Alyson Dodd

Extreme positive and negative appraisals of activated states interact to discriminate bipolar disorder from unipolar depression and non-clinical controls

BACKGROUND This research aimed to test whether positive, negative, or conflicting appraisals about activated mood states (e.g., energetic and high states) predicted bipolar disorder. METHODS A sample of individuals from clinical and control groups (171 with bipolar disorder, 42 with unipolar depression, and 64 controls) completed a measure of appraisals of internal states. RESULTS High negative appraisals related to a higher likelihood of bipolar disorder irrespective of positive appraisals. High positive appraisals related to a higher likelihood of bipolar disorder only when negative appraisals were also high. Individuals were most likely to have bipolar disorder, as opposed to unipolar depression or no diagnosis, when they endorsed both extremely positive and extremely negative appraisals of the same, activated states. LIMITATIONS Appraisals of internal states were based on self-report. CONCLUSIONS The results indicate that individuals with bipolar disorder tend to appraise activated, energetic internal states in opposing or conflicting ways, interpreting these states as both extremely positive and extremely negative. This may lead to contradictory attempts to regulate these states, which may in turn contribute to mood swing symptoms. Psychological therapy for mood swings and bipolar disorder should address extreme and conflicting appraisals of mood states.

Extreme Appraisals of Internal States and Bipolar Symptoms: The Hypomanic Attitudes and Positive Predictions Inventory.

The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI; W. Mansell, 2006) was developed to assess multiple, extreme, self-relevant appraisals of internal states. The present study aimed to validate the HAPPI in a clinical sample. Participants (N = 50) with a diagnosis of bipolar disorder (confirmed by a structured clinical interview) completed a series of questionnaires pertaining to clinical factors, reward motivation, cognitive style, symptoms, and functioning at baseline, in addition to the HAPPI. Over the following 4 weeks, participants were asked to complete self-report measures of symptoms (activation, perceived conflict, depression, and well-being), as well as work and social functioning, twice weekly. The authors hypothesized that the HAPPI would be associated with prospective bipolar symptoms and functioning, when controlling for baseline symptoms and potentially confounding measures. The HAPPI was positively, independently associated with activation and conflict after 4 weeks. Furthermore, individual HAPPI factors were associated with activation, conflict, and depression. The results provided preliminary support for the predictive validity of the HAPPI in a clinical sample. The HAPPI could be used in the future as a tool in cognitive behavioral therapy for bipolar disorder to identify problematic beliefs and guide formulation.

Principal components analysis of the hypomanic attitudes and positive predictions inventory and associations with measures of personality, cognitive style and analogue symptoms in a student sample.

BACKGROUND An integrative cognitive model proposed that ascribing extreme personal appraisals to changes in internal state is key to the development of the symptoms of bipolar disorder. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) was developed to measure these appraisals. AIMS The aim of the current study was to validate an expanded 61-item version of the HAPPI. METHOD In a largely female student sample (N = 134), principal components analysis (PCA) was performed on the HAPPI. Associations between the HAPPI and analogue bipolar symptoms after 3 months were examined. RESULTS PCA of the HAPPI revealed six categories of belief: Self Activation, Self-and-Other Critical, Catastrophic, Extreme Appraisals of Social Approval, Appraisals of Extreme Agitation, and Loss of Control. The HAPPI predicted all analogue measures of hypomanic symptoms after 3 months when controlling for baseline symptoms. In a more stringent test incorporating other psychological measures, the HAPPI was independently associated only with activation (e.g. thoughts racing) at 3 months. Dependent dysfunctional attitudes predicted greater conflict (e.g. irritability), depression and reduced well-being, hypomanic personality predicted self-reported diagnostic bipolar symptoms, and behavioural dysregulation predicted depression. CONCLUSIONS Extreme beliefs about internal states show a modest independent association with prospective analogue bipolar symptoms, alongside other psychological factors. Further work will be required to improve the factor structure of the HAPPI and study its validity in clinical samples.

Feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): Trial protocol

BACKGROUND Relapse prevention interventions for Bipolar Disorder are effective but implementation in routine clinical services is poor. Web-based approaches offer a way to offer easily accessible access to evidence based interventions at low cost, and have been shown to be effective for other mood disorders. METHODS/DESIGN This protocol describes the development and feasibility testing of the ERPonline web-based intervention using a single blind randomised controlled trial. Data will include the extent to which the site was used, detailed feedback from users about their experiences of the site, reported benefits and costs to mental health and wellbeing of users, and costs and savings to health services. We will gain an estimate of the likely effect size of ERPonline on a range of important outcomes including mood, functioning, quality of life and recovery. We will explore potential mechanisms of change, giving us a greater understanding of the underlying processes of change, and consequently how the site could be made more effective. We will be able to determine rates of recruitment and retention, and identify what factors could improve these rates. DISCUSSION The findings will be used to improve the site in accordance with user needs, and inform the design of a large scale evaluation of the clinical and cost effectiveness of ERPonline. They will further contribute to the growing evidence base for web-based interventions designed to support people with mental health problems.

Development and Validation of a New Multidimensional Measure of Inspiration: Associations with Risk for Bipolar Disorder

Background Individuals at risk for, and diagnosed with, bipolar disorder (BD) appear to have heightened levels of creativity. Although inspiration is creativity, the ways in which individuals appraise and respond emotionally to inspiration in BD remain unexplored. Method The present study reports on a new measure of inspiration (External and Internal Sources of Inspiration Scale - EISI). The reliability and validity of EISI were explored along with associations between EISI and BD risk. Results Among a cross-national student sample (N = 708) 5 inspiration factors were derived from EISI (self, other, achievement, prosocial and external inspiration). Reliability, concurrent validity and convergent/divergent validity were good. Total EISI and all subscales were associated with increased positive rumination, and total EISI and the achievement EISI subscale were associated with impulsivity. Total EISI, self and prosocial EISI subscales were independently associated with BD risk and current mania symptoms. Conclusion This new measure of inspiration is multidimensional, reliable and valid. Findings suggest that self and prosocial focused inspiration are particularly associated with risk for BD after controlling for current manic symptoms. Future studies in clinical populations may illuminate the relationships between inspiration and creativity in BD.

Assessing Feasibility and Acceptability of Web-Based Enhanced Relapse Prevention for Bipolar Disorder (ERPonline): A Randomized Controlled Trial

Background Interventions that teach people with bipolar disorder (BD) to recognize and respond to early warning signs (EWS) of relapse are recommended but implementation in clinical practice is poor. Objectives The objective of this study was to test the feasibility and acceptability of a randomized controlled trial (RCT) to evaluate a Web-based enhanced relapse prevention intervention (ERPonline) and to report preliminary evidence of effectiveness. Methods A single-blind, parallel, primarily online RCT (n=96) over 48 weeks comparing ERPonline plus usual treatment with “waitlist (WL) control” plus usual treatment for people with BD recruited through National Health Services (NHSs), voluntary organizations, and media. Randomization was independent, minimized on number of previous episodes (<8, 8-20, 21+). Primary outcomes were recruitment and retention rates, levels of intervention use, adverse events, and participant feedback. Process and clinical outcomes were assessed by telephone and Web and compared using linear models with intention-to-treat analysis. Results A total of 280 people registered interest online, from which 96 met inclusion criteria, consented, and were randomized (49 to WL, 47 to ERPonline) over 17 months, with 80% retention in telephone and online follow-up at all time points, except at week 48 (76%). Acceptability was high for both ERPonline and trial methods. ERPonline cost approximately £19,340 to create, and £2176 per year to host and maintain the site. Qualitative data highlighted the importance of the relationship that the users have with Web-based interventions. Differences between the group means suggested that access to ERPonline was associated with: a more positive model of BD at 24 weeks (10.70, 95% CI 0.90 to 20.5) and 48 weeks (13.1, 95% CI 2.44 to 23.93); increased monitoring of EWS of depression at 48 weeks (−1.39, 95% CI −2.61 to −0.163) and of hypomania at 24 weeks (−1.72, 95% CI −2.98 to −0.47) and 48 weeks (−1.61, 95% CI −2.92 to −0.30), compared with WL. There was no evidence of impact of ERPonline on clinical outcomes or medication adherence, but relapse rates across both arms were low (15%) and the sample remained high functioning throughout. One person died by suicide before randomization and 5 people in ERPonline and 6 in WL reported ideas of suicide or self-harm. None were deemed study related by an independent Trial Steering Committee (TSC). Conclusions ERPonline offers a cheap accessible option for people seeking ongoing support following successful treatment. However, given high functioning and low relapse rates in this study, testing clinical effectiveness for this population would require very large sample sizes. Building in human support to use ERPonline should be considered. Trial registration International Standard Randomized Controlled Trial Number (ISRCTN): 56908625; http://www.isrctn.com/ISRCTN56908625 (Archived by WebCite at http://www.webcitation.org/6of1ON2S0)

Bipolar Vulnerability and Extreme Appraisals Of Internal States: A Computerized Ratings Study

A recent integrative cognitive model proposed that multiple, extreme, personalized, positive and negative appraisals of internal states predispose to maintain and exacerbate bipolar symptoms. This study aimed to directly assess conviction in a range of positive and negative appraisals of internal states suggested by the model, by using a laboratory-based computerized task. In a student sample (n = 68), a history of hypomania was associated with more positive and less negative appraisals of internal states, and a history of depression was associated with more negative appraisals and less positive appraisals of internal states. The sample was then split into three groups for comparison: bipolar risk (n = 18), depression risk (n = 20) and controls (n  = 30). Relative to controls, the bipolar risk group made more extreme ratings of catastrophic appraisals of low activation states and tended to make more extreme ratings of appraisals of high activation states. The depression risk group scored higher on a range of negative appraisals of low activation states. These findings provide tentative support for the role of both positive and negative, extreme, personalized appraisals of internal states in hypomania and depression.

Response styles, bipolar risk, and mood in students: The Behaviours Checklist.

OBJECTIVES An Integrative Cognitive Model of mood swings and bipolar disorder proposes that extreme positive and negative appraisals about internal states trigger ascent and descent behaviours, contributing to the onset and maintenance of mood swings. This study investigated the reliability and validity of a new inventory, the Behaviours Checklist (BC), by measuring associations with appraisals, response styles to positive and negative affect, bipolar risk, mania, and depression. DESIGN Correlational analogue study. METHODS Students (N = 134) completed the BC alongside measures of appraisals, response styles to positive and negative mood, mania, depression, and hypomanic personality (bipolar risk). RESULTS The BC was of adequate reliability and showed good validity. Ascent behaviours and appraisals predicted bipolar risk, whereas descent behaviours and appraisals were associated with depression. CONCLUSIONS Appraisals, ascent, and descent behaviours may play an important role in the development and maintenance of mood swings. Limitations and research recommendations are outlined. PRACTITIONER POINTS Extreme positive and negative appraisals of internal states, and subsequent behavioural responses (ascent and descent behaviours), are associated with bipolar risk and bipolar mood symptoms in a student sample. These processes are involved with mood dysregulation in clinical populations as well as bipolar risk in students, with implications for mood management.

Web-based indicated prevention of common mental disorders in university students in four European countries – study protocol for a randomised controlled trial

Background Mental disorders and their symptoms are highly prevalent in the university student population, and the transition from secondary to tertiary education is associated with a rise in mental health problems. Existing web-based interventions for the prevention of common mental disorders in student populations often focus on just one disorder and have not been designed specifically for students. There is thus a need for transdiagnostic, student-specific preventative interventions that can be widely disseminated. This two-arm, parallel group randomised controlled trial aims to evaluate the effectiveness and cost-effectiveness of a web-based transdiagnostic mental health problem prevention programme (PLUS) across several universities in four countries. Method Students (N = 5550) will be recruited through a variety of channels and asked to complete a personality assessment to determine whether they are at high risk for developing common mental disorders. Students at high risk will be randomly allocated to either PLUS or a control intervention, which provides practical support around issues commonly experienced at university. Students at low risk will be allocated to the control intervention. Both intervention groups will be assessed at baseline, 4 weeks, 3 months, 6 months and 12 months after randomisation. Depression and generalised anxiety, assessed using the Patient Health Questionnaire and the Generalised Anxiety Disorder scales, will form the primary outcomes in this study. Secondary outcome measures include alcohol and drug use, eating behaviour, self-esteem, and quality of life. The cost-effectiveness of the intervention will also be evaluated. Conclusions This study will contribute to understanding the role of transdiagnostic indicated web-based interventions for the prevention of common mental disorders in university students. It will also be one of the first studies to investigate the cost-effectiveness of such interventions. Trial Registration This trial was registered in the ISRCTN register (ISRCTN15570935) on 12th February 2016.

Structured group psychoeducation in patients with bipolar disorder delays time to mania and time to any episode compared with a peer support group

ABSTRACT FROM: Morriss R, Lobban F, Riste L, et al . Clinical effectiveness and acceptability of structured group psychoeducation versus optimised unstructured peer support for patients with remitted bipolar disorder (PARADES): a pragmatic, multicentre, observer-blind, randomised controlled superiority trial. Lancet Psychiatry 2016;3:1029–38. Based in part on the resource heavy group psychoeducation delivered in Barcelona, the National Institute for Health and Care Excellence (NICE) argue that psychological interventions specifically developed for adults with bipolar disorder improve outcome, and therefore have made a developmental quality standard that patients with bipolar disorder should be offered psychological interventions.1 However, trials of more accessible interventions, for example, with fewer sessions or delivered by psychiatric nurses, have not shown such clear benefit.2 This research aims to determine whether pragmatic group psychoeducation reduces relapse risk in NHS (National Health Service) patients. Participants (n = 304) were recruited from secondary and primary care and by …