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Behavioural and Cognitive Psychotherapy, 2007, 35, 515–539 First published online 27 June 2007 doi:10.1017/S1352465807003827
The Interpretation of, and Responses to, Changes in Internal States: An Integrative Cognitive Model of Mood Swings and Bipolar Disorders Warren Mansell and Anthony P. Morrison University of Manchester, UK
Graeme Reid and Ian Lowens Early Intervention Services, Bolton, Salford & Trafford Mental Health NHS Trust, UK
Sara Tai University of Manchester, UK
Abstract. 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. Keywords: Mania, hypomania, depression, cognitive behavioural therapy, information processing, goal conflict.
Introduction Bipolar disorder typically represents a severe and enduring mental health problem involving periods of extreme disruptions to mood, behaviour and cognitive functioning. People with the
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disorder typically experience periods of severe depression, mania or hypomania, in addition to periods of relatively stable mood. However, even during periods of so-called “remission” sufferers can still display mood swings and sub-clinical symptoms (Judd et al., 2002, 2003). Rates of relapse remain high, despite use of medication, with approximately 50% of individuals relapsing within a year (Solomon, Keitner, Miller, Shea and Keller, 1995). Bipolar I disorder, characterized by a history of mania and depression, is thought to have a prevalence of at least 1.5% (American Psychiatric Association, 1994; Bebbington and Ramana, 1995), although some argue that as many as 6.5% of the population have symptoms that are severe enough to cause significant disruption to daily living, and would qualify for a diagnosis of a bipolar spectrum disorder, which includes bipolar II disorder, cyclothymia and bipolar disorder not-otherwise-specified (Angst, 1998). A significant number of those with the disorder experience a severe decline in occupational and social functioning, potentially leading to great personal and financial loss. The overall impact can be vast for sufferers, their relatives, and the wider community. For example, it is estimated that within the UK, the cost of bipolar disorder to society in 2001 amounted to £2 billion, 85% of which can be accounted for through indirect costs such as unemployment and premature mortality (Das Gupta and Guest, 2002). Despite the impact of bipolar disorders, current understanding of the mechanisms involved is limited. Several commentators have noted that primacy has been given to hypothetical biological factors in attempts to provide an understanding of causal factors (e.g. Scott, 1995). However, increasing evidence has emerged that emphasizes the importance of psychological factors in the development and maintenance of the disorder. We aim to briefly summarize four of the most prominent accounts (which overlap with one another to some degree), move on to explain a novel approach built upon the previous theories, followed by a focus upon implications for a focused psychological intervention. From the 1980s onwards (Depue et al., 1981; Depue, Krauss and Spoont, 1987; Johnson et al., 2000), a series of authors have proposed that bipolar disorders can be explained by the increased sensitivity of a neuropsychological system governing reward-seeking behaviour: termed the behavioural activation system (BAS; Gray, 1972, 1994). It is proposed that individuals vulnerable to the disorders have more sensitive and reactive regulatory systems, leading to increased vulnerability to extreme mood variations. Johnson and colleagues (Lozano and Johnson, 2001; Johnson et al., 2000; Johnson, Ruggero and Carver, 2005) have suggested that “goal-attainment life events” are likely to trigger this system, resulting in increases in manic symptoms; they provide some evidence to support this proposal. In turn, several authors have proposed that dysfunctional beliefs relating to extreme goal-attainment, perfectionism and need for approval may interact with these life events and further raise the risk of an episode (Johnson et al., 2005; Wright and Lam, 2004). A second approach has focused on the disruption of circadian rhythms: biological cycles governing sleep, activity levels and other intrinsic drives. Disruption is thought to occur when the environmental cues that influence the pattern of the cycles are disturbed by the disruption of normal routines as a result of pharmacological, environmental or interpersonal events, as might occur following stressful life events (Meyer, Johnson and Winters, 2001; Wehr, Sack, Rosenthal, Duncan and Gillin, 1983; Wehr, Sack and Rosenthal, 1987). The consequence is thought to be a neuropsychological state characterized by elevated arousal and psychomotor agitation. Extending circadian rhythms theory, Jones (2001) provided an elaborate cognitive framework that expanded upon an early proposition by Healy and Williams (1989). Jones (2001) suggested that during the development of mania, neuropsychological symptoms may
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be appraised in ways that are positive and self-dispositional rather than situational (e.g. “My fast thinking is a sign of my inherent intelligence and creativity”), thus leading to behaviours that further disrupt rhythms and feed into a vicious cycle of escalating symptoms. In a third line of work, Bentall and colleagues (Bentall, 2003; Lyon, Startup and Bentall, 1999) further examined the idea of cognitive style in bipolar disorders, reviving a modified form of the manic-defence hypothesis (Abraham, 1911). Abraham initially stated that depression and mania represented different response styles to a common problem, with people becoming manic in the process of trying to avoid the experience of depression (Bentall, 2003). According to this approach, depressed and bipolar patients have a similar ruminative style of coping with depression, but people with bipolar disorders also tend to employ the additional strategy of behavioural risk-taking, which is thought to contribute to the specific symptoms of mania (e.g. Knowles, Tai, Christensen and Bentall, 2005; Knowles, Tai, Jones, Morriss and Bentall, 2006; Thomas and Bentall, 2002). In a fourth line of work, clinicians have noted the tendency for cognitive style during mania to be opposite to that of depression; for example, the self is perceived as creative, talented and superior in contrast to slow, worthless and unlovable, and the perception of unlimited future possibilities replaces a view of the future that is hopeless and pessimistic (Beck, 1967; Leahy and Beck, 1988). It is proposed that the cognitive biases have subsequent effects on mood and behaviour that contribute to manic symptoms. In a related account, Leahy (1999) has articulated how biases of this kind can be viewed within a theory of decision-making (portfolio theory) as examples of high risk-preference. Each of the above approaches has advanced the understanding of the role of psychological mechanisms in bipolar disorders, and informed the related psychological interventions (e.g. Basco and Rush, 1996; Lam, Jones, Hayward and Bright, 1999; Leahy, 2005; Newman, Leahy, Beck, Reilly-Harrington and Gyulai, 2002; Scott, Stanton, Garland and Ferrier, 2000). However, many of the constructs implicated in these models remain hypothetical and offer plausible but incomplete accounts of the wide range of symptoms involved in the disorder. For example, there is a difficulty with theories placing an emphasis on behavioural components (such as behavioural activation, disruption to daily rhythms, and coping strategies) without specifying the role of the implicated cognitive mechanisms. Emphasis has also been placed on explaining mechanisms leading to mania that do not adequately explain how people make transition from one phase to another (e.g. from mania to depression), or account for the processes involved in mixed episodes. Furthermore, the complexity of these models potentially limits the extent to which they can be applied in clinical situations to help people become more mindful of their cycles of mood, cognition and behaviour. Consequently, we aim to outline an approach grounded in existing cognitive behavioural theory, which is sufficiently simple to ease the process of creating collaborative formulations, while being versatile enough to account for the multiple experiences associated with bipolar disorders. We first summarize the model and then elaborate in detail on each component and the evidence relating to it. Interpretations of and responses to changes in internal state: an integrative model Recent developments in the cognitive conceptualization of anxiety disorders and psychosis have incorporated the occurrence and interpretation of intrusions. These advances in theoretical understanding have resulted in new and refined clinical approaches to intervention. In addition to the seminal work of Beck (1967) and the more recent work of leading theorists in the
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anxiety disorders field (e.g. Clark, 1999; Salkovskis, 1991; Wells and Matthews, 1994), our approach has been specifically influenced by two further recent theoretical developments: the metacognitive conceptualization of psychosis (Morrison, 2001) and the conceptualizations of cognitive and behavioural processes common to a range of psychological disorders (“transdiagnostic” processes: Harvey, Watkins, Mansell and Shafran, 2004). These approaches to the cognitive conceptualization of mental health problems suggest that such difficulties (whether psychotic or not) are characterized by similar themes: intrusions into awareness (such as body state information, affect, thoughts and images, or external sensory input) that are appraised in a problematic manner (commonly involving some kind of catastrophic misinterpretation). These appraisals, which are influenced by beliefs that have been formed as the result of life experiences, also influence the selection of potentially unhelpful strategies for self-regulation, which may consequently contribute to mood destabilization. We aim to apply these conceptualizations to the phenomenology of mood swings by proposing a new cognitive model of bipolar disorders. This model is not, and cannot be purely disorder-specific, as it specifies a mechanism for the maintenance and escalation of mood fluctuations that vary dynamically over time. Thus, although the model would most closely apply to bipolar disorders, it would also help to explain sub-clinical mood swings and mood fluctuations in other conditions such as anxiety disorders. We suggest that the manner in which mood fluctuations express themselves over time will determine the diagnosis that the individual receives at that stage. Consistent with this approach, longitudinal studies reveal that a diagnosis of bipolar disorder is relatively unstable over time (Chen, Swann and Johnson, 1998; Forrester, Owens and Johnstone, 2001). Furthermore, while mood fluctuations clearly characterize bipolar spectrum disorders, they are also significant features of schizoaffective disorder (APA, 1994), borderline personality disorder (APA, 1994), some anxiety disorders (e.g. Bowen, South and Hawkes, 2004), and sub-clinical hypomanic populations (e.g. Hofmann and Meyer, 2006). Therefore we would expect the model to be useful when working with each of these groups, in addition to conceptualizing mood fluctuations in superficially non-affective psychoses (cf. Krabbendam and van Os, 2005). We regard this transdiagnostic utility as a strength of the model, considering the increasing evidence that the key cognitive mechanisms maintaining psychological symptoms are common to a range of disorders (Harvey et al., 2004). For the sake of simplicity we will refer to “bipolar disorder” throughout this paper from this point onwards, but the model applies to a much wider population. In the first stage of the model, intrusions into awareness (i.e. changes in internal state in physiological, emotional or cognitive domains) are misinterpreted as signifying extreme personal meaning. Not only are these appraisals extreme, but they are multiple and contradictory, and therefore unresolved with respect to one another. Only one appraisal occupies awareness at any one time, but they have the capacity to switch with one another as the cycle evolves. In this respect, the model is consistent with dynamic models of behaviour, cognition and the environment that emphasize reciprocal change over time (e.g. Bandura, 1977). The appraisals include interpretations of the internal state as a sign of an imminent catastrophe, a personal success, or a personal weakness. Feared catastrophes may often focus upon concerns regarding the personal consequences of an impending episode of depression or mania. Predictions of imminent personal success typically involve the potential triumph over previous experiences of depression, adversity and failure. Appraisals of personal weakness typically involve attacks directed at the self that relate to the state of activation, e.g. “I should be ashamed of myself for getting so agitated”.
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According to the model, the appraisals of internal states as signifying extreme personal meaning trigger immediate efforts at exerting control to either prevent the catastrophe, reach safety, or attain personal success. These behaviours interfere with any opportunities to reappraise the internal state or to resolve the conflicting appraisals with respect to one another.1 Individuals may literally feel as though their “self ” is changing as they switch between these contradictory personal appraisals. The responses can be conceptualized in several ways. First, in relation to negative predictions (i.e. either catastrophic views of depression or manic episodes) such coping responses could be defined as safety-seeking behaviours (Salkovskis, 1991). While these behaviours would be intended to avoid catastrophic events, they can be counterproductive, as in the case of “antidepressive behaviours” (see Morrison, Peyton and Nothard, 2003). However, in addition to this explanation, behavioural responses may also be conceptualized as either “ascent” behaviours (Mansell and Lam, 2003) or “descent” behaviours. Ascent behaviours are carried out to try to enhance or control the activation level of the internal state and they contribute to increases in activation levels. Examples include increased involvement in activities and projects, risk-taking, alcohol and other drug use, extended wakefulness, seeking of social stimulation, and the dismissal of others’ attempts to moderate behaviour. Descent behaviours are carried out to try to enhance or control the activation level of the internal state and contribute to decreases in activation levels. Examples include social withdrawal and isolation, extended sleep, rumination and self-critical thinking. The model proposes that the appraisal of changes in internal state, and the associated use of ascent/decent behaviours, are influenced by a range of factors, including: personal beliefs regarding the self and others; procedural beliefs regarding information processing strategies (e.g. the advantages and disadvantages of rumination); and beliefs about affective and physiological states (e.g. positive and/or negative beliefs about depression: Reid, 2005). Such beliefs are likely to be affected by past life experiences, and ongoing current events. The model is illustrated graphically in Figure 1. The inter-relationships between the components demonstrate how escalation of symptoms occur, with a cycle of change in internal state, distorted appraisal, and attempts to control or enhance that contribute to further alterations in internal state, leading eventually to experiences that confirm dysfunctional beliefs. It is suggested that the cycle develops via an iterative process, with each factor becoming progressively amplified, manifesting as escalating symptoms within affective, physiological, cognitive and behavioural domains. Thus, at different phases (e.g. remission, prodromes, depression, mania, mixed states), the components of the model will vary in degree and content. Each part of the model will now be elaborated in detail with a discussion of evidence relevant to each component. Changes in internal state The model is dynamic, and driven by the individual and so can be “entered” at any point (see Figure 1). However, it makes most sense clinically and for descriptive purposes to start
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more elaborate model of conflict and control in psychopathology is beyond the scope of this paper, but readers are referred to Mansell (2005) for an explanation of how the CBT approach can be conceptualized under a broader conceptual framework, known as Perceptual Control Theory (Powers, 1973, 2005).
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Figure 1. A cognitive model of mood swings and bipolar disorders
at the top of the diagram with an event that triggers a change in internal state. For example, the opportunity provided by a carnival in town could prompt a reaction of excitement, or the ingestion of several cups of coffee could prompt an increase in arousal. The nature of the trigger can be varied; it is the change in internal state that it prompts or allows that is key. The change in state might be a change in mood, arousal, cognition (e.g. thoughts racing) or perceived behaviour (see Table 1). The model suggests that people with bipolar disorder would experience fluctuations in their internal state prior to episodes of intense affect change, and this fluctuation increases the likelihood of a cognitively driven cycle of escalating symptoms. As such, the model is consistent with evidence that people with bipolar disorder experience considerable affect change outside episodes of clear mania or depression (Judd et al., 2002, 2003; Perugi, Toni, Travierso and Akiskal, 2003). We emphasize that the changes in internal state experienced by people with bipolar disorders are on a continuum with mood fluctuations found in other clinical samples and non-clinical populations. For example, hypomanic experiences are reported by a range of individuals with no clinical conditions, including undergraduate students (Depue, Krauss, Spoont and Arbisi, 1989; Udachina and Mansell, 2007), individuals with a “hypomanic personality style” (Eckblad and Chapman, 1986), naturally short sleepers (Monk, Buysee, Welsh, Kennedy and Rose, 2001) and high functioning individuals past the peak age of onset of bipolar disorder (Seal, Mansell and Mannion, in press). The above proposal needs to be qualified to some degree. The cyclical, escalating, nature of the model predicts that internal state, in tandem with escalations in appraisal and behaviour
Table 1. The key components of the cognitive model of mood swings and bipolar disorders Definition
Subcategories
Examples
Change in internal state
Intrusions into awareness of the current quality of perception of the mind or body
Appraisal of extreme personal meaning
Attaching extreme personal significance to current changes in internal state
Ascent behaviours
Behaviours aimed at enhancing or controlling internal states (because of their extreme personal meaning) that have the effect of increasing the state of activation Behaviours aimed at enhancing or controlling internal states (because of their extreme personal meaning) that have the effect of decreasing the state of activation Underlying metacognitive beliefs that are formed from experience, accessible during different states, and influence on-line appraisals of internal states
Mood Physiology Cognition Self-success Self-critical Social approval Other-Negative Catastrophic Internal Physical Behaviour Social Internal Behaviour Social
“High”, “low”, “sad”, “irritable” “Buzzy”, “restless”, “agitated” “Thoughts racing”, “moving quicker” “I have the energy to do anything I want” “I am making a fool of myself ” “I can make everyone around me admire me” “Other people are trying to control me” “I am about to lose control of my mind” Recurrent goal setting and ideation, worry Ingest stimulating substances, extended wakefulness Do things quicker, act on spur of moment Seek out people to influence, ignore advice Rumination, self-critical thinking, suppression Reduce activity Withdraw from other people, increased dependence
Affect regulation
“I cannot cope feeling sad even for a short while” “If I feel good, I must act on the feeling straight way” “When I am energized I know that I am a very important person” “When I feel good, other people do not understand me” Trauma, failure experiences, experiences of “hyping self up” to overcome adversity Other peoples responses to changes in behaviour, e.g. encouragement, worry, neglect, anger, constraint
Descent behaviours
Beliefs about affect regulation, the self and others
Life experiences
Events in the outside world that contribute to beliefs, changes in internal state, and are influenced by the observable effects of ascent and descent behaviours
Self Others Early Ongoing
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change, could reach proportions that appear qualitatively different, yet emanate from a similar dynamic cycle to those that contribute to minor mood swings. At extreme states of mood and arousal, information processing may become biased considerably and further contribute to a person’s difficulties in stepping outside the cycle (cf. Steel, Fowler and Holmes, 2005; Clark and Sahakian, 2006). For example, heightened distractibility associated with arousal may be incompatible with the sustained, controlled attention necessary to engage in the contextual processing of experiences. These potential neuropsychological factors are beyond the scope of the current article, yet demonstrate an integrative capacity of the model on which we aim to elaborate in future work. A further consideration is whether certain genetic factors predispose to more pronounced changes in internal state that raise the risk for developing bipolar disorder. This possibility would be consistent with the model. Changes in internal state interpreted as having extreme personal meaning In the next stage of the model (see Figure 1), a change in internal state is subject to interpretation by the individual. This interpretation is characterized by extreme positive and negative personal meanings that have a significant propensity for conflict. These appraisals are at the heart of the model; they direct behavioural responses that are themselves perceived and appraised, serving as the “online” mediators of underlying beliefs. As described earlier, Healy and Williams (1989) were the first to highlight the findings that circadian rhythm disruption leading to a state of psychomotor activation and agitation could then form the basis of self-relevant appraisals. They focused on appraisals relating to positive personal traits. For example, an increase in the subjective rate of the speed of thinking could be interpreted as a sign of great intelligence, wit and natural intuition. Until recently, no studies have tested this hypothesis. Our current model is consistent with Healy and Williams’s (1989) approach, but emphasizes a wider range of extreme, conflicting, self-relevant appraisals. It is proposed that extreme personal appraisals are not limited to states of high activation, but that states of relative low activation such as tiredness and fatigue may also activate important beliefs (e.g. “Without the energy to do important things, my life has no purpose”: see also Jones, 2001), as might feelings of sadness (“I cannot cope with being sad even for a short while”). In addition to extreme positive meanings, states of high activation may receive self-critical and catastrophic personalized meanings (“When I get overexcited, I am always arrogant and overbearing” and “When I feel happy it is a sign I am about to lose control of my mind”). Note that these appraisals may, or may not turn out to have some truth in them: people with bipolar disorders do relapse. However, the model suggests that these appraisals are nonetheless functionally disruptive because they contribute to a cycle of escalating processes and can become self-fulfilling. Moreover, many individuals with bipolar disorder make these catastrophic predictions based on limited evidence, such as a brief change in energy levels, rather than basing them on a balanced, contextualized analysis of their experiences. It is the consistency between the appraisal and the evidence used to support it that is extreme rather than the absolute, potential truth value of the statement. It is also likely that idiosyncratic meanings would be invoked by other feelings, such as frustration (e.g. “When I feel irritated I am convinced that other people are trying to control me”). Thus, the model suggests that multiple, conflicting appraisals of internal states are available; therefore the appraisals change over time in tandem with the dynamic changes in
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internal state, behaviour and responses from others. The extreme appraisals often reflect an image of an “imminent possible self ” derived from earlier experiences stored in memory, in a similar way to those reported in other conditions such as social phobia and agoraphobia (for an overview, see Holmes and Hackmann, 2004). For example, Mansell and Lam (2004) found that people with bipolar disorder reported recurrent, distressing memories of themselves when they were in the depths of depression, or feeling viewed as a failure by others. The empirical evidence for the sensory self-relevant information associated with the appraisals of extreme personal meaning within the model is elaborated further in another article (Mansell and Hodson, in preparation). The direct evidence for the appraisals proposed in the model will be reviewed here. Mansell (2006) selected five categories: Self-Activation, Self-Catastrophic, Other-Positive, OtherNegative and Response-Style. Each of these categories had a good level of internal consistency. They formed the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI). The first two categories directly involve extreme personal appraisals of internal states (e.g. “When I feel more active I realise that I am a very important person”; “When I feel agitated and restless it means that I am about to have a breakdown”). The two categories of beliefs about others were also of extreme personal relevance (e.g. “When I feel really good, people don’t understand me”; “When I feel excited I know that other people desire me”). Individuals with bipolar disorder scored higher on this scale, and each of the subscales, than a matched non-clinical control sample. This finding was replicated in a more extensive study that controlled for current symptoms (Mansell and Jones, 2006). Jones, Mansell and Waller (2006) tested a similar hypothesis with a scale that they coined the Hypomanic Interpretations Questionnaire (HIQ). This scale measures the tendency for individuals to make personal attributions for the signs and symptoms of hypomania (e.g. “If I felt in high spirits and full of energy, I would probably think it was because I am a talented person with lots to offer”). Individuals vulnerable to bipolar disorder, and those reporting a diagnosis of bipolar disorder, were found to score significantly higher on this scale than matched non-clinical controls.
Behavioural components Ascent behaviours Ascent behaviours (see Figure 1) are triggered by extreme personal appraisals of alterations in internal state. They contribute to heightened activation levels that are themselves perceived and appraised. Ascent behaviours are critical to the capacity of the cycle to escalate symptoms. For example, a person who experienced racing thoughts and who subsequently believed that they are extremely intelligent would be more likely to dominate social interactions and ignore negative feedback from others. Ascent behaviours are goal-focused; yet they contribute to the development of manic symptoms (Mansell and Lam, 2003). For example, a person’s reaction to the consequences of dominating social interactions is likely to be affected by a confirmatory bias associated to their primary interpretation (e.g. “I am supremely intelligent; other people have to struggle to keep up”). Other people may consequently be viewed as incompetent, and the normal processing of social cues that might moderate extreme behaviour (e.g. looks of disquiet; explicit requests to slow down) will be disrupted. Other examples of ascent behaviours include: extended wakefulness; increased rate of activity; generating multiple
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ideas and goals, the seeking of social stimulation; and the dismissing of others’ attempts to moderate behavioural changes. Similarities exist in the concept of ascent behaviours and examples of poor coping strategies (e.g. “continue to move about and take on more tasks”) that have been associated with relapse into mania (Lam, Wong and Sham, 2001). Research into antidepressive behaviours (behaviours intended to prevent depression) appears to provide some evidence for our central assertion of a specific tendency for amplified behavioural responses to internal states in people with bipolar disorder. For example, Morrison et al. (2003) reported associations between self-reported frequencies of antidepressive behaviours and predisposition to mania in a non-patient sample. Increased reports of active coping (e.g. keeping busy) and social coping (e.g. talking to a friend) were also associated with a greater predisposition to mania. In addition, Morrison et al. (2003) reported that “active coping” as a solution to low mood was negatively correlated with current symptoms of depression, suggesting that these antidepressive behaviours may be effective in reducing negative affect. This finding was replicated in a clinical sample (Morrison et al., 2006). The latter study found that currently depressed individuals with a bipolar diagnosis and non-patients reported higher frequency of active coping than a unipolar-depressed group of participants. Although of considerable interest, further studies are required in order to explore the degree of specificity of particular types of active coping to people with bipolar disorder. Within the model, increased risk-taking would be viewed as a further example of ascent behaviour. In non-clinical samples, hypomanic personality has been associated with selfreported risk-taking as method of coping with negative moods (Knowles et al., 2005, 2006; Thomas and Bentall, 2002). Although consistent with the model, further evidence would be needed to clarify whether this coping style increased levels of subsequent activation and thus the possibility of an episode of mania. In most of the studies mentioned, the behavioural responses in bipolar disorder have been assessed with self-report questionnaires. In contrast, Mansell and Lam (2006) investigated a specific ascent behaviour (i.e. the tendency for people with bipolar disorder when in an elevated mood state to ignore or dismiss advice) using an experimental paradigm. Participants were either individuals with remitted bipolar disorder, remitted unipolar depression, or never depressed controls. They took part in a computerized paradigm assessing the use of advice during a goal-directed task before and after either a positive or negative mood induction. People with bipolar disorder were found to use less advice to inform their decisions after the positive mood induction, in contrast to never depressed controls and people with remitted unipolar depression. This study provides tentative evidence that certain ascent behaviours have the effect of reducing the influence of social feedback, which, if attended to, would serve the function of assisting a person to moderate their feelings and behaviour according to the social context. Descent behaviours The alternative responses that could follow from extreme personal appraisals are behaviours that contribute to lowered mood state, identified within the model as descent behaviours (see also Mansell, Colom and Scott, 2005). These can form a further vicious cycle; for example, some people may appraise their feelings of sadness in an extreme way (“I will look pathetic and be rejected by my friends”), contributing to a descent behaviour of avoiding social situations. Others may believe “I can only be productive when I am full of energy”, leading to other descent behaviours such as ceasing any activity and the initiation of prolonged periods of
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sleep. Such responses reduce the possibility of the discovery of disconfirmatory evidence, which contributes to their continued use. Our model would indicate that the behavioural symptoms that characterize bipolar depression are often the result of attempts to overcome perceived aversive consequences of high or low mood states. Recent research on unipolar depression has emphasized the role of “response style” in increasing symptom severity and precipitating relapse. In particular, there is evidence that rumination in response to low mood predicts increased severity of depressive symptoms (Nolen-Hoeksema and Morrow, 1991; Watkins, Teasdale and Williams, 2000; Watkins and Teasdale, 2001). Rumination involves recurrent thinking about the causes and implications of negative affect for the self. Several studies have found that vulnerability to bipolar disorders, as assessed by either self-report scales or familial risk, is correlated with high levels of selfreported rumination (Jones et al., 2006; Knowles et al., 2005, 2006; Thomas and Bentall, 2002). Beliefs about self, world, others, affect and affect regulation The beliefs illustrated in Figure 1 remain latent but can be accessed through introspection, questioning or situational context. The arrows in Figure 1 indicate that beliefs can determine both the “online” appraisals during different internal states and the choice of behaviours used to control, sustain or enhance them. Furthermore, life experiences and everyday events contribute to these beliefs in an ongoing fashion. Regarding beliefs about the self, world and others, several studies have shown that individuals with bipolar disorder report attitudes that are equivalent to those of people with unipolar depression (Lam, Wright and Smith, 2004; Scott et al., 2000; Scott and Pope, 2003; see Mansell and Scott, 2006, for a thorough review). It is of particular interest as to whether a proportion of these beliefs are more specific to bipolar disorder, and would therefore contribute to the appraisals that drive the central aspect of our model. Some evidence exists indicating that these beliefs focus upon extreme personal goals. For example, Lam et al. (2004) found that individuals with bipolar disorder scored higher on goal-attainment beliefs than a unipolar sample. In a separate study, such beliefs were maintained in individuals with remitted bipolar disorder after a positive mood induction, whereas they dropped in individuals with a history of unipolar depression, indicating that extreme personal beliefs may have a capacity to endure through states of elevated mood, a finding that does not apply to people without bipolar disorder (Wright, Lam and Strachan, 2006). Lam, Wright and Sham (2005) assessed the extent to which patients with bipolar disorder value and perceive that they possess a range of positive self-dispositional traits (e.g. dynamic, creative, successful) using a new measure - the Sense of Hyper-Positive Self Scale. They found that patients who had scored higher on this scale prior to treatment showed increased rates of relapse of hypomania or mania. Finally, in an analogue study, Johnson and Carver (2006) found that individuals who are vulnerable to mania report higher aspirations for fame, wealth, and political influence. In the model, beliefs regarding internal states are thought to guide appraisals of internal changes, leading to the further alterations in affect, and the activation of procedurally guided behavioural responses. The role of beliefs about affect and its regulation has received relatively little attention in the research literature to date. However some supportive evidence exists. In a non-clinical sample, Reid (2005) found correlations between predisposition to mania (as measured by the Hypomanic Personality Questionnaire; Ekblat and Chapman, 1986; Kwapil et al., 2000), and both negative and positive beliefs about depression (e.g. “If I get depressed I
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will never achieve anything”; “When I get depressed I see the world as it really is”). Negative beliefs about emotion such as “My emotions can be harmful”, and “My emotions are in control of me” were also found to be associated with a greater predisposition to mania. This is consistent with our suggestion that global beliefs regarding affect, rather than beliefs limited to depression, may contribute to affect instability. In focusing upon the influence of procedural beliefs upon behavioural responses, Mansell (2006) found that a set of beliefs concerning “response style” differentiated people with bipolar disorder and non-clinical controls. This scale included items such as “When I feel good, I must keep ‘on the go’ all the time or things will fall apart around me”, and “I need to have complete control over my moods in order to prevent myself from having a breakdown”. Such beliefs would be predicted to be triggered by changes in internal state and contribute to the maintenance behaviours in the model. Morrison et al. (2003) found that current depression was associated with low levels of belief in the use of social coping as a way of preventing depression in a non-clinical sample. Interestingly, this study failed to find any associations between self-reported beliefs about antidepressive behaviours and predisposition to mania, despite having found associations between frequencies of antidepressive behaviours and predisposition to mania, as discussed earlier. In contrast, Morrison et al. (2006) found that people with bipolar disorder were more likely to believe that both distraction and active coping would prevent depression when compared to people with unipolar depression and non-patient participants. In relation to unipolar depression, there is evidence of associations between metacognitive beliefs and ruminative thinking (e.g. Papageorgiou and Wells, 2003). There is also some evidence that procedural beliefs about cognitions are implicated in bipolar disorder. Taylor, Morrison and Bentall (2006) examined whether there were differences between manic, depressed and remitted bipolar participants (and non-patient controls). They found that bipolardepressed and bipolar-manic participants showed higher levels of unhelpful thought control strategies (as assessed by the Thought Control Questionnaire; TCQ; Wells and Davies, 1994) when compared with non-patients. In addition, bipolar-depressed participants and, to a lesser extent, bipolar-manic participants showed higher levels of dysfunctional metacognitive beliefs (as assessed by the Metacognitive Cognitions Questionnaire; MCQ; Cartwright-Hatton and Wells, 1997), in comparison with remitted bipolar participants and non-patient controls. Perhaps unsurprisingly, there are some inconsistencies in the findings of studies examining procedural beliefs. Procedural subroutines often operate outside of awareness and may therefore be difficult for people to identify and report (Wells and Mathews, 1994). In clinical practice, it can often be necessary to infer (via guided discovery) the content of procedural beliefs by observing consistencies in response styles to particular stimuli. Life experiences and current environment (including the reactions of other people) Our model incorporates life events that occur at three different stages: early independent events that contribute to dysfunctional beliefs (starting from the box labelled life events in Figure 1); partially independent events that follow on from the effects of ascent and descent behaviours and contribute to internal state changes and beliefs (arrows to and from the box in Figure 1); and dependent events that occur as a consequence of the spiralling of the vicious cycle over many iterations (i.e. occur as a result of an episode of significantly heightened, or lowered mood).
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Early independent life events As with “severe mental illness” in general (e.g. Mueser et al., 1998), a history of early trauma is common amongst people with bipolar disorder (e.g. Hyun, Friedman and Dunner, 2000; Kennedy et al., 2002; Leverich et al., 2002; Fox, 2005). Typically, such research has focused on childhood physical and sexual abuse, with a common finding that increased severity of abuse history appears to be associated with poorer clinical outcomes (e.g. Leverich et al., 2002; Neria, Bromet, Carlson and Naz, 2005). Recently, evidence has emerged that a wider range of adverse early experiences may be associated with the development of bipolar symptoms. In a non-clinical sample, Reid (2005) found that predisposition to mania was associated with a history of childhood emotional abuse, physical abuse, emotional neglect and physical neglect. Of these factors, reports of emotional abuse were found to be the best predictor of predisposition to mania. Interestingly, there was no association between a history of childhood sexual abuse and predisposition to mania. In a clinical study, Fox (2005) studied childhood trauma and parental bonding in three groups of individuals: those with a history of mania with positive symptoms of psychosis; those with a history of mania without such symptoms; and a non-patient control group. Seventy-one percent of the clinical sample reported a history of childhood abuse, compared to 20% in the control group. Low levels of maternal care and protection were found to significantly predict lifetime prevalence of mania, with emotional abuse approaching significance as predictor of lifetime prevalence.
Partially independent life events These are events that emerge during the cycle of escalating symptoms within the model. Reviews of the literature on stressful life events leading up to episodes in bipolar disorder indicate that they precede relapse at similar rates to that found in unipolar depression (see Johnson, 2005; Johnson and Roberts, 1995). Our model proposes a finer differentiation of the role of life events in that it is important to differentiate two different pathways through which experiences contribute to the cycle (see Figure 1). This is either by direct influence upon internal state (the dotted line in Figure 1), or through confirmation of extreme personal appraisals of the internal state (the unbroken line in Figure 1). Experiences of the first type would include events that disrupt circadian rhythms (e.g. night-shift work), events that involve the ingestion of psychoactive substances (e.g. substance use), and experiences of heightened external stimulation (e.g. nightclubs). A retrospective study found that mania was significantly more likely to be preceded by events that disrupt circadian rhythms than depression (MalkoffSchwartz et al., 1998). Experiences of the second kind include attainment or failure at personal goals (e.g. getting married, losing a job), and the negative and positive responses of others (e.g. criticism, praise). Importantly, behaviour from others that also reflects an extreme appraisal that is personalised to the individual would have the capacity to feed into the cycle. For example, close family members may appraise small changes in behaviour as signalling an imminent breakdown and respond in critical or overprotective fashion. This kind of response in family members has been found to predict relapse (Miklowitz, Goldstein, Nuechterlein, Snyder and Mintz, 1988). Other individuals, often recent acquaintances, may appraise the change in behaviour in an extremely positive manner, responding in ways that appear to endow the individual
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with high status and power. In response, the individual’s current appraisals are polarized into either sharing or contradicting those of others, but rarely are the appraisals directly tested for evidence or integrated with one another. This aspect of the model also helps explain how the current appraisals are maintained and change dynamically over time. Dependent life events When a person has experienced the vicious cycle illustrated in Figure 1 many times, this typically constitutes an “episode”. This leaves in its wake a series of potentially damaging life events, such as hospital admission, broken relationships, and stigmatization. According to the model, these experiences trigger further belief changes. For example, information given to service users about the diagnosis, and poorly implemented psychological interventions, may confirm or amplify catastrophic beliefs about affect change, and encourage hypervigilance for changes in internal states that have been identified as “early warning signs”. Catastrophic interpretations based on limited evidence, the consequent affect, and the subjective sense of either success or failure of behavioural responses may lead to intensification of affect, as previously outlined in the model. A similar process has been described in the psychosis literature (see Gumley et al., in press). Summary of the model We have proposed a new cognitive model of mood swings and bipolar disorders in some detail, alongside relevant evidence. Individuals with bipolar disorders experience changes in their internal state that are then appraised as having one of a range of extreme positive and negative personal meanings. Within an escalating cycle, appraisals can be activating (ascent behaviours) or deactivating (descent behaviours), with consequent impact on mood. Thus appraisals and the subsequent selection of behavioural response are determined by underlying beliefs about the self, the world, others, and also affect and its regulation. These beliefs have their origins in early independent life experiences, but are subject to change over time through life experiences, some of which occur as a consequence of the behavioural responses. As the cycle escalates in a self-perpetuating manner, these life experiences can include the damaging social effects of an episode of mood disorder. The model allows both for individual differences in genetic predisposition to internal state changes, and describes potential alterations in information processing style as individuals move round the cycle, yet it is the underlying beliefs and the conflict between them that is seen to drive mood swings and the development of mood symptoms. The nature of current symptoms will be a complex result of the previous experience of going through past vicious cycles, the nature of different underlying beliefs available, and the current environment. How does the model account for the course and symptom profile of bipolar disorder? Models of bipolar disorder need to address certain key features: the symptom profile of mania, including mixed states and psychosis; symptoms of depressive episodes; the temporary resolution of manic symptoms; and the occurrence of sub-clinical symptoms between episodes. As a full explanation of our model has been provided, we will now focus upon exploring its ability to coherently account for these specific points. Ultimately, an accurate prediction of the course
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and symptoms of bipolar disorders would only be possible from dynamic simulations of the model over time; however, the following section provides some of the more likely associations. Symptom profile of mania There is emerging consensus that there are multiple dimensions of manic symptoms that extend beyond the classic diagnostic symptoms. Factor analytic investigations have identified between four and seven components of mania that are very similar between studies (e.g. Akiskal, Azorin and Hantouche, 2003; Cassidy, Forest, Murry and Carroll, 1998; Rossi et al., 2001). For example, one well-controlled study identified five factors: dysphoria (including anxiety); psychomotor agitation/activation; irritability/aggression; elevated hedonic tone; and psychosis (Cassidy et al., 1998). Even studies that have excluded mixed states have identified a similar factor structure (Akiskal et al., 2003; Rossi et al., 2001). Thus, it is clear that the state of mania involves a heterogenous mixture of emotional states, both positive and negative, although there appears to be a core internal state of high activation. As mentioned, our model is based on the notion that people with bipolar disorder make extreme personal appraisals of changes in their internal state, and respond by striving to exert control. Many of these appraisals (as related to mania) are based on beliefs that states of high activation lead to extreme personal success and the ability to overcome major life problems. The central consequence of these appraisals is to trigger behaviours that increase levels of activation, which explains these individuals’ specific vulnerability to this core feature of mania. However, a further set of beliefs, likely to be shared with other disorders, involves the intolerance or catastrophic appraisal of depressed mood and other negative affective states. Thus, individuals will strive to suppress these feelings with states of high activation and positive affect (in a way that is consistent with the depression-avoidance hypothesis). Nevertheless, whether current affect is positive, negative, or a mixture of each will depend upon the extreme personal appraisals that are made of the current situation. According to our model, it is likely that mixed states of affect are the norm rather than the exception, as differing components of the model can be present simultaneously. For example, extreme negative beliefs about the consequences of depressed mood could co-occur with ascent behaviours directed at raising mood, such as striving to amuse other people, or taking substances that raise mood temporarily. Similarly, states of high activation, appraised as signalling extreme success leading to elevated mood, can co-exist with irritability and aggression stemming from interpreting others’ comments as controlling rather than caring. The model states that individuals with bipolar disorder have mixed, conflicting beliefs about their internal states (e.g. that activated feelings indicate both possible future success and catastrophe) rather than having one maladaptive belief. The fact that different features of the model can occur simultaneously also explains findings of mixed positive and negative self esteem during hypomania (Scott and Pope, 2003) and explicit high self-esteem co-occurring with implicit low self esteem (Lyon et al., 1999). In relation to psychotic experiences/symptoms, it is expected that voices/unusual beliefs are likely to develop in people who made specific kinds of appraisals about the content of their thoughts during the vicious cycle, especially when they have the opportunity to spiral round unchecked, thereby exacerbating the changes in internal state, extreme personal meaning and behaviour. Morrison (2001) has proposed that the identification of psychosis is characterized by the person holding culturally unacceptable (and potentially extremely distressing) appraisals
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of their intrusions, which would be likely to trigger a further vicious cycle of appraisal, behaviour and subsequent further intrusions. Morrison’s (2001) model serves as a supplement to the current model in attempting to explain the psychotic features of mania. There are also likely to be neurophysiological consequences of the spiralling process that increase the risk of psychosis (e.g. deficits in sustained attention), but we propose that these deficits are insufficient to fully explain psychotic symptoms (see also Kapur, 2003; Steel et al., 2005). The temporary resolution of mania Currently, episodes of mania tend to be identified and addressed relatively quickly by health services with psychotropic medication and, in extremes, forced constraint. Subsequently, due to such rapid responses, little is known about whether manic episodes naturally “burn out” if left untreated. The model predicts that the core components to treat in order to lead to long-term resolution of symptoms are the beliefs that feed into the extreme personal appraisals of the changes in internal state. However, most interventions focus on either reducing the emission of overt (but not internal mental) behaviours (i.e. constraint) or calming the internal state (i.e. medication). These interventions are sufficient to circumvent the vicious cycle of ascent and reduce symptoms of mania in the short to medium term. However, such interventions permit internal mental behaviours (e.g. rumination) about the now de-activated internal state to continue (see also Mansell et al., 2005). The experience of lack of control in the face of threat (i.e. of relapse) is likely to lead to a sense of entrapment, which has been shown to be highly associated with depression in a non-clinical sample (Gilbert and Allan, 1998). These individuals would remain vulnerable to another episode of mania when they experience increases in activation in the future; the high risk of relapse even with medication supports this view (e.g. Solomon et al., 1995). In contrast, the model suggests that people who manage to circumvent their ascent into mania by addressing the extreme appraisals will considerably lower the probability of further relapse. Symptoms of depressive episodes First, it is important to note a proportion of individuals within the general population (who therefore have not come to the attention of clinical services) fulfil the criteria for a diagnosis of bipolar disorder yet do not report episodes of depression, i.e. they have unipolar mania (Kessler, Rubinow, Holmes, Abelson and Zhao, 1997). For some individuals, the lack of depression has been confirmed when they are followed-up over long periods (Solomon et al., 2003). Classic bipolar disorder is thought to oscillate between depression and mania, yet there is emerging evidence that these two kinds of episodes are relatively independent (for a review, see Cuellar, Johnson and Winters, 2005). For many people, such as those diagnosed with bipolar II disorder, their condition is dominated by depression interspersed with episodes of hypomania (Judd et al., 2003). Our model is able to accommodate these findings, as it can provide an explanation of mood changes independent of depression, and yet its components have the capacity to clarify how depression can be maintained and exacerbated when triggered. Also, it is worth noting that individuals who have never experienced depression may nevertheless have dysfunctional beliefs about states of negative affect, which form part of the model. The vulnerability to depression depends on the specific beliefs of the individual. Those who specifically appraise changes in internal states in ways that trigger descent behaviours (e.g. rumination over the
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causes of low mood, or isolation in order to attempt to prevent a relapse) would be predicted to experience depressive symptoms (see also Mansell et al., 2005). Sub-syndromal symptoms Prospective studies over several years have indicated that individuals with bipolar disorder experience depressive symptoms between 30 to 50% of every day, in addition to occasional subclinical hypomanic symptoms (Judd et al., 2002; 2003). Our model suggests that the lack of resolution of past episodes (i.e. the preservation of key dysfunctional beliefs regarding internal states) accounts for the occurrence of these sub-syndromal experiences. As long as a person can remain within a relatively narrow range of changes in internal state, they can prevent full escalation of the cycle leading to relapse. However, a range of symptoms, including anxiety, depression, and occasional hypomania would also be predicted as the cycle switches between ascent and descent behaviours while in between episodes. This may account for the mixed pattern of explicit positive and implicit negative self esteem found during remitted states (Winters and Neale, 1985). It is proposed that most individuals in between episodes prevent the onset of mania by descent behaviours, such as social withdrawal, self-critical rumination, excessive dependency, or taking excessively high levels of medication. Sub-clinical depressive symptoms, in addition to anxiety symptoms, are likely to follow from the use of these kinds of descent behaviours. Of course, using descent behaviours to prevent relapse could be regarded as considerably more functional than risking a manic relapse, although the model indicates that they contribute to the long-term maintenance of sub-clinical symptoms. Clinical implications of the model There are several clinical implications of the model that will be summarized here. Existing interventions within CBT The cognitive model presented here is consistent with the use of some strategies already employed in CBT for bipolar disorder, but we suggest that they may currently have limited effectiveness. For example, the identification of prodromes and coping strategies can be very constructive if close attention is paid to the differences between normal changes in internal state and genuine clinical symptoms, and if attention is paid to whether the client feels confident regarding their ability to follow detailed action plans. However, if the distinction is blurred or ambiguous, or the client lacks confidence, then people may instead receive evidence for their dysfunctional belief that all moods need to be controlled for fear of imminent relapse. In turn, they would engage in ascent or descent behaviours to try control normal changes in internal state, and paradoxically escalate symptoms. The model is also consistent with the development of strategies to achieve goals that do not require high levels of activation, such as problemsolving and activity scheduling. However, without directly testing the belief that internal states signal imminent success or catastrophe, then clients may again remain vulnerable to ascent and descent behaviours when these states are triggered following relevant life events. In contrast to many existing approaches, the cognitive model presented here indicates the use of a range of experiential interventions that can target the underlying beliefs and related behaviours that are maintaining the disorder. These interventions do not, however, attempt to
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change mood or reduce symptoms directly. In accordance with the model this can reinforce the dysfunctional belief that internal states must be controlled or a catastrophic outcome will occur. We propose that problems emerge from the vicious cycle between internal state, appraisal, behaviour and experience, rather than from any one of these factors in isolation. Assessment and formulation The first stage of intervention that directly follows from this model is the joint development of the formulation itself, which provides a perspective on clinical symptoms that will be new to most patients and normalizing in its continuity with everyday experiences. This first stage is clearly critical because it allows the therapist and client to map out the key factors and agree on them before direct interventions is carried out. Indeed, part of the inspiration for this model itself has been drawn from collaborative formulations with clients (e.g. Mansell and Lam, 2003). Cognitive techniques There are a range of relatively simple interventions that are derived from the formulation using Socratic dialogue. For example, the therapist and client can discuss the conflicted beliefs about internal states, e.g. comparing pros and cons of being in a high, energetic mood. The aim is not for the therapist to get the client to give up high moods altogether, but to encourage them to notice and take responsibility for their contradictory beliefs about them. The appraisals of internal states can be directly addressed by allowing the client to describe the internal state in detail and generate less extreme interpretations. Often it is helpful to explore the origins of the extreme beliefs to consider how they were formed, and whether they still apply now, or whether there are exceptions. For example, one client learned that her agitation was a consequence of her attempts to control her anxiety by pacing around. Cognitive-experiential techniques The key experiential intervention is very similar to cognitively-oriented exposure in anxiety disorders (see Clark, 1999; Bennett-Levy et al., 2004). We suggest that the key to effective treatment is to help the client to learn to accept normal fluctuations in internal state by challenging their extreme appraisals, and by helping the client experiment with replacing ascent and descent behaviours with responses that do not contribute to escalating symptoms (these could be termed “balance” behaviours). For depression this may involve continuing with their normal routine rather than isolating themselves and ruminating and observing the longterm effects. For hypomania, this may involve practising inhibiting ascent behaviours and, for example, allowing other people to take control of challenging situations to test the outcome. The role of attention to internal states is very important within treatment adhering to this model. Clients are encouraged to acknowledge their internal state during problematic situations and focus on it without attempting to control it. A behavioural response may therefore involve actively choosing not to act, and to mindfully experience the change in mood. This “mindful” stance may promote the spontaneous reorganization of internal experience, and can often reveal other intrusive material that can be tackled with techniques such as imagery, restructuring, and narrative formation (see Arntz and Weertman, 1999; Grey, Young and Holmes, 2002; Hackmann and Holmes, 2004).
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It should be stressed that at all stages the treatment is collaborative and formulation-led. The current model is therefore best applied during euthymia, anxiety states, depression and mild hypomania, but not during acute mania. Clients in states of acute risk, such as during mania, who may be experiencing suicidal ideation, aggressive behaviour and counterproductive levels of substance-abuse would be treated using therapeutic approaches specifically designed to target these behaviours. Nevertheless, outside immediate situations implicating risk, the current model can be used to address the beliefs and behavioural patterns that may contribute to states of acute risk in the long-term. Additional research and development is required to evaluate and further refine these techniques. A full illustration of the model in use within a single case is provided in the associated webbased document on the journal website (available online in the table of contents for this issue: http://journals.cambridge.org/jid_BCP) and in a recent published case study (Mansell, 2007). Conclusions The present model provides a coherent framework that can be used to help clients meaningfully integrate the various factors associated with potentially chaotic experiences related with bipolar disorder. While it is consistent with earlier psychological accounts and draws on each of them to some degree, it provides a novel, highly focused account to guide formulation-based treatment. Key beliefs regarding internal state changes have been identified as contributing to the occurrence of complex patterns, cycles of affect, and behavioural change. It is hoped that our model will provide therapists with increased confidence in relation to understanding and intervening in ways that will minimize clients’ hopelessness and entrapment, and maximize the probability of successful recovery. Over time, we hope that CBT based on this conceptualization will allow clients to tolerate a greater variation in their internal states, and therefore broaden the “bandwidth” of situations in which they feel comfortable. We would like to see clients benefit from the improvement in functioning that this would entail. Further, we hope that the model will evoke further discussion and provide multiple avenues for future research. Acknowledgements Many people gave useful feedback and kind support to the first author on an earlier related model. They were: Jan Scott, Sheri Johnson, Richard J. Brown, Pasco Fearon, Steve Jones, Luke Clark, Phil Barnard, David M. Clark, Anke Ehlers, Frances Marshall, Geraldine Owen, Daniel Freeman, Elizabeth Kuipers, Dominic Lam, Paul Salkovskis, Jan Van Niekerk, and Edward Watkins. The authors would like to thank Nicholas Tarrier, Richard Bentall, the University of Manchester and Bolton, Salford and Trafford Mental Health NHS Trust for their financial and pastoral support. References Abraham, K. (1911/1953). Notes on the psycho-analytical investigation and treatment of manicdepressive insanity and allied conditions. In K. Abraham, Selected Papers on Psychoanalysis. New York: Basic Books.
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