The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.     

The neglected role of positive emotion in adolescent psychopathology

Adolescence is a developmental period characterized by elevated stress, heightened risky behaviors, and increases in psychopathology. Emotion dysregulation is a hypothesized contributor to negative outcomes and to the onset of psychopathology during adolescence. However, the dysregulation of negative emotion has been the focus of research while the literature on positive emotion in adolescent psychopathology is limited. This review highlights both the development of normative and dysregulated positive emotion during adolescence. First, the literature on normative adolescent emotional development and on negative emotional regulation is briefly reviewed, followed by a discussion of current theories of positive emotion, which are grounded in the adult literature. From a developmental perspective, the dimension of approach motivation within positive emotion is emphasized throughout and frames the review. This conceptualization guides organization of literatures on normative experiences of positive emotion in adolescence and the role of dysregulated positive emotion in adolescent psychopathology, specifically adolescent depression, anxiety, bipolar disorder, externalizing disorders and eating disorders. Last, future directions in the study of adolescent positive emotion and its regulation and the implications of highlighting approach motivation in normative and dysregulated positive emotion in adolescence are detailed.     

A prospective study of the association among impaired executive functioning, childhood attentional problems, and the development of bipolar disorder

Studies of adults who have been diagnosed with, and treated for, bipolar disorder have shown that these patients exhibit impairment on measures of executive functioning. However, it is unclear whether executive dysfunction precedes the diagnosis of bipolar illness, or develops subsequent to its onset. Moreover, investigators have failed to control for the effects of premorbid attentional problems on cognitive performance in these patients. The present authors explored these questions using data from a longitudinal prospective study of individuals at risk for major mood disorder. Results revealed that 67% of participants who met criteria for bipolar disorder in young adulthood showed impairment on the Wisconsin Card Sorting Test (WCST) when they were assessed during adolescence, as compared with 17% of individuals with no major mood diagnosis, and 19% with unipolar depression. This association between performance on the WCST and bipolar illness was not accounted for by high rates of premorbid attentional disturbance. In fact, among participants with early attentional problems, only those who ultimately developed bipolar disorder exhibited impairment on the WCST. Early attentional problems that preceded unipolar depression or no mood disorder were not associated with executive dysfunction.     

Cognitive and motor features in elderly people with bipolar disorder

BACKGROUND: Although elderly people will represent one third of the bipolar population in a few years, data about cognitive and motor features in these patients are very scarce. The aim of this study was to compare the cognitive and motor functioning between elderly euthymic patients with bipolar disorder (BD) and healthy controls, as well as to determine the degree of correlation with psychosocial functioning. METHODS: Euthymic older adults with BD (n=20) and healthy controls (n=20) were evaluated with traditional clinical instruments and measures of exposure to psychotropic drugs and extrapyramidal symptoms. All subjects completed an extensive neuropsychological battery. RESULTS: Patients with BD had more extrapyramidal symptoms and worse performance than healthy controls in psychomotor speed, verbal memory, and executive functions even after controlling sub-clinical symptomatology. These findings were not associated with age at onset or length of illness or with current pharmacological exposure. Psychosocial functioning correlated negatively with performance in psychomotor speed and executive function, and with extrapyramidal symptoms. LIMITATIONS: The small sample size and cross-sectional design. CONCLUSIONS: Older adult patients with BD in a euthymic state could have a similar cognitive and motor profile to that described in younger euthymic bipolar patients. Cognitive-motor disturbances may help to explain impairments in daily functioning among elderly patients with bipolar disorder during remission.     

Heritability of cognitive functions in families with bipolar disorder.

Bipolar disorder is highly heritable. Cognitive dysfunctions often observed in bipolar patients and their unaffected relatives implicate that these impairments may be associated with genetic predisposition to bipolar disorder and thus fulfill the criteria of a valid endophenotype for the disorder. However, the most fundamental criterion, their heritability, has not been directly studied in any bipolar population. This population-based study estimated the heritability of cognitive functions in bipolar disorder. A comprehensive neuropsychological test battery and the Structured Clinical Interview for DSM-IV were administered to a population-based sample of 110 individuals from 52 families with bipolar disorder. Heritability of cognitive functions as assessed with neuropsychological test scores were estimated using the Solar package. Significant additive heritabilities were found in verbal ability, executive functioning, and psychomotor processing speed. Genetic contribution was low to verbal learning functions. High heritability, in executive functioning and psychomotor processing speed suggest that these may be valid endophenotypic traits for genetic studies of bipolar disorder.     

Pretreatment predictors of cognitive deficits in early psychosis

BACKGROUND: Predicting cognitive deficits in early psychosis may well be crucial to identify those individuals most in need of receiving intensive intervention. As yet, however, the identification of potential pretreatment predictors for cognitive performance has been hampered by inconsistent findings across studies. We aimed to examine the associations of functional and clinical pretreatment variables with cognitive functioning after a first psychotic episode. METHOD: One hundred and thirty-one patients experiencing first-episode psychosis were assessed for psychopathology, pre-morbid functioning, duration of illness, age of onset, and family history of psychosis and neurocognitive functioning. Multiple regression analyses were conducted for six basic cognitive dimensions known to be affected in this population: verbal learning, verbal memory, verbal comprehensive abilities, executive functioning, motor dexterity and sustained attention. RESULTS: Pre-morbid functioning was the main predictor for five out of the six basic cognitive domains. Pre-morbid social adjustment difficulties were associated with worse performance in executive functioning, motor dexterity and sustained attention. Academic functioning was associated with verbal comprehension, and verbal learning and memory. Gender, age of onset, duration of untreated psychosis, and family history of psychosis had no or limited value as predictors of neurocognitive outcome. CONCLUSIONS: Poor pre-morbid functioning was related to a worse performance in the six basic cognitive dimensions evaluated; however, this accounted for only a small amount of the explained variance. Cognitive impairment is a prominent feature in patients with early psychosis regardless of favorable prognostic features such as short duration of illness, female gender, later age of onset, and non-family history of psychosis.     

PDD-NOS,psychotic features and executive function deficits in a boy with proximal 22q11.2 microduplication: Evolution of the psychiatric symptom profile from childhood to adolescence

22q11.2 microduplication (22q11.2DupS) is associated with a broad spectrum of phenotypes, including normality. Psychiatric disorders are described in 13% of these patients, including Attention Deficit and Hyperactivity Disorder (ADHD), Intellectual Deficiency (ID), and Autism Spectrum Disorder (ASD), but not schizophrenia. We report changes in the psychiatric symptom profile in the course of development of a young boy with a 22q11.2DupS syndrome, from early childhood to adolescence. The boy's psychiatric presentation was characterized by features of Pervasive Developmental Disorder (PDD), with ADHD in early childhood, a single psychotic episode in mid-infancy, and executive impairment in adolescence. We discuss the importance of an in-depth assessment of cognitive functions in children with22q11.2DupS throughout their development.     

Developmental and genetic influences on prefrontal function in adolescents: A longitudinal twin study of WCST performance

Adolescence is characterized by a relative immaturity of the prefrontal cortex and associated cognitive control functions, which is hypothesized to be a major contributing factor to high-risk behaviors. However, little is known about the role of genetic and environmental factors in frontal brain development during adolescence. Here we examined heritability of performance on the Wisconsin Card Sorting Test (WCST), an established neuropsychological measure of prefrontally mediated executive functioning, in a longitudinal sample of adolescent twins (n = 747) tested at ages 12 and 14. WSCT performance significant improved with age as indicated by a decrease in the number of perseverative errors (p < 0.001), which was paralleled by an increase in heritability in females (19% at age 12 and 49% at age 14) and shared environmental influences in males (non-significant at age 12 and 34% at age 14). The results suggest increasing influence of familial factors on frontal executive functioning during adolescence, as well as gender differences in the relative role of genetic and environmental factors.     

Absence of gender differences in pediatric bipolar disorder: findings from a large sample of referred youth

BACKGROUND: Because little is known about gender differences in pediatric bipolar disorder, we evaluated whether gender moderates the expression of pediatric bipolar disorder in a large clinical sample. METHODS: Subjects were consecutively referred youth aged 18 years or less who met full criteria for DSM-III-R bipolar disorder (BPD) (females, n=74; BD males, n=224). All subjects were assessed with a structured diagnostic interview and measures of psychosocial and family functioning. RESULTS: Most of the bipolar subjects (91% of males, 70% of females) also had ADHD. Bipolar disorder was equally prevalent in both genders. Among females and males, severe irritability (83% and 80%, respectively), mixed presentation (87% and 84%, respectively), chronic course (84% and 77%, respectively) and prepubertal onset (78% and 93%, respectively) predominated the clinical picture. We found no meaningful differences between genders in the number of BPD symptoms, type of treatment for BPD (counseling, medication, hospitalization), severity of educational deficits, severity of family and interpersonal functioning or patterns of psychiatric comorbidity. CONCLUSIONS: Because gender does not moderate the clinical expression of pediatric bipolar disorder, our data does not suggest that gender specific criteria for the disorder are warranted.     

Is the female preponderance in major depression secondary to a gender difference in specific anxiety disorders?

BACKGROUND: While a female preponderance in unipolar depression is a consistent finding in community-based studies, determinants remain speculative. This study aimed to examine whether a female preponderance in certain anxiety disorders drives a gender difference in depression. METHOD: The relevant data from the National Comorbidity Study (NCS) are analysed. RESULTS: We observed a biphasic pattern in the emergence of a female preponderance in the depressive and anxiety disorders, with an initial pre-pubertal or early adolescent onset, and after attenuation in early to middle adulthood, re-emergence in mid- to late-adulthood. Analyses focused on determinants of the initial female preponderance. Female gender, presence of an anxiety disorder and variable ages of onset in the anxiety disorder all contributed to the increased chance of an initial depressive episode. Some specificity in linking the onset of depressive temporally in early adolescence with two anxiety disorders was demonstrated, specifically generalized anxiety disorder and panic disorder. CONCLUSIONS: The separate anxiety disorders and their age of onset had variable links with depression, but female gender remained a significant predictor of depression after accounting for the effects of prior anxiety.     

Bipolar outcome in the course of depressive illness: Phenomenologic,familial, and pharmacologic predictors

Twenty percent of a cohort of 206 outpatient depressives with no past bipolar history switched during prospective observation. These 41 probands developed manic periods on the average of 6.4 years (median 4, range 1–25) after their first depressive episode. The change in polarity occurred throughout the life span, but was most common in adolescence and early adulthood. The following variables were found useful in predicting this outcome: onset ≤ 25 years, bipolar family history, loaded pedigrees, precipitation by childbirth, hypersomnic-retarded phenomenology, and pharmacologically-mobilized hypomania. Although the respective sensitivities of these findings were relatively low (32–71%), their specificities ranged from 69% to 100% for bipolar outcome; the diagnostic specificity of any 3 of these variables when combined was 98%. When compared with nonbipolar depression, bipolar disorder was seldom chronologically secondary to nonaffective psychiatric disorders. These findings suggest that many young depressives with lethargy and oversleeping are not manifesting a “neurotic” disorder, but rather a precursor of primary bipolar affective disorder. Finally, a psychotically depressed adolescent or young adult with positive bipolar family history should be observed for eventual bipolar outcome, especially when the clinical presentation is that of stupor.     

A prospective high-risk study of the association among maternal negativity, apparent frontal lobe dysfunction, and the development of bipolar disorder

In a previous paper, the authors found that impairment on the Wisconsin Card Sorting Test (WCST) in adolescence was predictive of bipolar disorder in young adulthood among offspring of mothers with bipolar illness. In the present study, the authors explore the contribution of maternal characteristics, beyond maternal mood disorder, to the prediction of offspring dysfunction on the WCST. Results showed that maternal bipolar disorder and maternal negativity were both predictive of impaired performance on the WCST during adolescence. The contribution of maternal negativity to offspring WCST impairment was not better explained by maternal personality disorder, mother's functional impairment, family loading for bipolar disorder, or offspring disruptive behavioral disturbance. Findings did not support a moderator model. However, support was found for a mediation model in which maternal negativity contributed to risk for offspring bipolar disorder through its negative association with apparent frontal lobe functioning, as measured by the WCST. Findings are discussed from the perspective of a vulnerability-stress model. In addition, the authors consider the possibility that maternal negativity and offspring impairment on the WCST may be reflective of a common heritable trait.     

Cognitive vulnerability in patients with bipolar disorder

BACKGROUND: No study has simultaneously explored key components of Beck's model of cognitive vulnerability to depression in people with bipolar disorders. METHODS: We compared 41 euthymic bipolar patients with 20 healthy control subjects. All subjects were assessed on the Hamilton Rating Scale for Depression, the Autobiographical Memory Test and the Mean Ends Problem-Solving procedure and also completed the Beck Depression Inventory, the Dysfunctional Attitude Scale, the Sociotropy Autonomy Scale and the Rosenberg Self-Esteem Questionnaire. RESULTS: In comparison to control subjects, patients with bipolar disorder demonstrated significantly higher levels of dysfunctional attitudes (particularly perfectionism and need for approval) and sociotropy, significantly greater over-general recall on an autobiographical memory test and significantly less ability to generate solutions to social problem-solving tasks. These between group differences remained significant when age, intelligence, latency to respond to autobiographical memory test cue words, and subjective mood ratings were included as co-variates in the statistical analysis. Within the patient group, cognitive dysfunction was significantly correlated with level of morbidity (as measured by number of previous illness episodes). CONCLUSIONS: This study suggests that cognitive vulnerability in patients with bipolar disorder is similar to that described in unipolar disorders. It is not clear whether this dysfunction is a cause or an effect of repeated episodes of bipolar disorder. However, the findings may have implications for clinical treatment as well as suggesting a number of important new avenues of research into psychological models of affective disorder.     

Cognitive functioning in a population-based sample of young adults with a history of non-psychotic unipolar depressive disorders without psychiatric comorbidity

BACKGROUND: There is evidence for cognitive dysfunction in unipolar depression among middle-aged and elderly patients, but cognitive functioning among depressed young adults has scarcely been systematically investigated. The aims of the present study were to examine cognitive functioning among depressed young adults identified from the general population and to determine whether cognitive deficits vary as a function of different disorder characteristics, such as severity and age at onset. METHODS: Performance in verbal and visual short-term memory, verbal long-term memory and learning, attention, processing speed, and executive functioning was compared between a population-based sample of 21-35-year-olds with a lifetime history of non-psychotic unipolar depressive disorders without psychiatric comorbidity (n=68) and healthy controls derived from the same population (n=70). RESULTS: Depressed young adults were not found to be impaired in any of the assessed cognitive functions, except for some suggestion of mildly compromised verbal learning. Nevertheless, younger age at depression onset was associated with more impaired executive functioning. LIMITATIONS: The results may slightly underestimate of the true association between depression and cognitive impairments in the young adult population due to possible dropout of participants. Additionally, the problem of multiple testing was not entirely corrected. CONCLUSION: The findings from this study indicate that a lifetime history of non-psychotic unipolar depressive disorders among young adults without psychiatric comorbidity may be associated only with minimal cognitive deficits, even when some residual depressive symptoms are prevalent. However, early-onset depression may represent a more severe form of the disorder, associated with more cognitive dysfunction.     

Weight change and appetite disturbance as symptoms of adolescent depression: Toward an integrative biopsychosocial model

The Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.] lists weight change and appetite disturbance as a single compound symptom of depression at all ages. Nonetheless, assessment of these symptoms is complicated during adolescence by normative increases in body weight and appetitive drive as well as heightened rates of body dissatisfaction, dieting, and eating disorders. This review outlines biological and psychological mechanisms that may change the relation of weight change and appetite disturbance to depression during adolescence. We propose a developmental model of the relation of these symptoms to the disorder and use the model as a framework to summarize findings, limitations, and future directions of research. Although the literature suggests that weight change and appetite disturbance are related to adolescent depression, preliminary evidence suggests that interpretation of weight and appetite symptoms may depend on developmental level.     

Executive functions in autism and Asperger's disorder: flexibility, fluency, and inhibition

The Color-Word Interference Test, Trail Making Test, Verbal Fluency Test, and Design Fluency Test from the Delis-Kaplan Executive Function System (Delis, Kaplan, & Kramer, 2001) were administered to 12 high-functioning adults and adolescents with autistic disorder or Asperger's disorder. Each test included a switching condition in addition to baseline and/or other executive-function conditions. Participants performed significantly below average on a composite measure of executive functioning adjusted for baseline cognitive ability. Complex verbal tasks that required cognitive switching and initiation of efficient lexical retrieval strategies produced the most consistent deficits, whereas cognitive inhibition was intact. We discuss implications of these findings for understanding the neurocognitive substrates of autistic spectrum disorders.     

Neurocognitive Functioning in Bipolar Disorder

Neuropsychological processes may have direct bearing on the emotional dysregulation and functional impairments characteristic of bipolar disorder. Neuropsychological deficits that have been identified in adults and children with bipolar disorder include impairments in executive functions, declarative memory, attentional processes, and possibly working memory. Structural and functional magnetic resonance imaging and magnetic resonance spectroscopy studies of adults and children with bipolar disorder also indicate abnormalities in regions thought to underlie these neuropsychological deficits, including the basal ganglia, amygdala, and dorsolateral, orbitofrontal, and anterior cingulate cortices. Study of this area is made challenging by the heterogeneity of bipolar disorder, the heterogeneity of neuropsychological deficits among groups of patients with different clinical characteristics, the lack of specificity of neurocognitive deficits for bipolar disorder, and difficulty ascertaining whether deficits are inherent in the disorder, predate the disorder, or are influenced by mood state, course, treatment, and comorbidity with other disorders. In this review, we integrate the literature on neuropsychological functioning and neuroimaging in both children and adults with bipolar disorder, propose a nascent integrative model of cognitive function in bipolar disorder, and make suggestions for future studies and model development.     

Stability and course of neuropsychological deficits in manic and depressed bipolar patients compared to patients with Major Depression

BACKGROUND: Neuropsychological functioning varies across different subgroups of patients with affective disorders; yet there have only been a few studies pointing out distinctive neuropsychological profiles and following-up possible changes in this functioning. The aim of this study was to compare neuropsychological functioning across remitted manic or depressed patients with bipolar disorder compared to remitted patients with Major Depression and to explore the course of their cognitive functioning. METHODS: 30 patients with Major Depression, 17 manic bipolar patients, and 22 depressed bipolar patients were assessed for memory, attention, and executive functions using the Auditory Verbal Learning Test (AVLT), the Modified Card Sorting Test (MCST), the Attention Network Test (ANT), and Stop-Signal Task. Neuropsychological assessment was performed at discharge and seven weeks after discharge. RESULTS: The three groups showed different neuropsychological performance at discharge. Regarding selective attention and speed of responding the manic bipolar patients displayed poorer performance than the other two groups. Furthermore, follow-up assessment revealed that although all patient groups demonstrated an overall improvement, some deficits (especially in executive functions) remain. Manic bipolar patients showed again the worst performance. Depressed bipolar patients, however, were not observed to show a poorer outcome than depressed unipolar patients. CONCLUSIONS: This study provides further evidence for distinct neuropsychological functioning in patients with affective disorders depending on their state of illness. Furthermore, it supports the hypothesis that especially manic bipolar patients stay impaired in certain cognitive functions after remission. These findings may be of clinical relevance regarding treatment and prevention programs and emphasize the need of further research investigating stability and course of patients with mood disorders.     

Clinical adolescent psychology: what it is, and what it needs to be

This commentary on the special section on clinical adolescent psychology (G. Holmbeck & P. Kendall. 2002) reviews and critiques the conceptual and empirical articles that this compilation comprises. As articulated in the conceptual contributions to this collection, two fundamental principles should guide research on the etiology, prevention, and treatment of psychological disorder and dysfunction during adolescence: First, drawing on the fiel of developmental psychopathology, the study of clinical adolescent psychology should focus on the trajectories of disorder that precede, characterize, and follow adolescence. Second, drawing on the literature on normative adolescent development, the study of clinical adolescent psychology must proceed with an explicit recognition of the unique biological, cognitive, psychosocial, and contextual features that define adolescence as a developmental period. The empirical contributions to this compilation are evaluated with respect to the extent to which they reflect these tenets. Although the study of clinical adolescent psychology, as evidenced by this collection of articles, is appropriately grounded in the broader enterprise of developmental psychopathology, less progress has been made with respect to the integration of the study of clinical phenomena in adolescence with the study of normative adolescent development.     

Development of executive functions through late childhood and adolescence in an Australian sample

Although there have been significant theoretical advances in the field of child neuropsychology, developmental features of adolescence have received less attention. Progress in clinical practice is restricted due to a lack of well-standardized, developmentally appropriate assessment techniques. This article addresses these issues in relation to executive skills. These abilities are targeted for 2 reasons: first, because they are often considered to be mature during late childhood and adolescence, despite limited investigation in this age range; and second, because of their central importance to efficient day-to-day functioning. Using a normative sample of 138 children, aged 11.0 to 17.11 years, this article plots the development of executive skills through late childhood and early adolescence and interprets progress in these skills with reference to current neurological and cognitive theory.