226 CHAPTER 6
Psychological Factors: Thoughts and Attributions
Most research on the contribution of psychological factors to bipolar disorders fo-
cuses on cognitive distortions and automatic negative thoughts, which not only are
common among people with depression but also plague people with a bipolar disor-
der during MDEs. In fact, research suggests that when depressed, people with either
MDD or a bipolar disorder have a similar internal attributional style for negative
events (Lyon, Startup, & Bentall, 1999; Scott et al., 2000). Mirroring these results,
people with cyclothymia or dysthymia have a similar negative attributional style
(Alloy et al., 1999).
In addition, even after a manic episode is completely resolved, up to a third of
people may have residual cognitive defi cits, ranging from diffi culties with atten-
tion, learning, and memory to problems with executive functioning (planning and
decision making) and problem solving (Martínez-Arán et al., 2000, 2005; Kolur
et al., 2006; Rubinztein et al., 2000; Scott et al., 2000; Thompson et al., 2005;
Zubieta et al., 2001). Moreover, the more mood episodes a person has, the more
severe these defi cits tend to be. Researchers propose that the persistent cognitive
defi cits associated with mania should become part of the diagnostic criteria for
bipolar disorders, in addition to criteria on mood-related behaviors (Phillips &
Frank, 2006).
Research results have not yet established a cause-and-effect relationship between
the cognitive defi cits and the mood symptoms of bipolar disorders. For instance, it is
possible that having more episodes of mania or depression somehow causes the en-
during cognitive defi cits. But it is also possible that aspects of their cognitive defi cits
lead some people to be more likely to have additional mood episodes. Alternatively,
it is possible that some other, as yet unidentifi ed, variable leads to both the enduring
cognitive defi cits and the frequency of mood episodes.Social Factors: Social and Environmental Stressors
Social factors such as starting a new job or moving to a different city can also
affect the course of bipolar disorders (Goodwin & Jamison, 1990; Malkoff-
Schwartz et al., 1998). Stress appears to be part of the process that leads to a fi rst
episode (Kessing, Agerbo, & Mortensen, 2004); people who develop a bipolar
disorder experience signifi cant stressors in their lives before their fi rst episode
(Goodwin & Ghaemi, 1998; Tsuchiya, Agerbo, & Mortensen, 2005). Stress can
also worsen the course of the disorder (Johnson & Miller, 1997). In addition,
stress—in particular, family-related stress—may contribute to relapse; people
who live with family members who are critical of them are more likely to relapse
than those whose family members are not critical (Honig et al., 1997; Miklowitz
et al., 1988).
Social factors can also have indirect effects, as occurs when a new job disrupts a
person’s sleep pattern, which in turn triggers neurological factors that can lead to a
mood episode (American Psychological Association, 2000).FEEDBACK LOOPS IN ACTION: Bipolar Disorders
Bipolar disorders have a clear genetic and neurological basis, but feedback loops still
operate among the neurological, psychological, and social factors associated with
these disorders (see Figure 6.5). Consider the effects of sleep deprivation. It may
directly or indirectly affect neurological functioning, making the individual more
vulnerable to a manic or depressive episode. Moreover, like people with depression,
people with a bipolar disorder tend to have an attributional style (psychological
factor) that may make them more vulnerable to becoming depressed. In turn, their
attributional style may affect how these people interact with others (social factor),
such as their responses to problems in relationships. Even after a mood episode is
over, residual problems with cognitive functioning—which affects problem solving,
planning, or decision making—can adversely infl uence the work and social life of a
person with a bipolar disorder.P SN