Hypomania, anxiety and the emotional Stroop

Dynamics of affect, cognition and behavior in a general population sample of adolescents and young adults with current and remitted anxiety disorders: An Ecological Momentary Assessment study

BACKGROUND

Measures of dynamic changes in affect/emotions (variability, instability, inertia) have been linked to anxiety disorders (AD). We examine dynamics in affect, cognition and behavior in youth with current and remitted AD.

METHODS

Mental disorders were assessed in a general population sample (N = 1180, age 14-21; Dresden, Germany) using standardized interview. Ecological Momentary Assessment of real-life affect, cognition and behavior took place eight times/day for four days.

RESULTS

Individuals with current AD (n = 65) compared to healthy controls (HC, n = 531) revealed heightened variability of anxious and manic symptomatology, experiential avoidance, optimism and positive thoughts. Remitted AD (n = 52) showed lower variability of anxious and manic symptomatology and positive thoughts compared to current AD, while no differences were found compared to HC. Current AD and HC differed significantly in instability. Remitted AD showed lower instability of all constructs except for anger than current AD, and higher instability on all constructs except for positive and negative thoughts compared to HC. Current AD showed higher inertia of anger and negative thoughts than HC, and less inertia of positive thoughts than remitted AD.

DISCUSSION

AD in youths is particularly linked to higher variability and instability of intertwined emotion-related experiences that partly persist after remission, informing emotion regulation models and interventions.

How current and past anxiety disorders affect daily life in adolescents and young adults from the general population-An epidemiological study with ecological momentary assessment

BACKGROUND

Prior research indicated, based on retrospective assessments of symptomatology, that 25% of individuals with "remitted" anxiety disorders (AD) experience a relapse. The present study used ecological momentary assessment (EMA) to examine how ADs affect everyday life among community adolescents and young adults with current or remitted AD compared to healthy controls and to each other.

METHODS

Data come from the baseline assessment of the epidemiological Behavior and Mind Health study, conducted in Dresden (Germany) from 11/2015-12/2016. The sub-sample analyzed (n = 648, age 14-21) consisted of 65 participants with current DSM-5 AD-diagnosis, 52 participants with lifetime AD-diagnosis but not within the last 6 months (remitted), and 531 healthy controls (no psychopathology; healthy controls [HC]). EMA of various constructs took place 8 times a day for 4 days.

RESULTS

The highest levels of symptoms were reported by those with current AD, followed by remitted AD and HC. Regression analyses revealed significantly worse mood, self-efficacy, quality of life and sleep-quality and more experiential avoidance, stress, negative thoughts and pessimism in remitted and current AD compared to HC. Current AD additional differed significantly from HC in optimism and positive thoughts. Furthermore, individuals with remitted AD without comorbidities differed significantly from HC on five out of 16 constructs.

CONCLUSION

Not only current but also remitted AD is associated with diverse negative experiences in everyday life, which cannot merely be explained by comorbidities. As the remaining burden and impairment in individuals with remitted AD might contribute to relapse, interventions might be targeted to improve mental health.

A study on attentional bias and response inhibition of facial expressions in manic patients: evidence from eye movement

Introduction: In recent years, evidence has accumulated to suggest that patients with bipolar disorder show altered processing of emotionally relevant information. However, only a few studies have examined manic patients' eye movements when processing facial expressions. Method: A free viewing task and anti-saccade task were used separately to investigate attentional bias and response inhibition while processing emotional stimuli. Data were drawn from matched samples of manic patients (n = 25) and healthy controls (n = 20). Results: The analyses of eye-movement data revealed that there was a significant difference between manic patients and healthy controls in the total duration of fixations but not in the orientation or duration of the first fixation. However, no significant differences between manic patients and healthy controls in response inhibition were detected. Conclusion: These results demonstrate that compared to healthy controls, manic patients show a deficiency in processing speed. The patients showed no attentional vigilance to happy or sad expressions but did showed avoidance of the sad expression and focused more on the happy expression in later emotion processing. There were no impairments of response inhibition detected in manic patients. Key points Abnormal processing of emotional information and having aberrant inner-experiences of emotion is a feature of bipolar disorders. Processing speed is slow in manic patients versus healthy controls. Manic patients focused lesser on sad expression than healthy controls, which suggesting an avoidance of sad expressions. The findings show that psychotherapies like CBT may be applicable to manic patients.

Initial Psychometric Properties of the Korean Altman Self-Rating Mania Scale: Preliminary Validation Study in a Non-Clinical Sample

OBJECTIVE

We aimed to examine the reliability and validity of the Korean Altman Self-Rating Mania Scale (K-ASRM) in a large sample of Korean non-clinical undergraduates.

METHODS

Participants (n=1,091) filled out the K-ASRM with other self-report questionnaires assessing bipolarity, mood symptoms and affect. Reliability test, exploratory factor analysis and correlation analyses were conducted to examine its psychometric properties.

RESULTS

The reliability of the K-ASRM was adequate (Cronbach's α=0.73, item-to-total correlation 0.53-0.78) and the exploratory factor analysis yielded one factor of mania. The K-ASRM demonstrated significant associations with measures of hypomanic personality (r=0.33), lifetime history of hypomanic symptoms (r=0.23). Also, the K-ASRM was significantly correlated with positive affect (r=0.53), negative affect (r=-0.17) and depressive symptoms (r=-0.35).

CONCLUSION

These results suggest preliminary possibility that the K-ASRM can be utilized as self-rating tool for mania in Korea as well as future directions for further validation.

Impaired cognitive control over emotional material in euthymic bipolar disorder

BACKGROUND

Previous research suggests that bipolar disorder (BD) is characterized by deficits in cognitive control (CC). Impaired CC has been found in high-risk samples and is associated with the maintenance of BD symptoms. It remains unclear, however, whether BD is characterized by a general deficit in CC or by a deficit that is specifically related to the processing of emotional material.

METHODS

The sample consisted of 42 remitted bipolar patients and 39 healthy controls (HC). We examined whether BD individuals display impaired CC when confronted with negative as well as positive material using an arithmetic inhibition task that required inhibition of pictorial stimulus material.

RESULTS

Whereas both groups showed difficulties in exerting CC over negative material, only BD individuals exhibited deficient CC over positive material.

LIMITATIONS

Even though we intended the negative and positive pictures in the arithmetic inhibition task to be similarly arousing, participants in the current study rated the negative compared to the positive pictures as more arousing.

CONCLUSIONS

BD is associated with impaired CC when processing emotional - especially positive - stimuli even when patients are in remission. Possible implications of this deficit especially for emotion regulation are discussed.

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.

Automatic processing of emotional stimuli in euthymic patients with bipolar disorder

BACKGROUND

Biased information processing styles are a core feature of cognitive models of unipolar depression (UD). The manic-defence hypothesis (MDH) posits that UD and Bipolar Disorder (BD) are subject partially to the same underlying cognitive processes, which may act as putative vulnerability factors. Previous studies have used experimental paradigms as a way of measuring automatic (non-intentional) processing of emotional information in order to test the MDH with some studies providing some evidence for a negatively biased automatic processing of emotionally-relevant information in BD. However, most prior studies used supraliminal stimuli (i.e. presented above perceptual threshold). Based on the MDH we predicted that subliminally presented negative stimuli will affect performance of patients with BD differently than non-clinical participants, but similarly to what has been observed in prior studies with currently depressed patients.

METHODS

The current study used an affective priming paradigm with both supraliminally and subliminally presented emotional images as primes to measure automatic processing. Seventeen euthymic individuals with a BD diagnosis were recruited along with seventeen non-clinical control participants (NCC) matched for age and gender.

RESULTS

We found interference (increased response times) due to masked, subliminally presented negative primes in patients with BD when negative prime images were followed by negative targets, but decreased response times (facilitation) in NCCs.

LIMITATIONS

We did not include a psychiatric control group and the sample size was small.

CONCLUSION

Our findings suggest that euthymic patients with BD do exhibit an affective bias suggesting an increased sensitivity to negative emotional information even when euthymic.

The role of negative mood induction on working memory capacity in individuals putatively at risk for bipolar disorder: A pilot study

OBJECTIVE

Bipolar disorder (BD) is characterized by cognitive deficits. Usually individuals at risk for BD do not exhibit such deficits but they might be evident under cognitive or emotionally stressful conditions. To our knowledge this is the first study examining working memory capacity under mood induction in individuals at risk for BD.

METHODS

Using the Hypomanic Personality Scale (HPS) 68 participants out of an initial pool of 148 students were divided into groups at high and low risk for BD. They completed twice a Dual Task Paradigm (DTP) task assessed under high and low cognitive load prior to and following a negative mood induction.

RESULTS

As expected stimuli incongruency, high cognitive load and mood induction increased response times. Contrary to our hypothesis the mood induction did not differentially affect at-risk individuals. However, they generally reacted faster to neutral stimuli compared to those at low risk.

CONCLUSIONS

While we replicated former results related to the DTP, we did not find evidence for the hypothesis that individuals putatively at risk for BD will be more affected by negative mood when doing such a cognitive task. Replication using a larger sample is needed which should also examine whether changes in positive mood might more relevant in the context of risk for mania.

Attentional bias in euthymic bipolar I disorder

Little is known about the nature of the relation between information-processing biases and affective traits in bipolar disorder. The present study was designed to investigate whether attentional biases are evident in persons diagnosed with bipolar disorder when they are in a positive mood state, and whether biases are related to indices of emotion regulation and to prior history of mood episodes. Ninety adults diagnosed with bipolar I disorder and 81 controls with no lifetime mood disorder underwent a positive mood induction and then completed an emotion face dot-probe task; participants in the bipolar disorder group also completed a self-report measure of responses to positive affect. Attentional bias was not related to a diagnosis of bipolar disorder or to symptom severity. Consistent with hypotheses, analyses within the bipolar group indicated that greater dampening of positive affect related to significantly less attention paid to the positively valenced faces. Discussion focuses on the potential role of affective traits in shaping attentional bias in bipolar disorder.

[Social cognition in patients with mood disorders. Part II: bipolar disorder : a selective review of the literature]

OBJECTIVE

Overview on the current knowledge regarding social cognition in patients with bipolar disorder.

METHODS

Selective literature research on deficits in social cognition intrinsic to bipolar disorder, their occurrence and effects.

RESULTS

Deficits in social cognition are considered to be core features of bipolar disorder. They are apparent during acute episodes of the disorder, endure when patients are in remission and have a significant negative impact on the patients' psychosocial outcomes.

CONCLUSIONS

It is important to consider deficits in social cognition as an integral part of a treatment approach to achieve mental stabilization in patients with bipolar disorder.

Self-referent information processing in individuals with bipolar spectrum disorders

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Genetic and neurocognitive foundations of emotion abnormalities in bipolar disorder

INTRODUCTION

Bipolar Disorder (BD) is a serious mood disorder, the aetiology of which is still unclear. The disorder is characterised by extreme mood variability in which patients fluctuate between markedly euphoric, irritable, and elevated states to periods of severe depression. The current research literature shows that BD patients demonstrate compromised neurocognitive ability in addition to these mood symptoms. Viable candidate genes implicated in neurocognitive and socioemotional processes may explain the development of these core emotion abnormalities. Additionally, links between faulty neurocognition and impaired socioemotional ability complement genetic explanations of BD pathogenesis. This review examines associations between cognition indexing prefrontal neural regions and socioemotional impairments including emotion processing and regulation. A review of the effect of COMT and TPH2 on these functions is also explored.

METHODS

Major computer databases including PsycINFO, Google Scholar, and Medline were consulted in order to conduct a comprehensive review of the genetic and cognitive literature in BD.

RESULTS

This review determines that COMT and TPH2 genetic variants contribute susceptibility to abnormal prefrontal neurocognitive function which oversees the processing and regulation of emotion. This provides for greater understanding of some of the emotional and cognitive symptoms in BD.

CONCLUSIONS

Current findings in this direction show promise, although the literature is still in its infancy and further empirical research is required to investigate these links explicitly.

Risk for Mania and its Relationship to Implicit and Explicit Achievement Motivation

There is evidence that bipolar disorders are associated with achievement-related cognitions such as setting high goals. A psychodynamic model, the manic defense hypothesis, postulates that a threat to fragile self-esteem triggers grandiosity and manic behaviors in vulnerable people. Vulnerability to bipolar disorders should therefore be positively associated with indicators of explicit hope of success (HS) and implicit fear of failure (FF). Using an online sample (n = 252), we tested these hypotheses using the well-validated Hypomanic Personality Scale as risk indicator for mania, the Multi-Motive Grid for achievement motivation, controlling for current and lifetime depression. Contrary to expectations, we found that vulnerability for mania was significantly and positively related to implicit HS but not to FF after controlling for depression. All measures were self-report tools. Our results contradict the Manic Defense Hypothesis, but they are in line with the idea that achievement-related cognitions are of relevance to vulnerability in bipolar disorders. This is in line with research focusing on the role of the Behavioral Activation System in relation to vulnerability for mania.

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

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

Cognitive styles in hypomanic episodes of bipolar I disorder

OBJECTIVES

Cognitive vulnerability-stress theories have recently been extended to bipolar disorder by suggesting that an activation of negative cognition might lead to depressive mood episodes and an activation of positive cognition might lead to manic mood episodes. Alternatively, the manic defense hypothesis claims that hypomanic and manic states are not the opposite of depression but rather contain similar underlying negative cognitions. The objective of this study was to further evaluate these theories by examining the cognitive patterns in bipolar I hypomania.

METHODS

We compared 15 hypomanic bipolar I disorder patients, 26 remitted bipolar I disorder patients, and 21 healthy individuals in a cross-sectional study. All participants completed the Dysfunctional Attitude Scale, the Attributional Style Questionnaire, the Emotional Stroop Task, and the Emotional Auditory Verbal Learning Test.

RESULTS

Hypomanic bipolar disorder individuals showed cognitions associated with depressive states as well as cognitions associated with manic states. The results for the remitted bipolar disorder patients paralleled those for the control group.

CONCLUSION

Dysfunctional cognition in bipolar disorder seems to relate to state rather than to trait. Hypomania includes depression-related as well as mania-related cognitions and can therefore not be considered as the mere opposite of depression.

Patterns of attentional deficits and emotional bias in bipolar and major depressive disorder

OBJECTIVES

Previous studies have reported deficits in selective attention and specific emotional biases in patients with bipolar (BP) disorder. The extent to which these distinguish BP patients from those with major depressive disorder (MDD) remain unclear. We aimed to examine the relationship between selective attentional impairments and emotional biases in symptomatic and euthymic BP, and symptomatic MDD patients.

DESIGN

A between-group design was used. The time taken for BP patients to perform on Stroop tasks was compared with that in patients with MDD, and a normal healthy control group.

METHODS

BP patients during manic (N = 14) and depressed (N = 13) episodes, and euthymia (N = 15), together with symptomatic patients with MDD (N = 17) and normal healthy controls (N = 18) were matched for IQ, gender, and age. Selective attention was measured using the Golden (1978) version of the Stroop task, and emotional bias, using the Lyon, Startup, and Bentall (1999) version of the emotional Stroop task.

RESULTS

On the Card Stroop, all patients were significantly slower than normal healthy controls on all three conditions. On the emotional Stroop Test, all patients were slower on neutral, positive, and negative conditions.

CONCLUSIONS

Our findings suggest that both BP and MDD patients demonstrate impaired performance on neutral and emotionally salient attentionally demanding tasks. The finding of impaired performance in all patients on baseline conditions in each task, however, indicates the need for inclusion of additional baseline conditions in these tasks in order to elucidate the nature of attentional impairments specific to these patient populations.

Self-discrepancies in bipolar disorder: Comparison of manic, depressed, remitted and normal participants

OBJECTIVES

To study the role of self-discrepancies in different phases of bipolar disorder (manic-depression).

METHOD AND DESIGN

Patients with a diagnosis of bipolar disorder in three groups, currently depressed, currently manic or hypomanic, and currently in remission, together with healthy control participants, were administered a modified version of Higgins' Selves Questionnaire. Consistencies between the self-actual, self-ideal and self-ought representations were calculated, together with consistencies between the self-actual representation and the believed views of generalized others about the self.

RESULTS

In contrast to all other groups, bipolar depressed patients showed marked discrepancies between their self-actual and self-ideal representations, and between their self-actual and self-ought representations. Manic or hypomanic patients showed higher self-actual:self-ideal consistency than non-patient controls. The differences between the depressed participants and the other groups appeared to be accounted for by their very negative self-actual descriptions. Participants in all four groups showed high levels of consistency between self-perceptions and the believed perceptions of others about the self.

CONCLUSIONS

These findings confirm that beliefs about the self differ between different phases of bipolar disorder and are consistent with the hypothesis that the manic phase involves active avoidance of discrepancies between the self and self-ideals.

Is mood affected by interactions with people at risk for affective disorders?

The interpersonal behavior of individuals who have affective disorders can increase the likelihood of interpersonal conflicts. A related issue is whether vulnerability for developing affective disorder expresses itself in social interactions that affect the mood of interaction partners as well. Adolescents (n = 119) have been divided into subgroups: "mania risk" (scoring high on "Hypomanic Personality"); "unipolar risk" (scoring high on "Rigidity"); and a control group (scoring low on both scales). Interviews were conducted by raters blind to risk status. Interviewers provided ratings of their own mood before and after the interview. Negative mood of the interviewers did not change. Interviewers' positive mood decreased when interacting with individuals at risk for unipolar disorder as well as when interacting with the control subjects, but not when interacting with people at risk for mania. It seems that individuals high in hypomanic traits keep the interaction partner longer engaged and interested.

Self-discrepancy in students with bipolar disorder II or NOS

BACKGROUND

Studies on self-representation in bipolar disorder have mainly focused on the single dimension of self-esteem and recruited patients either in episode or in remission. The aim of the study was to examine multi-dimensional aspects of the self (discrepancy between actual- and ideal-selves and between actual- and feared-selves) in a student sample with a history of significant experience of hypomania (with or without experience of major depression) as compared to healthy control students.

METHODS

Bipolar students and healthy control students completed the Self-Discrepancy Questionnaire (SDQ: Carver, Lawrence, & Scheier, 1999). The degree of similarity to, and the perceived likelihood of ideal-self and feared-self characteristics were assessed.

RESULTS

The difference between the groups in level of ideal-self similarity was at trend level. Students with prior hypomania but no history of depression showed higher similarity to their feared-self than healthy controls and also rated themselves as more likely to have these feared-self characteristics in the future.

LIMITATION

The small sample size, especially in the bipolar group with no history of depression, limits the power of the study.

CONCLUSIONS

The presence of ideal-self discrepancy was not convincingly demonstrated in this sample and it is possible that where it has been identified in previous studies it may, at least in part, represent a scar of previous episodes of depression or mania rather than a predisposing factor. However a sub-sample of students who had experienced hypomania in the absence of history of depression were distinguished from healthy controls in perceived closeness to the feared-self qualities. The feared-self concept warrants further investigation in bipolar patients.

Stroop and emotional Stroop interference in unaffected relatives of patients with schizophrenic and bipolar disorders: distinct markers of vulnerability?

Reduced inhibition has been demonstrated in both schizophrenic and bipolar patients through the findings of increased interference on the Stroop Colour-Word Task (SCWT) and increased emotional interference on specific versions of the Emotional Stroop Task (EST). Despite previous findings of enhanced interference in unaffected relatives of schizophrenic and bipolar patients, it remains unclear whether interference might be a candidate endophenotype to both disorders. Moreover, data regarding emotional interference in unaffected relatives are critically lacking. In the present study, we aimed to compare unaffected relatives of patients with schizophrenia (SZ-rel, N = 30) and bipolar disorder (BD-rel, N= 30) with normal controls (N = 60) when performing the SCWT and an EST designed with neutral, depressive, paranoid and manic words. SZ-rel exhibited greater interference effect on both the SCWT and the EST as compared to either BD-rel or normal controls. BD-rel, and by contrast to SZ-rel and controls, showed increased emotional interference effect on the EST that was specifically associated to the disease-related words. The findings support the hypothesis of different markers of vulnerability to schizophrenic and bipolar disorders; impairment in cognitive inhibition could characterize high-risk individuals for schizophrenia whereas an emotional bias towards mood-related information could be a trait marker of bipolar disease.

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.

A review of potential cognitive and environmental risk markers in children of bipolar parents

Although there is clear evidence that bipolar disorder runs in families, the mechanisms by which this illness is transmitted across generations are poorly understood. In particular, there has been limited consideration of nature of the psychosocial risk factors that might be present in offspring of bipolar parents and of how these factors might increase the likelihood of transition to illness. Recent research has begun to explore psychosocial factors in both healthy and diagnosed children of bipolar parents. This review explores the findings that have been obtained to date in terms of personality, cognitive functioning, life events and family factors. Three potential theoretical frameworks are then considered which might prove fruitful for facilitating theoretically driven empirical studies in this important area. Implications for future research and therapy are noted.

[Selecting material to develop an emotional Stroop test adapted to schizophrenia and bipolar disorders]

OBJECTIVE

The emotional Stroop test evaluates the influence of the emotional valence of stimuli on cognitive inhibition processes. In subjects with psychiatric disorders, interference increases in this test when valence refers to their specific psychopathology. This study aims to develop a version of the emotional Stroop test adapted to paranoid schizophrenia and bipolar disorder.

METHOD

The emotional valence and the number of times patients used 200 words related to schizophrenia and bipolar disorder psychopathology were assessed by 25 clinicians; then a principal component analysis was performed with an ascending hierarchical classification.

RESULTS

Words are distributed according to 2 factorial dimensions, emotionality and tonality, into 4 valence classifications: depressive, paranoid, manic, and neutral words. There were no differences in the lexical frequency of the words chosen to develop the test.

CONCLUSIONS

The statistical validation of the emotional valence of words allows for the development of an emotional Stroop test adapted to exploring emotional bias in paranoid schizophrenia and bipolar disorder.

No strong evidence for abnormal levels of dysfunctional attitudes, automatic thoughts, and emotional information-processing biases in remitted bipolar I affective disorder

INTRODUCTION

Beck extended his original cognitive theory of depression by suggesting that mania was a mirror image of depression characterized by extreme positive cognition about the self, the world, and the future. However, there were no suggestions what might be special regarding cognitive features in bipolar patients (Mansell & Scott, 2006). We therefore used different indicators to evaluate cognitive processes in bipolar patients and healthy controls.

METHODS

We compared 19 remitted bipolar I patients (BPs) without any Axis I comorbidity with 19 healthy individuals (CG). All participants completed the Beck Depression Inventory, the Dysfunctional Attitude Scale, the Automatic Thoughts Questionnaire, the Emotional Stroop Test, and an incidental recall task.

RESULTS

No significant group differences were found in automatic thinking and the information-processing styles (Emotional Stroop Test, incidental recall task). Regarding dysfunctional attitudes, we obtained ambiguous results.

CONCLUSIONS

It appears that individuals with remitted bipolar affective disorder do not show cognitive vulnerability as proposed in Beck's theory of depression if they only report subthreshold levels of depressive symptoms. Perhaps, the cognitive vulnerability might only be observable if mood induction procedures are used.

The cognitive and neurophysiological basis of emotion dysregulation in bipolar disorder

BACKGROUND

Bipolar disorder is characterized by fluctuating affect and mood, and is associated with specific neurocognitive deficits consistent with neuropathology in cerebello-striatal-prefrontal neural networks. This network is critical for emotion regulation.

METHODS

Relevant literature was located via PsychINFO and Medline to provide a comprehensive review of cognitive and neural mechanisms of social information processing and affect generation in bipolar disorder (BD) in the context of recent research examining the neural mechanisms of emotion regulation via conscious cognitive strategies.

RESULTS

Emotion regulation relies on synergy within brainstem, limbic and cortical processes that promote the adaptive generation and regulation of affect, with prefrontal and cingulate regions inhibiting sub-cortical and cortical emotion processing systems in the cognitive control of emotional experience. Current evidence of structural and functional brain abnormalities in BD alongside aberrant social cognition, affect generation, and neuropsychological function are consistent with a model of emotion dysregulation to account for the symptoms of BD.

LIMITATIONS

A precise understanding of emotion dysregulation in BD is currently limited by a paucity of longitudinal research directly examining these issues.

CONCLUSION

Aberrant emotion perception alongside increased limbic activity during emotion perception and affect generation in BD, alongside impaired executive control associated with aberrant neurophysiological abnormalities in sub-regions of the prefrontal cortex, is consistent with impaired emotion regulation. We propose a cognitive and neurophysiological framework within which the variations of mood that are characteristic of BD can be understood as specific impairments of the cognitive control of emotion.

The automaticity of emotional Stroop: a meta-analysis

An automatic bias to threat is often invoked to account for colour-naming interference in emotional Stroop. Recent findings by McKenna and Sharma [(2004). Reversing the emotional Stroop effect reveals that it is not what it seems: The role of fast and slow components. Journal of Experimental Psychology: Learning, Memory, and Cognition, 30, 382-392], however, cast doubt on the fast and non-conscious nature of emotional Stroop. Interference by threat words only occurred with colour naming in the trial subsequent to the threat trial (i.e., a "slow" effect), but not immediately (i.e., a "fast" effect, as would be predicted by the bias hypothesis). In a meta-analysis of 70 published emotional Stroop studies the largest effects occurred when presentation of threat words was blocked, suggesting a strong contribution by slow interference. We did not find evidence; moreover, for interference in suboptimal (less conscious) presentation conditions and the only significant effects were observed in optimal (fully conscious) conditions with high-anxious non-clinical participants and patients. The emotional Stroop effect seems to rely more on a slow disengagement process than on a fast, automatic, bias.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

Is there evidence for social rhythm instability in people at risk for affective disorders?

Social rhythm disruptions are thought to be related to the etiology of affective symptoms. 'Hypomanic personality' and 'rigidity' are hypothesized to be risk factors for affective disorders. We examined whether people scoring high on such scales would demonstrate instability of social rhythms and sleep. In a short-term prospective diary study with one group factor, the following three groups were selected from a non-university student sample: 'bipolar risk' (scoring high on the 'Hypomanic Personality Scale'; n=56); 'Unipolar risk' (scoring high on the 'Rigidity Scale'; n=37); and a control group (scoring low on both scales; n=48). The participants completed ratings of their activities and sleep for 28 days. People at risk for bipolar disorders showed a lower regularity of daily activities than controls. Their sleeping pattern was not characterized by fewer but by more variable hours of sleep. The unipolar risk group did not differ from the control group at all. Despite some limitations, there is partial evidence for social rhythm and sleep irregularities in people putatively at risk for bipolar disorders. Further research is, however, needed to replicate and extend these results.

No evidence for verbal memory impairment in individuals putatively at risk for bipolar disorder

BACKGROUND

Hypomanic temperament and rigid personality are putative risk factors for affective episodes and even bipolar disorder. Individuals with bipolar disorder exhibit neuropsychological impairments, especially memory difficulties, not only during mood episodes but also when they are euthymic. Such cognitive impairments may also constitute a risk factor for bipolar disorder. The purpose of the present study was to investigate the presence of memory difficulties in individuals with hypomanic and rigid personality traits.

METHODS

Study participants were 6000 German students recruited from high schools, colleges, and vocational schools in Germany. The students completed the Hypomanic Personality Scale and the Rigidity subscale of the Munich Personality Test. Four groups of students were selected from this sample based on their scores in the Hypomanic Personality Scale and Rigidity subscale: individuals with (1) hypomanic temperament, (2) rigid temperament, or (3) hypomanic-rigid temperament and (4) control participants. These students (n = 153) completed the Rey-Auditory Verbal Learning Test, a well-established measure of verbal learning and memory, as well an IQ test (Leistungsprüfsystem).

RESULTS

Multiple regression analyses indicated that sex and IQ, but not temperament, predicted learning of the Auditory Verbal Learning Test word list, the number of words recalled at short-delayed recall, and recognition.

LIMITATIONS

The risk for affective disorders was only defined by psychometric measures, and we did not control for family history of bipolar disorders.

CONCLUSIONS

Hypomanic temperament and Rigid personality were not associated with verbal learning and memory. Cognitive impairment may be associated with repeated mood episodes rather than constituting a risk factor for bipolar disorder.

The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.

Are measures of hypomanic personality, impulsive nonconformity and rigidity predictors of bipolar symptoms?

OBJECTIVES

It has been suggested that temperaments such as 'hypomanic personality' (HYP) have an explanatory role in affective disorders. Similarly, the impulsive nonconformity scale, originally designed to assess psychosis proneness, was recently found to augment the prediction of manic episodes. Conversely, research indicates that 'rigidity', a central feature of Typus Melancholicus (TMEL; von Zerssen, 1996), may characterize the premorbid personality of depressives.

DESIGN

The present study combines these three scales to prospectively predict manic and depressive symptoms diagnosed 2 years later in a non-college student population.

METHOD

Structured clinical interviews for DSM-IV were conducted with 114 individuals (60% female, mean age = 19 . 9 years), 2 years after an initial screening.

RESULTS

It was found that none of the predictors predicted purely depressive symptoms. As expected, HYP emerged as the strongest predictor of (hypo-)manic symptoms.

CONCLUSIONS

While rigidity did not predict depression, people with a hypomanic temperament are at risk of developing symptoms of bipolar disorder, especially (hypo-)manic ones. It is noteworthy that this was evident in our young sample, still in the earlier stages of the high-risk period.

Psychological therapies for bipolar disorder: the role of model-driven approaches to therapy integration

OBJECTIVES

The psychological and social aspects of bipolar disorder are receiving increasing recognition. Recently, there have been promising developments in psychological interventions, but there is scope for further improvement of therapeutic outcomes. This paper argues for the use of more detailed psychological models of bipolar disorder to inform the further development of therapeutic approaches.

METHOD

Evidence for psychological, family and social factors in bipolar disorder is reviewed. The efficacy of current individual and family interventions are discussed. A model, which has potential to synthesize group and individual approaches, is outlined.

RESULTS

Psychological, social and family factors have important influences on the onset, course and outcome of bipolar disorder. Interventions based on vulnerability stress models have proved effective. However, to enhance efficacy future developments need to be based on models that integrate current understandings of the multiple levels at which mood fluctuations occur. A particular recent model is discussed which leads to specific proposals for future intervention research.

CONCLUSIONS

Psychological and family approaches to BD have much potential. They clearly have a role in conjunction with appropriate pharmacological treatment. If this potential is to be fully realized future developments need to be based on psychological models that can accommodate the complexity of this illness.

Attention and memory biases in the offspring of parents with bipolar disorder: indications from a pilot study

BACKGROUND

Although children of bipolar parents are at heightened risk for developing emotional disorders, the processes underlying this vulnerability are not well understood. This study examined biases in the processing of emotional stimuli as a potential vulnerability marker of bipolar disorder.

METHODS

Sixteen children of bipolar parents who did not show any indication of having an emotional disorder at the time of testing and ten children of never-disordered control parents underwent a negative mood induction designed to activate cognitive schemas and were then administered an emotion Stroop task and a self-referent encoding task.

RESULTS

Children of bipolar parents were found to exhibit an attentional bias towards social-threat and manic-irritable words. Furthermore, although high- and low-risk children did not differ in their endorsement of positive and negative words as self-descriptive, the high-risk children demonstrated better recall of negative words than did the low-risk children.

CONCLUSIONS

Thus, children without a mood disorder who are at high risk for developing a mood disorder were found to exhibit biases in attention and memory that are similar to those found for bipolar and unipolar depressed adults, suggesting that children at increased risk for affective disorder are characterized by potentially pathogenic cognitive structures that can be activated by sad mood. These findings offer insights into mechanisms of cognitive vulnerability for bipolar disorders.

Screening for bipolar disorders using the Hypomanic Personality Scale

INTRODUCTION

The Hypomanic Personality Scale (Hyp; Eckblad and Chapman, 1986) might be an indicator for the risk for bipolar affective disorders. We investigated whether the results with American samples can be replicated in a different sample.

METHODS

The participants (N=224) completed a questionnaire package including the Hyp Scale and were independently interviewed with a psychiatric interview schedule.

RESULTS

Compared to the control group, persons scoring high on the Hyp scale reported significantly more manic or hypomanic episodes but not episodes of major depression. Correspondingly, the risk group exceeded the control group only on the rate of bipolar affective disorders (20.8% vs. 1.3%) but not unipolar depression, anxiety disorders, or other psychiatric conditions.

CONCLUSIONS

It seems that the Hyp scale assesses a similar concept in American and German samples, and that it might be a useful tool to study more closely the processes associated with the development of bipolar spectrum disorders.

Erste Ergebnisse zur prädiktiven Validität der Skala Hypomane Persönlichkeit - 3 Jahre später

Zusammenfassung.Theoretischer Hintergrund: Die Skala Hypomane Persönlichkeit (Hyp) von Eckblad und Chapman wird als möglicher Risikofaktor für affektive Störungen diskutiert. Fragestellung: Ziel der Studie ist, erste Ergebnisse zur prädiktiven Validität der deutschen Fassung der Skala vorzustellen. Methode: In einer Gruppe junger Erwachsener wurde die deutsche Version 1994 erstmals evaluiert, und drei Jahre später wurde den Probanden ein Fragebogen zugeschickt, um zu prüfen, ob diese Skala spätere Depressivität, Ängstlichkeit und andere Faktoren (z.B. Streß) vorhersagt. 148 von 289 Personen (51,2 %) füllten den Katamnesefragebogen aus. Ergebnisse: Die per Mediansplitting gebildete “hypomane“ Risikogruppe berichtete drei Jahre später vermehrt depressive Symptome, aber dies galt nicht für Ängstlichkeit. Außerdem tendierten sie im Vergleich dazu, seltener in festen Partnerschaften zu leben und mehr Stressoren anzugeben. Schlußfolgerung: Zwar schränken einige methodische Punkte die Generalisierbarkeit der Ergebnisse ein, aber insgesamt sprechen die Befunde für die Validität der Skala Hyp.