye-Blink Rate as an Index of Reward Responsivity: Validation and Links to Bipolar Disorder

Extensive research supports the role of striatal dopamine in pursuing and responding to reward, and that eye-blink rate is a valid indicator of striatal dopamine. This study tested whether phasic changes in blink rate could provide an index of reward pursuit. This hypothesis was tested in people with bipolar I disorder (BD; a population with aberrations in reward responsivity), and in those without BD. Thirty-one adults with BD and 28 control participants completed a laboratory task involving effort towards monetary reward. Blink rate was recorded using eye-tracking at baseline, reward anticipation, and post-reward. Those in the BD group completed self-report measures relating to reward and ambition. Results showed that across all participants, blink rates increased from reward anticipation to post-reward. In the BD group, reward-relevant measures were strongly correlated with variation in blink rate. These findings provide validation for phasic changes in blink rate as an index of reward response.

Age associations with neural processing of reward anticipation in adolescents with bipolar disorders

Reward/behavioral approach system hypersensitivity is implicated in bipolar disorders (BD) and in normative development during adolescence. Pediatric onset of BD is associated with a more severe illness course. However, little is known about neural processing of rewards in adolescents with BD or developmental (i.e., age) associations with activation of these neural systems. The present study aims to address this knowledge gap. The present sample included 21 adolescents with BD and 26 healthy adolescents, ages 13 to 19. Participants completed a functional magnetic resonance imaging (fMRI) protocol using the Monetary Incentive Delay (MID) task. Behavioral performance was similar between groups. Group differences in BOLD activation during target anticipation and feedback anticipation periods of the task were examined using whole-brain analyses, as were group differences in age effects. During both target anticipation and feedback anticipation, adolescents with BD, compared to adolescents without psychopathology, exhibited decreased engagement of frontal regions involved in cognitive control (i.e., dorsolateral prefrontal cortex). Healthy adolescents exhibited age-related decreases, while adolescents with BD exhibited age-related increases, in activity of other cognitive control frontal areas (i.e., right inferior frontal gyrus), suggesting altered development in the BD group. Longitudinal research is needed to examine potentially abnormal development of cognitive control during reward pursuit in adolescent BD and whether early therapeutic interventions can prevent these potential deviations from normative development.

Adjunctive Behavioral Activation for the Treatment of Bipolar Depression: A Proof of Concept Trial

BACKGROUND

Grounded in a model focused on exposure to response-contingent positive reinforcement, and with evidence supporting its acute treatment effects for unipolar depression, an adjunctive behavioral activation (BA) intervention may be especially well suited to the treatment of bipolar depression. The goal of this study was to modify BA for the adjunctive treatment of bipolar depression and to pilot it in a proof of concept trial to assess its preliminary feasibility and acceptability for this population.

METHODS

Twelve adults with bipolar depression were recruited from hospital settings and enrolled in a 20-week open trial of the modified BA, delivered in 16 outpatient sessions, as an adjunct to community pharmacotherapy for bipolar disorder. Symptom severity was assessed at pretreatment and posttreatment by an independent evaluator. Patient satisfaction was also assessed posttreatment.

RESULTS

Feasibility and acceptability were high, with 10 of 12 patients completing treatment, an average of 14.8 (SD=5.2) of 16 sessions attended, and high levels of self-reported treatment satisfaction. Patients exhibited statistically significant improvement from pretreatment to posttreatment on measures of depressive symptoms, manic symptoms, and severity of suicidal ideation.

CONCLUSIONS

Although preliminary and requiring replication in a larger sample, these study data suggest that a modified BA intervention may offer promise as an adjunctive approach for the acute treatment of bipolar depression. Future studies that use more rigorous randomized controlled designs and that directly assess potential mechanisms of action are recommended.

Associations of age with reward delay discounting and response inhibition in adolescents with bipolar disorders

OBJECTIVES

Bipolar disorders' (BD) onset before age 18 is a potential marker for a more severe illness course. Adolescence is also a period of significant normative maturation of inhibitory control and reward-relevant decision-making processes, such as decreased delay discounting (i.e., decreased preference for smaller, immediate versus larger, delayed rewards). Adults with BD exhibit elevated delay discounting rates. Very little is known about developmental changes in delay discounting in adolescents with BD, or about associations between inhibitory control and delay discounting in BD. The present study addresses these questions.

METHODS

The sample included 78 participants, ages 13 to 23, with BD or without history of mental illness. Group differences and group by age interaction effects on delay discounting (32 BD, 32 controls with valid responses), probability discounting (34 BD, 37 controls) and inhibitory control indices (34 BD, 38 controls) were assessed.

RESULTS

Among healthy controls, less discounting of delayed rewards was associated with older age, whereas adolescents with BD did not show age-related associations. There were no group differences in probability discounting or inhibitory control.

LIMITATIONS

The cross-sectional nature of the study cannot fully rule out the less likely interpretation of group differences in cohort effects.

CONCLUSIONS

The lack of age-related improvement in delay tolerance in BD suggests disrupted development of executive control processes within reward contexts, which in turn may contribute to understanding more severe course of pediatric onset BD. Longitudinal studies are needed to examine delay discounting in relation to maturation of neural reward systems among adolescents with BD.

Emotion-relevant impulsivity predicts sustained anger and aggression after remission in bipolar I disorder

Recent evidence suggests that anger and aggression are of concern even during remission for persons with bipolar I disorder, although there is substantial variability in the degree of anger and aggression across individuals. Little research is available to examine psychological models of anger and aggression for those with remitted bipolar disorder, and that was the goal of this study. Participants were 58 persons diagnosed with bipolar I disorder using the Structured Clinical Interview for DSM-IV, who were followed with monthly symptom severity interviews until they achieved remission, and then assessed using the Aggression-Short Form. We examined traditional predictors of clinical parameters and trauma exposure, and then considered three trait domains that have been shown to be elevated in bipolar disorder and have also been linked to aggression outside of bipolar disorder: emotion-relevant impulsivity, approach motivation, and dominance-related constructs. Emotion-relevant impulsivity was related to anger, hostility, verbal aggression, and physical aggression, even after controlling for clinical variables. Findings extend the importance of emotion-relevant impulsivity to another important clinical outcome and suggest the promise of using psychological models to understand the factors driving aggression and anger problems that persist into remission among persons with bipolar disorder.

TRPM2, a Susceptibility Gene for Bipolar Disorder, Regulates Glycogen Synthase Kinase-3 Activity in the Brain

Bipolar disorder (BD) is a psychiatric disease that causes mood swings between manic and depressed states. Although genetic linkage studies have shown an association between BD and TRPM2, a Ca(2+)-permeable cation channel, the nature of this association is unknown. Here, we show that D543E, a mutation of Trpm2 that is frequently found in BD patients, induces loss of function. Trpm2-deficient mice exhibited BD-related behavior such as increased anxiety and decreased social responses, along with disrupted EEG functional connectivity. Moreover, the administration of amphetamine in wild-type mice evoked a notable increase in open-field activity that was reversed by the administration of lithium. However, the anti-manic action of lithium was not observed in the Trpm2(-/-) mice. The brains of Trpm2(-/-) mice showed a marked increase in phosphorylated glycogen synthase kinase-3 (GSK-3), a key element in BD-like behavior and a target of lithium. In contrast, activation of TRPM2 induced the dephosphorylation of GSK-3 via calcineurin, a Ca(2+)-dependent phosphatase. Importantly, the overexpression of the D543E mutant failed to induce the dephosphorylation of GSK-3. Therefore, we conclude that the genetic dysfunction of Trpm2 causes uncontrolled phosphorylation of GSK-3, which may lead to the pathology of BD. Our findings explain the long-sought etiologic mechanism underlying the genetic link between Trpm2 mutation and BD.

SIGNIFICANCE STATEMENT

Bipolar disorder (BD) is a mental disorder that causes changes in mood and the etiology is still unknown. TRPM2 is highly associated with BD; however, its involvement in the etiology of BD is still unknown. We show here that TRPM2 plays a central role in causing the pathology of BD. We found that D543E, a mutation of Trpm2 frequently found in BD patients, induces the loss of function. Trpm2-deficient mice exhibited mood disturbances and impairments in social cognition. TRPM2 actively regulates the phosphorylation of GSK-3, which is a main target of lithium, a primary medicine for treating BD. Therefore, abnormal regulation of GSK-3 by hypoactive TRPM2 mutants accounts for the pathology of BD, providing the possible link between BD and TRPM2.

Affective Disruption from Social Rhythm and Behavioral Approach System (BAS) Sensitivities: A Test of the Integration of the Social Zeitgeber and BAS Theories of Bipolar Disorder

The Behavioral Approach System (BAS)/Reward Hypersensitivity Theory and the Social Zeitgeber Theory are two biopsychosocial theories of bipolar spectrum disorders (BSD) that may work together to explain affective dysregulation. The present study examined whether BAS sensitivity is associated with affective symptoms via a) increased social rhythm disruption in response to BAS-relevant life events, or b) greater exposure to BAS events leading to social rhythm disruption and subsequent symptoms. Results indicated that high BAS individuals were more likely to experience social rhythm disruption following BAS-relevant events. Social rhythm disruption mediated the association between BAS-relevant events and symptoms (hypothesis a). High BAS individuals experienced significantly more BAS-relevant events, which predicted greater social rhythm disruption, which predicted greater levels of affective symptoms (hypothesis b). Individuals at risk for BSD may be sensitive to BAS-relevant stimuli, experience more BAS-relevant events, and experience affective dysregulation due to the interplay of the BAS and circadian rhythms.

Elevated striatal reactivity across monetary and social rewards in bipolar I disorder

Bipolar disorder (BD) is associated with increased reactivity to rewards and heightened positive affectivity. It is less clear to what extent this heightened reward sensitivity is evident across contexts and what the associated neural mechanisms might be. The present investigation used both a monetary and social incentive delay task among adults with remitted BD Type I (n = 24) and a healthy nonpsychiatric control group (HC; n = 25) using fMRI. Both whole-brain and region-of-interest analyses revealed elevated reactivity to reward receipt in the striatum, a region implicated in incentive sensitivity, in the BD group. Post hoc analyses revealed that greater striatal reactivity to reward receipt, across monetary and social reward tasks, predicted decreased self-reported positive affect when anticipating subsequent rewards in the HC but not in the BD group. Results point toward elevated striatal reactivity to reward receipt as a potential neural mechanism of persistent reward pursuit in BD.

Comparison of precipitating factors for mania and partial seizures: Indicative of shared pathophysiology?

OBJECTIVES

Mania in bipolar disorder (BD) and partial (focal) seizures (PS) arising from the temporal lobes, have a number of similarities. Typically, a chronic course of the disorders is punctuated by acute illness episodes. Common features of episodes may include sensory, perceptual, cognitive and affective changes. Both respond to anticonvulsant treatment. Common mechanisms imputed include neurotransmitters and kindling processes. Further investigation may improve understanding of the occurrence of both mania and PS, casting light on the relevance of temporal lobe mediated processes and pathology. One avenue of investigation is to compare aetiological factors and determine the extent of overlap which may indicate shared brain localization or pathophysiology. Aetiology includes predisposing, precipitating or perpetuating factors. This paper examines the literature on precipitating factors of mania, first or subsequent episode, and of PS in diagnosed epilepsy, which is the second or subsequent seizure, to identify the extent and nature of their overlap.

METHOD

Narrative review based on a literature search of PubMed and Google Scholar.

RESULTS

Precipitating factors for both mania and PS were stress, sleep deprivation, antidepressant medication and, tentatively, emotion. For mania alone, goal-attainment events, spring and summer season, postpartum, and drugs include steroids and stimulants. For PS alone, winter season, menstruation and specific triggers in complex reflex epilepsies. Those not substantiated include lunar phase and menopause. A wide range of chemicals may provoke isolated seizures but by definition epilepsy requires at least two seizures.

CONCLUSIONS

The overlap of precipitating factors in mania and PS imply that common brain processes may contribute to both, consistent with findings from neuroscience research.

Thought Speed, Mood, and the Experience of Mental Motion

This article presents a theoretical account relating thought speed to mood and psychological experience. Thought sequences that occur at a fast speed generally induce more positive affect than do those that occur slowly. Thought speed constitutes one aspect of mental motion. Another aspect involves thought variability, or the degree to which thoughts in a sequence either vary widely from or revolve closely around a theme. Thought sequences possessing more motion (occurring fast and varying widely) generally produce more positive affect than do sequences possessing little motion (occurring slowly and repetitively). When speed and variability oppose each other, such that one is low and the other is high, predictable psychological states also emerge. For example, whereas slow, repetitive thinking can prompt dejection, fast, repetitive thinking can prompt anxiety. This distinction is related to the fact that fast thinking involves greater actual and felt energy than slow thinking does. Effects of mental motion occur independent of the specific content of thought. Their consequences for mood and energy hold psychotherapeutic relevance.

The development and course of bipolar spectrum disorders: an integrated reward and circadian rhythm dysregulation model

In this article, we present and review the evidence for two major biopsychosocial theories of the onset and course of bipolar spectrum disorders (BSDs) that integrate behavioral, environmental, and neurobiological mechanisms: the reward hypersensitivity and the social/circadian rhythm disruption models. We describe the clinical features, spectrum, age of onset, and course of BSDs. We then discuss research designs relevant to demonstrating whether a hypothesized mechanism represents a correlate, vulnerability, or predictor of the course of BSDs, as well as important methodological issues. We next present the reward hypersensitivity model of BSD, followed by the social/circadian rhythm disruption model of BSD. For each model, we review evidence regarding whether the proposed underlying mechanism is associated with BSDs, provides vulnerability to the onset of BSDs, and predicts the course of BSDs. We then present a new integrated reward/circadian rhythm (RCR) dysregulation model of BSD and discuss how the RCR model explains the symptoms, onset, and course of BSDs. We end with recommendations for future research directions.

Depression: discrete or continuous?

Elucidating the true structure of depression is necessary if we are to advance our understanding and treatment options. Central to the issue of structure is whether depression represents discrete types or occurs on a continuum. Nature almost universally operates on the basis of continuums, whereas human perception favors discrete categories. This reality might be formalized into a 'continuum principle': natural phenomena tend to occur on a continuum, and any instance of hypothesized discreteness requires unassailable proof. Research evidence for discrete types falls far short of this standard, with most evidence supporting a continuum. However, quantitative variation can yield qualitative differences as an emergent property, fostering the appearance of discreteness. Depression as a continuum is best characterized by duration and severity dimensions, with the latter understood in terms of depressive inhibition. In the absence of some degree of cognitive, emotional, social, and physical inhibition, depression should not be diagnosed. Combining the dimensions of duration and severity provides an optimal way to characterize the quantitative and related qualitative aspects of depression and to describe the overall degree of dysfunction. The presence of other symptom types occurs when anxiety, hypomanic/manic, psychotic, and personality continuums interface with the depression continuum.