Bipolar spectrum-substance use co-occurrence: Behavioral approach system (BAS) sensitivity and impulsiveness as shared personality vulnerabilities

Trait reward sensitivity modulates connectivity with the temporoparietal junction and Anterior Insula during strategic decision making

Many decisions happen in social contexts such as negotiations, yet little is understood about how people balance fairness versus selfishness. Past investigations found that activation in brain areas involved in executive function and reward processing was associated with people offering less with no threat of rejection from their partner, compared to offering more when there was a threat of rejection. However, it remains unclear how trait reward sensitivity may modulate activation and connectivity patterns in these situations. To address this gap, we used task-based fMRI to examine the relation between reward sensitivity and the neural correlates of bargaining choices. Participants (N = 54) completed the Sensitivity to Punishment (SP)/Sensitivity to Reward (SR) Questionnaire and the Behavioral Inhibition System/Behavioral Activation System scales. Participants performed the Ultimatum and Dictator Games as proposers and exhibited strategic decisions by being fair when there was a threat of rejection, but being selfish when there was not a threat of rejection. We found that strategic decisions evoked activation in the Inferior Frontal Gyrus (IFG) and the Anterior Insula (AI). Next, we found elevated IFG connectivity with the Temporoparietal junction (TPJ) during strategic decisions. Finally, we explored whether trait reward sensitivity modulated brain responses while making strategic decisions. We found that people who scored lower in reward sensitivity made less strategic choices when they exhibited higher AI-Angular Gyrus connectivity. Taken together, our results demonstrate how trait reward sensitivity modulates neural responses to strategic decisions, potentially underscoring the importance of this factor within social and decision neuroscience.

The path from mood symptoms to substance use: A longitudinal examination in individuals with and at risk for bipolar spectrum disorders

BACKGROUND

Adolescent substance use poses a critical public health challenge, intertwined with risk-taking behavior, criminality, functional impairment, and comorbid mental and physical health issues. Adolescents with bipolar spectrum disorders (BSD) exhibit heightened susceptibility to substance use, necessitating a nuanced exploration of the bipolar-substance use relationship.

METHODS

This study addressed gaps in the literature by employing a prospective, longitudinal design with 443 Philadelphia-area adolescents, tracking BSD symptoms and substance use. We predicted that BSD symptoms would be associated with increases in substance use, and that these effects would be more pronounced for individuals with a BSD and those with high reward sensitivity.

RESULTS

Hypomanic symptoms predicted subsequent substance use, with a stronger association observed in individuals diagnosed with BSD. Contrary to expectations, depressive symptoms did not exhibit a similar relationship. Although the hypothesized moderating role of reward sensitivity was not supported, higher reward sensitivity predicted increased substance use.

LIMITATIONS

Symptoms and substance use are only captured for the month prior to each session due to the assessment timeline. This highlights the benefits of frequent assessments over a shorter time frame to monitor real-time changes. Alternative classification methods for reward sensitivity, such as brain or behavior-based assessments, might yield different results.

CONCLUSIONS

This study's contributions include evaluating substance use broadly, utilizing a longitudinal design for temporal clarity, and shifting the focus from substance use predicting mood symptoms to the inverse. The findings underscore the need for continued exploration of mood symptom predictors of substance use, emphasizing the role of reward sensitivity.

Trait Reward Sensitivity Modulates Connectivity with the Temporoparietal Junction and Anterior Insula during Strategic Decision Making

Many decisions happen in social contexts such as negotiations, yet little is understood about how people balance fairness versus selfishness. Past investigations found that activation in brain areas involved in executive function and reward processing was associated with people offering less with no threat of rejection from their partner, compared to offering more when there was a threat of rejection. However, it remains unclear how trait reward sensitivity may modulate activation and connectivity patterns in these situations. To address this gap, we used task-based fMRI to examine the relation between reward sensitivity and the neural correlates of bargaining choices. Participants (N = 54) completed the Sensitivity to Punishment (SP)/Sensitivity to Reward (SR) Questionnaire and the Behavioral Inhibition System/Behavioral Activation System scales. Participants performed the Ultimatum and Dictator Games as proposers and exhibited strategic decisions by being fair when there was a threat of rejection, but being selfish when there was not a threat of rejection. We found that strategic decisions evoked activation in the Inferior Frontal Gyrus (IFG) and the Anterior Insula (AI). Next, we found elevated IFG connectivity with the Temporoparietal junction (TPJ) during strategic decisions. Finally, we explored whether trait reward sensitivity modulated brain responses while making strategic decisions. We found that people who scored lower in reward sensitivity made less strategic choices when they exhibited higher AI-Angular Gyrus connectivity. Taken together, our results demonstrate how trait reward sensitivity modulates neural responses to strategic decisions, potentially underscoring the importance of this factor within social and decision neuroscience.

An fMRI dataset of social and nonsocial reward processing in young adults

Trait reward sensitivity, risk for developing substance use, and mood disorders have each been linked with altered striatal responses to reward. Moreover, striatal response to reward is sensitive to social context, such as the presence of a peer, and drugs are often sought out and consumed in social contexts or as a result of social experiences. Thus, mood disorder symptoms, striatal responses to social context and social reward may play a role in substance use. To investigate this possibility, this dataset was collected as part of a National Institute on Drug Abuse (NIDA) grant titled "Aberrant Reward Sensitivity: Mechanisms Underlying Substance Use" (R03-DA046733). The overarching goal was to characterize the associations between neural responses to social and nonsocial rewards, trait reward sensitivity, substance use, and mood disorder symptoms. After obtaining questionnaire data quantifying reward sensitivity, substance use, and other psychosocial characteristics, young adults (N=59; 14 male, 45 female; mean age: 20.89 years ± 1.75 years) completed four fMRI tasks testing different features of social and reward processing. These included: 1) a strategic reward-based decision-making task with Ultimatum and Dictator Game conditions; 2) a task where participants shared rewards or losses with peers, strangers, or non-human partners; 3) a task in which participants received well-matched social and monetary rewards and punishment; and 4) a monetary incentive delay (MID) task in which participants tried to obtain or avoid rewards and losses of different magnitude. This dataset includes sociodemographic questionnaire data, anatomical, task-based fMRI, and corresponding behavioral task-based data. We outline several opportunities for extension and reuse, including exploration of individual differences, cross-task comparisons, and representational similarity analyses.

Corticostriatal Responses to Social Reward are Linked to Trait Reward Sensitivity and Subclinical Substance Use in Young Adults

Aberrant levels of reward sensitivity have been linked to substance use disorder and are characterized by alterations in reward processing in the ventral striatum (VS). Less is known about how reward sensitivity and subclinical substance use relate to striatal function during social rewards (e.g., positive peer feedback). Testing this relation is critical for predicting risk for development of substance use disorder. In this pre-registered study, participants (N=44) underwent fMRI while completing well-matched tasks that assess neural response to reward in social and monetary domains. Contrary to our hypotheses, aberrant reward sensitivity blunted the relationship between substance use and striatal activation during receipt of rewards, regardless of domain. Moreover, exploratory whole-brain analyses showed unique relations between substance use and social rewards in temporoparietal junction. Psychophysiological interactions demonstrated that aberrant reward sensitivity is associated with increased connectivity between the VS and ventromedial prefrontal cortex during social rewards. Finally, we found that substance use was associated with decreased connectivity between the VS and dorsomedial prefrontal cortex for social rewards, independent of reward sensitivity. These findings demonstrate nuanced relations between reward sensitivity and substance use, even among those without substance use disorder, and suggest altered reward-related engagement of cortico-VS responses as potential predictors of developing disordered behavior.

Alcohol Cue Processing in Co-Occurring Bipolar Disorder and Alcohol Use Disorder

Importance

Reward circuitry dysfunction is a candidate mechanism of co-occurring bipolar disorder and alcohol use disorder (BD + AUD) that remains understudied. This functional magnetic resonance imaging (fMRI) research represents the first evaluation of alcohol cue reward processing in BD + AUD.

Objective

To determine how alcohol cue processing in individuals with BD + AUD may be distinct from that of individuals with AUD or BD alone.

Design, Setting, and Participants

This cross-sectional case-control study (April 2013-June 2018) followed a 2 × 2 factorial design and included individuals with BD + AUD, AUD alone, BD alone, and healthy controls. A well-validated visual alcohol cue reactivity fMRI paradigm was administered to eligible participants following their demonstration of 1 week or more of abstinence from alcohol and drugs assessed via serial biomarker testing. Study procedures were completed at the Medical University of South Carolina. Analysis took place between June and August 2022.

Main Outcomes and Measures

Past-week mood symptoms were rated by clinicians using the Montgomery-Åsberg Depression Rating Scale and Young Mania Rating Scale. The Alcohol Dependence Scale, Obsessive-Compulsive Drinking Scale, and Barratt Impulsiveness Scale were included questionnaires. Functional MRI whole-brain data were analyzed along with percent signal change within a priori regions of interest located in the ventral striatum, dorsal striatum, and ventromedial prefrontal cortex. Exploratory analyses of associations between cue reactivity and select behavioral correlates (alcohol craving, impulsivity, maximum number of alcohol drinks on a single occasion, and days since last alcohol drink) were also performed.

Results

Of 112 participants, 28 (25.0%) had BD + AUD, 26 (23.2%) had AUD alone, 31 (27.7%) had BD alone, and 27 (24.1%) were healthy controls. The mean (SD) age was 38.7 (11.6) years, 50 (45.5%) were female, 33 (30%) were smokers, and 37 (34.9%) reported recent alcohol consumption. Whole-brain analyses revealed a BD × AUD interaction (F = 10.64; P = .001; η2 = 0.09) within a cluster spanning portions of the right inferior frontal gyrus and insula. Region of interest analyses revealed a main association of BD (F = 8.02; P = .006; η2 = 0.07) within the dorsal striatum. In each instance, individuals with BD + AUD exhibited reduced activation compared with all other groups who did not significantly differ from one another. These hypoactivations were associated with increased impulsivity and obsessive-compulsive alcohol craving exclusively among individuals with BD + AUD.

Conclusion and Relevance

The findings of this study suggest conceptualizing reward dysfunction in BD + AUD by the potential interaction between blunted reward responsivity and deficient inhibitory control may help guide treatment development strategies. To this end, reduced right inferior frontal gyrus and insula alcohol cue reactivity represents a novel candidate biomarker of BD + AUD that may respond to pharmacological interventions targeting impulsivity-related neural mechanisms for improved executive control.

Social Context and Reward Sensitivity Enhance Corticostriatal Function during Experiences of Shared Rewards

Although prior research has demonstrated enhanced striatal response when sharing rewards with close social connections, less is known about how individual differences affect ventral striatal (VS) activation and connectivity when experiencing rewards within social contexts. Given that self-reported reward sensitivity and level of substance use have been associated with differences in VS activation, we set out to investigate whether these factors would be independently associated with enhancements to neural reward responses within social contexts. In this pre-registered study, participants (N=45) underwent fMRI while playing a card guessing game in which correct or incorrect guesses resulted in monetary gains and losses that were shared evenly with either a close friend, stranger (confederate), or non-human partner. Consistent with our prior work, we found increased VS activation when sharing rewards with a socially close peer as opposed to an out-of-network stranger. As self-reported reward sensitivity increased, the difference in VS response to rewards shared with friends and strangers decreased. We also found enhanced connectivity between the VS and temporoparietal junction when sharing rewards with close friends as opposed to strangers. Finally, exploratory analyses revealed that as reward sensitivity and sub-clinical substance use increase, the difference in VS connectivity with the right fusiform face area increases as a function of social context. These findings demonstrate that responsivity to the context of close friends may be tied to individual reward sensitivity or sub-clinical substance use habits; together these factors may inform predictions of risk for future mental health disorders.

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.

The Interplay between Reward-Relevant Life Events and Trait Reward Sensitivity in Neural Responses to Reward Cues

The reward hypersensitivity model posits that trait reward hypersensitivity should elicit hyper/hypo approach motivation following exposure to recent life events that activate (goal-striving and goal-attainment) or deactivate (goal-failure) the reward system, respectively. To test these hypotheses, eighty-seven young adults with high (HRew) versus moderate (MRew) trait reward sensitivity reported frequency of life events via the Life Event Interview. Brain activation was assessed during the fMRI Monetary Incentive Delay task. Greater exposure to goal-striving events was associated with higher nucleus accumbens (NAc) reward anticipation among HRew participants and lower orbitofrontal cortex (OFC) reward anticipation among MRew participants. Greater exposure to goal-failure events was associated with higher NAc and OFC reward anticipation only among HRew participants. This study demonstrated different neural reward anticipation (but not outcome) following reward-relevant events for HRew versus MRew individuals. Trait reward sensitivity and reward-relevant life events may jointly modulate reward-related brain function, with implications for understanding psychopathology.

Mathematical modeling of risk-taking in bipolar disorder: Evidence of reduced behavioral consistency, with altered loss aversion specific to those with history of substance use disorder

Bipolar disorder (BD) is associated with excessive pleasure-seeking risk-taking behaviors that often characterize its clinical presentation. However, the mechanisms of risk-taking behavior are not well-understood in BD. Recent data suggest prior substance use disorder (SUD) in BD may represent certain trait-level vulnerabilities for risky behavior. This study examined the mechanisms of risk-taking and the role of SUD in BD via mathematical modeling of behavior on the Balloon Analogue Risk Task (BART). Three groups-18 euthymic BD with prior SUD (BD+), 15 euthymic BD without prior SUD (BD-), and 33 healthy comparisons (HC)-completed the BART. We modeled behavior using 4 competing hierarchical Bayesian models, and model comparison results favored the Exponential-Weight Mean-Variance (EWMV) model, which encompasses and delineates five cognitive components of risk-taking: prior belief, learning rate, risk preference, loss aversion, and behavioral consistency. Both BD groups, regardless of SUD history, showed lower behavioral consistency than HC. BD+ exhibited more pessimistic prior beliefs (relative to BD- and HC) and reduced loss aversion (relative to HC) during risk-taking on the BART. Traditional measures of risk-taking on the BART (adjusted pumps, total points, total pops) detected no group differences. These findings suggest that reduced behavioral consistency is a crucial feature of risky decision-making in BD and that SUD history in BD may signal additional trait vulnerabilities for risky behavior even when mood symptoms and substance use are in remission. This study also underscores the value of using mathematical modeling to understand behavior in research on complex disorders like BD.

Neural Cognitive Control Moderates the Longitudinal Link between Hedonia and Substance Use across Adolescence

Hedonic dysregulation is evident in addiction and substance use disorders, but it is not clearly understood how hedonic processes may interact with brain development related to cognitive control to influence risky decision making and substance use during adolescence. The present study used prospective longitudinal data to clarify the role of cognitive control in the link between hedonic experiences and the development of substance use during adolescence. Participants included 167 adolescents (53% male) assessed at four time points, annually. Adolescents participated in a functional magnetic resonance imaging (fMRI) session where blood-oxygen level dependent (BOLD) response was monitored during the Multi-Source- Interference Task to assess cognitive control. Substance use and hedonia were assessed using self-report. A two-group growth curve model of substance use with hedonia as a time-varying covariate indicated that higher levels of hedonia predicted higher substance use, but only in adolescents with higher activation in the frontoparietal regions and in the rostral anterior cingulate cortex during cognitive control. Results elucidate the moderating effects of neural cognitive control on associations between hedonia and adolescent substance use, suggesting that lower cognitive control functioning in the brain may exacerbate risk for substance use promoted by hedonia.

•

Increased risk-taking in adolescence may be due to immature cognitive processes combined with heightened reward seeking.

•

The role of hedonia in the development of substance use behavior is not clearly understood.

•

Using RDoC framework, the roles positive valence and cognitive systems in the development of substance use were examined.

•

Results suggest that less efficient neural cognitive functioning may serve as risk for substance use promoted by hedonia.

•

Implications include promoting cognitive control related to risky decision making in the presence of potential rewards.

Decreased reward-related brain function prospectively predicts increased substance use

Substance use and addiction are prominent global health concerns and are associated with abnormalities in reward sensitivity. Reward sensitivity and approach motivation are supported by a fronto-striatal neural circuit including the orbitofrontal cortex (OFC), ventral striatum (VS), and dorsal striatum (DS). Although research highlights abnormalities in reward neural circuitry among individuals with problematic substance use, questions remain about whether such use arises from excessively high, or excessively low, reward sensitivity. This study examined whether reward-related brain function predicted subsequent substance use course. Participants were 79 right-handed individuals (Mage = 21.52, SD = 2.19 years), who completed a monetary incentive delay (MID) fMRI task, and follow-up measures assessing substance use frequency and impairment. The average duration of the follow-up period was 9.1 months. Regions-of-interest analyses focused on the reward anticipation phase of the MID. Decreased activation in the VS during reward anticipation predicted increased substance use frequency at follow-up. Decreased DS activation during reward anticipation predicted increased substance use frequency at follow-up, but this finding did not pass correction for multiple comparisons. Analyses adjusted for relevant covariates, including baseline substance use and the presence or absence of a lifetime substance use disorder prior to MRI scanning. Results support the reward hyposensitivity theory, suggesting that decreased reward-related brain function is a risk factor for increased substance use. Results have implications for understanding the pathophysiology of problematic substance use and highlight the importance of the fronto-striatal reward circuit in the development and maintenance of addiction. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Impulsivity and sleep and circadian rhythm disturbance predict next-day mood symptoms in a sample at high risk for or with recent-onset bipolar spectrum disorder: An ecological momentary assessment study

BACKGROUND

Impulsivity and sleep and circadian rhythm disturbance are core features of bipolar spectrum disorders (BSDs) that are antecedents to onset and persist even between mood episodes; their pervasive presence in BSD suggests that they may be particularly relevant to understanding BSD onset and course. Considerable research demonstrates bidirectional associations between impulsivity and sleep disturbance in healthy individuals; thus, it is important to examine how these features interact to impact BSD symptomatology.

METHODS

Young adults (N = 107, 55% female, M age = 21.82 years) at high risk for developing BSD (based on high self-reported reward sensitivity) or with recent-onset BSD participated in ecological momentary assessment (EMA) to examine relationships between impulsivity, sleep and circadian rhythm alterations, and mood symptoms in everyday life. Impulsivity was measured via self-report/behavioral task, sleep was measured via actigraphy, circadian rhythms were measured via dim light melatonin onset (DLMO) time, and mood symptoms were measured three times daily via self-report.

RESULTS

Multi-level modeling revealed that less total sleep time predicted increased next-day mood symptoms. Moreover, DLMO, total sleep time, and sleep onset latency moderated the relationship between impulsivity and EMA-assessed mood symptoms. Fewer minutes of sleep and later DLMO strengthened the positive relationship between impulsivity and mood symptoms.

LIMITATIONS

Mood symptoms in our sample were mild; future studies should replicate findings in populations with more severe mood symptoms.

CONCLUSIONS

This multi-method assessment of dynamic relationships revealed novel associations between impulsivity, sleep and circadian rhythm disturbance, and symptoms within individuals at high-risk for or with recent-onset BSD.

Transdiagnostic neuroimaging of reward system phenotypes in ADHD and comorbid disorders

ADHD is a disorder characterized by changes in the reward system and which is highly comorbid with other mental disorders, suggesting common neurobiological pathways. Transdiagnostic neuroimaging findings could help to understand whether a dysregulated reward pathway might be the actual link between ADHD and its comorbidities. We here synthesize ADHD neuroimaging findings on the reward system with findings in obesity, depression, and substance use disorder including their comorbid appearance regarding neuroanatomical features (structural MRI) and activation patterns (resting-state and functional MRI). We focus on findings from monetary-incentive-delay (MID) and delay-discounting (DD) tasks and then review data on striatal connectivity and volumetry. Next, for better understanding of comorbidity in adult ADHD, we discuss these neuroimaging features in ADHD, obesity, depression and substance use disorder and ask whether ADHD heterogeneity and comorbidity are reflected by a common dysregulation in the reward system. Finally, we highlight conceptual issues related to heterogeneous paradigms, different phenotyping, longitudinal prediction and highlight some promising future directions for using striatal reward functioning as a clinical biomarker.

Neural reward circuit dysfunction as a risk factor for bipolar spectrum disorders and substance use disorders: A review and integration

Bipolar spectrum disorders (BSDs) and substance use disorders (SUDs) are associated with neural reward dysfunction. However, it is unclear what pattern of neural reward function underlies pre-existing vulnerability to BSDs and SUDs, or whether neural reward function explains their high co-occurrence. The current paper provides an overview of the separate literatures on neural reward sensitivity in BSDs and SUDs. We provide a systematic review of 35 studies relevant to identifying neural reward function vulnerability to BSDs and SUDs. These studies include those examining neural reward processing on a monetary reward task with prospective designs predicting initial onset of SUDs, familial risk studies that examine unaffected offspring or first-degree relatives of family members with BSDs or SUDs, and studies that examine individuals with BSDs or SUDs who are not currently in an episode of the disorder. Findings from the review highlight that aberrant responding and connectivity across neural regions associated with reward and cognitive control confers risk for the development of BSDs and SUDs. Discussion focuses on limitations of the extant literature. We conclude with an integration and theoretical model for understanding how aberrant neural reward responding may constitute a vulnerability to the development of both BSDs and SUDs.

Goal-striving tendencies moderate the relationship between reward-related brain function and peripheral inflammation

Inflammation is associated with both lower and higher activity in brain regions that process rewarding stimuli. How can both low and high sensitivity to rewards be associated with higher inflammation? We propose that one potential mechanism underlying these apparently conflicting findings pertains to how people pursue goals in their environment. This prediction is based on evidence that both an inability to disengage from unattainable goals and low interest in and pursuit of important life goals are associated with poor health outcomes, including inflammation. Accordingly, this study examined the relationship between reward-related brain function and peripheral inflammation among individuals with different levels of ambitious goal-striving tendencies. Eighty-three participants completed an ambitious goal-striving tendency measure, an fMRI Monetary Incentive Delay task assessing orbitofrontal cortex (OFC) and nucleus accumbens (NAc) activation during reward anticipation and outcome, and a venous blood draw to assess the inflammatory biomarkers interleukin (IL)-6, IL-8, tumor necrosis factor-alpha, and C-reactive protein, from which we computed an inflammation composite score. We observed a reward anticipation by goal-striving interaction on inflammation, such that high OFC and NAc activation to reward anticipation (but not outcome) were associated with more inflammation, among high goal-striving individuals. By contrast, low NAc activation during reward anticipation (but not outcome) was associated with more inflammation, among low goal-striving individuals. The current study provides further evidence that both blunted and elevated reward function can be associated with inflammation. It also highlights the role that goal-striving tendencies may play in moderating the relationship between neural reward anticipation and inflammation.

A Multimethod Examination of Sensitivity to Reward and Sensitivity to Punishment in Bipolar Disorder and Alcohol Dependence: Results from a 2 × 2 Factorial Design

INTRODUCTION

Shared neurobehavioral characteristics of bipolar disorder (BD) and alcohol dependence (AD), including heightened sensitivity to reward (SR), may account for high rates of BD and AD co-occurrence (BD + AD). However, empirical research is lacking. The present multimethod investigation examined SR and sensitivity to punishment (SP) among these patient groups using a reliable and well-validated self-report questionnaire of SR and SP along with a laboratory task specifically designed to distinguish SR and SP activation.

METHODS

One-hundred participants formed 4 groups: BD + AD (n = 40), BD (n = 18), AD (n = 25), and healthy controls (n = 17). Clinical interviews were administered, and participants completed the Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSR-Q) and the Point Score Reaction Test behavioral task. Pearson correlations, hierarchical linear regression, and 2 × 2 factorial general linear modeling with Bonferroni-corrected pairwise comparisons were performed.

RESULTS

BD and AD main effects were significant on self-reported SR and SP; however, BD × AD interactions were not. BD + AD individuals were significantly higher on self-reported SR than BD and AD individuals, yet all clinical groups were similar on SP. Behavioral response times did not distinguish groups nor did they associate with self-report data.

DISCUSSION/CONCLUSION

BD and AD had additive, rather than interactive, effects on self-reported SR and SP. The methods employed, paired with their application to the present sample, may account for a lack of positive findings with behavioral data.

Reward Responsiveness and Ruminative Styles Interact to Predict Inflammation and Mood Symptomatology

Abnormal reward responsiveness and rumination each are associated with elevated inflammation and mood symptoms. Ruminating on positive and negative affect, or dampening positive affect, may amplify, or buffer, the associations of reward hyper/hyposensitivity with inflammation and mood symptoms. Young adults (N = 109) with high or moderate reward sensitivity completed reward responsiveness and ruminative style measures at the initial visit of a longitudinal study of mood symptoms, a blood draw to assess inflammatory biomarkers, and mood symptom measures at the study visits before and after the day of the blood draw. The interaction between high reward responsiveness and rumination on positive affect was associated with higher levels of an inflammatory composite measure and hypomanic symptoms. The interaction between lower reward responsiveness and high dampening of positive affect was associated with higher levels of the inflammatory composite measure and depressive symptoms. Lower reward responsiveness also interacted with low rumination on positive affect to predict increases in depressive symptoms and higher levels of the inflammatory composite. Thus, levels of reward responsiveness and ruminative response styles may synergistically influence the development of inflammatory phenotypes and both hypomanic and depressive mood symptoms.

Are existing self-ratings of acute manic symptoms in adults reliable and valid?-A systematic review

BACKGROUND

Depression research historically uses both self- and clinician ratings of symptoms with significant and substantial correlations. It is often assumed that manic patients lack insight and cannot accurately report their symptoms. This delayed the development of self-rating scales for mania, but several scales now exist and are used in research. Our objective is to systematically review the literature to identify existing self-ratings of symptoms of (hypo)mania and to evaluate their psychometric properties.

METHODS

PubMed, Web of Knowledge, and Ovid were searched up until June 2018 using the keywords: "(hypo)mania," "self-report," and "mood disorder" to identify papers which included data on the validity and reliability of self-rating scales for (hypo)mania in samples including patients with bipolar disorder.

RESULTS

We identified 55 papers reporting on 16 different self-rating scales claiming to assess (hypo)manic symptoms or states. This included single item scales, but also some with over 40 items. Three of the scales, the Internal State Scale (ISS), Altman Self-Rating Mania Scale (ASRM), and Self-Report Manic Inventory (SRMI), provided data about reliability and/or validity in more than three independent studies. Validity was mostly assessed by comparing group means from individuals in different mood states and sometimes by correlation to clinician ratings of mania.

CONCLUSIONS

ASRM, ISS, and SRMI are promising self-rating tools for (hypo)mania to be used in clinical contexts. Future studies are, however, needed to further validate these measures; for example, their associations between each other and sensitivity to change, especially if they are meant to be outcome measures in studies.

Reward Sensitivity, Cognitive Response Style, and Inflammatory Response to an Acute Stressor in Adolescents

Inflammation is gaining support as a biological mediator between stress and many negative outcomes that have heightened risk during adolescence (e.g., mood disorders). Thus, an important line of inquiry is evaluating whether risk factors for mood psychopathology also are associated with heightened inflammatory responses to stress during this developmental period. Two prominent risk factors that interact to predict mood psychopathology are reward sensitivity and perseverative cognitive response styles, which also have been associated with heightened inflammatory proteins. These factors could influence inflammation by synergistically amplifying stress reactivity. Ninety-nine late adolescents (M_age = 18.3 years, range = 15.6-21.9 years) completed measures of reward sensitivity, cognitive response style, and blood draws before and 60-min after a modified Trier Social Stress Task to determine levels of inflammation. Higher reward drive interacted with more perseverative response style ratios (rumination relative to distraction + problem-solving) to predict larger increases in interleukin-6 (a proinflammatory protein). Follow-up analyses found that reward drive interacted with all three components of the ratio to predict change in interleukin-6. Thus, these results suggest that high reward drive and perseverative cognitive response styles are associated with increased inflammatory response to social stress in adolescents, a potential physiological mechanism linking these risk factors to mood psychopathology during this developmental period.

Personality traits and the risk of incident (hypo)mania among subjects initially suffering from depressive and anxiety disorders in a 9-year cohort study

BACKGROUND

Bipolar disorder (BD) is characterized by the alternating occurrence of (hypo)manic and depressive episodes. The aim of the current study was to determine whether personality traits independently predicted the subsequent development of (hypo)manic episodes within a group of patients who were initially diagnosed with depressive and anxiety disorders.

METHODS

The Netherlands Study of Depression and Anxiety is a cohort study with measurements taken at baseline and at 2-, 4-, 6-, and 9-year follow-up. Development of a (hypo)manic episode during follow-up was assessed with the Composite International Diagnostic Interview and (hypo)manic symptoms were evaluated with the Mood Disorder Questionnaire. The Big Five personality traits were the independent variables in multivariable Cox regression analyses.

RESULTS

There were 31 incident cases of (hypo)manic episodes (n = 1888, mean age 42.5 years, 68.3% women), and 233 incident cases of (hypo)manic symptoms (n = 1319, mean age 43.1, 71.9% women). In multivariable analyses, low agreeableness was independently associated with an increased risk of developing a (hypo)manic episode, with a hazard ratio (HR) of 0.54 (p = 0.002, 95% CI [0.37, 0.78]). This finding was consistent with the development of (hypo)manic symptoms (HR 0.77, p = 0.001, 95% CI [0.66, 0.89]).

LIMITATIONS

The 2-year lag-time analysis reduced the number of participants at risk of a (hypo)manic episode.

CONCLUSIONS

We conclude that low agreeableness is a personality-related risk factor for incident (hypo)mania among subjects initially suffering from depressive and anxiety disorders. Increased attention to personality deviances could help to recognize BD at an early stage.

An Imbalance of Approach and Effortful Control Predicts Externalizing Problems: Support for Extending the Dual-Systems Model into Early Childhood

Although the association between deficits in effortful control and later externalizing behavior is well established, many researchers (Nigg Journal of Child Psychology and Psychiatry, 47(3-4), 395-422, 2006; Steinberg Developmental Review, 28(1), 78-106, 2008) have hypothesized this association is actually the product of the imbalance of dual systems, or two underlying traits: approach and self-regulation. Very little research, however, has deployed a statistically robust strategy to examine that compelling model; further, no research has done so using behavioral measures, particularly in longitudinal studies. We examined the imbalance of approach and self-regulation (effortful control, EC) as predicting externalizing problems. Latent trait models of approach and EC were derived from behavioral measures collected from 102 children in a community sample at 25, 38, 52, and 67 months (2 to 5 ½ years), and used to predict externalizing behaviors, modeled as a latent trait derived from parent-reported measures at 80, 100, 123, and 147 months (6 ½ to 12 years). The imbalance hypothesis was supported: Children with an imbalance of approach and EC had more externalizing behavior problems in middle childhood and early preadolescence, relative to children with equal levels of the two traits.

Neural responses to monetary incentives in bipolar disorder

Although behavioral sensitivity to reward predicts the onset and course of mania in bipolar disorder, the evidence for neural abnormalities in reward processing in bipolar disorder is mixed. To probe neural responsiveness to anticipated and received rewards in the context of bipolar disorder, we scanned individuals with remitted bipolar I disorder (n = 24) and well-matched controls (n = 24; matched for age and gender) using Functional Magnetic Resonance Imaging (FMRI) during a Monetary Incentive Delay (MID) task. Relative to controls, the bipolar group showed reduced NAcc activity during anticipation of gains. Across groups, this blunting correlated with individual differences in impulsive responses to positive emotions (Positive Urgency), which statistically accounted for the association of blunted NAcc activity with bipolar diagnosis. These results suggest that blunted NAcc responses during gain anticipation in the context of bipolar disorder may reflect individual differences in Positive Urgency. These findings may help resolve discrepancies in the literature on neural responses to reward in bipolar disorder, and clarify the relationship between brain activity and the propensity to experience manic episodes.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial

BACKGROUND

Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD.

METHODS

A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse).

RESULTS

44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up.

LIMITATIONS

As a feasibility and acceptability trial any secondary results should be treated with caution.

CONCLUSIONS

Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

Blunted Reward Sensitivity and Trait Disinhibition Interact to Predict Substance Use Problems

Reward deficit models of addiction posit weaknesses in reward sensitivity to be promotive of substance dependence, while the externalizing spectrum model views substance problems as arising in large part from a general disinhibitory liability. The current study sought to integrate these perspectives by testing for separate and interactive associations of disinhibition and reward dysfunction with interview-assessed substance use disorders (SUDs). Community and college adults (N = 199) completed a scale measure of trait disinhibition and performed a gambling-feedback task yielding a neural index of reward sensitivity, the 'Reward Positivity' (RewP). Disinhibition and blunted RewP independently predicted SUDs, and also operated synergistically, such that participants - in particular, men - with high levels of disinhibition together with blunted RewP exhibited especially severe substance problems. Though limited by its cross-sectional design, this work provides new information about the interplay of disinhibition, reward processing, and gender in SUDs and suggests important directions for future research.

Delay discounting and reward sensitivity in a 2 × 2 study of bipolar disorder and alcohol dependence

BACKGROUND AND AIMS

Separate studies have shown increased delay discounting in people with bipolar disorder (BD) and people with alcohol dependence (AD) relative to people without mental health problems. Delay discounting was compared in people with no mental health problems, AD, BD and AD plus BD. Associations of delay discounting with self-reported impulsivity and reward sensitivity were also assessed.

DESIGN

The study was a two-by-two factorial comparative observational design.

SETTING

Data were collected at baseline diagnostic visits as part of a neuroimaging study at a medical university in South Carolina, USA.

PARTICIPANTS

Twenty-two BD + AD, 33 BD, 28 AD and 27 people without mental health problems participated.

MEASUREMENTS

Diagnostic and clinician-rated symptom measures, self-report questionnaires and a computerized delay discounting task were administered. Two-by-two general linear univariate models were tested to examine between-group differences on discounting rates, and bivariate correlations and hierarchical regression analyses were performed to examine associations between discounting rates and self-reported reward sensitivity and impulsivity.

FINDINGS

There was a significant main effect of AD (P = 0.006, η2  = 0.068). The main effect of BD and the BD × AD interaction terms were non-significant (P ≥ 0.293, η2  ≤ 0.010). Reward sensitivity and impulsivity were not significantly associated with discounting rates after adjustment for the other (P ≥ 0.089).

CONCLUSIONS

People with alcohol dependence appear to have higher delay discounting, while previously found associations between bipolar disorder and delay discounting may be secondary to alcohol use disorder.

Future Directions for Understanding Adolescent Bipolar Spectrum Disorders: A Reward Hypersensitivity Perspective

The idea that bipolar spectrum disorders (BSDs) are characterized by enhanced sensitivity to rewarding stimuli is at the core of the reward hypersensitivity model, one of the most prominent and well-supported theories of BSDs. In this article, we present the reward hypersensitivity model of BSDs, review evidence supporting it, discuss its relevance to explaining why BSDs typically begin and consolidate during the period of adolescence, and consider three major unresolved issues for this model that provide important directions for future research. Finally, we present integrations of the reward hypersensitivity model with circadian rhythm and immune system models that should provide greater understanding of the mechanisms involved in BSDs, and then suggest additional directions for future research deriving from these integrated models.

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.

Linking Cognitive Measures of Response Inhibition and Reward Sensitivity to Trait Impulsivity

Impulsivity is regarded as a multifaceted construct that comprises two dimensions: rapid-response impulsivity and reward-delay impulsivity. It is unclear, however, which aspects of trait impulsivity, as assessed by self-report measures are related to rapid-response impulsivity and/or to reward-delay impulsivity, as different results have been reported in studies using both self-report and cognitive measures. This study aimed to directly relate self-report measures of impulsivity to cognitive measures of impulsivity in individuals at low- or high-levels on two impulsivity dimensions, specifically rapid-response impulsivity and reward-delay impulsivity. Participants were classified into high- or low-impulsivity groups based on (1) level of rapid-response impulsivity (determined by BIS-11 Motor subscale scores); (2) level of reward-delay impulsivity (determined by BIS/BAS subscale scores); and (3) a combination of rapid-response impulsivity and reward-delay impulsivity levels. Impulsivity was assessed using Go/No-Go, Stop-Signal and Delay-Discounting tasks and self-report measures. The high rapid-response impulsivity group showed significantly higher reward-delay impulsivity on both, the Delay-Discounting tasks and on self-report measures assessing reward-delay impulsivity, than the low-risk group. Based on the level of reward-delay impulsivity, the high reward-delay impulsivity group scored significantly higher on task-based (cognitive) and self-report measures assessing rapid-response inhibition than the low reward-delay impulsivity group. Combining both dimensions of impulsivity showed that the high-impulsivity group performed significantly worse in rapid-response paradigms and temporally discounted significantly more impulsively than the low-impulsivity group. Thus, combined impulsivity factors provide better assessment of impulsivity than each dimension alone. In conclusion, robust differences in impulsivity can be identified in non-clinical young adults.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Age of onset of cannabis use and decision making under uncertainty

Objective

Cannabis, like other substances, negatively affects health, inducing respiratory problems and mental and cognitive alterations. Memory and learning disorders, as well as executive dysfunctions, are also neuropsychological disorders associated to cannabis use. Recent evidence reveals that cannabis use during adolescence may disrupt the normal development of the brain. This study is aimed to analyze possible differences between early-onset and late-onset cannabis consumers.

Method

We used a task based on a card game with four decks and different programs of gains/losses. A total of 72 subjects (19 women; 53 men) participated in the study; they were selected through a purposive sampling and divided into three groups: early-onset consumers, late-onset consumers, and control (non-consumers). The task used was the “Cartas” program (computerized version based on the Iowa Gambling Task (IGT)), with two versions: direct and inverse. The computational model “Prospect Valence Learning” (PVL) was applied in order to describe the decision according to four characteristics: utility, loss aversion, recency, and consistency.

Results

The results evidence worst performance in the IGT in the early-onset consumers as compared to late-onset consumers and control. Differences between groups were also found in the PVL computational model parameters, since the process of decision making of the early-onset consumers was more influenced by the magnitude of the gains-losses, and more determined by short-term results without loss aversion.

Conclusions

Early onset cannabis use may involve decision-making problems, and therefore intervention programs are necessary in order to reduce the prevalence and delay the onset of cannabis use among teenagers.

College alcohol beliefs and drinking consequences: A multiple mediation analysis of norms, expectancies, and willingness to experience drinking consequences

OBJECTIVE

We explored the potential mediating role of willingness to experience drinking consequences and other traditional alcohol outcome predictors (descriptive norms, injunctive norms, positive alcohol expectancies) in explaining the association between college alcohol beliefs ¹ (CABs) and the actual experience of drinking consequences among college students.

PARTICIPANTS

The sample consisted of 415 college students tested in October 2014.

METHODS

Participants responded to an online survey.

RESULTS

When compared to both types of norms and positive alcohol expectancies, CABs demonstrated the strongest associations to both willingness to experience drinking consequences and actual drinking consequences among college students. A multiple mediation analysis revealed that the impact of CABs on students' actual drinking consequences was mediated only through their willingness to experience drinking consequences.

CONCLUSIONS

Students' college alcohol beliefs and their corresponding willingness to experience drinking consequences should be targeted in prevention and intervention programs designed to address the problem of college student drinking.

Reward anticipation revisited- evidence from an fMRI study in euthymic bipolar I patients and healthy first-degree relatives

BACKGROUND

Symptomatic phases in bipolar disorder (BD) are hypothesized to result from a hypersensitive behavioral activation system (BAS) being sensitive to potential rewards. However, studies on the neuronal underpinnings of reward anticipation in BD are scarce with contradictory findings and possibly confounded by effects of dopaminergic medication, necessitating further research on dysfunctional motivation in BD. Moreover, its role as vulnerability marker for BD is unclear.

METHODS

Functional imaging was conducted in 16 euthymic BD-I patients free from dopaminergic medication and 19 healthy first-degree relatives using a monetary incentive delay task and compared to parallelized control groups. Further, reward proneness, using the BIS/BAS questionnaire, and its relationship to neural reward anticipation was investigated.

RESULTS

BD-I patients displayed greater anterior cingulate cortex (ACC) activity during reward anticipation and higher BIS total scores compared to controls, with a positive relationship between the two measures. There were no neural or self-report group differences between relatives and controls.

LIMITATIONS

Due to the experimental design, the role of the ACC during receipt of reward remains unknown, sample sizes were rather small, and patients were not naïve to dopaminergic drugs, making an exclusion of medication effects on findings impossible.

CONCLUSIONS

Our findings give new insights on reward anticipation in BD. BD-I patients rated themselves as more risk avoidant and showed larger recruitment of the ACC rather than ventral striatum compared to controls during reward anticipation, possibly to down-regulate hyperactive limbic reward regions. This activation seems to be a consequence of rather than a vulnerability marker for the disorder.

Is adolescent alcohol use associated with self-reported hypomanic symptoms in adulthood? - Findings from a prospective birth cohort

High rates of alcohol use disorder (AUD) are reported in people with major depression (MD) and bipolar disorder (BD). Substance abuse problems in adolescence may also indicate risk for future onset of mood disorders, especially BD. Data collected from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large UK birth cohort, allowed information to be collected over several different time points and to test whether problematic alcohol use at age 16 was predictive of vulnerability to hypomanic symptoms at age 23. Controlling for a participant's gender, SES, marital status of the mother, a likely history of maternal depression, and adolescents' level of depressive symptoms at age 16, a hierarchical linear regression revealed that self-reported alcohol use in adolescence predicted the future onset of hypomanic/manic symptoms. Limitations include attrition and relying solely on self-ratings. Despite these limitations, the results suggest problematic alcohol use in adolescence predicts a vulnerability to hypomanic or manic symptoms.

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.

Are self-rated and behavioural measures of impulsivity in bipolar disorder mainly related to comorbid substance use problems?

INTRODUCTION

Impulsivity is a multidimensional feature observed in bipolar disorder (BD) and substance use disorder (SUD). We previously found a relationship between SUD and risk taking in BD. It is still unclear whether self-rated and behavioral impulsivity measures differ between BD with and without comorbid SUD, or are specific to BD.

METHODS

93 adults with BD with comorbid SUD, 91 BD without SUD, and 93 healthy controls (HC) were administered the Barratt Impulsivity Scale (BIS), the Behavioral Inhibition/Behavioral Activation System Scale (BIS/BAS), and the Cambridge Neuropsychological Test Automated Battery. Analyses compared impulsivity measures across groups controlling for age. Discriminant function analyses (DFA) assessed the combination of variables effectively predicting group membership.

RESULTS

BD displayed increased BIS, BIS/BAS scores, reduced performance on the Cambridge Gambling and Rapid Visual Processing, and Affective Go/No-Go tasks compared to HC. Comparisons between BD with and without SUD showed increased BIS Motor impulsiveness. The overall predictive power of DFA was weak.

CONCLUSIONS

Some facets of impulsivity are a core trait of BD and are partially independent from the presence of SUD. Motor impulsiveness may be distinctive of BD+SUD. More research is needed to understand the role of impulsive behaviors as risk factors for relapse in SUD.

A path model of different forms of impulsivity with externalizing and internalizing psychopathology: Towards greater specificity

OBJECTIVES

A growing empirical literature indicates that emotion-related impulsivity (compared to impulsivity that is unrelated to emotion) is particularly relevant for understanding a broad range of psychopathologies. Recent work, however, has differentiated two forms of emotion-related impulsivity: A factor termed Pervasive Influence of Feelings captures tendencies for emotions (mostly negative emotions) to quickly shape thoughts, and a factor termed Feelings Trigger Action captures tendencies for positive and negative emotions to quickly and reflexively shape behaviour and speech. This study used path modelling to consider links from emotion-related and non-emotion-related impulsivity to a broad range of psychopathologies.

DESIGN AND METHODS

Undergraduates completed self-report measures of impulsivity, depression, anxiety, aggression, and substance use symptoms.

RESULTS

A path model (N = 261) indicated specificity of these forms of impulsivity. Pervasive Influence of Feelings was related to anxiety and depression, whereas Feelings Trigger Action and non-emotion-related impulsivity were related to aggression and substance use.

CONCLUSIONS

The findings of this study suggest that emotion-relevant impulsivity could be a potentially important treatment target for a set of psychopathologies.

PRACTITIONER POINTS

Recent work has differentiated two forms of emotion-related impulsivity. This study tests a multivariate path model linking emotion-related and non-emotion-related impulsivity with multiple forms of psychopathology. Impulsive thoughts in response to negative emotions were related to anxiety and depression. Impulsive actions in response to emotions were related to aggression and substance use, as did non-emotion-related impulsivity. The study was limited by the reliance on self-report measures of impulsivity and psychopathology. There is a need for longitudinal work on how these forms of impulsivity predict the onset and course of psychopathology.

Aggression Protects Against the Onset of Major Depressive Episodes in Individuals With Bipolar Spectrum Disorder

A growing body of research suggests that bipolar spectrum disorders (BSDs) are associated with high aggression. However, little research has prospectively examined how aggression may affect time to onset of hypomanic/manic versus major depressive episodes. In a longitudinal study, we tested the hypothesis that aggression would prospectively predict a shorter time to the onset of hypomanic/manic episodes and a longer time to the onset of major depressive episodes, based on the behavioral approach system theory of BSDs. Young adults (N = 120) diagnosed with cyclothymia, bipolar II disorder, or bipolar disorder not otherwise specified were followed every 4 months for an average of 3.55 years. Participants completed measures of depressive and manic symptoms, family history of mood disorder, impulsivity, and aggression at baseline and were followed prospectively with semistructured diagnostic interview assessments of hypomanic/manic and major depressive episodes and treatment seeking for mood problems. Cox proportional hazard regression analyses indicated that overall, physical, and verbal aggression predicted a longer time to major depressive episode onset, even after controlling for baseline depressive and manic symptoms, family history of mood disorder, treatment seeking for mood problems, and impulsivity. Aggression, however, did not significantly predict time to onset of hypomanic/manic episodes, controlling for the same covariates. The findings suggest that approach-related behaviors may be utilized to delay the onset of major depressive episodes among people with BSDs.

Personality disorder symptom severity predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum disorder

Although personality disorders (PDs) are highly comorbid with bipolar spectrum disorders (BSDs), little longitudinal research has been conducted to examine the prospective impact of PD symptoms on the course of BSDs. The aim of this study is to examine whether PD symptom severity predicts shorter time to onset of bipolar mood episodes and conversion to bipolar I disorder over time among individuals with less severe BSDs. Participants (n = 166) with bipolar II disorder, cyclothymia, or bipolar disorder not otherwise specified completed diagnostic interview assessments of PD symptoms and self-report measures of mood symptoms at baseline. They were followed prospectively with diagnostic interviews every 4 months for an average of 3.02 years. Cox proportional hazard regression analyses indicated that overall PD symptom severity significantly predicted shorter time to onset of hypomanic (hazard ratio [HR] = 1.42; p < .001) and major depressive episodes (HR = 1.51; p < .001) and conversion to bipolar I disorder (HR = 2.51; p < .001), after controlling for mood symptoms. Results also suggested that cluster B severity predicted shorter time to onset of hypomanic episodes (HR = 1.38; p = .002) and major depressive episodes (HR = 1.35; p = .01) and conversion to bipolar I disorder (HR = 2.77; p < .001), whereas cluster C severity (HR = 1.56; p < .001) predicted shorter time to onset of major depressive episodes. These results support predisposition models in suggesting that PD symptoms may act as a risk factor for a more severe course of BSDs. (PsycINFO Database Record

Suicidality in Bipolar Disorder: The Role of Emotion-Triggered Impulsivity

A growing body of research suggests that impulsive responses to emotion more robustly predict suicidality than do other forms of impulsivity. This issue has not yet been examined within bipolar disorder, however. Participants diagnosed with bipolar I disorder (n = 133) and control participants (n = 110) diagnosed with no mood or psychotic disorder completed self-report measures of emotion-triggered impulsivity (Negative and Positive Urgency Scales) and interviews concerning lifetime suicidality. Analyses examined the effects of emotion-triggered impulsivity alone and in combination with gender, age of onset, depression severity, comorbid anxiety, comorbid substance use, and medication. A history of suicide ideation and attempts, as well as self-harm, were significantly more common in the bipolar disorder group compared with the control group. Impulsive responses to positive emotions related to suicide ideation, attempts, and self-harm within the bipolar group. Findings extend research on the importance of emotion-triggered impulsivity to a broad range of key outcomes within bipolar disorder. The discussion focuses on limitations and potential clinical implications.

Development of Alcohol and Drug Use in Youth With Manic Symptoms

OBJECTIVE

This analysis examined alcohol and drug use over a 6-year follow-up of children in the Longitudinal Assessment of Manic Symptoms (LAMS) study.

METHOD

LAMS screened 6- to 12.9-year-old children visiting 9 child outpatient mental health (MH) clinics, using the Parent General Behavior Inventory 10-item mania scale. All children with scores ≥12 and a matched group with scores ≤12 were invited to enroll. Children were assessed every 6 months. Assessments included demographics, family, MH history, child diagnoses, child stress, and alcohol and drug use. Univariate, bivariate, and interval censored survival analyses were conducted.

RESULTS

Of those >9 years at baseline, 34.9% used alcohol at least once, with 11.9% regular users; 30.1% used drugs at least once, with 16.2% regular users. Predictors of any alcohol use were parental marital status, older age at study entry, a primary diagnosis of disruptive behavior disorders at baseline, and number of impactful child life events. Predictors of regular alcohol use included parental marital status, age, and sustained high mania symptoms over the first 24 months of follow-up. Predictors of any drug use were single parent, parental substance use, and stressful child life events. Predictors of regular drug use were parental marital status, stressful child life events, and a baseline disruptive behavior disorder diagnosis. Baseline medications decreased the risk of regular drug use.

CONCLUSION

Longitudinal data on youth with elevated manic symptoms suggest that comorbid disruptive behavior disorder, manic symptom burden, family environment, and stress are predictors of initiation and regular use of substances.

Low social rhythm regularity predicts first onset of bipolar spectrum disorders among at-risk individuals with reward hypersensitivity

The social zeitgeber model (Ehlers, Frank, & Kupfer, 1988) suggests that irregular daily schedules or social rhythms provide vulnerability to bipolar spectrum disorders. This study tested whether social rhythm regularity prospectively predicted first lifetime onset of bipolar spectrum disorders in adolescents already at risk for bipolar disorder based on exhibiting reward hypersensitivity. Adolescents (ages 14-19 years) previously screened to have high (n = 138) or moderate (n = 95) reward sensitivity, but no lifetime history of bipolar spectrum disorder, completed measures of depressive and manic symptoms, family history of bipolar disorder, and the Social Rhythm Metric. They were followed prospectively with semistructured diagnostic interviews every 6 months for an average of 31.7 (SD = 20.1) months. Hierarchical logistic regression indicated that low social rhythm regularity at baseline predicted greater likelihood of first onset of bipolar spectrum disorder over follow-up among high-reward-sensitivity adolescents but not moderate-reward-sensitivity adolescents, controlling for follow-up time, gender, age, family history of bipolar disorder, and initial manic and depressive symptoms (β = -.150, Wald = 4.365, p = .037, odds ratio = .861, 95% confidence interval [.748, .991]). Consistent with the social zeitgeber theory, low social rhythm regularity provides vulnerability to first onset of bipolar spectrum disorder among at-risk adolescents. It may be possible to identify adolescents at risk for developing a bipolar spectrum disorder based on exhibiting both reward hypersensitivity and social rhythm irregularity before onset occurs.

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.

Impulsivity predicts the onset of DSM-IV-TR or RDC hypomanic and manic episodes in adolescents and young adults with high or moderate reward sensitivity

BACKGROUND

A growing body of research suggests that bipolar disorders (BD) are associated with high impulsivity. Using a multi-method approach, the current study provided the first examination of the hypothesis that impulsivity would prospectively predict shorter time to onset of DSM-IV-TR or RDC hypomanic or manic episodes in a sample selected based on reward sensitivity, a biobehavioral trait shown to predict onset and course of BD.

METHODS

163 participants with high reward sensitivity and 114 participants with moderate reward sensitivity were followed every six months for an average of 2.68 years. Participants completed the Barratt Impulsiveness Scale - Version 11 (BIS-11), Balloon Analog Risk Task (BART), Beck Depression Inventory, Altman Self-Rating Mania Scale, and an expanded Schedule for Affective Disorders and Schizophrenia (exp-SADS) - Lifetime Version at baseline and were followed prospectively with the exp-SADS - Change Version to assess onset of hypomanic or manic episodes and treatment seeking for mood problems.

RESULTS

Cox proportional hazard regression analyses indicated that impulsivity as measured by a behavioral task (BART; OR=1.04, p=.03) and a self-report measure (BIS-11 Attentional Impulsiveness subscale; OR=1.16, p=.01) predicted shorter time to hypomania/mania onset, after controlling for baseline depressive and manic symptoms, family history of mood disorder, treatment seeking for mood problems, and reward sensitivity.

LIMITATIONS

The study was limited by non-comprehensive assessment of impulsivity and unknown generalizability to clinical samples.

CONCLUSIONS

Impulsivity confers vulnerability to hypomania or mania. Future studies would benefit from considering how impulsivity can be integrated into existing biopsychosocial models of BD.

Vulnerability for mania - is it linked to problems delaying gratification?

Impulsivity is described as one of the main risk factors for mania. One facet of impulsivity, the inability to delay gratification, might be of special relevance, because a hypersensitivity to reward is hypothesized to be related to mania. The main aim of this study was to examine whether risk for mania is associated with deficits in the ability to delay gratification using both a behavioral and a self-report (UPPS) measure. An additional reason for choosing the UPPS was to see if prior results about an association between risk for mania and positive urgency could be replicated. Thirty-three individuals at risk for mania and a matched control group were selected using the Hypomanic Personality Scale and interviewed for a history of mood disorders. The main outcome measures were the Single-Key-Impulsivity-Paradigm and Monetary Choice Questionnaire. The groups did not differ in measures of gratification delay but we replicated other studies reporting significantly higher levels of positive urgency and sensation seeking in at-risk individuals. We suggest that individuals at risk might not generally be more impulsive but rather that impulsive behaviors might be triggered in response to specific mood states.

Candidate Risks Indicators for Bipolar Disorder: Early Intervention Opportunities in High-Risk Youth

BACKGROUND

Psychiatric illnesses like bipolar disorder are increasingly understood to be neurodevelopmental disorders with clinical, psychological, and biological indicators recognizable long before the emergence of the full-blown syndromes.

METHODS

This paper is a selective review of findings from studies of high-risk children of affected parents that inform the knowledge of illness risk and development markers of bipolar disorder. We specifically focus on candidate clinical, biological, and psychological risk indicators that could serve as targets for future early intervention and prevention studies.

RESULTS

There is convergent evidence from prospective studies that bipolar disorder typically debuts as depressive episodes after puberty. In some high-risk children, sleep and anxiety disorders precede mood disorders by several years and reflect an increased vulnerability. An association between early exposure to adversity (eg, exposure to parental illness, neglect from mother) and increased risk of psychopathology may be mediated through increased stress reactivity evident at both behavioral and biological levels. Inter-related psychological processes including reward sensitivity, unstable self-esteem, rumination, and positive self-appraisal are risk factors for mood disorders. Disturbances in circadian rhythm and immune dysfunction are associated with mood disorders and may be vulnerability markers influenced by these other risk factors.

CONCLUSIONS

There is accruing evidence of a number of measurable and potentially modifiable markers of vulnerability and developing illness in youth at familial risk for bipolar disorder. Longitudinal studies of multiple biological and psychological risk processes in high-risk offspring, both individually and together, will improve our understanding of illness onset and lead to the development of specific early interventions.

Anxiety comorbidity in bipolar spectrum disorders: the mediational role of perfectionism in prospective depressive symptoms

BACKGROUND

Bipolar spectrum disorders (BSDs) are highly comorbid with anxiety, which is associated with an extended duration and exacerbation of depressive symptoms. Unfortunately, the underlying mechanisms are not known. This study examined the role of maladaptive cognitive styles in the co-occurrence of BSDs and anxiety disorders and prediction of depressive symptoms.

METHODS

Participants included 141 young adults (69.6% female, mean age=20.24, SD=2.11), in one of three groups: a BSD group (bipolar II, cyclothymia, n=48), a comorbid BSD/anxiety group (n=50), and a demographically-matched healthy control group (n=43), who were followed prospectively. Participants completed the Cognitive Style Questionnaire (CSQ), Depressive Experiences Questionnaire (DEQ), Dysfunctional Attitudes Scale (DAS), Sociotropy Autonomy Scale (SAS), Halberstadt Mania Inventory (HMI) and Beck Depression Inventory (BDI) at the initial assessment. One year later, participants completed the BDI and HMI again to assess severity of depressive and hypomanic/manic symptoms.

RESULTS

A multivariate analysis of co-variance (MANCOVA) revealed significant differences between the three groups on their DAS Perfectionism, DEQ Dependency, DEQ Self-Criticism, CSQ Negative, SAS Autonomy, and Time 2 BDI scores, with the BSD/anxiety group scoring higher than the BSD only group on all measures except the CSQ. Preacher and Hayes׳ (2008) bootstrapping method was used to test for mediational effects of the significant cognitive style measures on depressive symptoms at follow-up. The 95% confidence intervals for the indirect effect of group on follow-up depressive symptoms through DAS Perfectionism did not include zero, indicating the presence of a significant mediating relationship for perfectionism.

LIMITATIONS

This study only used two waves of data; three waves of data would allow one to investigate the full causal effect of one variable on another. Further, a comorbid anxiety diagnosis consisted of any anxiety disorder. Further research should separate groups by their specific anxiety diagnoses; this could afford a more complete understanding of the effect of types of anxiety on prospective depressive symptoms.

CONCLUSIONS

After taking into account initial levels of depressive and hypomanic/manic symptoms, we found that those with BSD/anxiety comorbidity experienced more severe depressive symptoms, but not more severe hypomanic/manic symptoms. Further, their more severe prospective depressive symptoms are explained by a perfectionistic cognitive style.