Sara Tai

The Interpretation of, and Responses to, Changes in Internal States: An Integrative Cognitive Model of Mood Swings and Bipolar Disorders

A cognitive approach to understanding mood swings and bipolar disorders is provided, with the interpretation of changes in internal state as a central explanatory factor. The model explains how attempts at affect regulation are disturbed through the multiple and conflicting extreme personal meanings that are given to internal states. They prompt exaggerated efforts to enhance or exert control over internal states, which paradoxically provoke further internal state changes, thereby feeding into a vicious cycle that can maintain or exacerbate symptoms. Counterproductive attempts at control are classified as either ascent behaviours (increasing activation), or descent behaviours (decreasing activation). It is suggested that appraisals of extreme personal meaning are influenced by specific sets of beliefs about affect and its regulation, and about the self and relations with others, leading to an interaction that raises vulnerability to relapse. Pertinent literature is reviewed and found to be compatible with such a model. The clinical implications are discussed and compared to existing interventions.

The Evolution of Cognitive Behavior Therapy for Schizophrenia: Current Practice and Recent Developments

Cognitive behavior therapy (CBT) evolved from behavioral theory and developed to focus more on cognitive models that incorporated reappraisal of thinking errors and schema change strategies. This article will describe the key elements of CBT for schizophrenia and the current evidence of its efficacy and effectiveness. We conclude with a description of recent concepts that extend the theoretical basis of practice and expand the range of CBT strategies for use in schizophrenia. Mindfulness, meta-cognitive approaches, compassionate mind training, and method of levels are postulated as useful adjuncts for CBT with psychotic patients.

Coping with depression and vulnerability to mania: A factor analytic study of the Nolen-Hoeksema (1991) Response Styles Questionnaire

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

Predictors of Outcome in Brief Cognitive Behavior Therapy for Schizophrenia

Antipsychotic medications, while effective, often leave patients with ongoing positive and negative symptoms of schizophrenia. Guidelines recommend using cognitive behavior therapy (CBT) with this group. Clearly, mental health professionals require training and supervision to deliver CBT-based interventions. This study tested which antipsychotic-resistant patients were most likely to respond to brief CBT delivered by psychiatric nurses. Staff were trained over 10 consecutive days with ongoing weekly supervision. Training for carers in the basic principles of CBT was also provided. This article represents the secondary analyses of completer data from a previously published randomized controlled trial (Turkington D, Kingdon D, Turner T. Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry. 2002;180:523-527) (n = 354) to determine whether a number of a priori variables were predictive of a good outcome with CBT and treatment as usual. Logistic regression was employed to determine whether any of these variables were able to predict a 25% or greater improvement in overall symptoms and insight. In the CBT group only, female gender was found to strongly predict a reduction in overall symptoms (P = .004, odds ratio [OR] = 2.39, 95% confidence interval [CI] = 1.33, 4.30) and increase in insight (P = .04, OR = 1.84, 95% CI = 1.03, 3.29). In addition, for individuals with delusions, a lower level of conviction in these beliefs was associated with a good response to brief CBT (P = .02, OR = 0.70, 95% CI = 0.51, 0.95). Women with schizophrenia and patients with a low level of conviction in their delusions are most likely to respond to brief CBT and should be offered this routinely alongside antipsychotic medications and other psychosocial interventions.

Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial

BACKGROUND Although antipsychotic medication is the first line of treatment for schizophrenia, many service users choose to refuse or discontinue their pharmacological treatment. Cognitive therapy (CT) has been shown to be effective when delivered in combination with antipsychotic medication, but has yet to be formally evaluated in its absence. This study evaluates CT for people with psychotic disorders who have not been taking antipsychotic medication for at least 6 months. METHOD Twenty participants with schizophrenia spectrum disorders received CT in an open trial. Our primary outcome was psychiatric symptoms measured using the Positive and Negative Syndromes Scale (PANSS), which was administered at baseline, 9 months (end of treatment) and 15 months (follow-up). Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning. RESULTS T tests and Wilcoxons signed ranks tests revealed significant beneficial effects on all primary and secondary outcomes at end of treatment and follow-up, with the exception of self-rated recovery at end of treatment. Cohens d effect sizes were moderate to large [for PANSS total, d=0.85, 95% confidence interval (CI) 0.32-1.35 at end of treatment; d=1.26, 95% CI 0.66-1.84 at follow-up]. A response rate analysis found that 35% and 50% of participants achieved at least a 50% reduction in PANSS total scores by end of therapy and follow-up respectively. No patients deteriorated significantly. CONCLUSIONS This study provides preliminary evidence that CT is an acceptable and effective treatment for people with psychosis who choose not to take antipsychotic medication. An adequately powered randomized controlled trial is warranted.

Do current beliefs predict hypomanic symptoms beyond personality style? Factor analysis of the hypomanic attitudes and positive predictions inventory (HAPPI) and its association with hypomanic symptoms in a student population.

A self-report scale called the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) has been developed to assess cognitions that distinguish between bipolar disorder and nonclinical controls (Mansell, 2006; Mansell & Jones, 2006). We recruited 191 undergraduate students to assess the associations between the HAPPI and self-reported past (MDQ; Hirschfeld et al., 2000) and present (ISS; Bauer et al., 1991) bipolar symptoms, and to explore the factor structure of the scale. The HAPPI correlated with past and present symptoms independently of the BIS/BAS subscales (Carver & White, 1994) and the HPS (Eckblad & Chapman, 1986). Five factors of the HAPPI were identified: success activation and triumph over fear, activating response style, reduced social regulation, loss of control when activated, and catastrophic beliefs about internal states. The HAPPI factors showed specific relationships with current bipolar symptoms that largely fitted with predictions based on the model. Further work is required to establish whether they have a causal role.

Psychological Processes Mediate the Impact of Familial Risk, Social Circumstances and Life Events on Mental Health

Background Despite widespread acceptance of the ‘biopsychosocial model’, the aetiology of mental health problems has provoked debate amongst researchers and practitioners for decades. The role of psychological factors in the development of mental health problems remains particularly contentious, and to date there has not been a large enough dataset to conduct the necessary multivariate analysis of whether psychological factors influence, or are influenced by, mental health. This study reports on the first empirical, multivariate, test of the relationships between the key elements of the biospychosocial model of mental ill-health. Methods and Findings Participants were 32,827 (age 18–85 years) self-selected respondents from the general population who completed an open-access online battery of questionnaires hosted by the BBC. An initial confirmatory factor analysis was performed to assess the adequacy of the proposed factor structure and the relationships between latent and measured variables. The predictive path model was then tested whereby the latent variables of psychological processes were positioned as mediating between the causal latent variables (biological, social and circumstantial) and the outcome latent variables of mental health problems and well-being. This revealed an excellent fit to the data, S-B χ2 (3199, N = 23,397) = 126654·8, p<·001; RCFI = ·97; RMSEA = ·04 (·038–·039). As hypothesised, a family history of mental health difficulties, social deprivation, and traumatic or abusive life-experiences all strongly predicted higher levels of anxiety and depression. However, these relationships were strongly mediated by psychological processes; specifically lack of adaptive coping, rumination and self-blame. Conclusion These results support a significant revision of the biopsychosocial model, as psychological processes determine the causal impact of biological, social, and circumstantial risk factors on mental health. This has clear implications for policy, education and clinical practice as psychological processes such as rumination and self-blame are amenable to evidence-based psychological therapies.

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.

Hypomanic personality, stability of self-esteem and response styles to negative mood

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

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.