Cognitive style in bipolar disorder

Common threads: Altered interoceptive processes across affective and anxiety disorders

There is growing attention towards atypical brain-body interactions and interoceptive processes and their potential role in psychiatric conditions, including affective and anxiety disorders. This paper aims to synthesize recent developments in this field. We present emerging explanatory models and focus on brain-body coupling and modulations of the underlying neurocircuitry that support the concept of a continuum of affective disorders. Grounded in theoretical frameworks like peripheral theories of emotion and predictive processing, we propose that altered interoceptive processes might represent transdiagnostic mechanisms that confer common vulnerability traits across multiple disorders. A deeper understanding of the interplay between bodily states and neural processing is essential for a holistic conceptualization of mental disorders.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between dysfunctional attitudes, maladaptive perfectionism, metacognition and symptoms of mania and depression in bipolar disorder: The role of self-compassion as a mediating factor

BACKGROUND

Maladaptive cognitions appear to be associated with the severity of mood symptoms in bipolar disorder (BD), but findings are mixed and generally cross-sectional in design.

METHOD

This study (n = 331) explored the associations between maladaptive cognitions and mood symptoms in BD over time (3 months), and the potential mediating effect of self-compassion cross-sectionally. Dysfunctional attitudes, maladaptive perfectionism and maladaptive metacognitions were explored separately with depressive and manic symptoms, and with current mood state in BD.

RESULTS

The results showed maladaptive metacognitions to be the only significant predictor of depression at 3-month follow-up (β = 0.31, p < .001), with no relationship to mania over time. Cross-sectionally, self-compassion partially mediated the relationship between all maladaptive cognitions and depression, with higher dysfunctional cognitions and lower self-compassion predicting increased severity of depressive symptoms. Only the relationship between dysfunctional attitudes and mania was partially mediated by self-compassion, however, the relationship was weak and suggestive that higher self-compassion predicted increased mania.

LIMITATIONS

The study duration limited the possible analysis. Future longitudinal research is needed. Also, the study sample was not representative of the clinical population, making results less generalisable. Additionally, limited significant findings regarding manic symptoms supports the need for further research into active cognitions during this phase of BD.

CONCLUSIONS

Maladaptive metacognitions were predictive of future depression severity, therefore, further exploration of metacognitive therapy for BD should be explored. Furthermore, self-compassion was shown to partially mediate the relationship between negative cognitions and mood, therefore further exploration of compassion-based therapies for BD is needed.

Are all reasons for living made equally? Reasons for living and dysfunctional attitudes in psychotic disorders and bipolar I

OBJECTIVES

Persons with schizophrenia, schizoaffective, or bipolar I disorder are more likely to die by suicide compared to the general population. Dysfunctional attitudes have been shown to be significant predictors of cognitive vulnerability to depression, hopelessness, and poor problem-solving skills, which predict suicidal ideation. Dysfunctional attitudes are common in persons with schizophrenia spectrum disorders (SSDs) and bipolar I. The Reasons for Living Inventory (RFLI) examines distinct reasons for not dying by suicide. This study's objectives were to examine the relationship between the RFLI subscales and dysfunctional attitudes among persons with SSDs and bipolar I. We hypothesized significant positive correlations between two RFLI subscales (Fear of Suicide and Fear of Social Disapproval) and total score on the Dysfunctional Attitude Scale (DAS). We did not expect significant correlations between other subscales.

DESIGN AND METHODS

This correlational, cross-sectional study examined baseline scores on the RFLI and dysfunctional attitudes (DAS) among N = 102 outpatients with SSDs or bipolar I.

RESULTS

Significant positive correlations were observed between RFLI subscales Fear of Suicide and Fear of Social Disapproval and DAS total scores. No other significant relationships were observed.

CONCLUSIONS

Certain reasons for living (i.e. fear of suicide and social disapproval) may be associated with dysfunctional attitudes among persons with SSDs or bipolar I. These, in turn, may place these individuals at a greater risk for suicide by increasing their cognitive vulnerability. These findings may inform clinical treatment targets for persons with SSDs and bipolar I.

Mindfulness based cognitive therapy (MBCT) reduces depression-related self-referential processing in patients with bipolar disorder: an exploratory task-based study

Negative self-referential processing has fruitfully been studied in unipolar depressed patients, but remarkably less in patients with bipolar disorder (BD). This exploratory study examines the relation between task-based self-referential processing and depressive symptoms in BD and their possible importance to the working mechanism of mindfulness-based cognitive therapy (MBCT) for BD. The study population consisted of a subsample of patients with BD (n = 49) participating in an RCT of MBCT for BD, who were assigned to MBCT + TAU (n = 23) or treatment as usual (TAU) (n = 26). Patients performed the self-referential encoding task (SRET), which measures (1) positive and (2) negative attributions to oneself as well as (3) negative self-referential memory bias, before and after MBCT + TAU or TAU. At baseline, all three SRET measures were significantly related to depressive symptoms in patients with BD. Moreover, repeated measures analyses of variance revealed that negative self-referential memory bias diminished over time in the MBCT + TAU group, compared with the TAU group. Given the preliminary nature of our findings, future research should explore the possibly mediating role of reducing negative self-referential memory bias in preventing and treating depressive symptoms in BD through MBCT.

Impaired Self-Referential Cognitive Processing in Bipolar Disorder: A Functional Connectivity Analysis

Patients with bipolar disorder have deficits in self-referenced information. The brain functional connectivity during social cognitive processing in bipolar disorder is unclear. Electroencephalogram (EEG) was recorded in 23 patients with bipolar disorder and 19 healthy comparison subjects. We analyzed the time-frequency distribution of EEG power for each electrode associated with self, other, and font reflection conditions and used the phase lag index to characterize the functional connectivity between electrode pairs for 4 frequency bands. Then, the network properties were assessed by graph theoretic analysis. The results showed that bipolar disorder induced a weaker response power and phase lag index values over the whole brain in both self and other reflection conditions. Moreover, the characteristic path length was increased in patients during self-reflection processing, whereas the global efficiency and the node degree were decreased. In addition, when discriminating patients from normal controls, we found that the classification accuracy was high. These results suggest that patients have impeded integration of attention, memory, and other resources of the whole brain, resulting in a deficit of efficiency and ability in self-referential processing.

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.

Dysfunctional cognition in individuals with an increased risk for mania

Background

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

Method

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

Results

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

Conclusion

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

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

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

Psychological factors in personal and clinical recovery in bipolar disorder

BACKGROUND

Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy.

METHODS

This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months.

RESULTS

107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes.

LIMITATIONS

Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample.

CONCLUSIONS

Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

A narrative review of cross-sectional and prospective associations between self-schemas and bipolar disorder

The role of self-concept in bipolar disorder (BD) has not been well understood. The present review utilizes the notion of self-schema and interrogates existing research concerning evidence for cross-sectional and prospective associations between four schema-like constructs (i.e. trait self-esteem, dysfunctional beliefs concerning contingent self-worth, early maladaptive schemas and implicit self-esteem) and various facets of BD. Existing findings demonstrate various types of involvement of self-schemas in BD. Of particular clinical relevance, the present review suggests that low trait self-esteem and dysfunctional beliefs concerning contingent self-worth are risk factors for ongoing BD symptoms and mood episodes. The present review also yields important yet unaddressed questions with respect to the evaluative content of self-schemas associated with the hypo/manic phase of BD.

Buffering against maladaptive perfectionism in bipolar disorder: The role of self-compassion

BACKGROUND

Maladaptive perfectionism is a transdiagnostic risk and maintaining factor for a range of mental health conditions, including bipolar disorder (BD). Self-compassion represents a potential protective factor against maladaptive perfectionism, however no studies to date have examined the relationship of these constructs in BD. The aim of the present study was to examine associations between maladaptive perfectionism, self-compassion and symptoms among individuals with BD.

METHODS

Baseline data were collected from 302 participants with a DSM-IV diagnosis of BD participating in an international randomised controlled trial. Participants completed measures of maladaptive perfectionism, self-compassion, symptom severity and emotion regulation difficulties. Clinician-administered measures of depression and mania severity were additionally collected. Correlation and mediation analyses were conducted.

RESULTS

Maladaptive perfectionism was positively associated with depression, anxiety and emotion regulation difficulties. Lower levels of self-compassion correlated with greater self-reported depression, anxiety and emotion regulation difficulties. Self-compassion partially mediated relationships between maladaptive perfectionism, depression, anxiety and emotion regulation difficulties.

LIMITATIONS

The cross-sectional design limits conclusions about causal relationships between study variables. Results may not be generalizable to other BD populations. The role of maladaptive perfectionism and self-compassion in elevated mood states of BD remains unclear.

CONCLUSION

Self-compassion represents one mechanism through which maladaptive perfectionism influences symptoms of depression, anxiety and emotion regulation difficulties in BD. Self-compassion represents a modifiable treatment target; individuals with BD exhibiting maladaptive perfectionistic tendencies may benefit from interventions fostering self-compassion.

Identity in bipolar disorder: Self-worth and achievement

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

Connectomics of bipolar disorder: a critical review, and evidence for dynamic instabilities within interoceptive networks

The notion that specific cognitive and emotional processes arise from functionally distinct brain regions has lately shifted toward a connectivity-based approach that emphasizes the role of network-mediated integration across regions. The clinical neurosciences have likewise shifted from a predominantly lesion-based approach to a connectomic paradigm-framing disorders as diverse as stroke, schizophrenia (SCZ), and dementia as "dysconnection syndromes". Here we position bipolar disorder (BD) within this paradigm. We first summarise the disruptions in structural, functional and effective connectivity that have been documented in BD. Not surprisingly, these disturbances show a preferential impact on circuits that support emotional processes, cognitive control and executive functions. Those at high risk (HR) for BD also show patterns of connectivity that differ from both matched control populations and those with BD, and which may thus speak to neurobiological markers of both risk and resilience. We highlight research fields that aim to link brain network disturbances to the phenotype of BD, including the study of large-scale brain dynamics, the principles of network stability and control, and the study of interoception (the perception of physiological states). Together, these findings suggest that the affective dysregulation of BD arises from dynamic instabilities in interoceptive circuits which subsequently impact on fear circuitry and cognitive control systems. We describe the resulting disturbance as a "psychosis of interoception".

A novel task for examining the neural basis of Theory of Mind deficits in bipolar disorder

Deficits in theory of mind (ToM) processing have been observed in people with bipolar disorder (BD), but the neural basis of these deficits remains unclear. Here, we studied the relations between neural activation, dysfunctional beliefs and behavioral responses in people with BD during a second-order ToM task. Twenty-five patients and 25 healthy-control participants (HC) underwent functional magnetic resonance imaging (fMRI) while performing a novel ToM task. The Dysfunctional Attitudes scale (DAS) and the Brief Hypomanic Attitudes and Positive Predictions Inventory (BHAPPI) were used to assess dysfunctional beliefs. Significant differences in neural activation were observed between HC and BD patients in regions associated with ToM processing: medial frontal, cingulate, anterior cingulate and superior temporal gyri. Correlations between DAS scores and neural activity in medial frontal and cingulate gyri were observed for HC only. Increased activation in brain regions associated with ToM processing in patients compared to HC provides further evidence of disruption in networks controlling social-cognitive processes. Whether this results from compensatory responses to maintain appropriate behavior is unknown.

Association Between Schizophrenia-Related Polygenic Liability and the Occurrence and Level of Mood-Incongruent Psychotic Symptoms in Bipolar Disorder

Importance

Bipolar disorder (BD) overlaps schizophrenia in its clinical presentation and genetic liability. Alternative approaches to patient stratification beyond current diagnostic categories are needed to understand the underlying disease processes and mechanisms.

Objective

To investigate the association between common-variant liability for schizophrenia, indexed by polygenic risk scores (PRSs), and psychotic presentations of BD.

Design, Setting, and Participants

This case-control study in the United Kingdom used multinomial logistic regression to estimate differential PRS associations across categories of cases and controls. Participants included in the final analyses were 4436 cases of BD from the Bipolar Disorder Research Network. These cases were compared with the genotypic data for 4976 cases of schizophrenia and 9012 controls from the Type 1 Diabetes Genetics Consortium study and the Generation Scotland study. Data were collected between January 1, 2000, and December 31, 2013. Data analysis was conducted from March 1, 2016, to February 28, 2017.

Exposures

Standardized PRSs, calculated using alleles with an association threshold of P < .05 in the second Psychiatric Genomics Consortium genome-wide association study of schizophrenia, were adjusted for the first 10 population principal components and genotyping platforms.

Main Outcomes and Measures

Multinomial logit models estimated PRS associations with BD stratified by Research Diagnostic Criteria subtypes of BD, by lifetime occurrence of psychosis, and by lifetime mood-incongruent psychotic features. Ordinal logistic regression examined PRS associations across levels of mood incongruence. Ratings were derived from the Schedules for Clinical Assessment in Neuropsychiatry interview and the Bipolar Affective Disorder Dimension Scale.

Results

Of the 4436 cases of BD, 2966 (67%) were female patients, and the mean (SD) age at interview was 46 [12] years. Across clinical phenotypes, there was an exposure-response gradient, with the strongest PRS association for schizophrenia (risk ratio [RR] = 1.94; 95% CI, 1.86-2.01), followed by schizoaffective BD (RR = 1.37; 95% CI, 1.22-1.54), bipolar I disorder subtype (RR = 1.30; 95% CI, 1.24-1.36), and bipolar II disorder subtype (RR = 1.04; 95% CI, 0.97-1.11). Within BD cases, there was an effect gradient, indexed by the nature of psychosis. Prominent mood-incongruent psychotic features had the strongest association (RR = 1.46; 95% CI, 1.36-1.57), followed by mood-congruent psychosis (RR = 1.24; 95% CI, 1.17-1.33) and BD with no history of psychosis (RR = 1.09; 95% CI, 1.04-1.15).

Conclusions and Relevance

For the first time to date, a study shows a polygenic-risk gradient across schizophrenia and BD, indexed by the occurrence and level of mood-incongruent psychotic symptoms.

Depression in Tourette syndrome: A controlled and comparison study

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental condition characterised by multiple tics and co-morbid behavioural problems. Previous research found that up to 76% of patients with TS experience affective symptoms, with 13% fulfilling diagnostic criteria for depression.

OBJECTIVES

We aimed to assess the severity of depression and profile of depressive symptoms in adult patients with TS compared to patients with major depression and healthy controls.

METHODS

Depression ratings were collected from patients with TS (N=65) using the BDI-II and from patients with recurrent major depressive disorder (rMDD, N=696) and healthy controls (N=293) using the Beck Depression Inventory (BDI)-IA. Direct comparisons were possible for 14/21 BDI items.

RESULTS

Patients with TS scored significantly higher on the BDI than controls (P<0.001) and all individual symptoms were reported more frequently by patients with TS than by controls (P<0.001). Total BDI score in TS was not significantly different to that in rMDD, however irritability was significantly more frequently reported in the TS group and this remained significant after controlling for age and gender differences between the two groups (OR 5.24, 95% CI 1.97-14.00; P=0.001).

CONCLUSIONS

Our findings show that depression is a prominent feature in TS and may present with a more irritable phenotype than rMDD. Patients with TS should be routinely screened for depression to implement treatment as appropriate.

Extreme Appraisals of Internal States and Duration of Remission in Remitted Bipolar Patients

INTRODUCTION

To identify dysfunctional attitudes seen in bipolar disorder (BPD) is important for the cognitive theories of BPD and corresponding psychosocial interventions. Cognitions are seen as vulnerability factors in the development and maintenance of BPD. The present study aims to contribute to the cognitive literature on BPD by examining depressive and hypomanic attitudes and their contribution to the prediction of BPD diagnosis as well as by exploring the relationship between dysfunctional cognitions and clinical features (types of episodes experienced, duration of illness, and duration of remission).

METHODS

One hundred and eighteen remitted bipolar patients and 103 healthy controls completed the Mood Disorder Questionnaire (MDQ), Turkish Brief-Hypomanic Interpretations and Positive Predictions Inventory (HAPPI), and Dysfunctional Attitudes Scale.

RESULTS

The bipolar group had significantly higher depressive and hypomanic attitudes than the control group. No significant differences were found regarding the types of episodes experienced and duration of illness. However, both types of attitudes decreased as the duration of remission increased. They were also found to contribute to the prediction of bipolar diagnosis together with the screening of the MDQ.

CONCLUSION

The results pointed out that dysfunctional cognitions may be utilized as possible indicators for the risk of relapse in clinical groups and vulnerability for BPD among other populations.

Cognitive Styles in Mood Disorders: Discriminative Ability of Unipolar and Bipolar Cognitive Profiles

Although previous research has identified cognitive styles that distinguish individuals with bipolar disorder (BD), individuals with major depressive disorder (MDD), and individuals without mood disorders from one another, findings have been inconsistent. The current study included 381 participants classified into a BD group, a MDD group, and a no mood disorder group. To differentiate between these groups, this study evaluated cognitive styles with a battery of traditional and more recently-developed measures. Receiver operating characteristics (ROC) analyses were used to determine the discriminate ability of variables with significant between group differences. Results supported that BD and MDD may be characterized by distinct cognitive styles. Given work showing that interventions for MDD may not be effective at treating BD, it is important to directly compare individuals with these disorders. By clarifying the overlapping and divergent cognitive styles characterizing BD and MDD, research can not only improve diagnostic validity, but also provide more efficacious and effective interventions.

Comorbid medical illness in bipolar disorder

BACKGROUND

Individuals with a mental health disorder appear to be at increased risk of medical illness.

AIMS

To examine rates of medical illnesses in patients with bipolar disorder (n = 1720) and to examine the clinical course of the bipolar illness according to lifetime medical illness burden.

METHOD

Participants recruited within the UK were asked about the lifetime occurrence of 20 medical illnesses, interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and diagnosed according to DSM-IV criteria.

RESULTS

We found significantly increased rates of several medical illnesses in our bipolar sample. A high medical illness burden was associated with a history of anxiety disorder, rapid cycling mood episodes, suicide attempts and mood episodes with a typically acute onset.

CONCLUSIONS

Bipolar disorder is associated with high rates of medical illness. This comorbidity needs to be taken into account by services in order to improve outcomes for patients with bipolar disorder and also in research investigating the aetiology of affective disorder where shared biological pathways may play a role.

Adverse childhood experiences worsen cognitive distortion during adult bipolar depression

BACKGROUND

Cognitive distortion is a central feature of depression, encompassing negative thinking, dysfunctional personality styles and dysfunctional attitudes. It has been hypothesized that ACEs could increase the vulnerability to depression by contributing to the development of a stable negative cognitive style. Nevertheless, little research has been carried out on possible associations between adverse childhood experiences (ACEs) and cognitive distortion, and whether any gender differences exist.

AIM

The aim of this study was to examine the association between ACEs and cognitive distortions and possible differences between genders in a sample of patients affected by bipolar disorder.

METHOD

130 patients with bipolar disorder (BD) (46 men and 84 females), completed the Risky Family Questionnaire to assess ACEs and the Cognition Questionnaire (CQ) to assess cognitive distortions.

RESULTS

A positive association was found between ACE and the CQ total score. Investigating the 5 dimensions assessed through the CQ, only the dimension "generalization across situations" was significantly associated to ACE. An interaction between ACE and gender was found for "generalization across situations", while no differential effect among females and males was found for CQ total score.

CONCLUSION

This is the first study to report a relationship between negative past experiences and depressive cognitive distortions in subjects affected by BD. Growing in a family environment affected by harsh parenting seems to a cognitive vulnerability to depression; this effect is especially strong in females.

Metacognitions and emotional schemas: a new cognitive perspective for the distinction between unipolar and bipolar depression

INTRODUCTION

Clinicians need to make the differential diagnosis of unipolar and bipolar depression to guide their treatment choices. Looking at the differences observed in the metacognitions, and the emotional schemas, might help with this differentiation, and might provide information about the distinct psychotherapeutical targets.

METHODS

Three groups of subjects (166 unipolar depressed, 140 bipolar depressed, and 151 healthy controls) were asked to fill out the Metacognitions Questionnaire-30 (MCQ-30), and the Leahy Emotional Schema Scale (LESS). The clinicians diagnosed the volunteers according to the criteria of DSM-IV-TR with a structured clinical interview (MINI), and rated the moods of the subjects with the Montgomery Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS). Statistical analyses were undertaken to identify the group differences on the MCQ-30, and the LESS.

RESULTS

The bipolar and unipolar depressed patients' scores on the MCQ-30 were significantly different from the healthy controls, but not from each other. On the LESS dimensions of guilt, duration, blame, validation, and acceptance of feelings, all three groups significantly differed from each other. There were no statistically different results on the LESS dimensions of comprehensibility, consensus, and expression. The mood disordered groups scored significantly different than the healthy controls on the LESS dimensions of simplistic view of emotions, numbness, rationality, rumination, higher values, and control.

CONCLUSIONS

These results suggest that the metacognitive model of unipolar depression might be extrapolated for patients with bipolar depression. These results are also compatible to a great extent with the emotional schema theory of depression.

Implicit and explicit self-associations in bipolar disorder: a comparison with healthy controls and unipolar depressive disorder

According to cognitive theory, negative self-schemas are involved in the occurrence of depression. Whereas implicit depressive self-associations have been found in unipolar depression, it is unknown whether impaired associations with regard to the self are also involved in Bipolar Disorder (BD). This study investigated whether a bias in self-associations is a characteristic of bipolar disorder and whether discrepancies between implicit and explicit self-evaluations may be relevant for understanding bipolar psychopathology. Implicit and explicit self-associations were assessed in patients with BD (n=99), in patients with depressive disorder (n=1236), and healthy controls (n=387). Analyses of variance and correlation analyses were used to compare bipolar patients to controls and unipolar patients on implicit self-associations and the discrepancy between implicit and explicit self-associations. Similar to unipolar patients, patients with BD showed stronger implicit depressive self-associations than controls. Specifically for bipolar patients there was no significant correlation between implicit and explicit depressive self-associations. In a similar vein, discrepancies between implicit and explicit self-associations were relatively pronounced in symptomatic bipolar patients as compared to both healthy controls and unipolar depressed patients. Thus automatic depressive self-associations were characteristic for all mood disorders whereas a lack of concordance between implicit and explicit self-associations was specific for BD.

Implicit motives and cognitive variables: specific links to vulnerability for unipolar or bipolar disorder

Cognitive variables contribute to the etiology of affective disorders. With the differentiation between explicit and implicit measures some studies have indicated underlying depressogenic schemata even in bipolar disorders. We tested for differences in implicit motives and cognitive variables between patients with remitted unipolar and bipolar disorder compared to controls and in a high-risk sample. Additionally we investigated whether affective symptoms relate to those variables. We cross-sectionally examined N=164 participants (53 with bipolar disorder, 58 with major depression, and 53 without affective disorders) and a high-risk sample (N=49) of adolescent children of either parents with unipolar or bipolar disorder or of healthy parents. The Multi-Motive-Grid was used to measure the implicit motives achievement, affiliation, and power, in addition to the cognitive measures of self-esteem, dysfunctional attitudes, and perfectionism. Unipolar and bipolar groups did not differ from healthy controls in implicit motives but showed higher scores in the cognitive factors. Adolescents at high risk for unipolar disorder showed lower scores in the power and achievement motives compared to adolescents at low risk. Subsyndromal depressive symptoms were related to the cognitive variables in both samples. Our results underline the importance of cognitive-behavioral treatment for both unipolar and bipolar disorder.

Self-referent information processing in individuals with bipolar spectrum disorders

BACKGROUND

Bipolar spectrum disorders (BSDs) are common and impairing, which has led to an examination of risk factors for their development and maintenance. Historically, research has examined cognitive vulnerabilities to BSDs derived largely from the unipolar depression literature. Specifically, theorists propose that dysfunctional information processing guided by negative self-schemata may be a risk factor for depression. However, few studies have examined whether BSD individuals also show self-referent processing biases.

METHODS

This study examined self-referent information processing differences between 66 individuals with and 58 individuals without a BSD in a young adult sample (age M=19.65, SD=1.74; 62% female; 47% Caucasian). Repeated measures multivariate analysis of variance (MANOVA) was conducted to examine multivariate effects of BSD diagnosis on 4 self-referent processing variables (self-referent judgments, response latency, behavioral predictions, and recall) in response to depression-related and nondepression-related stimuli.

RESULTS

Bipolar individuals endorsed and recalled more negative and fewer positive self-referent adjectives, as well as made more negative and fewer positive behavioral predictions. Many of these information-processing biases were partially, but not fully, mediated by depressive symptoms.

LIMITATIONS

Our sample was not a clinical or treatment-seeking sample, so we cannot generalize our results to clinical BSD samples. No participants had a bipolar I disorder at baseline.

CONCLUSIONS

This study provides further evidence that individuals with BSDs exhibit a negative self-referent information processing bias. This may mean that those with BSDs have selective attention and recall of negative information about themselves, highlighting the need for attention to cognitive biases in therapy.

Cognitive functions and cognitive styles in young euthymic patients with bipolar I disorder

BACKGROUND

Recent evidences suggest that bipolar disorder patients do not return to premorbid functioning levels during the inter-episode periods. Cognitive deficits may impair patients working and functioning status and may also have negative impact on other aspects of thinking.

OBJECTIVES

To assess the prevalence of cognitive dysfunction in patients with bipolar disorder in euthymic state and to explore any evident cognitive style problems.

METHOD

Case-control naturalistic study 60 patients with bipolar I disorder in euthymic state according to DSM-IV were recruited and subdivided into two groups each contains of 30 patients; (Group BPM) euthymic patients with recent manic episode, and Group BPD euthymic patients with recent depressive episode. Both groups were further compared with control group (Group C) consisted of 30 frequency matched healthy volunteers. Groups were subjected to the following: 1-clinical psychiatric examination, 2-Hamilton Depression Scale (HAMD-17) and Bech-Rafaelsen Melancholia Scale (MES) for patients' group (BPD), 3-Young Mania Rating Scale (YMRS) and Bech-Rafaelsen Mania Scale (MAS) for patients' group (BPM), 4-assessment of euthymic state of mood included both MAS and MES, 5-MMSE, MTS and CDT were performed to assess cognitive functions, 6-cognitive styles evaluation included Fear of Failure, Hopelessness Scale, (the Social Dysfunction and Aggression Scale SDAS-9 and Arabic Anger Scale.

RESULTS

Definite cognitive function impairment and different patterns of cognitive style were detected in case groups. MMSE, MTS and CDT scores were statistically significant. Fear of Failure Scale Scores were higher in BPM; 16 (53.33%) reported severe intensity compared to 16 (53.33%) of BPD Group reporting moderate intensity and 30 (100%) of the control group reporting only mild intensity of fear of failure with statistically significant differences. Although patients were in euthymic state; Hopelessness Scale discriminated between those with affective disorders and controls and other scores for hostility SADS-9 and Arabic Anger Scale. Moreover, measures of cognitive styles showed differences among patients of the case groups who joined psychotherapy program in their management (28) compared to those who did not (32).

LIMITATION

Cognitive impact of psychotropic drugs could not be eliminated since the current study is naturalistic study.

CONCLUSIONS

Those with BAD in euthymic state suffer from cognitive dysfunction and some aspects of cognitive styles that may negatively interfere with their performance. Psychotherapeutic programs should consider these findings in their approaches for better impact on patients' quality of life and overall treatment outcome.

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.

Cognitive style in bipolar disorder sub-types

Clearer understanding of psychological processes and mechanisms such as cognitive style inform more targeted psychological treatments for mood disorders. Studies to date have focused on bipolar I disorder or combined bipolar sub-types, precluding identification of any distinctive cognitive style profiles. We examined cognitive style separately in the bipolar sub-types, contrasted with unipolar and non-clinical controls. A total of 417 participants (94 bipolar I, 114 bipolar II, 109 unipolar, 100 healthy controls) completed cognitive style measures including the Rosenberg Self-Esteem Scale, Dysfunctional Attitudes Scale, Inferential Styles Questionnaire, Stress Appraisal Measure and the Behavioural Inhibition System/Behavioural Activation System Scale. Overall, cognitive styles were similar in unipolar and bipolar participants, but with styles relevant to the Behavioral Activation System differentiating bipolar I disorder in particular. State anxiety influenced negative inferential style in unipolar participants and appraisal of stress in bipolar II participants. Analyses restricted to bipolar I vs. II comparisons revealed subtle differences in terms of dispositional stress appraisal, with higher scores on two stress appraisal sub-scales in the bipolar I group. Further exploration of cognitive style in bipolar sub-types is indicated in order to determine whether there are specific psychological vulnerabilities that would benefit from more targeted psychological interventions.

The dynamics of mood and coping in bipolar disorder: longitudinal investigations of the inter-relationship between affect, self-esteem and response styles

BACKGROUND

Previous research has suggested that the way bipolar patients respond to depressive mood impacts on the future course of the illness, with rumination prolonging depression and risk-taking possibly triggering hypomania. However, the relationship over time between variables such as mood, self-esteem, and response style to negative affect is complex and has not been directly examined in any previous study--an important limitation, which the present study seeks to address.

METHODS

In order to maximize ecological validity, individuals diagnosed with bipolar disorder (N = 48) reported mood, self-esteem and response styles to depression, together with contextual information, up to 60 times over a period of six days, using experience sampling diaries. Entries were cued by quasi-random bleeps from digital watches. Longitudinal multilevel models were estimated, with mood and self-esteem as predictors of subsequent response styles. Similar models were then estimated with response styles as predictors of subsequent mood and self-esteem. Cross-sectional associations of daily-life correlates with symptoms were also examined.

RESULTS

Cross-sectionally, symptoms of depression as well as mania were significantly related to low mood and self-esteem, and their increased fluctuations. Longitudinally, low mood significantly predicted rumination, and engaging in rumination dampened mood at the subsequent time point. Furthermore, high positive mood (marginally) instigated high risk-taking, and in turn engaging in risk-taking resulted in increased positive mood. Adaptive coping (i.e. problem-solving and distraction) was found to be an effective coping style in improving mood and self-esteem.

CONCLUSIONS

This study is the first to directly test the relevance of response style theory, originally developed to explain unipolar depression, to understand symptom changes in bipolar disorder patients. The findings show that response styles significantly impact on subsequent mood but some of these effects are modulated by current mood state. Theoretical and clinical implications are discussed.

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.

Cognitive processes and attitudes in bipolar disorder: a study into personality, dysfunctional attitudes and attention bias in patients with bipolar disorder and their relatives

BACKGROUND

Research in cognitive processes and attitudes in bipolar disorder is scarce and has provided mixed findings, possibly due to differences in current mood state. It is unclear whether alterations in cognitive processes and attitudes are only related to the depressive mood states of bipolar patients or also represent a vulnerability marker for the development of future (depressive) episodes. This was investigated in the current study.

METHODS

Both implicit (attentional bias for emotional words) and explicit (dysfunctional attitudes and personality characteristics) measures of cognitive processes and attitudes were assessed in 77 bipolar patients with varying levels of depressive symptoms (depressed=17, euthymic n=60), their healthy first-degree relatives (n=39) and a healthy control group (n=61). Analyses of variance were used to investigate differences between groups.

RESULTS

Mildly depressed patients with bipolar disorder demonstrated an attentional bias away from positive emotional words and showed increased dysfunctional attitudes and higher levels of neuroticism. Euthymic patients were largely comparable to healthy controls and only differed from controls in higher levels of neuroticism. Relatives were similar to controls on all measures, although they significantly differed from bipolar patients in displaying less neuroticism and more extraversion.

LIMITATIONS

No firm conclusions regarding causality can be drawn from the associations that were found between cognitive processes and attitudes and the evolution of mood symptoms in bipolar disorder.

CONCLUSION

Alterations in cognitive processes and attitudes in bipolar patients appear to be mostly related to the expression of mood symptomatology rather than to the vulnerability for bipolar disorder.

Cognitive behaviour therapy and supportive therapy for bipolar disorders: relapse rates for treatment period and 2-year follow-up

BACKGROUND

The efficacy of adjunctive psychosocial interventions such as cognitive behaviour therapy (CBT) for bipolar disorder (BD) has been demonstrated in several uncontrolled and controlled studies. However, these studies compared CBT to either a waiting list control group, brief psycho-education or treatment as usual (TAU). Our primary aim was to determine whether CBT is superior to supportive therapy (ST) of equal intensity and frequency in preventing relapse and improving outcome at post-treatment. A secondary aim was to look at predictors of survival time.

METHOD

We conducted a randomized controlled trial (RCT) at the Department of Psychology, University of Tübingen, Germany (n=76 patients with BD). Both CBT and ST consisted of 20 sessions over 9 months. Patients were followed up for a further 24 months.

RESULTS

Although changes over time were observed in some variables, they were not differentially associated with CBT or ST. CBT showed a non-significant trend for preventing any affective, specifically depressive episode during the time of therapy. Kaplan-Meier survival analyses revealed that 64.5% of patients experienced a relapse during the 33 months. The number of prior episodes, the number of therapy sessions and the type of BD predicted survival time.

CONCLUSIONS

No differences in relapse rates between treatment conditions were observed, suggesting that certain shared characteristics (e.g. information, systematic mood monitoring) might explain the effects of psychosocial treatment for BD. Our results also suggest that a higher number of prior episodes, a lower number of therapy sessions and a diagnosis of bipolar II disorder are associated with a shorter time before relapse.

Rumination in bipolar disorder: evidence for an unquiet mind

Depression in bipolar disorder has long been thought to be a state characterized by mental inactivity. However, recent research demonstrates that patients with bipolar disorder engage in rumination, a form of self-focused repetitive cognitive activity, in depressed as well as in manic states. While rumination has long been associated with depressed states in major depressive disorder, the finding that patients with bipolar disorder ruminate in manic states is unique to bipolar disorder and challenges explanations put forward for why people ruminate. We review the research on rumination in bipolar disorder and propose that rumination in bipolar disorder, in both manic and depressed states, reflects executive dysfunction. We also review the neurobiology of bipolar disorder and recent neuroimaging studies of rumination, which is consistent with our hypothesis that the tendency to ruminate reflects executive dysfunction in bipolar disorder. Finally, we relate the neurobiology of rumination to the neurobiology of emotion regulation, which is disrupted in bipolar disorder.

Hypomanic personality, stability of self-esteem and response styles to negative mood

OBJECTIVES

This paper aims to study dysfunctional self-schematic processes, abnormal coping styles, over-responsiveness to reward stimuli (indicative of an over-sensitive behavioural activation system) and stability of self-esteem in relation to subclinical hypomania.

DESIGN

Three cross-sectional studies were conducted on selected students on the basis of their scores on the Hypomanic Personality Scale (HPS) (study 1) and on elevated HPS and Dysfunctional Attitude Scale scores (studies 2 and 3).

METHODS

In studies 1 and 2, participants completed questionnaires and kept a self-esteem diary for 6 days. In study 3, the experience sampling method was used to assess momentary self-esteem, emotion and use of different coping styles over a 6-day period.

RESULTS

Study 1 demonstrated that hypomanic traits are associated with high fluctuations in self-esteem. In study 2, high scores on both the HPS and the Dysfunctional Attitude Scale, but not the HPS alone, were associated with bipolar spectrum symptoms. These participants showed more evidence of alcohol and substance abuse, greater self-esteem fluctuation and dysfunctional coping styles (rumination and risk-taking) compared with controls. Changes in self-esteem were related to the use of these strategies.

CONCLUSIONS

Vulnerability to bipolar disorder is associated with a combination of depression-related and reward-related processes.

Co-occurring manic symptomatology as a dimension which may help explaining heterogeneity of depression

BACKGROUND

The dichotomous distinction between unipolar and bipolar disorders may be challenged by heterogeneity within diagnoses and overlap between different diagnoses. A broad mood disorder category in which patients differ as a result of variation along separate manic and depressive mood dimensions can be proposed. To test this, it is hypothesized that heterogeneity in clinical and other features of subjects selected for unipolar depression can be partly explained by coexisting manic symptoms.

METHODS

A cohort selected for unipolar depressive disorder was followed up for two years at which time co-occurring manic symptoms were assessed, yielding four groups with increasing manic symptomatology: i) pure unipolar depressive disorder (n=1598), ii) unipolar depressive disorder with subthreshold manic symptomatology (n=64), iii) bipolar II disorder (n=39), and iv) bipolar I disorder (n=86). Multivariate logistic regression and analyses of covariance controlled for depression severity were used to investigate whether patients with increasing manic symptomatology could be differentiated from patients with pure depressive disorder.

RESULTS

Male gender, a lower age at first episode, a history of suicide attempts and increased aggressive cognitions were independently associated with an increase in manic symptoms. The additional presence of (hypo)mania was associated with greater depression severity and more disability than pure depressive disorder.

LIMITATIONS

The groups with manic symptomatology (subthreshold, hypomania and mania) were considerably smaller compared to the pure depression group.

CONCLUSIONS

The heterogeneity in depressive illness can be partly explained by the coexisting variation along the manic symptom dimension. Co-occurring manic symptoms should be taken into account in depression and a symptom dimensional approach of mood disorders may provide phenotypes that are more informative than current mood disorder categories.

Presenteeism in college students: reliability and validity of the Presenteeism Scale for Students

OBJECTIVE

Presenteeism is the impaired work performance due to health problems. We aimed to develop a Presenteeism Scale for Students (PSS), and to reveal the existence of presenteeism among students.

METHODS

Students (n = 5,701) in 4 national universities in Japan were recruited via the school-based health examination. Moreover, 122 students participated in a 2-week interval test-retest to examine the reliability and criterion-related validity of the PSS.

RESULTS

Of the students, 59.2% indicated some health problems. Allergy was most prevalent health problems, affecting 35.7% of the whole students. Students with emotional problems had higher degree of presenteeism than those with the other problems. The Cronbach's α of the work impairment score of the PSS was 0.90. The Spearman's coefficient for the test-retest score was 0.80 (P < 0.001). Regarding criterion-related validity, Spearman's coefficient between the work impairment score of the PSS and summary score of the SF-36 was -0.60 (P < 0.001).

CONCLUSIONS

These findings suggest that the PSS can be expected to be useful for assessment of students with presenteeism. Furthermore, we found that the majority of students have some health problems, and proposed that the issue of presenteeism on campus should be addressed.

Severity of affective temperament and maladaptive self-schemas differentiate borderline patients, bipolar patients, and controls

OBJECTIVES

There is an unsettled debate on whether borderline personality disorder and bipolar disorder should be considered related or distinct. This study aimed to further the understanding of the similarities and differences between the 2 disorders by comparing borderline patients, bipolar patients, and controls in terms of various affective temperaments and maladaptive self-schemas.

METHODS

The sample consisted of 85 participants (31 borderline patients, 25 bipolar patients and 29 student controls) who completed 2 questionnaires: The Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire and the Young Schema Questionnaire. All of the patients were in remission from affective episodes.

RESULTS

Compared to the bipolar patients and the controls, the borderline patients were characterized by significantly higher mean scores on most of the maladaptive self-schemas and affective temperaments. The bipolar patients differed significantly from controls by higher mean scores on the cyclothymic temperament and insufficient self-control.

CONCLUSIONS

The study suggests that affective temperaments and maladaptive self-schemas are more severe in borderline patients than in bipolar patients. These findings point to phenomenological differences between the 2 disorders and therefore question their degree of kinship.

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

OBJECTIVES

Low self-esteem has been found to be a risk factor for depression in major depressive disorder (MDD). In contrast, the role of self-esteem in bipolar disorder (BD) is still uncertain. In order to examine the characteristics of self-esteem in BD, we synthesized studies comparing self-esteem in BD patients with self-esteem in MDD patients and in normal controls.

METHODS

Database searches and identification of studies were conducted by two of the authors independently. Remission of BD and MDD was a major selection criterion. The results were generated through meta-analyses.

RESULTS

Random-effects models of 19 between-group comparisons (N= 1,838) suggested that the self-esteem of remitted BD patients was significantly lower than that of normal controls (Cohen's d= -0.83), while significantly higher than that of remitted MDD patients (Cohen's d= 0.54). Fail-safe numbers and tests for funnel plot asymmetry indicated that the results were robust and unlikely to reflect publication biases. Additional studies indicated that self-esteem may take a fluctuating course during remission of BD.

CONCLUSIONS

By revealing that BD patients do experience low self-esteem, the findings implicate a need for further understanding the causes and therapeutic impact of such abnormality in BD.

Dysfunctional beliefs in bipolar disorder: hypomanic vs. depressive attitudes

BACKGROUND

To date the effect of cognitive behavioural therapy modified for bipolar disorder has been inconsistent and sometimes disappointing. However studies exploring cognitive style in bipolar disorder have not identified the unique patterns of beliefs specific to bipolar disorder. The current study examines whether Mansell's hypomania-related dysfunctional belief scale specifically identifies bipolar disorder patients.

METHOD

Forty remitted bipolar patients, twenty remitted unipolar patients and twenty healthy controls completed the Hypomanic Attitudes and Positive Prediction Inventory (HAPPI) and the Dysfunctional Attitude Scale (DAS).

RESULTS

The remitted bipolar group scored higher than the unipolar and healthy control groups on the HAPPI scale overall score and on three subscales that measured self-catastrophic beliefs, beliefs related to negative responses from other people when in elevated mood and beliefs related the response style to activation and elevation.

CONCLUSION

The study finds evidence of unique dysfunctional beliefs elevated only in remitted bipolar patients. Such findings could be used to inform the development of a specific cognitive behavioural therapy for bipolar disorder.

Cognitive style, personality and vulnerability to postnatal depression

BACKGROUND

Only some women with recurrent major depressive disorder experience postnatal episodes. Personality and/or cognitive styles might increase the likelihood of experiencing postnatal depression.

AIMS

To establish whether personality and cognitive style predicts vulnerability to postnatal episodes over and above their known relationship to depression in general.

METHOD

We compared personality and cognitive style in women with recurrent major depressive disorder who had experienced one or more postnatal episodes (postnatal depression (PND) group, n=143) with healthy female controls (control group, n=173). We also examined parous women with recurrent major depressive disorder who experienced no perinatal episodes (non-postnatal depression (NPND) group, n=131).

RESULTS

The PND group had higher levels of neuroticism and dysfunctional beliefs, and lower self-esteem than the control group. However, there were no significant differences between the PND and NPND groups.

CONCLUSIONS

Established personality and cognitive vulnerabilities for depression were reported by women with a history of postnatal depression, but there was no evidence that any of these traits or styles confer a specific risk for the postnatal onset of episodes.

A preliminary investigation of the effect of hypomanic personality on the specificity and speed of autobiographical memory recall

There is some evidence that patients with bipolar disorder recall more overgeneral than specific autobiographical memories, a pattern widely reported in depression. However, there are also theoretical arguments (Barnard, Watkins, & Ramponi, 2006) suggesting that experiential processing should predominate during mania/hypomania, with an associated prediction of an increase in specific rather than overgeneral memories. This hypothesis was explicitly tested using the Autobiographical Memory Test (AMT). The specificity and speed of autobiographical recollection was compared for those with high or low levels of hypomanic personality as indexed by the Hypomanic Personality Scale (HPS). High HPS scorers recalled specific autobiographical memories in response to unpleasant cues more frequently and faster than low scorers. These results provide partial support for the hypothesis, but only for unpleasant cues.