A Cognitive Factor
Differentiates Bipolar Patients
in a Mixed Clinical Sample
Bradford C. Richards, Ph.D.
Jeanne A. Czajka, Ph.D.
Pamela J. Stanley, LPCC, ACT
Jennifer A. Harrington, Ph.D.
Meagan C. Parmley, Ph.D.
Cognitive Behavioral Institute of Albuquerque
Our Interest

Seeking greater clarity:



Many of our patients are diagnosed as
Bipolar by their prescribing psychiatrists, but
do not appear to meet criteria
Bipolar Disorder is clearly over-diagnosed in
our community (Stewart & El-Mallakh, 2007)
When we began this study, no measurable
cognitive factors were known to distinguish
bipolar patients from unipolar patients while
euthymic
Our Interest

Challenge and Opportunity
Only 4 or 5 years ago, many experts
believed that bipolar and unipolar
patients could not be distinguished by
cognitive factors unless the bipolar
patients were manic
 If cognitive markers for Bipolar Disorder
could be found during stable periods,
these markers might help point to new
targets for treatment

Quasi-experimental design

Specific aims



We theorized that there are stable cognitive
factors in bipolar patients that are identifiable
during euthymic states
We hoped to find significant differences in the
levels of some of these factors when comparing
bipolar patients to a mixed clinical sample and
to a sample of unipolar depressed patients.
We hoped that these factors could be used to
successfully discriminate bipolar patients from a
mixed clinical sample and from unipolars
Method: Participants



Actual clinical population in treatment at the Cognitive
Behavioral Institute of Albuquerque
N=33, 15 males (avg age=45), 18 females (avg age=43)
Therapist’s diagnoses:
 Unipolar
14
9 Males, 5 Females
 Bipolar
8
4 Males, 4 Females, 7 with hx of hosp.
 OCD
2
1 Male, 1Female
 PTSD
2
0 Males, 2 Females
 GAD
1
0 Males, 1Female
 Borderline
2
0 Males, 2 Females
 Adjust. D/O
3
1 Male,2 Females
 OCPD
1
0 Males, 1 Female
Method: Measures

Preparing our exploratory measures



We read Eisner, Johnson, & Carver’s (2008)
finding that Upward Generalization items were
associated with Hypomanic Personality in college
students.
We generated additional items based on
speculation about Hyper-positivity (Lam, 2000),
Risk-taking (Leahy, 2004), Action Predisposition,
Self-Proof, and Self-Redemption
We attempted to craft items reflecting adequate
levels of social desirability
The ten items we came up with
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy
for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in
anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a
book.
Strongly disagree
1
2
3
4
5
6
7
Strongly agree
Therapist’s concurrent ratings (blind)





History of all DSM-IV Bipolar Disorder symptoms, each rated for
severity by therapist on a scale of 1-7
Number of hospitalizations for manic, non-depressed states
Therapist’s overall impression of patient’s chronic bipolar
tendency severity
Therapist’s rating of patient’s current arousal state:
(Comatose) 1 2 3 4 5 6 7 (Extremely excited)
Therapist’s rating of patient’s current level of depression
(Not at all depressed) 1 2 3 4 5 6 7 (Severely depressed)
Procedure



Therapists (n=4) were instructed to administer the
10-item self-report questionnaire to all of their
most clear-cut and severe cases of Bipolar
Disorder, along with a mixture of other non-Bipolar
patients
Therapists were instructed to administer the
questionnaires and make their own ratings only
while patients were experiencing euthymic periods,
not while patients were experiencing any manic,
hypomanic, or depressive symptoms
Therapists remained blind to their patients’
responses throughout the course of the study
Preliminary Analyses



Therapist ratings of overall Bipolar Tendency had
no associations with any of the clients’ responses
to the ten questions, all ps > .05
Therapist ratings of specific symptoms had no
associations with any of the clients’ responses, all
ps > .05
The best differentiator of clients’ responses turned
out to be a history of hospitalization for mania.
Patients with any history of hospitalization for
mania showed significantly elevated responses on 3
of the ten questions, ps < .05
The items associated with history of
hospitalization for mania (ANOVA)
2.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to
pay it off later.
Accepting mediocrity is the worst kind of failure.
3.
My actions speak louder than my words. (p = .041)
1.
5.
Because people have told me that I’m smart, I know I can earn people’s respect in anything
I do.
Virtue should be its own reward.
6.
I am able to do things with more energy than most people. (p < .001)
4.
7.
8.
9.
10.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a
book. (p = .012)
MANOVA for 10 items was significant, Wilks’ Lambda = .291, p = .001
Still significant after controlling for both
depression and arousal (ANCOVA)
2.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to
pay it off later.
Accepting mediocrity is the worst kind of failure.
3.
My actions speak louder than my words. (p = .040)
1.
5.
Because people have told me that I’m smart, I know I can earn people’s respect in anything
I do.
Virtue should be its own reward.
6.
I am able to do things with more energy than most people. (p < .001)
4.
7.
8.
9.
10.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a
book. (p = .008)
MANCOVA for 10 items was significant, Wilks’ Lambda = .258, p < .001
Considering only the Unipolar 14 and
Bipolar 7 (ANOVA)
2.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to
pay it off later.
Accepting mediocrity is the worst kind of failure.
3.
My actions speak louder than my words. (p = .049)
1.
5.
Because people have told me that I’m smart, I know I can earn people’s respect in anything
I do.
Virtue should be its own reward.
6.
I am able to do things with more energy than most people. (p < .001)
4.
7.
8.
9.
10.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a
book. (p = .025)
MANOVA for 10 items was significant, Wilks’ Lambda = .232, p = .036
Unipolar 14 vs. Bipolar 7 controlling for
arousal and depression (ANCOVA)
2.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to
pay it off later.
Accepting mediocrity is the worst kind of failure.
3.
My actions speak louder than my words. (p = .05)
1.
5.
Because people have told me that I’m smart, I know I can earn people’s respect in anything
I do.
Virtue should be its own reward.
6.
I am able to do things with more energy than most people. (p < .002)
4.
7.
8.
9.
10.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a
book. (p = .023)
MANCOVA for 10 items was significant, Wilks’ Lambda = .172, p = .034
Can these items classify patients
accurately? Discriminant Analysis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using all 10 items:
Wilks’ Lambda = .291, Chi-square = 32.086, sig. p < .001
100% of cases correctly classified as hospitalized for mania or not
Can these items classify patients
accurately? Discriminant Analysis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only the 3 significant items:
Wilks’ Lambda = .510, Chi-square = 19.884, sig. p < .001
87.9 % of cases correctly classified as hospitalized for mania or not
Discriminant Analysis considering only
the Unipolar 14 and Bipolar 7, all items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using all 10 items:
Wilks’ Lambda = .232, Chi-square = 20.475, sig. p < .025
100% of cases correctly classified as bipolar or unipolar
Discriminant Analysis considering only
the Unipolar 14 and Bipolar 7, 3 items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only the 3 significant items:
Wilks’ Lambda = .460, Chi-square = 13.595, sig. p = .004
81.0 % of cases correctly classified as bipolar or unipolar
Conclusions


The notion that Unipolar and Bipolar
patients are indistinguishable while
euthymic is strongly contradicted by the
present results – they were highly
discriminable, with correct classifications
81% - 100% of the time.
Replication of Eisner, Johnson, & Carver’s
(2008) association of hypomanic
personalities with upward generalization
tendencies supports theories based on
Behavioral Approach System Sensitivity
(Alloy et al., 2009)
Conclusions


Our discriminative items support new
theorizing by Mansell et al. (2009) about
self-perceptions and appraisals of mood
states in bipolar disorder. The hypothesized
importance of the “strong personal
meanings” of Action and Energy are
supported by the present findings.
The discrimination of Bipolar patients by
their explicit Action Predisposition is a
promising lead for future study.
Implications for psychotherapy


It is not safe to conclude that the 3
discriminating items we found are merely
psychologically inert scars of previous manic
episodes.
It is quite possible that excessive valuations of
energy, excessive valuations of action, and
excessive tendencies to upwardly generalize
from rewards function as enduring latent
cognitive vulnerabilities to mania. We owe it to
our patients to explore these factors as
possible ongoing vulnerabilities.
Implications for psychotherapy


With regard to excesssive Upward Generalization,
therapy targeting Moderation in Goal-Setting has
already achieved some empirical support (Johnson &
Fulford, 2009)
Therapy for excessive valuation of energy and excessive
valuation of action would require change at the level of
core implicit values. Explicit Functional Analysis of
Specific Emotional Responses may help patients see the
potential value in tolerating Low-energy, Inactive states.
As far as we know, therapy aimed at enhancing
tolerance for passivity and disinterest has never been
systematically studied.
Implications for psychotherapy



Therapy aimed at increasing Action could actually
reinforce a cognitive vulnerability to Bipolar Disorder
An alternative therapeutic target for functional analysis
might be Increasing Reflection rather than Action
Reflection may be usefully directed to:





Understanding the Meanings of low-energy, low-activity states
The Utility of inactive, low-energy “decompression”
Reducing Aversion to low energy states
Finding Self-efficacy in low-activity states
Noticing increases in Personal Reliability as low-energy, lowactivity states become valued (e.g., ability to listen)
Factor analysis
Principal Components Analysis on all 10 items, Varimax rotation
Scree Plot
2.5
Eigenvalue
2.0
1.5
1.0
0.5
0.0
1
2
3
4
5
6
Component Number
7
8
9
10
Factor analysis
Principal Components Analysis on all 10 items, Varimax rotation,
five-factor solution.
Factor 3:
My actions speak louder than my words. (Loading = .792)
Virtue should be its own reward. (Loading = .693)
I am able to do things with more energy than most people. (Loading = .531)
Virtuous action energy? Underlined items significantly discriminated bipolar
patients.
Factor analysis
Principal Components Analysis on all 10 items, Varimax rotation,
five-factor solution.
Factor 5:
If someone praises the way I express something, it makes me think of writing
a book. (Loading = .922)
I am able to do things with more energy than most people. (Loading = .530)
Upward generalization energy? Both of these items significantly
discriminated bipolar patients.
Factor analysis
Principal Components Analysis limited to the 3 items that
significantly differentiated bipolar patients yielded a one-factor
solution.
Factor 1:
I am able to do things with more energy than most people. (Loading = .827)
My actions speak louder than my words. (Loading = .619)
If someone praises the way I express something, it makes me think of writing
a book. (Loading = .553)
Discriminant Analysis, all subjects, only
2 items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only 2 significant items:
Wilks’ Lambda = .604, Chi-square = 15.148, sig. p = .001
81.8 % of cases correctly classified as hospitalized for mania or not
Discriminant Analysis, all subjects, only
1 item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only 1 item:
Wilks’ Lambda = .873, Chi-square = 4.155, sig. p = .042
60.6 % of cases correctly classified as bipolar or unipolar
Discriminant Analysis, all subjects, only
1 item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only 1 item:
Wilks’ Lambda = .643, Chi-square = 13.464, sig. p < .001
78.8 % of cases correctly classified as bipolar or unipolar
Discriminant Analysis, all subjects, only
1 item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s absolutely safe for me to go into a lot of debt now because it will be very easy for me to pay it off later.
Accepting mediocrity is the worst kind of failure.
My actions speak louder than my words.
Because people have told me that I’m smart, I know I can earn people’s respect in anything I do.
Virtue should be its own reward.
I am able to do things with more energy than most people.
If people underestimate me, it’s up to me to show them what I can do.
Every task I do is an opportunity to prove what kind of person I am.
No matter what I’ve done, I can always redeem myself through my actions.
If someone praises the way I express something, it makes me think of writing a book.
Discriminant Function Analysis using only 1 item:
Wilks’ Lambda = .815, Chi-square = 6.242, sig. p < .012
69.7 % of cases correctly classified as bipolar or unipolar