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Objectives: Although the cyclic nature of bipolarity is almost by definition a network system, no research to date has attempted to scrutinize the relationship of the two bipolar poles using network psychometrics. We used state-of-the-art network and machine learning methodologies to identify symptoms, as well as relations thereof, that bridge depression and mania., Methods: Observational study that used mental health data (12 symptoms for depression and 12 for mania) from a large, representative Canadian sample (the Canadian Community Health Survey of 2002). Complete data (N = 36,557; 54.6% female) were analysed using network psychometrics, in conjunction with a random forest algorithm, to examine the bidirectional interplay of depressive and manic symptoms., Results: Centrality analyses pointed to symptoms relating to emotionality and hyperactivity as being the most central aspects of depression and mania, respectively. The two syndromes were spatially segregated in the bipolar model and four symptoms appeared crucial in bridging them: sleep disturbances (insomnia and hypersomnia), anhedonia, suicidal ideation, and impulsivity. Our machine learning algorithm validated the clinical utility of central and bridge symptoms (in the prediction of lifetime episodes of mania and depression), and suggested that centrality, but not bridge, metrics map almost perfectly onto a data-driven measure of diagnostic utility., Conclusions: Our results replicate key findings from past network studies on bipolar disorder, but also extend them by highlighting symptoms that bridge the two bipolar poles, while also demonstrating their clinical utility. If replicated, these endophenotypes could prove fruitful targets for prevention/intervention strategies for bipolar disorders., (© 2023 The Authors. Bipolar Disorders published by John Wiley & Sons Ltd.)

Background: In recent years, the Kraepelinian dichotomy has been challenged in light of evidence on shared genetic and environmental factors for schizophrenia and bipolar disorder, but empirical efforts to identify a transdiagnostic phenotype of psychosis remain remarkably limited., Aims: To investigate whether schizophrenia spectrum and bipolar disorder lie on a transdiagnostic spectrum with overlapping non-affective and affective psychotic symptoms., Method: Multidimensional item-response modelling was conducted on symptom ratings of the OPerational CRITeria (OPCRIT) system in 1168 patients with schizophrenia spectrum and bipolar disorder., Results: A bifactor model with one general, transdiagnostic psychosis dimension underlying affective and non-affective psychotic symptoms and five specific dimensions of positive, negative, disorganised, manic and depressive symptoms provided the best model fit and diagnostic utility for categorical classification., Conclusions: Our findings provide support for including dimensional approaches into classification systems and a directly measurable clinical phenotype for cross-disorder investigations into shared genetic and environmental factors of psychosis., (© The Royal College of Psychiatrists 2016.)

Background: There is amassing evidence that risky decision-making in bipolar disorder is related to reward-based differences in frontostriatal regions. However, the roles of early attentional and later cognitive processes remain unclear, limiting theoretical understanding and development of targeted interventions., Methods: Twenty euthymic bipolar disorder and 19 matched control participants played a Roulette task in which they won and lost money. Event-related potentials and source analysis were used to quantify predominantly sensory-attentional (N1), motivational salience (feedback-related negativities [FRN]), and cognitive appraisal (P300) stages of processing. We predicted that the bipolar disorder group would show increased N1, consistent with increased attentional orienting, and reduced FRN, consistent with a bias to perceive outcomes more favorably., Results: As predicted, the bipolar disorder group showed increased N1 and reduced FRN but no differences in P300. N1 amplitude was additionally associated with real-life risk taking, and N1 source activity was reduced in visual cortex but increased activity in precuneus, frontopolar, and premotor cortex, compared to those of controls., Conclusions: These findings demonstrate an early attentional bias to reward that potentially drives risk taking by priming approach behavior and elevating reward salience in the frontostriatal pathway. Although later cognitive appraisals of these inputs may be relatively intact in remission, interventions targeting attention orienting may also be effective in long-term reduction of relapse., (Copyright © 2016 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Psychiatric illnesses like bipolar disorder are increasingly understood to be neurodevelopmental disorders with clinical, psychological, and biological indicators recognizable long before the emergence of the full-blown syndromes., Methods: This paper is a selective review of findings from studies of high-risk children of affected parents that inform the knowledge of illness risk and development markers of bipolar disorder. We specifically focus on candidate clinical, biological, and psychological risk indicators that could serve as targets for future early intervention and prevention studies., Results: There is convergent evidence from prospective studies that bipolar disorder typically debuts as depressive episodes after puberty. In some high-risk children, sleep and anxiety disorders precede mood disorders by several years and reflect an increased vulnerability. An association between early exposure to adversity (eg, exposure to parental illness, neglect from mother) and increased risk of psychopathology may be mediated through increased stress reactivity evident at both behavioral and biological levels. Inter-related psychological processes including reward sensitivity, unstable self-esteem, rumination, and positive self-appraisal are risk factors for mood disorders. Disturbances in circadian rhythm and immune dysfunction are associated with mood disorders and may be vulnerability markers influenced by these other risk factors., Conclusions: There is accruing evidence of a number of measurable and potentially modifiable markers of vulnerability and developing illness in youth at familial risk for bipolar disorder. Longitudinal studies of multiple biological and psychological risk processes in high-risk offspring, both individually and together, will improve our understanding of illness onset and lead to the development of specific early interventions., (© The Author 2015. Published by Oxford University Press on behalf of CINP.)

The response styles theory of depression (Nolen-Hoeksema, 1991) proposes three main strategies individuals employ in response to low mood: rumination, active coping (distraction and problem-solving) and risk taking. Although recent research has suggested this theory has utility in understanding the symptoms of bipolar disorder (BD), the role of these processes in conferring vulnerability to the condition is poorly understood. Twenty-three adolescent children of patients with BD and 25 offspring of well parents completed the Experience Sampling Method (ESM; Csikszentmihalyi and Larson, 1987) diary for six days. Longitudinal analyses were carried out to examine inter-relationships between mood, self-esteem and response styles. Increased negative as well as positive mood resulted in greater rumination in both groups. Low self-esteem triggered greater risk-taking at the subsequent time point in the at-risk group, while negative affect instigated increased active coping in the control group. In both groups, engagement in risk-taking improved mood at the subsequent time point, whilst rumination dampened self-esteem. Differential longitudinal associations between mood, self-esteem and response styles between at-risk and control children suggest early psychological vulnerability in the offspring of BD parents, with important indications for early intervention., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Bipolar disorder is a highly heritable illness, with a positive family history robustly predictive of its onset. It follows that studying biological children of parents with bipolar disorder may provide information about developmental pathways to the disorder. Moreover, such studies may serve as a useful test of theories that attribute a causal role in the development of mood disorders to psychological processes., Method: Psychological style (including self-esteem, coping style with depression, domain-specific risk-taking, sensation-seeking, sensitivity to reward and punishment, and hypomanic personality and cognition) was assessed in 30 offspring of bipolar parents and 30 children of well parents. Parents of both child groups completed identical assessments., Results: Although expected differences between parents with bipolar disorder and well parents were detected (such as low self-esteem, increased rumination, high sensitivity to reward and punishment), offspring of bipolar parents were, as a group, not significantly different from well offspring, apart from a modest trend towards lower adaptive coping. When divided into affected and non-affected subgroups, both groups of index children showed lower novelty-seeking. Only affected index children showed lower self-esteem, increased rumination, sensitivity to punishment, and hypomanic cognitions. Notably, these processes were associated with symptoms of depression., Conclusion: Psychological abnormalities in index offspring were associated with having met diagnostic criteria for psychiatric illnesses and the presence of mood symptoms, rather than preceding them. Implications of the present findings for our understanding of the development of bipolar disorder, as well as for informing early interventions, are discussed., (© 2014 The British Psychological Society.)

Objectives: Self-esteem is a key feature of bipolar symptomatology. However, so far no study has examined the interaction between explicit and implicit self-esteem in individuals vulnerable to bipolar disorder., Design: Cross-sectional design was employed., Methods: Thirty children of parents with bipolar disorder and 30 offspring of control parents completed Hamilton Rating Scale for Depression, the Bech-Rafaelson Mania Scale, the Self-esteem Rating Scale and the Implicit Association Test., Results: No differences between groups were revealed in levels of explicit or implicit self-esteem. However, bipolar offspring showed increased levels of symptoms of depression and mania. Furthermore, depressive symptoms were associated with low explicit self-esteem, whilst symptoms of mania were associated with low implicit self-esteem. When self-esteem discrepancies were examined, damaged self-esteem (i.e., low explicit but high implicit self-esteem) was associated with depression, whilst no associations between mania and self-esteem discrepancies were found., Conclusions: Not only explicit, but also implicit self-esteem, and the interactions between the two are of relevance in bipolar symptoms. Clinical implications and future research directions are discussed., Practitioner Points: Explicit as well as implicit SE, and particularly their relationship, are relevant for mental health. Fluctuations in implicit SE may serve as an early indicator for risk of bipolarity. Psychotherapeutic approaches may be more suitable for one kind of SE challenge than the other., (© 2013 The British Psychological Society.)

The negative implications of living in a socially unequal society are now well documented. However, there is poor understanding of the pathways from specific environmental risk to symptoms. Here we examine the associations between social deprivation, depression, and psychotic symptoms using the 2007 Adult Psychiatric Morbidity Survey, a cross-sectional dataset including 7,353 individuals. In addition we looked at the mediating role of stress, discrimination, trust and lack of social support. We found that the participants' neighbourhood index of multiple deprivation (IMD) significantly predicted psychosis and depression. On inspection of specific psychotic symptoms, IMD predicted paranoia, but not hallucinations or hypomania. Stress and trust partially mediated the relationship between IMD and paranoid ideation. Stress, trust and a lack of social support fully mediated the relationship between IMD and depression. Future research should focus on the role deprivation and social inequalities plays in specific manifestations of psychopathology and investigate mechanisms to explain those associations that occur. Targeting the mediating mechanisms through appropriate psychological intervention may go some way to dampen the negative consequences of living in an unjust society; ameliorating economic injustice may improve population mental health.

Bipolar disorder is characterized by impaired decision-making captured in impulsivity and risk-taking. We sought to determine whether this is driven by a failure to effectively weight the lower-order goal of obtaining a strongly desired reward in relation to higher-order goals, and how this relates to trait impulsivity and risk-taking. We hypothesized that in bipolar disorder the weighting of valuation signals converging on ventromedial prefrontal cortex are more heavily weighted towards ventral striatum inputs (lower-order), with less weighting of dorsolateral prefrontal cortex inputs (higher-order). Twenty euthymic patients with bipolar disorder not in receipt of antipsychotic medication and 20 case-matched controls performed a roulette task during functional magnetic resonance imaging. Activity in response to high-probability ('safe') and low-probability ('risky') prospects was measured during both anticipation, and outcome. In control subjects, anticipatory and outcome-locked activity in dorsolateral prefrontal cortex was greater for safe than risky reward prospects. The bipolar disorder group showed the opposite pattern with preferential response to risky rewards. This group also showed increased anticipatory and outcome-locked activity in ventral striatum in response to rewards. In control subjects, however, ventromedial prefrontal activation was positively associated with both ventral striatum and dorsolateral prefrontal activity; patients evidenced a strong positive association with ventral striatum, but a negative association with dorsolateral prefrontal cortex. Response to high-probability rewards in dorsolateral prefrontal cortex was inversely associated with trait impulsivity and risk-taking in the bipolar disorder group. Our findings suggest that clinically impulsive and risky decision-making are related to subjective valuation that is biased towards lower-order preference, with diminished integration of higher-order goals. The findings extend a functional neuroanatomical account of disorders characterized by clinically impulsive decision-making, and provide targets for evaluating interventions that foster self-control., (© The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain.)

Background: Psychiatric taxonomists have sometimes argued for a unitary psychosis syndrome and sometimes for a pentagonal model, including 5 diagnostic constructs of positive symptoms, negative symptoms, cognitive disorganization, mania, and depression. This continues to be debated in preparation for impending revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. We aimed to identify general and specific dimensions underlying psychopathological features of psychosis., Methods: The samples comprised 309 patients admitted to psychiatric services in the acute phase of their first or second episode of psychosis and 507 patients with enduring psychosis recruited from community mental health teams. Patients' symptoms were assessed on the Positive and Negative Symptom Scale. Analyses compared unitary, pentagonal, and bifactor models of psychosis., Results: In both samples, a bifactor model including 1 general psychosis factor and, independently, 5 specific factors of positive symptoms, negative symptoms, disorganization, mania, and depression gave the best fit. Scores of general and specific symptom dimensions were differentially associated with phase of illness, diagnosis, social functioning, insight, and neurocognitive functioning., Conclusions: The findings provide strong evidence for a general psychosis dimension in both early and enduring psychosis. Findings further allowed for independent formation of specific symptom dimensions. This may inform the current debate about revised classification systems of psychosis.

Background: Previous research has suggested that the way bipolar patients respond to depressive mood impacts on the future course of the illness, with rumination prolonging depression and risk-taking possibly triggering hypomania. However, the relationship over time between variables such as mood, self-esteem, and response style to negative affect is complex and has not been directly examined in any previous study--an important limitation, which the present study seeks to address., Methods: In order to maximize ecological validity, individuals diagnosed with bipolar disorder (N = 48) reported mood, self-esteem and response styles to depression, together with contextual information, up to 60 times over a period of six days, using experience sampling diaries. Entries were cued by quasi-random bleeps from digital watches. Longitudinal multilevel models were estimated, with mood and self-esteem as predictors of subsequent response styles. Similar models were then estimated with response styles as predictors of subsequent mood and self-esteem. Cross-sectional associations of daily-life correlates with symptoms were also examined., Results: Cross-sectionally, symptoms of depression as well as mania were significantly related to low mood and self-esteem, and their increased fluctuations. Longitudinally, low mood significantly predicted rumination, and engaging in rumination dampened mood at the subsequent time point. Furthermore, high positive mood (marginally) instigated high risk-taking, and in turn engaging in risk-taking resulted in increased positive mood. Adaptive coping (i.e. problem-solving and distraction) was found to be an effective coping style in improving mood and self-esteem., Conclusions: This study is the first to directly test the relevance of response style theory, originally developed to explain unipolar depression, to understand symptom changes in bipolar disorder patients. The findings show that response styles significantly impact on subsequent mood but some of these effects are modulated by current mood state. Theoretical and clinical implications are discussed.

Objectives: Previous studies of social adjustment in bipolar disorder have been cross-sectional and small in sample size, have examined a limited number of roles, or were not controlled for baseline mood and other clinical, social, or treatment confounders. We aimed to prospectively explore the strength and stability of correlations between depression and mania-type symptoms and impairment in a broad range of social adjustment roles and domains., Methods: Multilevel modeling analysis of correlation coefficients between depression and mania-type symptoms with roles and domains of the modified social adjustment scale (overall, work, social/leisure, extended family, marital, parental social adjustment roles, performance, interpersonal behavior, friction, dependency, overactivity domains) was used. Interview assessments were made at eight-week intervals beginning at eight weeks and continuing through 72 weeks after baseline in 253 patients in a multicenter randomized controlled trial., Results: After controlling for baseline mood episodes, and other clinical, social, and treatment variables, depression symptoms showed strong and stable correlations over time with performance, overall social adjustment, and the work role; and a moderate but stable relationship with interpersonal behavior. The relationships of depression symptoms with the other roles were weak, non-significant, or not stable. For mania-type symptoms, only the correlation with interpersonal friction was moderately strong and reasonably stable over time. Mood episodes, substance use disorder, and borderline/antisocial personality disorder increased role impairment, while employment and marriage mildly decreased it., Conclusions: Depression and mania-type symptoms have specific effects on social adjustment in bipolar I disorder. Depression symptoms are correlated strongly with performance and moderately with interpersonal behavior, while mania-type symptoms are correlated moderately with interpersonal friction., (© 2013 John Wiley and Sons A/S.)

Background: Hypomania is associated with impulsive decision making and risk taking, characteristics that may arise from hypersensitivity to reward. To date, the neural dynamics underlying intertemporal reward processing have neither been characterized clinically nor in the general population. Taking vulnerability to hypomania as a surrogate model of impulsivity, we utilized event-related potentials to study the neural mechanisms of delay discounting., Methods: In the first experiment, 32 participants completed an established Two Choice Impulsivity Paradigm in which free choice between immediate and delayed rewards was used to quantify impulsivity behaviorally. In the second experiment, electroencephalography was recorded while 32 separately recruited participants completed a speeded response task involving gains and losses of monetary incentives to be paid at three different delays after the experiment., Results: In the first experiment, the hypomania-prone group made significantly more immediate choices than the control group. In the second experiment, the hypomania-prone group evidenced greater differentiation between delayed and immediate outcomes in early attention-sensitive (N1) and later reward-sensitive (feedback-related negativity) components. Proneness to hypomania was also associated with greater N1 amplitude to rewards per se., Conclusions: These results indicate steeper delay discounting in hypomania at multiple stages of information processing. The N1 modulation by valence and delay suggests an attentional bias to immediate rewards, which may drive subsequent cognitive appraisal of outcomes (feedback-related negativity). These results highlight the early influence of attention on reward processing and provide support for reward dysregulation accounts of bipolar disorder. Potential implications for mindfulness training and other therapeutic interventions are highlighted., (Copyright © 2012 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Mania is characterised by increased impulsivity and risk-taking, and psychological accounts argue that these features may be due to hypersensitivity to reward. The neurobiological mechanisms remain poorly understood. Here we examine reinforcement learning and sensitivity to both reward and punishment outcomes in hypomania-prone individuals not receiving pharmacotherapy., Method: We recorded EEG from 45 healthy individuals split into three groups by low, intermediate and high self-reported hypomanic traits. Participants played a computerised card game in which they learned the reward contingencies of three cues. Neural responses to monetary gain and loss were measured using the feedback-related negativity (FRN), a component implicated in motivational outcome evaluation and reinforcement learning., Results: As predicted, rewards elicited a smaller FRN in the hypomania-prone group relative to the low hypomania group, indicative of greater reward responsiveness. The hypomania-prone group also showed smaller FRN to losses, indicating diminished response to negative feedback., Conclusion: Our findings indicate that proneness to hypomania is associated with both reward hypersensitivity and discounting of punishment. This positive evaluation bias may be driven by aberrant reinforcement learning signals, which fail to update future expectations. This provides a possible neural mechanism explaining risk-taking and impaired reinforcement learning in BD. Further research will be needed to explore the potential value of the FRN as a biological vulnerability marker for mania and pathological risk-taking.

Objectives: This paper aims to study dysfunctional self-schematic processes, abnormal coping styles, over-responsiveness to reward stimuli (indicative of an over-sensitive behavioural activation system) and stability of self-esteem in relation to subclinical hypomania., Design: Three cross-sectional studies were conducted on selected students on the basis of their scores on the Hypomanic Personality Scale (HPS) (study 1) and on elevated HPS and Dysfunctional Attitude Scale scores (studies 2 and 3)., Methods: In studies 1 and 2, participants completed questionnaires and kept a self-esteem diary for 6 days. In study 3, the experience sampling method was used to assess momentary self-esteem, emotion and use of different coping styles over a 6-day period., Results: Study 1 demonstrated that hypomanic traits are associated with high fluctuations in self-esteem. In study 2, high scores on both the HPS and the Dysfunctional Attitude Scale, but not the HPS alone, were associated with bipolar spectrum symptoms. These participants showed more evidence of alcohol and substance abuse, greater self-esteem fluctuation and dysfunctional coping styles (rumination and risk-taking) compared with controls. Changes in self-esteem were related to the use of these strategies., Conclusions: Vulnerability to bipolar disorder is associated with a combination of depression-related and reward-related processes., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: Mania is argued to stem from the dysfunctional processing of reward. Investigation of hypomania in healthy samples has the potential to offer refined insight into the particular aspects of reward processing in mania that are dysfunctional., Method: In this study, fMRI was employed in contrasting a sample of 12 unmedicated subclinical hypomanic individuals with a sample of 12 unmedicated controls in order to investigate reward-related processing in a reinforcement-learning task., Results: Four findings in the hypomania-prone group relative to the control group supported atypical reward processing. Firstly, striatal activation that correlated with reward value and prediction error was stronger in response to cues and outcomes respectively, consistent with hypomania being related to an enhanced perception of the value of goals that may lead to reward. Secondly, value-related medial temporal activation was stronger in response to cues, suggesting that in hypomania-prone individuals, stimuli in memory were represented in accordance with their perceived value. Thirdly, these effects failed to be modulated by the actual value of outcomes, suggesting that hypomania is related to a decreased ability to discriminate between cues differing in value. Fourthly, increased insula activation in response to expected, but absent, reward was consistent with a bias towards expecting positive outcomes in decision-making., Conclusion: Together, the findings suggest that enhanced perception and representation of goal-value that nonetheless fails to discriminate on the basis of actual goal-value, coupled with a positive outcome-expectancy bias, could be causally related to insatiable and indiscriminate reward seeking in mania., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: The present study uses an indirect measure to explore whether dysfunctional attitudes are characteristic of all phases of bipolar disorder. Previous studies with bipolar patients using indirect measurements have uncovered depression-like responses that were otherwise undetected., Design: A cross-sectional study design was adopted to explore the presence of dysfunctional attitudes within each phase of the illness., Method: Manic patients, depressed bipolar patients, remitted bipolar patients, and healthy controls were compared on a sentence stem completion task designed to implicitly assess dysfunctional attitudes., Results: The manic, depressed, and remitted patients all exceeded the controls on implicit measures of dysfunctional attitudes., Conclusions: The findings are consistent with the hypothesis that all phases of bipolar disorder are associated with depressogenic dysfunctional attitudes.

Objectives: To determine how security of adult attachment style is related to the mania, major depression and euthymic mood states in bipolar 1 (BP1) disorder., Design: An observational cross-sectional study., Method: One hundred and seven BP1 patients (34 in a manic type episode, 30 in major depressive episode, and 43 in remission) and 41 healthy controls similar in age, gender, reading age, and education were recruited. The groups were compared on self-reported mean and preferred attachment style controlling for psychiatric comorbidity., Results: Preferred attachment style was insecure in 84 (78%) BP1 patients but only 13 (32%) healthy controls (chi(2)=34.3, df=3, and p<.001). Healthy controls reported higher secure attachment, lower anxious, and lower preoccupied attachment scores than all groups of patients with bipolar disorder, although the scores for secure attachment in mania and preoccupied attachment in euthymic patients were not significantly different from healthy controls. Overall, within the bipolar groups, anxious attachment style varied little with mood but mania was associated with higher secure and preoccupied attachment style, and depression with higher preoccupied and lower dismissing attachment style scores., Conclusions: Insecure attachment is found in most patients with BP1 disorder. Attachment style is affected by mood episodes so it should be assessed when a patient with bipolar disorder is in remission with minimal residual depressive or manic symptoms.

Background: Psychological processes in bipolar disorder are of both clinical and theoretical importance., Aims: To examine depressogenic psychological processes and reward responsivity in relation to different mood episodes (mania, depression, remission) and bipolar symptomatology., Method: One hundred and seven individuals with bipolar disorder (34 in a manic/hypomanic or mixed affective state; 30 in a depressed state and 43 who were euthymic) and 41 healthy controls were interviewed with Structured Clinical Interview for DSM-IV and completed a battery of self-rated and experimental measures assessing negative cognitive styles, coping response to negative affect, self-esteem stability and reward responsiveness., Results: Individuals in all episodes differed from controls on most depression-related and reward responsivity measures. However, correlational analyses revealed clear relationships between negative cognitive styles and depressive symptoms, and reward responsivity and manic symptoms., Conclusions: Separate psychological processes are implicated in depression and mania, but cognitive vulnerability to depression is evident even in patients who are euthymic.

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.

Objectives: To examine relationships between parental communication styles and family environment in parents with bipolar disorder (BD) and their children (CBP)., Methods: On measures of parental communication styles and family environment, 20 BD parents and their 23 children (CBP) were compared to controls. Children completed a current mood measure., Results: BD parents endorsed more negative communication styles and were less expressive than controls. CBP presented with more current or lifetime mood disorder diagnoses than control children (CC). Current depressive mood was associated with different perceptions of family environment for both CBP and CC., Conclusions: This familial high risk design indicated differences in family environment, parenting style, and in children of bipolar parents' perception of their family environment as it relates to their current mood.

Objectives: Changes in beliefs about the self are a central feature of bipolar disorder, with grandiose self-belief common in mania and low self-esteem evident in periods of depression. We investigated whether unstable self-esteem is a characteristic of bipolar disorder in remission., Methods: We compared 18 patients with DSM-IV bipolar disorder in remission, 16 patients with unipolar disorder in remission, and 19 healthy controls. The primary measure was a diary kept for one week and completed twice each day, measuring self-esteem and positive and negative affect. We also administered Winters and Neale's (J Abnorm Psychol 1985; 94: 282-290) implicit measure of attributional style., Results: Whereas mean levels of self-esteem and affect were not abnormal in the remitted bipolar patients, the bipolar patients showed strong fluctuations in these processes. In common with the unipolar patients, they also showed a pessimistic attributional style on the Pragmatic Inference Task (PIT)., Conclusions: Instability of self-esteem and affect is present in bipolar patients, even when their symptoms are in remission, and has previously been found in people at genetic risk of the disorder. It may be a marker of vulnerability to the disorder.

Background: It has been hypothesised that dysfunctional strategies for avoiding depression play an important role in the pathway to mania. Support for this hypothesis comes from studies demonstrating that remitted and manic bipolar patients show similar cognitive biases to currently depressed patients., Method: Manic patients, depressed bipolar patients, remitted bipolar patients and healthy controls were compared on an expanded version of Nolen-Hoeksema's [Nolen-Hoeksema, S., 1991. Responses to depression and their effects on the duration of depressed mood. Journal of Abnormal Psychology, 100, 569-582.] Response Styles Questionnaire, measuring strategies for coping with depression., Results: Manic patients reported greater use of active-coping and risk-taking compared to the depressed, remitted and healthy controls. Bipolar remitted patients reported greater rumination., Conclusions: The findings are consistent with the hypothesis that mania is associated with dysfunctional strategies for regulating negative emotion.

Objectives: To determine the effects of mood and additional clinical variables on different domains of current interviewer-rated social adjustment reflecting the reported behaviour of patients with bipolar disorder (BD)., Method: Multi-center cross-sectional study employing multiple linear regression to investigate whether mood and other clinical features, previously linked to self-rated social adjustment, were associated with eight domains of interviewer-rated social adjustment in 253 BD patients. Baseline variables were entered sequentially in blocks representing current mood, demographic, current other psychiatric, past psychiatric and current treatment variables., Results: Mood episode or symptoms together with five other variables (borderline/antisocial personality disorder, male gender, living alone, hypnotic drug and drugs for physical illness) were associated with impairment on two or more domains of interviewer-rated social adjustment. They explained up to 31% of the variance in social adjustment, although friction, dependence and overactivity were associated with a different pattern of variables. Hypomanic symptoms were associated with increased friction and worse social adjustment with the extended family in the whole sample but improved performance and social and leisure activities in patients who were not in acute bipolar episode., Conclusion: Clinicians may determine up to about 30% of outcome in current social adjustment in BD patients from the patient's current mood episode or symptoms and a small number of other clinical or demographic variables. Hypomanic episodes and symptoms usually worsen friction and overall social adjustment, but in patients who are not in acute episode, hypomanic symptoms can increase performance and social and leisure activities.

Objectives: Disturbances in cognition, affect, sleep and activity have been identified in bipolar disorder (BD) but little is known about the possible role of these factors in the development of the condition. We studied these variables in a familial high-risk sample., Methods: Twenty-five children (13-19 years) of bipolar parents were compared with 22 similar aged children of age- and sex-matched healthy controls. Participants were assessed using Schedule for Affective Disorders and Schizophrenia-Lifetime version (SADS-L) and completed self-report measures of dysfunctional attitudes, behavioural inhibition/activation, social rhythms, coping styles and subjective experience of sleep. Children completed a 7-day recording of actigraphy (sleep and activity) and a 7-day diary measuring self-esteem, positive and negative affect and reactions to positive and negative events., Results: Fifty-six per cent of children of bipolar parents (CBP) reported mood symptoms compared to 9% of children of control parents (CC). The CBP group had coping styles and instability of self-esteem consistent with abnormal strategies for regulating affect. Both groups also differed on sleep measures. The majority of differences observed were between CBP with a current or past mood diagnosis and CC. BD parents reported dysfunctional coping styles and (to a lesser extent) disrupted activity patterns., Conclusions: A familial high-risk strategy for studying the role of psychological factors in BD is feasible and informative. This pilot study indicates that abnormal coping styles, instability of self-esteem and dysregulation of sleep may be early markers of bipolar illness. However, current findings need to be explored further in longitudinal studies to clarify which potential markers are truly predictive of BD.

Background: Efficacy trials suggest that structured psychological therapies may significantly reduce recurrence rates of major mood episodes in individuals with bipolar disorders., Aims: To compare the effectiveness of treatment as usual with an additional 22 sessions of cognitive-behavioural therapy (CBT)., Method: We undertook a multicentre, pragmatic, randomised controlled treatment trial (n=253). Patients were assessed every 8 weeks for 18 months., Results: More than half of the patients had a recurrence by 18 months, with no significant differences between groups (hazard ratio=1.05; 95% CI 0.74-1.50). Post hoc analysis demonstrated a significant interaction (P=0.04) such that adjunctive CBT was significantly more effective than treatment as usual in those with fewer than 12 previous episodes, but less effective in those with more episodes., Conclusions: People with bipolar disorder and comparatively fewer previous mood episodes may benefit from CBT. However, such cases form the minority of those receiving mental healthcare.

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.

Objectives: To assess the factor structure of the Nolen-Hoeksema (1991) Response Styles Questionnaire (RSQ), and to investigate the relationship between coping with depression and other measures of affective symptomatology in a student sample., Design: A factor analytic study of the RSQ followed by an investigation of the relationship between RSQ scale scores and measures of affective symptomatology., Method: Five hundred twenty-eight undergraduate students completed a battery of questionnaires comprising the RSQ, Beck Depression Inventory, Hypomania Personality Questionnaire, Positive and Negative Affect Scale and the Dysfunctional Attitudes Scale. Factor analysis of the RSQ was performed and correlational and regression analyses were conducted on the data from the other four questionnaire measures., Results: Factor analysis revealed a meaningful 3-factor solution which measured coping styles characterized by (i) rumination; (ii) pleasant distraction and problemsolving; and (iii) risk-taking. Rumination and risk-taking were independently associated with both depression and hypomania scores, and hypomania was associated with both depression and dysfunctional attitudes. Additional relationships between coping and the other measures are also reported., Conclusions: The results support the validity of the coping styles concept and suggest their natural separation into three distinct strategies. Abnormal coping is discussed as a potential contributing factor to affective symptoms, including symptoms of bipolar disorder.

Background: Strong evidence exists for an association between childhood trauma, particularly childhood sexual abuse, and hallucinations in schizophrenia. Hallucinations are also well-documented symptoms in people with bipolar affective disorder., Aims: To investigate the relationship between childhood sexual abuse and other childhood traumas and hallucinations in people with bipolar affective disorder., Method: A sample of 96 participants was drawn from the Medical Research Council multi-centre trial of cognitive-behavioural therapy for bipolar affective disorder. The trial therapists recorded spontaneous reports of childhood sexual abuse made during the course of therapy. Symptom data were collected by trained research assistants masked to the hypothesis., Results: A significant association was found between those reporting general trauma (n=38) and auditory hallucinations. A highly significant association was found between those reporting childhood sexual abuse (n=15) and auditory hallucinations., Conclusions: The relationship between childhood sexual abuse and hallucinations in bipolar disorder warrants further investigation.

Background: Bipolar affective disorder patients often show cognitive deficits that are similar to those found in schizophrenia patients. Theory of mind (the ability to understand others' mental states) is compromised in currently ill schizophrenia patients. This study aimed to establish whether similar deficits are found in bipolar patients., Methods: We measured theory of mind ability in 20 bipolar-manic patients, 15 bipolar-depressed patients, 13 bipolar patients in remission and 15 normal controls. The task, which controlled for memory and comprehension, had previously been used in a study of schizophrenia patients., Results: Impaired performance on theory of mind was found for both bipolar-depressed and bipolar-manic patients, even when memory was controlled for. No impairment was observed in the remitted patients., Limitations: The manic patients scored lower than the remitted patients on a brief measure of intelligence; no other group differences in IQ were significant., Conclusions: Theory of mind deficits are found in currently symptomatic bipolar patients. These findings add to growing evidence that common mechanisms may contribute to bipolar affective disorder and schizophrenia.

Objectives: To test the hypothesis that the manic defence involves specific response styles to depression, namely distraction and indulging in dangerous activities., Design: A correlational study was conducted with undergraduate participants assessed for hypomanic traits using Eckblad and Chapman's Hypomanic Personality Scale., Method: Participants also completed the Beck Depression Inventory, and an expanded version of Nolen-Hoeksema's Response Styles Questionnaire., Results: Depression was strongly associated with a ruminative response style. Hypomanic traits were associated with rumination, a distraction response style and with indulging in dangerous activities. However, as only 17% of the variance in hypomania scores was accounted for, other factors must play an important role in determining this trait., Conclusions: Hypomania (and possibly mania) may be products of ineffective styles of coping with negative emotions.

Background: Efficacy trials of medications and/or psychological interventions for bipolar disorders (BD) aim to recruit homogenous samples of patients who are euthymic and such populations show high levels of adherence to the treatments offered. This study describes a secondary analysis of a large-scale multi-centre pragmatic effectiveness randomized controlled trial (RCT) of cognitive behaviour therapy plus treatment as usual (CBT) or treatment as usual alone (TAU) and explores outcomes in individuals who were: (i) recruited in depressive episodes, or (ii) receiving suboptimal doses of or no mood stabilizers (MS). Methods: Data were extract on two separate subsamples (out of 253 RCT participants). Sample 1 comprised 67 individuals in a depressive episode (CBT: 34; TAU: 33); Sample 2 comprised 39 individuals receiving suboptimal MS treatment (CBT: 19; TAU: 20). Survival analyses (adjusted for confounding variables) were used to explore recovery in Sample 1 and relapse in Sample 2. Results: In Sample 1 (individuals with depression), Cox proportional hazards regression model revealed that the median time to recovery was significantly shorter in the CBT group (10 weeks; 95% confidence intervals (CI) 8, 17) compared to the TAU group (17 weeks; 95% CI 9, 30) [Adjusted Hazard Ratio (HR) 1.89; 95% CI 1.04, 3.4; p < 0.035]. In Sample 2 (suboptimal MS), the median time to any relapse was significantly longer in the CBT group compared to the TAU group (~ 35 versus ~ 20 weeks; Adjusted HR 2.01; 95% CI 1.01, 3.96; p < 0.05) with the difference in survival time to first depressive relapse also reaching statistical significance (X2 = 14.23, df 6, p 0.027). Conclusions: Adjunctive use of CBT appears to have benefits for individuals diagnosed with BD who are highly representative of the patients seen in routine clinical practice, but often excluded from efficacy RCTs. However, as this is a secondary analysis of 42% of the original RCT sample, it is important to replicate these findings in independent larger scale studies specifically designed for purpose. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated whether there were differences in coping strategies and self-esteem between offspring of parents with bipolar disorder (high-risk) and offspring of unaffected parents (control), and whether these psychological factors predicted the onset and recurrence of mood episodes. Methods: High-risk and control offspring were followed longitudinally as part of the Flourish Canadian high-risk bipolar offspring cohort study. Offspring were clinically assessed annually by a psychiatrist using semi-structured interviews and completed a measure of coping strategies and self-esteem. Results: In high-risk offspring, avoidant coping strategies significantly increased the hazard of a new onset Diagnostic and Statistical Manual of Mental Disorders, 4th Edition twice revised mood episode or recurrence (hazard ratio: 1.89, p = 0.04), while higher self-esteem significantly decreased this hazard (hazard ratio: 2.50, p < 0.01). Self-esteem and avoidant coping significantly interacted with one another (p < 0.05), where the risk of a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition twice revised new onset mood episode or recurrence was only significantly increased among high-risk offspring with both high avoidant coping and low self-esteem. Conclusion: A reduction of avoidant coping strategies in response to stress and improvement of self-esteem may be useful intervention targets for preventing the new onset or recurrence of a clinically significant mood disorder among individuals at high familial risk. [ABSTRACT FROM AUTHOR]

Background: Psychiatric illnesses like bipolar disorder are increasingly understood to be neurodevelopmental disorders with clinical, psychological, and biological indicators recognizable long before the emergence of the full-blown syndromes. Methods: This paper is a selective review of findings from studies of high-risk children of affected parents that inform the knowledge of illness risk and development markers of bipolar disorder. We specifically focus on candidate clinical, biological, and psychological risk indicators that could serve as targets for future early intervention and prevention studies. Results: There is convergent evidence from prospective studies that bipolar disorder typically debuts as depressive episodes after puberty. In some high-risk children, sleep and anxiety disorders precede mood disorders by several years and reflect an increased vulnerability. An association between early exposure to adversity (eg, exposure to parental illness, neglect from mother) and increased risk of psychopathology may be mediated through increased stress reactivity evident at both behavioral and biological levels. Inter-related psychological processes including reward sensitivity, unstable self-esteem, rumination, and positive self-appraisal are risk factors for mood disorders. Disturbances in circadian rhythm and immune dysfunction are associated with mood disorders and may be vulnerability markers influenced by these other risk factors. Conclusions: There is accruing evidence of a number of measurable and potentially modifiable markers of vulnerability and developing illness in youth at familial risk for bipolar disorder. Longitudinal studies of multiple biological and psychological risk processes in high-risk offspring, both individually and together, will improve our understanding of illness onset and lead to the development of specific early interventions. [ABSTRACT FROM AUTHOR]

Bipolar disorder is characterized by impaired decision-making captured in impulsivity and risk-taking. We sought to determine whether this is driven by a failure to effectively weight the lower-order goal of obtaining a strongly desired reward in relation to higher-order goals, and how this relates to trait impulsivity and risk-taking. We hypothesized that in bipolar disorder the weighting of valuation signals converging on ventromedial prefrontal cortex are more heavily weighted towards ventral striatum inputs (lower-order), with less weighting of dorsolateral prefrontal cortex inputs (higher-order). Twenty euthymic patients with bipolar disorder not in receipt of antipsychotic medication and 20 case-matched controls performed a roulette task during functional magnetic resonance imaging. Activity in response to high-probability (‘safe’) and low-probability (‘risky’) prospects was measured during both anticipation, and outcome. In control subjects, anticipatory and outcome-locked activity in dorsolateral prefrontal cortex was greater for safe than risky reward prospects. The bipolar disorder group showed the opposite pattern with preferential response to risky rewards. This group also showed increased anticipatory and outcome-locked activity in ventral striatum in response to rewards. In control subjects, however, ventromedial prefrontal activation was positively associated with both ventral striatum and dorsolateral prefrontal activity; patients evidenced a strong positive association with ventral striatum, but a negative association with dorsolateral prefrontal cortex. Response to high-probability rewards in dorsolateral prefrontal cortex was inversely associated with trait impulsivity and risk-taking in the bipolar disorder group. Our findings suggest that clinically impulsive and risky decision-making are related to subjective valuation that is biased towards lower-order preference, with diminished integration of higher-order goals. The findings extend a functional neuroanatomical account of disorders characterized by clinically impulsive decision-making, and provide targets for evaluating interventions that foster self-control. [ABSTRACT FROM AUTHOR]

An integrative cognitive model (Mansell et al. in Behav Cogn Psychother 35(5):515-539, ) proposed that multiple, extreme, personalised beliefs about internal states are key to the development and maintenance of mood swings and bipolar disorders. These beliefs can be assessed by the Hypomanic Attitudes & Positive Predictions Inventory (HAPPI; Mansell in Behav Cogn Psychother 34:467-476, ). In a student sample ( N = 175), the HAPPI independently predicted bipolar-relevant mood states and hypomania-relevant behaviours over a 4-day period. In line with previous research, the Hypomanic Personality Scale (HYP; Eckblad and Chapman in J Abnorm Psychol 95(3):214-222, ) and subscales of the Behavioural Inhibition and Behavioural Activation Scales (BIS/BAS; Carver and White in J Pers Soc Psychol 67(2):319-333, ) showed independent associations with outcome variables. The findings are discussed in the context of Mansell et al's (Behav Cogn Psychother 35(5):515-539, model. [ABSTRACT FROM AUTHOR]

The author comments on a study published within the issue which examined the association between the personality characteristics and serious mental illness. Topics covered include how the personality assessments were conducted by trained psychologists, neuroticism as animportant risk factor for psychosis, and the association between social maturity and bipolar disorder.