by Michael D. Anestis, M.S.
For most individuals with a bipolar spectrum disorder (e.g., bipolar I, bipolar II, cyclothymia), life is experienced as a series of shifts between three phases: depression, mania/hypomania, and euthymia, a period during which the individual is relatively symptom free. The question however, is not necessarily what an individual with a bipolar spectrum disorder's symptoms will be, but rather how to predict when those symptoms become more likely to emerge. In a study recently published in the journal Bipolar Disorders, June Gruber and colleagues (2009) attempted to provide some clarity on this topic.
Building off prior work they had conducted in this area, the authors wanted to examine the role of positive emotions in predicting depressive and manic symptoms in a sample of individuals diagnosed with but recovered from a bipolar spectrum disorder (BD) relative to a sample of nonclinical controls (NC). Prior studies using both self-report measures and physiological measures (e.g., vagal tone) have demonstrated that individuals with BD exhibit higher average levels of positive emotionality (Johnson, Gruber, & Eisner, 2007; Johnson, Ruggero, & Carver, 2005; Sutton & Johnson, 2002). In this particular study, however, the authors sought to expand upon this point by looking at specific positive emotions as predictors.
Gruber and colleagues (2009) noted that, in prior work examining the relationship between positive emotions and BD, researchers had only considered "happiness" and "positivity," broad constructs that do not differentiate between the potentially varied roles of different positive affective states. As such, the authors decided to examine four specific positive emotions with a history of prior research (pride, compassion, happiness/joy, and amusement) and three specific positive emotions with less of a research history (love, awe, and contentment). The authors only had a priori hypotheses (predictions made prior to the analysis of data) for the specific emotions that had previously been subject to research, as there was no evidence upon which to base any predictions for the other three.
Given prior findings, the authors anticipated that the recovered BD participants would report higher levels of trait joy and pride at baseline relative to NC participants. In addition to the data collected at baseline, the authors also assessed participants at a six-month follow-up, thus allowing them to examine if levels of particular positive emotions at baseline predicted changes in depression and mania symptoms six months later. The authors anticipated that higher levels of joy, pride, and amusement would predicted increases in symptoms of mania. On the other hand, the authors anticipated that higher levels of compassion would predict decreased mania and depression symptoms.
In total, the BD participants included 55 individuals who had been diagnosed with bipolar I (n = 27), bipolar II (n = 21), or bipolar disorder not otherwise specified (n = 7). 39 of these individuals also took part in the six month follow-up examination. All of these individuals were recovered, meaning that they had been euthymic for a period of at least two months. The rationale for using only recovered participants was to determine whether increased positive emotionality was a trait-like, stable characteristic of individuals with BD or if it simply represented a fleeting symptom of manic phases. The NC group included 32 individuals with no prior history of any mental illnesses. Impressively, the authors utilized two semi-structured clinical interviews based on DSM-IV-TR criteria for each participant in order to reach diagnostic decisions. This is a level of rigor that is rare in any psychological study and vastly increases the reliability of their information. Given the findings we reported in an earlier PBB article on misdiagnosing bipolar disorder, this was particularly important for the authors' chosen topic.
The results for this study were fairly impressive, particularly with respect to the analyses predicting changes in symptoms at six month follow-up. Surprisingly, however, the baseline findings comparing trait levels of positive emotions between BD and NC individuals did not always support the authors' hypotheses. BD individuals actually reported lower levels of joy than did NC individuals and did not differ from NC individuals on levels of pride.
At six month follow-up, the data yielded much more informative findings. High levels of joy and amusement predicted increased symptoms of mania whereas high levels of compassion predicted decreased mania severity. Additionally, amusement predicted increased depression severity whereas pride predicted decreased depression severity. Importantly, only two BD individuals had actually relapsed at the six-month follow-up time, so the authors were not measuring whether these emotions predicted the onset of a full manic or depressive phase. Instead, they were examining whether they could predict shifts in the levels of various symptoms, independent of whether or not such shifts would be considered clinically significant. An important consideration in these longitudinal findings is the sample size of the study. Because only 39 individuals took part in both Time 1 and Time 2, the authors' ability to actually test their hypotheses and find significant effects was limited, which could have resulted in type II (false negative) errors.
Ultimately, this study tells us several things. First, although the baseline findings did not conform to the author's hypotheses, they offered the first look at how individuals with BD might differ from others on trait levels of positive emotions. Future studies on this topic will be helpful in clarifying the matter. Additionally, and perhaps more importantly, the authors demonstrated that, in recovered BD individuals, a heightened presence of certain positive emotions can be either helpful (compassion for mania and pride for depression) or harmful (joy and amusement for mania and amusement for depression). The point is not that recovered BD individuals should not feel positive emotions, but rather, when such individuals exhibit extremely high levels of particular positive emotions, care should be taken to adjust that individual's environment so as to reduce risk of relapse. An example of such an adjustment would be an increased focus on social rhythms. Positive emotions are, by nature, a good thing. For particular individuals, however, extremely high levels of positive emotions might reflect a vulnerability to symptoms of BD and care must be taken to ensure that, when risk emerges, necessary resources are available to help prevent the onset of a manic or depressive phase.
If you would like to learn more about bipolar spectrum disorders, we recommend checking out the "Real World of Bipolar" blog.
Additionally, we recommend the following products, all of which are available through our online store:
The Bipolar Disorder Survival Guide: What You and Your Family Need to Know
The Bipolar Teen: What You Can Do to Help Your Child and Your Family
Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition
Bipolar Disorder, Second Edition: A Family-Focused Treatment Approach
Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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