Elsevier

Clinical Psychology Review

Volume 25, Issue 2, February 2005, Pages 241-262
Clinical Psychology Review

Mania and dysregulation in goal pursuit: a review

https://doi.org/10.1016/j.cpr.2004.11.002Get rights and content

Abstract

This paper reviews evidence for deficits in goal regulation in bipolar disorder. A series of authors have described mania as related to higher accomplishment, elevated achievement motivation, and ambitious goal setting. These characteristics appear to be evident outside of episodes, and to some extent, among family members of people with a history of mania. In addition, people with a history of mania demonstrate intense mood reactivity, particularly in response to success and reward. During positive moods, they appear to experience robust increases in confidence. These increases in confidence, coupled with a background of ambitious goals, are believed to promote excessive pursuit of goals. This excessive goal engagement is hypothesized to contribute to manic symptoms after an initial life success.

Introduction

Genetic vulnerability has been estimated to account for as much as 85% of the variance in who develops mania (McGuffin et al., 2003, Vehmanen et al., 1995). Nonetheless, there is tremendous variability in the course of bipolar disorder, both between and within individuals. To understand this variability, it is important to identify triggers that determine how and when the biological vulnerability is expressed. This article examines the idea that the genetic vulnerability to mania is expressed behaviorally in dysregulated goal pursuit, and that excessive goal pursuit serves as a trigger for manic symptoms.

Over the past 100 years, clinicians and researchers have described various facets of goal setting and goal pursuit among people with a history of mania. The first part of this article reviews this evidence. Early studies focused on high accomplishment, both by persons with a history of mania and by their family members. A second set of studies examined traits that may explain accomplishment among these people, including achievement motivation and high ambitions. A third body of literature centers on mood reactivity and related cognitive changes that occur among people with a history of mania under certain goal-related circumstances. In particular, a set of studies is examined that focuses on confidence during positive moods.

The final section of this paper presents a model that focuses on two themes in goal regulation: constantly high ambitions and fluctuating confidence. It is argued that bursts of extreme confidence, against a background of stably high ambitions, contribute to excessive goal pursuit, which can spiral into mania. The article closes with a brief discussion of future research goals and clinical implications.

This paper focuses on mania. As such, this paper will review studies that have focused on bipolar I disorder, defined by the presence of at least one full manic episode, bipolar II disorder, which is defined on the basis of hypomania (less severe periods of manic symptoms), and studies of people at-risk for the development of mania. Parallels and distinctions across these three populations will be noted where possible. Unfortunately, many relevant studies examined bipolar disorder as a whole, without distinguishing mania from depression. These studies are surely relevant to mania, because the diagnostic definition of bipolar disorder does not require an episode of depression (APA, 2002). Indeed, in community samples, 25–33% of individuals with a lifetime history of mania report no episodes of depression (Karkowski & Kendler, 1997, Kessler et al., 1997, Weissman & Myers, 1978). Nonetheless, the failure to disentangle these aspects of bipolar disorder raises an ambiguity in some of the research. Where analyses differentiate mania from depression, it will be noted.

Section snippets

Achievement by people with a history of mania

High levels of accomplishment among people with mood disorders were noted almost 100 years ago. For example, Stern (1913) examined the occupational status of 1326 individuals admitted to the Psychiatric Clinic in Freiburg between 1906 and 1912. He found that patients with affective psychosis or their fathers were more likely to be professionals than were patients with schizophrenia or their fathers. Consistent with this, a report concerning the United States census data on hospital admissions (

Achievement and confidence: an integrative model

Summarizing across clinical observations and research findings, two patterns emerge. First, high goal setting appears to be a stable characteristic among persons with bipolar disorder. Second, unrealistically high success expectancies emerge with symptoms of hypomania and after initial successes. These two patterns suggest a tentative way of thinking about goal regulation in mania, as displayed in Fig. 1. High goal setting alone does not trigger episode onset, as this characteristic appears to

Future research and implications

Although one can draw a picture from the findings in this field, the current state of the empirical evidence is weak. There are several fundamental needs.

  • 1.

    There is a need for epidemiological studies of accomplishment in family members of people with bipolar disorder.

  • 2.

    There is a need for studies of premorbid levels of creativity, productivity, and accomplishment among people with bipolar disorder.

  • 3.

    Because so many different measures have been used to assess setting high goals, valuing those goals,

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    The author is grateful to Charles S. Carver, Ian Gotlib, Jeanne Tsai, Camilo Ruggero, and Amy Cuellar for their helpful comments throughout the writing process.

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