Applications of time-series analysis to mood fluctuations in bipolar disorder to promote treatment innovation: a case series

Experiences of imagery-based treatment for anxiety in bipolar disorder: A qualitative study embedded within the image based emotion regulation feasibility randomised controlled trial

OBJECTIVES

Intrusive mental imagery is associated with anxiety in bipolar disorder (BD) and presents a novel treatment target. Imagery-based treatments show promise in targeting anxiety and improving mood instability. This qualitative study explored experiences of receiving up to 12 sessions of a brief structured psychological intervention: Image-Based Emotion Regulation (IBER), which targets maladaptive mental imagery in the context of BD with an aim to modify the emotional impact of these images.

DESIGN

A qualitative study embedded within the Image Based Emotion Regulation (IBER) feasibility randomised controlled trial.

METHODS

Semi-structured interviews were conducted with 12 participants in the treatment arm of the trial who received IBER + treatment as usual. Data were analysed using thematic analysis.

RESULTS

Despite some initial scepticism about imagery-focused treatment, all participants expressed broadly positive accounts of treatment experiences. High levels of engagement with imagery modification techniques, beneficial use of techniques post treatment and improvements in anxiety management and agency were described by some. Three sub-groups were identified: those who reported a powerful transformative impact of treatment; those who embedded some new techniques into their daily lives, and those who felt they had techniques to use when needed. No participants reported overall negative experiences of the IBER treatment.

CONCLUSIONS

Findings from this study highlight the value for treatment recipients of modifying the underlying meanings associated with maladaptive imagery, and the personalised skills development to manage anxiety within bipolar disorders. Findings can inform treatment refinements and further trial-based evaluations.

The purpose of early maladaptive schemas (EMS) in the relationship dysfunction among people with bipolar disorder in the euthymic phase

OBJECTIVES

Although free from characterized manic and depressive episodes, the euthymic period in bipolar disorder (BD) remains characterized by a whole host of difficulties, particularly relational. These difficulties are factors of vulnerabilities and relapses. People's perception of their own relationships has an impact on their symptomatology, their responses to treatment and on relapse rates. Young's early maladaptive schemas (EMS) approach proves to be relevant for understanding the construction of these perceptions and working on them. Nevertheless, to this date, few studies have investigated which EMS are related to relationship dysfunction in this particular population. Determining the link between EMS and relationship difficulties would be relevant to understand psychosocial impairment of people with BD in euthymic states. The present study aims to investigate the associations between the different domains of EMS and relationship dysfunction among patients with bipolar disorder in the euthymic phase.

METHODS

Data are extracted from the FACE-BD cohort, within the BD Expert Center in Versailles. Inclusion criteria were to be aged between 18 and 65 and to be an outpatient with a diagnosis of bipolar disorder (DSM-IV-TR). Patients had to be euthymic at the time of inclusion, according to DSM-IV-TR criteria with a cut-off score of 14 on the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale. Non-inclusion criteria were meeting at the time of the study the criteria for characteristic depressive episode, hypomania or mania according to the DSM-IV-TR. Sociodemographic data, clinical features associated with relationship dysfunction were assessed. EMS and EMS domains were assessed with the YSQ-R short form (Young Schema Questionnaire 3 Short Form) and current relationship dysfunction were assessed with the FAST (Functioning assessment short test subscale). Successive simple linear regression analyses were performed to investigate the association between the severity scores of each EMS and the intensity of relationship dysfunction. Furthermore, successive simple linear regression analyses investigated the association between EMS domain scores and intensity of relationship dysfunction. Multiple linear regression analyses were performed to test the association between EMS scores, then EMS domains, and the intensity of relationship dysfunction after adjusting for age as well as the intensity of residual depressive and manic symptoms.

RESULTS

Relationship dysfunction is partly associated with EMS activation in particular in the separation and rejection domain (P<0.0001), the other-directedness domain (P=0.031) and the over-vigilance and inhibition domain (P=0.005). Having residual depressive symptoms is also among the factors contributing to the relationship dysfunctions of people with bipolar disorder in the euthymic phase.

DISCUSSION

This is the first study demonstrating that the activation of several domains of EMS is a risk factor of relationships difficulties for people in euthymic phase of bipolar disorder. It is necessary to identify which EMS are specifically activated and their domains of belonging in order to prevent and reduce them. EMS are a lever for functional remission. It is therefore relevant to refer people reporting relationship problems to schema therapy consistent with a personalized care. Finally, future studies should focus on the mechanisms underlying the complex relationship between EMS domains and relationship dysfunction in people with bipolar disorder in the euthymic phase. It may also be relevant for future research to control for different types of relationship dysfunction. EMS may be differentially associated with several types of interpersonal problems. The relations between different adaptation styles and EMS should be further investigated to offer more personalized care, with the aim to improve functional remission.

Individual-Specific Animated Profiles of Mental Health

How important is the timing of the pretreatment evaluation? If we consider mental health to be a relatively fixed condition, the specific timing (e.g., day, hour) of the evaluation is immaterial and often determined on the basis of technical considerations. Indeed, the fundamental assumption underlying the vast majority of psychotherapy research and practice is that mental health is a state that can be captured in a one-dimensional snapshot. If this fundamental assumption, underlying 80 years of empirical research and practice, is incorrect, it may help explain why for decades psychotherapy failed to rise above the 50% efficacy rate in the treatment of mental-health disorders, especially depression, a heterogeneous disorder and the leading cause of disability worldwide. Based on recent studies suggesting within-individual dynamics, this article proposes that mental health and its underlying therapeutic mechanisms have underlying intrinsic dynamics that manifest across dimensions. Computational psychotherapy is needed to develop individual-specific pretreatment animated profiles of mental health. Such individual-specific animated profiles are expected to improve the ability to select the optimal treatment for each patient, devise adequate treatment plans, and adjust them on the basis of ongoing evaluations of mental-health dynamics, creating a new understanding of therapeutic change as a transition toward a more adaptive animated profile.

What's in the mind's eye of individuals with bipolar disorders: an exploration of the content and characteristics of mental images in different thymic phases

BACKGROUND

Mental imagery, or 'seeing with the mind's eye' (Kosslyn et al. ), provokes strong emotional responses (Ji et al., ). To date, there is a lack of data on the content and clinical characteristics (e.g. vividness, likelihood, emotional effects) of spontaneous mental images (MI) in people with bipolar disorder (BD) according to their thymic states.

AIM

The current study sought to assess the characteristics associated with the contents of MI in people with BD.

METHOD

Forty-two euthymic individuals diagnosed with BD (American Psychiatric Association, ) were asked to self-report their MI during depression, (hypo)mania and euthymia. Participants also rated levels of vividness, likelihood and emotional activation related to MI (i.e. valence, arousal, type of emotion).

RESULTS

The contents of the MI revealed phenomenological aspects of BD. Different themes were associated with each thymic phase. In (hypo)mania and in euthymia, the mental images were assessed as being as vivid as probable (p>.05). (Hypo)manic and euthymic-related MI activated more pleasure than displeasure (p<.001) and were mainly associated with joy. In depression, MI were assessed as more vivid than likely (p<.05). In depression, MI activated more displeasure than pleasure (p<.0001) and induced mainly sadness.

DISCUSSION

Overall, a congruence between the contents of images and the three thymic phases was found. The content of the MI was related to self-reported emotional effects that were congruent with the thymic phases concerned. The results add new clinical information for the use of imagery-based cognitive therapy in individuals with BD.

Assessing the delivering of iMAgery-focused therapy for PSychosis (iMAPS) via telehealth

OBJECTIVES

To examine the feasibility and acceptability of a novel telehealth (video-conferencing software and telephone calls) imagery-based therapeutic intervention for people experiencing persecutory delusions. Utilising a multiple baseline case series design and exploring imagery-focused therapy for psychosis (iMAPS).

DESIGN

A non-concurrent A-B multiple baseline design was used.

METHODS

Participants experiencing persecutory delusions and self-reporting a psychosis or schizophrenia-spectrum diagnosis were recruited through online adverts. On completion of assessments, participants were randomly assigned to multiple baseline assessments, of between three and five sessions. Six therapy sessions followed, consisting of imagery formulation, safe-place imagery creation, compassionate imagery, imagery manipulation and rescripting. Participants completed pre- and post-measures and sessional measures via an online survey software or in semi-structured interviews. Two weeks post-intervention, a final measure was completed exploring any potential adverse effects of psychotherapy.

RESULTS

Five female participants completed all baseline and therapeutic sessions, suggesting the therapy was and mode of delivery was feasible and acceptable. Results indicate strong effect sizes across PANSS positive subscale and mood, as well as participants reporting a clinically significant change in at least one measure, for example, PSYRATS. All participants reported a reduction in the realness and compelling nature of distressing imagery.

CONCLUSIONS

Results suggest delivering a telehealth imagery-focused therapy is acceptable and feasibly delivered via telehealth. A control group and blinding of assessments would strengthen the methodological limitations present.

The IBER study: a feasibility randomised controlled trial of imagery based emotion regulation for the treatment of anxiety in bipolar disorder

BACKGROUND

Intrusive mental imagery is associated with anxiety and mood instability within bipolar disorder and therefore represents a novel treatment target. Imagery Based Emotion Regulation (IBER) is a brief structured psychological intervention developed to enable people to use the skills required to regulate the emotional impact of these images.

METHODS

Participants aged 18 and over with a diagnosis of bipolar disorder and at least a mild level of anxiety were randomly assigned (1:1) to receive IBER plus treatment as usual (IBER + TAU) or treatment as usual alone (TAU). IBER was delivered in up to 12 sessions overs 16 weeks. Clinical and health economic data were collected at baseline, end of treatment and 16-weeks follow-up. Objectives were to inform the recruitment process, timeline and sample size estimate for a definitive trial and to refine trial procedures. We also explored the impact on participant outcomes of anxiety, depression, mania, and mood stability at 16-weeks and 32-weeks follow-up.

RESULTS

Fifty-seven (28: IBER + TAU, 27: TAU) participants from two sites were randomised, with 50 being recruited within the first 12 months. Forty-seven (82%) participants provided outcome data at 16 and 32-weeks follow-up. Thirty-five participants engaged in daily mood monitoring at the 32-week follow-up stage. Retention in IBER treatment was high with 27 (96%) attending ≥ 7 sessions. No study participants experienced a serious adverse event.

DISCUSSION

The feasibility criteria of recruitment, outcome completion, and intervention retention were broadly achieved, indicating that imagery-focused interventions for bipolar disorder are worthy of further investigation.

Attachment patterns and autobiographical episodic memory functioning: A systemic review of adult studies to advance clinical psychological science

Patterns of insecure attachment are associated with psychopathology but the mechanisms involved remain poorly understood. Cognitive science proposes that attachment patterns are influenced by the autobiographical memory system and in turn influence its ongoing functioning. Disturbances in autobiographical memory represent cognitive risks for later emotional difficulties. We systemically reviewed 33 studies (in 28 articles) examining the association between attachment patterns and autobiographical episodic memory (AEM) in individuals from the age of 16 (i.e., from young to older adulthood). Attachment patterns were associated with key areas of AEM phenomenology, including intensity and arousal; detail, specificity, and vividness; coherence and fragmentation; and accuracy and latency. These associations appeared to be moderated by contextual and individual factors; mediated by emotional regulation and schema-based processing; linked to mental health outcomes. Attachment patterns may also influence the impact of certain AEM-based manipulations. We conclude by providing a critical discussion and a research agenda for bringing together attachment, memory, and emotion, with a view to promote mechanism-driven treatment innovation in clinical psychology.

Comparing the effectiveness of imagery focussed cognitive therapy to group psychoeducation for patients with bipolar disorder: A randomised trial

BACKGROUND

Bipolar disorder is a severe, chronic mental disorder. Treatment options are limited, with pharmacological approaches continuing to dominate. However, relapse rates remain high. Several adjunctive psychosocial interventions, mostly psychoeducation (PE) and cognitive behavioural therapy (CBT), have been trialled, but treatment innovation is still needed. In the past, brief group PE has proven as beneficial as longer individual CBT in reducing levels of depression and increasing self-management strategies. We compared the relative effectiveness of group PE to an imagery focussed cognitive behavioural therapy (ImCT).

STUDY DESIGN

This was a randomised parallel group study with both daily and weekly measures. A total of 62 adult patients were randomly allocated to either ImCT or group PE. Daily, weekly and pre-and post-intervention measures were used to assess impact on (i) mood instability, (ii) overall levels of depression, anxiety and mania, and (iii) general functioning, hopelessness and imagery characteristics. A four-week baseline and 16-week follow-up period were included.

RESULTS

Mood instability reduced in both conditions after intervention. Levels of mania, depression and anxiety also reduced in both conditions, but on the daily measures, depression and anxiety significantly more so in the ImCT condition. Compared with the PE condition, the ImCT condition additionally showed increased level of functioning, reduced hopelessness, and a decrease in intrusive, problematic imagery.

LIMITATIONS

These findings need to be replicated in a larger trial.

CONCLUSIONS

Findings suggest that ImCT is a promising new avenue for management of bipolar disorder, an area in which treatment development is urgently needed.

Modelling Identity Disturbance: A Network Analysis of the Personality Structure Questionnaire (PSQ)

Due to the relevance of identity disturbance to personality disorder this study sought to complete a network analysis of a well validated measure of identity disturbance; the personality structure questionnaire (PSQ). A multi-site and cross-national methodology created an overall sample of N = 1549. The global network structure of the PSQ was analysed and jointly estimated networks were compared across four subsamples (UK versus Italy, adults versus adolescents, clinical versus community and complex versus common presenting problems). Stability analyses assessed the robustness of identified networks. Results indicated that PSQ3 (unstable sense of self) and PSQ5 (mood variability) were the most central items in the global network structure. Network structures significantly differed between the UK and Italy. Centrality of items was largely consistent across subsamples. This study provides evidence of the potential network structure of identity disturbance and so guides clinicians in targeting interventions facilitating personality integration.

Positive moods are all alike? Differential affect amplification effects of 'elated' versus 'calm' mental imagery in young adults reporting hypomanic-like experiences

Positive mood amplification is a hallmark of the bipolar disorder spectrum (BPDS). We need better understanding of cognitive mechanisms contributing to such elevated mood. Generation of vivid, emotionally compelling mental imagery is proposed to act as an 'emotional amplifier' in BPDS. We used a positive mental imagery generation paradigm to manipulate affect in a subclinical BPDS-relevant sample reporting high (n = 31) vs. low (n = 30) hypomanic-like experiences on the Mood Disorder Questionnaire (MDQ). Participants were randomized to an 'elated' or 'calm' mental imagery condition, rating their momentary affect four times across the experimental session. We hypothesized greater affect increase in the high (vs. low) MDQ group assigned to the elated (vs. calm) imagery generation condition. We further hypothesized that affect increase in the high MDQ group would be particularly apparent in the types of affect typically associated with (hypo)mania, i.e., suggestive of high activity levels. Mixed model and time-series analysis showed that for the high MDQ group, affect increased steeply and in a sustained manner over time in the 'elated' imagery condition, and more shallowly in 'calm'. The low-MDQ group did not show this amplification effect. Analysis of affect clusters showed high-MDQ mood amplification in the 'elated' imagery condition was most pronounced for active affective states. This experimental model of BPDS-relevant mood amplification shows evidence that positive mental imagery drives changes in affect in the high MDQ group in a targeted manner. Findings inform cognitive mechanisms of mood amplification, and spotlight prevention strategies targeting elated imagery, while potentially retaining calm imagery to preserve adaptive positive emotionality.

Aphantasia and psychological disorder: Current connections, defining the imagery deficit and future directions

Aphantasia is a condition characterized by a deficit of mental imagery. Since several psychopathologies are partially maintained by mental imagery, it may be illuminating to consider the condition against the background of psychological disorder. After outlining current findings and hypotheses regarding aphantasia and psychopathology, this paper suggests that some support for defining aphantasia as a lack of voluntary imagery may be found here. The paper then outlines potentially fruitful directions for future research into aphantasia in general and its relation to psychopathology in particular, including rethinking use of the SUIS to measure involuntary imagery, whether aphantasia offers protection against addiction, and whether hyperphantasia is a potential risk factor for maladaptive daydreaming, among others.

Mathematical Model of Interaction of Therapist and Patients with Bipolar Disorder: A Systematic Literature Review

Mood swings in patients with bipolar disorder (BD) are difficult to control and can lead to self-harm and suicide. The interaction between the therapist and BD will determine the success of therapy. The interaction model between the therapist and BD begins by reviewing the models that were previously developed using the Systematic Literature Review and Bibliometric methods. The limit of articles used was sourced from the Science Direct, Google Scholar, and Dimensions databases from 2009 to 2022. The results obtained were 67 articles out of a total of 382 articles, which were then re-selected. The results of the selection of the last articles reviewed were 52 articles. Using VOSviewer version 1.6.16, a visualization of the relationship between the quotes “model”, “therapy”, “emotions”, and “bipolar disorder” can be seen. This study also discusses the types of therapy that can be used by BD, as well as treatment innovations and the mathematical model of the therapy itself. The results of this study are expected to help further researchers to develop an interaction model between therapists and BD to improve the quality of life of BD.

Stimulus-Driven Affective Change: Evaluating Computational Models of Affect Dynamics in Conjunction with Input

The way in which emotional experiences change over time can be studied through the use of computational models. An important question with regard to such models is which characteristics of the data a model should account for in order to adequately describe these data. Recently, attention has been drawn on the potential importance of nonlinearity as a characteristic of affect dynamics. However, this conclusion was reached through the use of experience sampling data in which no information was available about the context in which affect was measured. However, affective stimuli may induce some or all of the observed nonlinearity. This raises the question of whether computational models of affect dynamics should account for nonlinearity, or whether they just need to account for the affective stimuli a person encounters. To investigate this question, we used a probabilistic reward task in which participants either won or lost money at each trial. A number of plausible ways in which the experimental stimuli played a role were considered and applied to the nonlinear Affective Ising Model (AIM) and the linear Bounded Ornstein-Uhlenbeck (BOU) model. In order to reach a conclusion, the relative and absolute performance of these models were assessed. Results suggest that some of the observed nonlinearity could indeed be attributed to the experimental stimuli. However, not all nonlinearity was accounted for by these stimuli, suggesting that nonlinearity may present an inherent feature of affect dynamics. As such, nonlinearity should ideally be accounted for in the computational models of affect dynamics.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42761-022-00118-5.

Individual Response to Botulinum Toxin Therapy in Movement Disorders: A Time Series Analysis Approach

On a group level, satisfaction with botulinum neurotoxin (BoNT) treatment in neurological indications is high. However, it is well known that a relevant amount of patients may not respond as expected. The aim of this study is to evaluate the BoNT treatment outcome on an individual level using a statistical single-case analysis as an adjunct to traditional group statistics. The course of the daily perceived severity of symptoms across a BoNT cycle was analyzed in 20 cervical dystonia (CD) and 15 hemifacial spasm (HFS) patients. A parametric single-case autoregressive integrated moving average (ARIMA) time series analysis was used to detect individual responsiveness to BoNT treatment. Overall, both CD and HFS patients significantly responded to BoNT treatment with a gradual worsening of symptom intensities towards BoNT reinjection. However, only 8/20 CD patients (40%) and 5/15 HFS patients (33.3%) displayed the expected U-shaped curve of BoNT efficacy across a single treatment cycle. CD (but not HFS) patients who followed the expected outcome course had longer BoNT injection intervals, showed a better match to objective symptom assessments, and were characterized by a stronger certainty to control their somatic symptoms (i.e., internal medical locus of control). In addition to standard evaluation procedures, patients should be identified who do not follow the mean course-of-treatment effect. Thus, the ARIMA single-case time series analysis seems to be an appropriate addition to clinical treatment studies in order to detect individual courses of subjective symptom intensities.

Exploring the digital footprint of depression: a PRISMA systematic literature review of the empirical evidence

BACKGROUND

This PRISMA systematic literature review examined the use of digital data collection methods (including ecological momentary assessment [EMA], experience sampling method [ESM], digital biomarkers, passive sensing, mobile sensing, ambulatory assessment, and time-series analysis), emphasizing on digital phenotyping (DP) to study depression. DP is defined as the use of digital data to profile health information objectively.

AIMS

Four distinct yet interrelated goals underpin this study: (a) to identify empirical research examining the use of DP to study depression; (b) to describe the different methods and technology employed; (c) to integrate the evidence regarding the efficacy of digital data in the examination, diagnosis, and monitoring of depression and (d) to clarify DP definitions and digital mental health records terminology.

RESULTS

Overall, 118 studies were assessed as eligible. Considering the terms employed, "EMA", "ESM", and "DP" were the most predominant. A variety of DP data sources were reported, including voice, language, keyboard typing kinematics, mobile phone calls and texts, geocoded activity, actigraphy sensor-related recordings (i.e., steps, sleep, circadian rhythm), and self-reported apps' information. Reviewed studies employed subjectively and objectively recorded digital data in combination with interviews and psychometric scales.

CONCLUSIONS

Findings suggest links between a person's digital records and depression. Future research recommendations include (a) deriving consensus regarding the DP definition and (b) expanding the literature to consider a person's broader contextual and developmental circumstances in relation to their digital data/records.

Fear and anxiety in the face of COVID-19: Negative dispositions towards risk and uncertainty as vulnerability factors

In the face of the COVID-19 pandemic it is important to identify factors that make people particularly vulnerable of developing mental-health issues in order to provide case-specific treatments. In this article, we examine the roles of two psychological constructs - originally put forth in the behavioral decision sciences - in predicting interindividual differences in fear responses: general risk aversion (GRA) and intolerance of uncertainty (IU). We first provide a review of these constructs and illustrate why they may play important roles in shaping anxiety-related disorders. Thereafter we present an empirical study that collected survey data from 550 U.S. residents, comprising self-assessments of dispositions towards risk and uncertainty, anxiety- and depression levels, as well as demographic variables - to thus test the extent to which these psychological constructs are predictive of strong fear responses related to COVID-19 (i.e., mortal fear, racing heart). The results from Bayesian multi-model inference analyses showed that GRA and IU were more powerful predictors of fear responses than demographic variables. Moreover, the predictive power of these constructs was independent of general anxiety- and depression levels. Subsequent mediation analyses showed that the effects of GRA and IU were both direct and indirect via anxiety. We conclude by discussing possible treatment options, but also highlight that future research needs to further examine causal pathways and conceptual overlaps.

Mental Imagery in the Science and Practice of Cognitive Behaviour Therapy: Past, Present, and Future Perspectives

Mental imagery has a long history in the science and practice of cognitive behaviour therapy (CBT), stemming from both behavioural and cognitive traditions. The past decade or so has seen a marked increase in both scientific and clinical interest in mental imagery, from basic questions about the processes underpinning mental imagery and its roles in everyday healthy functioning, to clinical questions about how dysfunctions in mental imagery can cause distress and impairment, and how mental imagery can be used within CBT to effect therapeutic change. This article reflects on the current state of mental imagery in the science and practice of CBT, in the context of past developments and with a view to future challenges and opportunities. An ongoing interplay between the various strands of imagery research and the many clinical innovations in this area is recommended in order to realise the full therapeutic potential of mental imagery in CBT.

The Continuum Between Temperament and Mental Illness as Dynamical Phases and Transitions

The full range of biopsychosocial complexity is mind-boggling, spanning a vast range of spatiotemporal scales with complicated vertical, horizontal, and diagonal feedback interactions between contributing systems. It is unlikely that such complexity can be dealt with by a single model. One approach is to focus on a narrower range of phenomena which involve fewer systems but still cover the range of spatiotemporal scales. The suggestion is to focus on the relationship between temperament in healthy individuals and mental illness, which have been conjectured to lie along a continuum of neurobehavioral regulation involving neurochemical regulatory systems (e.g., monoamine and acetylcholine, opiate receptors, neuropeptides, oxytocin), and cortical regulatory systems (e.g., prefrontal, limbic). Temperament and mental illness are quintessentially dynamical phenomena, and need to be addressed in dynamical terms. A meteorological metaphor suggests similarities between temperament and chronic mental illness and climate, between individual behaviors and weather, and acute mental illness and frontal weather events. The transition from normative temperament to chronic mental illness is analogous to climate change. This leads to the conjecture that temperament and chronic mental illness describe distinct, high level, dynamical phases. This suggests approaching biopsychosocial complexity through the study of dynamical phases, their order and control parameters, and their phase transitions. Unlike transitions in physical systems, these biopsychosocial phase transitions involve information and semiotics. The application of complex adaptive dynamical systems theory has led to a host of markers including geometrical markers (periodicity, intermittency, recurrence, chaos) and analytical markers such as fluctuation spectroscopy, scaling, entropy, recurrence time. Clinically accessible biomarkers, in particular heart rate variability and activity markers have been suggested to distinguish these dynamical phases and to signal the presence of transitional states. A particular formal model of these dynamical phases will be presented based upon the process algebra, which has been used to model information flow in complex systems. In particular it describes the dual influences of energy and information on the dynamics of complex systems. The process algebra model is well-suited for dealing with the particular dynamical features of the continuum, which include transience, contextuality, and emergence. These dynamical phases will be described using the process algebra model and implications for clinical practice will be discussed.

Hypomanic-like experiences and spontaneous emotional mental imagery

BACKGROUND

Bipolar spectrum disorders (BPSD) are associated with frequent and emotional mental imagery, theorized to play a role in mood instability. However, we lack methods for measuring tendency to experience emotional mental imagery in daily life. The current study developed such a measure and evaluated the hypothesis that a high tendency to experience emotional imagery in daily life would be associated with higher levels of hypomanic-like experiences.

METHODS

We conducted two rounds of studies to develop and refine a measure of spontaneous emotional imagery (E-SUIS) using factor analysis. We conducted a third study to test the relationship between E-SUIS score and hypomanic-like experiences. Participants (total N = 554, age 18-25) comprised an unselected community sample.

RESULTS

First, factor analysis indicated a unidimensional factor structure and excellent reliability (α=0.87) of our novel measure of spontaneous emotional mental imagery. Second, higher scores on a hypomanic-like experiences scale related to higher use of both spontaneous emotional imagery and spontaneous non-emotional imagery. Spontaneous emotional mental imagery significantly improved the prediction of hypomanic-like experiences over non-emotional mental imagery.

LIMITATIONS

Only two mental imagery measures were included. To determine discriminant validity of the E-SUIS requires additional imagery measures or interviews.

CONCLUSIONS

Levels of hypomanic-like experiences were related to the tendency to use emotional imagery in daily life. Additionally, spontaneous use of emotional imagery appears to be a better predictor of hypomanic-like experiences in the general population compared to spontaneous use of non-emotional imagery.

Suicidal Imagery in Borderline Personality Disorder and Major Depressive Disorder

A better understanding of suicidal behavior is important to detect suicidality in at-risk populations such as patients with borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). Suicidal tendencies are clinically assessed by verbal thoughts rather than by specifically asking about mental images. This study examines whether imagery and verbal thoughts about suicide occur and differ between patients with BPD with and without comorbid PTSD compared to patients with MDD (clinical controls). All patient groups experienced suicide-related images. Patients with BPD with comorbid PTSD reported significantly more vivid images than patients with MDD. Severity of suicidal ideation, number of previous suicide attempts, and childhood traumata were significantly associated with suicidal imagery across all patient groups. The authors demonstrate for the first time that suicide-related mental imagery occurs in BPD and is associated with suicidal ideation. This finding highlights the importance of assessing mental imagery related to suicide in clinical practice.

Targeting intrusive imagery using a competing task technique: a case study

BACKGROUND

Even in cases with complexity, simple techniques can be useful to target a specific symptom. Intrusive mental images are highly disruptive, drive emotion, and contribute to maintaining psychopathology. Cognitive science suggests that we might target intrusive images using competing tasks.

AIMS

We describe an imagery competing task technique within cognitive behavioural therapy (CBT) with a patient with bipolar disorder and post-traumatic stress disorder (PTSD) symptoms. The intervention - including Tetris computer game-play - was used (1) to target a specific image within one therapy session, and (2) to manage multiple images in daily life.

METHOD

A single case (AB) design was used. (1) To target a specific image, the patient brought the image to mind and, after mental rotation instructions and game-play practice, played Tetris for 10 minutes. Outcomes, pre- and post-technique, were: vividness/distress ratings when the image was brought to mind; reported intrusion frequency over a week. (2) To manage multiple images, the patient used the intervention after an intrusive image occurred. Outcomes were weekly measures of: (a) imagery characteristics; (b) symptoms of PTSD, anxiety, depression and mania.

RESULTS

(1) For the target image, there were reductions in vividness (80% to 40%), distress (70% to 0%), and intrusion frequency (daily to twice/week). (2) For multiple images, there were reductions from baseline to follow-up in (a) imagery vividness (38%), realness (66%) and compellingness (23%), and (b) PTSD symptoms (Impact of Events Scale-Revised score 26.33 to 4.83).

CONCLUSION

This low-intensity intervention aiming to directly target intrusive mental imagery may offer an additional, complementary tool in CBT.

The IBER study: study protocol for a feasibility randomised controlled trial of Imagery Based Emotion Regulation for the treatment of anxiety in bipolar disorder

Background

Anxiety is highly prevalent in people diagnosed with bipolar disorder (BD), and can persist between acute episodes of mania and depression. Recent studies indicate that people with BD are prone to experiencing frequent, intrusive and emotional mental images which further fuel their levels of anxiety and mood instability. These intrusive emotional mental images represent a specific target for treatment for this disorder with the potential to reduce anxiety and improve mood stability. A new brief structured psychological intervention for BD called Imagery Based Emotion Regulation (IBER) has been developed, which translates experimental work in the area of imagery and emotion into a skills training programme to improve the regulation of intrusive and distressing emotional mental images in BD. A feasibility trial is required in order to assess whether a full randomised controlled trial is indicated in order to evaluate this approach.

Methods

The design is a two-arm feasibility randomised controlled trial (RCT), with 1:1 randomisation stratified by trial site and minimised on medication status and anxiety severity. Participants are 60 individuals diagnosed with bipolar disorder and experiencing at least a mild level of anxiety. Sites are defined by the geographical boundaries of two National Health Service (NHS) Trusts, with recruitment from NHS teams, GP surgeries and self-referral. The intervention is up to 12 sessions of Imagery Based Emotion Regulation within 16 weeks. The comparator is NHS standard care. The primary aim is to assess the feasibility of conducting a powered multi-site RCT to evaluate effectiveness. Measures of anxiety, depression, mania, mood stability and health care use will be conducted at baseline, end of treatment and at 16-week follow-up.

Discussion

This is the first feasibility trial of an imagery-based intervention for the treatment of anxiety in bipolar disorder. If the trial proves feasible, a large multi-site trial will be required.

Trial registration

ISRCTN16321795. Registered on October 16, 2018. 10.1186/ISRCTN16321795

Profiles of Perfectionistic Ruminations in Undergraduates: Impact on the Spontaneous Use of Mental Images

Perfectionistic Automatic Thoughts (PAT) negatively affects people who present it. Hence the importance of their study to determine possible ways of reduction. The current study tried to identify PAT profiles and specify the statistically significant differences in the Spontaneous Use of Mental Imaging in 647 undergraduates. For this the Perfectionism Cognitions Inventory and the Spontaneous Use of Imagery Scale were used. The cluster analyses showed three groups of PATs; low (LPAT), moderate (MPAT) and high (HPAT). An analysis of variance revealed moderate size differences in the visual-spatial capacity as well as in the total of the Spontaneous Use of Mental Images for MPAT and LPAT. Implications for the training of future teachers related to the use of mental imagery that can reduce maladaptive PAT are discussed.

A cognitive behavioural group therapy for bipolar disorder using daily mood monitoring

BACKGROUND AND AIM

This study investigated the effects of group cognitive behavioural therapy (CBT) for patients with bipolar disorder. The development of CBT for this disorder is relatively under-explored.

METHOD

Participants with bipolar I or II disorder were treated with group CBT in addition to treatment as usual. The effectiveness of the protocol was explored through sequence analysis of daily mood monitoring prior to, during and after the intervention. Also, a repeated measures design was used assessing symptomatology, dysfunctional attitudes, sense of mastery, psychosocial functioning, and quality of life at start and end of intervention, and at follow-up 2 and 12 months later.

RESULTS

The results indicate that variation in mood states diminished over the course of the intervention. Also, there was a change from depressive states to more euthymic states. Greater number of reported lifetime depressive episodes was associated with greater diversity of mood states. There was an increase in overall psychosocial functioning and self-reported psychological health following the intervention. Improvement continued after treatment ended until follow-up at 2 months, and measured 1 year later, for outcomes representing depression, general psychosocial functioning and self-reported psychological health. Due to small sample size and the lack of a control group the results are preliminary.

CONCLUSIONS

The results of this pilot study suggest that both offering CBT in group interventions and sequence analysis of time series data are helpful routes to further explore when improving standard CBT interventions for patients suffering from bipolar disorder.

iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series

Background:

Many people with psychosis experience persecutory delusions and report negative schematic beliefs and intrusive mental images which may be maintaining factors for psychotic symptoms.

Aims:

This study examined the feasibility and acceptability of a new psychological therapy targeting schemas and images (iMAPS therapy).

Method:

The study used a randomised multiple baseline design. Participants with first episode psychosis were randomised using a multiple baseline design with 2–5 assessments. Six sessions of therapy, consisting of a combination of imagery techniques and imagery rescripting techniques, was used. In each session, participants completed a Mental Imagery in Psychosis Questionnaire (MIPQ) and imagery interview. Mood and delusional beliefs (PSYRATS) were also measured at each session.

Results:

Five participants with first episode psychosis completed the baseline visits and attended all therapy sessions. One participant declined the final assessment. Results demonstrated significant reductions in negative schematic beliefs, delusions, imagery distress and other measures of schema (YSQ, SMI). Although multiple baseline randomisation strengthens the study, it lacked a control arm and blind assessments.

Conclusions:

iMAPS appears a feasible and acceptable treatment for psychosis, and further evaluation is indicated.

Online mood monitoring in treatment-resistant depression: qualitative study of patients' perspectives in the NHS

AIMS AND METHOD

True Colours is an automated symptom monitoring programme used by National Health Service psychiatric services. This study explored whether patients with unipolar treatment-resistant depression (TRD) found this a useful addition to their treatment regimes. Semi-structured qualitative interviews were conducted with 21 patients with TRD, who had engaged in True Colours monitoring as part of the Lithium versus Quetiapine in Depression study. A thematic analysis was used to assess participant experiences of the system.

RESULTS

Six main themes emerged from the data, the most notable indicating that mood monitoring increased patients' insight into their disorder, but that subsequent behaviour change was absent.

CLINICAL IMPLICATIONS

Patients with TRD can benefit from mood monitoring via True Colours, making it a worthwhile addition to treatment. Further development of such systems and additional support may be required for patients with TRD to experience further benefits as reported by other patient groups.

Effects of intense assessment on statistical power in randomized controlled trials: Simulation study on depression

Smartphone-based devices are increasingly recognized to assess disease symptoms in daily life (e.g. ecological momentary assessment, EMA). Despite this development in digital psychiatry, clinical trials are mainly based on point assessments of psychopathology. This study investigated expectable increases in statistical power by intense assessment in randomized controlled trials (RCTs). A simulation study, based on three scenarios and several empirical data sets, estimated power gains of two- or fivefold pre-post-assessment. For each condition, data sets of various effect sizes were generated, and AN(C)OVAs were applied to the sample of interest (N = 50-N = 200). Power increases ranged from 6% to 92%, with higher gains in more underpowered scenarios and with higher number of repeated assessments. ANCOVA profited from a more precise estimation of the baseline covariate, resulting in additional gains in statistical power. Fivefold pre-post EMA resulted in highest absolute statistical power and clearly outperformed traditional questionnaire assessments. For example, ANCOVA of automatized PHQ-9 questionnaire data resulted in absolute power of 55 (for N = 200 and d = 0.3). Fivefold EMA, however, resulted in power of 88.9. Non-parametric and multi-level analyses resulted in comparable outcomes. Besides providing psychological treatment, digital mental health can help optimizing sensitivity in RCT-based research. Intense assessment appears advisable whenever psychopathology needs to be assessed with high precision at pre- and post-assessment (e.g. small sample sizes, small treatment effects, or when applying optimization problems like machine learning). First empiric studies are promising, but more evidence is needed. Simulations for various effects and a short guide for popular power software are provided for study planning.

The Emerging Neurobiology of Bipolar Disorder

(Reprinted with permission from Trends in Neurosciences, January 2018, Vol. 41, No. 1 ).

Scientific challenges for precision public health

The notion of ‘precision’ public health has been the subject of much debate, with recent articles coming to its defence following the publication of several papers questioning its value.

Critics of precision public health raise the following problems and questionable assumptions: the inherent limits of prediction for individuals; the limits of approaches to prevention that rely on individual agency, in particular the potential for these approaches to widen inequalities; the undue emphasis on the supposed new information contained in individuals’ molecules and their ‘big data’ at the expense of their own preferences for a particular intervention strategy and the diversion of resources and attention from the social determinants of health.

In order to refocus some of these criticisms of precision public health as scientific questions, this article outlines some of the challenges when defining risk for individuals; the limitations of current theory and study design for precision public health; and the potential for unintended harms.

Remediating reduced memory specificity in bipolar disorder: A case study using a Computerized Memory Specificity Training

OBJECTIVES

Reduced autobiographical memory specificity (rAMS) is a vulnerability factor found across unipolar depression (UD), posttraumatic stress disorder (PTSD), eating disorder, schizophrenia, and bipolar disorder (BD). A group delivered psychological therapy training called Memory Specificity Training (MeST) remediates rAMS in UD and PTSD, with additional downstream effects on related psychological processes and symptoms. Its impact in BD is unknown. In this case study, we examined the impact of a computerized version of MeST (c-MeST) on improving AMS and related symptoms and processes in participant with rapid cycling type I BD.

METHOD

An experimental case study with an ABA design was used. During baseline (14 days, Phase A), the training phase (nine sessions across 17 days, Phase B), and a 1-month follow-up (Phase A), memory specificity, depressive symptoms, and related processes and symptoms were repeatedly measured.

RESULTS

Memory specificity increased significantly after the participant completed c-MeST. Session-to-session scores indicated that AMS improved most from the in-person baseline assessment to the first online session. All other measures of processes and symptoms deteriorated during the training phase but regressed to baseline during follow-up.

CONCLUSION

Memory specificity was improved as indicated by increased AMS from pre-intervention measurement to 1-month follow-up. Other improvements in symptoms were not observed. Rather, some related maladaptive psychological processes and symptoms worsened during the training phase and regressed to baseline during follow-up.

Systema Temporis: A time-based dimensional framework for consciousness and cognition

This study uses a combined categorical-dimensional approach to depict a hierarchical framework for consciousness similar to, and contiguous with, factorial models of cognition (cf., intelligence). On the basis of the longstanding definition of time consciousness, the analysis employs a dimension of temporal extension, in the same manner that psychology has temporally organised memory (i.e., short-term, long-term, and long-lasting memories). By defining temporal extension in terms of the structure of time perception at short timescales (<100 s), memory and time consciousness are proposed to fit along the same logarithmic dimension. This suggests that different forms of time consciousness (e.g., experience, wakefulness, and self-consciousness) are embedded within, or supported by, the ascending timescales of different modes of memory (i.e., short-term, long-term, etc.). A secondary dimension is also proposed to integrate higher-order forms of consciousness/emotion and memory/cognition. The resulting two-dimensional structure accords with existing theories of cognitive and emotional intelligence.

Emotional Mental Imagery Abnormalities in Monozygotic Twins With, at High-Risk of, and Without Affective Disorders: Present in Affected Twins in Remission but Absent in High-Risk Twins

Background: Mental imagery abnormalities feature across affective disorders including bipolar disorder (BD) and unipolar depression (UD). Maladaptive emotional imagery has been proposed as a maintenance factor for affective symptomatology and a target for mechanism-driven psychological treatment developments. Where imagery abnormalities feature beyond acute affective episodes, further opportunities for innovation arise beyond treatments, such as for tertiary/relapse prevention (e.g., in remitted individuals) or primary prevention (e.g., in non-affected but at-risk individuals). The aim of our study was to investigate for the first time the presence of possible mental imagery abnormalities in affected individuals in remission and at-risk individuals for affective disorders using a familial risk design. Methods: A population-based cohort of monozygotic twins was recruited through linkage between the Danish national registries (N=204). Participants were grouped as: affected (remitted BD/UD; n = 115); high-risk (co-twin with history of BD/UD; n = 49), or low-risk (no co-twin history of BD/UD; n = 40). Twins completed mental imagery measures spanning key subjective domains (spontaneous imagery use and emotional imagery) and cognitive domains (imagery inspection and imagery manipulation). Results: Affected twins in remission reported enhanced emotional mental imagery compared to both low- and high-risk twins. This was characterized by greater impact of i) intrusive prospective imagery (Impact of Future Events Scale) and ii) deliberately-generated prospective imagery of negative scenarios (Prospective Imagery Task). There were no significant differences in these key measures between affected BD and UD twins in remission. Additionally, low- and high-risk twins did not significantly differ on these emotional imagery measures. There were also no significant differences between the three groups on non-emotional measures including spontaneous imagery use and cognitive stages of imagery. Conclusions: Abnormalities in emotional prospective imagery are present in monozygotic twins with affective disorders in remission-despite preserved cognitive stages of imagery-but absent in unaffected high-risk twins, and thus do not appear to index familial risk (i.e., unlikely to qualify as "endophenotypes"). Elevated emotional prospective imagery represents a promising treatment/prevention target in affective disorders.

A Dynamical Bifurcation Model of Bipolar Disorder Based on Learned Expectation and Asymmetry in Mood Sensitivity

Bipolar disorder is a common psychiatric dysfunction characterized by recurring episodes of mania and depression. Despite its prevalence, the causes and mechanisms of bipolar disorder remain largely unknown. Recently, theories focusing on the interaction between emotion and behavior, including those based on dysregulation of the so-called behavioral approach system (BAS), have gained popularity. Mathematical models built on this principle predict bistability in mood and do not invoke intrinsic biological rhythms that may arise from interactions between mood and expectation. Here we develop and analyze a model with clinically meaningful and modifiable parameters that incorporates the interaction between mood and expectation. Our nonlinear model exhibits a transition to limit cycle behavior when a mood-sensitivity parameter exceeds a threshold value, signaling a transition to a bipolar state. The model also predicts that asymmetry in response to positive and negative events can induce unipolar depression/mania, consistent with clinical observations. We analyze the model with asymmetric mood sensitivities and show that large unidirectional mood sensitivity can lead to bipolar disorder. Finally, we show how observed effects of lithium- and antidepressant-induced mania can be explained within the framework of our proposed model.

Affective instability in those with and without mental disorders: A case control study

BACKGROUND

Affective instability (AI) is transdiagnostic, and associated with suicidality and healthcare use. It has rarely been compared between diagnoses or to controls. We investigated: whether AI differs between clinical cases and controls and between diagnoses; how different AI components are correlated; and whether AI is associated with functioning in clinical cases.

METHODS

Cases (N = 69) from psychiatric services had a diagnosis of borderline personality disorder, bipolar disorder, major depression or psychosis and were compared to primary care controls (N = 25). Participants completed the affective lability scale (ALS), affective intensity measure (AIM), affective control scale (ACS), scored mood fluctuation rate and the WHO-DAS.

RESULTS

There was a significant difference in affective lability between cases and controls and across diagnostic groups (p < 0.001). Compared to controls, cases showed lower affective control (p < 0.05). There were no differences in affective intensity between cases and controls or between diagnostic groups, or in mood fluctuation rate between groups. ALS score (p < 0.001), and total number of medications (p < 0.046), were associated with functioning, independent of diagnosis.

LIMITATIONS

The sample size was modest. Cases were not in an acute illness episode and this could bias estimates of group difference towards the null.

CONCLUSION

Individuals with mental disorder demonstrate higher levels of affective lability and lower affect control than those without mental disorder. In contrast affective intensity may not be useful in demarcating abnormal affective experience. Independent of diagnosis, affective instability, as measured by affect lability, adversely impacts day-to-day functioning. It could be an important target for clinical intervention.

Neural response during emotion regulation in monozygotic twins at high familial risk of affective disorders

PURPOSE

We investigated the neural correlates of emotion regulation and -reactivity in adult unaffected monozygotic twins with a co-twin history of unipolar or bipolar disorder (high-risk), remitted or partially remitted twins with a personal history of unipolar or bipolar disorder (affected) and twins with no personal or first-degree family history of unipolar or bipolar disorder (low-risk).

METHODS

We assessed 37 high-risk, 56 affected and 28 low-risk participants. Participants viewed unpleasant and neutral pictures during functional magnetic resonance imaging and were instructed to down-regulate their emotional response through reappraisal or mental imagery, as well as to maintain the elicited emotion.

RESULTS

After adjusting for subsyndromal depressive symptoms, bilateral supplementary motor areas, posterior dorsal anterior cingulate cortices and the left frontal eye field showed less activity during reappraisal of unpleasant pictures in high-risk than low-risk participants. Notably, affected participants did not differ from high-risk or low-risk participants in neural response during reappraisal. There were no group differences in ventrolateral prefrontal cortex seed based functional connectivity during reappraisal or neural response during mental imagery or emotional reactivity.

CONCLUSION

Lesser response in dorsal midline areas might reflect familial risk related abnormalities during down regulation of emotional reactivity through reappraisal.

Imagery-Focused Cognitive Therapy (ImCT) for Mood Instability and Anxiety in a Small Sample of Patients with Bipolar Disorder: a Pilot Clinical Audit

BACKGROUND

Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT).

AIMS

This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service.

METHOD

Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire.

RESULTS

Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus.

CONCLUSIONS

This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability.

A Markov approach for increasing precision in the assessment of data-intensive behavioral interventions

Health interventions using real-time sensing technology are characterized by intensive longitudinal data, which has the potential to enable nuanced evaluations of individuals' responses to treatment. Existing analytic tools were not developed to capitalize on this opportunity as they typically focus on first-order findings such as changes in the level and/or slope of outcome variables over different intervention phases. This paper introduces an exploratory, Markov-based empirical transition method that offers a more comprehensive assessment of behavioral responses when intensive longitudinal data are available. The procedure projects a univariate time-series into discrete states and empirically determines the probability of transitioning from one state to another. State transition probabilities are summarized separately in phase-specific transition matrices. Comparing transition matrices illuminates intricate, quantifiable differences in behavior between intervention phases. Statistical significance is estimated via bootstrapping techniques. This paper introduces the methodology via three case studies from a secondhand smoke reduction trial utilizing real-time air particle sensors. Analysis enabled the identification of complex phenomena such as avoidance and escape behavior in response to punitive contingencies for tobacco use. Additionally, the largest changes in behavior dynamics were associated with the introduction of behavioral feedback. The Markov approach's ability to elucidate subtle behavioral details has not typically been feasible with standard methodologies, mainly due to historical limitations associated with infrequent repeated measures. These results suggest that the evaluation of intervention effects in data-intensive single-case designs can be enhanced, providing rich information that can ultimately be used to develop interventions uniquely tailored to specific individuals.

Innovations in digital interventions for psychological trauma: harnessing advances in cognitive science

A range of digital psychological interventions have demonstrated a positive impact on trauma-related problems in controlled trials, but there is room for further improvements in their form, reach and impact. Most to date have been adaptions of established face-to-face treatments. In this paper, we highlight a complementary emerging route to their development, which draws on advances in cognitive science theory and research and applies them to clinical contexts. Three examples are given regarding laboratory research with potential applications to digital interventions for trauma-related mental health problems: a digital game to reduce intrusive memories of trauma, novel cognitive techniques for worry, and digitally supported mental imagery to enhance motivation for functional behavior change. Much of this research is still at an early stage, meriting a balance of optimism and caution. However, even if only a few digital applications of cognitive science constitute substantial improvements to complement current treatments, their potential for large-scale use at low unit cost may provide significant benefits across populations.

The Emerging Neurobiology of Bipolar Disorder

Bipolar disorder (BD) is a leading cause of global disability. Its biological basis is unknown, and its treatment unsatisfactory. Here, we review two recent areas of progress. First, the discovery of risk genes and their implications, with a focus on voltage-gated calcium channels as part of the disease process and as a drug target. Second, facilitated by new technologies, it is increasingly apparent that the bipolar phenotype is more complex and nuanced than simply one of recurring manic and depressive episodes. One such feature is persistent mood instability, and efforts are underway to understand its mechanisms and its therapeutic potential. BD illustrates how psychiatry is being transformed by contemporary neuroscience, genomics, and digital approaches.

Emotional cascade theory and non-suicidal self-injury: the importance of imagery and positive affect

Grounded in Emotional Cascade Theory, we explored whether rumination and multisensory imagery-based cognitions moderated the relationships between affect and both odds of non-suicidal self-injury (NSSI), and frequency of the behaviour. A sample of 393 university students completed self-report questionnaires assessing the constructs of interest. Contrary to expectations, rumination did not emerge as a significant moderator of the affect-NSSI relationship. However, the relationship between affect and frequency of NSSI was moderated by the use of imagery. Further, the relationship between negative affect and NSSI was moderated by positive affect, underscoring the need to consider both negative and positive affect in models of NSSI. Most youth who self-injured reported thinking in images while the urge to self-injure was strong, with 53% thinking in images at least half the time. Future work is needed to explore how positive and negative affect work in concert to govern NSSI, and how imagery might either exacerbate or reduce risk of NSSI.

Clinical Insight Into Latent Variables of Psychiatric Questionnaires for Mood Symptom Self-Assessment

BACKGROUND

We recently described a new questionnaire to monitor mood called mood zoom (MZ). MZ comprises 6 items assessing mood symptoms on a 7-point Likert scale; we had previously used standard principal component analysis (PCA) to tentatively understand its properties, but the presence of multiple nonzero loadings obstructed the interpretation of its latent variables.

OBJECTIVE

The aim of this study was to rigorously investigate the internal properties and latent variables of MZ using an algorithmic approach which may lead to more interpretable results than PCA. Additionally, we explored three other widely used psychiatric questionnaires to investigate latent variable structure similarities with MZ: (1) Altman self-rating mania scale (ASRM), assessing mania; (2) quick inventory of depressive symptomatology (QIDS) self-report, assessing depression; and (3) generalized anxiety disorder (7-item) (GAD-7), assessing anxiety.

METHODS

We elicited responses from 131 participants: 48 bipolar disorder (BD), 32 borderline personality disorder (BPD), and 51 healthy controls (HC), collected longitudinally (median [interquartile range, IQR]: 363 [276] days). Participants were requested to complete ASRM, QIDS, and GAD-7 weekly (all 3 questionnaires were completed on the Web) and MZ daily (using a custom-based smartphone app). We applied sparse PCA (SPCA) to determine the latent variables for the four questionnaires, where a small subset of the original items contributes toward each latent variable.

RESULTS

We found that MZ had great consistency across the three cohorts studied. Three main principal components were derived using SPCA, which can be tentatively interpreted as (1) anxiety and sadness, (2) positive affect, and (3) irritability. The MZ principal component comprising anxiety and sadness explains most of the variance in BD and BPD, whereas the positive affect of MZ explains most of the variance in HC. The latent variables in ASRM were identical for the patient groups but different for HC; nevertheless, the latent variables shared common items across both the patient group and HC. On the contrary, QIDS had overall very different principal components across groups; sleep was a key element in HC and BD but was absent in BPD. In GAD-7, nervousness was the principal component explaining most of the variance in BD and HC.

CONCLUSIONS

This study has important implications for understanding self-reported mood. MZ has a consistent, intuitively interpretable latent variable structure and hence may be a good instrument for generic mood assessment. Irritability appears to be the key distinguishing latent variable between BD and BPD and might be useful for differential diagnosis. Anxiety and sadness are closely interlinked, a finding that might inform treatment effects to jointly address these covarying symptoms. Anxiety and nervousness appear to be amongst the cardinal latent variable symptoms in BD and merit close attention in clinical practice.

Moods in Clinical Depression Are More Unstable than Severe Normal Sadness

OBJECTIVE

Current descriptions in psychiatry and psychology suggest that depressed mood in clinical depression is similar to mild sadness experienced in everyday life, but more intense and persistent. We evaluated this concept using measures of average mood and mood instability (MI).

METHOD

We prospectively measured low and high moods using separate visual analog scales twice a day for seven consecutive days in 137 participants from four published studies. Participants were divided into a non-depressed group with a Beck Depression Inventory score of ≤10 (n = 59) and a depressed group with a Beck Depression Inventory score of ≥18 (n = 78). MI was determined by the mean square successive difference statistic.

RESULTS

Mean low and high moods were not correlated in the non-depressed group but were strongly positively correlated in the depressed group. This difference between correlations was significant. Low MI and high MI were weakly positively correlated in the non-depressed group and strongly positively correlated in the depressed group. This difference in correlations was also significant.

CONCLUSION

The results show that low and high moods, and low and high MI, are highly correlated in people with depression compared with those who are not depressed. Current psychiatric practice does not assess or treat MI or brief high mood episodes in patients with depression. New models of mood that also focus on MI will need to be developed to address the pattern of mood disturbance in people with depression.

An investigation of mental imagery in bipolar disorder: Exploring "the mind's eye"

OBJECTIVES

Mental imagery abnormalities occur across psychopathologies and are hypothesized to drive emotional difficulties in bipolar disorder (BD). A comprehensive assessment of mental imagery in BD is lacking. We aimed to test whether (i) mental imagery abnormalities (abnormalities in cognitive stages and subjective domains) occur in BD relative to non-clinical controls; and (ii) to determine the specificity of any abnormalities in BD relative to depression and anxiety disorders.

METHODS

Participants included 54 subjects in the BD group (depressed/euthymic; n=27 in each subgroup), subjects with unipolar depression (n=26), subjects with anxiety disorders (n=25), and non-clinical controls (n=27) matched for age, gender, ethnicity, education, and premorbid IQ. Experimental tasks assessed cognitive (non-emotional) measures of mental imagery (cognitive stages). Questionnaires, experimental tasks, and a phenomenological interview assessed subjective domains including spontaneous imagery use, interpretation bias, and emotional mental imagery.

RESULTS

(i) Compared to non-clinical controls, the BD combined group reported a greater impact of intrusive prospective imagery in daily life, more vivid and "real" negative images (prospective imagery task), and higher self-involvement (picture-word task). The BD combined group showed no clear abnormalities in cognitive stages of mental imagery. (ii) When depressed individuals with BD were compared to the depressed or anxious clinical control groups, no significant differences remained-across all groups, imagery differences were associated with affective lability and anxiety.

CONCLUSIONS

Compared to non-clinical controls, BD is characterized by abnormalities in aspects of emotional mental imagery within the context of otherwise normal cognitive aspects. When matched for depression and anxiety, these abnormalities are not specific to BD-rather, imagery may reflect a transdiagnostic marker of emotional psychopathology.

Daily longitudinal self-monitoring of mood variability in bipolar disorder and borderline personality disorder

BACKGROUND

Traditionally, assessment of psychiatric symptoms has been relying on their retrospective report to a trained interviewer. The emergence of smartphones facilitates passive sensor-based monitoring and active real-time monitoring through time-stamped prompts; however there are few validated self-report measures designed for this purpose.

METHODS

We introduce a novel, compact questionnaire, Mood Zoom (MZ), embedded in a customised smart-phone application. MZ asks participants to rate anxiety, elation, sadness, anger, irritability and energy on a 7-point Likert scale. For comparison, we used four standard clinical questionnaires administered to participants weekly to quantify mania (ASRM), depression (QIDS), anxiety (GAD-7), and quality of life (EQ-5D). We monitored 48 Bipolar Disorder (BD), 31 Borderline Personality Disorders (BPD) and 51 Healthy control (HC) participants to study longitudinal (median±iqr: 313±194 days) variation and differences of mood traits by exploring the data using diverse time-series tools.

RESULTS

MZ correlated well (|R|>0.5,p<0.0001) with QIDS, GAD-7, and EQ-5D. We found statistically strong (|R|>0.3,p<0.0001) differences in variability in all questionnaires for the three cohorts. Compared to HC, BD and BPD participants exhibit different trends and variability, and on average had higher self-reported scores in mania, depression, and anxiety, and lower quality of life. In particular, analysis of MZ variability can differentiate BD and BPD which was not hitherto possible using the weekly questionnaires.

LIMITATIONS

All reported scores rely on self-assessment; there is a lack of ongoing clinical assessment by experts to validate the findings.

CONCLUSIONS

MZ could be used for efficient, long-term, effective daily monitoring of mood instability in clinical psychiatric practice.