Cognitive Vulnerability Stress Prediction of Bipolar Mood Episodes

Do the negative cognitive styles or self-referent information processing featured as vulnerabilities in the cognitive theories of unipolar depression also act as vulnerability factors for bipolar spectrum disorders in response to life events? That is, do negative cognitive styles increase the likelihood that bipolar individuals become depressed or hypomanic/manic when confronted with positive or negative life events? Five studies have examined the cognitive vulnerability-stress hypothesis for bipolar disorders.

Hammen, Ellicott, Gitlin, and Jamison (1989) tested Beck's (1987) event congruence, vulnerability-stress hypothesis in 22 unipolar and 25 bipolar patients. Specifically, the patients were categorized into sociotropic and autonomous subtypes and then followed for 6 months with independent assessments of symptoms and life events. Based on Beck's (1987) theory, it was predicted that patients who experienced a preponderance of negative life events that were congruent with their personality style (interpersonal events for sociotropic patients and achievement events for autonomous patients) would be more likely to experience an onset or exacerbation of symptoms. Hammen et al. obtained support for the event congruence hypothesis only in the unipolar patients. However, there were trends consistent with the hypothesis for the bipolar patients as well and Hammen et al. suggested that a longer period of follow-up might be needed to obtain the effect in bipolar patients. Indeed, in a later study, Hammen et al. (1992) followed a larger sample of 49 remitted bipolar patients for an average of 18 months. Although onset of symptoms was not associated with a preponderance of negative events that matched the bipolar patients' personality type, subsequent symptom severity was significantly related to the interaction of sociotropy and negative interpersonal events, consistent with Beck's (1987) hypothesis. Similarly, in analyses using the first 6 months of follow-up data in the LIBS Project, Francis-Raniere, Alloy, and Abramson (2004) revealed that among bipolar participants, after controlling for initial depressive symptoms and total negative life events experienced, the interaction of autonomous cognitive styles with congruent, autonomy-relevant negative events, and the interaction of sociotropic cognitive styles with con gruent, sociotropy-relevant negative events, each predicted increases in depressive symptoms over the 6 months. In addition, after controlling for initial hypomanic symptoms and total positive events experienced, the autonomous styles x autonomy-relevant positive events and sociotropic styles x sociotropy-relevant positive events interactions each predicted increases in hypomanic symptoms over the 6 months.

Two studies tested the cognitive vulnerability-stress hypotheses of both the Beck (1967) and hopelessness (Abramson et al., 1989) theories in samples including bipolar individuals. Alloy, Reilly-Harrington, et al. (1999) examined whether attributional styles and/or dysfunctional attitudes assessed at Time 1 in a normal mood state interacted with subsequent positive and negative life events to predict prospective increases in depressive and hypomanic symptoms among their sample of undergraduates with untreated subsyndromal unipolar and bipolar mood disorders. Consistent with the hopelessness theory, an internal, stable, global attributional style for negative events at Time 1 interacted with subsequent negative life events to predict increases in depressive symptoms at Times 2 and 3 (see Fig. 4.1 for prediction to Time 2). In addition, an internal, stable, global attributional style for positive events at Time 1 interacted with subsequent positive life events to predict increases in hypomanic symptoms at Time 2 (see Fig. 4.2). Dysfunctional attitudes at Time 1 did not interact with positive or negative life events to predict changes in either depressive or hypomanic symptoms at Times 2 or 3.

In a longitudinal design, Reilly-Harrington et al. (1999) also examined whether the interaction of Time 1 attributional styles, dysfunctional attitudes, and negative self-referent information processing (as assessed by a battery of tasks) and intervening negative life events predicted increases in 97 unipolar (most of them remitted) and 49 bipolar (most of them remitted) individuals' clinician-rated depressive and manic symptomatology at Time 2, a month later. Consistent with both hopelessness and Beck's theories, negative attributional style, dysfunctional attitudes, and negative self-referent information processing each interacted significantly with subsequent negative life events to predict increases in depressive symptoms (see Table 4.3) and, within the bipolar group, manic symptoms (see Table 4.4) at Time 2. As predicted, only individuals with negative cognitive styles or information processing at Time 1 who reported a high number of negative life events experienced increases in depressive and manic symptoms at Time 2. Moreover, these findings were maintained when the data of the few unipolar and bipolar students who had received treatment were removed from the analyses.

In summary, the results of the few vulnerability-stress studies to date are promising in supporting the applicability of the cognitive theories of unipolar depression to bipolar spectrum disorders. As such, they suggest

FIG. 4.1. Residualized change in Beck Depression Inventory (BDI) scores at Time 2 as a function of attributional style for negative events and the proportion of negative life events (total negative events/total events) experienced. High ASQ-NC refers to a more internal, stable, global attributional style for negative events and Low ASQ-NC is a less internal, stable, global attributional style for negative events. Adapted from "Cognitive Styles and Life Events in Subsyndromal Unipolar and Bipolar Mood Disorders: Stability and Prospective Prediction of Depressive and Hypomanic Mood Swings," by L. B. Alloy, N. Reilly-Harrington, D. M. Fresco, W. G. Whitehouse, and J. S. Zechmeister, 1999, Journal of Cognitive Psychotherapy: An International Quarterly, 13, p. 33. Adapted with permission from Springer Publishing Co.

FIG. 4.1. Residualized change in Beck Depression Inventory (BDI) scores at Time 2 as a function of attributional style for negative events and the proportion of negative life events (total negative events/total events) experienced. High ASQ-NC refers to a more internal, stable, global attributional style for negative events and Low ASQ-NC is a less internal, stable, global attributional style for negative events. Adapted from "Cognitive Styles and Life Events in Subsyndromal Unipolar and Bipolar Mood Disorders: Stability and Prospective Prediction of Depressive and Hypomanic Mood Swings," by L. B. Alloy, N. Reilly-Harrington, D. M. Fresco, W. G. Whitehouse, and J. S. Zechmeister, 1999, Journal of Cognitive Psychotherapy: An International Quarterly, 13, p. 33. Adapted with permission from Springer Publishing Co.

that similar cognitive and psychosocial processes may contribute vulnerability to both unipolar and bipolar forms of mood disorder. Two issues raised by the findings of the vulnerability-stress studies to date remain to be resolved in future research. First, although two studies (Hammen et al., 1992; Reilly-Harrington et al., 1999) found that negative life events in interaction with negative cognitive styles predicted both depressive and manic symptoms among bipolar individuals, two other studies (Alloy, Reilly-Harrington, et al., 1999; Francis-Raniere et al., 2004) indicated that positive life events predicted increases in hypomanic symptoms in combi-

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