Looking for bipolar spectrum psychopathology: identification and expression in daily life

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Abstract

Objectives

Current clinical and epidemiological research provides support for a continuum of bipolar psychopathology: a bipolar spectrum that ranges from subclinical manifestations to full-blown bipolar disorders. Examining subthreshold bipolar symptoms may identify individuals at risk for clinical disorders, promote early interventions and monitoring, and increase the likelihood of appropriate treatment. The present studies examined the construct validity of bipolar spectrum psychopathology using the Hypomanic Personality Scale.

Methods

Study 1 used interview and questionnaire measures of bipolar spectrum psychopathology in a sample of 145 nonclinically ascertained young adults. Study 2 assessed the expression of the bipolar spectrum in daily life using experience sampling methodology in the same sample.

Results

In study 1, Hypomanic Personality Scale scores were positively associated with clinical bipolar disorders, bipolar spectrum disorders, the presence of hypomania or hyperthymia, depressive symptoms, poor psychosocial functioning, cyclothymia, irritability, and symptoms of borderline personality disorder. In study 2, bipolar spectrum psychopathology was associated with negative affect, thought disturbance, risky behavior, and measures of grandiosity. These findings remained independent of clinical bipolar disorders.

Conclusions

In the present studies, bipolar-like disruptions in cognition, affect, and behavior were not limited to clinical diagnoses or mood episodes, providing further validation of the bipolar spectrum construct. The bipolar spectrum model appears to provide a conceptually richer basis for understanding and ultimately treating bipolar psychopathology than current diagnostic formulations.

Section snippets

A broader spectrum of bipolar psychopathology?

Recent reports of the lifetime prevalence of bipolar disorder estimate that 2% of the population qualify for bipolar I and II disorders [7]. Bipolar disorders are a leading cause of premature mortality (largely from suicide and accidental death) and are associated with significant impairment in functioning [8], [9], [10], [11]. However, there is considerable epidemiological and clinical evidence to support a wider bipolar spectrum that extends beyond the boundaries of the DSM-IV-TR and is

Characteristics of bipolar spectrum psychopathology

Whether defined narrowly (eg, DSM-IV-TR) or broadly (eg, the current subclinical and clinical conceptualizations), bipolar spectrum psychopathology involves dysregulation in mood, cognition, and behavior. With regard to mood, bipolar spectrum psychopathology is characterized by extreme manifestations of euphoria, dysphoria, and irritability as well as lability of affect [6]. Disruptions in cognition include changes in form of thought, such as racing thoughts and fullness of thought, as well as

Assessment of bipolar spectrum psychopathology

Assessment and validation of a broader spectrum of bipolar psychopathology have proven difficult, in part, due to a lack of reliable instruments. The self-report Hypomanic Personality Scale (HPS [22]) offers a promising point of entry for studying the construct. The scale, which was designed to identify individuals at risk for bipolar disorders, assesses mild, trait-like manic functioning. Eckblad and Chapman [22] indicated that 77% of high HPS scorers met criteria for a hypomanic episode

Expression of bipolar spectrum psychopathology in daily life

One way to enhance understanding of bipolar spectrum psychopathology is to examine its expression in daily life. Researchers have recently begun using ESM to examine the expression of clinical and subclinical psychopathology in daily life (eg, Myin-Germeys et al [27] and Brown et al [28]). Experience sampling methodology is a widely used, within-day, self-assessment technique in which participants are prompted at random intervals to complete brief questionnaires. Experience sampling methodology

Goals of the present studies

The present research examined the construct validity of bipolar spectrum psychopathology as identified by the HPS in a nonclinically ascertained sample of young adults. Study 1 used interview and questionnaire measures of bipolar spectrum psychopathology, and study 2 assessed the expression of the bipolar spectrum in daily life using ESM in the same sample. The construct of bipolar spectrum psychopathology indicates that bipolar characteristics should be identifiable in people who do not have

Goals and hypotheses

Study 1 examined the relation of bipolar spectrum psychopathology (as measured by the HPS) with interview and questionnaire measures of psychopathology, personality, and functioning. It was hypothesized that HPS scores would be associated with lifetime diagnoses of DSM-IV-TR bipolar episodes and disorders and the bipolar spectrum disorders of Akiskal [4] as well as global ratings of impaired functioning. Bipolar spectrum psychopathology was hypothesized to be associated with interview-based

Participants

Approximately 1200 students enrolled in general psychology courses completed the HPS in mass-screening sessions during 3 consecutive semesters. College students are an appropriate sample for examining bipolar characteristics, given that bipolar psychopathology frequently first emerges in late adolescence and early adulthood [6] (the age of the sample in the present study), rates of bipolar disorder are relatively comparable among college-educated and non–college-educated samples [34], and

Hypomanic Personality Scale data

Participants completed the HPS at mass screening and at the time of the interview (2-12 weeks later; mean, 5.5 weeks). Hypomanic Personality Scale scores were examined at both time points (mass screening: mean, 22.6; SD, 11.0; range, 3-42; interview: mean, 17.5; SD, 10.0; range, 0-41). The lower mean HPS score at the second assessment likely reflected regression to the mean (given the selection procedure). Hypomanic Personality Scale scores were strongly correlated across the 2 time points

Goals and hypotheses

Study 2 examined the expression of bipolar spectrum psychopathology, as assessed by the HPS, in daily life using ESM. Table 3 shows hypothesized relations of bipolar spectrum psychopathology with experiences in daily life. The findings were expected to remain independent of DSM-IV-TR bipolar disorders.

In addition to the direct effects of bipolar spectrum psychopathology on experiences in daily life, it was expected that the HPS would moderate the effects of stress in daily life on behaviors. It

Participants

Participants who completed study 1 took part in study 2. Seven participants were dropped because of failure to complete sufficient ESM protocols (final, n = 138).

Materials and procedures

The ESM protocol was designed to assess experiences relevant to bipolar spectrum psychopathology (eg, racing thoughts) and contextual factors (stressful situations). The Appendix A lists the ESM items and indices. After the completion of study 1, participants received a personal digital assistant (PDA) and were instructed about ESM

Results

Participants averaged completing 40.4 usable questionnaires (SD, 9.9). Table 4 presents the direct effects of bipolar spectrum psychopathology with affect, thoughts, and behaviors in daily life. As hypothesized, we found positive associations with negative affect, including anger, sadness, irritability, worry, and perceiving one's situation as stressful. The HPS was positively associated with exuberance (ie, energetic enthusiasm) but was not associated with happiness or viewing one's situation

Reconsidering traditional views of bipolar psychopathology

Traditional psychiatric literature divides the world into those with bipolar disorders and those without. This categorical system simplifies the diagnosis of bipolar disorders but does not map onto the continuous expression of psychopathology and impairment existing in nature [3], [47]. The DSM-IV-TR focuses on defining reliable diagnostic categories. As a result, it lacks guidelines for conceptualizing individuals who have bipolar symptoms that do not meet the diagnostic criteria [48]. The

Acknowledgment

There are no conflicts of interest. Neus Barrantes-Vidal is supported by the Generalitat de Catalunya (Suport als Grups de Recerca 2009SGR672). The authors thank Jason Mesner, Alison O'Leary, and Ann Henderson for their assistance with data collection and Donald Lynam and Paul Silvia for their comments on the manuscript.

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