Bipolar disorder is a mental health condition characterized by extreme shifts in mood and energy levels, cycling between emotional highs (mania/hypomania) and lows (depression).
Mood episodes can last for days or months and profoundly impact emotions, thoughts, and behaviors.
Mania often manifests as elevated mood, impulsivity, and risk-taking behaviors, while depression involves sadness, low energy, loss of interest, and hopelessness.
These severe mood swings in bipolar disorder can significantly impair function and quality of life when not effectively treated and managed.
Woods, C., Richardson, T., & Palmer‐Cooper, E. (2023). Are dysfunctional attitudes elevated and linked to mood in bipolar disorder? A systematic review and meta‐analysis. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12442
Key Points
The key findings of the paper were:
- Dysfunctional attitudes were significantly higher in people with bipolar disorder compared to healthy controls (d = .70) based on a meta-analysis of 23 studies (Woods, Richardson, & Palmer-Cooper, 2023).
- There was no significant difference in dysfunctional attitudes between bipolar disorder and unipolar depression groups (d = -.16) per the meta-analysis.
- Among bipolar samples, dysfunctional attitudes were higher when participants were in a depressed state compared to a euthymic state (d = -.71) based on study comparisons.
- Three studies found psychological interventions, like CBT and psychoeducation, reduced dysfunctional attitudes in bipolar disorder (d = -.38) (Woods et al., 2023).
Rationale
Dysfunctional attitudes reflect deeply held assumptions and beliefs that impact information processing and contribute to depressive symptoms (Weissman, 1979).
They have been consistently shown to be elevated in unipolar depression compared to healthy controls.
However, less research has examined dysfunctional attitudes in bipolar disorder. Some studies found bipolar patients have higher dysfunctional attitudes than controls (Lam et al., 2004), while others did not (Scott & Pope, 2003).
Comparing attitudes between diagnostic groups and mood states can clarify if they represent a stable vulnerability factor versus fluctuating with episodes in bipolar disorder (Mansell et al., 2007). This could inform psychological treatment targets for prevention and management.
Method
This systematic review included 47 studies related to dysfunctional attitudes in bipolar disorder samples in both the descriptive review and quality ratings.
A subset of 23 studies were included in meta-analyses calculating standardized mean differences. Tests of heterogeneity determined consistency of effects across studies. Funnel plots assessed publication bias.
Sample
The included studies involved 3575 total bipolar disorder participants. Comparison groups included healthy controls (21 studies, n = 3453) and unipolar depression (13 studies, n = 1372). Participant demographic details were not reported at the review level.
Statistical Measures
Standardized mean differences (Hedges’ g) were calculated between bipolar patients and control groups and between mood states. Random effects models account for heterogeneity.
Funnel plots assessed publication bias. Subgroup analyses explored categorical moderators. Tests for heterogeneity (I2) were conducted per best practice guidelines (Higgins et al., 2021).
Results
The meta-analysis found a large, significant effect for higher dysfunctional attitudes in bipolar groups versus healthy controls (d = 0.70, 95% CI 0.51–0.88, p < .001) with significant heterogeneity between studies (I2 = 78.26%, p < .001) (Woods et al., 2023).
There was no significant difference between bipolar and unipolar depression groups (d = -0.16, 95% CI -0.47–0.16, p = .33).
In comparisons of mood states among bipolar patients, dysfunctional attitudes were significantly higher when participants were experiencing depressive symptoms compared to euthymia (d = -0.71, 95% CI -1.14 − -0.28, p = .001).
Insight
The results indicate dysfunctional attitudes are elevated in bipolar disorder, confirming them as a characteristic of the disorder, as seen in unipolar depression.
However, attitudes appear more severe when patients experience depressive but not manic symptoms. This implies dysfunctional attitudes may “go offline” outside mood episodes.
Psychological interventions also ameliorate dysfunctional attitudes in bipolar patients, suggesting they can be targeted therapeutically.
Strengths
- The systematic review methodology provides a robust quantitative synthesis of the research literature on dysfunctional attitudes in bipolar disorder. The meta-analysis increases statistical power to detect effects.
- The study assessed research quality using a standardized rating checklist to weight study contributions to the overall findings. This helps validate results.
- Tests of publication bias through funnel plots indicated a low risk that significant findings are overrepresented due to reporting biases. This increases confidence in the reliability of effects.
- The inclusion of both clinical (unipolar depression) and non-clinical comparison groups aids interpretation of whether dysfunctional attitudes specifically relate to bipolar diagnosis versus broadly to mood disorders.
Limitations
- Individual studies included in the meta-analysis often had relatively small sample sizes of bipolar patients, though aggregating studies helps overcome this limitation.
- There was some variability in the operationalization of mood states across studies, with not all using validated clinical measures. Standardizing definitions could improve reliability.
- The analyses demonstrate significant associations between dysfunctional attitudes and diagnostic/mood variables but cannot determine causality or directionality.
Implications
These findings indicate dysfunctional attitudes should be assessed and addressed in psychological treatments for bipolar disorder, with a particular focus on intervening when patients are depressed (Lam et al., 2004; Scott & Pope, 2003).
Tracking attitudes and mood episodes over time can help discern if improving attitudes mitigates episodes or vice versa.
Evaluating other cognitive constructs like self-compassion may further explain cognitive–affective dynamics in bipolar disorder.
References
Primary references
Woods, C., Richardson, T., & Palmer-Cooper, E. (2023). Are dysfunctional attitudes elevated and linked to mood in bipolar disorder? A systematic review and meta-analysis. British Journal of Clinical Psychology. Advance online publication. https://doi.org/10.1111/bjc.12442
Other references
Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., Parr-Davis, G., & Sham, P. (2003). A randomised controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60(2), 145–152. https://doi.org/10.1001/archpsyc.60.2.145
Mansell, W., Morrison, A. P., Reid, G., Lowens, I., & Tai, S. (2007). The interpretation of, and responses to, changes in internal states: An integrative cognitive model of mood swings and bipolar disorders. Behavioural and Cognitive Psychotherapy, 35(5), 515–539. https://doi.org/10.1017/S1352465807003827
Scott, J., & Pope, M. (2003). Cognitive styles in individuals with bipolar disorders. Psychological Medicine, 33(6), 1081–1088. https://doi.org/10.1017/s0033291703008167
Weissman, A. N. (1979). The Dysfunctional Attitude Scale: A validation study (Doctoral dissertation, University of Pennsylvania). ProQuest Dissertations Publishing.
Yang, Y., Fletcher, K., Michalak, E. E., & Murray, G. (2020). An investigation of self- compassion and nonattachment to self in people with bipolar disorder. Journal of Affective Disorders, 262, 43–48. https://doi.org/10.1016/j.jad.2019.10.042
Keep Learning
Here are some Socratic discussion questions about this paper for a college class:
- How might dysfunctional attitudes develop in bipolar disorder? What factors may maintain them?
- Why might psychological treatments help change dysfunctional attitudes? What techniques could target attitudes?
- How could we study dysfunctional attitudes’ role as a vulnerability factor for bipolar episodes prospectively? What methodology would help test causal hypotheses?
