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Scholl J, Panchal P, Nelissen N, Atkinson LZ, Kolling N, Saunders KE, Geddes J, Rushworth MF, Nobre AC, Harrison PJ, Harmer CJ. Neural signatures of risk-taking adaptions across health, bipolar disorder, and lithium treatment. Mol Psychiatry 2025:10.1038/s41380-025-02900-w. [PMID: 39880901 DOI: 10.1038/s41380-025-02900-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/27/2024] [Accepted: 01/16/2025] [Indexed: 01/31/2025]
Abstract
Cognitive and neural mechanisms underlying bipolar disorder (BD) and its treatment are still poorly understood. Here we examined the role of adaptations in risk-taking using a reward-guided decision-making task. We recruited volunteers with high (n = 40) scores on the Mood Disorder Questionnaire, MDQ, suspected of high risk for bipolar disorder and those with low-risk scores (n = 37). We also recruited patients diagnosed with BD who were assigned (randomized, double-blind) to six weeks of lithium (n = 19) or placebo (n = 16) after a two-week baseline period (n = 22 for FMRI). Participants completed mood ratings daily over 50 (MDQ study) or 42 (BD study) days, as well as a risky decision-making task and functional magnetic resonance imaging. The task measured adaptation of risk taking to past outcomes (increased risk aversion after a previous win vs. loss, 'outcome history'). While the low MDQ group was risk averse after a win, this was less evident in the high MDQ group and least so in the patients with BD. During fMRI, 'outcome history' was linked to medial frontal pole activation at the time of the decision and this activation was reduced in the high risk MDQ vs. the low risk MDQ group. While lithium did not reverse the pattern of BD in the task, nor changed clinical symptoms of mania or depression, it changed reward processing in the dorsolateral prefrontal cortex. Participants' modulation of risk-taking in response to reward outcomes was reduced as a function of risk for BD and diagnosed BD. These results provide a model for how reward may prime escalation of risk-related behaviours in bipolar disorder and how mood stabilising treatments may work.
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Affiliation(s)
- Jacqueline Scholl
- Université Claude Bernard Lyon 1, CNRS, Inserm, Lyon Neuroscience Research Centre U1028 UMR 5292, PsyR2 team, Centre Hospitalier Le Vinatier, Bron, France.
- Oxford Centre for Human Brain Activity (OHBA), Wellcome Centre for Integrative Neuroimaging (WIN), Department of Psychiatry, University of Oxford, Oxford, UK.
| | | | | | - Lauren Z Atkinson
- Oxford Centre for Human Brain Activity (OHBA), Wellcome Centre for Integrative Neuroimaging (WIN), Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Nils Kolling
- Université Claude Bernard Lyon 1, Inserm, Stem Cell and Brain Research Institute U1208, Bron, France
| | - Kate Ea Saunders
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Matthew Fs Rushworth
- Department of Experimental Psychology, Wellcome Centre for Integrative Neuroimaging (WIN), University of Oxford, Oxford, UK
| | - Anna C Nobre
- Oxford Centre for Human Brain Activity (OHBA), Wellcome Centre for Integrative Neuroimaging (WIN), Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Psychology and Wu Tsai Institute, Yale University, New Haven, CT, USA
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Álvarez-Cadenas L, García-Vázquez P, Ezquerra B, Stiles BJ, Lahera G, Andrade-González N, Vieta E. Detection of bipolar disorder in the prodromal phase: A systematic review of assessment instruments. J Affect Disord 2023; 325:399-412. [PMID: 36623571 DOI: 10.1016/j.jad.2023.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early detection of prodromal symptoms may contribute to improving the prognosis of patients with bipolar disorder (BD). The main objective of this systematic review is to present the different procedures for the identification of initial and relapse prodromes in these patients. METHODS PsycINFO, Web of Science and PubMed databases were searched using a predetermined strategy, until January 4, 2022. Then, by means of a regulated process, studies that used a BD prodrome detection procedure, in English-language and all ages participants were selected. Quantitative and qualitative studies were assessed using a modified version of the Newcastle-Ottawa Scale and by Critical Appraisals Skills Programme checklist, respectively. RESULTS Forty-five studies were selected. Of these, 26 used procedures for identifying initial prodromes (n = 8014) and 19 used procedures for detecting relapse prodromes (n = 1136). The interview was the most used method in the detection of both types of prodromes (k = 30 papers, n = 4068). It was variable in its degree of structure. Mobile applications and digital technologies are gaining importance in the detection of the relapse prodromes. LIMITATIONS A retrospective design in most papers, small samples sizes, existence of persistent subsyndromal symptoms and difficulty to identify the end of the prodrome and the onset of the disorder. CONCLUSIONS There is a wide variety of assessment instruments to detect prodromes in BD, among which the clinical interview is most frequently used. Future research should consider development of a brief tool to be applied in different formats to patients and family members.
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Affiliation(s)
- Laura Álvarez-Cadenas
- Central University Hospital of Asturias, Health Service of Principality of Asturias, Oviedo, Spain.
| | - Paula García-Vázquez
- Central University Hospital of Asturias, Health Service of Principality of Asturias, Oviedo, Spain
| | - Berta Ezquerra
- Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Bryan J Stiles
- Department of Psychology and Neuroscience, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Guillermo Lahera
- Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain; IRyCIS, CIBERSAM, Madrid, Spain; Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain
| | - Nelson Andrade-González
- Psychiatry and Mental Health Research Group, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain; Faculty of Medicine, Alfonso X el Sabio University, Villanueva de la Cañada, Madrid, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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Chan SHW, Yu CH, Liu KHK, Lau C, Fung AOY, Tse S. Evaluating the emotion regulation of positive mood states among people with bipolar disorder using hierarchical clustering. World J Psychiatry 2021; 11:619-634. [PMID: 34631465 PMCID: PMC8474994 DOI: 10.5498/wjp.v11.i9.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/25/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND People with bipolar disorder (BD) frequently struggle with the recurrence of affective symptoms. However, the interplay between coping mechanism and positive mood state remains under-researched.
AIM To explore the associations among behavioral approach system (BAS) sensitivity level, coping, and positive mood states among people with BD.
METHODS Using a cross-sectional study design, 90 participants with BD were presented with four BAS-activating life event scenarios and assessed with regard to their BAS trait sensitivity, coping flexibility, and mood states. A hierarchical clustering method was used to identify different groups with different styles of coping. Multiple hierarchical regression analyses were conducted to examine the mediating and moderating roles of different components of coping on mood states.
RESULTS A three-cluster solution was found to best fit the present data set. The findings showed that a low mass of coping combined with low BAS sensitivity level protects people with BD from detrimentally accentuating mood states when they encounter BAS-activating life events. Moreover, coping flexibility is demonstrated to mediate and moderate the relationships between BAS sensitivity level and mood states. Specifically, subduing the perceived controllability and reducing the use of behavioral-activation/emotion-amplifying coping strategies could help buffer the effect of positive affect.
CONCLUSION The judicious use of coping in emotion regulation for people with BD when encountering BAS-activating life events was indicated. Practical applications and theoretical implications are highlighted.
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Affiliation(s)
- Sunny Ho-Wan Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Chong Ho Yu
- School of Behavioral and Applied Science, Azusa Pacific University, Azusa, CA 91702, United States
| | - Ken Ho Kan Liu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Charlie Lau
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Anna On Yee Fung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Samson Tse
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
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Aksoy Poyraz C, Özdemir A, Çakir Şen C, Usta Sağlam NG, Enginkaya S, Tomruk N. The Impact of Coping Strategies on Suicide Attempts and Suicidal Ideation in Bipolar Disorder. J Nerv Ment Dis 2021; 209:564-570. [PMID: 33867505 DOI: 10.1097/nmd.0000000000001347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The stress coping strategies of patients with bipolar disorder (BD) may affect their suicide risk. We examined coping behaviors and impact of coping strategies and clinical characteristics on suicide attempts and lifetime suicidal ideation in patients with BD I, compared with a healthy control group. We recruited 185 euthymic patients with BD and 94 healthy controls. Participants completed the Coping Orientation to Problems Experienced Inventory. Suicide attempt prevalence in patients with BD was around 34%, and frequency of lifetime suicide ideation was around 60%. Binary logistic regression analysis revealed greater use of behavioral disengagement and religious coping strategies among patients with BD, compared with controls. Patients with previous suicide attempts presented a more severe illness course, notably early onset, with more depressive and mixed episodes and a more dysfunctional coping style than nonsuicidal patients. Behavioral interventions can target avoidant coping behavior, such as denial, especially in patients with suicide attempts.
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Affiliation(s)
- Cana Aksoy Poyraz
- Department of Psychiatry, İstanbul University-Cerrahpaşa Medical School
| | - Armağan Özdemir
- Department of Psychology, Altinbaş University, School of Medicine
| | - Cansu Çakir Şen
- Bakirköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital
| | - Nazife Gamze Usta Sağlam
- Erenkoy Training and Research Hospital for Psychiatry and Neurological Diseases, Istanbul, Turkey
| | - Semra Enginkaya
- Bakirköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital
| | - Nesrin Tomruk
- Bakirköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital
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Wright K, Dodd AL, Warren FC, Medina-Lara A, Dunn B, Harvey J, Javaid M, Jones SH, Owens C, Taylor RS, Duncan D, Newbold A, Norman S, Warner F, Lynch TR. Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme). Int J Bipolar Disord 2021; 9:20. [PMID: 34195864 PMCID: PMC8245616 DOI: 10.1186/s40345-021-00226-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022] Open
Abstract
Background A subgroup of those with bipolar spectrum disorders experience ongoing mood fluctuations outside of full episodes. We conducted a randomised, controlled feasibility study of a Dialectical Behavioural Therapy-informed approach for bipolar mood fluctuations (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). Our study aimed to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. Participants were required to meet diagnostic criteria for a bipolar spectrum disorder and report frequent mood swings outside of acute episodes. They were randomised to treatment as usual (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points were at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point. To evaluate feasibility and acceptability we examined recruitment and retention rates, completion rates for study measures, adverse events and feedback from participants on their experience of study participation and therapy. Results Of the target 48 participants, 43 were recruited (22 in the intervention arm; 21 in the control arm), with a recruitment rate of 3.9 participants per month. At 9 months 74% of participants engaged in research follow-up assessment, exceeding the pre-specified criterion of 60%. There were no serious concerns about the safety of the research procedures or the intervention. On one of the four candidate primary outcome measures, the 95% CI for the between-group mean difference score excluded the null effect and included the minimal clinically important difference, favouring the intervention arm, whilst on no measure was there evidence of deterioration in the intervention arm relative to the control arm. Attendance of the intervention (50% attending at least half of the mandatory sessions) was below the pre-specified continuation criterion of 60%, and qualitative feedback from participants indicated areas that may have hampered or facilitated engagement. Conclusions It is broadly feasible to conduct a trial of this design within the population of people with frequent bipolar mood swings. Changes should be made to the therapy to increase uptake, such as simplifying content and considering individual rather than group delivery. Trial registration ISRCTN: ISRCTN54234300. Registered 14th July 2017, http://www.isrctn.com/ISRCTN54234300 Supplementary Information The online version contains supplementary material available at 10.1186/s40345-021-00226-4.
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Affiliation(s)
- Kim Wright
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK.
| | - Alyson L Dodd
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Fiona C Warren
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Antonieta Medina-Lara
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Barnaby Dunn
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Julie Harvey
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Mahmood Javaid
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Steven H Jones
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Christabel Owens
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Rod S Taylor
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Deborah Duncan
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Alexandra Newbold
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Shelley Norman
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Faith Warner
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
| | - Thomas R Lynch
- Washington Singer Labs., University of Exeter Department of Psychology, Perry Road, Exeter, EX4 4QG, UK
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ÇAKMAK S, TAMAM L. Remisyonda olan bipolar bozukluk tip I olgularında bilinçli farkındalık ve atak sıklığı ilişkisi. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.904859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Abstract
AbstractBackgroundA relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients.MethodsA systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords.ResultsPsychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients' health beliefs and illness-awareness.ConclusionsThe usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents.
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Affiliation(s)
- Francesc Colom
- Bipolar Disorders Program, IDIBAPS, Barcelona Stanley Medical Research Center, Barcelona, Spain.
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O'Brien B, Lee D, Swann AC, Mathew SJ, Lijffijt M. Psychotherapy for Mixed Depression and Mixed Mania. Psychiatr Clin North Am 2020; 43:199-211. [PMID: 32008685 DOI: 10.1016/j.psc.2019.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Treatment guidelines for mixed states of depression or (hypo)mania focus almost exclusively on psychopharmacologic intervention without tapping into the benefits of psychotherapy. The authors highlight the complex clinical picture and illness course of mixed states, and discuss the benefit of taking a patient-centered approach to treatment incorporating techniques from a variety of evidence-based psychotherapies. A careful assessment of suicide risk as well as interventions designed specifically for anxiety are also recommended.
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Affiliation(s)
- Brittany O'Brien
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Delphine Lee
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Alan C Swann
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Sanjay J Mathew
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Marijn Lijffijt
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA.
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Andrade-González N, Álvarez-Cadenas L, Saiz-Ruiz J, Lahera G. Initial and relapse prodromes in adult patients with episodes of bipolar disorder: A systematic review. Eur Psychiatry 2020; 63:e12. [PMID: 32093795 PMCID: PMC7315869 DOI: 10.1192/j.eurpsy.2019.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Distinguishing prodromes of bipolar disorder (BD) specific to children/adolescents, adults, and elderly patients is essential. The primary objective of this systematic review was to determine initial and relapse prodromes identifying adult patients with BD. METHODS PubMed, PsycINFO, and Web of Science databases were searched using a predetermined strategy. A controlled process of study selection and data extraction was performed. RESULTS The 22 articles selected included 1,809 adult patients with BD. Initial prodromes cited most frequently in these studies showed low specificity. Among relapse prodromes cited most frequently, more talkative than usual, increased energy/more goal-directed behavior, thoughts start to race, increased self-esteem, strong interest in sex, increase in activity, and spending too much were identified exclusively before a manic/hypomanic episode, while loss of interest and hypersomnia were detected only before a depressive episode. Initial prodromal phases lasted longer than prodromal relapse phases. In the selected studies, the most used prodrome identification procedure was the clinical interview. CONCLUSIONS For adult patients with BD, initial and relapse prodromes of manic, hypomanic, and depressive episodes were identified. It is proposed that the most frequent prodromes found in this review be incorporated into a smartphone app that monitors the functioning of people at risk of BD and patients who have already been diagnosed. Data from this app would constitute a relevant source of big data.
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Affiliation(s)
- Nelson Andrade-González
- Relational Processes and Psychotherapy Research Group, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain
| | | | - Jerónimo Saiz-Ruiz
- Ramón y Cajal University Hospital, Madrid, Spain.,Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,IRyCIS, CIBERSAM, Madrid, Spain
| | - Guillermo Lahera
- Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,IRyCIS, CIBERSAM, Madrid, Spain
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10
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Painter JM, Mote J, Peckham AD, Lee EH, Campellone TR, Pearlstein JG, Morgan S, Kring AM, Johnson SL, Moskowitz JT. A positive emotion regulation intervention for bipolar I disorder: Treatment development and initial outcomes. Gen Hosp Psychiatry 2019; 61:96-103. [PMID: 31439286 PMCID: PMC6861691 DOI: 10.1016/j.genhosppsych.2019.07.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Dysfunction in positive affect is a defining symptom of bipolar I disorder (BD), both during and between mood episodes. We hypothesize that helping people with BD learn skills to create balance in their affective experiences by engaging in strategies that increase low activation positive emotion (LAP; e.g., relaxation) could help to improve well-being during periods of symptom remission. We discuss the development and preliminary outcomes of a positive emotion regulation (PER) group treatment for people with BD, designed as a supplement to pharmacological treatment. METHOD The Learning Affective Understanding for a Rich Emotional Life (LAUREL) intervention is a group-based intervention covering 10 empirically supported skills designed to increase LAP. Sixteen people with BD enrolled in the LAUREL intervention and twelve completed baseline and post-intervention assessments. RESULTS Participants who completed the study (n = 12) attended the majority of groups (87.96%) and reported practicing skills, on average, 16 times a week. We were unable to detect significant differences in mania symptoms following engagement in this PER intervention. Finally, participants reported increases in several areas associated with well-being post-intervention, including mindfulness, reappraisal, and self-compassion. CONCLUSION This study provides a theoretical framework and preliminary support for a PER intervention for BD.
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Affiliation(s)
- Janelle M Painter
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Jasmine Mote
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Andrew D Peckham
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Erica H Lee
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Timothy R Campellone
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Jennifer G Pearlstein
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Stefana Morgan
- University of California, San Francisco, Department of Psychiatry, United States of America.
| | - Ann M Kring
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Sheri L Johnson
- University of California, Berkeley, Department of Psychology, United States of America.
| | - Judith T Moskowitz
- University of California, San Francisco, Department of Psychiatry, United States of America.
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11
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Van Meter A, Guinart D, Bashir A, Sareen A, Cornblatt BA, Auther A, Carrión RE, Carbon M, Jiménez-Fernández S, Vernal DL, Walitza S, Gerstenberg M, Saba R, Cascio NL, Correll CU. Bipolar Prodrome Symptom Scale - Abbreviated Screen for Patients: Description and validation. J Affect Disord 2019; 249:357-365. [PMID: 30807937 DOI: 10.1016/j.jad.2019.02.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/04/2019] [Accepted: 02/11/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE There is no standard method for assessing symptoms of the prodrome to bipolar disorder (BD), which has limited progress toward early identification and intervention. We aimed to validate the Bipolar Prodrome Symptom Scale-Abbreviated Screen for Patients (BPSS-AS-P), a brief self-report derived from the validated, clinician-rated Bipolar Prodrome Symptom Interview and Scale-Full Prospective (BPSS-FP), as a means to screen and identify people for whom further evaluation is indicated. METHOD Altogether, 134 participants (aged 12-18 years) were drawn from a study of the pre-syndromal stage of mood and psychotic disorders. All participants had chart diagnoses of a mood- or psychosis-spectrum disorder. Participants were interviewed with the BPSS-FP and completed measures of mania and non-mood psychopathology. Prior to being interviewed, patients completed the BPSS-AS-P. Scores on the BPSS-AS-P were determined by summing the severity and frequency ratings for each item. RESULTS BPSS-AS-P scores were highly reliable (Cronbach's alpha = 0.94) and correlated with the interview-based BPSS-FP Mania Symptom Index (r = 0.55, p < .0001). BPSS-AS-P scores had good convergent validity, correlating with the General Behavior Inventory-10M (r = 0.65, p < .0001) and Young Mania Rating Scale; r = 0.48, p < .0001). The BPSS-AS-P had good discriminant validity, not being correlated with scales measuring positive and negative symptoms of psychotic disorders (p-values = 0.072-0.667). LIMITATIONS Findings are limited by the cross-sectional nature of the study by the fact that the participants were all treatment-seeking. Future studies need to evaluate the predictive validity of the BPSS-AS-P for identifying those who develop BD in a community sample. CONCLUSION BPSS-AS-P has promise as a screening tool for people at risk for BD. Adopting the BPSS-AS-P would support the goal of characterizing the prodrome systematically in order to facilitate research and clinical care.
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Affiliation(s)
- Anna Van Meter
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Daniel Guinart
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Asjad Bashir
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Aditya Sareen
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Barbara A Cornblatt
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Andrea Auther
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Ricardo E Carrión
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Maren Carbon
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Jaén Medical Center, Jaén, Spain; Department of Psychiatry, University of Granada, Granada, Spain
| | - Ditte L Vernal
- Research Unit for Child- and Adolescent Psychiatry, Aalborg University Hospital, North Denmark Region, Denmark
| | - Susanne Walitza
- Psychiatric University Hospital Zurich, Department of Child and Adolescent Psychiatry and Psychotherapy, Zurich, Switzerland
| | - Miriam Gerstenberg
- Psychiatric University Hospital Zurich, Department of Child and Adolescent Psychiatry and Psychotherapy, Zurich, Switzerland
| | - Riccardo Saba
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Nella Lo Cascio
- Charité Universitätsmedizin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA; Charité Universitätsmedizin, Department of Child and Adolescent Psychiatry, Berlin, Germany.
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12
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Bridi KPB, Loredo-Souza ACM, Fijtman A, Moreno MV, Kauer-Sant'Anna M, Ceresér KMM, Kunz M. Differences in coping strategies in adult patients with bipolar disorder and their first-degree relatives in comparison to healthy controls. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2019; 40:318-325. [PMID: 30570103 DOI: 10.1590/2237-6089-2017-0140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/20/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The objective of this study was to compare patients with bipolar disorder (BD), their first-degree relatives and a group of healthy controls in terms of use of adaptive and maladaptive coping strategies, exploring differences between specific types of strategies and their correlations with clinical variables. METHODS This was a cross-sectional study enrolling 36 euthymic patients with BD, 39 of their first-degree relatives and 44 controls. Coping strategies were assessed using the Brief COPE scale. RESULTS Significant differences were detected in the use of adaptive and maladaptive strategies by patients, their first-degree relatives and controls. Patients used adaptive strategies less often than the patients' relatives (p<0.001) and controls (p = 0.003). There was no significant difference between first-degree relatives and controls (p=0.707). In contrast, patients (p<0.001) and their relatives (p=0.004) both exhibited higher scores for maladaptive coping than controls. There was no significant difference regarding the use of maladaptive strategies between patients and their relatives (p=0.517). CONCLUSIONS First-degree relatives were at an intermediate level between patients with BD and controls regarding the use of coping skills. This finding supports the development of psychosocial interventions to encourage use of adaptive strategies rather than maladaptive strategies in this population.
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Affiliation(s)
- Kelen Patrícia Bürke Bridi
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Ana Claudia M Loredo-Souza
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Adam Fijtman
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Mirela Vasconcelos Moreno
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Márcia Kauer-Sant'Anna
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Keila Maria Mendes Ceresér
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Mauricio Kunz
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
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13
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Chan SHW, Tse S. An explorative study on coping flexibility with behavioral approach system-activating stimuli: A comparison of people with and without bipolar disorder. Psychiatry Res 2018; 269:399-407. [PMID: 30173047 PMCID: PMC7112654 DOI: 10.1016/j.psychres.2018.08.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 06/26/2018] [Accepted: 08/24/2018] [Indexed: 12/20/2022]
Abstract
Life events play a significant role in affecting mood symptoms of people with bipolar disorder (BD). However, we lack empirical data about the associations among disorder, mood state, behavioral activation system (BAS) sensitivity, and psychosocial functioning level. Thus, the present study aimed to identify the role of coping flexibility with BAS activating stimuli in relation to mood states among a sample of individuals with BD (n = 90) and a healthy control group (n = 90). Through multiple regressions, the moderating role of coping flexibility was determined. Findings showed that coping flexibility had an additional value in predicting mood states beyond BAS sensitivity and psychosocial functioning level. Specifically, perceived controllability was considerably important for the BD group, whereas fit index was crucial in the controls. In addition, a moderation analysis showed that perceived controllability alleviated the effects of BD diagnosis, BAS sensitivity, and psychosocial functioning level on mood states. Theoretically, this study helps integrate the concept of coping flexibility into the BAS dysregulation theory as it applies to BD. The practical implication for enhancing mindfulness practice is also discussed.
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Affiliation(s)
- Sunny H W Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong.
| | - Samson Tse
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
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14
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Chan SHW, Tse S. Coping with amplified emotionality among people with bipolar disorder: A longitudinal study. J Affect Disord 2018; 239:303-312. [PMID: 30031250 DOI: 10.1016/j.jad.2018.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/20/2018] [Accepted: 07/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The amplified emotionality characteristics of bipolar disorder (BD) may interfere with goal pursuit in the recovery process. This is the first study to test the coping flexibility model empirically among people with BD. Finding ways to cope with goal-striving life events should shed light on managing elevated mood states. METHODS Using a 12-month longitudinal follow-up design, this study examined the stability in coping flexibility with experimentally-devised Behavioral Approach System (BAS) activating life events and mood states at 6- and 12-month time points for individuals with BD (n = 83) and healthy controls (n = 89). Hierarchical linear modeling tested the individual growth model by studying the longitudinal data. RESULTS The findings showed fluctuations in different components of coping flexibility and mood states across time. They confirmed the amplified emotionality characteristics of BD. Moreover, coping flexibility took precedence over BAS sensitivity and psychosocial functioning levels in predicting mood states. LIMITATIONS Measurements of BAS sensitivity may focus on trait nature only and prone to subjective bias. The assessment of mood or coping flexibility may not accurately capture actual experience in daily life. Lack of respective data on bipolar subtypes and significant differences in some dimensions between the BD and control groups are further limitations of the study. CONCLUSIONS The study's findings have implications for coping with amplified emotionality within the personal recovery process for people with BD. Judicious application of coping strategies and adjustment of perceived controllability are crucial for individuals to reach goals pertinent to personal recovery and manage potential manic mood symptoms.
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Affiliation(s)
- Sunny H W Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China.
| | - Samson Tse
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
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15
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Paans NPG, Dols A, Comijs HC, Stek ML, Schouws SNTM. Associations between cognitive functioning, mood symptoms and coping styles in older age bipolar disorder. J Affect Disord 2018; 235:357-361. [PMID: 29665519 DOI: 10.1016/j.jad.2018.04.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Older age patients with bipolar disorder (OABD) have often passive coping styles, generally considered as detrimental for functioning. The aim of the current study is to identify the contribution of cognitive functioning, subjective cognitive complaints and mood symptoms to passive and active coping styles in older age BD. METHODS In 90 euthymic patients (age > 60) with BD I or II, we examined coping, neuropsychological profile including memory, attention, executive function and fluency, subjective cognitive complaints and mood symptoms. RESULTS Better executive functioning and fewer depressive symptoms were associated with more active coping (p = .02 and p = .001 respectively). Associations between executive functioning and coping styles turned nonsignificant when combined with depressive symptoms in one model, indicating the importance of mood on coping styles. No associations were found between subjective cognitive complaints and coping styles. LIMITATIONS Cross-sectional data were used and no conclusions about causality can be made. CONCLUSIONS Even in euthymic patients, subclinical depressive symptoms may influence active coping negatively. Subjective cognitive complaints and objectified cognitive functioning seem to be of less importance for coping styles. Important implications are on the one hand optimizing treatment on reducing depressive symptoms and on the other hand focusing therapeutic interventions on coping in bipolar patients.
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Affiliation(s)
- Nadine P G Paans
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Annemiek Dols
- Department of Old Age Psychiatry, GGZ inGeest/VU University Medical Center, Amsterdam Public Health research institute, Amsterdam, The Netherlands; Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Hannie C Comijs
- Department of Old Age Psychiatry, GGZ inGeest/VU University Medical Center, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Max L Stek
- Department of Old Age Psychiatry, GGZ inGeest/VU University Medical Center, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Sigfried N T M Schouws
- Department of Old Age Psychiatry, GGZ inGeest/VU University Medical Center, Amsterdam Public Health research institute, Amsterdam, The Netherlands
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16
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Increased sensitivity to positive social stimuli in monozygotic twins at risk of bipolar vs. unipolar disorder. J Affect Disord 2018; 232:212-218. [PMID: 29499503 DOI: 10.1016/j.jad.2018.02.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/12/2018] [Accepted: 02/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Abnormalities in affective cognition are putative endophenotypes for bipolar and unipolar disorders but it is unclear whether some abnormalities are disorder-specific. We therefore investigated affective cognition in monozygotic twins at familial risk of bipolar disorder relative to those at risk of unipolar disorder and to low-risk twins. METHODS Seventy monozygotic twins with a co-twin history of bipolar disorder (n = 11), of unipolar disorder (n = 38) or without co-twin history of affective disorder (n = 21) were included. Variables of interest were recognition of and vigilance to emotional faces, emotional reactivity and -regulation in social scenarios and non-affective cognition. RESULTS Twins at familial risk of bipolar disorder showed increased recognition of low to moderate intensity of happy facial expressions relative to both unipolar disorder high-risk twins and low-risk twins. Bipolar disorder high-risk twins also displayed supraliminal attentional avoidance of happy faces compared with unipolar disorder high-risk twins and greater emotional reactivity in positive and neutral social scenarios and less reactivity in negative social scenarios than low-risk twins. In contrast with our hypothesis, there was no negative bias in unipolar disorder high-risk twins. There were no differences between the groups in demographic characteristics or non-affective cognition. LIMITATIONS The modest sample size limited the statistical power of the study. CONCLUSIONS Increased sensitivity and reactivity to positive social stimuli may be a neurocognitive endophenotype that is specific for bipolar disorder. If replicated in larger samples, this 'positive endophenotype' could potentially aid future diagnostic differentiation between unipolar and bipolar disorder.
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17
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Abstract
Although mood stabilisers have substantially improved the treatment of bipolar disorder, recent studies suggest that treatment with lithium is not as effective as originally claimed. Furthermore, patients still have high rates of relapse even when prescribed medication. Recent research has shown that poor coping strategies in response to bipolar prodromes and disruptions of sleep and social routines increase the risk of relapse. Combining a psychosocial approach with medication may improve the rate of relapse prevention. Cognitive therapy teaches patients better self-monitoring and coping skills and is therefore an appropriate means of minimising psychosocial risk factors for relapse. Recent randomised controlled trials suggest that combined medication and cognitive therapy significantly reduce bipolar relapse compared with medication alone.
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18
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Abstract
BACKGROUND AND OBJECTIVES Patients with bipolar disorder (BD), despite recovering symptomatically, suffer from several functional impairments even in remission. The actual causes of impaired functioning are less known. MATERIALS AND METHODS The study aimed to examine the clinical and psychosocial determinants of functioning in patients with BD in remission. A cross-sectional single-group design was adopted (n = 150). Participants meeting the study criteria were screened with Mini-International Neuropsychiatric Interview Scale. The selected participants were administered various tools to assess the level of functioning and the clinical, psychosocial determinants of functioning. RESULTS The clinical characteristics of the sample included early age of onset of illness, presence of precipitating factors, fewer episodes, minimal comorbidities, history of psychotic episodes, family history of mental illness, good medication adherence, and low depression and mania scores. Psychosocial factors included higher stress and moderate social support and self-esteem in the sample. Poor functioning patients had a history of longer hospital stay and had greater scores on depression, mania, stress, and maladaptive coping styles than better functioning patients. CONCLUSION Higher depression, mania, stress, and maladaptive coping strategies were related to poor functioning, while higher medication adherence, self-esteem, and social support were related to better functioning.
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Affiliation(s)
| | - M Manjula
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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19
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Ng TH, Freed RD, Titone MK, Stange JP, Weiss RB, Abramson LY, Alloy LB. Aggression Protects Against the Onset of Major Depressive Episodes in Individuals With Bipolar Spectrum Disorder. Behav Ther 2017; 48:311-321. [PMID: 28390495 PMCID: PMC5385844 DOI: 10.1016/j.beth.2016.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 08/05/2016] [Accepted: 08/20/2016] [Indexed: 12/11/2022]
Abstract
A growing body of research suggests that bipolar spectrum disorders (BSDs) are associated with high aggression. However, little research has prospectively examined how aggression may affect time to onset of hypomanic/manic versus major depressive episodes. In a longitudinal study, we tested the hypothesis that aggression would prospectively predict a shorter time to the onset of hypomanic/manic episodes and a longer time to the onset of major depressive episodes, based on the behavioral approach system theory of BSDs. Young adults (N = 120) diagnosed with cyclothymia, bipolar II disorder, or bipolar disorder not otherwise specified were followed every 4 months for an average of 3.55 years. Participants completed measures of depressive and manic symptoms, family history of mood disorder, impulsivity, and aggression at baseline and were followed prospectively with semistructured diagnostic interview assessments of hypomanic/manic and major depressive episodes and treatment seeking for mood problems. Cox proportional hazard regression analyses indicated that overall, physical, and verbal aggression predicted a longer time to major depressive episode onset, even after controlling for baseline depressive and manic symptoms, family history of mood disorder, treatment seeking for mood problems, and impulsivity. Aggression, however, did not significantly predict time to onset of hypomanic/manic episodes, controlling for the same covariates. The findings suggest that approach-related behaviors may be utilized to delay the onset of major depressive episodes among people with BSDs.
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20
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Depp C, Torous J, Thompson W. Technology-Based Early Warning Systems for Bipolar Disorder: A Conceptual Framework. JMIR Ment Health 2016; 3:e42. [PMID: 27604265 PMCID: PMC5031894 DOI: 10.2196/mental.5798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/03/2016] [Accepted: 06/04/2016] [Indexed: 12/21/2022] Open
Abstract
Recognition and timely action around "warning signs" of illness exacerbation is central to the self-management of bipolar disorder. Due to its heterogeneity and fluctuating course, passive and active mobile technologies have been increasingly evaluated as adjunctive or standalone tools to predict and prevent risk of worsening of course in bipolar disorder. As predictive analytics approaches to big data from mobile health (mHealth) applications and ancillary sensors advance, it is likely that early warning systems will increasingly become available to patients. Such systems could reduce the amount of time spent experiencing symptoms and diminish the immense disability experienced by people with bipolar disorder. However, in addition to the challenges in validating such systems, we argue that early warning systems may not be without harms. Probabilistic warnings may be delivered to individuals who may not be able to interpret the warning, have limited information about what behaviors to change, or are unprepared to or cannot feasibly act due to time or logistic constraints. We propose five essential elements for early warning systems and provide a conceptual framework for designing, incorporating stakeholder input, and validating early warning systems for bipolar disorder with a focus on pragmatic considerations.
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Affiliation(s)
- Colin Depp
- Stein Institute for Research on Aging, Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States.
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21
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Alloy LB, Olino T, Freed RD, Nusslock R. Role of Reward Sensitivity and Processing in Major Depressive and Bipolar Spectrum Disorders. Behav Ther 2016; 47:600-621. [PMID: 27816074 PMCID: PMC5119651 DOI: 10.1016/j.beth.2016.02.014] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 02/25/2016] [Accepted: 02/27/2016] [Indexed: 12/11/2022]
Abstract
Since Costello's (1972) seminal Behavior Therapy article on loss of reinforcers or reinforcer effectiveness in depression, the role of reward sensitivity and processing in both depression and bipolar disorder has become a central area of investigation. In this article, we review the evidence for a model of reward sensitivity in mood disorders, with unipolar depression characterized by reward hyposensitivity and bipolar disorders by reward hypersensitivity. We address whether aberrant reward sensitivity and processing are correlates of, mood-independent traits of, vulnerabilities for, and/or predictors of the course of depression and bipolar spectrum disorders, covering evidence from self-report, behavioral, neurophysiological, and neural levels of analysis. We conclude that substantial evidence documents that blunted reward sensitivity and processing are involved in unipolar depression and heightened reward sensitivity and processing are characteristic of hypomania/mania. We further conclude that aberrant reward sensitivity has a trait component, but more research is needed to clearly demonstrate that reward hyposensitivity and hypersensitivity are vulnerabilities for depression and bipolar disorder, respectively. Moreover, additional research is needed to determine whether bipolar depression is similar to unipolar depression and characterized by reward hyposensitivity, or whether like bipolar hypomania/mania, it involves reward hypersensitivity.
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Assessment and Treatment of Bipolar Spectrum Disorders in Emerging Adulthood: Applying the Behavioral Approach System Hypersensitivity Model. COGNITIVE AND BEHAVIORAL PRACTICE 2016; 23:289-299. [PMID: 28133431 DOI: 10.1016/j.cbpra.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bipolar disorder is associated with a host of negative physical and interpersonal outcomes including suicide. Emerging adulthood is an age of risk for the onset of bipolar spectrum disorders (BSD) and there has been increased effort to focus on early identification and subsequent intervention for BSDs during this developmental period. Recent research on the behavioral approach system (BAS) hypersensitivity model of bipolar disorder may have implications for the assessment and treatment of BSD in emerging adulthood. We summarize relevant findings on the BAS hypersensitivity model that support the use of reward sensitivity in the early identification of BSDs and suggest evidence-based strategies for clinical work with emerging adults with bipolar spectrum disorders.
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23
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Coping strategies and real-world functioning in bipolar disorder. J Affect Disord 2016; 198:185-8. [PMID: 27017375 PMCID: PMC4859149 DOI: 10.1016/j.jad.2016.03.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/11/2016] [Accepted: 03/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bipolar disorder (BD) patients encounter significant life adversity, which has contributed to bipolar disorder being a leading cause of disability worldwide. Studies suggest BD patients have more maladaptive coping strategies, some of which can impact their illness course. Yet research on which coping strategies most influence disability is lacking. Such research could inform cognitive-behavioral targets to improve functional outcomes. Thus, we sought to identify relations between coping strategies and real-world function in BD. METHODS In 92 affectively-stable BD outpatients, we measured coping strategies via the Brief COPE, real-world disability via the World Health Organization Disability Assessment Schedule, current symptoms, illness chronicity, and neurocognitive functioning via the MATRICS. Multiple regression analysis served to identify the neurocognitive domains predictive of disability for entry into subsequent analyses. Multiple regressions assessed how adaptive and maladaptive coping strategies influenced disability. RESULTS Only one neurocognitive domain, verbal learning, significantly predicted disability and was included in subsequent analyses. Maladaptive coping significantly predicted disability while adaptive coping did not. Behavioral disengagement (giving up) and self-blame were the only remaining predictors of disability, after controlling for age, sex, illness chronicity, current symptoms, and neurocognitive functioning. LIMITATIONS The study was limited by the use of a self-report disability measure and a brief-form coping scale. CONCLUSIONS Results suggest that giving up and self-blame are significant predictors of real-world functioning beyond sub-threshold depressive symptoms. Our results in BD expand upon recent schizophrenia studies suggesting that defeatist beliefs negatively influence functional outcomes across the range of major psychiatric disorders.
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Van Meter AR, Burke C, Youngstrom EA, Faedda GL, Correll CU. The Bipolar Prodrome: Meta-Analysis of Symptom Prevalence Prior to Initial or Recurrent Mood Episodes. J Am Acad Child Adolesc Psychiatry 2016; 55:543-55. [PMID: 27343882 DOI: 10.1016/j.jaac.2016.04.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/09/2016] [Accepted: 05/02/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to meta-analyze the prevalence of symptoms before an initial mood episode of bipolar disorder (BD) and the prevalence of subthreshold symptoms before a BD mood episode recurrence, to facilitate early identification and prevention. METHOD Systematic literature reviews were conducted in PsycINFO and PubMed for prospective or retrospective studies reporting on the prevalence and longest duration of symptoms before an initial or recurrent mood episode of BD. Random effects meta-regression explored whether geographic location, age, percentage of female individuals, and study quality moderated the overall prevalence. RESULTS In 11 studies (n = 1,078), the prodrome preceding an initial mood episode lasted 27.1 ± 23.1 months (range, 4.6-130 months). In 10 studies (n = 1,000), the subthreshold symptoms preceding a recurrent mood episode lasted 1.0 ± 0.9 months (range, 0.5-1.3 months). The most common symptoms were largely consistent with diagnostic criteria symptoms associated with the subsequent mood polarity for both the initial prodrome and the period prior to a recurrent mood episode. Few moderators of symptom prevalences emerged, and significant heterogeneity remained. CONCLUSION The initial prodromal period is sufficiently long and characterized by symptoms of the subsequent mood episode to make early identification and intervention programs feasible. Conversely, the period of subthreshold symptoms before a recurrent mood episode is short, mandating adequate psychoeducation of patients and families, monitoring of changes in sleep and activity, plus sufficiently frequent follow-up visits to identify patients before a mood episode recurrence. Future prospective investigations, designed to address the identified shortcomings in the extant literature, are needed to identify more clinically applicable information.
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Affiliation(s)
| | - Coty Burke
- University of North Carolina at Chapel Hill
| | | | - Gianni L Faedda
- Lucio Bini Mood Disorders Center, New York University Medical Center, and the Child Study Center, New York
| | - Christoph U Correll
- The Zucker Hillside Hospital, New York, Northwell Health System, and the Hofstra Northwell School of Medicine, East Garden City, NY
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25
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Johnson SL, Gershon A, Starov V. Is energy a stronger indicator of mood for those with bipolar disorder compared to those without bipolar disorder? Psychiatry Res 2015; 230:1-4. [PMID: 26257089 DOI: 10.1016/j.psychres.2015.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 06/11/2015] [Accepted: 06/25/2015] [Indexed: 11/29/2022]
Abstract
Theory and research indicate that activity is fundamental to mood episodes in bipolar disorder (BD), yet researchers have not tested whether energy is more closely tethered to mood in BD compared to those without BD. Eighty-seven participants (13 with self-reported BD) completed 4396 energy and mood ratings through a mood-monitoring application. Mixed modeling analyses indicated that low energy, but not high energy, was related to mood within the BD group. Low energy could provide a strong and easily recognized indicator of negative mood states in persons with BD.
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Affiliation(s)
- Sheri L Johnson
- Department of Psychology, University of California, 3210 Tolman Hall, Berkeley, CA 94720-1650, USA.
| | - Anda Gershon
- Stanford University, School of Medicine, Stanford, CA, USA
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Nusslock R, Walden K, Harmon-Jones E. Asymmetrical frontal cortical activity associated with differential risk for mood and anxiety disorder symptoms: An RDoC perspective. Int J Psychophysiol 2015; 98:249-261. [DOI: 10.1016/j.ijpsycho.2015.06.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 06/06/2015] [Accepted: 06/09/2015] [Indexed: 01/13/2023]
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Fortgang RG, Hultman CM, Cannon TD. Coping Styles in Twins Discordant for Schizophrenia, Bipolar Disorder, and Depression. Clin Psychol Sci 2015; 4:216-228. [PMID: 27022508 DOI: 10.1177/2167702615583228] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Schizophrenia, bipolar disorder, and major depression share several clinical and etiological factors. Coping is a critical mediator of the relationship between stress and psychopathology and a point of clinical intervention for all three disorders. However, little is known about their degree of overlap in coping style, or the influence of unique or shared genetic diathesis. In this study, we examined five factors of coping within and across disorder proband and co-twin groups, modeled heritability, and tested for endophenotypic pattern in a sample of twin pairs recruited from the Swedish Twin Registry (N = 420). Although there was substantial phenotypic overlap across disorders, including low levels of Productive, Problem-Focused coping and high levels of Disengagement, each disorder was associated with a unique profile across other dimensions of coping. We also found evidence of heritability for three of five factors, yet little evidence of genotypic overlap among disorders contributing to similar strategy-use.
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Alloy LB, Nusslock R, Boland EM. The development and course of bipolar spectrum disorders: an integrated reward and circadian rhythm dysregulation model. Annu Rev Clin Psychol 2015; 11:213-50. [PMID: 25581235 PMCID: PMC4380533 DOI: 10.1146/annurev-clinpsy-032814-112902] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this article, we present and review the evidence for two major biopsychosocial theories of the onset and course of bipolar spectrum disorders (BSDs) that integrate behavioral, environmental, and neurobiological mechanisms: the reward hypersensitivity and the social/circadian rhythm disruption models. We describe the clinical features, spectrum, age of onset, and course of BSDs. We then discuss research designs relevant to demonstrating whether a hypothesized mechanism represents a correlate, vulnerability, or predictor of the course of BSDs, as well as important methodological issues. We next present the reward hypersensitivity model of BSD, followed by the social/circadian rhythm disruption model of BSD. For each model, we review evidence regarding whether the proposed underlying mechanism is associated with BSDs, provides vulnerability to the onset of BSDs, and predicts the course of BSDs. We then present a new integrated reward/circadian rhythm (RCR) dysregulation model of BSD and discuss how the RCR model explains the symptoms, onset, and course of BSDs. We end with recommendations for future research directions.
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Affiliation(s)
- Lauren B Alloy
- Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122; ,
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Nusslock R, Young CB, Damme KSF. Elevated reward-related neural activation as a unique biological marker of bipolar disorder: assessment and treatment implications. Behav Res Ther 2014. [PMID: 25241675 DOI: 10.1016/j.brat.2014.08.011.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Growing evidence indicates that risk for bipolar disorder is characterized by elevated activation in a fronto-striatal reward neural circuit involving the ventral striatum and orbitofrontal cortex, among other regions. It is proposed that individuals with abnormally elevated reward-related neural activation are at risk for experiencing an excessive increase in approach-related motivation during life events involving rewards or goal striving and attainment. In the extreme, this increase in motivation is reflected in hypomanic/manic symptoms. By contrast, unipolar depression (without a history of hypomania/mania) is characterized by decreased reward responsivity and decreased reward-related neural activation. Collectively, this suggests that risk for bipolar disorder and unipolar depression are characterized by distinct and opposite profiles of reward processing and reward-related neural activation. The objective of the present paper is threefold. First, we review the literature on reward processing and reward-related neural activation in bipolar disorder, and in particular risk for hypomania/mania. Second, we propose that reward-related neural activation reflects a biological marker of differential risk for bipolar disorder versus unipolar depression that may help facilitate psychiatric assessment and differential diagnosis. We also discuss, however, the challenges to using neuroscience techniques and biological markers in a clinical setting for assessment and diagnostic purposes. Lastly, we address the pharmacological and psychosocial treatment implications of research on reward-related neural activation in bipolar disorder.
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Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL, USA.
| | - Christina B Young
- Department of Psychology, Northwestern University, Evanston, IL, USA
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Billsborough J, Mailey P, Mailey P, Hicks A, Sayers R, Smith R, Clewett N, Griffiths CA, Larsen J, Larsen J. 'Listen, empower us and take action now!': reflexive-collaborative exploration of support needs in bipolar disorder when 'going up' and 'going down'. J Ment Health 2014; 23:9-14. [PMID: 24484186 DOI: 10.3109/09638237.2013.815331] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND People with a diagnosis of bipolar disorder experience mood fluctuation from depression to mania, and their support needs may differ during these fluctuations. AIMS To investigate support needed during periods of mania and depression, and when 'going up' or 'going down'. METHOD Five service user researchers were supported in a reflexive-collaborative approach to undertake and analyse semi-structured interviews with 16 people with a diagnosis of bipolar disorder and 11 people providing informal support. RESULTS Support needs differed when becoming manic or depressed. When manic, people needed a calming approach and encouragement to avoid overly stimulating activities. When depressed, positive activity and engaging in everyday life routines were helpful. Three core themes determined the effectiveness of support: (1) being listened to with active engagement through affirmation and encouragement, (2) empowerment through development of personal coping and self-management strategies, and (3) early action and understanding of early warning signs to respond to developing crises and protect wellbeing. CONCLUSION Periods of depression or mania, and lesser 'ups' and 'downs', all require different support needs. Active listening and engagement, facilitating empowerment and appropriate early action are crucial elements of effective support.
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Nusslock R, Young CB, Damme KSF. Elevated reward-related neural activation as a unique biological marker of bipolar disorder: assessment and treatment implications. Behav Res Ther 2014; 62:74-87. [PMID: 25241675 DOI: 10.1016/j.brat.2014.08.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/17/2014] [Accepted: 08/18/2014] [Indexed: 12/29/2022]
Abstract
Growing evidence indicates that risk for bipolar disorder is characterized by elevated activation in a fronto-striatal reward neural circuit involving the ventral striatum and orbitofrontal cortex, among other regions. It is proposed that individuals with abnormally elevated reward-related neural activation are at risk for experiencing an excessive increase in approach-related motivation during life events involving rewards or goal striving and attainment. In the extreme, this increase in motivation is reflected in hypomanic/manic symptoms. By contrast, unipolar depression (without a history of hypomania/mania) is characterized by decreased reward responsivity and decreased reward-related neural activation. Collectively, this suggests that risk for bipolar disorder and unipolar depression are characterized by distinct and opposite profiles of reward processing and reward-related neural activation. The objective of the present paper is threefold. First, we review the literature on reward processing and reward-related neural activation in bipolar disorder, and in particular risk for hypomania/mania. Second, we propose that reward-related neural activation reflects a biological marker of differential risk for bipolar disorder versus unipolar depression that may help facilitate psychiatric assessment and differential diagnosis. We also discuss, however, the challenges to using neuroscience techniques and biological markers in a clinical setting for assessment and diagnostic purposes. Lastly, we address the pharmacological and psychosocial treatment implications of research on reward-related neural activation in bipolar disorder.
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Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL, USA.
| | - Christina B Young
- Department of Psychology, Northwestern University, Evanston, IL, USA
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Mohiuddin S. A systematic and critical review of model-based economic evaluations of pharmacotherapeutics in patients with bipolar disorder. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:359-372. [PMID: 24838515 DOI: 10.1007/s40258-014-0098-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Bipolar disorder (BD) is a chronic and relapsing mental illness with a considerable health-related and economic burden. The primary goal of pharmacotherapeutics for BD is to improve patients' well-being. The use of decision-analytic models is key in assessing the added value of the pharmacotherapeutics aimed at treating the illness, but concerns have been expressed about the appropriateness of different modelling techniques and about the transparency in the reporting of economic evaluations. OBJECTIVES This paper aimed to identify and critically appraise published model-based economic evaluations of pharmacotherapeutics in BD patients. METHODS A systematic review combining common terms for BD and economic evaluation was conducted in MEDLINE, EMBASE, PSYCINFO and ECONLIT. Studies identified were summarised and critically appraised in terms of the use of modelling technique, model structure and data sources. Considering the prognosis and management of BD, the possible benefits and limitations of each modelling technique are discussed. RESULTS Fourteen studies were identified using model-based economic evaluations of pharmacotherapeutics in BD patients. Of these 14 studies, nine used Markov, three used discrete-event simulation (DES) and two used decision-tree models. Most of the studies (n = 11) did not include the rationale for the choice of modelling technique undertaken. Half of the studies did not include the risk of mortality. Surprisingly, no study considered the risk of having a mixed bipolar episode. CONCLUSIONS This review identified various modelling issues that could potentially reduce the comparability of one pharmacotherapeutic intervention with another. Better use and reporting of the modelling techniques in the future studies are essential. DES modelling appears to be a flexible and comprehensive technique for evaluating the comparability of BD treatment options because of its greater flexibility of depicting the disease progression over time. However, depending on the research question, modelling techniques other than DES might also be appropriate in some cases.
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Affiliation(s)
- Syed Mohiuddin
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK,
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The role of psychological factors in bipolar disorder: prospective relationships between cognitive style, coping style and symptom expression. Acta Neuropsychiatr 2014; 26:81-95. [PMID: 24855886 DOI: 10.1017/neu.2013.41] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Psychological factors contribute to bipolar disorder illness course, representing targets for psychological intervention. Research to date has focused on bipolar I disorder, extrapolating results to bipolar II disorder. The current study addresses this discrepancy by exploring cognitive and coping styles in patients diagnosed with bipolar I or II disorder. METHODS Participants were recruited from the Sydney-based Black Dog Institute. Diagnoses were derived via the MINI International Neuropsychiatric Interview. Baseline cognitive and coping style measures were completed, and mood symptoms assessed over a 6-month period. Clinician-rated mood status was assessed at follow-up to determine the predictive utility of cognitive and coping styles. RESULTS The follow-up sample comprised 151 participants. Differential relationships between cognitive style, coping styles and mood symptoms emerged across the bipolar sub-types. Some key differences were that a broader set of negative cognitive styles were associated with bipolar II depression symptoms; while few relationships were observed between coping styles and bipolar II symptoms. CONCLUSION Differences in cognitive and coping style relationships with symptom expression across bipolar I and II disorder may provide clinicians with fruitful guides for directing treatment interventions when relevant maladaptive styles are observed. Further exploration of differences in cognitive and coping styles in bipolar I and II disorder is warranted.
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Peay HL, Rosenstein DL, Biesecker BB. Adaptation to bipolar disorder and perceived risk to children: a survey of parents with bipolar disorder. BMC Psychiatry 2013; 13:327. [PMID: 24294897 PMCID: PMC3879194 DOI: 10.1186/1471-244x-13-327] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 11/12/2013] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Bipolar disorder (BPD) is a common condition associated with significant morbidity and reduced quality of life. In addition to challenges caused by their mood symptoms, parents affected with BPD harbor concerns about the mental health of their children. Among adult parents who perceive themselves to have BPD, this study aims to examine participants' coping methods; identify predictors of adaptation; assess parental perceptions of risks for mood disorders among their children; and describe the relationships among illness appraisals, coping, adaptation to one's own illness, and perceived risk to one's children. METHODS Parents who self-identified as having BPD completed a web-based survey that assessed dispositional optimism, coping, perceived illness severity, perceived etiology of BPD, perceived risk to offspring, and adaptation to BPD. Participants had at least one unaffected child who was 30 years of age or below. RESULTS 266 parents were included in the analysis. 87% of parents endorsed a "somewhat greater" or "much greater" risk for mood disorders in one's child(ren) than someone without a family history. Endorsing a genetic/familial etiology to BPD was positively correlated with perceived risk for mood disorders in children (rs = .3, p < 0.01) and active coping with BDP (r = .2, p < 0.01). Increased active coping (β = 0.4, p < 0.001) and dispositional optimism (β = 0.3, p < 0.001) were positively associated with better adaptation, while using denial coping was negatively associated with adaptation (β = -0.3, p < 0.001). The variables explained 55.2% of the variance in adaptation (F = 73.2, p < 0.001). Coping mediated the effect of perceived illness severity on adaptation. CONCLUSIONS These data inform studies of interventions that extend beyond symptom management and aim to improve the psychological wellbeing of parents with BPD. Interventions targeted at illness perceptions and those aimed at enhancing coping should be studied for positive effects on adaptation. Parents with BPD may benefit from genetic counseling to promote active coping with their condition, and manage worry about perceived risk to their children.
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Affiliation(s)
- Holly L Peay
- Social and Behavioral Research Branch, National Human Genome Research Institute NHGRI, Building 31 Room B1B36 31 Center Drive MSC 2073, Bethesda, MD 20892, USA.
| | - Donald L Rosenstein
- Department of Psychiatry and Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Physicians Office Building, Room 3134, Chapel Hill, NC 27599, USA
| | - Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute NHGRI, Building 31 Room B1B36 31 Center Drive MSC 2073, Bethesda, MD 20892, USA
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Coping profiles in bipolar disorder. Compr Psychiatry 2013; 54:1177-84. [PMID: 23810079 DOI: 10.1016/j.comppsych.2013.05.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE As coping responses have the capacity to distinctly influence the illness course in affective disorders, they form targets for psychological intervention. Beneficial effects have been reported for interventions incorporating adaptive coping in bipolar disorder. Identification of differential coping preferences in bipolar disorder sub-types has etiological and clinical implications. As most studies to date have focused exclusively on bipolar I disorder, the current study examines coping profiles in those with a bipolar I or II disorder, contrasted with unipolar depressive and healthy controls. METHODS Groups were derived on the basis of agreement between clinician and DSM-IV diagnoses. Participants (94 bipolar I, 114 bipolar II, 109 unipolar recurrent depression, 100 healthy controls) completed coping style measures including the Brief Cope, Responses to Positive Affect questionnaire, Response Styles Questionnaire, the Coping Inventory for Prodromes of Mania, and the Cognitive Emotion Regulation Questionnaire. RESULTS Bipolar (I and II) participants were more likely than unipolar participants to ruminate about positive affect, and engage in risk taking when faced with negative affect. Medication status and current mood symptoms influenced risk-taking scores in the bipolar sub-sets, however rumination about positive affect appeared to represent a trait-like response in those with a bipolar II disorder. Behavioral coping strategies differentiated bipolar sub-types, with bipolar II participants being less likely to seek support when faced with stress, and less likely to engage in strategies to down-regulate hypomania. CONCLUSION Coping style differences were observed between bipolar sub-types. Further consideration of such differentiating characteristics should serve to direct the focus towards specific targets for clinical intervention, reflecting nuances integral to the differing conditions.
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Fletcher K, Parker G, Manicavasagar V. Behavioral Activation System (BAS) differences in bipolar I and II disorder. J Affect Disord 2013; 151:121-8. [PMID: 23810478 DOI: 10.1016/j.jad.2013.05.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/23/2013] [Accepted: 05/23/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND A growing body of evidence supports the Behavioral Activation System (BAS) dyresgulation model of bipolar disorder, however its application to bipolar II disorder is limited. The current study examines its potential relevance to bipolar I and II disorders. We specifically sought to determine whether bipolar sub-types would differ in terms of BAS sensitivity, and examined for differential prospective relationships between BAS sensitivity and bipolar I and II symptom expression. METHOD Participants were recruited from the Sydney-based Black Dog Institute. Diagnostic groups were derived on the basis of agreement between clinician and DSM-IV diagnoses from structured interviews. Baseline measures of BAS sensitivity, mood symptoms and anxiety were completed. Self-rated mood was assessed over a 6-month period. Clinician-rated mood status was re-assessed at follow-up to determine the predictive utility of BAS scores. RESULTS The sample comprised 151 bipolar participants (69 bipolar I, 82 bipolar II). BAS-Drive and Reward Responsiveness scores were significantly higher in bipolar I disorder participants. BAS sub-scale scores were uniquely positively associated with mood variability in bipolar I and II disorder. BAS-Drive and Reward Responsiveness scores were positively associated with bipolar I hypo(mania), and with the former also positively associated with bipolar II depression. BAS scores did not predict bipolar I or II mood episode status at 6-month follow-up. LIMITATIONS BAS sensitivity was self-reported; inability to establish independence of BAS scores from residual symptoms; lack of controlling for medication effects; inability to determine the influence of life events; length of follow-up period may have not been sufficient to evaluate the predictive utility of BAS sensitivity for mood episodes or detect course of illness differences across bipolar sub-types. CONCLUSIONS Differences in BAS sensitivity and associations with mood variability were quantified in bipolar I and II disorder, suggesting the need for tailored treatments for these separate conditions. Further investigation of the role of the BAS in bipolar sub-types is warranted.
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Affiliation(s)
- Kathryn Fletcher
- School of Psychiatry, University of New South Wales, NSW, Australia.
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Edge MD, Miller CJ, Muhtadie L, Johnson SL, Carver CS, Marquinez N, Gotlib IH. People with bipolar I disorder report avoiding rewarding activities and dampening positive emotion. J Affect Disord 2013; 146:407-13. [PMID: 23021378 PMCID: PMC3557770 DOI: 10.1016/j.jad.2012.07.027] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 07/21/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Researchers have linked bipolar disorder to elevations in reward sensitivity and positive affect. Little is known, however, about how people with bipolar disorder respond to rewards and positive affect and how these tendencies relate to functioning or quality of life. METHODS Persons diagnosed with bipolar I disorder and matched controls completed the Responses to Positive Affect (RPA) measure and the Brief Quality of Life in Bipolar Disorder scale. Bipolar participants also completed the Reward Responses Inventory, which we designed to assess the extent to which participants avoid rewarding activities to prevent mania. A subsample of participants with bipolar disorder completed a positive mood induction procedure to examine the validity of the Response to Positive Affect scale. RESULTS The majority of bipolar participants reported avoiding at least one rewarding activity as a means of preventing mania. In addition, people with bipolar I disorder reported more dampening responses to positive affect than did control participants. Dampening positive emotions was related to lower quality of life. LIMITATIONS This study does not address whether responses to affect and reward are related to the longitudinal course of symptoms. CONCLUSIONS These findings suggest that people with bipolar I disorder seem to be aware of the potential of goal achievements to trigger mania, and many people with bipolar disorder seem to take steps to avoid positive emotion and reward.
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Affiliation(s)
- Michael D. Edge
- University of California, Berkeley, Department of Psychology. Berkeley, CA, USA.
| | | | - Luma Muhtadie
- University of California, Berkeley, Department of Psychology. Berkeley, CA, USA.
| | - Sheri L. Johnson
- University of California, Berkeley, Department of Psychology. Berkeley, CA, USA.
| | - Charles S. Carver
- University of Miami, Department of Psychology, Coral Gables, FL, USA.
| | - Nicole Marquinez
- University of South Florida, Department of Psychology, St. Petersburg, FL, USA.
| | - Ian H. Gotlib
- Stanford University, Department of Psychology, Stanford, CA, USA.
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Abstract
This article provides recommendations for the diagnosis and treatment of mania, which characterizes bipolar I disorder (BD I). Failure to detect mania leads to misdiagnosis and suboptimal treatment. To diagnose mania, clinicians should include a detailed mood history within their assessment of patients presenting with depression, agitation, psychosis or insomnia. With regards to treatment, by synthesizing the findings from recent treatment guidelines, and reviewing relevant literature, this paper has distilled recommendations for both acute and long-term management. Antimanic agents including atypical antipsychotics and traditional mood stabilizers are employed to reduce acute manic symptoms, augmented by benzodiazepines if needed, and in refractory or severe cases with behavioural and/or psychotic disturbance, electroconvulsive therapy may occasionally be necessary. Maintenance/prophylaxis therapy aims to reduce recurrences/relapse, for which the combination of psychological interventions with pharmacotherapy is beneficial as it ensures adherence and monitoring of tolerability.
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Ryu V, Song DH, Ha R, Ha K, Cho HS. Prodromes and coping types in bipolar patients with nonpsychotic or psychotic mania. Compr Psychiatry 2012; 53:732-9. [PMID: 22099704 DOI: 10.1016/j.comppsych.2011.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 09/19/2011] [Accepted: 10/03/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Bipolar disorder is a recurrent and cyclical illness frequently accompanied by psychotic symptoms. Detecting prodromes and enhancing coping skills for prodromal symptoms in bipolar patients are very important for relapse prevention. Psychotic features in bipolar patients are related to poor prognosis. We aimed to investigate the differences in prodromal symptoms and coping styles in psychotic and nonpsychotic bipolar patients. METHODS Eighty-three euthymic bipolar patients with or without a history of manic psychosis were interviewed about their demographic, diagnostic, and clinical information and completed a 40-item checklist for prodromal symptoms. After the interview, they completed the Coping Inventory for Prodromes of Mania. RESULTS The differences between the psychotic patients and the nonpsychotic patients were found in the prodromal durations, and a few prodromal symptoms such as afraid of going crazy (P = .03), energetic-very active (P = .01), and hearing hallucination (P = .02). The psychotic patients showed a higher score of denial or blame than the nonpsychotic ones (1.92 ± 0.73 in nonpsychosis, 2.32 ± 0.84 in psychosis; P = .03). Logistic regression revealed that the duration of prodromes (P = .02) and hearing hallucination (P = .01) were related to the presence of psychotic features. CONCLUSION Psychotic patients had a tendency to use denial or blame coping strategy and to experience attenuated psychotic symptoms a little more during the prodromal period. Timely psychosocial approaches for detecting signs and enhancing coping strategies would improve the outcomes.
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Affiliation(s)
- Vin Ryu
- Department of Psychiatry, College of Medicine, Konyang University, Daejeon, South Korea
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Johnson SL, Fulford D, Carver CS. The double-edged sword of goal engagement: consequences of goal pursuit in bipolar disorder. Clin Psychol Psychother 2012; 19:352-62. [PMID: 22610999 DOI: 10.1002/cpp.1801] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A series of studies suggest that bipolar disorder is related to high sensitivity to incentives and that incentive sensitivity (or sensitivity of the approach system) can predict the course of mania. Incentive sensitivity in bipolar disorder seems to be related to two processes: a tendency to invest in difficult-to-attain goals and an over-reactivity to cues of goal progress versus thwarting. Both of those processes appear relevant to symptom generation. Hence, bipolar disorder seems related to a greater emphasis on reaching goals and also a problematic reactivity to reaching those highly desired goals. We suggest directions for treatment development focused on these issues in goal regulation.
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Stern T, Sin J. Implementing a structured psychosocial interventions group programme for people with bipolar disorder. J Psychiatr Ment Health Nurs 2012; 19:180-9. [PMID: 22070393 DOI: 10.1111/j.1365-2850.2011.01816.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
It has been reported that, at any time, over half of the people with bipolar disorder are receiving no active treatment. Despite the availability of effective medications and psychotherapies, research concludes that the care of bipolar disorder in everyday practice is often deficient. Evidence base reports the effectiveness of psychosocial interventions using many of the same ideas as the recovery approach; both attempt to place clients at the heart of service delivery. This paper reports on the development and implementation of three pilot group programmes for service users with bipolar disorder, in a community clinical setting in South East England. The group programme design and development was based upon the evidence-based psychosocial interventions advocated in national clinical guidelines and research literature. The programme incorporated the key effective psychosocial interventions and self-management mechanisms within its 12 sessions spanning over 3 months, followed by three booster sessions in 6 months' time. Twenty-three service users have to date completed the programme. Participant feedback will be discussed and reported to inform further development and research implications of such innovative evidence-based interventions for service users with bipolar disorder.
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Affiliation(s)
- T Stern
- Bracknell Community Mental Health Team, Berkshire Healthcare NHS Foundation Trust, Bracknell, UK.
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Abstract
For over two decades, theorists have suggested that mania relates to heightened sensitivity of the behavioral activation system (BAS). In this article, we review a burgeoning empirical literature on this model, drawing on both cross-sectional and prospective studies. As evidence has emerged for this model, we argue that it is time to consider more specific aspects of BAS sensitivity in this disorder. We review evidence that bipolar disorder relates to an increased willingness to expend effort toward reward and to increases in energy and goal pursuit after an initial reward. We conclude by considering the strengths and weaknesses of this literature, with an eye toward future directions and implications for treatment.
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Affiliation(s)
- Sheri L Johnson
- Department of Psychology, University of California, Berkeley, Berkeley, California 94720, USA.
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Abstract
For over two decades, theorists have suggested that mania relates to heightened sensitivity of the behavioral activation system (BAS). In this article, we review a burgeoning empirical literature on this model, drawing on both cross-sectional and prospective studies. As evidence has emerged for this model, we argue that it is time to consider more specific aspects of BAS sensitivity in this disorder. We review evidence that bipolar disorder relates to an increased willingness to expend effort toward reward and to increases in energy and goal pursuit after an initial reward. We conclude by considering the strengths and weaknesses of this literature, with an eye toward future directions and implications for treatment.
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Affiliation(s)
- Sheri L Johnson
- Department of Psychology, University of California, Berkeley, Berkeley, California 94720, USA.
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Lobban F, Solis-Trapala I, Symes W, Morriss R. Early warning signs checklists for relapse in bipolar depression and mania: utility, reliability and validity. J Affect Disord 2011; 133:413-22. [PMID: 21640385 DOI: 10.1016/j.jad.2011.04.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/26/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recognising early warning signs (EWS) of mood changes is a key part of many effective interventions for people with Bipolar Disorder (BD). This study describes the development of valid and reliable checklists required to assess these signs of depression and mania. METHODS Checklists of EWS based on previous research and participant feedback were designed for depression and mania and compared with spontaneous reporting of EWS. Psychometric properties and utility were examined in 96 participants with BD. RESULTS The majority of participants did not spontaneously monitor EWS regularly prior to use of the checklists. The checklists identified most spontaneously generated EWS and led to a ten fold increase in the identification of EWS for depression and an eight fold increase for mania. The scales were generally reliable over time and responses were not associated with current mood. Frequency of monitoring for EWS correlated positively with social and occupational functioning for depression (beta=3.80, p=0.015) and mania (beta=3.92, p=0.008). LIMITATIONS The study is limited by a small sample size and the fact that raters were not blind to measures of mood and function. CONCLUSIONS EWS checklists are useful and reliable clinical and research tools helping to generate enough EWS for an effective EWS intervention.
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Affiliation(s)
- Fiona Lobban
- Spectrum Centre, School of Health and Medicine, Lancaster University, United Kingdom.
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Bender RE, Alloy LB. Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories. Clin Psychol Rev 2011; 31:383-98. [PMID: 21334286 DOI: 10.1016/j.cpr.2011.01.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 01/11/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Rachel E Bender
- Department of Psychology, Temple University, 1701 N. 13th Street, Philadelphia, PA 19122, USA.
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Gumley A, Karatzias A, Power K, Reilly J, McNay L, O'Grady M. Early intervention for relapse in schizophrenia: Impact of cognitive behavioural therapy on negative beliefs about psychosis and self-esteem. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2010; 45:247-60. [PMID: 16719982 DOI: 10.1348/014466505x49925] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The study aimed to test two hypotheses. Firstly, that participants who relapsed during the 12-month follow-up period of our randomized controlled trial, would show increased negative beliefs about their illness and reduced self-esteem, in comparison to the non-relapsed participants. Secondly, that cognitive behavioural therapy (CBT) for early signs of relapse would result in a reduction in negative beliefs about psychosis and an improvement in self-esteem at 12 months. DESIGN AND METHODS A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU; N=72) or CBT (N=72). Participants completed the Personal Beliefs about Illness Questionnaire (PBIQ; Birchwood, Mason, MacMillan, & Healy, 1993) and the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) at entry, 3 months, 6 months, and 12 months. RESULTS At 12 months, relapsers showed greater increase in scores for PBIQ entrapment compared with non-relapsers. In addition, after controlling for baseline covariates (treatment group and PBIQ self versus illness), relapsers also showed greater increase in scores for PBIQ self versus illness at 12 months. Furthermore, in comparison to treatment as usual, participants who received CBT showed greater improvement in PBIQ loss and in Rosenberg self-esteem. CONCLUSIONS The study provides evidence that relapse is associated with the development of negative appraisals of entrapment and self-blame (self vs. illness). In addition, this is the first study to show that CBT reduces negative appraisals of loss arising from psychosis and improvements in self-esteem. Implications for future research and treatment are discussed.
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Recognising prodromes of manic or depressive recurrence in outpatients with bipolar disorder: A cross-sectional study. Int J Nurs Stud 2010; 47:1201-7. [DOI: 10.1016/j.ijnurstu.2010.01.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 01/20/2010] [Accepted: 01/31/2010] [Indexed: 11/23/2022]
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La thérapie cognitive-comportementale pour le traitement des symptômes dépressifs dans le trouble bipolaire. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.jtcc.2010.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Nusslock R, Abramson LY, Harmon-Jones E, Alloy LB, Coan JA. Psychosocial Interventions for Bipolar Disorder: Perspective from the Behavioral Approach System (BAS) Dysregulation Theory. ACTA ACUST UNITED AC 2009; 16:449-469. [PMID: 20161456 DOI: 10.1111/j.1468-2850.2009.01184.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Ankers D, Jones SH. Objective assessment of circadian activity and sleep patterns in individuals at behavioural risk of hypomania. J Clin Psychol 2009; 65:1071-86. [DOI: 10.1002/jclp.20608] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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