Download psychological behaviorism theory of bipolar disorder

The Psychological Record, 2001 , 51 , 507-532
PSYCHOLOGICAL BEHAVIORISM THEORY OF BIPOLAR DISORDER
HELMUT P. R. RIEDEL, ELAINE M. HEIBY, and STEPHEN KOPETSKIE
University of Hawaii at Manoa
This review addresses the etiology of bipolar disorder and
presents the literature within a psychological behaviorism
framework (Staats, 1996; Staats & Heiby, 1985). The proposed
theory attempts to provide an integrative developmental approach
that is grounded in established behavioral principles. The bipolar
theory posits 15 hypotheses based on past and concurrent
biological and situational factors as well as their interactions with
an individual's basic behavioral repertoires. Implications for
subclassification and treatment research are noted.
During the past several decades, there has been a proliferation of
psychological theories of adult unipolar depression that have been
extended to children (e.g. , Abramson, Seligman, & Teasdale, 1978; Beck,
1967; Fe rster, 1973; Lewinsohn , 1974; Rehm , 1977; Staats & Heiby,
1985). Meanwhile, there has been a paucity of psychological theories of
bipolar disorder since Kraepelin (1921) observed mania not only among
adults but also among 3% of his child and adolescent patients.
The apparent assumption of most of the research evaluating the
etiology and treatment of bipolar disorder has been that this is primarily a
biological condition for which primarily biological interventions are
indicated. Biological bias has left the psychological aspects of bipolar
disorder largely unexplored and the biological research poorly integrated
with advances in other areas of investigation (Depue & Iacono, 1989).
Fortunately, a number of investigators have expressed concern about this
state of affairs (e.g ., Akiskal , 1986; Bebbington, 1986; Depue & Iacono,
1989; O'Connell , 1986; Perris, 1986; Rehm & Tyndall, 1993).
The recent developments of psychosocial (Craighead, Miklowitz,
Vajk, & Frank, 1998), cognitive behavioral (Basco & Rush, 1996), and
family (Miklowitz & Goldstein, 1997) treatments for bipolar disorder are
promising but have focused primarily on enhancement of medication
compliance. They are extensions of treatments developed for unipolar
Correspondence may be sent to Elaine Heiby, University of Hawaii at Manoa,
Department of Psychology, 2430 Campus Road , Honolulu , HI 96822 . (E-mail:
he'lby @hawaH,edu) .
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depression and chronic and severe disorders. These treatments are not
based upon a psychological theory of the development of bipolar disorder
and are not designed as behavioral prevention and change alternatives to
psychoactive substances.
It is the purpose of this paper to suggest an integration of the bipolar
literature on vulnerability factors in childhood and maintenance factors in
adulthood. The guiding theoretical framework for this integration is Staats'
(1975) social behaviorism , later referred to as paradigmatic (e.g., Staats,
1986) and more recently psychological behaviorism (Staats, 1996). The
theory is an extension of classical and operant conditioning as well as
developmental and cumulative human learning principles. Each revision
of the theory was accompanied with a broader integration of levels of
analysis (e.g., inclusion of organic factors) and additional behavioral
principles (e.g. , self-administered verbal-emotional stimuli that have
directive, affective, and reinforcing effects). Psychological behaviorism
(PB) was selected because it has been shown to have heuristic value for
organizing the disparate research on intelligence (Leduc, Dumais, &
Evans, 1990), unipolar depression (Heiby & Staats, 1990; Staats & Heiby,
1985), anxiety disorders (Hekmat, 1990), and other forms of
psychopathology for which there is no generally accepted theory (Eifert &
Evans, 1990; Staats, 1996). Although the application of PB theory to
unipolar depression includes some mention of bipolar disorder, the utility
of the theory for integration of the bipolar literature has not been
evaluated previously.
First, bipolar disorder will be described. Second, a summary of
general PB theory will be presented . Third , the research investigating the
childhood and adult etiology of bipolar disorder will be organized
according to the situational , behavioral, and organic factors proposed in
PB theory. Finally, 15 hypotheses regarding the etiology of bipolar
disorder will be offered and directions for the development of
psychological treatments and subtyping are noted.
Definitions and Phenomenology of Bipolar Disorder
The reliability and utility of the distinction of bipolar from unipolar
depression has been long established (Leonhard, Korff, & Shulz, 1962).
The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV;
APA, 1994) identifies four types of bipolar disorders, all of which include
a history of mania, hypomania, or some admixture of mania and
depression. However, a review (Rehm & Tyndall, 1993) of the unipolarbipolar distinction argues that bipolar disorder may involve numerous
subtypes so that a history of mania, as defined in DSM-IV, is insufficient
to specify a taxonomy.
The disparity of the literature on factors related to bipolar disorder is
understandable given the episodic and highly variable characteristics
inherent in the definition of a manic episode itself. The definition of a manic
episode in OSM-\V (APA, 1994) is heterogeneous in terms of the emotion
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involved as well as accompanying behaviors. An "elevated, expansive, or
irritable mood" (p. 332) is one necessary criterion. This criterion permits
excessive positive emotions (happiness; euphoria) or excessive negative
emotions (anger; irritability). This inclusion of two dysfunctional moods under
one category is in contrast to the DSM-IV criteria for a major depressive
episode in which one negative emotional state, dysphoria or loss of
pleasure, is the defining dysfunctional mood characteristic.
Heterogeneity is also illustrated in the DSM-IV criteria indicating that
any three or four of a possible seven remaining symptoms can constitute
the definition of a manic episode. These include inflated self-esteem or
grandiosity, decreased necessary sleep, talkativeness, racing ideas,
distractibility, increased activity, and excessive involvement in pleasurable
activities such that there is a risk for eventual adverse consequences. For
children and adolescents, these behaviors overlap with normal
development at some ages as well as with irritable depression, conduct
disorder, attention-deficit/hyperactivity disorder (APA, 1994), and
schizophrenia (Goodyer, 1992), further obfuscating a clear identification
of bipolar disorder among youth.
The characteristics of manic episodes are a challenge to establish
because they are relatively rare and the onset is difficult to predict.
Prevalence during childhood and adolescence is unknown. Childhood
onset of mania among adults exhibiting bipolar disorder has been
estimated to occur in 20% of cases (Goodwin & Jamison, 1990). Among
adults, a 1 month U. S. adult population prevalence of 0.4% for manic vs.
2.2% for major depressive episodes has been estimated (Regier et aI.,
1988). Lifetime prevalence of a manic episode has been estimated to be
1.6% and of a depressive episode to be 17.1% (Kessler et aI., 1994).
Some epidemiological research has addressed the degree of variability in
expression of the behaviors included in the DSM-IV (APA, 1994) definition
of a manic episode. In their review, Rehm and Tyndall (1993) indicate that
racing ideas may be present in 41 % to 100% of manic episodes,
pressured speech in 75% to 100%, delusions in 44% to 75%,
hallucinations in 4% to 40%, heightened activity in 87%, and decreased
sleep in 81%.
It is unknown what percentage of individuals exhibiting manic
episodes express irritability. However, one review suggests anger may be
as common as euphoria (Goodwin & Jamison, 1990) while one study
found 8% exhibit irritability only, 30% euphoria only, and 62% both
irritability and euphoria (Winokur & Tsuang, 1975). The presence of
irritability seems like an important distinction as the affective states of
euphoria and anger are not only subjectively different, but may also emit
and reinforce quite different operant behaviors (e.g., prosocial yet
unproductive gambling versus antisocial dangerousness to others).
Given the stark contrast between the behaviors defining depression
and mania, it is not surprising that research comparing characteristics of
depression between individuals exhibiting unipolar and bipolar
depression has identified a variety of distinctions. This research most
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likely involves a subclass of bipolar subjects, as the reported percentage
of bipolar individuals exhibiting a history of depressive episodes has
ranged from 5% to 100% (Goodwin & Jamison, 1990). The temporal
nature of the mood change between depression and mania has been
reported to range from less than 2 days to years (Rehm & Tyndall , 1993).
Compared to unipolar depression " depression in a bipolar disorder
has been shown to differ on the following characteristics: (a) an earlier
average age of onset (Rehm & Tyndall, 1993; Shulman, Tohen, Satlin, &
Mallya, 1992); (b) more sporadic, frequent, and rapid severe mood
changes but with less chronicity (Winokur, Coryell, Keller, Endicott, &
Akiskal, 1993); (c) psychomotor retardation (vs. agitation) ; and (d)
hypersomnia (vs. hyposomnia) (Rehm & Tyndall , 1993).
The importance of the distinctions between bipolar and unipolar
depression is unclear. Rehm and Tyndall (1993) conclude in their review
of major theories of mood disorders that current approaches are too
narrow and very little is known or theorizeq about bipolar disorder among
children and adults. They agreed with a suggestion by Craighead (1980)
two decades ago that future subtyping of mood disorders integrate
biological , environmental, and psychological factors. The following
sections describe a psychological behaviorism theory of bipolar disorder
as one step toward addressing the need to provide a framework to study
the development of and heterogeneity in the expression of mania. The
proposed framework is an extension of the then called paradigmatic
behavioral theory of depression (Heiby & Staats, 1990; Staats, 1996;
Staats & Heiby, 1985) which focused primarily upon unipolar depression
and the determinants of a depressive episode.
Overview of Psychological Behaviorism
Staats' theoretical formulations date back to the 1950s and 1960s. At
that time he argued that the further development of behaviorism required
a comprehensive and integrative frame of reference, which could be
applied to complex human behaviors (Staats, 1956, 1957a, 1957b, 1961 ,
1963, 1968). In this perspective, the learning principles of classical and
operant conditioning are viewed as interactive processes, and stimulus
situations are described as having three potential basic functions: (a) they
can elicit affect and attitudes, (b) they can reinforce behavior, and (c) they
can prompt the direction of behavior, that is, approach or avoidance of a
stimulus. This aspect of PB theory is called ''three function learning
theory" (Staats, 1975, p. 34) or "A-R-D theory" (p. 86) , referring to the
affective, reinforcing, and directive properties of stimuli. Staats (1975)
suggested that when these principles of PB theory are applied to complex
human behaviors (e.g., those involved in psychopathology) another
theoretical concept becomes useful-the concept of "basic behavioral
repertoires" (BBRs; p. 246). BBRs are the result of an individual's
developmental learning history and organic conditions.
For heuristic purposes the BBRs are divided into three types:
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emotional-motivational (e-m) , sensory-motor (s-m), and languagecognitive (I-c) . In actuality, however, most behaviors are regulated by all
three types of BBR processes. An individual's BBRs encompass the
various forms and patterns of responding which make up an individual's
personality (Staats, 1975). BBRs can be regarded as personality
characteristics, insofar as they are viewed as having a causal role in
determining current behavior.
According to Staats (1975, 1996), there are individual differences in the
e-m BBRs people learn, meaning people differ in what emotional responses
that have become associated with various external and internal stimuli.
These BBRs are theoretically important in explaining psychopathology
because they define for the individual which stimuli have attitude-mood
altering, reinforcing, and directive (A-R-D) functions. They also, in
conjunction with environmental and organic conditions, determine affective
states, which in themselves are central symptoms of many disorders.
The s-m BBRs consist of instrumental responses, including basic
functional ability, vocational skills, educational skills, social skills, and
recreational skills. The s-m BBRs are modified and maintained by operant
conditioning and modeling. Skills relevant for adaptation obviously differ
developmentally as do the s-m deficits that contribute to and characterize
psychopathology. Indeed, a deficit in performance of social roles is
included in most DSM-IV (APA, 1994) definitions of disorders, with
problems at school being a common marker for children and problems at
work a common marker for adults.
The I-c BBRs are conceived as covert language and imagery
responses and stimuli, which follow the established principles of classical
and operant conditioning. Thus, cognitions may be subject to modification
as a result of stimulus contiguities (classical conditioning) as well as
reinforcement contingencies (operant conditioning). Cognitions may also
become conditioned stimuli or cues for further cognitions. According to
Staats' theory, cognitions affect a person's behaviors and feelings,
through their connections with the s-m BBRs and the e-m BBRs.
Maladaptive cognitions are likely to be associated with performance
deficits and excessive affect.
PB theory emphasizes five classes of factors that are likely to play an
etiological role in psychopathology. Past organic and childhood situational
factors (01 and S1 , respectively) are hypothesized to produce an
individual's basic behavioral repertoires (BBRs). The BBRs interact with
concurrent organic and concurrent situational factors (02, 03, and S2,
respectively) to produce the symptoms of psychopathology. The
distinction between 02 and 03 is a recent development (Staats & Burns,
1992) in which 02 refers to concurrent somewhat stable organic factors
which affect behavior through their effects on the BBRs (e.g. , brain
damage that limits language expression) and 03 refers to concurrent
somewhat transient organic factors which do not affect the BBRs yet do
have an impact on behavior (e.g. , a headache temporarily affecting
concentration) . Thus, a list of potential etiological factors in
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psychopathology involves past organic factors (01), past situational
factors (51) , the BBRs, concurrent organic factors which affect the BBRs
(02), concurrent organic factors which do not affect the BBRs (03) , and
concurrent situational factors (52). The relations among these six
potential etiological factors are shown in Figure 1.
S1~
01
~
02/
82
BBRs----I~
03
Figure 1. Psychological behaviorism's theory of bipolar disorder. Past psychosocial (81) and
organic (01 ; 02) factors lead to the development of basic behavioral repertoires (BBRs), which
interact with concurrent psychosocial (82) and organic (03) factors to produce bipolar symptoms.
The Psychological Behaviorism Approach to Bipolar Disorder
Individual differences in predisposing BBRs partly account for the
onset and the heterogeneity of a manic episode. When these
characteristics do not grossly impair functioning, they are often referred to
as hypomania (APA, 1994). As pOinted out by others (Rehm & Tyndall,
1993), hypomania can involve heightened reported well-being and
productivity in the form of unusually elevated and persistent euphoria,
active and creative thinking , and more productive physical activity.
PB theory posits that in the sensory-motor (s-m) BBR area, certain
types of potentially adaptive instrumental skills, which yield short-term
reinforcement and long-term punishment when exercised, may constitute
risk factors for bipolar disorder. These assets are hypothesized to include
persuasive conversational techniques, social manipulativeness, and other
social, recreational, educational, or occupational skills required for high
risk activities. The focus on childhood development of pathogenic assets
rather than deficits in the s-m repertOire is a unique aspect of PB theory.
In the language-cognitive (I-c) area, bipolar vulnerable individuals
may tend towards grandiose self-labeling. "Positive self-esteem" is usually
considered to be an adaptive characteristic for children and adults.
However, some individuals may have concomitant deficits in cautionary
cognitive processes, which are needed for inhibiting potentially harmful
behaviors and for ascertaining negative consequences. Additionally, there
may be poor problem-solving skills in generating options and anticipating
possible consequences.
In the emotion-motivation (e-m) area, individuals at risk for bipolar
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disorder may respond with excessive or inappropriate positive arousal to
certain psychosocial stimuli. For example, they may have inappropriately
pleasant emotional responses to dangerous situations and imagery.
Euphoric mood can also constitute a state of well-being that evokes
positive responses from others, again suggesting e-m characteristics of
hypomania may function as assets under certain circumstances. This is
consistent with studies suggesting that hypomania can constitute an
adaptive emotional state (Kendall, Howard, & Hays, 1989).
The sporadic and abrupt nature of manic episodes also suggests that
e-m characteristics may have both adaptive and maladaptive functions.
Although research cited throughout this article involves diagnosis of a
manic episode without a distinction of the e-m states of euphoria vs.
irritability, it is possible that these seemingly incompatible mood states
involve different determinants. The current PB theory of bipolar disorder
primarily considers mania in the form of maladaptive euphoria. However,
PB theory recognizes that the determinants of irritability need further
explication . This type of negative affect in a manic episode may represent
a distinct mood disorder with different determinants and course.
Staats and Heiby (1985) hypothesized that individuals at risk for
bipolar disorder exhibit s-m BBRs, such as an adolescent street racing or
an adult playing casino poker, that at some points receive short-term
reinforcement (S2) from the successful exercise of their predisposing
skills. The reinforcing stimuli also elicit positive emotional responses that
would elevate mood and cue further BBR activity. The short-term
reinforcement and emotion elicitation would increase the frequency of the
s-m skilled behaviors, thus producing more short-term reinforcement and
more positive emotion that would add up to excessive euphoria.
Furthermore, there would be little inhibition of these short-term rewarding ,
yet risky, activities, due to the deficit cautionary I-c BBRs. The short-term
reinforcements could then elicit increasingly numerous and exaggerated
positive self-statements, also due to I-c BBRs. These positive selfstatements, in turn, would elicit and add to the euphoric e-m responses.
Thus, bipolar vulnerability BBRs would make an individual susceptible to
a process in which s-m, I-c, and e-m BBRs interact to accelerate the
emergence of manic symptoms, referred to as the compounding principle
(Staats, 1996). This process could progressively flood a bipolar individual
with feelings of elation and success and escalate to an episode of mania.
This compounding process would be reversed when the long-term
punishments stemming from the exercise of pathogenic skills (risky s-m
behaviors) start to emerge. Manic behavior could result in a mounting
number of set-backs and failure experiences. For the individual with the
attitudes (e-m) and cautionary, problem-solving (I-c) and instrumental (sm) skills needed to restore a positive situation (S2), euthymia rather than
a depressive episode would be expected to follow setbacks. However, if
these failure experiences elicit negative self-statements (I-c) and negative
emotional responses (e-m), the cumulative effects of unpleasant events
(S2) interacting with vulnerable bipolar BBRs would ultimately produce
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dysphoria and symptoms of a depressive episode (Staats & Heiby, 1985).
Thus, the constellation of bipolar vulnerability BBRs would contribute to
both the manic/hypomanic as well as the depressive aspects of a bipolar
disorder, depending on the adequacy of dysphoria-regulating skills.
As stated above, the bipolar BBRs are hypothesized to specifically
yield the type of behaviors that result in both short-term rewards and longterm punishments. Because the long-term punishments are delayed , the
punishments would not be automatically associated with the skill
behaviors, and thus the inappropriate s-m skill behaviors would not
necessarily diminish. This would also be true for the deficits in e-m and 1c repertoires. Thus, the individual would be left with the predisposition for
further manic (and , for some, depressive) episodes. Normal mood
periods would be experienced during times when the individual's life
situation (S2) provides few or no stimuli that would lead to a compounding
episode. For example, the person may be preoccupied with a harmless
hobby, such as an adolescent frequently skateboarding in the parent's
driveway. Then , when opportunity presents itself, such as an invitation
from skateboarding peers to road race, exercise of the pathogenic skills
would again start a manic compounding process. In this sense, the
concurrent psychosocial environment would exert an influence over the
course of bipolar disorder with an interaction of BBRs and S2.
It is also hypothesized in PB theory that 01, 02, and 03 factors may
be causal in bipolar disorder. The 01 factors could involve genetic or
prenatal conditions such as temperament with heightened tendency to
euphoria. The 02 and 03 factors would involve direct biological factors
heightening euphoria, such as injury to the frontal lobes or diet-related
insulin dysregulation, respectively. Given the complexity of the potential
causal factors proposed , it is not surprising that there is a great deal of
difficulty predicting the temporal and behavioral characteristics of bipolar
disorder (Gottschalk, Bauer, & Whybrow, 1995; Rehm & Tyndall , 1993).
The following sections will focus on past research pertaining to each
of the hypothesized etiological factors of the PB framework-01, 02 , 03,
S1, S2 , and the BBRs. After the summary, additional etiologic hypotheses
based on the PB formulation are generated.
Past Organic Factors (01)
In principle, factors in this category may include all organic variables
that affect learning of the BBRs including genetics, early brain injury, birth
trauma, and exposure of the fetus or infant to toxic substances. Of all
these possible past organic factors most of the literature on bipolar
disorder has focused on genetic factors in terms of family concordance.
Partially, this may be because of DSM-III-R (APA, 1987) diagnostic
criteria, which called for a diagnosis of organic Mood Disorder if a definite
organic cause can be ascertained, and DSM-IV (APA, 1994) criteria,
which define a special category for Mood Disorder Due to a General
Medical Condition .
Several studies, reported in Schlesser and Altshuler (1983) , have
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indicated that an estimated 80% to 90% of bipolar individuals have at
least one first-degree relative with a mood disorder. For unipolar
depressed individuals this rate is only an estimated 40% to 60%.
Monozygotic concordance rates are about 75% for bipolar disorder and
41 % for unipolar depression. Dizygotic concordance rates are much
less-about 19% for bipolar disorder and 13% for unipolar depression
(Kendler, Pederson , Johnson, Neale, & Maathe, 1993; Schlesser &
Altshuler, 1983). In addition , a review of studies using pairwise
concordance indices of genetic transmission for bipolar disorder
concludes an average of 56% concordance among monozygotic twins
and 14% among dizygotic twins (Torrey, 1992). Mendlewicz and Rainer
(1977) ascertained mood disorders among biological parents of four
groups: (a) bipolar adoptees, (b) bipolar non-adoptees, (c) normal
adoptees, and (d) non-adoptees who had poliomyelitis living with their
biological parents. The percentages of biological parents with disorders
involving mood (bipolar, unipolar, schizoaffective, and cyclothymic) were
31 %, 26%, 2%, and 10%, respectively. They also found that for the bipolar
adoptees mood disorders were significantly more frequent among
biological parents than adoptive parents.
The evidence for a genetic predisposition to bipolar disorder is
generally considered to be strong (Blehar, Weissman, Gershon, &
Hirschfeld, 1988; Kendler et aI., 1993; Schlesser & Altshuler, 1983).
However, the family and twin studies do not rule out a psychosocial
transmission of bipolar disorder, for example, through cross-generational
modeling and greater environmental similarity for monozygotic twins than
for dizygotic twins. Adoption studies come closest to ruling out the effect
of psychosocial factors but fall short in that there is usually some degree
of psychosocial contact with biological parents before adoption. For
example, Mendlewicz and Rainer (1977) included adoptions within the
first year of life.
In summary, it is probably warranted to say that genetic endowment
(01) may have an etiologic role in some cases of bipolar disorder.
However, one may also argue that the genetic research provides an
indication of the existence of psychosocial etiological factors because the
monozygotic concordance of 56% to 75% for bipolar disorder leaves 25%
to 44% of the variability of the occurrence of bipolar disorder to be
explained in terms of other factors. Similarly, Hoffman's (1987) finding of
differential responses to lithium among bipolar identical twins suggests
that nongenetic factors also play a role in bipolar symptomatology.
However the evidence for genetic factors is interpreted, one implication is
that there should be behavioral risk factors apparent in early childhood.
Past Psychosocial Factors (S1)
O'Connell (1986) called for greater attention to psychosocial factors in
theorizing about bipolar disorder. His argument was cogent, but,
unfortunately, he presented little evidence for childhood psychosocial
etiology. There is a paucity of research on behavioral interventions for bipolar
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disorder (Craighead et aI., 1998). Couples therapy alone (Davenport, Ebert,
Adland , & Goodwin, 1977) and group therapy in combination with
medications (Wulsin, Bachhop, & Hoffman, 1988) have been shown to
reduce bipolar symptoms. Obviously, far more research is needed in th is
area because there are many unexplored hypotheses about early learning
factors that have theoretical and prevention implications.
The poor understanding of S1 factors in bipolar disorder is in stark
contrast to the state of the science for unipolar depression , for which
there is a large learning-based treatment literature indirectly implicating
early learning causal factors and thereby supporting the investigation of
early prevention and behavioral and situational change techniques. For
example, a recent review comparing behavioral versus antidepressant
medication interventions for unipolar depression concluded that the
former is more effective and less expensive (Antonuccio, Thomas, &
Danton , 1998). If past psychosocial events were demonstrated to play an
etiological role in bipolar disorder one would need to explain the causal
mechanisms involved. The PB frame of reference may provide one
explanation by describing the childhood development of basic behavioral
repertoires (BBRs) that are vulnerability factors for psychopathology and
targets for treatment and prevention programming. For an explication and
summary of the empirical support for the learning principles guiding the
development of the BBRs, see Staats (1975, 1996).
At present, PB theory only suggests the type of learning histories that
can result in pathogenic BBRs. For example, bipolar histories including
significant others with naively optimistic or happy-go-lucky attitudes can
encourage an overly positive emotional conditioning to high-risk situations
(e-m BBR) and can result in bipolar individuals failing to learn prediction of
long-term future danger (a deficit I-c BBR) . Also, a childhood environment
providing learning opportunities for risky behavior (s-m BBR) and grandiose
self-labeling (I-c BBR) can increase the risk for bipolar disorder. For example,
significant others in a bipolar person's developmental history may have
provided positive emotional temporal associations (classical conditioning) ,
modeling, and reinforcement for the thoughts, feelings, and actions involved
in gambling and exaggerating one's prospects.
Studies reporting the family history of bipolar disorder have not
looked specifically at learning factors and environmental conditions (S1 ).
They do, however, report a significant relationship between a history of
bipolar disorder by a nuclear family member and meeting the diagnostic
criteria for a manic episode (e.g., Winokur et aI., 1993). One study of
family interactions suggested the parents of adults exhibiting bipolar
disorder demonstrated more odd word usage and sentence construction
than parents of controls (Miklowitz, Velligan, Goldstein , Nuechterlein, &
Gitlin , 1991). The authors did not specify whether the odd word usage by
parents involved modeling the language-cognitive characteristics of
bipolar disorder during childhood or whether the language was
necessarily odd in order to respond to the individual speaking during a
manic episode. Another study found that adults with bipolar disorder were
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more likely than matched controls to be treated as a "special child" in the
family (Glassner & Haldipur, 1985) suggesting an unspecified effect of
training . Similarly, children living with bipolar vs. normal parents tend to
exhibit more irritability, more positive self-image, greater number of
interests and hobbies, and generally more emotion (Goodwin & Jamison,
1990), although it is unknown if these children developed bipolar disorder.
Although the above findings do not provide causal evidence and
possibly involve a confound of 01 and S1 factors, they do permit the
speculation that some early learning of the language deficits in bipolar
disorder derives from parental modeling and reinforcement of pathogenic
BBRs. Further research into the behavior of significant others is needed
to establish the mechanisms by which bipolar vulnerability BBRs develop
during childhood and adolescence.
Basic Behavioral Repertoires (BBRs)
The concept of the BBR role in bipolar symptoms implies the
existence of personality risk factors. Personality has played a small role in
theories of bipolar disorder since the development of psychodynamic
theory (e.g. , Freud, 1933), which has received little support in positing
that mania is a defense for depression. Similarly, attempts to identify
bipolar personality types have not been successful (Perris, 1992).
However, one behavioral position has included a focus on personality
vulnerability factors. Depue and Iacono (1989) suggested that bipolar
symptoms are correlated and regulated by an integrated behavioral
system , called the "behavioral facilitation system" (BFS; p. 458). They
hypothesized that, among bipolar individuals, this BFS is susceptible to
dysregulation by reinforcement and punishment. The concept of a BFS is
useful insofar as it provides a target personality construct for investigating
the effects of psychosocial and organic factors, although this has not
been made explicit.
In terms of evidence for bipolar personality factors, one starting point
is the clinical observation that bipolar individuals have greater and more
frequent than average mood swings (DSM-IV; APA, 1994). If this
phenomenon reflects a personality characteristic, one would expect a
chronicity of greater than average variation in mood-even during socalled euthymic periods, as several authors have argued (Depue &
Fuhrman , 1987; Depue et aI. , 1981 ; Wetzel, Cloninger, Hong, & Reich ,
1980). At least one study (Depue et aI. , 1981; Study V) has documented
such pervasive mood variation. These authors utilized a self-administered
checklist and found greater than average behavioral variability (including
variability of mood) on a day-to-day basis among subclinical bipolar
individuals than among noncase individuals.
One review of the comorbidity of personality disorders and
depression concludes there is a small body of research involving bipolar
disorder individuals that reports rates of at least one personality disorder
ranging from 23% to 62% (Shea, Widiger, & Klein , 1992). The studies
reviewed reported over nine different personality disorders listed in DSM-
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III-R (APA, 1987), with no apparent common disorder represented. This
may be caused in part by small sample sizes, the heterogeneity of bipolar
disorder, and the lack of specificity of personality deficits defining
personality disorders (Goodwin & Jamison, 1990) that may be relevant to
mood regulation.
It appears, however, that the search for bipolar personality risk factors
may benefit from an analysis in terms of e-m, I-c, and s-m BBR patterns.
The PB theory's tripartite view of BBR risk factors is consistent with prior
formulations of bipolar behavior in which personality characteristics are
classified as involving mood (e-m), cognition (I-c), and activity (s-m)
(Akiskal , Djenderedjian, Rosenthal , & Khani, 1977). Global personality
traits, such as aggressiveness, extroversion, or dependency, often involve
more than one type of BBR and are likely to obscure specific bipolar
BBRs. Also, there is little evidence that global personality traits are
significantly deviant among bipolar individuals before or in between mood
episodes. For example, MacVane, Lange, Brown, and Zayat (1978)
compared 35 bipolars who had stabilized on lithium with 35 normal
subjects and found no differences on the Social Desirability Scale
(Crowne & Marlowe, 1964), Internal and Powerful Other Locus of Control
Scales (Levenson, 1972), Personal Orientation Inventory (Shostrum,
1966), Embedded Figures Test (Witkin, Oltman, Raskin, & Karp, 1971), or
the Brief Psychiatric Rating Scale (Overall & Gorham, 1962).
Angst and Clayton (1986) reported similar results with regard to
premorbid personality traits among bipolar subjects. Scores on the
Freiburg Personality Inventory (Fahrenberg, Selg , & Hampel, 1970) were
available from the 1971 Swiss military examination for 87 male subjects
with various psychiatric diagnoses. The bipolar men scored within the
normal range on each of the three factors of the inventory-aggression,
extroversion, and autonomic liability.
Results such as those referred to above call for different methods of
assessment focusing on more specific aspects of the e-m, I-c, and s-m
repertoires. In the following sections, studies which are more specifically
relevant to bipolar BBRs have been grouped together according to their
possible primary association with Staats' (1975, 1996) three types of BBRs.
This separation is mainly useful for heuristic purposes, particularly in devising
prevention and intervention strategies. For example, I-c deficits may be best
treated with cognitive restructuring, s-m deficits with operant and modeling
techniques, and e-m deficits with exposure/desensitization approaches.
Emotional-motivational (e-m) BBRs. So far, the literature has not
directly addressed the task of mapping out bipolar e-m response patterns
as they develop during childhood and adolescence. This is an odd state
of affairs as bipolar disorder is defined largely in terms of affect. PB theory
hypothesizes that people with bipolar disorder have learned since
childhood to experience exaggerated emotional responses to certain
stimulus situations. As indicated earlier, the e-m characteristics of bipolar
disorder with maladaptive euphoria rather than irritability is the major
focus of the present PB analysis.
BIPOLAR DISORDER
519
There is some indirect evidence for e-m deficits in bipolar disorder.
Montag and Birenbaum (1986) administered the Clinical Analysis
Questionnaire (CAQ; Delhees & Cattell , 1971) and the Sensation Seeking
Scale (Zuckerman , 1979) to 765 male job applicants. The results yielded
a relationship between sensation seeking and hypomania (scores on the
agitation scale of the CAQ). Their study provided evidence for a possible
subclinical personality characteristic. This finding is in keeping with the PB
hypothesis that individuals with bipolar vulnerable e-m systems respond
differently than those with normal e-m systems. Specifically, it may be that
threatening situations for most people are experienced as pleasantly
thrilling by euphoric bipolar individuals both before and during a manic
episode. Additionally, it may be positive psychosocial events rather than
negative ones (S2) which are important in eliciting exaggerated bipolar
emotional responses, because it is the elicitation of euphoria as opposed
to anxiety that initiates bipolar symptoms in PB theory. There is some
indirect evidence in support of this notion that negative life events are not
necessarily etiologic. Depue, Kleiman, Davis, Hutchinson, and Krauss
(1985) presented cyclothymic and normal individuals with a mild stressor
(simple mathematics problems) and found no differences in subjective
ratings of stress on a 5-point scale nor in changes of cortisol secretion .
The PB model calls for research on whether ch ildren at risk and
bipolar persons overrespond to positive events, particularly when
predicting mania involving euphoria rather than irritability. Such evidence
is scanty, but there is some suggestion that bipolar individuals may
manifest relatively positive evaluations of situations involving risk or threat
(e.g ., Montag & Birenbaum, 1986). The area of e-m BBRs needs further
studies on differential euphoric and anger responsiveness to stimuli in
order to identify excessive emotional arousal as a vulnerability factor for
bipolar disorder.
Sensory-motor (s-m) BBRs. The s-m BBRs consist of instrumental
responses to the environment, including basic functional ability,
vocational skills, educational skills, social skills, and recreational skills.
Staats and Heiby (1985) hypothesized that bipolar individuals have
potentially adaptive skills for activities that provide short-term euphoria or
a reduction in irritabil ity and long-term dysphoria. Such activities may
include promiscuous dating , skillful high speed driving , gambling ,
financial investments, or various forms of crime. Therefore, both assets
and deficits of the s-m repertoire are in need of investigation. There is little
research in this area, possibly because the proposed focus includes
assets related to bipolar disorder.
There is some indirect evidence relevant to s-m deficits. Kochanska,
Kuczynski , Radke-Yarrow, and Welch (1987) found that bipolar severity
was associated with deficits in child-rearing skills. Others have shown a
correlation between bipolar disorder and marital (e.g., Dunner, Gershon ,
& Goodwin , 1976) and occupational instability (Tohen, Waternaux, &
Tsuang , 1990). A few studies directly measuring social skills among
adults with bipolar disorder indicate that under some conditions they can
520
RIEDEL ET AL.
be charming (e.g., gregarious) while under other conditions the same
behaviors can be alienating (e.g., excessive talking) (Segrin, 2000) .
These findings encourage further investigation of the adaptive and
maladaptive s-m characteristics and effects upon family, school, work,
and peer relationships (S2) that may be relevant to bipolar disorder.
Language-cognitive (I-c) BBRs. The importance of cognition in bipolar
disorder has been recognized since the original writings of Kraepelin
(Kendler, 1986). Kraepelin found that thought disorganization occurred in
both manic-depressive illness as well as dementia praecox, but that it
differed qualitatively. Kraepelin recognized that thinking is slowed down
during depression. During mania, thinking is characterized by a flight of
ideas, (i.e., a jumping from idea to idea with little relatedness between
ideas and without completing anyone train of thought). Schizophrenic
thought, in contrast, is more often characterized as involving elements
such as perseveration , use of neologisms, blocking, or clang
associations. More recently, the role of cognitions in bipolar disorder has
been suggested by the development of a cognitive behavior therapy for
this condition (Basco & Rush, 1996) although the focus of this treatment
is upon medication compliance rather than modification of the I-c BBRs
that contribute to and characterize the disorder.
Within the literature dealing with the psychological functioning of
bipolar individuals, studies of cognition have been the most numerous,
perhaps because Kraepelin provided a framework to guide such
research. Studies have documented rather general I-c deficits among
bipolar individuals. Bipolar thinking may be characterized by deficits in
memory formation (Calev, Korin, Shapira, Kugelmass, & Lerer, 1986;
Henry, Weingartner, & Murphy, 1971 ; Rosen & Fox, 1986), slow
information processing (Saccuzzo & Braff, 1986), speech degeneration
(Fraser, King, Thomas, & Kendell, 1986; Miklowitz et aI., 1991), playful
and loose combinations of ideas (Holzman, Shenton, & Solovay, 1986;
Solovay, Shenton , & Holzman, 1987), and overinclusive thinking
(Andreasen & Powers, 1974). A review of cognitive theory and research
in mood disorders indicates that there has been little progress in
specifying more precise cognitive aspects of individuals who exhibit a
manic episode (Rehm & Tyndall, 1993). In addition, the definition of I-c
deficits in children and adolescents at different ages needs explication.
For example, a loose combination of ideas may be normative in a 5-yearold but deviant in a 15-year-old.
The above findings are in keeping with PB formulations. The deficits
in bipolar cognitive functioning may engender poor problem-solving and
deficit ability to foresee the potential risks in certain actions. Also, reduced
cognitive functioning may facilitate less critical acceptance of grandiose selflabeling, or exaggerated beliefs in personal control (Berrenberg, 1987).
Research is still needed to determine the extent to which such deficits are
produced at different stages of development by inadequate I-c BBRs and
interactions with concurrent psychosocial (S2) and organic factors that do
not affect the BBRs (03). If the BBRs are involved, one should find I-c
BIPOLAR DISORDER
521
aberrations during so-called euthymic periods or before onset of bipolar
disorder among children and adolescents. In addition, such I-c deficits
should be responsive to prevention and treatment training strategies.
Although a few I-c deficits have been identified in bipolar disorder, it
is noteworthy that some aspects of these I-c characteristics, such as
playful ideas (Holzman et aI., 1986), have adaptive potential , as indicated
earlier in the sections on hypomania. In a paper entitled "Healthy
Thinking," Kendall (1992) concluded that hypomanic cognitions can
involve adaptive distortions in the prediction of future events, perhaps
when S2 does not involve long-term punishment.
Concurrent Organic Factors (02 and 03)
A number of physical factors have been found to increase the risk of a
manic episode. In most cases definite causal relationships have not been
established because of ethical limitations of experimentation. Also, the
literature has usually not distinguished between 02 and 03, with the former
referring to organic conditions affecting the BBRs and the latter to transient
conditions directly evoking the manic mood. One exception is a study
focusing on late life onset of mania in which it is suggested that geriatric
individuals are less likely to report a family history (01; S1) of affective
disorders and more likely to report recent organic factors that may directly
affect mood (03), such as drug side effects (Young & Klerman, 1992). Most
research on organic factors has involved electroconvulsive therapy (ECT),
antidepressants, and sleep-reduction among adults.
Various studies have documented the mood-elevating properties of
sleep deprivation among individuals with bipolar disorder. For example,
Wehr, Sack, and Rosenthal (1987) observed that 9 of 12 subjects with
bipolar disorder experienced mania or hypomania following one night of
sleep deprivation. Similar mood elevating properties have been noted for
electroconvulsive therapy (Lewis & Nasrallah , 1986) and for
antidepressants (Wehr & Goodwin , 1987), although the mechanisms
relating these organic factors to euphoria have not been explicated.
The evidence for the mania-inducing properties of sleep deprivation ,
ECT, and antidepressants has primarily implicated persons who already
have or are at risk for developing bipolar disorder. Thus, the evidence fits the
PB notion of an interaction between concurrent organic factors and other
etiological factors. There appears to be no evidence that current organic
factors (02 and 03) are either necessary or sufficient in producing bipolar
disorder. Partly, this is due to the consensus, indicated earlier, that the
definitional criteria for a manic episode should exclude mood disturbances
with obvious organic precipitants (DSM-IV; APA, 1994, p. 332).
One type of indirect evidence for 02 and 03 involvement in the
etiology of bipolar disorder derives from the psychopharmacological
treatment outcome literature. Although the effects of such treatments do
not provide evidence of a biological cause, they would be consistent with
such a possibility. In other words, if a concurrent organic factor (e.g.,
lithium) can reduce bipolar symptoms then, perhaps, there is a concurrent
organic factor that is maintaining the bipolar symptoms.
522
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Dysregulation in the dopaminergic system is one hypothesized
organic precipitant of excessive positive affect (Depue & Iacono, 1989;
Shelton, Hollon, Purdon, & Loosen, 1991) although it remains to be
established whether such dysregulation is genetically transmitted (01) ,
disrupts behavioral expression of BBR assets (02), and/or directly elicits
manic affect (03). Such distinctions must await synthesis of various
neuromodulatory systems and the investigation of the role of such
systems in mood (Goodwin & Jamison, 1990). Furthermore, the organic
level of irritable mood in some cases of mania remains to be explored.
However, it must be kept in mind that the efficacy of biological treatments
does not weaken the argument for psychosocial etiology, in some cases.
In recent reviews, Tyrer (1985) and O'Connell (1986) reported that the
overall response rate to ongoing lithium treatment was about 70%. While
it is important to consider dosage, compliance, concomitant medications,
and so forth , this response rate suggests that a substantial proportion of
individual differences must be accounted for by factors which lithium does
not counteract. These might include the BBRs and S2.
Concurrent Psychosocial Factors (S2)
Some reviews of the literature conclude that life crises may
precipitate a first mood episode in bipolar disorder but that later episodes
seem less dependent on stress and that life stress is neither necessary
nor sufficient in causing a mood episode (O'Connell, 1986; Post, 1992).
In some studies, no relation between stressful life events and onset of
mania has been found (e.g., Sclare & Creed, 1990). Unfortunately,
studies of precipitating life events have been correlational or retrospective
and have not permitted causal inferences or an inspection of interactions
with organic or personality factors, as is true of most studies relating to
the etiology of bipolar disorder.
Chung, Langeluddecke, and Tennant (1986) interviewed first admissions
with diagnoses of hypomania, schizophrenia, and schizophreniform
psychosis to assess life stress for the 6 months preceding onset of their
symptoms. Only the schizophreniform psychotics had experienced
significantly more stressful life events than their controls. At least for
hypomania, precipitating life stress does not appear to be greater than for
schizophrenia. However, it is proposed by PB theory that in many cases the
onset of bipolar symptoms is preceded by pleasant events to which bipolarprone individuals overreact (Staats & Heiby, 1985).
Inappropriate social support may be another concurrent psychosocial
factor that may increase the 'risk for developing bipolar disorder. In one
study, deficient social support predicted lithium treatment outcome
among bipolars, in contrast to demographic factors such as social class,
education, or age, which did not predict outcome (O'Connell, 1986). Also,
Miklowitz, Goldstein, Nuechterlein, Snyder, and Mintz (1988) found that
high rates of family members' critical comments and emotional overinvolvement (expressed emotion) and unsupportive family interactions
with the bipolar patient (affective style) predicted relapse of discharged
BIPOLAR DISORDER
523
bipolar patients at a 9-month follow-up. Inappropriate current family
interactions with a bipolar member were reported in a similar study
(Miklowitz et aI., 1991), mentioned earlier in the section on S1 deficits.
Inappropriate social support could include encouragement to engage in
high-risk activities or failure to discourage such activities. Also, a finding
that social supports are inadequate among some bipolars would raise the
question of social skills deficits (BBRs) as etiologic (Segrin, 2000). In
contrast, Miller, Kabacoff, Keitner, Epstein, and Bishop (1986), assessed
families with the Family Assessment Device (FAD) (Epstein, Baldwin, &
Bishop, 1983) and found that bipolar patients' families were significantly
less pathological than depressed patients' families on General
Functioning and Communication. Moreover, the bipolar patients' families
did not differ significantly from non psychiatric control families on any of
the FAD variables (Problem Solving, Communication, Roles, Affective
Responsiveness, Affective Involvement, Behavior Control, and General
Functioning). Thus, family social factors may affect the manifestation of
bipolar symptoms, but there is little evidence that bipolar families in
general are particularly dysfunctional.
Although research on possible psychosocial factors has been
increasing (e.g., Ellicott, Hammen , Gitlin, Brown, & Jamison, 1990), the
emphasis on psychosocial stress still lacks a theoretical link between
psychosocial events and bipolar behavior. Covert stimulus-response
mechanisms, manifested as BBRs, may be the missing link. In addition, -it
may be necessary to measure pleasant events given that some cases of
bipolar disorder involve an euphoric (versus irritable) emotional response.
Discussion
The PB theory of bipolar disorder provides a framework for integrating
the disparate research into six types of potential etiological factors--01 , 02,
03, S1, S2, and the BBRs. While there is a paucity of research relevant to
many of these six types of factors, the theory does offer an additional 15
hypotheses regarding the etiology of bipolar disorder listed below. The
theory also has implications for subclassification and psychological
treatment and prevention evaluation efforts.
The greatest amount of information is available for the basic behavioral
repertoires (BBRs) (especially for the language-cognitive [I-c] BBRs), past
organic factors (01), and concurrent organic factors which do not modify the
BBRs (03). It appears that bipolar I-c functioning is deficit and that there is
an exaggerated belief in internal control (Berrenberg, 1987), except in the
case of bipolar mothers perceiving little control over their children's
maturation (Kochanska et aI. , 1987). Also, it is clear that past organic risk
factors (01) include a genetic predisposition (Schlesser & Altschuler, 1983).
Organic risk factors close to the actual time of onset of bipolar disorder (03)
may include ECT (Lewis & Nasrallah, 1986), antidepressants (Wehr &
Goodwin, 1987), or sleep deprivation (Wehr et aI., 1987).
Information on the other PB factors in the childhood development of
524
RIEDEL ET AL.
vulnerability for bipolar disorder is sparse and is mainly based on indirect
evidence or clinical observations. It is in these areas that the PB model is
likely to make the greatest contributions, by providing a rationale for
hypotheses that are amenable to empirical investigation. The most salient
of these hypotheses are listed below.
Past Psychosocial Factors (S1)
1. Bipolar individuals have had developmental histories in which
significant others modeled and shaped risky types of activities, such
as gambling , crime, or substance abuse.
2. Significant others punished a cautious or realistic attitude towards
the future and modeled and reinforced impulsivity and , perhaps,
denial or disregard of consequences.
3. Bipolar individuals learned (from the modeling and shaping by
significant others) to use grandiose self-labeling and denial as ways
to cope with stress as well as to enhance feelings of elation and
confidence in response to superficial successes.
Concurrent Psychosocial Factors (S2)
4. Manic episodes involving euphoria may be triggered (compounding
principle) by pleasant events, such as superficial successes (e.g.,
winning at gambling) and major life events (e.g. , school honors; job
promotion) .
5. Bipolar individuals may lack adequate social support systems that
involve significant others who model and reinforce euthymic
emotions, veridical self-labeling and cautionary statements, and
safe behavior.
6. Significant others may provide reinforcement for elevated emotions,
grandiose self-labeling , and risky behavior.
Transient Concurrent Organic Factors (03)
7. Medical problems, such as sleep deprivation, may precipitate the
onset of bipolar symptoms.
8. Medical treatment, such as antidepressant medication, may be
iatrogenic.
Emotional-Motivational Basic Behavioral Repertoires (e-m BBRs)
9. Bipolar emotional responses to certain stimulus situations are
excessive (i.e., nonveridical).
10. Bipolar individuals respond with positive emotional arousal to
situations that others would find threatening or anxiety provoking.
Sensory-Motor Basic Behavioral Repertoires (s-m BBRs)
11. Bipolar individuals have above average skills for engaging in risky
types of activities, which produce short-term reinforcement and
long-term punishment. These may include persuasive
conversational techniques or social manipulativeness.
BIPOLAR DISORDER
525
12. Bipolar individuals have deficit social skills in maintaining adequate
social support networks.
Language-Cognitive Basic Behavioral Repertoires (I-c BBRs)
13. Bipolar individuals are deficit in estimating long-term negative
consequences.
14. Bipolar individuals tend to employ grandiose self-labeling and denial
to elevate mood.
15. Bipolar individuals have poor cognitive problem-solving skills.
In considering the variety of potential etiological factors it is important to
realize the role of interactions between these influences. For example,
genetic factors (01) may play a role in the acquisition of bipolar-related
BBRs. They may, to some extent, underlie the finding of slow information
processing (Saccuzzo & Braff, 1986) and memory deficits (Calev et aI. ,
1986), emotional lability (APA, 1994), and perhaps even conversational skills
(Fraser et aI. , 1986). Also, there are likely to be interactions between the
BBRs and concurrent factors (02, 03, and S2). For example, bipolar BBRs
may interact uniquely with situations of high "expressed emotion" (Miklowitz
et aI. , 1988) to produce bipolar symptoms, whereas persons with healthy
BBRs may simply find ways to avoid such situations without overreacting.
One of the important gaps in the literature is in the area of
psychosocial factors. This is an important gap because for many it might
create the impression that the sole source of risk for bipolar disorder is
found in genetiC factors rather than childhood learning. There is
increasing evidence that this is not the case (O'Connell, 1986). It is not
likely that genetic factors are direct determinants of all bipolar BBR
characteristics. For example, a tendency towards grandiose self-labeling
or skills required for potentially harmful activities is difficult to explain
without the notion of past learning histories. The problem regarding
bipolar etiology is discovering the type of learning that interacts with
genetiC factors to increase the potential for bipolar symptoms. According
to the PB theory, such psychosocial factors exist, and need to be
identified. The resulting understanding would then guide the development
of psychological treatments and prevention strategies for bipolar disorder
as well as more accurate and useful subclassifications.
Treatment Perspectives
The attention given to psychological variables in the PB model holds
implications for the development of psychological treatments for bipolar
disorder. The indication in this and other reviews (e.g., O'Connell, 1986)
that bipolar symptoms respond to psychosocial factors suggests that
reliably effective psychological treatments and prevention strategies may
be developed. The development of an effective psychotherapy for bipolar
disorder may help lessen the problems of medications. The available drug
treatments are not universally effective, produce side effects (Lerer, 1985;
O'Connell , 1986; Tyrer, 1985), and have not been evaluated
systematically for children. It is becoming apparent that bipolar disorder is
526
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not a purely biological disturbance, and this calls for a more
comprehensive approach to its treatment.
There are presently no established psychological treatments for
bipolar disorder (Goodwin & Jamison, 1990; Lerer, 1985). However, the
recently proposed psychosocial (Craighead et aI. , 1998), cognitive
behavioral (Basco & Rush , 1996), and family (Miklowitz & Goldstein ,
1997) treatments for bipolar disorder may stimulate this type of research .
Psychological behavioral prevention and treatment of bipolar disorder
would focus on training directed at avoiding or ameliorating BBR deficits
as well as improving concurrent organic and psychosocial conditions.
This review suggests that evaluation of prevention and treatment outcome
for bipolar disorder should focus on grandiose self-labeling, assessment
of potential long-term risks, control of euphoric responses to pleasant
events, and adaptive use of highly developed social , educational ,
occupational , and recreational skills.
Subclassification
There is variation in bipolar symptoms from individual to individual ,
as indicated earlier in the section on definitions and phenomenology of
bipolar disorder. Differentiation of subtypes can be useful as this may lead
to greater specificity and efficacy of treatments. The various
manifestations have received different labels over time. These have
included "bipolar I disorder," which involves mania and usually some
degree of depression , "bipolar II disorder;' which involves hypomania and
the occurrence of significant depression, "rapid cycling bipolar disorder,"
which involves at least four mood episodes per year, and "complicated
mania" which involves mania plus another physical or psychiatric disorder
(APA, 1987, 1994; Black, Winokur, Bell, Nasralla, & Hulbert, 1988; Dunner
& Fieve, 1974). However, the evidence shows that such variations in
bipolar symptoms do not constitute unrelated subtypes of bipolar
disorder, and similarity across subtypes has been documented. For
example, cyclothymia and bipolar I disorder have demonstrated similar
rates of family psychopathology, lithium response, and type of symptoms
(Akiskal et aI. , 1977; Alarcon , 1985; Coryell , 1982; Depue & Fuhrman,
1987; Depue et aI. , 1981). However, proponents of subclasses as well as
proponents of a continuity model of bipolar disorder have focused on a
description of symptoms in seeking support for their positions.
The PB model , in contrast, also draws attention to differences in
etiology as a basis for subclassification. This approach is in keeping with
Person's (1986) arguments for a psychological rather than diagnostic
analysis of psychopathology. This may be a more legitimate starting point
because differential etiology might suggest differential prevention and
treatment. Bipolar individuals may differ with regard to predisposing BBR
constellations and concurrent psychosocial and organic factors that gave
rise to symptoms, despite behavioral similarities. An etiology-based
classification of bipolar disorder suggests specific targets for assessment
and intervention. Also, different treatment methods may be appropriate for
527
BIPOLAR DISORDER
different etiologies. As mentioned previously, I-c deficits may be best
treated with cognitive restructuring , s-m deficits with operant and
modeling techniques, and e-m with exposure/desensitization approaches.
Early and concurrent psychosocial factors, such as modeling cautionary
statements and highly expressed emotion within family settings, may
require environmental engineering, such as in family therapy.
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