1. 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

2. 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

3. 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

4. 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

5. 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:  Unipolar149 Males, 5 Females  Bipolar84 Males, 4 Females, 7 with hx of hosp.  OCD21 Male, 1Female  PTSD20 Males, 2 Females  GAD10 Males, 1Female  Borderline20 Males, 2 Females  Adjust. D/O31 Male,2 Females  OCPD10 Males, 1 Female

6. 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

7. The ten items we came up with 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

8. 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)

9. 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

10. Preliminary Analyses  Therapist ratings of overall Bipolar Tendency had no associations with any of the clients’ responses to the ten questions, all p s >.05  Therapist ratings of specific symptoms had no associations with any of the clients’ responses, all p s >.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, p s <.05

11. The items associated with history of hospitalization for mania (ANOVA) 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. (p =.041) 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. (p <.001) 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

12. Still significant after controlling for both depression and arousal (ANCOVA) 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. (p =.040) 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. (p <.001) 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

13. Considering only the Unipolar 14 and Bipolar 7 (ANOVA) 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. (p =.049) 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. (p <.001) 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

14. Unipolar 14 vs. Bipolar 7 controlling for arousal and depression (ANCOVA) 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. (p =.05) 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. (p <.002) 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

15. Can these items classify patients accurately? Discriminant Analysis 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

16. Can these items classify patients accurately? Discriminant Analysis 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

17. Discriminant Analysis considering only the Unipolar 14 and Bipolar 7, all items 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

18. Discriminant Analysis considering only the Unipolar 14 and Bipolar 7, 3 items 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

19. 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)

20. 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.

21. 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.

22. 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.

23. 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, low- activity states become valued (e.g., ability to listen)

25. Factor analysis Principal Components Analysis on all 10 items, Varimax rotation

26. 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.

27. 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.

28. 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)

29. Discriminant Analysis, all subjects, only 2 items 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

30. Discriminant Analysis, all subjects, only 1 item 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

31. Discriminant Analysis, all subjects, only 1 item 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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

32. Discriminant Analysis, all subjects, only 1 item 1. 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. 2. Accepting mediocrity is the worst kind of failure. 3. My actions speak louder than my words. 4. Because people have told me that I’m smart, I know I can earn people’s respect in anything I do. 5. Virtue should be its own reward. 6. I am able to do things with more energy than most people. 7. If people underestimate me, it’s up to me to show them what I can do. 8. Every task I do is an opportunity to prove what kind of person I am. 9. No matter what I’ve done, I can always redeem myself through my actions. 10. 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