Reactivity of affect and self-esteem during remission in bipolar affective disorder: An experimental investigation

doi:10.1016/j.jad.2011.04.023

Journal of Affective Disorders

Volume 134, Issues 1–3, November 2011, Pages 102-111

https://doi.org/10.1016/j.jad.2011.04.023 Get rights and content

Abstract

Background

Bipolar affective disorder (BPAD) is characterised by a lifelong vulnerability to develop episodes of depressed or elevated mood in response to stressful life events involving achievement or failure. We hypothesised that this latent vulnerability can manifest as reactivity of affect and self-esteem to experimentally induced experiences of success and failure and is shaped by history of childhood adversity.

Methods

Twenty-four people with remitted BPAD and twenty-four healthy controls underwent anagram-solving tasks designed to generate experiences of success and failure in two separate sessions. Positive and negative affect and implicit and explicit self-esteem were measured before and after each task. Early adversity was measured by Childhood Trauma Questionnaire.

Results

People with BPAD showed larger reactivity of affect and explicit self-esteem in response to experimental success and failure than did healthy controls. There were no significant differences in reactivity of implicit self-esteem. History of childhood trauma predicted increased affective reactivity to failure but not to success.

Limitations

We used a convenience sample.

Conclusions

The present experimental paradigm reveals reactivity of affect and self-esteem as features of BPAD, which are present even during good remission and thus are accessible as targets of interventions aiming at relapse prevention. Differential associations with childhood adversity indicate aetiological heterogeneity, with reactivity to failure influenced by early trauma and reactivity to success driven by other mechanisms.

Introduction

Bipolar affective disorder (BPAD) is characterised by discrete episodes of depressed and elated mood separated by periods of remission (American Psychiatric Association, 1994, World Health Organization, 1993). Accordingly, most psychological interventions to date have focussed on early warning signs of future affective episodes. The efficacy of these interventions is limited. It has been proposed that therapeutic work with BPAD including normalising the presence of mood fluctuations during remission may be more effective than necessarily interpreting them as early sign of relapse (Mansell et al., 2007).

Recent studies of individuals in remission are changing our perception of BPAD. There is growing evidence that people with BPAD experience marked fluctuations of mood even during remission (Henry et al., 2008, Knowles et al., 2007). Mood instability during remission is associated with an earlier onset, increased comorbidity and frequent episodes (Henry et al., 2008, Leibenluft et al., 2003). If affective instability is a persistent prognosis-relevant feature of BPAD, it may be appropriate to target it directly rather than interpreting it as an early sign of relapse. However, successful intervention depends on making this trait manifest during remission. In this study, we set out to establish if affective instability in people with BPAD can be measured in response to experimental challenge.

It is presently unclear which processes mediate the relationship between persistent affective instability and major affective episodes. The observation of increased orientation on achievement amongst individuals with BPAD suggests a plausible mechanism (Johnson et al., 2009, Lam et al., 2004, Scott et al., 2000, Spielberger et al., 1963). Achievement orientation predicts intensity of manic symptoms (Lozano and Johnson, 2001) and goal attainment events increase manic symptoms (Johnson et al., 2000). The affective instability in response to achievement events may also be mediated by unstable self-esteem. This may be relatively specific to BPAD, as people with remitted BPAD experience greater fluctuations of self-esteem than healthy controls and people with remitted unipolar depression (Knowles et al., 2007, van der Gucht et al., 2009). These considerations lead to the primary hypothesis that affective instability in people with BPAD can be elicited by experimental challenge involving success or failure and is accompanied by marked changes in self-esteem.

Apart from diagnostic status, childhood adversity may predispose to increased reactivity to life events. History of childhood trauma is a risk factor for BPAD (Garno et al., 2005), is associated with psychosocial triggering of major mood episodes (Leverich et al., 2002) and with increased affective reactivity during remission (Etain et al., 2008). Childhood abuse is associated with BPAD severity, rapid cycling, comorbidity and suicide attempts (Garno et al., 2005). Given the importance of childhood trauma in shaping the affective reactivity to psychosocial context, we formulated a secondary hypothesis that history of adversity in childhood moderates increased reactivity to achievement and failure.

Section snippets

Participants

The project was approved by the Camden & Islington Community Local Research Ethics Committee and participants gave informed consent. Twenty-four individuals with BPAD were recruited through advertisements in printed media and from clinical services. Twenty-four age- and sex-matched healthy controls with no history of affective or psychotic disorders and no current Axis I disorder (DSM) were recruited by advertisements at community sites. All participants were native English speakers, aged over

Sample description

Characteristics of participants are presented in Table 1. The two groups did not differ in sex, age, ethnicity, education, home ownership or marital status. Compared to the control group, significantly fewer individuals with BPAD were in employment or education. Participants with BPAD were in good remission, but still experienced significantly more affective symptoms over the preceding week than controls (Table 1). The BPAD group was representative of severe BPAD, with an early mean age of

Discussion

As hypothesised, affect and explicit self-esteem were more reactive to success and failure in people with BPAD than in healthy controls. Changes in affect and explicit self-esteem were highly correlated. History of childhood trauma predicted stronger affective reactivity to failure.

Conclusion

This is the first experimental study to demonstrate that people with BPAD are more reactive to experiences of success and failure than healthy controls. Whilst reactivity to success was strongly related to the diagnosis of BPAD, reactivity to failure was strongly predicted by a history of childhood trauma. These differential associations point to a possible aetiological heterogeneity, with reactivity to failure determined by early experiences and reactivity to success driven by other

Role of funding source

The Psychiatry Research Trust at the Institute of Psychiatry, King's College London provided funds to reimburse participants for travel expenses and time. The funding source has had no role in designing the study, writing the manuscript or the decision to submit.

Conflicts of interest

The authors have no conflict of interests.

Acknowledgment

We thank MDF The Bipolar Organisation for help with recruitment.

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Citation Excerpt :
Studies using frequent momentary assessments show that euthymic BD patients report more overall negative affect (Gruber et al., 2013; Havermans et al., 2010) and more fluctuations in both negative and positive emotionality compared to HC's (Knowles et al., 2007). However, the majority of laboratory studies that measure self-reported negative emotional intensity after mood induction or emotional stimuli fail to find differences in reactivity in euthymic BD compared to HC's (Aminoff et al., 2011; Edge et al., 2015; Gruber et al., 2014; Lemaire et al., 2015; M'Bailara et al., 2009; Mansell and Lam, 2006; Ruggero and Johnson, 2006; Wright et al., 2005) although some studies did find increased reactivity in BD patients (Gruber et al., 2011b; Pavlova et al., 2011). Results are also conflicting with respect to positive stimuli, with some laboratory studies finding increased self-reported reactivity (Gruber et al., 2011a, 2009; Gruber et al., 2011b) whilst others do not (Farmer et al., 2006; Gruber et al., 2014).
Bipolar disorder is characterized by extreme mood fluctuations and ongoing affective instability. Mechanisms involved in emotion regulation (ER) seem to be a contributing factor, however the nature and extent of these are not clear yet. The aim of the current review is to contribute to a comprehensive model that covers the full scope of the emotion regulation processes in BD, in order to understand the psychological mechanisms that could contribute to the onset of both manic and depressive states. To this end we review each stage (attentional, behavioural and cognitive processes) of the Process Model of Emotion Regulation in relation to the extant literature on mood or emotion-linked responses in BD. Additionally, potential vulnerability factors (e.g. biological, genetic, personality) for dysfunctional emotion regulation patterns are described. We conclude that on all levels of the emotion regulation model there are seemingly contradictory findings in BD, with evidence for a profile that is characterized by the tendency to upregulate positive affect, as well as a profile that tends to over-use downregulation strategies for both positive and negative affect. These profiles could be characterized by different emotion regulation mechanisms, personality profiles and biological and psychological vulnerability factors. Based on these findings we tentatively identify two emotion regulation profiles in BD (reflecting ‘approach’ and ‘avoidant’ behaviours respectively) and discuss clinical implications and different treatment approaches. To illustrate the latter, we present two clinical cases of both ER profiles and their different treatment approaches.
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Dysregulation of the behavioral activation system (BAS) has been theorized to be a core factor underlying mood swings in bipolar disorder (BD). However, few studies have directly addressed BAS dysregulation and more research is needed to understand its dynamic expression in daily life. The aim of this study was to directly assess BAS dysregulation, and to examine its moderating effect on the relationship between life events and bipolar spectrum symptoms via multilevel modeling. Korean young adults (n = 100) were screened using the Hypomanic Personality Scale (HPS) from a large sample (N = 1,591). They completed online diaries for 7 consecutive days including the Daily Events Record as well as bipolar spectrum symptoms. BAS-activating and/or -deactivating scores were allocated to each reported life event by an expert consensus rating. Cross-level interaction analysis showed that the occurrence of BA life events contributed to a steeper increase in bipolar spectrum symptoms, particularly for individuals with high BAS dysregulation. The present study suggests that BAS dysregulation is a unique construct that deserves further exploration in BD.
An investigation of self-compassion and nonattachment to self in people with bipolar disorder
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Citation Excerpt :
These findings align with the broader research picture, whereby BD appears to be characterised by multiple vulnerabilities at the level of self-concept. For instance, people with BD in prior research have been observed to show low and/or unstable self-esteem (Knowles et al., 2007; Nilsson et al., 2010; Pavlova et al., 2011), self-perception of incompetence and inadequacy in multiple social roles (Prerost and Song, 2012), elevation of problematic self-schemas such as undeveloped self and grandiosity (Ak et al., 2012), and greater self-compartmentalisation and self-complexity representing disintegrated self-concept (Power et al., 2002; Taylor et al., 2007). The present study adds to this literature an indicator that the vulnerabilities of self-concept in BD might also be manifested in diminished self-compassion and nonattachment to self.
There have been longstanding theories and research evidence into the important role of the person's vulnerability at the level of self-concept in bipolar disorder (BD). The current study investigated two emerging self-related constructs, self-compassion and nonattachment to self in BD. Specifically, we examined the levels of the two constructs in people with BD compared with those from the general population, and the associations between the constructs and bipolar symptomologies within the BD group.
The BD group consisted of 302 individuals with a diagnosis of BD participating in an international randomised controlled trial. A general population sample (n = 372) was recruited from an Australian university as a comparison group. All participants completed measures of self-compassion and nonattachment to self. The BD group completed additional measures of depression and symptoms of hypo/mania.
Participants with BD showed significantly lower self-compassion and nonattachment to self than those from the comparison group after controlling for demographic variables (e.g., gender, age, education, occupation). In the BD group, lower self-compassion and nonattachment to self were associated with greater severity of depression on both self- and clinician-rated scales. Nonattachment to self but not self-compassion was negatively associated with hypo/mania symptomology.
The cross-sectional design cannot determine the direction of the relationships between study variables. Nonattachment to self is a novel psychological construct and further research is needed to replicate study findings.
The study findings suggest that self-compassion and nonattachment to self may be meaningful targets in psychological interventions for people with BD.
Cognitive deficits in bipolar disorders: Implications for emotion
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Prominent cognitive deficits have been documented in bipolar disorder, and multiple studies suggest that these deficits can be observed among non-affected first-degree relatives of those with bipolar disorder. Although there is variability in the degree of cognitive deficits, these deficits are robustly relevant for functional outcomes. A separate literature documents clear difficulties in emotionality, emotion regulation, and emotion-relevant impulsivity within bipolar disorder, and demonstrates that these emotion-relevant variables are also central to outcome. Although cognitive and emotion domains are typically studied independently, basic research and emergent findings in bipolar disorder suggest that there are important ties between cognitive deficits and the emotion disturbances observed in bipolar disorder. Understanding these relationships has relevance for fostering more integrative research, for clarifying relevant aspects related to functionality and vulnerability within bipolar disorder, and for the development of novel treatment interventions.
Bipolar disorder (BD) is a severe psychiatric illness that has been ranked as one of the 20 leading medical causes of disability (WHO, 2011). BD has been shown to be the psychiatric disorder with the highest rates of completed suicide across two major cohort studies (Ilgen et al., 2010, Nordentoft et al., 2011). In a cross-national representative sample, one in four persons diagnosed with bipolar I disorder reported a suicide attempt (Merikangas et al., 2011). Rates of relapse remain high despite available treatments (Gitlin, Swendsen, Heller, & Hammen, 1995), and in the year after hospitalization for manic episode, two-thirds of patients do not return to work (Strakowski et al., 1998). Poverty, homelessness, and incarceration are all too common (Copeland et al., 2009).
Despite the often poor outcomes, there is also evidence for outstanding accomplishments and creativity among those with milder forms of the disorder and their family members (Coryell et al., 1989, Jamison, 1993, Murray and Johnson, 2010). Some individuals appear to achieve more than the general population, suggesting the importance of understanding the variables that predict differential outcome within bipolar disorder.
Within this paper, we focus on two key predictors of outcomes within bipolar disorder: cognition and emotionality. We review evidence that problems in cognition and emotionality are prominent among those diagnosed with the disorder, are not artifacts of symptom state, and relate substantively to poorer outcomes. Although traditionally studied separately, new work points toward the idea that cognition and emotionality are intricately linked within bipolar disorder. Drawing from research within bipolar disorder as well as outside of bipolar disorder, we build a model of how cognition and emotionality might be tied within bipolar disorder. We then provide suggestions for future research.
Before considering findings, it is worth noting that there are several forms of the disorder, defined by varying degrees and duration of manic symptoms (American Psychiatric Association, 2013, World Health Organization, 1993). Manic episodes are defined by abnormally elevated or irritable mood, accompanied by increased activity and at least three symptoms (four if mood is only irritable) such as decreased need for sleep, increased self-confidence, racing thoughts or flight of ideas, rapid speech, distractibility, goal-directed activity, and engagement in pleasurable activities without regard to potential negative consequences. To meet criteria for mania, these symptoms must persist for at least one week or require hospitalization, and must lead to difficulties with functioning. If functional impairment is not more than mild and duration is between 4 and 6 days, the episode is considered a hypomanic episode. Bipolar I disorder (BD I) is diagnosed on the basis of at least one lifetime manic episode within the DSM-5 and by at least two episodes within the ICD, whereas bipolar II disorder is diagnosed on the basis of at least one hypomanic episode (and no manic episodes) as well as major depressive episodes. Cyclothymic disorder is defined by chronic but milder fluctuations between manic and depressive symptoms. Most research focuses on BD I.
In addition to diagnosed samples, research has focused on those at high risk for bipolar disorder, including first-degree relatives of those with BD. This work draws on the evidence for extremely high heritability of BD I, with estimates from community-based twin studies of 0.85 (Kieseppä, Partonen, Haukka, Kaprio, & Lönnqvist, 2014). Other research has considered high risk for BD by virtue of lifetime subsyndromal symptoms, as measured by scales such as the Hypomanic Personality Scale (Eckblad & Chapman, 1986) or the General Behavior Inventory (Depue, Krauss, Spoont, & Arbisi, 1989). The study of high-risk individuals provides a way to decipher whether deficits are present before the onset of the disorder, of importance given models suggesting that episodes of the disorder may change brain function (Chang, Steiner, & Ketter, 2000; Strakowski, 2012) as well as individuals' perceptions of their emotion regulation.
Beyond defining BD, it is worth defining some of the many different neuropsychological tasks that have been widely studied in BD. Perhaps no area has received more attention than executive function. Executive function is related to three core functions: 1) inhibition, the ability to suppress irrelevant information in working memory in order to accomplish an established goal; 2) working memory, the ability to hold and manipulate information in mind; and 3) cognitive flexibility, the ability to shift strategies in response to feedback (Diamond, 2013, Miyake et al., 2000). Attention (defined as the process of selecting information reception from internal or external cues) is implicated in all three of these aspects of executive function. Much of the literature we will discuss focuses on response inhibition, or the ability to suppress a prepotent response, which is considered a subtype of inhibition. Some tests measure multiple facets of executive function; for example the Trails B test likely requires working memory and cognitive flexibility (Sánchez-Cubillo et al., 2009).
Aside from executive function, multiple other facets of cognition have been widely studied in bipolar disorder. Verbal and non-verbal memory are related to the ability to register, store and retrieve verbal or visual information (Lezak, 1995). Verbal fluency is measured as the number of verbal responses a person can generate to a given target, such as a specific semantic category (e.g., animals, furniture) or phonetic category (e.g., words that begin with letter F) (Diamond, 2013). Although cognitive tasks have been designed to evaluate these specific functions, it is important to note that most measures are highly inter-correlated and may assess multiple overlapping functions to some extent (for example, the Trails B test is often described as an “executive function” task, although this task likely involves both working memory and cognitive flexibility. Not surprisingly, then, some authors label the function of certain tests differently, and this is particularly evident in meta-analyses of cognition. As we describe findings in this paper, we will use the terms proposed by the authors but will also identify key tests used to define a cognitive construct.
With this background in mind, we turn to a discussion of cognitive deficits, then of emotion-related traits. Our hope is that those concise summaries provide evidence for the importance of both domains, but also specificity regarding the facets of emotion and cognition that are most impaired in BD. This specificity then guides our consideration of models that integrate cognition and emotion.
Anxiety disorders and childhood maltreatment as predictors of outcome in bipolar disorder
2018, Journal of Affective Disorders
Citation Excerpt :
Hoertel et al. (2015) found that this relationship is independent of psychopathology (Hoertel et al., 2015), which concurs with our finding that the association between childhood maltreatment and suicide attempts is not explained by anxiety disorders comorbidity. Several mechanisms could be involved: Affective lability and reactivity to failure experiences is associated with childhood maltreatment (Aas et al., 2014; Pavlova et al., 2011) and affective lability in people with bipolar disorder has been linked to suicidality (Palmier-Claus et al., 2012). It is possible that people who experienced childhood maltreatment are more likely to respond to stressful life events with large decreases in mood which may in turn make them more likely to attempt suicide.
Comorbid anxiety disorders and childhood maltreatment have each been linked with unfavourable outcomes in people with bipolar disorder. Because childhood maltreatment is associated with anxiety disorders in this population, their respective predictive value remains to be determined.
In 174 adults with bipolar disorder, we assessed childhood maltreatment using the Childhood Trauma Questionnaire and lifetime anxiety disorders with the MINI International Neuropsychiatric Interview. We constructed an overall index of severity of bipolar disorder as a sum of six indicators (unemployment, psychotic symptoms, more than five manic episodes, more than five depressive episodes, suicide attempt, and hospital admission). We tested the relationship between childhood maltreatment, the number of anxiety disorders and the overall severity index using ordered logistic regression.
The number of lifetime anxiety disorders was associated with the overall severity index (OR = 1.43, 95%CI = 1.01–2.04, p = 0.047). This relationship was only slightly attenuated when controlled for childhood maltreatment (OR = 1.39, 95%CI = 0.97–2.00, p = 0.069). The relationship between childhood maltreatment and the overall severity index was not statistically significant (OR = 1.26, 95%CI = 0.92–1.74, p = 0.151). Secondary analyses revealed that childhood maltreatment was associated with suicide attempts (OR = 1.70, 95%CI = 1.15–2.51, p = 0.008) and obsessive compulsive disorder was associated with the overall severity index (OR = 9.56, 95%CI = 2.20–41.47, p = 0.003).
This was a cross-sectional study with a moderate-sized sample recruited from a specialist program.
While comorbid anxiety disorders are associated with the overall severity of bipolar disorder, childhood maltreatment is specifically associated with suicide attempts. Clinicians should systematically assess both factors. Interventions to improve outcomes of people with bipolar disorder with comorbid anxiety disorders and history of childhood maltreatment are needed.
Effect of early trauma on the sleep quality of euthymic bipolar patients
2016, Journal of Affective Disorders
Poor quality of sleep is frequent in euthymic bipolar patients and conveys worse clinical outcomes. We investigated the features of euthymic bipolar patients associated with poor sleep quality, with a focus on the effect of childhood trauma.
493 euthymic patients with DSM-IV-defined bipolar disorders were recruited in FondaMental Advanced Centers of Expertize for Bipolar Disorders (FACE-BD) between 2009 and 2014. Clinical variables were recorded. Subjective sleep quality and history of childhood trauma were respectively measured by the Pittsburgh Sleep Quality Index (PSQI) and the Childhood Trauma Questionnaire (CTQ).
Poor sleepers were older, less professionally active, had significantly higher anxiety levels, took more anxiolytic drugs and did endorse more suicide attempts and suicidal ideas than good sleepers after adjusting for anxiety levels and age. Emotional abuse was associated with poor sleep quality after adjustment for BMI, age, professional activity, and bipolar disorders (BD) type (OR=1.83; 95% CI [1.30; 3.10]; p=0.02). However, this association was lost after adjustment for anxiety levels, anxiolytic treatment and suicide ideation/attempts.
The main limitation was the type of sleep assessment, which only measured the subjective part of sleep complaints.
A history of emotional abuse might underlie sleep problems in many bipolar patients but anxiety seems to act as a confounding factor in this relationship. New studies are needed to elucidate the role of childhood maltreatment on poor sleep among bipolar patients.

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Research reportReactivity of affect and self-esteem during remission in bipolar affective disorder: An experimental investigation

Abstract

Background

Methods

Results

Limitations

Conclusions

Introduction

Section snippets

Participants

Sample description

Discussion

Conclusion

Role of funding source

Conflicts of interest

Acknowledgment

Child Abuse Negl.

J. Exp. Soc. Psychol.

J. Affect. Disord.

Behav. Res. Ther.

J. Psychosom. Res.

Psychoneuroendocrinology

Psychiatry Res.

J. Affect. Disord.

J. Affect. Disord.

Biol. Psychiatry

Biol. Psychiatry

J. Pain

J. Affect. Disord.

J. Psychiatr. Res.

Behav. Res. Ther.

Biol. Psychiatry

Behav. Res. Ther.

J. Affect. Disord.

Diagnostic and statistical manual of mental disorders

Stalking the perfect measure of implicit self-esteem: the blind men and the elephant revisited?

J. Pers. Soc. Psychol.

A comparison of self-esteem lability and low trait self-esteem as vulnerability factors for depression

J. Pers. Soc. Psychol.

Applied multiple correlation analysis for the behavioural sciences

A 24-week open-label extension study of olanzapine-fluoxetine combination and olanzapine monotherapy in the treatment of bipolar depression

J. Clin. Psychiatry

The positive and negative affect schedule (PANAS): construct validity, measurement properties and normative data in a large non-clinical sample

Br. J. Clin. Psychol.

The independence of positive and negative affect

J. Pers. Soc. Psychol.

Beyond genetics: childhood affective trauma in bipolar disorder

Bipolar Disord.

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID)

Impact of childhood abuse on the clinical course of bipolar disorder

Br. J. Psychiatry

Neuropsychology

Rapid antimanic effect of risperidone monotherapy: a 3-week multicenter, double-blind, placebo-controlled trial

Am. J. Psychiatry

Research report
Reactivity of affect and self-esteem during remission in bipolar affective disorder: An experimental investigation