Increases in manic symptoms after life events involving goal attainment

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION/CONCLUSION

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

Mania Following Bereavement: State of the Art and Clinical Evidence

Bereavement is the state of loss, determined in most of the cases by the death of a close person. It is probably the greatest sorrow that can occur in an individual life. Grief is a normal, healthy response to loss, evolving through stages in the process of mourning. In some cases, bereavement may lead to the outburst of manic episode: despite literature data being scarce, reports have explored this important clinical entity, variously called as "funeral mania" or "bereavement mania". We systematically reviewed the literature exploring the possible relationships between bereavement and the onset of a manic episode, both first or recurrent pre-existing episode, besides describing a case report on a manic episode in the aftermath of a loss event, with an accurate evaluation of prior mild mood spectrum instability, supporting the role of loss-events as potential risk factor for bipolar illness progression. This article tries summarizing existing evidence on the debate whether clinicians should consider mania as a possible bereavement reaction.

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.

The Behavioral Approach System (BAS) Model of Vulnerability to Bipolar Disorder: Evidence of a Continuum in BAS Sensitivity across Adolescence

Behavioral Approach System (BAS) sensitivity has been implicated in the development of a variety of different psychiatric disorders. Prominent among these in the empirical literature are bipolar spectrum disorders (BSDs). Given that adolescence represents a critical developmental stage of risk for the onset of BSDs, it is important to clarify the latent structure of BAS sensitivity in this period of development. A statistical approach especially well-suited for delineating the latent structure of BAS sensitivity is taxometric analysis, which is designed to evaluate whether the latent structure of a construct is taxonic (i.e., categorical) or dimensional (i.e., continuous) in nature. The current study applied three mathematically non-redundant taxometric procedures (i.e., MAMBAC, MAXEIG, and L-Mode) to a large community sample of adolescents (n = 12,494) who completed two separate measures of BAS sensitivity: the BIS/BAS Scales Carver and White (Journal of Personality and Social Psychology, 67, 319-333. 1994) and the Sensitivity to Reward and Sensitivity to Punishment Questionnaire (Torrubia et al. Personality and Individual Differences, 31, 837-862. 2001). Given the significant developmental changes in reward sensitivity that occur across adolescence, the current investigation aimed to provide a fine-grained evaluation of the data by performing taxometric analyses at an age-by-age level (14-19 years; n for each age ≥ 883). Results derived from taxometric procedures, across all ages tested, were highly consistent, providing strong evidence that BAS sensitivity is best conceptualized as dimensional in nature. Thus, the findings suggest that BAS-related vulnerability to BSDs exists along a continuum of severity, with no natural cut-point qualitatively differentiating high- and low-risk adolescents. Clinical and research implications for the assessment of BSD-related vulnerability are discussed.

Electrocardiographic and Electrooculographic Responses to External Emotions and Their Transitions in Bipolar I and II Disorders

Bipolar disorder has two main types, bipolar I (BD I) and II (BD II), which present different affective states and personality characteristics, they might present different modes of emotional regulation. We hypothesized that the electrocardiogram and electrooculogram to external emotions are different in BD I and BD II. We asked 69 BD I and 54 BD II patients, and 139 healthy volunteers to undergo these tests in response to disgust, erotica, fear, happiness, neutral, and sadness, and their transitions. Their affective states were also measured. The heart rate in BD I was significantly higher under background fear after target neutral. The eyeball movement was quicker in BD I under target happiness after background disgust; in BD I under target sadness after background disgust; and in BD I under background disgust after target neutral. Some electrocardiographic and electrooculographic changes were correlated with affective states in patients. BD I and BD II had different physiological responses to external emotions and their transitions, indicating different pathophysiologies and suggesting different emotional-therapies for BD I and BD II.

Schizophrenia: Reaction to Positive Life Events

Negative life events can exacerbate symptoms in schizophrenia, but there is no literature on the effect on psychotic symptoms of positive life events. The purpose of this review was to scan the literature that studies how the joy that accompanies positive life events can be dampened and dismissed or, alternatively, savored and maintained, and how this contrast applies to schizophrenia. A literature search elicited 53 articles relevant to schizophrenia. Schizophrenia was found to be linked with difficulties in the processing of reward, in feeling that one was deserving of a reward, in sharing news of positive events, in knowing with whom to share, in knowing how to elicit a positive response from listeners when communicating good news, and in ensuring that positive feelings endure. There was no evidence that positive life events reduce psychosis symptoms but teaching the various skills of how to capitalize on good fortune can nevertheless improve the quality of life of individuals with schizophrenia.

Eye Tracking of Attention to Emotion in Bipolar I Disorder: Links to Emotion Regulation and Anxiety Comorbidity

Research has yielded mixed findings regarding whether bipolar disorder is related to attentional bias for emotionally-relevant stimuli, yet little research has utilized advances in eye-tracking technology to study attention in this population. The current study used a free-viewing eye-tracking paradigm to test whether people with remitted bipolar disorder show preferential attention to positive faces, and to test if comorbid anxiety or emotion regulation strategies are related to attention bias. Twenty-nine adults with bipolar I disorder and 28 control participants viewed images of emotionally valenced faces while their gaze was tracked, and participants completed self-report measures of emotion regulation. Contrary to hypotheses, people with bipolar disorder did not differ from control participants in attention to positive stimuli, and both anxiety comorbidity and emotion regulation were unrelated to attentional indices. Unlike some findings in unipolar depression, these results suggest that attention to valenced faces may not be characteristic of remitted bipolar disorder.

Assessment and Treatment of Bipolar Spectrum Disorders in Emerging Adulthood: Applying the Behavioral Approach System Hypersensitivity Model

Bipolar disorder is associated with a host of negative physical and interpersonal outcomes including suicide. Emerging adulthood is an age of risk for the onset of bipolar spectrum disorders (BSD) and there has been increased effort to focus on early identification and subsequent intervention for BSDs during this developmental period. Recent research on the behavioral approach system (BAS) hypersensitivity model of bipolar disorder may have implications for the assessment and treatment of BSD in emerging adulthood. We summarize relevant findings on the BAS hypersensitivity model that support the use of reward sensitivity in the early identification of BSDs and suggest evidence-based strategies for clinical work with emerging adults with bipolar spectrum disorders.

Spontaneous Eye-Blink Rate as an Index of Reward Responsivity: Validation and Links to Bipolar Disorder

Extensive research supports the role of striatal dopamine in pursuing and responding to reward, and that eye-blink rate is a valid indicator of striatal dopamine. This study tested whether phasic changes in blink rate could provide an index of reward pursuit. This hypothesis was tested in people with bipolar I disorder (BD; a population with aberrations in reward responsivity), and in those without BD. Thirty-one adults with BD and 28 control participants completed a laboratory task involving effort towards monetary reward. Blink rate was recorded using eye-tracking at baseline, reward anticipation, and post-reward. Those in the BD group completed self-report measures relating to reward and ambition. Results showed that across all participants, blink rates increased from reward anticipation to post-reward. In the BD group, reward-relevant measures were strongly correlated with variation in blink rate. These findings provide validation for phasic changes in blink rate as an index of reward response.

Adjunctive Behavioral Activation for the Treatment of Bipolar Depression: A Proof of Concept Trial

BACKGROUND

Grounded in a model focused on exposure to response-contingent positive reinforcement, and with evidence supporting its acute treatment effects for unipolar depression, an adjunctive behavioral activation (BA) intervention may be especially well suited to the treatment of bipolar depression. The goal of this study was to modify BA for the adjunctive treatment of bipolar depression and to pilot it in a proof of concept trial to assess its preliminary feasibility and acceptability for this population.

METHODS

Twelve adults with bipolar depression were recruited from hospital settings and enrolled in a 20-week open trial of the modified BA, delivered in 16 outpatient sessions, as an adjunct to community pharmacotherapy for bipolar disorder. Symptom severity was assessed at pretreatment and posttreatment by an independent evaluator. Patient satisfaction was also assessed posttreatment.

RESULTS

Feasibility and acceptability were high, with 10 of 12 patients completing treatment, an average of 14.8 (SD=5.2) of 16 sessions attended, and high levels of self-reported treatment satisfaction. Patients exhibited statistically significant improvement from pretreatment to posttreatment on measures of depressive symptoms, manic symptoms, and severity of suicidal ideation.

CONCLUSIONS

Although preliminary and requiring replication in a larger sample, these study data suggest that a modified BA intervention may offer promise as an adjunctive approach for the acute treatment of bipolar depression. Future studies that use more rigorous randomized controlled designs and that directly assess potential mechanisms of action are recommended.

Emotion in bipolar I disorder: Implications for functional and symptom outcomes

Despite the centrality of emotion disturbance in neurobiological models of bipolar disorder, the behavioral literature has not yet clearly identified the most central aspects of emotion disturbance in bipolar disorder. Toward this aim, we gathered a battery of emotion-related measures in 67 persons diagnosed with bipolar I disorder as assessed with the SCID and a well-matched control group of 58 persons without a history of mood disorders. Those with bipolar disorder were interviewed monthly until they achieved remission, and then tested on emotion measures. A subset of 36 participants with bipolar disorder completed symptom severity interviews at 12-month follow-up. Factor analyses indicated 4 emotion factor scores: Negative Emotion, Positive Emotion, Reappraisal, and Suppression. Bivariate analyses suggested that bipolar disorder was tied to a host of emotion disturbances, but multivariate analyses suggested that bipolar disorder was particularly tied to elevations of Negative Emotion. High Negative Emotion, low Positive Emotion, and high Suppression were conjointly related to lower functioning. Reappraisal predicted declines in depression over time for those with bipolar disorder. Findings highlight the importance of considering the overall profile of emotion disturbance in bipolar disorder. Emotion and emotion regulation appear central to a broad range of outcomes in bipolar disorder.

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.

Elevated reward-related neural activation as a unique biological marker of bipolar disorder: assessment and treatment implications

Growing evidence indicates that risk for bipolar disorder is characterized by elevated activation in a fronto-striatal reward neural circuit involving the ventral striatum and orbitofrontal cortex, among other regions. It is proposed that individuals with abnormally elevated reward-related neural activation are at risk for experiencing an excessive increase in approach-related motivation during life events involving rewards or goal striving and attainment. In the extreme, this increase in motivation is reflected in hypomanic/manic symptoms. By contrast, unipolar depression (without a history of hypomania/mania) is characterized by decreased reward responsivity and decreased reward-related neural activation. Collectively, this suggests that risk for bipolar disorder and unipolar depression are characterized by distinct and opposite profiles of reward processing and reward-related neural activation. The objective of the present paper is threefold. First, we review the literature on reward processing and reward-related neural activation in bipolar disorder, and in particular risk for hypomania/mania. Second, we propose that reward-related neural activation reflects a biological marker of differential risk for bipolar disorder versus unipolar depression that may help facilitate psychiatric assessment and differential diagnosis. We also discuss, however, the challenges to using neuroscience techniques and biological markers in a clinical setting for assessment and diagnostic purposes. Lastly, we address the pharmacological and psychosocial treatment implications of research on reward-related neural activation in bipolar disorder.

Reward dysregulation and mood symptoms in an adolescent outpatient sample

Research on bipolar spectrum disorders (BPSD) in adolescence has burgeoned in the last decade, but continued work is needed to identify endophenotypic markers associated with illness onset and course. The present study examined reward dysregulation--measured via the behavioral activation system (BAS)--as one putative marker of BPSD in adolescence. A diverse group of 425 outpatient adolescents between 11 and 17 years of age (52 % male) completed the Behavioral Inhibition and Activation Scale (BIS-BAS) scale to measure reward dysregulation. Semi-structured interviews determined diagnoses and severity of mood symptoms. Parent-reported BAS was associated with increased symptoms of mania, and parent and adolescent-reported BAS were associated with symptoms of depression. Parent-reported BIS scores were associated with increased symptoms of mania. Results held independent of diagnostic status. Furthermore, parent BIS/BAS reports were stronger predictors for manic symptoms compared to adolescent-reports. Results extend work in adults with BPSD, suggesting a transdiagnostic association between reward dysregulation and mood symptom severity in adolescence.

How assess drugs in the treatment of acute bipolar mania?

Bipolar affective disorder is a serious mental disease associated with significant morbidity and mortality. Good-quality research available to guide treatment strategies remains insufficient, particularly with regard to manic or hypomanic episodes. A critical review of the various stages of mania might be helpful for pharmaceutical companies and investigators as a prerequisite for the clinical evaluation of potential antimanic properties of medications. The main difficulty is with a comparison between anticonvulsants, antipsychotics, and mood stabilizers such as lithium (with equal efficacy in the acute phase and the prevention of recurrent manic episodes). No consensus has been reached with regard to the treatment of bouts of acute mania in various parts of the world. Controlled clinical trials have, at last, provided irrefutable evidence of the activity of lithium, which has long been used alone, as well as that of divalproate or its derivatives and, to a lesser extent, carbamazepine. The new antipsychotic agents have more recently established their efficacy, especially aripiprazole, asenapine, quetiapine; olanzapine, risperidone, and ziprasidone (not sure where the paradox is). In Europe, haloperidol is still the reference substance used in clinical trials despite the fact that it is not officially indicated in the treatment of mania. In the USA, lithium, divalproate, or antipsychotics can be prescribed as first-line treatment. In Europe, lithium remains the first-line medication, whereas divalproate and atypical antipsychotic agents are used only as second-line therapy. Although both types of medication (antipsychotics, normothymic agents, and/or anticonvulsants) have proved to be clinically effective in the management of mania by reducing the mania scores overall, the same does not apply, however, to all symptoms of mania. Factorial approaches to mania have all shown that since there are several clinical forms of mania, several clusters of manic symptoms can be identified. Antipsychotic and normothymic agents and/or anticonvulsants do not appear to have the same effects on each of these identifiable clusters of symptoms, mainly psychotic features. We believe that it is vitally important for future clinical trials of mania treatment to focus on the treatment effect by adopting a factorial approach to characterization of the episode using an appropriate methodological structure. These questions highlight the uncertainty shrouding the very structure of manic episodes, namely that these are predominantly of a thymic or psychotic nature. The Europeans undoubtedly consider mania to be more of a thymic episode and prefer lithium as the first-line treatment, whereas the Americans believe that psychotic symptoms dominate and widely prescribe antipsychotic agents. However, from the standpoint of clinical trials currently available, even though antipsychotic agents are certainly effective in reducing the scores on the mania scales, it is not clear whether they can be considered purely as antimania treatments.

Family influences on mania-relevant cognitions and beliefs: a cognitive model of mania and reward

OBJECTIVE

The present study proposed and tested a cognitive model of mania and reward.

METHOD

Undergraduates (N = 284; 68.4% female; mean age = 20.99 years, standard deviation ± 3.37) completed measures of family goal setting and achievement values, personal reward-related beliefs, cognitive symptoms of mania, and risk for mania.

RESULTS

Correlational analyses and structural equation modeling supported two distinct, but related facets of mania-relevant cognition: stably present reward-related beliefs and state-dependent cognitive symptoms in response to success and positive emotion. Results also indicated that family emphasis on achievement and highly ambitious extrinsic goals were associated with these mania-relevant cognitions. Finally, controlling for other factors, cognitive symptoms in response to success and positive emotion were uniquely associated with lifetime propensity towards mania symptoms.

CONCLUSIONS

Results support the merit of distinguishing between facets of mania-relevant cognition and the importance of the family in shaping both aspects of cognition.

Positive overgeneralization and Behavioral Approach System (BAS) sensitivity interact to predict prospective increases in hypomanic symptoms: a behavioral high-risk design

Recent work has identified Behavioral 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 the prospective development of hypomanic symptoms in individuals at risk for, but without a history of, bipolar disorder. The present study used a prospective behavioral high-risk design to evaluate the impact of positive overgeneralization, a cognitive correlate of risk for hypomania, on hypomanic symptoms in individuals with high vs. moderate BAS sensitivity, but without a history of mood elevation. Hierarchical linear regressions indicated that upward positive overgeneralization and BAS sensitivity interacted to predict increased levels of hypomanic symptoms at follow-up, controlling for initial hypomanic symptoms. The pattern of this interaction was such that positive overgeneralization predicted higher levels of hypomanic symptoms among high-BAS, but not moderate-BAS, individuals. Thus, the self-reported tendency to experience grandiose increases in confidence following success may confer additional risk for mood elevation among individuals already at risk for developing bipolar disorder. Potential implications for prevention and treatment are discussed.

Cognitive reactivity to success and failure relate uniquely to manic and depression tendencies and combine in bipolar tendencies

The present study examined simultaneously the relations between cognitive reactivity to success and failure, on the one hand, and depression, manic, and bipolar tendencies, on the other hand. Participants (161 students) completed measures of success and failure reactivity, current manic and depressive symptoms, and tendencies towards depression, mania, and bipolarity. Results showed that respondents with a greater tendency towards depression evidenced greater (negative) reactivity to failure, whereas those with a greater tendency toward mania evidenced greater (positive) reactivity to success. Depression vulnerability was unrelated to success reactivity, and manic vulnerability was unrelated to failure reactivity. Tendencies toward bipolarity correlated significantly with both failure and success reactivity in a negative and positive manner, respectively. These findings add to the growing body of literature, suggesting that different features or cognitive tendencies are related to depression vulnerability versus manic vulnerability and imply that these "mirrored" cognitive features both form part of vulnerability to bipolar disorder.

The behavioral activation system and mania

For over two decades, theorists have suggested that mania relates to heightened sensitivity of the behavioral activation system (BAS). In this article, we review a burgeoning empirical literature on this model, drawing on both cross-sectional and prospective studies. As evidence has emerged for this model, we argue that it is time to consider more specific aspects of BAS sensitivity in this disorder. We review evidence that bipolar disorder relates to an increased willingness to expend effort toward reward and to increases in energy and goal pursuit after an initial reward. We conclude by considering the strengths and weaknesses of this literature, with an eye toward future directions and implications for treatment.

High Behavioral Approach System (BAS) sensitivity, reward responsiveness, and goal-striving predict first onset of bipolar spectrum disorders: a prospective behavioral high-risk design

A prospective, behavioral high-risk design provided a theoretically guided examination of vulnerability to first onset of bipolar spectrum disorder based on the Behavioral Approach System (BAS) model. Adolescents (ages 14-19) at an "age of risk" for bipolar disorder onset were screened on BAS sensitivity by interviewers blind to current symptoms, lifetime history, and family history of psychopathology. Participants were selected with high versus moderate levels of BAS sensitivity and administered a lifetime diagnostic interview. Those with a bipolar spectrum disorder, psychosis, or hypomanic episode with onset prior to the BAS sensitivity assessment were excluded. High BAS (n = 171) and moderate BAS (n = 119) sensitivity participants in the final sample completed baseline measures of symptoms, goal-setting, and reward responsiveness and were followed prospectively with semistructured diagnostic interviews every 6 months. Consistent with the vulnerability hypothesis of the BAS model of bipolar disorder, high BAS participants had a greater likelihood, and shorter time to onset, of bipolar spectrum disorder than moderate BAS participants across an average of 12.8 months of follow-up (12.9% vs. 4.2%), controlling for baseline depressive and hypomanic symptoms, and family history of bipolar disorder. High reward responsiveness on a behavioral task and ambitious goal-striving for popular fame and financial success (but not impulsivity) also predicted first onset of bipolar spectrum disorder controlling for the covariates and BAS risk group, and ambitious goal-striving partially mediated the BAS risk group effect. We discuss implications of the findings for the BAS model of bipolar disorder and early intervention efforts.

High Behavioral Approach System (BAS) sensitivity, reward responsiveness, and goal-striving predict first onset of bipolar spectrum disorders: a prospective behavioral high-risk design

A prospective, behavioral high-risk design provided a theoretically guided examination of vulnerability to first onset of bipolar spectrum disorder based on the Behavioral Approach System (BAS) model. Adolescents (ages 14-19) at an "age of risk" for bipolar disorder onset were screened on BAS sensitivity by interviewers blind to current symptoms, lifetime history, and family history of psychopathology. Participants were selected with high versus moderate levels of BAS sensitivity and administered a lifetime diagnostic interview. Those with a bipolar spectrum disorder, psychosis, or hypomanic episode with onset prior to the BAS sensitivity assessment were excluded. High BAS (n = 171) and moderate BAS (n = 119) sensitivity participants in the final sample completed baseline measures of symptoms, goal-setting, and reward responsiveness and were followed prospectively with semistructured diagnostic interviews every 6 months. Consistent with the vulnerability hypothesis of the BAS model of bipolar disorder, high BAS participants had a greater likelihood, and shorter time to onset, of bipolar spectrum disorder than moderate BAS participants across an average of 12.8 months of follow-up (12.9% vs. 4.2%), controlling for baseline depressive and hypomanic symptoms, and family history of bipolar disorder. High reward responsiveness on a behavioral task and ambitious goal-striving for popular fame and financial success (but not impulsivity) also predicted first onset of bipolar spectrum disorder controlling for the covariates and BAS risk group, and ambitious goal-striving partially mediated the BAS risk group effect. We discuss implications of the findings for the BAS model of bipolar disorder and early intervention efforts.

Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories

Most life stress literature in bipolar disorder (BD) fails to account for the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. According to Post's (1992) influential kindling hypothesis, major life stress is required to trigger initial onsets and recurrences of affective episodes, but successive episodes become progressively less tied to stressors and may eventually occur autonomously. Subsequent research on kindling has largely focused on unipolar depression (UD), and the model has been tested in imprecise and inconsistent ways. The aim of the present paper is to evaluate evidence for the kindling model as it applies to BD. We first outline the origins of the hypothesis, the evidence for the model in UD, and the issues needing further clarification. Next, we review the extant literature on the changing relationship between life stress and bipolar illness over time, and find that evidence from the methodologically strongest studies is inconsistent with the kindling hypothesis. We then integrate this existing body of research with two emerging biopsychosocial models of BD: the Behavioral Approach System dysregulation model, and the circadian and social rhythm theory. Finally, we present therapeutic implications and suggestions for future research.

Thought suppression in patients with bipolar disorder

Suppression of negative thoughts has been observed under experimental conditions among patients with major depressive disorder (MDD) but has never been examined among patients with bipolar disorder (BD). Patients with BD (n = 36), patients with MDD (n = 20), and healthy controls (n = 20) completed a task that required unscrambling 6-word strings into 5-word sentences, leaving out 1 word. The extra word allowed the sentences to be completed in a negative, neutral, or “hyperpositive” (manic/goal-oriented) way. Participants completed the sentences under conditions of cognitive load (rehearsing a 6-digit number), reward (a bell tone), load and reward, or neither load nor reward. We hypothesized that patients with BD would engage in more active suppression of negative and hyperpositive thoughts than would controls, as revealed by their unscrambling more word strings into negative or hyperpositive sentences. Under conditions of load or reward and in the absence of either load or reward, patients with BD unscrambled more negative sentences than did controls. Under conditions of reward, patients with BD unscrambled more negative sentences than did patients with MDD. Patients with BD also reported more use of negative thought suppression than did controls. These group differences in negative biases were no longer significant when current mood states were controlled. Finally, the groups did not differ in the proportion of hyperpositive sentence completions in any condition. Thought suppression may provide a critical locus for psychological interventions in BD.

The clinical significance of creativity in bipolar disorder

Clinical implications of the high rates of creativity within bipolar disorder (BD) have not been explored. The aim of this review is to outline these implications by (i) reviewing evidence for the link between creativity and BD, (ii) developing a provisional model of mechanisms underpinning the creativity-BD link, (iii) describing unique challenges faced by creative-BD populations, and (iv) systematically considering evidence-based psychosocial treatments in the light of this review. While more research into the creativity-BD nexus is urgently required, treatment outcomes will benefit from consideration of this commonly occurring phenotype.

Cognitive correlates of mania risk: are responses to success, positive moods, and manic symptoms distinct or overlapping?

Several measures of cognitive style have been shown to be elevated among persons diagnosed with bipolar disorder and those at risk for bipolar disorder. Several of these scales capture responses to positive affect, success, and hypomanic symptoms. We had two goals: (a) to use factor analyses to assess whether the constructs within these scales were statistically independent and (b) to examine whether the factors identified uniquely related to mania risk. A cross-national sample of 638 participants completed measures of cognitive style, including the Responses to Positive Affect scale, the Positive Overgeneralization Scale, and the Hypomanic Interpretations Questionnaire. To assess whether these measures might simply reflect more impulsive reactions to positive mood states, participants also completed the Barratt Impulsivity Scale. To measure risk of mania, participants completed the Hypomanic Personality Scale (HPS). Factor analyses suggested seven factors of cognitive style and impulsivity. Four factors uniquely correlated with HPS. That is, risk for mania related to higher scores on separable factors of acting before thinking, being overly positive in interpreting manic symptoms, being overly confident in response to success, and tendencies to dampen positive affect. Current findings suggest the need to consider multifaceted aspects of cognition in refining psychological treatments of bipolar disorder.

On the Role of Goal Dysregulation in the Treatment of Bipolar Disorder

Nusslock, Abramson, Harmon-Jones, Alloy, and Coan (this issue) propose that current psychosocial treatments for bipolar disorder be supplemented with interventions focused on altering goal dysregulation pathways. While innovations to existing treatment manuals are always welcome, there are several reasons why this suggestion may require further consideration. We highlight issues pertaining to the status of cognitive-behavioral therapy for bipolar disorder, the distinction between education and psychoeducation, the nature of familial expressed emotion, differences between clinical and analog samples, and the larger question of how to assess mechanisms in psychosocial treatment studies. We also raise the question of whether an optimistic goal orientation can be a protective factor in patients' long-term coping with bipolar disorder.

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

Bipolar disorders and substance use disorders (SUDs) show high co-occurrence. One explanation for this co-occurrence may be common personality vulnerabilities involved in both. The authors tested whether high behavioral approach system (BAS) sensitivity and impulsiveness are shared personality vulnerabilities in bipolar spectrum disorders and substance use problems and their co-occurrence in a longitudinal study of 132 individuals on the bipolar spectrum and 153 control participants. At Time 1, participants completed the Behavioral Inhibition System/BAS Scales and the Impulsive Nonconformity Scale. Substance use problems were assessed via the Michigan Alcoholism Screening Test and the Drug Abuse Screening Test at 4-month intervals for 1 year. Participants with bipolar disorder had higher rates of lifetime SUDs and substance use problems during the follow-up, relative to control participants. In line with hypotheses, higher BAS sensitivity and impulsiveness predicted bipolar status and increased substance use problems prospectively. BAS total, BAS Fun Seeking, and impulsiveness mediated the association between bipolar spectrum status and prospective substance use problems, with impulsiveness as the most important mediator. High BAS sensitivity and impulsiveness may represent shared personality vulnerabilities for both disorders and may partially account for their co-occurrence.

Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions

This article reviews the role of social factors, notably life events and family relationships, in the course of bipolar illness in adults and youth. We also discuss psychological variables that help explain the vulnerability of bipolar patients to social environments, including personality factors (e.g., neuroticism), reward sensitivity, and difficulty with the accurate perception of facial emotions. Bipolar patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment events may be one pathway to mania. Negative life events predict depressive symptoms, as do levels of familial expressed emotion. Psychosocial interventions can speed recoveries from episodes and delay recurrences over 1-2 year intervals. Future research should examine the nature of vulnerability/stress interactions at different phases of development, and the role of psychosocial interventions in altering these processes.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.

Development of the treatment attitudes questionnaire in bipolar disorder

Despite the success of pharmacotherapy in the management of bipolar disorder, as many as one-half of those in treatment discontinue their medication over time. Currently, no self-report measure is available that predicts treatment engagement in bipolar disorder. The goal of the current study was to develop a measure of awareness of symptoms and attitudes toward treatment among those with bipolar disorder. Sixty-six participants diagnosed with bipolar I disorder on the SCID completed the Treatment Attitudes Questionnaire (TAQ) and were then followed for up to 2 years to assess symptom levels. Medication data were available for 37 participants. Analyses of the TAQ were conducted to examine reliability, predictors of subscales, and how well scores predicted medication and symptom levels over time. Results indicate that previous episodes of depression, but not episodes of mania, correlated with increased scores on the Insight and the Enjoyment of Mania subscales. Scores on the Nonbiological Attributions subscale predicted lower levels of lithium as well as increased depressive symptoms over time. Although the current study includes limited measurement of treatment engagement and a small sample size, this easily administered scale may help treatment planning for those with bipolar disorder.

Cognitive responses to failure and success relate uniquely to bipolar depression versus mania

This project examined cognitive responses to failure and success and their association with depression and mania within bipolar disorder. Many cognitive variables that are associated with unipolar depression have been found to be involved in bipolar disorder, more specifically bipolar depression. This research was the first to examine tendencies to hold high standards, engage in self-criticism, and generalize from failure to an overall sense of self-worth. In Study 1, undergraduates were screened for risk of mood disorders and completed structured diagnostic interviews. History of bipolar spectrum disorders and history of depression had separate associations with negative generalization. The association of generalization with bipolar spectrum disorders was accounted for by current depressive symptoms. For Study 2, the authors developed a measure of the tendency to engage in positive generalization following success experiences. In a sample of 276 undergraduates, this measure related uniquely to risk for mania. Results of these 2 studies suggest that responses to failure are associated with a history of depression, whereas responses to success are associated with a risk for mania. Implications for future research and clinical work are discussed.

Unique association of approach motivation and mania vulnerability

Bipolar disorder involves experiences of both mania and depression over time, and measures of mania-risk and depression-risk therefore tend to be correlated, making it difficult to disentangle the shared versus unique aspects of mania and depression vulnerability. In theory, strong approach motivation is uniquely linked with mania risk, but this relation tends to be obscured unless co-occurring depression risk is statistically controlled. In this study, 461 college students completed the General Behaviour Inventory (GBI)-a validated questionnaire of bipolar disorder vulnerability-and they reported their degree of approach motivation in response to four vignettes that varied in relative incentive versus threat strength. After controlling for the effect of depression vulnerability, mania vulnerability was associated with approach motivation, particularly in response to more threatening scenarios, and this association remained significant even when controlling for dispositional threat and incentive responsiveness, current symptoms, mood, self-esteem, and optimism. The results are consistent with models that regard heightened approach motivation as a unique aspect of mania vulnerability.

Positive Mood Induction and Facial Affect Recognition among Students at Risk for Mania

Previous research has suggested that bipolar disorder is characterized by a state-dependent decrease in the ability to recognize facial affect during mania. It remains unclear, though, whether people who are only vulnerable to the disorder show these changes in facial affect recognition. It is also unclear whether minor shifts in mood affect the recognition of facial emotion. Thus, this study examined the effects of positive mood induction on the facial affect recognition of undergraduates vulnerable to mania. Fifty-two undergraduates completed the Hypomanic Personality Scale, and also completed a measure of their ability to recognize affect in pictures of faces. After receiving false success feedback on another task to induce a positive mood, they completed the facial affect recognition measure again. Although we expected to find a relationship between higher Hypomanic Personality Scale (HPS) scores and an impaired ability to recognize negative facial affect after a positive mood induction, this was not found. Rather, there was a significant interaction between HPS scores and happiness level, such that individuals with higher scores on the HPS who also reported higher levels of happiness were particularly adept at identifying subtle facial expressions of happiness. This finding expands a growing literature linking manic tendencies to sensitivity to positive stimuli and demonstrates that this sensitivity may have bearing on interpersonal interactions.

Extreme Goal Setting and Vulnerability to Mania Among Undiagnosed Young Adults

During euthymia people with bipolar disorder and their unaffected family members accomplish more than the general population. People with bipolar disorder, or those who are at risk for it, also set higher goals in laboratory tasks than other people. The work reported here examines whether persons vulnerable to mania set elevated goals in their lives. In two studies, a measure of lifetime vulnerability to mania was related to traits bearing on incentive sensitivity, and also to endorsement of high ambitions for fame, wealth, and political influence (assessed by a new measure). Relations were weaker to ambitions for other kinds of extreme goals. The effects were independent of current symptoms of mania and depression and lifetime depression. There was also evidence that incentive sensitivity and elevated aspirations made independent contributions to variance in the measure of manic risk. Discussion focuses on the implications of high goal setting for understanding goal dysregulation and mania.

New Psychosocial Interventions for Bipolar Disorder: A Review of Literature and Introduction of the Systematic Treatment Enhancement Program

What is the evidence that psychosocial treatment adds to the efficacy of pharmacotherapy in forestalling episodes of bipolar disorder (BPD)? This article gives the rationale for including psychosocial intervention in the outpatient maintenance of BPD. Attention is placed on 4 psychosocial modalities that have achieved empirical support in randomized trials: family-focused psychoeducational treatment (FFT), cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), and group psychoeducation. FFT, CBT, and IPSRT are being contrasted with a psychosocial control condition in the context of the ongoing, multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The objectives, design, and potential contributions of the STEP-BD study are explained. Future directions for the evaluation and dissemination of manual-based psychosocial interventions are discussed.

Assessing the dysregulation of the Behavioral Activation System: the Hypomanic Personality Scale and the BIS-BAS scales

We discuss the Hypomanic Personality Scale (Hyp; Eckblad & Chapman, 1986) and the Behavioral Inhibition System (BIS-BAS; Carver & White, 1994) and Behavioral Activation System (BAS; Gray, 1991) Scales as risk factors for bipolar disorders. The dysregulation of the BAS is considered to be central and results in higher variability in mood. Therefore, we examined how those scales are associated with mood fluctuations. A total of 59 participants completed a diary for at least 17 days. It included a modified Center for Epidemiologic Studies-Depression Scale (Meyer & Hautzinger, 2001) assessing depression and mania and the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988). Hyp and BAS predicted levels of mania and of positive affect but also fluctuations of mania. Hyp also predicted instability of negative affect. Our data also suggest that mood variability is a trait-like feature. Both scales seem not to be perfect measures of the dysregulation factor. Future research should assess this dysregulation more directly.

The psychopathology and treatment of bipolar disorder

In this chapter we review research on the diagnosis, course, etiology, and pharmacological and psychosocial treatment of bipolar disorder (BD). BD is a highly recurrent and severe illness, with high rates of suicidality and functional impairment. The disorder is heritable and appears to share susceptibility genes with schizophrenia. It is characterized by dysregulation in the dopamine and serotonin systems and by pathology in the brain systems involved in regulating emotion. Psychosocial stressors, notably life events and familial expressed emotion, significantly influence the course of the illness in the context of these vulnerabilities. Findings of randomized clinical trials indicate that psychosocial interventions enhance long-term outcomes when added to pharmacotherapy. Much remains to be clarified about the interactive contributions of genetic, neurobiological, and psychosocial factors to the course of the disorder, and the moderators and mediators of treatment effects.

Negative Cognitions Predict the Course of Bipolar Depression, Not Mania

Cognitive interventions for bipolar disorder have received increased attention, but very few prospective studies have focused on whether cognitive variables predict the course of bipolar disorder. Available studies have yielded conflicting results concerning the effects of negative cognitions on mania. In this study, 60 individuals with bipolar I disorder completed monthly symptom severity interviews. At a 6-month follow-up, they completed the Dysfunctional Attitudes Scale, the Negative Automatic Thoughts Questionnaire, and the Positive Automatic Thoughts Questionnaire. Participants then completed monthly symptom severity interviews for another 6 months. Cognitive scales were correlated with current depression and predicted increases in depression over time, but were not related to mania. Although results do not support negative cognitions as a predictor of mania, they do provide support for the increasingly common use of cognitive interventions to treat bipolar depression.