Coping with depression and vulnerability to mania: A factor analytic study of the Nolen-Hoeksema (1991) Response Styles Questionnaire

Cognitive attentional syndrome and metacognitive beliefs as potential treatment targets for metacognitive therapy in bipolar disorder

Most treatment guidelines emphasize the use of psychotropic drugs for both the acute and maintenance treatment of bipolar disorder (BD). However, relying only on psychotropics without adjunctive psychosocial interventions may be insufficient in treating patients with BD. Given its unique view in the explanation of psychopathological states, metacognitive therapy (MCT) might be helpful for BD. Metacognitive theory posits that psychopathology is a result of the cognitive attentional syndrome (CAS) and that it is influenced and maintained by dysfunctional metacognitive beliefs, perseverative thinking, attentional biases, and dysfunctional coping strategies. In this review, literature data regarding these areas in BD are examined. Studies suggest that perseverative thinking might be among the emotion regulation strategies endorsed in individuals with BD. Regarding attentional biases, literature data show that state-dependent, mood-changing attentional biases and a ruminative self-focused attention are present. Studies also suggest that cognitive self-consciousness is higher in BD compared to controls. It is seen that maladaptive coping strategies are frequently reported in BD, and that these strategies are associated with depression severity, negative affect and relapse risk. Studies focusing on dysfunctional metacognitive beliefs in BD reported that individuals with BD had higher scores for negative metacognitive beliefs, self-consciousness, need to control thoughts, and a lack of cognitive confidence. Also, dysfunctional metacognitive beliefs were associated with depressive symptomatology. These findings suggest that the components of CAS and dysfunctional metacognitive beliefs are evident in BD. For a subgroup of patients with BD who fail to respond to evidence-based psychopharmacological and adjunctive psychotherapeutic interventions, MCT might be an alternative way to consider as a treatment option. In conclusion, taken the available data together, we propose a sequential treatment protocol for BD, mainly based on the MCT treatment plan of depressive disorders.

Associations of Attachment and Coping Styles With Social Functioning in Patients With Bipolar Disorder I

ABSTRACT

The aim of this study was to investigate the relationship of attachment and coping mechanisms with social functioning in patients with bipolar disorder (BD). Sixty-three patients with BD type I and 63 healthy controls were evaluated. Structured Clinical Interview for DSM-IV Axis I Disorders, Hamilton Depression Rating Scale, Young Mania Rating Scale, Experiences in Close Relationships Questionnaire II, Coping Orientation to Problems Experienced (COPE) inventory, and Social Functioning Scale were used. In the BD group, adaptive coping style scores and attachment avoidance scores were significantly lower than the control group, but mean scores of maladaptive coping styles were higher than the control group. Regression analysis showed that positive reinterpretation and growth, active coping, use of emotional social support, planning, religious activities, and mental disengagement subscales of COPE were significantly associated with social functioning. Psychosocial interventions to strengthen adaptive coping mechanisms may help improve the social functioning in patients with BD.

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.

Anxiety Symptoms and Alcohol-Related Problems among College Students: A Moderated-Mediation Model of Rumination and Emotion Dysregulation

Prior research has individually linked rumination, anxiety, and emotion dysregulation to alcohol misuse, but limited research has examined a comprehensive model linking these variables together. The present study tested a moderated-mediation model to examine whether emotion dysregulation moderated the indirect association of anxiety symptoms on alcohol-related problems via ruminative thinking styles. Method: Participants were 448 college students who consumed alcohol in the previous month. A plurality of participants identified as being White, non-Hispanic (40.6%), female (68.6%), and reported a mean age of 22.75 (Median = 20.00; SD = 6.84) years. Results: Brooding and reflection subtypes of ruminative thinking mediated the association between anxiety symptoms and alcohol-related problems with higher rates of anxiety symptoms associated with higher ruminative thinking, which in turn was associated with more alcohol-related problems. Further, the indirect effect of anxiety symptoms on alcohol-related problems through ruminative thinking was stronger for individuals who reported high levels of emotion dysregulation compared to those with average and low levels of emotion dysregulation. Conclusions: In support of prior work, our results suggest that ruminative thinking, particularly brooding and reflection, are key mechanisms through which anxiety symptoms relate to problematic alcohol use, especially among individuals with high emotion dysregulation. Additional work is needed to test whether decoupling the associations between negative emotional states and ruminative thinking among college students with high emotion dysregulation is a viable intervention target to reduce problematic alcohol use.

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

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

A multimethod assessment to study the relationship between rumination and gender differences

Rumination is described as the propensity of responding to distress by repetitively and passively focusing on one's negative emotions, and failures, and their consequences (Nolen-Hoeksema, 1991, 1998). Therefore, given that rumination is characterized especially by difficulties in managing and controlling negative emotional states, it is considered as the most common (impaired) emotional regulation strategy, and can be defined as an emotional process related to a repetitive, undesired, and past-oriented negatively inclined thought (Compare, Zarbo, Shonin, Van Gordon, & Marconi, 2014; Smith & Alloy, 2009). Recent evidence suggested that because of problems related to monitoring of negative states, rumination may be associated with exaggerated physiological reactivity relative to demands from the environment, and to some difficulties in attentional control abilities. The current study aimed at deepening our understanding of the role that a maladaptive emotional regulation strategy - such as rumination - might play in physiological response changes and in engaging dysfunctional attentional strategies. We used a multimethod assessment including self-reports (i.e., Rumination and Reflection Questionnaire, and Difficulties in Emotion Regulation Scale), physiological measures, (i.e., Heart Rate Variability recording), and attention tasks (i.e., Stroop Task) in order to examine the multiple aspects of rumination across genders. Sixty-eight individuals (30 males and 38 females) were administered DERS -16, RRQ and, soon after them, the Stroop task. Immediately after completing the Stroop task (T1), participants were exposed to a three-phase, baseline-stress-recovery experimental paradigm while their heart rate variability (HRV) was recorded. After completing the experimental paradigm, Stroop stimuli were presented for the second time (T2), in order to examine possible intra-individual differences between the two performances in the Stroop task. Our findings showed that rumination was higher in females than in males, but in men it appeared to be strongly associated with an overall impaired emotional regulation. However, no gender differences in rumination and emotion dysregulation were found when inspecting physiological data. The current study aims to contribute towards a better understanding which emotion regulation strategies and which physiological mechanisms are associated with rumination.

Attitudes of Mothers Regarding Willingness to Enroll Their Children in Research

This study assessed mothers' perspectives regarding research involvement by their children, factors that might affect perceptions of research risks, and attitudes regarding willingness to enroll children in research. Participants completed a survey on Amazon Mechanical Turk. Mothers were less inclined to enroll children in research involving procedures posing higher risk (regression coefficient = -0.51). Mothers without mental health issues with children without health issues were more sensitive to risk than mothers without mental health issues with children with health issues (estimated difference = 0.49). Mothers with mental health issues were more willing than mothers without mental health issues to enroll children in research (regression coefficient = -0.90). Among mothers with mental health issues, having a child with a health issue was associated with increased willingness to enroll in research, compared with having children without health issues (estimated difference = 0.65).

Negative association of perceived risk and willingness to participate in innovative psychiatric research protocols

Psychiatric researchers grapple with concerns that individuals with mental illness may be less likely to appreciate risks of research participation, particularly compared to people not suffering from mental illness. Therefore, empirical studies that directly compare the perspectives of such individuals are needed. In addition, it is important to evaluate perspectives regarding varied types of research protocols, particularly as innovative psychiatric research protocols emerge. In this pilot study, respondents with a mood disorder (n = 25) as well as respondents without a mood disorder (n = 55) were recruited using Amazon's Mechanical Turk (MTurk) platform. These respondents were surveyed regarding four psychiatric research projects (i.e., experimental medication [pill form]; non-invasive magnetic brain stimulation; experimental medication [intravenous infusion]; and implantation of a device in the brain). Regardless of health status, respondents rated the four research protocols as somewhat to highly risky. The brain-device implant protocol was seen as the most risky, while the magnetic brain stimulation project was viewed as "somewhat risky". Respondents, on average and regardless of health status, rated their willingness at or below "somewhat willing." Respondents were least willing to participate in the brain-device implant protocol, whereas they were "somewhat willing" to participate in the magnetic brain stimulation protocol. Trust in medical research was negatively associated with perceived risk of research protocols. Perceived risk was negatively associated with willingness to participate, even when adjusting for potential confounders, suggesting that attunement to risk crosses diagnostic, gender, and ethnic categories, and is more salient to research decision-making than trust in medical research and dispositional optimism. The findings of this study may offer reassurance about the underlying decision-making processes of individuals considering participation in innovative neuroscience studies.

Decoding rumination: A machine learning approach to a transdiagnostic sample of outpatients with anxiety, mood and psychotic disorders

OBJECTIVE

To employ machine learning algorithms to examine patterns of rumination from RDoC perspective and to determine which variables predict high levels of maladaptive rumination across a transdiagnostic sample.

METHOD

Sample of 200 consecutive, consenting outpatient referrals with clinical diagnoses of schizophrenia, schizoaffective, bipolar, depression, anxiety disorders, obsessive compulsive and post-traumatic stress. Machine learning algorithms used a range of variables including sociodemographics, serum levels of immune markers (IL-6, IL-1β, IL-10, TNF-α and CCL11) and BDNF, psychiatric symptoms and disorders, history of suicide and hospitalizations, functionality, medication use and comorbidities.

RESULTS

The best model (with recursive feature elimination) included the following variables: socioeconomic status, illness severity, worry, generalized anxiety and depressive symptoms, and current diagnosis of panic disorder. Linear support vector machine learning differentiated individuals with high levels of rumination from those ones with low (AUC = 0.83, sensitivity = 75, specificity = 71).

CONCLUSIONS

Rumination is known to be associated with poor prognosis in mental health. This study suggests that rumination is a maladaptive coping style associated not only with worry, distress and illness severity, but also with socioeconomic status. Also, rumination demonstrated a specific association with panic disorder.

Emotion regulation strategies in mania risk: A systematic review

OBJECTIVES

Difficulties in emotion regulation may contribute to the development of mania. This review aimed to assess how emotion regulation strategies reported by individuals at risk of mania compare with clinical and nonclinical controls.

METHODS

Search terms relating to mania risk and emotion regulation were entered into three databases. Sixteen studies were included.

RESULTS

Mania risk was typically associated with overall endorsement of emotion regulation strategies, particularly dampening, and positive and negative rumination.

CONCLUSIONS

Findings were limited by overall lack of evidence for individual strategies, lack of consideration of key mediating factors and reliance upon self-report designs.

Beliefs about the automaticity of positive mood regulation: examination of the BAMR-Positive Emotion Downregulation Scale in relation to emotion regulation strategies and mood symptoms

Emotion regulation is a topic of great interest due to its relevance to navigating everyday life, as well as its relevance to psychopathology. Recent research indicates that beliefs about the automaticity of mood regulation are critical to psychological health. In the present study we assessed beliefs about the automaticity of positive mood regulation in relationship to self-reported mood symptoms and explicit emotion regulation strategies. Participants (n = 200) completed an online survey including a scale assessing beliefs about automatic downregulation of positive emotions (i.e. BAMR-PED), beliefs about automatic mood regulation for negative emotions, mood symptoms, and emotion regulation strategies. Results suggested that beliefs about automatic positive emotion regulation were associated with unhelpful emotion regulation strategies and reduced negative affect as well as fewer depressive, manic, and anxiety symptoms. Test-retest of the novel BAMR-PED measure was tested with a further sample (n = 46) and found to be acceptable. Future research should explore how these automatic beliefs have relevance to clinical disorders characterised by positive emotion disturbance, such as bipolar disorder.

Moment-to-moment interaction between affectivity and coping behaviours in bipolar disorder and the role of cognitive appraisals

BACKGROUND

Individuals with bipolar disorder respond to affective symptoms with a range of coping behaviours, which may further maintain the symptoms.

AIMS

To examine moment-to-moment dynamics between affective states and coping behaviours, and to evaluate the role of cognitive appraisals of internal states as moderators.

METHOD

Forty-six individuals with bipolar disorder completed a clinical interview and an experience sampling assessment over 6 days. Time-lagged analyses were conducted by multilevel regression modelling.

RESULTS

A total of 1807 momentary entries were analysed. Negative affect predicted an increase in rumination at the subsequent time point (β = 0.21, s.e. = 0.08, P = 0.009, 95% CI 0.05-0.36), and vice versa (β = 0.03, s.e. = 0.01, P = 0.009, 95% CI 0.01-0.05). Positive affect predicted an increase in adaptive coping (β = 0.26, s.e. = 0.11, P = 0.018, 95% CI 0.04-0.47), and vice versa (β = 0.02, s.e. = 0.01, P = 0.019, 95% CI 0.00-0.03). Positive affect also predicted a decrease in rumination (β = -0.15, s.e. = 0.06, P = 0.014, 95% CI -0.26 to -0.03), and vice versa (β = -0.03, s.e. = 0.01, P = 0.016, 95% CI -0.06 to -0.01). Extreme cognitive appraisals predicted stronger associations between affective states and coping behaviours.

CONCLUSIONS

Feedback loops between affective states and coping behaviours were revealed in the daily life of individuals with bipolar disorder, which were moderated by extreme cognitive appraisals.

DECLARATION OF INTEREST

None.

Effects of Rumination and Worry on Sleep

Recent research suggests that the stress-sleep relationship is mediated by pre-sleep arousal (PSA) and that cognitive arousal has a stronger mediating effect than somatic arousal; however, this has not been directly tested. Using multilevel moderated mediation, we compared the effects of cognitive arousal and somatic arousal within the stress-sleep relationship. We also assessed whether two forms of repetitive negative thought-rumination and worry-are similarly involved in the stress-sleep relationship. Data was collected from 178 participants across the United States via an online platform. Participants completed baseline self-report surveys examining rumination tendencies and worry tendencies. Over the course of 2 weeks, participants completed daily questionnaires assessing daily stress, PSA, and sleep quality. Results indicated that indirect effects from stress to sleep quality via PSA were statistically significant at low and high levels of rumination and worry, and people at high levels of rumination and worry had stronger relationships between stress and PSA. Across all models, cognitive arousal consistently accounted for more of the variance in the stress-sleep relationship as compared to somatic arousal. Implications for the cognitive behavioral treatment of insomnia are discussed.

Mindfulness, rumination, and coping skills in young women with Eating Disorders: A comparative study with healthy controls

Eating Disorders (ED) have been associated with dysfunctional coping strategies, such as rumination. Promoting alternative ways of experiencing mental events, based on a mindfulness approach, might be the clue for learning more effective coping and regulatory strategies among young women with ED. This study examined the comparison between patients with ED diagnosis and healthy subjects in mindfulness, rumination and effective coping. In addition, we analyzed the independent association of those with the presence of ED. The study sample was formed by two groups of young women ranged 13-21 years: Twenty-five with an ED diagnosis and 25 healthy subjects. They were assessed by using the Freiburg Mindfulness Inventory (FMI) and the Responses Styles Questionnaire (RSQ). Our findings show that ED patients have significantly lesser average scores in mindfulness and effective coping than the healthy sample (p < .05). Also, our data concludes that mindfulness and effective coping independently predict the presence or absence of ED in young women. The study results suggest that training mindfulness abilities may contribute to making effective coping strategies more likely to occur in ED patients, which is incompatible with some eating-related symptoms. Further studies are needed, trough prospective and experimental designs, to evaluate clinical outcomes of mindfulness training among young women with ED.

Is the widely used two-factor structure of the Ruminative Responses Scale invariant across different samples of women?

OBJECTIVES

Although the Ruminative Responses Scale is one of the most widely used measures of rumination, its two-factor structure remains controversial. Taking this into account, we aimed to test the RRS-10 two-factor invariance (Brazilian version) between different samples of women and to study its internal consistency and convergent validity.

METHODS

A sample of 321 women (general population, n = 106; college students, n = 115; and medical population of patients with overweight and obesity, n = 100) participated in the study. The two-factor structure of RRS-10 was assessed by CFA and multigroup analysis using Mplus software. Internal consistency was assessed by Cronbach's alpha and the convergent validity by Pearson correlations.

RESULTS

The two-factor structure of RRS-10 showed a good fit, factorial invariance across three samples, good internal consistency, and adequate convergent validity. Brooding and Reflection subscales were both positively correlated with psychological inflexibility, cognitive fusion, anxiety, depression, and stress symptoms, although Brooding presented significantly stronger associations with these variables than Reflection.

CONCLUSIONS

This study provides further discussion and evidence regarding the RRS-10 two-factor structure, as well as a valid version of RRS-10 to use in Brazil in order to reliably assess rumination in medical and research settings.

PRACTITIONER POINTS

This is the first study to test and confirm the RRS two-factor structure invariance across groups. RRS-10 two-dimensionality was confirmed in medical and non-medical samples of women. Brooding subscale showed significantly stronger relationships with psychopathology and experiential avoidance than Reflection. The study provides evidence that RRS can be used as a valid and sound measure to accurately assess the clinically relevant dimensions of rumination simultaneously across distinct groups.

Overarousal as a mechanism of the relation between rumination and suicidality

Rumination, particularly brooding, is associated with suicidal ideation and attempts; however, mechanisms of these associations have not been identified. The present study examined manifestations of overarousal-agitation, insomnia, and nightmares-that have been linked to both rumination and suicide as indirect indicators of the link between brooding and suicidal ideation/attempts. A sample of 492 psychiatric outpatients (64.2% female), aged 17-65 years (M = 26.75, SD = 10.32), completed self-report measures before their intake appointments with a therapist. Results indicated that agitation and nightmares, but not insomnia, each significantly explained the association between brooding and suicidal ideation and between brooding and the presence of a past suicide attempt. Overall, these findings provide evidence that certain types of overarousal may serve as a mechanism of the association between brooding and suicidal ideation and attempts. Clinical implications, limitations, and future research directions are discussed.

"When my Moods Drive Upward There Is Nothing I Can Do about It": A Review of Extreme Appraisals of Internal States and the Bipolar Spectrum

The integrative cognitive model provides a comprehensive account of bipolar disorder (BD) that, if empirically supported, has important potential implications for psychological therapies. This article is the first to review the evidence for this model. We evaluate the evidence (up to 2017) for four hypotheses derived uniquely from the model: extreme positive and negative appraisals of internal states are associated with (1) risk of developing BD; (2) BD diagnosis; (3) relevant clinical and functional outcomes including hypomanic and depressive mood symptoms; and (4) outcomes over time. Research involving individuals with diagnosed mood disorders as well as non-clinical populations is reviewed. The hypotheses were broadly supported and several consistent findings were not accounted for by alternative psychological models of BD. The evidence base is limited by a relative paucity of prospective studies; only 6 of the 31 studies identified. Implications for theory, research and clinical practice are discussed.

Characterization of Risk-Taking in Adults With Bipolar Spectrum Disorders

Individuals with bipolar spectrum disorders experience higher morbidity and mortality rates relative to the general population because of increased commission of dangerous behaviors. Despite this impact, little is known about the overall rates of risk-taking behaviors in patients currently being treated for such illness. This study examined the frequency of a variety of risk-taking behaviors in 100 adults with bipolar spectrum disorders in an active outpatient psychiatric treatment. It was found that 70% of individuals assessed reported at least one risk-taking behavior over the preceding 7 days. Implications for assessment and intervention are discussed.

Psychometric properties of the 10-item ruminative response scale in Chinese university students

BACKGROUND

Rumination increases vulnerability to depression, exacerbates and perpetuates negative moods. This study was aimed to examine the psychometric properties of the Chinese version of the 10-item Ruminative Response Scale (RRS-10) in a large undergraduate sample.

METHODS

A sample of 5,236 university students finished the RRS and the Center for Epidemiological Studies Depression Scale (CES-D). Confirmatory Factor Analysis (CFA) was performed to examine the two-factor structure and the measurement equivalence of the RRS-10 across gender. The internal consistency, test-retest reliability, correlations among RRS, RRS-10 and CES-D were also explored. In addition, gender difference on rumination and the relationship between rumination and depression were further investigated.

RESULTS

The two-factor model of RRS-10 fit the data reasonably and had acceptable internal consistency and test-retest reliability in Chinese undergraduates sample. And the measurement equivalence of the RRS-10 was acceptable across gender in Chinese university students. Findings in respect of latent means and manifest means revealed non-significant gender difference in RRS-10. Besides, participants with high-level rumination had more depressive symptoms than those with low-level rumination.

CONCLUSIONS

The Chinese version of the RRS-10 showed good psychometric properties and was measurement invariant across gender in undergraduates.

Emotional dysregulation in those with bipolar disorder, borderline personality disorder and their comorbid expression

BACKGROUND

Differentiation of the bipolar disorders (BP) from a borderline personality disorder (BPD) can be challenging owing to shared features, with emotional dysregulation being the likely principal one.

AIM

To assess differences in emotion regulation strategies in those with BP alone, BPD alone and those comorbid for both.

METHODS

We interviewed participants previously receiving a BP or BPD diagnosis, studying those who met DSM criteria for one or both conditions.

RESULTS

The sample comprised 83 with bipolar disorder, 53 with BPD and 54 comorbid for both. Analyses established linear trends, with the greatest impairment in emotion regulation strategies in the comorbid group followed by the BPD group, and with the lowest in the BP group. Specific deficits in the comorbid group included impulsivity, difficulties with goal directed behaviour, and accessing strategies. A similar linear profile was quantified for maladaptive cognitive emotion regulation strategies, weighted to catastrophizing and rumination. Adaptive emotion regulation strategies were superior in the bipolar group, without significant differences observed between the comorbid and BPD groups.

LIMITATIONS

Reliance on self-report measures; combined BP I and II participants limits generalisability of results to each bipolar sub-type; use of DSM diagnoses risking artefactual comorbidity; while there was an over-representation of females in all groups.

CONCLUSIONS

Differences in emotion regulation strategies advance differentiation of those with either BP or BPD, while we identify the specificity of differing strategies to each condition and their synergic effect in those comorbid for both conditions. Study findings should assist the development and application of targeted strategies for those with either or both conditions.

The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models

Research in developmental psychopathology and clinical staging models has increasingly sought to identify trans-diagnostic biomarkers or neurocognitive deficits that may play a role in the onset and trajectory of mental disorders and could represent modifiable treatment targets. Less attention has been directed at the potential role of cognitive-emotional regulation processes such as ruminative response style. Maladaptive rumination (toxic brooding) is a known mediator of the association between gender and internalizing disorders in adolescents and is increased in individuals with a history of early adversity. Furthermore, rumination shows moderate levels of genetic heritability and is linked to abnormalities in neural networks associated with emotional regulation and executive functioning. This review explores the potential role of rumination in exacerbating the symptoms of alcohol and substance misuse, and bipolar and psychotic disorders during the peak age range for illness onset. Evidence shows that rumination not only amplifies levels of distress and suicidal ideation, but also extends physiological responses to stress, which may partly explain the high prevalence of physical and mental co-morbidity in youth presenting to mental health services. In summary, the normative developmental trajectory of rumination and its role in the evolution of mental disorders and physical illness demonstrates that rumination presents a detectable, modifiable trans-diagnostic risk factor in youth.

Emotion regulation and mania risk: Differential responses to implicit and explicit cues to regulate

BACKGROUND AND OBJECTIVES

People prone to mania use emotion regulation (ER) strategies well when explicitly coached to do so in laboratory settings, but they find these strategies ineffective in daily life. We hypothesized that, compared with control participants, mania-prone people would show ER deficits when they received implicit, but not explicit, cues to use ER.

METHODS

Undergraduates (N = 66) completed the Hypomanic Personality Scale (HPS) and were randomly assigned to one of three experimental conditions: automatic ER (scrambled sentence primes), deliberate ER (verbal instructions), or control (no priming or instructions to use ER). Then, participants played a videogame designed to evoke anger. Emotion responses were measured with a multi-modal assessment of self-reported affect, psychophysiology, and facial expressions. Respiratory sinus arrhythmia (RSA) was used to index ER.

RESULTS

The videogame effectively elicited subjective anger, angry facial expressions, and heart rate increases when keys malfunctioned. As hypothesized, persons who were more mania prone showed greater RSA increases in the deliberate ER condition than in the automatic or control conditions.

LIMITATIONS

One potential limitation is the use of an analog sample.

CONCLUSIONS

Findings suggest that those at risk for mania require more explicit instruction to engage ER effectively.

Response style and severity and chronicity of depressive disorders in primary health care

BACKGROUND

Response styles theory of depression postulates that rumination is a central factor in occurrence, severity and maintaining of depression. High neuroticism has been associated with tendency to ruminate. We investigated associations of response styles and neuroticism with severity and chronicity of depression in a primary care cohort study.

METHODS

In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up with a graphic life chart enabling evaluation of the longitudinal course of episodes. Neuroticism was measured with the Eysenck Personality Inventory (EPI-Q). Response styles were investigated at five years using the Response Styles Questionnaire (RSQ-43).

RESULTS

At five years, rumination correlated significantly with scores of Hamilton Depression Rating Scale (r=0.54), Beck Depression Inventory (r=0.61), Beck Anxiety Inventory (r=0.50), Beck Hopelessness Scale (r=0.51) and Neuroticism (r=0.58). Rumination correlated also with proportion of follow-up time spent depressed (r=0.38). In multivariate regression, high rumination was significantly predicted by current depressive symptoms and neuroticism, but not by anxiety symptoms or preceding duration of depressive episodes.

CONCLUSIONS

Among primary care patients with depression, rumination correlated with current severity of depressive symptoms, but the association with preceding episode duration remained uncertain. The association between neuroticism and rumination was strong. The findings are consistent with rumination as a state-related phenomenon, which is also strongly intertwined with traits predisposing to depression.

Response styles, bipolar risk, and mood in students: The Behaviours Checklist

OBJECTIVES

An Integrative Cognitive Model of mood swings and bipolar disorder proposes that extreme positive and negative appraisals about internal states trigger ascent and descent behaviours, contributing to the onset and maintenance of mood swings. This study investigated the reliability and validity of a new inventory, the Behaviours Checklist (BC), by measuring associations with appraisals, response styles to positive and negative affect, bipolar risk, mania, and depression.

DESIGN

Correlational analogue study.

METHODS

Students (N = 134) completed the BC alongside measures of appraisals, response styles to positive and negative mood, mania, depression, and hypomanic personality (bipolar risk).

RESULTS

The BC was of adequate reliability and showed good validity. Ascent behaviours and appraisals predicted bipolar risk, whereas descent behaviours and appraisals were associated with depression.

CONCLUSIONS

Appraisals, ascent, and descent behaviours may play an important role in the development and maintenance of mood swings. Limitations and research recommendations are outlined.

PRACTITIONER POINTS

Extreme positive and negative appraisals of internal states, and subsequent behavioural responses (ascent and descent behaviours), are associated with bipolar risk and bipolar mood symptoms in a student sample. These processes are involved with mood dysregulation in clinical populations as well as bipolar risk in students, with implications for mood management.

Rethinking Rumination

The response styles theory (Nolen-Hoeksema, 1991) was proposed to explain the insidious relationship between rumination and depression. We review the aspects of the response styles theory that have been well-supported, including evidence that rumination exacerbates depression, enhances negative thinking, impairs problem solving, interferes with instrumental behavior, and erodes social support. Next, we address contradictory and new findings. Specifically, rumination appears to more consistently predict the onset of depression rather than the duration, but rumination interacts with negative cognitive styles to predict the duration of depressive symptoms. Contrary to original predictions, the use of positive distractions has not consistently been correlated with lower levels of depressive symptoms in correlational studies, although dozens of experimental studies show positive distractions relieve depressed mood. Further, evidence now suggests that rumination is associated with psychopathologies in addition to depression, including anxiety, binge eating, binge drinking, and self-harm. We discuss the relationships between rumination and worry and between rumination and other coping or emotion-regulation strategies. Finally, we highlight recent research on the distinction between rumination and more adaptive forms of self-reflection, on basic cognitive deficits or biases in rumination, on its neural and genetic correlates, and on possible interventions to combat rumination.

Rumination in bipolar disorder: a systematic review

OBJECTIVE

To conduct a systematic review of the literature about the symptom of rumination in bipolar disorder (BD).

METHODS

We searched the MEDLINE (PubMed), ISI Web of Knowledge, PsycINFO, and SciELO databases using the descriptors "rumination" and "bipolar disorder" and no time limits. This strategy yielded 105 references, of which 74 were selected. Inclusion criteria were studies involving patients with BD and the use of at least one validated scale for the assessment of rumination. Review articles were excluded. Seventeen articles were ultimately analyzed and included in the review.

RESULTS

Rumination is present in all BD phases, is a stable interepisodic symptom, is associated with symptoms of depression, anxiety, and hypomania, and may occur in response to both positive and negative affect. There is no research on rumination and neurobiological findings in patients with BD.

CONCLUSIONS

Rumination seems to be independent of mood state, but shows close relationship with it. It is possible that rumination has a negative impact on cognitive and executive functions, particularly inhibitory control. Finally, rumination is an important symptom in both phases of BD, and, therefore, may be a useful target for further exploration as a dimensional domain and a transdiagnostic phenomenon in Research Domain Criteria (RDoC) projects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Appraisals to affect: Testing the integrative cognitive model of bipolar disorder

OBJECTIVE

Cognitive models have suggested that extreme appraisals of affective states and maladaptive affect regulation strategies are important in the development of bipolar symptomatology. Little is known about the pathway by which these appraisals and behaviours interact in the formation of activated and depressed affective states. This study tested the predictions that (1) ascent behaviours mediate the relationship between positive appraisals of activated mood and activation; and (2) descent behaviours mediate the relationship between negative appraisals of activated mood and depression.

METHOD

A total of 52 individuals with a DSM-IV diagnosis of bipolar I or II disorder (confirmed by structured interview) completed biweekly assessments of affect regulation behaviours and mood for 4 weeks. Positive and negative appraisals of affective states were assessed at baseline through the Hypomanic Attitudes and Positive Prediction Inventory. Multilevel mediation analysis was used to explore the data.

RESULTS

Ascent behaviours partially mediated the relationship between positive appraisals of activated mood and activation. Descent behaviours, but not negative appraisals of activated mood, predicted levels of depression indicating the absence of a mediation effect.

CONCLUSION

The results suggest that positive appraisals of activated mood can escalate activation in individuals with bipolar disorder. Such appraisals may be inherently rewarding and reinforcing directly elevating levels of activation, whilst increasing individuals' use of ascent behaviours. The results are consistent with the view that appraisals and behaviours should be targeted during cognitive behavioural therapy for bipolar disorder.

PRACTITIONER POINTS

It may be beneficial to target positive appraisals of activated mood in cognitive behavioural therapy for mania. Cognitive behavioural therapists may also wish to focus on identifying and targeting individuals' use of ascent behaviours to reduce highly activated states.

The inter-relationship between mood, self-esteem and response styles in adolescent offspring of bipolar parents: an experience sampling study

The response styles theory of depression (Nolen-Hoeksema, 1991) proposes three main strategies individuals employ in response to low mood: rumination, active coping (distraction and problem-solving) and risk taking. Although recent research has suggested this theory has utility in understanding the symptoms of bipolar disorder (BD), the role of these processes in conferring vulnerability to the condition is poorly understood. Twenty-three adolescent children of patients with BD and 25 offspring of well parents completed the Experience Sampling Method (ESM; Csikszentmihalyi and Larson, 1987) diary for six days. Longitudinal analyses were carried out to examine inter-relationships between mood, self-esteem and response styles. Increased negative as well as positive mood resulted in greater rumination in both groups. Low self-esteem triggered greater risk-taking at the subsequent time point in the at-risk group, while negative affect instigated increased active coping in the control group. In both groups, engagement in risk-taking improved mood at the subsequent time point, whilst rumination dampened self-esteem. Differential longitudinal associations between mood, self-esteem and response styles between at-risk and control children suggest early psychological vulnerability in the offspring of BD parents, with important indications for early intervention.

Depressive rumination and experiential avoidance: a task based exploration

Depressive rumination has been conceptualized as being closely connected with experiential avoidance. Evidence supporting this hypothesis derives primarily from studies using self-report measures. The present study explores this idea using a task-based assessment of avoidance. College students (N = 100) rated their emotional responses to 60 computer-presented images (positive, negative and neutral). Response times for the image-rating task were surreptitiously recorded, along with Ruminative Response Scale and Beck Depression Inventory II scores. Rumination was correlated with faster response times for negative, but not positive or neutral images. These findings are interpreted as lending support to the experiential avoidance conceptualization of rumination; however, consideration is also given to a potentially synergistic interpretation implicating heightened threat monitoring.

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

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

Brooding, Reflection, and Distraction: Relation to Non-Suicidal Self-Injury versus Suicide Attempts

The present study examined the relation between cognitive response styles (i.e., brooding, reflection, distraction) and cognitive inflexibility in differentially predicting history of non-suicidal self-injury (NSSI) only, suicide attempt (SA) only, or both (NSSI + SA). College students (N = 352) completed self-report measures of rumination, distraction, and self-harm history, a diagnostic interview, and a computerized task measuring cognitive flexibility. Brooding uniquely predicted SA-only history, while reflection uniquely predicted history of NSSI-only and NSSI + SA. Distraction was associated with lower odds of NSSI-only and NSSI + SA. Cognitive inflexibility was not significantly associated with self-harm history. Cognitive vulnerabilities may help identify individuals who are at risk for self-harm and may differentiate between NSSI and SA.

Cognitive styles and clinical correlates of childhood abuse in bipolar disorder

OBJECTIVES

In a relatively small number of previous studies, childhood abuse has been found to be associated with more severe symptom course, earlier onset, greater comorbidity, and greater suicidality in those diagnosed with bipolar disorder. There have been no prior reports looking for any association between childhood abuse and cognitive style. This study aimed to examine the relationship between cognitive factors, such as response styles to depressed mood and dysfunctional attitudes, clinical features, and childhood physical and sexual abuse in this population.

METHODS

A total of 157 adult participants diagnosed with DSM-IV bipolar disorder I or II were assessed on clinical features of this condition and measures of childhood sexual and physical abuse. Participants also completed self-report questionnaires covering areas such as symptom measures of depression, anxiety and stress, dysfunctional attitudes, and response styles to depressed mood.

RESULTS

Seventy-four participants (37%) reported having experienced either sexual or physical abuse. Those who reported physical or sexual abuse were significantly more likely to report self-harm or suicidal behaviors and showed higher stress scores. Specifically, those who reported sexual abuse were more likely to have simple phobias, to have attempted suicide, and to have had more hospitalizations for depression. After controlling for current mood severity, there were no significant differences on the self-report cognitive style measures for those who reported childhood sexual or physical abuse compared to those who did not report abuse.

CONCLUSIONS

Cognitive styles were not found to be associated with childhood sexual or physical abuse in participants with bipolar disorder. Stress may be important to target in psychological interventions, whilst special attention should also be paid to those with a history of sexual abuse given the greater likelihood of suicide attempt.

Cognitive emotion regulation in euthymic bipolar disorder

BACKGROUND

Based on findings indicating increased stress reactivity and prolonged stress recovery in individuals with bipolar disorder (BD), it has been proposed that emotion regulation (ER) deficits lie at the core of this disorder. Recent studies show an increased use of maladaptive ER strategies and a decreased use of adaptive ER strategies in BD. Whether this pattern is merely a correlate of affective episodes or might be a stable characteristic of BD, however, remains to be explored. In addition, it is unclear whether these deficits in ER are specific to people with a history of BD.

METHODS

We examined whether euthymic BD individuals differ from healthy controls (HC) and individuals with a history of Major Depressive Disorder (MDD) with respect to the cognitive ER strategies they habitually use (CERQ) in response to negative affect. The sample consisted of 42 bipolar patients, 43 patients with MDD and 39 HC.

RESULTS

Compared to HC, euthymic BD and MDD individuals reported increased use of rumination, catastrophizing, and self-blame alongside decreased use of positive reappraisal, and putting into perspective. No differences were found between BD and MDD groups.

LIMITATIONS

These findings are based on self-reports reflecting the habitual use of ER-strategies. The use of more objective methods and the examination of the spontaneous use of ER-strategies in euthymic BD would be desirable.

CONCLUSIONS

Deficits in the habitual use of ER strategies may characterize BD and MDD individuals even outside of an acute episode and thereby play a role in the recurrence of affective disorders.

The role of psychological factors in bipolar disorder: prospective relationships between cognitive style, coping style and symptom expression

OBJECTIVE

Psychological factors contribute to bipolar disorder illness course, representing targets for psychological intervention. Research to date has focused on bipolar I disorder, extrapolating results to bipolar II disorder. The current study addresses this discrepancy by exploring cognitive and coping styles in patients diagnosed with bipolar I or II disorder.

METHODS

Participants were recruited from the Sydney-based Black Dog Institute. Diagnoses were derived via the MINI International Neuropsychiatric Interview. Baseline cognitive and coping style measures were completed, and mood symptoms assessed over a 6-month period. Clinician-rated mood status was assessed at follow-up to determine the predictive utility of cognitive and coping styles.

RESULTS

The follow-up sample comprised 151 participants. Differential relationships between cognitive style, coping styles and mood symptoms emerged across the bipolar sub-types. Some key differences were that a broader set of negative cognitive styles were associated with bipolar II depression symptoms; while few relationships were observed between coping styles and bipolar II symptoms.

CONCLUSION

Differences in cognitive and coping style relationships with symptom expression across bipolar I and II disorder may provide clinicians with fruitful guides for directing treatment interventions when relevant maladaptive styles are observed. Further exploration of differences in cognitive and coping styles in bipolar I and II disorder is warranted.

Coping profiles in bipolar disorder

OBJECTIVE

As coping responses have the capacity to distinctly influence the illness course in affective disorders, they form targets for psychological intervention. Beneficial effects have been reported for interventions incorporating adaptive coping in bipolar disorder. Identification of differential coping preferences in bipolar disorder sub-types has etiological and clinical implications. As most studies to date have focused exclusively on bipolar I disorder, the current study examines coping profiles in those with a bipolar I or II disorder, contrasted with unipolar depressive and healthy controls.

METHODS

Groups were derived on the basis of agreement between clinician and DSM-IV diagnoses. Participants (94 bipolar I, 114 bipolar II, 109 unipolar recurrent depression, 100 healthy controls) completed coping style measures including the Brief Cope, Responses to Positive Affect questionnaire, Response Styles Questionnaire, the Coping Inventory for Prodromes of Mania, and the Cognitive Emotion Regulation Questionnaire.

RESULTS

Bipolar (I and II) participants were more likely than unipolar participants to ruminate about positive affect, and engage in risk taking when faced with negative affect. Medication status and current mood symptoms influenced risk-taking scores in the bipolar sub-sets, however rumination about positive affect appeared to represent a trait-like response in those with a bipolar II disorder. Behavioral coping strategies differentiated bipolar sub-types, with bipolar II participants being less likely to seek support when faced with stress, and less likely to engage in strategies to down-regulate hypomania.

CONCLUSION

Coping style differences were observed between bipolar sub-types. Further consideration of such differentiating characteristics should serve to direct the focus towards specific targets for clinical intervention, reflecting nuances integral to the differing conditions.

An attentional scope model of rumination

Rumination, defined as repetitive thinking about negative information, has been found to lead to serious maladaptive consequences, including longer and more severe episodes of major depression. In this review, we present and discuss research findings motivated by the formulation that individual differences in cognitive processes that control how information is processed influence the likelihood that thoughts will become repetitive and negative. Several studies have demonstrated that a tendency to ruminate (i.e., trait rumination) is related to difficulties updating working memory (WM) and disengaging from and forgetting no-longer-relevant information. Other investigators have documented that trait rumination is also associated with an enhanced ability to ignore distracting information and with more stable maintenance of task-relevant information. In contrast to trait rumination, a state of rumination has been found to be related to widespread deficits in cognitive control. In this article, we discuss how the current accounts of control functioning cannot explain this pattern of anomalous control functioning. To explain these findings, including unexpected and contradictory results, we present an attentional scope model of rumination that posits that a constricted array of thoughts, percepts, and actions that are activated in WM or available for selection from long-term memory affects the control functioning of trait ruminators. This model explains, at a cognitive level, why rumination is particularly likely to arise when individuals are in a negative mood state; it also accounts for a number of findings outside of the rumination-control literature and generates several novel predictions.

Gender differences in rumination: A meta-analysis

Starting in adolescence and continuing through adulthood, women are twice as likely as men to experience depression. According to the response styles theory (RST), gender differences in depression result, in part, from women's tendency to ruminate more than men. A meta-analysis was performed to evaluate gender differences in rumination in adults (k = 59; N = 14,321); additionally, an analysis of subtypes of rumination - brooding and reflection - was conducted (k = 23). Fixed effects analyses indicated that women scored higher than men in rumination (d = .24, p < .01, SEd = .02), brooding (d = .19, p < .01, SEd = .03) and reflection (d = .17, p < .01, SEd = .03); there was no evidence of heterogeneity or publication bias across studies for these effect sizes. Although statistically significant, the effect sizes for gender differences in rumination were small in magnitude. Results are discussed with respect to the RST and gender differences in depression.

Cognitive regulation of negative affect in schizophrenia and bipolar disorder

Schizophrenia (SZ) and bipolar disorder (BD) exhibit common cognitive deficits that may impede the capacity for self-regulating affect. We examined the use of particular cognitive strategies for regulating negative affect in SZ and BD, and their associations with levels of mood symptomatology. Participants were 126 SZ, 97 BD, and 81 healthy controls (HC) who completed the Cognitive Emotion Regulation Questionnaire (CERQ), the Depression Anxiety Stress Scales (DASS) and the Hypomanic Personality Scale (HPS). Patients with SZ and BD reported more frequent rumination, catastrophising and self-blame, and less use of putting into perspective, relative to HC. Additionally, SZ patients were more likely to engage in other-blame, compared to HC. The most consistent predictors of symptomatology for SZ were self-blame and catastrophising, while for BD were rumination and reduced positive reappraisal. These findings demonstrate maladaptive use of cognitive strategies to self-regulate negative affect in SZ and BD, resembling those reported previously for unipolar depression. The ineffective use of adaptive cognitive reframing strategies in both patient groups may reflect the impact of their shared cognitive deficits, and requires further investigation. Remediation of cognitive capacities contributing to ineffective self-regulation may facilitate reduced mood symptomatology in SZ and BD.

A randomized controlled trial of mindfulness-based cognitive therapy for bipolar disorder

OBJECTIVE

To compare the efficacy of mindfulness-based cognitive therapy (MBCT) plus treatment as usual (TAU) to TAU alone for patients with bipolar disorder over a 12-month follow-up period.

METHOD

Participants with a DSM-IV diagnosis of bipolar disorder were randomly allocated to either MBCT plus TAU or TAU alone. Primary outcome measures were time to recurrence of a DSM-IV major depressive, hypomanic or manic episode; the Montgomery-Åsberg Depression Rating Scale (MADRS); and Young Mania Rating Scale (YMRS). Secondary outcome measures were number of recurrences, the Depression Anxiety Stress Scales (DASS), and the State Trait Anxiety Inventory (STAI).

RESULTS

Ninety-five participants with bipolar disorder were recruited to the study (MBCT = 48; TAU = 47). Intention-to-treat (ITT) analysis found no significant differences between the groups on either time to first recurrence of a mood episode or total number of recurrences over the 12-month period. Furthermore, there were no significant between-group differences on the MADRS or YMRS scales. A significant between-group difference was found in STAI - state anxiety scores. There was a significant treatment by time interaction for the DAS - achievement subscale.

CONCLUSION

While MBCT did not lead to significant reductions in time to depressive or hypo/manic relapse, total number of episodes, or mood symptom severity at 12-month follow-up, there was some evidence for an effect on anxiety symptoms. This finding suggests a potential role of MBCT in reducing anxiety comorbid with bipolar disorder.

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.

A unique emotional processing profile of euthymic bipolar disorder? A critical review

OBJECTIVES

To undertake a critical review of the literature on emotional processing (EP) in bipolar patients in remission. This literature review focuses on a number of dimensions of EP including facial emotion recognition, emotional memory, affective theory of mind (ToM), affective attention and affective auditory information processing.

METHODS

A systematic search was conducted through PsychINFO and Medline databases to obtain relevant literature. Studies that include behavioural measures of EP were included.

RESULTS

The findings from this review demonstrate that bipolar disorder (BD) patients continue to exhibit some EP deficits during euthymic phases. A number of factors believed to contribute to such findings have been highlighted.

CONCLUSIONS

This review has shed light on some of the conflicting findings reported in the literature and thus offers a more comprehensive profile of euthymic bipolar patients' EP abilities. This information could enrich clinicians' therapeutic efforts to minimise relapse by attending to euthymic bipolar patients' specific emotional processing difficulties.

Emotion regulation characteristics and cognitive vulnerabilities interact to predict depressive symptoms in individuals at risk for bipolar disorder: a prospective behavioural high-risk study

Recent work has identified behavioural approach system (BAS) sensitivity as a risk factor for the first onset and recurrence of mood episodes in bipolar disorder, but little work has evaluated risk factors for depression in individuals at risk for, but without a history of, bipolar disorder. The present study evaluated cognitive styles and the emotion-regulatory characteristics of emotional clarity and ruminative brooding as prospective predictors of depressive symptoms in individuals with high versus moderate BAS sensitivity. Three separate regressions indicated that the associations between dysfunctional attitudes, self-criticism, and neediness with prospective increases in depressive symptoms were moderated by emotional clarity and brooding. Whereas brooding interacted with these cognitive styles to exacerbate their impact on depressive symptoms, emotional clarity buffered against their negative impact. These interactions were specific to high-BAS individuals for dysfunctional attitudes, but were found across the full sample for self-criticism and neediness. These results indicate that emotion-regulatory characteristics and cognitive styles may work in conjunction to confer risk for and resilience against depression, and that some of these relationships may be specific to individuals at risk for bipolar disorder.

Responses to positive affect predict mood symptoms in children under conditions of stress: a prospective study

Rumination to negative affect has been linked to the onset and maintenance of mood disorders in adults as well as children. Responses to positive affect have received far less attention thus far. A few recent studies in adults suggest that responses to positive affect are involved in the development of both depressive and hypomanic symptoms, but thus far no study has investigated their role in childhood mood problems. The purpose of the present study was to validate a child version of the Responses to Positive Affect questionnaire and examine the extent to which responses to positive affect prospectively predict mood symptoms over a 3-month interval. The Responses to Positive Affect questionnaire for Children was found to assess two types of responses to positive affect: Positive Rumination and Dampening. Both subscales showed sufficient internal consistency and moderate stability over a 3-month interval. Low levels of positive rumination and high levels of dampening were concurrently associated with depressive symptoms, over and above responses to negative affect. Importantly, low levels of positive rumination also predicted increases in depressive symptoms over a 3-month interval over and above baseline symptoms in children reporting high levels of stress. Both positive rumination and dampening were positively related to concurrent hypomanic symptoms and high levels of positive rumination predicted increases in hypomanic symptoms over a 3-month interval over and above baseline symptoms in children reporting high levels of stress. The results underscore the added value of assessing responses to positive affect in addition to responses to negative affect.

Cognitive vulnerability to depression: an exploration of dysfunctional attitudes and ruminative response styles in the United Arab Emirates

BACKGROUND

There has been little exploration of Beck's cognitive theory of depression and Nolen-Hoeksem's response styles theory within Arab populations.

OBJECTIVES

The study investigates the generalizability of these clinically influential models to Emirati citizens residing within United Arab Emirates (UAE).

METHOD

An opportunity sample of 450 undergraduate participants was assessed for dysfunctional attitudes using an Arabic/English 40-item version of Weissman and Beck's Dysfunctional Attitudes Scale (DAS). Participants also completed Arabic/English versions of Nolen-Hoeksema's ruminative response styles (RRS) scale and the Beck Depression Inventory-II (BDI-II).

RESULTS

Correlation and regression analyses showed depression to be associated with both RRS and dysfunctional attitudes.

CONCLUSION

The study supports the generalization of these clinically influential theories of depression within a UAE context.