Little longitudinal research has examined progression to more severe bipolar disorders in individuals with “soft” bipolar spectrum conditions. We examine rates and predictors of progression to bipolar I and II diagnoses in a non-patient sample of college-age participants (n = 201) with high General Behavior Inventory scores and childhood or adolescent onset of “soft” bipolar spectrum disorders followed longitudinally for 4.5 years from the Longitudinal Investigation of Bipolar Spectrum (LIBS) project. Of 57 individuals with initial cyclothymia or bipolar disorder not otherwise specified (BiNOS) diagnoses, 42.1% progressed to a bipolar II diagnosis and 10.5% progressed to a bipolar I diagnosis. Of 144 individuals with initial bipolar II diagnoses, 17.4% progressed to a bipolar I diagnosis. Consistent with hypotheses derived from the clinical literature and the Behavioral Approach System (BAS) model of bipolar disorder, and controlling for relevant variables (length of follow-up, initial depressive and hypomanic symptoms, treatment-seeking, and family history), high BAS sensitivity (especially BAS Fun Seeking) predicted a greater likelihood of progression to bipolar II disorder, whereas early age of onset and high impulsivity predicted a greater likelihood of progression to bipolar I (high BAS sensitivity and Fun-Seeking also predicted progression to bipolar I when family history was not controlled). The interaction of high BAS and high Behavioral Inhibition System (BIS) sensitivities also predicted greater likelihood of progression to bipolar I. We discuss implications of the findings for the bipolar spectrum concept, the BAS model of bipolar disorder, and early intervention efforts.
bipolar disorder; Behavioral Approach System sensitivity; impulsivity
Bipolar spectrum disorders are characterized by highs and lows of mood, energy, motivation, cognition, and activity. The behavioral approach system (BAS) dysregulation theory provides an integrated model for understanding psychosocial and biological features of bipolar disorders. The theory emphasizes the role that sensitivity to rewards and goals plays in bipolar disorder. We review theory and evidence for the BAS-dysregulation model of bipolar disorders. We consider whether high BAS sensitivity is a correlate of, vulnerability factor for, and predictor of the course of bipolar spectrum disorders. We also discuss BAS-relevant life events as triggers of bipolar mood episodes. Finally, we address the implications of the BAS model for treatment and prevention of bipolar disorders and suggest directions for further research.
bipolar disorder; behavioral approach system; hypomania; mania; depression
We examined concurrent and prospective associations of self-focused cognitive styles with bipolar spectrum disorders. Controlling for depressive and hypomanic/manic symptoms, 125 individuals with bipolar spectrum disorders scored higher than 149 demographically similar normal controls on the rumination scale of the Response Styles Questionnaire (RSQ) and the private self-consciousness subscale of the Self-Consciousness Scale (SCS). The two groups did not differ on the distraction scale of the RSQ or the public self-consciousness and social anxiety subscales of the SCS. In addition, among the bipolar individuals, controlling for initial depressive and hypomanic/manic symptoms, rumination predicted the number, but not the likelihood of onset, of depressive episodes, whereas private self-consciousness predicted the likelihood of onset, but not the number, of hypomanic/manic episodes over a 3.5-year follow-up.
Bipolar Spectrum Disorder; Self-focused cognitive styles; Rumination; Self-consciousness; Depression; Hypomania/Mania
Bipolar disorders and substance use disorders (SUDs) show high co-occurrence. One explanation for this co-occurrence may be common personality vulnerabilities involved in both. We tested whether high Behavioral Approach System (BAS) sensitivity and impulsiveness are shared personality vulnerabilities in bipolar spectrum disorders and substance use problems and their co-occurrence in a longitudinal study of 132 bipolar spectrum and 153 normal individuals. At Time 1, participants completed the BIS/BAS Scales and the Impulsive Nonconformity Scale. Substance use problems were assessed via the Michigan Alcoholism Screening Test and the Drug Abuse Screening Test at 4 month intervals for one year. Bipolar participants had higher rates of lifetime SUDs and substance use problems during the follow-up, relative to normal controls. In line with hypotheses, higher BAS sensitivity and impulsiveness predicted bipolar status and increased substance use problems prospectively. BAS Total, BAS Fun-seeking, and impulsiveness mediated the association between bipolar spectrum status and prospective substance use problems, with impulsiveness as the most important mediator. High BAS sensitivity and impulsiveness may represent shared personality vulnerabilities for both disorders, and may partially account for their co-occurrence.
Bipolar Spectrum; Substance Use; Behavioral Approach System (BAS) Sensitivity; Impulsiveness
We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal – distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.
We examined the concurrent associations between multiple cognitive vulnerabilities to depression featured in Hopelessness Theory, Beck’s Theory, and Response Styles Theory and depressive symptoms and diagnoses in a sample of early adolescents. We also examined the specificity of these cognitive vulnerabilities to depression versus anxiety and externalizing psychopathology, controlling for co-occurring symptoms and diagnoses.
Male and female, Caucasian and African-American, 12–13 year old adolescents were assessed in a cross-sectional design. Cognitive vulnerabilities of hopelessness, inferential style, rumination, and self-referent information processing were assessed with self-reports and behavioral tasks. Symptoms and diagnoses of depressive, anxiety, and externalizing disorders were assessed with self-report questionnaires and diagnostic interviews.
Hopelessness exhibited the greatest specificity to depressive symptoms and diagnoses, whereas negative inferential styles, rumination, and negative self-referent information processing were associated with both depressive and anxiety symptoms and diagnoses and, in some cases, with externalizing disorders.
Consistent with cognitive theories of depression, hopelessness, negative inferential styles, rumination, and negative self-referent information processing were associated with depressive symptoms and diagnoses. However, with the exception of hopelessness, most of the remaining cognitive vulnerabilities were not specific to depression. With further maturation of our sample, these cognitive vulnerabilities may become more specific to depression as cognitive styles further develop and consolidate, the rates of depression increase, and individuals’ presentations of psychopathology become more differentiated.
cognitive vulnerability; depression; psychopathology; adolescence
Although past research has documented a link between adverse childhood experiences – particularly childhood emotional (CEA), physical (CPA), and sexual abuse (CSA) – and depression, relatively few studies have examined the unique impact of each of these highly co-occurring abuse types. Moreover, relatively little is known about the specific aspects of abuse experiences that increase risk for depression (e.g., number of perpetrators). The current study provides a conservative test of the association between the number of CEA, CPA, and CSA perpetrators, and depressive episodes in adulthood.
Two hundred and ninety-nine participants were followed longitudinally for 2.5 years. CEA, CPA, and CSA were measured using the Lifetime Experiences Questionnaire, and depressive episodes were assessed with diagnostic interviews administered every six weeks.
After statistically controlling for the influence of cognitive risk for depression, baseline depressive symptoms, past history of clinical depression, and total number of different types of CEA, CSA, and CPA events, the number of CEA and CSA, but not CPA, perpetrators were uniquely associated with the number of depressive episodes experienced over the prospective follow-up.
These results indicate that experiencing CEA and CSA from multiple perpetrators increased risk for clinical depression beyond what is accounted for by the total number of types of abuse experiences. This study highlights the need for future research to assess the specific qualities of childhood abuse experiences that uniquely confer risk for clinical depression, as well as possible mechanisms through which they exert their deleterious effect.
Depression; Childhood Abuse; Emotional Abuse; Sexual Abuse; Physical Abuse
The hopelessness theory of depression proposes that individuals with a depressogenic cognitive style are more likely to become hopeless and experience depression following negative life events. Although the neurophysiological underpinnings of cognitive style remain speculative, research indicates that decreased relative left-frontal brain electrical activity holds promise as a trait-like marker of depression. This begs the question: do measures of depressogenic cognitive style and resting frontal brain asymmetry index a common vulnerability? The present study provides preliminary support for this hypothesis. At baseline assessment, increased cognitive vulnerability to depression was associated with decreased relative left-frontal brain activity at rest in individuals with no prior history of, or current, depression. Following baseline assessment, participants were followed prospectively an average of 3.0 years with structured diagnostic interviews at 4-month intervals. Both cognitive vulnerability and asymmetric frontal cortical activity prospectively predicted onset of first depressive episode in separate univariate analyses. Furthermore, multivariate analyses indicated that cognitive vulnerability and frontal asymmetry represented shared, rather than independent, predictors of first depression onset.
Cognitive Vulnerability; Frontal EEG; Depression
Most life stress literature in bipolar disorder (BD) fails to account for the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. According to Post’s (1992) influential kindling hypothesis, major life stress is required to trigger initial onsets and recurrences of affective episodes, but successive episodes become progressively less tied to stressors and may eventually occur autonomously. Subsequent research on kindling has largely focused on unipolar depression (UD), and the model has been tested in imprecise and inconsistent ways. The aim of the present paper is to evaluate evidence for the kindling model as it applies to BD. We first outline the origins of the hypothesis, the evidence for the model in UD, and the issues needing further clarification. Next, we review the extant literature on the changing relationship between life stress and bipolar illness over time, and find that evidence from the methodologically strongest studies is inconsistent with the kindling hypothesis. We then integrate this existing body of research with two emerging biopsychosocial models of BD: the Behavioral Approach System dysregulation model, and the circadian and social rhythm theory. Finally, we present therapeutic implications and suggestions for future research.
Kindling; bipolar disorder; life events; stress sensitization; stress autonomy
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ's length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test-retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
Cognitive style; Depression; Anxiety
► We developed a Short-Form version of the Cognitive Style Questionnaire (CSQ). ► The CSQ Short Form (CSQ-SF) demonstrated satisfactory internal reliability. ► Test–retest reliability was also satisfactory. ► Scores demonstrated predicted correlations with measures of depression and anxiety. ► The CSQ-SF may be a useful research tool in assessing vulnerability to depression.
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ’s length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test–retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
Cognitive style; Depression; Anxiety
This study examined an experiential avoidance conceptualization of depressive rumination in 3 ways: 1) associations among questionnaire measures of rumination, experiential avoidance, and fear of emotions; 2) performance on a dichotic listening task that highlights preferences for non-depressive material; and 3) psychophysiological reactivity in an avoidance paradigm modeled after the one used by Borkovec and colleagues (1993) in their examination of worry. One hundred and thirty eight undergraduates completed questionnaire measures and participated in a clinical interview to diagnose current and past episodes of depression. Of those, 100 were randomly assigned to a rumination or relaxation induction condition and participated in a dichotic listening task, rumination/relaxation induction, and depression induction. Questionnaire measures confirmed a relationship between rumination status and avoidance; however, no significant effects were found in the dichotic listening task. Psychophysiological measures indicated no difference in physiological response to a depression induction among high ruminators (HR). However, low ruminators (LR) in the relaxation condition exhibited a larger IBI response than LR in the rumination condition. Overall, these results provide partial support for an avoidance conceptualization of depressive rumination. Implications of these findings are discussed.
The extent to which stress generation occurs in bipolar spectrum disorders (BSD) is not well understood. The present study examined whether 75 BSD participants experienced elevated rates of behavior-dependent life events, as compared with 88 normal control participants. Within the BSD group, we also examined whether depressive or hypomanic symptoms prospectively predicted increases in various types of negative and positive life events. Results indicated that BSD participants experienced overall increases in behavior-dependent events over the follow-up, as compared with normal controls. At the symptom level, the event generation process occurred in more specific event domains. Results suggest that the stress generation theory of unipolar depression can be extended to BSD and that the type of generated events may be polarity-specific.
bipolar spectrum disorder; stress generation; life events; hypomania; depression
The current study sought to examine three forms of negative, repetitive thinking in non-clinical children and adolescents aged between 10 and 18. More specifically, this study addressed the degree to which stress-reactive rumination can be differentiated from other forms of repetitive thinking, such as emotion-focused rumination and worry, and the associations between the various indices of repetitive thinking and symptoms of anxiety and depression. Participants completed a battery of self-report questionnaires including measures of stress-reactive rumination, emotion-focused rumination, worry, and symptoms of anxiety and depression. Results showed that stress-reactive rumination, emotion-focused rumination and worry are related but distinct forms of repetitive negative thinking. Positive associations were found between all indices of repetitive thinking and symptoms of depression and anxiety, but the effects of emotion-focused rumination disappeared when controlling for the other forms of repetitive thinking. The findings are discussed in the light of current theories and previous research, and directions for future research are provided.
anxiety; depression; repetitive thinking; rumination; worry
The current study explored longitudinal evidence for prodromal symptoms of depression episodes. A model based on previous findings of the relations between prodromal and residual symptoms was described and used to generate hypotheses tested in this study. Data were analyzed from 160 participants from the Cognitive Vulnerability to Depression (CVD) Project (Alloy & Abramson, 1999) who experienced an episode of depression during the prospective follow-up period and 60 CVD participants who did not. Congruent with the hypothesis, individuals who subsequently developed an episode of depression experienced significantly greater numbers of depression symptoms in the period of time leading up to the acute episode compared with those who did not develop a depressive episode. Seven depression symptoms were particularly likely to appear before the onset of an acute episode. Further, all three predictions from the model were supported: the durations of prodromal and residual phases were correlated, the prodromal and residual symptom profiles were quite similar, and the order of symptom onset was significantly and highly negatively correlated with the order of symptom remission. Additionally, residual symptom profiles were similar to subsequent prodromal symptom profiles in individuals who experienced more than one depressive episode. These findings are discussed in terms of the importance of understanding the earliest prodromal symptoms to appear and their relation to the symptomatic course of depression episodes. Implications for early intervention are also discussed.
Depression; prodrome; symptoms; course
Research indicates that life events involving goal-attainment and goal-striving trigger hypomania/mania and negative life events trigger bipolar depression. These findings are consistent with the behavioral approach system (BAS) dysregulation model of bipolar disorders, which suggests that individuals with bipolar disorders are hypersensitive to cues signaling opportunity for reward and cues signaling failure and loss of rewards. However, no studies to date have investigated whether individuals with bipolar spectrum disorders experience increased rates of these BAS-relevant life events, which would place them at double-risk for developing bipolar episodes. The present study found that individuals with bipolar II disorder and cyclothymia experience increased rates of BAS-activating and BAS-deactivating, but not Goal-attainment, life events. Finally, for bipolar spectrum individuals only, BAS-activating events predicted BAS-deactivating events' rates.
Behavioral Approach System; Bipolar Disorder; Life Events
Within the past 20 years, depression research has given increasing consideration to the possibility of complex and reciprocal relations between stress and depression. Not only does stress increase risk for depression (i.e., a stress exposure model of depression), but depression, or depressogenic vulnerabilities, in turn, also increases susceptibility to stressful events that are at least in part influenced by the individual (i.e., stress generation; Hammen, 1991). The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression. The research thus far appears most consistent in supporting the role of depression in predicting generated stress, although more research is still required. In addition to highlighting these findings, methodological limitations and conceptual gaps in the literature are discussed with the view of informing future research in this area.
Stress generation; Depression; Stress
The present study addressed convergence between self-report and indirect approaches to assessing dependency. The study was moderately successful in validating an implicit measure, which was found to be reliable, orthogonal to two self-report instruments, and predictive of external criteria. This study also examined discrepancies between scores on self-report and implicit measures, and has implications for their significance. The possibility that discrepancies themselves are pathological was not supported, although discrepancies were associated with particular personality profiles. Finally, this study offered additional evidence for the relation between dependency and depressive symptomatology, and identified implicit dependency as contributing unique variance in predicting past major depression.
Research has emerged providing consistent support for the behavioral approach system (BAS) dysregulation theory of bipolar disorder. The objective of the current article is to examine the extent to which findings from the BAS dysregulation theory can inform psychosocial interventions for bipolar disorder. Towards this end, we first provide an overview of the BAS dysregulation theory. Second, we review extant research on psychosocial interventions for bipolar disorder. And, third, we discuss means by which research and theory in line with the BAS dysregulation model can inform psychosocial interventions for bipolar disorder. Particular attention is given to the clinical implications of research suggesting that bipolar disorder is characterized by high drive/incentive motivation, ambitious goal-setting, and perfectionism in the achievement domain.
bipolar disorder; treatment; BAS
Depressive rumination, as assessed by Nolen-Hoeksema’s Response Styles Questionnaire (RSQ; Nolen-Hoeksema & Morrow, 1991), predicts the onset, chronicity, and duration of depressed mood. However, some RSQ items contain depressive content and result in a heterogeneous factor structure. After the a priori elimination of items potentially confounded with depressed item content, Treynor et al. (2003) identified two factors within the remaining RSQ rumination subscale that were differentially related to depression: brooding and pondering. However, Treynor et al. (2003) used a non-standard form and administration of the RSQ. The present study sought to address these methodological idiosyncrasies and replicate the factor structure of Treynor et al. (2003) through exploratory factor analysis and structural equation modeling. Findings support the brooding and pondering solution and demonstrate that brooding relates more strongly to depression and anxiety than does pondering.
response styles; depressive rumination; factor analysis; brooding; pondering
The present study sought to test predictions of the response styles theory in a sample of children and adolescents. More specifically, a ratio approach to response styles was utilized to examine the effects on residual change scores in depression and anxiety. Participants completed a battery of questionnaires including measures of rumination, distraction, depression, and anxiety at baseline (Time 1) and 8–10 weeks follow-up (Time 2). Results showed that the ratio score of rumination and distraction was significantly associated with depressed and anxious symptoms over time. More specifically, individuals who have a greater tendency to ruminate compared to distracting themselves have increases in depression and anxiety scores over time, whereas those who have a greater tendency to engage in distraction compared to rumination have decreases in depression and anxiety symptoms over time. These findings indicate that a ratio approach can be used to examine the relation between response styles and symptoms of depression and anxiety in non-clinical children and adolescents. Implications of the results may be that engaging in distractive activities should be promoted and that ruminative thinking should be targeted in juvenile depression treatment.
adolescents; children; distraction; response styles theory; rumination
We examined concurrent and prospective associations of Behavioral Approach System (BAS)-relevant and non-BAS-relevant cognitive styles with bipolar spectrum disorders. Controlling for depressive and hypomanic/manic symptoms, 195 individuals with bipolar spectrum disorders scored higher than 194 demographically matched normal controls on BAS sensitivity and BAS-relevant cognitive dimensions of performance concerns, autonomy, and self-criticism, but not on BIS sensitivity and non-BAS-relevant dimensions of approval-seeking, sociotropy, and dependency. Moreover, group differences on autonomy fully mediated the association between higher BAS sensitivity and bipolar status. In addition, only BAS-related cognitive dimensions predicted the likelihood of onset of depressive and hypomanic/manic episodes among the bipolar individuals over a 3.2-year follow-up, controlling for initial symptoms and past history of mood episodes. Higher autonomy and self-criticism predicted a greater likelihood of hypomanic/manic episodes and higher autonomy predicted a lower likelihood of major depressive episodes. In addition, autonomy mediated the associations between BAS sensitivity and prospective hypomanic/manic episodes. These findings suggest that individuals with bipolar spectrum disorders may exhibit a unique profile of BAS-relevant cognitive styles that influence the course of their mood episodes.
Bipolar Spectrum Disorder; Behavioral Approach System (BAS); Cognitive Styles
This study examined the social zeitgeber theory, which suggests that affective symptoms are caused by life events disrupting vulnerable individuals’ social and biological rhythms. Undergraduate participants were selected based on a two phase screening process, including a semi-structured diagnostic interview. The final sample consisted of 101 bipolar spectrum participants and 100 demographically matched normal controls. Participants who completed up to three follow-up visits, approximately every four months, as part of a longitudinal study were included in the current study. Life events did not predict social rhythm regularity and social rhythm regularity inconsistently predicted affective symptoms. However, life events, particularly social rhythm disruption (SRD) events, did predict depressive symptoms and episodes, and less consistently predicted hypo(manic) symptoms and episodes. Thus, the current study obtained mixed support for the social zeitgber theory.
Bipolar disorder; life events; social rhythms; affective symptoms
Negative cognitive styles are an important cognitive vulnerability for depression, but stability of high cognitive risk, once developed, is unclear. The current study examined stability of cognitive vulnerability to depression in individuals at high and low cognitive risk (extreme scores on both the CSQ and DAS) over a 7-year period from late adolescence through early adulthood. Cognitive vulnerability showed high relative stability, as evidenced by the moderate to high correlation (rs = .62) between cognitive risk status at study onset and at final assessment 7 years later. Consistent with stability, subgroups were identified using growth mixture modeling, and most cognitively high-risk (62.22% for CSQ, 68.89% for DAS) and low-risk (55.05% for CSQ, 57.96% for DAS) participants showed stable trajectories of cognitive vulnerability. Despite this overall pattern of stability, small mean group changes were found, and a minority of participants showed changing trajectories, consistent with regression toward the mean. Predictors of change and implications for risk for depression in high- and low-risk individuals are discussed.
cognitive vulnerability; depression; trajectory; stability
Prospective tests of the impact of sociotropy and autonomy on the course of depression are lacking. In a sample of 97 cognitive high-risk and 62 cognitive low-risk undergraduates who experienced at least one prospective depressive episode, the interactions of sociotropy and interpersonal life events and autonomy and achievement-related life events were examined as predictors of four indicators of the course of depression. Initial analyses failed to support the hypothesis that global scores for sociotropy and autonomy interact with domain-congruent life events to predict the course indicators. The autonomy-achievement events interaction predicted less severe episodes, contrary to hypothesis. Then, factors hypothesized to underlie Sociotropy (Fear of Criticism and Rejection; Preference for Affiliation) and Autonomy were also analyzed. The puzzling autonomy-achievement life event interaction was explained by the underlying Independent Goal Attainment factor. Interactions between Fear of Criticism and Rejection and achievement events, and between Sensitivity to Others’ Control and interpersonal events, significantly predicted chronicity, number and severity of episodes. The findings are discussed in terms of the event-congruency hypothesis.
Sociotropy; Autonomy; Depression; Course