Self-esteem in remitted bipolar disorder patients: a meta-analysis

Illness and narrative identity: examining past and future life story chapters in individuals with bipolar disorder, diabetes mellitus or no chronic illness

The purpose of this study was to investigate whether narrative identity challenges are specific to Bipolar Disorder (BD) as a mental illness or a reflection of living with chronic illness. Nineteen individuals diagnosed with BD, 29 individuals diagnosed with Type 1 Diabetes Mellitus (T1DM) and 25 controls without chronic mental or somatic illness identified past and future life story chapters which were self-rated on emotional tone and self-event connections and content-coded for agency and communion themes. Individuals with BD self-rated their past chapters as more negative and less positive, and their chapters were lower on content-coded agency and communion themes compared to T1DM and controls. There were fewer group differences for future chapters, but BD was associated with lower self-rated positive emotional tone and self-stability connections as well as lower content-coded agency and communion themes. The results indicate that narrative identity is affected in individuals with BD above and beyond the consequences of living with chronic illness. This may reflect distinct effects of mental versus somatic illness on narrative identity.

The Relationship of Functioning and Life Satisfaction with Illness Management and Recovery in Patients with Bipolar Disorder: A Cross-Sectional Study

The aim of this study was to determine relationship between functioning and life satisfaction with illness management and recovery, and determinants of illness management and recovery in patients with bipolar disorder. This descriptive and correlational study was conducted with 152 participants between August 2022 and February 2023. "Personal Information Form", "Illness Management and Recovery Scale", "Functioning Assessment Short Test" and "Adult Life Satisfaction Scale" were used to collecting data. In study, a positive relationship was found between illness management and recovery and total functionality, autonomy, cognitive functionality, interpersonal relationships, and life satisfaction. Gender, marital status, educational status, employment status, total functioning, autonomy, cognitive functioning, interpersonal relationships, and life satisfaction were found to be effective in illness management and recovery. Being female, single, primary school graduate, unemployed, having low functioning (autonomy, cognitive functioning, interpersonal relationships) and having low life satisfaction were found to be determinants of illness management and recovery.

Intersections of phenomenology, voice beliefs and distress in bipolar disorder: a comparison with schizophrenia

BACKGROUND

Auditory verbal hallucinations (AVH), or voice-hearing, can be a prominent symptom during fluctuating mood states in bipolar disorder (BD).

AIMS

The current study aimed to: (i) compare AVH-related distress in BD relative to schizophrenia (SCZ), (ii) examine correlations between phenomenology and voice beliefs across each group, and (iii) explore how voice beliefs may uniquely contribute to distress in BD and SCZ.

METHOD

Participants were recruited from two international sites in Australia (BD=31; SCZ=50) and the UK (BD=17). Basic demographic-clinical information was collected, and mood symptoms were assessed. To document AVH characteristics, a 4-factor model of the Psychotic Symptoms Rating Scale and the Beliefs about Voices Questionnaire-Revised were used. Statistical analyses consisted of group-wise comparisons, Pearson's correlations and multiple hierarchical regressions.

RESULTS

It was found that AVH-related distress was not significantly higher in BD than SCZ, but those with BD made significantly more internal attributions for their voices. In the BD group, AVH-related distress was significantly positively correlated with malevolence, omnipotence and resistance, However, only resistance, alongside mania and depressive symptoms, significantly contributed to AVH-related distress in BD.

DISCUSSION

Our findings have several clinical implications, including identification of voice resistance as a potential therapeutic target to prioritise in BD. Factoring in the influence of mood symptoms on AVH-related distress as well as adopting more acceptance-oriented therapies may also be of benefit.

Better than expected: the gap between self-reported and objective measures of cognitive performance in remitted bipolar disorder

Background

Studies comparing objective and self-reported cognitive functioning as well as influencing factors in individuals with remitted bipolar disorder are scarce and contradictory.

Methods

The aim of this study was to compare executive functioning and other objective and self-reported cognitive impairment between 26 individuals with remitted bipolar disorder (15 BD I) and 24 healthy controls using a cross-sectional design. Executive functions were measured by the TAP Go/No-go subtest as well as the Stroop Task. Self-rated functioning was assessed using the Attention Deficit Experience Questionnaire. In addition, possible predictors of self-reported and objective cognitive functioning were examined to perform regression analyses.

Results

Individuals with remitted bipolar disorder did not differ significantly in executive functions or other objective cognitive domains from the healthy control group, but showed a significantly lower level of self-reported cognitive functioning and self-esteem. While self-esteem was the strongest predictor in healthy controls for self-reported cognitive functioning, severity of illness and subthreshold depressive mood were the most important predictors in individuals with remitted bipolar disorder.

Conclusion

The results once again demonstrate the cognitive heterogeneity in bipolar disorder. In the treatment of cognitive deficits, factors such as subthreshold depressive symptomatology and self-esteem should be focused on in addition to cognitive training in remitted patients.

Cognitive reserve in patients with mood disorders: Validation study of the Chinese version of the cognitive reserve assessment scale in health

BACKGROUND

Cognitive reserve (CR) is closely associated with cognitive and functional outcome, disease severity, progression and prognosis in psychiatric patients; however, it has not been extensively tested in mood disorders. This study examined the psychometric properties of the Cognitive Reserve Assessment Scale in Health (CRASH) in mood disorder patients.

METHODS

Altogether 166 subjects were recruited, 44 with major depressive disorder (MDD), 64 with bipolar disorder (BD), and 58 healthy controls. CR was assessed using the CRASH and the Cognitive Reserve Questionnaire (CRQ).

RESULTS

Internal consistency (Cronbach's alpha) was 0.779 for the CRASH. The Receiver Operating Characteristic (ROC) curve analysis revealed an area under the ROC curve (AUC) value of 0.73 (95 % CI: 0.647-0.809). The optimal cut-off score of 51 generated the best combination of sensitivity (0.78) and specificity (0.43) for discriminating between patients with mood disorders and healthy controls. The CRASH score was highly correlated with the CRQ score in both mood disorder patients (r_s = 0.586, P < 0.001) and healthy controls (r_s = 0.627, P < 0.001), indicating acceptable convergent validity for the CRASH. Within the mood disorder sample, the CRASH score was associated with functional outcomes (FAST: r_s = -0.243, P = 0.011).

CONCLUSIONS

The CRASH is a useful tool to measure CR in mood disorder with acceptable psychometric properties and could be used in both research and clinical practice.

"My life disappeared in illness": bipolar disorder and themes in narrative identity

Bipolar Disorder (BD) has substantial consequences for the course of life and the formation of self and identity. In the present study, we extended the existing literature by examining narrative identity. Fifteen female outpatients with remitted BD and fifteen non-clinical control participants described past and future chapters in their life stories. The chapters were coded for agency, communion, redemption and contamination. Patients diagnosed with BD described their past chapters with lower agency, lower communion and more contamination compared to the control group. Contrary to our expectations, the future chapters described by the BD patients did not differ significantly from the control group. A focus on narrative identity may contribute to understanding the disorder and inspire interventions targeting personal recovery.

Differential diagnosis of borderline personality disorder and bipolar disorder: Self-concept, identity and self-esteem

Symptoms of borderline personality disorder (BPD) and bipolar disorder (BD) often overlap. In some cases, it is difficult to conduct a differential diagnosis based only on current diagnostic criteria Therefore, it is important to find clinical factors with high discriminatory specificity that, used together with structured or semi-structured interviews, could help improve diagnostic practice. We propose that a clinical analysis of identity, self-concept and self-esteem may help distinguish the two disorders, when they are not co-morbid. Our review of the studies that analyse these constructs in BD and BPD, separately, points in the direction of qualitative differences between the two disorders. In BPD, there is a well-documented identity diffusion, and the self-concept appears predominantly negative; shifts in self-concept and self-esteem are often tied to interpersonal triggers. In BD, patients struggle with their identity, but narrative identity might be less compromised compared with BPD; the shifts in self-concept and self-esteem appear more linked to internal (i.e. mood and motivational) factors. We end the paper by discussing the implications for clinicians and ideas for future comparative research.

Relationship between dysfunctional beliefs, self-esteem, extreme appraisals, and symptoms of mania and depression over time in bipolar disorder

OBJECTIVES

Bipolar disorder (BD) is a mental health problem characterized by episodes of mania and depression which can lead to significant difficulties impairing one's daily functioning. Cross-sectional research has highlighted self-esteem and dysfunctional beliefs in those with this diagnosis, but there has been little research into how self-esteem and dysfunctional beliefs relate to symptoms of mania and depression over time.

DESIGN

A secondary data analysis of a prospective cohort study was used.

METHODS

Forty patients with BD attending a community adult mental health service completed the Dysfunctional Attitudes Scale, Rosenberg Self-Esteem Scale, Brief Hypomanic Attitudes and Positive Predictions Inventory, Centre for Epidemiologic Studies Depression Scale, and Altman Self-Rating Mania Scale at two time points 4 months apart.

RESULTS

Cross-sectional correlations revealed significant associations between elevated goal attainment dysfunctional beliefs and higher symptoms of mania; however, this did not hold over time. Elevated dependency-related dysfunctional beliefs and lower self-esteem were linked to higher symptoms of depression, and this relationship held over time. There was no impact of achievement-related dysfunctional beliefs on mood. Extreme appraisals were correlated with higher depression symptoms at baseline, but this did not hold over time.

CONCLUSIONS

Findings suggest lower self-esteem and specific dysfunctional beliefs around dependency may precede symptoms of depression. Further research is required to further explore these associations.

PRACTITIONER POINTS

Elevated dysfunctional beliefs around dependency on others and lower levels of self-esteem may precede symptoms of depression in BD. Therapeutic interventions and relapse prevention targeting these psychological factors may help reduce the risk of depression relapse.

An investigation of self-compassion and nonattachment to self in people with bipolar disorder

BACKGROUND

There have been longstanding theories and research evidence into the important role of the person's vulnerability at the level of self-concept in bipolar disorder (BD). The current study investigated two emerging self-related constructs, self-compassion and nonattachment to self in BD. Specifically, we examined the levels of the two constructs in people with BD compared with those from the general population, and the associations between the constructs and bipolar symptomologies within the BD group.

METHODS

The BD group consisted of 302 individuals with a diagnosis of BD participating in an international randomised controlled trial. A general population sample (n = 372) was recruited from an Australian university as a comparison group. All participants completed measures of self-compassion and nonattachment to self. The BD group completed additional measures of depression and symptoms of hypo/mania.

RESULTS

Participants with BD showed significantly lower self-compassion and nonattachment to self than those from the comparison group after controlling for demographic variables (e.g., gender, age, education, occupation). In the BD group, lower self-compassion and nonattachment to self were associated with greater severity of depression on both self- and clinician-rated scales. Nonattachment to self but not self-compassion was negatively associated with hypo/mania symptomology.

LIMITATIONS

The cross-sectional design cannot determine the direction of the relationships between study variables. Nonattachment to self is a novel psychological construct and further research is needed to replicate study findings.

CONCLUSIONS

The study findings suggest that self-compassion and nonattachment to self may be meaningful targets in psychological interventions for people with BD.

Financial difficulties in bipolar disorder part 2: psychological correlates and a proposed psychological model

OBJECTIVES

A number of psychological variables have been shown to be prominent in bipolar disorder. However, no research has looked at the relationship between financial difficulties and psychological factors in bipolar disorder.

AIMS

This study aims to look at the relationship between financial difficulties and psychological factors in bipolar disorder.

METHOD

Fifty-four participants with diagnosis of bipolar disorder in an adult secondary care NHS mental health service completed the questionnaire pack which included measures examining financial variables including difficulty paying bills and perceived financial wellbeing. Questionnaires measured self-esteem, impulsivity, mindfulness and dysfunctional attitudes.

RESULTS

Financial difficulties cross-sectionally were related to a number of psychological variables such as mindfulness and impulsivity. Over time, the strongest effects were for compulsive spending which was increased over time by higher dependency and achievement cognitions, lower mindfulness and lower self-esteem. Poor perceived financial wellness lower self-esteem over time. A psychological model incorporating these and related findings is presented.

CONCLUSION

Psychological factors appear to be related to financial difficulties in bipolar disorder. Future research is needed to confirm the model presented here and develop interventions.

The impact of a CBT-based bipolar disorder psychoeducation group on views about diagnosis, perceived recovery, self-esteem and stigma

Previous research has shown that psychoeducation for bipolar disorder (BD) improves symptoms and reduces relapse risk, but there is little research on how this impacts stigma, perceived recovery and views about diagnosis. The aim of this study was to explore whether a cognitive behaviour therapy (CBT)-based 12-week BD psychoeducation group conducted in a community mental health team for adults impacted perceived stigma, diagnosis-related self-esteem, recovery and views about diagnosis. The case series pre- and post-group had 23 participants across three groups. The Brief Illness Perception Questionnaire, views on Manic Depression Questionnaire, Bipolar Recovery Questionnaire and author-constructed questions were completed pre and post. Twenty participants completed the group. An intent-to-treat repeated measures multiple analysis of variance showed significantly improved perceived recovery and improvements in sense of control and understanding around their diagnosis. Other specific questions such as understanding of triggers and impact of thinking patterns also improved. However, there was no change in the perceived stigma or self-esteem associated with living with BD. CBT-based psychoeducation groups may help improve perceived recovery and factors such as sense of control in BD. However, there appears to be no impact on stigma and self-esteem, and the role of non-specific factors needs to be examined further.

Key learning aims

(1)

Toward New Therapeutic Mechanisms in Bipolar Disorder: Analog Investigation of Self-Compassion and Nonattachment to Self

There is growing interest in psychological processes that might be targeted in treatments for bipolar disorder (BD). One such process is a vulnerability at the level of self-concept, characterized by presence of, and fluctuations between positive and negative self-concept. The aim of the present study was to advance this literature by investigating the role of two emerging meta-cognitive processes – self-compassion and nonattachment to self – which have potential to therapeutically modulate this unstable self-concept in BD. Using an analog design, it was hypothesized that both variables would mediate the relationship between bipolar tendencies and psychological distress in a general population sample. Participants (N = 372 Australian university students) completed self-report measures of manic and depressive tendencies, self-compassion, nonattachment to self and psychological distress. To investigate the specificity of the two hypothesized mediators, a better-researched psychological variable – rumination – was also included in mediation analyses. Bivariate analyses found tendencies toward mania and depression to be associated with diminished self-compassion and nonattachment to self, while both psychological processes were negatively associated with psychological distress. Mediation analyses showed, as expected, self-compassion and nonattachment to self mediated the relationship between bipolar tendencies and psychological distress after controlling for the effects of rumination. The present findings add incrementally to this literature by demonstrating that two meta-cognitive processes – self-compassion and nonattachment to self – act as mediators, and may be modifiable mechanisms linking bipolar vulnerability to negative mood outcomes. Future research should tackle longstanding conceptual issues in this domain, including the relationship between contents of self-concept (an established focus of BD research) and the person’s meta-cognitive approach to their self-concept (the focus here).

[Influence of a therapeutic patient education (TPE) program on quality of life in bipolar disorder: Preliminary results]

INTRODUCTION

Bipolar disorder is a mental illness that is associated with a long-term impairment in psychosocial functioning and quality of life. The objective of this study was to evaluate the influence of a therapeutic education program on the quality of life of patients with bipolar disorder (type 1 or 2).

METHOD

This study included 18 patients with bipolar disorder (type 1 or 2) following the therapeutic education program on bipolar disorder which includes 8 sessions of 2hours each. The assessment of quality of life and mood, self-esteem, insight and global functioning was performed before and after the program using the following tools: World Health Organization Quality Of Life questionnaire in short version (WHOQOL-Bref), Hamilton Depression Rating Scale, Young Mania Rating Scale, Rosenberg Self-Esteem Scale, Birchwood Insight Scale and Global Assessment of Functioning Scale. The total score of WHOQOL-Bref constitutes the primary study outcome. The under-scores of WHOQOL-Bref as insight, self-esteem, functioning, depression and mania scores constitute secondary outcomes.

RESULTS

Our results show an improvement in quality of life, regarding global and main dimension scores of WHOQOL-Bref. The mean total scores for quality of life at the beginning and the end of the program were respectively 55.47/100 (standard deviation=14.11) and 60.03/100 (standard deviation=12.62). However, the difference was still not significant even after statistical adjustment with depression, mania and functioning scores. Self-esteem was significantly improved (P=0.0469). Quality of life and self-esteem evolutions were strongly related (correlation coefficient=0.80, P=0.0006). At the end of the program, the less depressed the patients were, the better their quality of life was (correlation coefficient=0.67, P=0.0090). We did not find any correlation between quality of life and mania intensity or global functioning level at the end of the program.

CONCLUSION

This study suggests a need to focus on self-esteem perception in order to understand and ameliorate the quality of life of patients with bipolar disorders. Going further, the use of bipolar disorder specific scales to assess quality of life would be more relevant.

Interepisodic Functioning in Patients with Bipolar Disorder in Remission

BACKGROUND AND OBJECTIVES

Patients with bipolar disorder (BD), despite recovering symptomatically, suffer from several functional impairments even in remission. The actual causes of impaired functioning are less known.

MATERIALS AND METHODS

The study aimed to examine the clinical and psychosocial determinants of functioning in patients with BD in remission. A cross-sectional single-group design was adopted (n = 150). Participants meeting the study criteria were screened with Mini-International Neuropsychiatric Interview Scale. The selected participants were administered various tools to assess the level of functioning and the clinical, psychosocial determinants of functioning.

RESULTS

The clinical characteristics of the sample included early age of onset of illness, presence of precipitating factors, fewer episodes, minimal comorbidities, history of psychotic episodes, family history of mental illness, good medication adherence, and low depression and mania scores. Psychosocial factors included higher stress and moderate social support and self-esteem in the sample. Poor functioning patients had a history of longer hospital stay and had greater scores on depression, mania, stress, and maladaptive coping styles than better functioning patients.

CONCLUSION

Higher depression, mania, stress, and maladaptive coping strategies were related to poor functioning, while higher medication adherence, self-esteem, and social support were related to better functioning.

Efficacy, safety and tolerability of aripiprazole in bipolar disorder: An updated systematic review and meta-analysis of randomized controlled trials

Numerous studies have investigated aripiprazole as a treatment for bipolar disorder (BD). therefore we conducted this comprehensive meta-analysis to investigate the efficacy and safety profile of aripiprazole in treating BD. Two authors conducted systematic searches of PubMed and ScienceDirect from inception until May 14th, 2017. Randomized controlled trials (RCTs) of people with BD who received aripiprazole were included. A total of 20 RCTs met the eligibility criteria, including two which investigated the efficacy of aripiprazole versus haloperidol (aripiprazole=340; haloperidol=337), three which compared aripiprazole versus lithium (aripiprazole=208; lithium=212), and 15 with multiple comparisons of aripiprazole versus a placebo (aripiprazole=1923; placebo=1499). Compared to a placebo, aripiprazole improved acute mania (Hedges' g: -0.299, p=0.001) and psychosis (Hedges' g: -0.296, p<0.001) in the acute mania state, but did not improve depressive symptoms (Hedges' g: -0.127, p=0.054) in the acute depressive state. Aripiprazole was associated with lower relapse rates in bipolar mania when used in combination versus a placebo in maintenance therapy (odds ratio: 0.522, p<0.029). Aripiprazole was also associated with higher levels of high density lipoprotein, lower dropout rates, but no difference in extrapyramidal symptoms in the maintenance phase versus a placebo or in comparison with other medications (haloperidol or lithium). Our results suggest that aripiprazole is effective and safe in treating bipolar mania. Further trials are necessary to evaluate the efficacy and tolerability versus other medications.

Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis

BACKGROUND

Anxiety disorders are increasingly recognised as an important determinant of outcomes in patients with bipolar disorder. However, a reliable estimate of their prevalence is still missing, because the published prevalence of anxiety disorders in individuals with bipolar disorder varies widely. In this study, we aimed to quantify the lifetime prevalence of anxiety disorders in individuals with bipolar disorder and compare it with rates in people without the disorder.

METHODS

We searched the Web of Knowledge and Medline (through the PubMed interface) for articles published in any language from the database inception dates up until June 1, 2014, using a combination of the word "bipolar" and search terms for anxiety disorders. We included studies that reported original data about the lifetime prevalence of DSM-III and DSM-IV anxiety disorders in adults with bipolar disorder that recruited participants irrespective of comorbidities and that used a validated diagnostic interview to establish the diagnoses of bipolar disorder and at least one anxiety disorder. We excluded studies that reported only the current prevalence or if we were unable to establish whether they described current or lifetime prevalence, and those with discrepancies in the data that could not be resolved by contacting the authors. We did a random-effects meta-analysis of lifetime prevalence of DSM-III and DSM-IV anxiety disorders in adults with bipolar disorder, in which we quantified the lifetime prevalence of any anxiety disorder in people with bipolar disorder. We compared this prevalence in people with bipolar I disorder versus those with bipolar II disorder, and in people with bipolar disorder versus population controls.

FINDINGS

Data from 40 studies, including 14 914 individuals from North America, Europe, Australia, South America, and Asia, indicate that the lifetime prevalence of anxiety disorders in individuals with bipolar disorder is 45% (95% CI 40-51). Direct comparison in five samples with a total of 1378 individuals with bipolar disorder and 56 812 population controls without bipolar disorder indicates a three-fold increase (risk ratio [RR] 3·22 [95% CI 2·41-4·29]; p<0·0001) in the prevalence of anxiety disorders in those with bipolar disorder. 13 studies that included both individuals with bipolar I disorder (n=4270) and those with bipolar II disorder (n=1939) showed no difference in the lifetime prevalence of anxiety disorders between these subtypes (RR 1·07 [95% CI 0·96-1·20]; p=0·223). We noted significant heterogeneity among included studies that was not accounted for by reported differences in study characteristics.

INTERPRETATION

People with bipolar disorder are at increased risk of anxiety disorders compared with those without bipolar disorder; nearly one in two has an anxiety disorder in their lifetime. Anxiety disorders should therefore be assessed alongside the mood symptoms in patients with bipolar disorder.

FUNDING

Capital Health Research Fund.

Low self-compassion in patients with bipolar disorder

BACKGROUND

Emerging research suggests that low self-compassion may be linked to psychopathology and in particular depressive symptoms. To further elucidate this topic, the present study investigated self-compassion in patients with Bipolar Disorder (BD).

METHOD

Thirty remitted BD patients were compared to thirty age- and sex matched controls on the Self-Compassion Scale (SCS). The BD patients also completed the Altman Self-Rating Mania Scale (ASRM), the Major Depression Inventory (MDI), the Work and Social Adjustment Scale (WSAS), the Satisfaction With Life Scale (SWLS) and the Internalized Stigma of Mental Illness Scale (ISMI-10) and further reported their illness history on a survey sheet.

RESULTS

The BD patients were found to have significantly lower self-compassion than controls. In addition, self-compassion correlated positively and significantly with life-satisfaction but no significant correlations with functional impairment, internalized stigma or frequency of past affective episodes were found.

LIMITATIONS

The small sample size entailed reduced statistical power.

CONCLUSIONS

By suggesting that self-compassion is reduced and possibly linked to life-satisfaction in BD, the findings highlight a potential vulnerability meriting further investigations.

FitzPatrick Lecture: King George III and the porphyria myth - causes, consequences and re-evaluation of his mental illness with computer diagnostics

Recent studies have shown that the claim that King George III suffered from acute porphyria is seriously at fault. This article explores some of the causes of this misdiagnosis and the consequences of the misleading claims, also reporting on the nature of the king's recurrent mental illness according to computer diagnostics. In addition, techniques of cognitive archaeology are used to investigate the nature of the king's final decade of mental illness, which resulted in the appointment of the Prince of Wales as Prince Regent. The results of this analysis confirm that the king suffered from bipolar disorder type I, with a final decade of dementia, due, in part, to the neurotoxicity of his recurrent episodes of acute mania.

Course and outcome following a first episode of mania: four-year prospective data from the Systematic Treatment Optimization Program (STOP-EM)

BACKGROUND

First episode mania (FEM) cohorts provide an opportunity to identify windows for intervention to potentially alter the course of bipolar disorder (BD). Despite several efforts to prospectively characterize first episode patients, follow-up of such cohorts has seldom exceeded 1 year. We present 4-year outcomes from the STOP-EM FEM cohort.

METHOD

Of 101 identified FEM patients, 81 had longitudinal follow-up. Clinical evaluations including substance misuse, sociodemographics and family history were characterized using semi-structured instruments. Clinical reassessments occurred every 6 months.

RESULTS

Within one year, all patients had remitted and 95% recovered. Recurrence following remission occurred in 58% of patients by 1 year and 74% by 4 years (60% depressive, 28% manic and 12% hypomanic). Recurrence within one year was associated with a higher rate of recurrence thereafter. Older age was associated with a shorter time to remission. Substance misuse was associated with delayed recovery and earlier recurrence.

LIMITATIONS

This prospective multiwave longitudinal design employed may be limited by the assessment schedule and associated recall bias. The influences of attrition of this sample should be considered when attempting to generalize our findings.

CONCLUSIONS

Best practices in FEM result in remission and recovery. While recurrence is common, minimizing recurrence within the first year through risk factor modification may alter the course of the BD.

Discrepancies between explicit and implicit self-esteem and their relationship to symptoms of depression and mania

OBJECTIVES

Self-esteem is a key feature of bipolar symptomatology. However, so far no study has examined the interaction between explicit and implicit self-esteem in individuals vulnerable to bipolar disorder.

DESIGN

Cross-sectional design was employed.

METHODS

Thirty children of parents with bipolar disorder and 30 offspring of control parents completed Hamilton Rating Scale for Depression, the Bech-Rafaelson Mania Scale, the Self-esteem Rating Scale and the Implicit Association Test.

RESULTS

No differences between groups were revealed in levels of explicit or implicit self-esteem. However, bipolar offspring showed increased levels of symptoms of depression and mania. Furthermore, depressive symptoms were associated with low explicit self-esteem, whilst symptoms of mania were associated with low implicit self-esteem. When self-esteem discrepancies were examined, damaged self-esteem (i.e., low explicit but high implicit self-esteem) was associated with depression, whilst no associations between mania and self-esteem discrepancies were found.

CONCLUSIONS

Not only explicit, but also implicit self-esteem, and the interactions between the two are of relevance in bipolar symptoms. Clinical implications and future research directions are discussed.

PRACTITIONER POINTS

Explicit as well as implicit SE, and particularly their relationship, are relevant for mental health. Fluctuations in implicit SE may serve as an early indicator for risk of bipolarity. Psychotherapeutic approaches may be more suitable for one kind of SE challenge than the other.

Évaluation de l’estime de soi chez des patients bipolaires en rémission

Introduction

Il est aujourd’hui admis par la plupart des auteurs que les épisodes affectifs se caractérisent par une perturbation de l’estime de soi ; cependant, l’estime de soi en dehors des phases thymiques est sujette à controverses. On se propose dans notre travail d’évaluer l’estime de soi dans un groupe de patients bipolaires type I en phase euthymique.

Méthodes

Nous avons mené une étude transversale descriptive auprès de 60 patients bipolaires euthymiques suivis en ambulatoire. L’euthymie était vérifiée par l’échelle de dépression de Hamilton (score ≤ 7), et l’échelle de manie de Young (score ≤ 6). La mesure de l’estime de soi a été faite au moyen du Rosenberg Self-Esteem scale (RSE).

Résultats

Notre échantillon était composé de 33,3 % femmes et 66,7 % hommes. La plupart des patients étaient mariés (46,7 %) et plus de la moitié (55,0 %) avaient un niveau d’enseignement secondaire. L’étendue des totaux possibles du RSE allant de 10 à 40, le score total moyen obtenu par les patients était de 28,3, soit dans la fourchette de l’estime de soi basse. Une estime de soi basse était associée au délai de prise en charge (p = 0,021) et au nombre d’hospitalisations (p = 0,032).

Conclusion

Les résultats impliquent la nécessité que toute notre attention se porte sur l’estime de soi dans nos interventions thérapeutiques.

Symptom-specific self-referential cognitive processes in bipolar disorder: a longitudinal analysis

BACKGROUND

Although depression and mania are often assumed to be polar opposites, studies have shown that, in patients with bipolar disorder, they are weakly positively correlated and vary somewhat independently over time. Thus, when investigating relationships between specific psychological processes and specific symptoms (mania and depression), co-morbidity between the symptoms and changes over time must be taken into account. Method A total of 253 bipolar disorder patients were assessed every 24 weeks for 18 months using the Hamilton Rating Scale for Depression (HAMD), the Bech-Rafaelsen Mania Assessment Scale (MAS), the Rosenberg Self-Esteem Questionnaire (RSEQ), the Dysfunctional Attitudes Scale (DAS), the Internal, Personal and Situational Attributions Questionnaire (IPSAQ) and the Personal Qualities Questionnaire (PQQ). We calculated multilevel models using the xtreg module of Stata 9.1, with psychological and clinical measures nested within each participant.

RESULTS

Mania and depression were weakly, yet significantly, associated; each was related to distinct psychological processes. Cross-sectionally, self-esteem showed the most robust associations with depression and mania: depression was associated with low positive and high negative self-esteem, and mania with high positive self-esteem. Depression was significantly associated with most of the other self-referential measures, whereas mania was weakly associated only with the externalizing bias of the IPSAQ and the achievement scale of the DAS. Prospectively, low self-esteem predicted future depression.

CONCLUSIONS

The associations between different self-referential thinking processes and different phases of bipolar disorder, and the presence of the negative self-concept in both depression and mania, have implications for therapeutic management, and also for future directions of research.

Initial evidence for sex-specific effects of early emotional abuse on affective processing in bipolar disorder

PURPOSE

This study investigates the effect of sex and childhood trauma on affective processing in bipolar disorder (BPD) patients.

METHODS

In a sample of fifty-six BPD patients, we administered the Childhood Trauma Questionnaire (CTQ), and the Iowa Gambling Task (IGT) and the Affective Go/No-Go (AGNG) to measure affective processing. Analysis of Variance (ANOVA) was used to evaluate the effect of sex and childhood trauma on IGT; Repeated-Measures ANOVAs to measure accuracy and bias measures across conditions on the AGNG.

RESULTS

In the context of childhood abuse, females evidenced a more conservative cognitive style than males by selecting fewer cards from the disadvantageous decks [F(1, 49)=14.218; P<0.001] and showed an improvement throughout the task, as noted in a normal learning curve [F(1.49)=4.385; P=0.041)]. For the AGNG, an interaction specific to the negative valence stimuli on response bias measures was found. Abused females scored higher (mean=8.38; SD=6.39) than abused males (mean=0.69; SD=1.19) [F(1.46)=6.348; P=0.015].

CONCLUSION

Severity of childhood trauma was significantly different between sexes. In the context of a history of emotional abuse, male bipolar patients tended toward a more risk-taking behavior compared to female. Further investigations are needed to elucidate potential pathophysiological mechanisms underlying this interaction.

Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients

BACKGROUND

Euthymic bipolar disorder (BD) patients often demonstrate better clinical outcomes than remitted patients with unipolar illness (UP). Reasons for this are uncertain, however, personality and coping styles are each likely to play a key role. This study examined differences between euthymic BD and UP patients with respect to the inter-relationship between personality, coping style, and clinical outcomes.

METHODS

A total of 96 UP and 77 BD euthymic patients were recruited through the CADE Clinic, Royal North Shore Hospital in Sydney, and assessed by a team comprising Psychiatrists and Psychologists. They underwent a structured clinical diagnostic interview, and completed self-report measures of depression, anxiety, stress, personality, coping, social adjustment, self-esteem, dysfunctional attitudes, and fear of negative evaluation.

RESULTS

Compared to UP, BD patients reported significantly higher scores on levels of extraversion, adaptive coping, self-esteem, and lower scores on trait anxiety and fear of negative evaluation. Extraversion correlated positively with self-esteem, adaptive coping styles, and negatively with trait anxiety and fear of negative evaluation. Trait anxiety and fear of negative evaluation correlated positively with eachother, and both correlated negatively with self-esteem and adaptive coping styles. Finally, self-esteem correlated positively with adaptive coping styles.

LIMITATIONS

The results cannot be generalised to depressive states of BD and UP, as differences in the course of illness and types of depression are likely to impact on coping and clinical outcomes, particularly for BD.

CONCLUSIONS

During remission, functioning is perhaps better 'preserved' in BD than in UP, possibly because of the protective role of extraversion which drives healthier coping styles.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.

Effects, experiences, and impact of stigma on patients with bipolar disorder

BACKGROUND

Many people with mental illness experience stigma that has impacted their lives. In this study, we validated the Inventory of Stigmatizing Experiences (ISE) as a tool to help quantify the stigma experienced by patients with bipolar disorder and its impact on their lives. The ISE has two components, ie, the Stigma Experiences Scale (SES) and the Stigma Impact Scale (SIS), which were administered to a population of Argentinean patients with bipolar disorder. We characterized the differences between these two populations using the SES and SIS. Finally, we compared SES and SIS scores with those in a population of Canadian patients with bipolar disorder.

METHODS

The SES and SIS scales were administered to tertiary care patients with bipolar I and II disorder in Argentina (n = 178) and Canada (n = 214).

RESULTS

In this study, we validated both SES (Kuder-Richardson coefficient of reliability, 0.78) and SIS (Cronbach's alpha, 0.91) scales in a population of Argentinean patients with bipolar disorder. There were no significant differences in stigma between patients with bipolar I or II disorder on SES or SIS. However, over 50% of all respondents believed that the average person is afraid of those with mental illnesses, that stigma associated with mental illness has affected their quality of life, and that their self-esteem has suffered due to stigma. In comparison with the Canadian population, Argentinean participants scored lower on both the SES and SIS, which may be due to cultural differences or to differences in population characteristics.

CONCLUSION

Stigma associated with mental illness is serious and pervasive. If we are to find successful strategies to mitigate stigma, it is first important to understand how patients perceive such stigma. The ISE is a valuable tool which allows us to do this with high reliability among cultures.

Overlapping prefrontal systems involved in cognitive and emotional processing in euthymic bipolar disorder and following sleep deprivation: a review of functional neuroimaging studies

Prefrontal cortex (PFC) mediated cognitive and emotional processing deficits in bipolar disorder lead to functional limitations even during periods of mood stability. Alterations of sleep and circadian functioning are well-documented in bipolar disorder, but there is little research directly examining the mechanistic role of sleep and/or circadian rhythms in the observed cognitive and emotional processing deficits. We systematically review the cognitive and emotional processing deficits reliant upon PFC functioning of euthymic patients with bipolar disorder and in healthy individuals deprived of sleep. The evidence from two parallel lines of investigation suggests that sleep and circadian rhythms may be involved in the cognitive and emotional processing deficits seen in bipolar disorder through overlapping neurobiological systems. We discuss current models of bipolar highlighting the PFC-limbic connections and discuss inclusion of sleep-related mechanisms. Sleep and circadian dysfunction is a core feature of bipolar disorder and models of neurobiological abnormalities should incorporate chronobiological measures. Further research into the role of sleep and circadian rhythms in cognition and emotional processing in bipolar disorder is warranted.

Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress

Mindfulness has been described as a practice of learning to focus attention on moment-bymoment experience with an attitude of curiosity, openness, and acceptance. Mindfulness practices have become increasingly popular as complementary therapeutic strategies for a variety of medical and psychiatric conditions. This paper provides an overview of three mindfulness interventions that have demonstrated effectiveness for psychiatric symptoms and/or pain. The goal of this review is to provide a synopsis that practicing clinicians can use as a clinical reference concerning Zen meditation, mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). All three approaches originated from Buddhist spiritual practices, but only Zen is an actual Buddhist tradition. MBSR and MBCT are secular, clinically based methods that employ manuals and standardized techniques. Studies indicate that MBSR and MBCT have broad-spectrum antidepressant and antianxiety effects and decrease general psychological distress. MBCT is strongly recommended as an adjunctive treatment for unipolar depression. The evidence suggests that both MBSR and MBCT have efficacy as adjunctive interventions for anxiety symptoms. MBSR is beneficial for general psychological health and stress management in those with medical and psychiatric illness as well as in healthy individuals. Finally, MBSR and Zen meditation have a role in pain management.

Self-referential thinking, suicide, and function of the cortical midline structures and striatum in mood disorders: possible implications for treatment studies of mindfulness-based interventions for bipolar depression

Bipolar depression is often refractory to treatment and is frequently associated with anxiety symptoms and elevated suicide risk. There is a great need for adjunctive psychotherapeutic interventions. Treatments with effectiveness for depressive and anxiety symptoms as well as suicide-related thoughts and behaviors would be particularly beneficial. Mindfulness-based interventions hold promise, and studies of these approaches for bipolar disorder are warranted. The aim of this paper is to provide a conceptual background for such studies by reviewing key findings from diverse lines of investigation. Results of that review indicate that cortical midline structures (CMS) appear to link abnormal self-referential thinking to emotional dysregulation in mood disorders. Furthermore, CMS and striatal dysfunction may play a role in the neuropathology underlying suicide-related thoughts and behaviors. Thus, combining studies of mindfulness interventions targeting abnormal self-referential thinking with functional imaging of CMS and striatal function may help delineate the neurobiological mechanisms of action of these treatments.

Aberrant emotional processing in posterior cortical midline structures in bipolar II depression

Bipolar II depression is a serious and disabling illness associated with significant impairment and high rates of suicide attempts. However, mechanisms underlying emotional dysregulation in this condition are poorly characterized. The goal of this work was to investigate one component of emotional processing in this disorder, brain activation associated with exposure to emotional faces. Functional MRI was used to study 16 unmedicated male subjects with bipolar II depression and 19 healthy male controls. The activation paradigm exposed subjects to happy, fearful and neutral faces. The two key findings of this study were as follows. First, bipolar subjects demonstrated significantly decreased activation in response to happy facial expression in the left posterior cortical midline structures (CMS) and frontal cortex. Second, depression severity was positively correlated with activation of the posterior CMS and other regions. Our results suggest that mechanisms involving CMS dysfunction may play a role in the neurobiology of bipolar II depression as has been demonstrated for unipolar illness. Further investigations of CMS function in bipolar spectrum disorders are warranted.

Emotional modulation of response inhibition in stable patients with bipolar I disorder: a comparison with healthy and schizophrenia subjects

OBJECTIVES

Bipolar disorder (BD) has been associated with impairment in affective processing during depressive and manic states; however, there are limited data as to whether this population exhibits such difficulty during stable periods. We examined the pattern of affective processing in stable BD patients and compared their profile to that of healthy controls (HC) and patients diagnosed with schizophrenia (SZ).

METHODS

A total of 336 subjects were administered an Affective Go/No-go test to evaluate target detection of negatively valenced, positively valenced, and neutral stimuli. Accuracy and response bias served as dependent variables in a series of multivariate analyses of covariance to test for group differences.

RESULTS

The BD group relative to the HC group exhibited response biases toward negatively valenced information (p<0.01). Deficits were also evident in discrimination of and accurate responses to positively valenced information in the BD group versus the HC group (p<0.05). In contrast to the controls, the SZ group performed poorly on all task components and was less accurate across all conditions regardless of affective valence (p<0.01). Patients with SZ evidenced reverse biases for positive information, as they were less likely to respond to positive words (p<0.05) despite comparable response bias on neutral and negative conditions.

CONCLUSIONS

Affective processing impairment evident in BD is a feature of the disorder that is present even during stable periods. Prior studies comparing BD with SZ have highlighted clear quantitative but inconsistent qualitative differences in cognitive functioning. Our data suggest that a response bias toward negative stimuli may be a critical and relatively specific feature of BD.