Sevinc ULUSOY, Kaasim Fatih YAVUZ, Murat ERKIRAN

Response styles and avoidance strategies in bipolar disorder and healthy controls: A comparative study

Objective: This study aimed to investigate stress appraisals, rumination, worry, and experiential avoidance (EA) in patients with bipolar disorder-I (BD-I) in the euthymic phase of the illness. The effects of these processes on functionality in individuals with BD-I are also investigated. Method: Using the Stress Appraisal Measure Dispositional Form (SAM-D), Ruminative Thinking Style Questionnaire (RTSQ), Penn State Worry Questionnaire (PSWQ), and Acceptance and Action Questionnaire-II (AAQ-II), we compared 67 BD-I patients with 70 healthy controls. Additionally, multiple linear regression analysis was used to determine the predictors of functionality levels measured by the Bipolar Disorder Functioning Questionnaire (BDFQ). Results: BD-I group showed significantly higher SAM-D “threat,” “uncontrollable by anyone,” and “control by others” scores. The BD-I group also reported higher EA (AAQ-II) than the control group. Rumination (RTSQ) and worry (PSWQ) did not show any significant differences between groups. BDFQ was negatively predicted “uncontrollable by anyone” and positively predicted by “control by others” subdimensions of SAM-D. Conclusion: Our findings suggested that patients with BD-I have differences in stress appraisals, even in the euthymic phase. Higher AAQ-II scores seemed to be a distinctive feature for patients with BD-I that may be related to perceiving stressful situations as threatening and uncontrollable. Our results present new perspectives for psychotherapeutic interventions both for the treatment and for the improvement of the functioning of these patients.

PDF

___

1. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). Fourth ed., Washington, DC: American Psychiatric Association, 2000
2. Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry 1995; 152:1635- 1640.
3. Hammen C, Gitlin M, Altshuler L. Predictors of work adjustment in Bipolar I patients: A naturalistic longitudinal follow-up. J Consult Clin Psychol 2000; 68:220-225.
4. Neale JM. Defensive functions of manic episodes. In: Oltmanns TF, Maher BA (editors). Delusional Beliefs. New York: John Wiley Sons, 1988, 138-156.
5. Lyon HM, Startup M, Bentall RP. Social cognition and the manic defense: Attributions, selective attention, and self-schema in bipolar affective disorder. J Abnorm Psychol 1999; 108:273-282.
6. Nolen-Hoeksema S, Seligman MEP, Girgus JS. Sex differences in unipolar depression: evidence and theory background on the affective disorders. Psychol Bull 1987; 101:259-282
7. Nolen-Hoeksema S. Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol. 1991; 100:569-582.
8. Thomas J, Bentall RP. Hypomanic traits and response styles to depression. Br J Clin Psychol 2002; 41:309-314.
9. Thomas J, Knowles R, Tai S, Bentall RP. Response styles to depressed mood in bipolar affective disorder. J Affect Disord 2007; 100:249-252.
10. Lam D, Wong G. Prodromes, coping strategies, insight and social functioning in bipolar affective disorders. Psychol Med 1997; 27:1091-1100.
11. Sibrava NJ, Borkovec TD. The Cognitive Avoidance Theory of Worry. In: Worry and its Psychological Disorders: Theory, Assessment and Treatment. 2008.
12. Borkovec TD, Alcaine OM, Behar E. Avoidance theory of worry and Generalized Anxiety Disorder. In: Heimberg R, Turk C, Mennin D (editors). Generalized Anxiety Disorder: Advances in Research and Practice. New York, NY, US: Guilford Press, 2004, 77-108.
13. Borkovec TD, Newman MG. Worry and Generalized Anxiety Disorder. In: Bellack A.S, Hersen M, Salkovskis P (editors.). Comprehensive Clinical Psychology. Oxford, England: Pergamon Press, 1998, 439-459.
14. Starcevic V. Pathological worry in major depression: A preliminary report. Behav Res Ther 1995; 33:55-56.
15. Kertz SJ, Bigda-Peyton JS, Rosmarin DH, Björgvinsson T. The importance of worry across diagnostic presentations: Prevalence, severity and associated symptoms in a partial hospital setting. J Anxiety Disord 2012; 26:126-133.
16. Gruber J, Eidelman P, Harvey AG. Transdiagnostic emotion regulation processes in bipolar disorder and insomnia. Behav Res Ther 2008; 46:1096-1100.
17. Samtani S, Moulds ML, Johnson SL, Ehring T, Hyett MP, Anderson R, et al. Higher order repetitive negative thinking is more robustly related to depression, anxiety, and mania than measures of rumination or worry. Cogn Ther Res 2021; 46:161- 170.
18. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: An experiential approach to behavior change. Open J Med Psychol 1999; 5:304.
19. Blackledge JT, Hayes SC. Emotion regulation in acceptance and commitment therapy. J Clin Psychol 2001; 57:243-255.
20. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol 1996; 64:1152-1168.
21. Wenze SJ, Kats DM, Gaudiano BA. Experiential avoidance and mood state in bipolar disorder. J Cogn Psychother 2018; 32:88- 96.
22. Hirsch I. Narcissism, mania and analysts’ envy. Am J Psychoanalysis 2011; 71:363-369.
23. Kuyken W, Watkins E, Beck AT. Cognitive–behavior therapy for mood disorders. In: Gabbard GO, Beck JS, Holmes J (editors). Oxford Textbook of Psychotherapy. New York: Oxford University Press, 2007, 111-126.
24. Ambelas A. Life events and mania. A special relationship? Br J Psychiatry 1987; 150:235-240.
25. Hammen C, Gitlin M. Stress reactivity in bipolar patients and its relation to prior history of disorder. Am J Psychiatry 1997; 154:856-857.
26. Fletcher K, Parker G, Manicavasagar V. Cognitive style in bipolar disorder sub-types. Psychiatry Res 2013; 206:232-239.
27. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56-62.
28. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: Reliability, validity and sensitivity. Br J Psychiatry 1978; 133:429-443.
29. Brinker JK, Dozois DJA. Ruminative thought style and depressed mood. J Clin Psychol 2009; 65:1-19.
30. Karatepe HT, Yavuz FK, Turkcan A. Validity and reliability of the Turkish version of the Ruminative Thought Style Questionnaire. Clin Psychopharmacol Bull 2013; 23:231-241.
31. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the penn state worry questionnaire. Behav Res Ther 1990; 28:487-495.
32. Boysan M, Keskin S, Besiroglu L. Assessment of hierarchical factor structure, reliability and validity of Penn State Worry Questionnaire Turkish version. Clin Psychopharmacol Bull 2008; 18:174-182.
33. Peacock EJ, Wong PTP. The stress appraisal measure (SAM): A multidimensional approach to cognitive appraisal. Stress Med 1990; 6:227-236.
34. Senol-Durak E, Durak M. Turkish validation of the dispositional form of stress appraisal measure. Education Science 2012; 37:48- 63.
35. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and eexperiential avoidance. Behav Ther 2011; 42:676–688.
36. Yavuz F, Ulusoy S, Iskin M, Esen FB, Burhan HS, Karadere ME, et al. Turkish version of acceptance and action Questionnaire-II (AAQ-II): A reliability and validity analysis in clinical and nonclinical samples. Clin Psychopharmacol Bull 2016; 26:397–408.
37. Aydemir O. Development of a Questionnaire to Assess Inter- Episode Functioning in Bipolar Disorder: Bipolar Disorder Functioning Questionnaire. Turk Psikiyatri Derg 2007; 18:344- 352. [Turkish]
38. Mathew MRK, Chandrasekaran R, Sivakumar V. A study of life events in mania. J Affect Disord 1994; 32:157-161.
39. Johnson SL, Sandrow D, Meyer B, Winters R, Miller I, Solomon D, et al. Increases in manic symptoms after life events involving goal attainment. J Abnorm Psychol 2000; 109:72-727.
40. Beck A. Cognitive theory and the emotional disorders. New York: International Universities Press, 1976.
41. Lam D, Jones S, Hayward P. Cognitive Therapy for Bipolar Disorder : A Therapist’s Guide to Concepts, Methods, and Practice. Second ed., West Sussex: Wiley-Blackwell, 2010, 45-57.
42. Hayes SC. Contextualism and the next wave of behavioral psychology. Behav Anal 1988; 23:7–22.
43. Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther 2016; 35:639-665.
44. Hayes SC, Hayes LJ, Reese HW, Sarbin TR. Analytic goals and the varieties of scientific contextualism. In: Hayes SC, Hayes LJ, Reese HW, Sarbin TR (editors). Varieties of Scientific Contextualism. Reno, NV: Context Press, 1993,11-27.
45. Ramnero J, Torneke N. The ABCs of Human Behavior: An İntroduction to Behavioral Psychology. Oakland: New Harbinger, 2011, 47-59.
46. Cheng C, Lau HPB obo, Chan MPS. Coping flexibility and psychological adjustment to stressful life changes: A metaanalytic review. Psychol Bull 2014; 140:1582-1607.
47. Peacock EJ, Wong PTP, Reker GT. Relations between appraisals and coping schemas: Support for the congruence model. Can J Behav Sci 1993; 25:64-80.
48. Knowles R, Tai S, Christensen I, Bentall R. Coping with depression and vulnerability to mania: A factor analytic study of the Nolen-Hoeksema (1991) Response Styles Questionnaire. Br J Clin Psychol 2005; 44:99-112.
49. Johnson SL, McKenzie G, McMurrich S. Ruminative responses to negative and positive affect among students diagnosed with bipolar disorder and major depressive disorder. Cogn Ther Res 2008; 32:702-713.
50. Favaretto E, Bedani F, Offredi A, Schroffenegger M, Sassaroli S, Ruggiero G, et al. Metacognitions and repetitive negative thinking in bipolar disorder and healthy controls: A comparative study. J Affect Disord 2020; 276:152-158.
51. Gruber J, Eidelman P, Johnson SL, Smith B, Harvey AG. Hooked on a feeling: Rumination about positive and negative emotion in inter-episode bipolar disorder. J Abnorm Psychol 2011; 120:956– 961.
52. Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. J Pers Soc Psychol 1991; 61:115- 121.
53. Wolgast M. What does the acceptance and action questionnaire (AAQ-II) really measure? Behav Ther 2014; 45:831-839.
54. Hayes SC, Strosahl K, Wilson KG, Bissett RT, Pistorello J, Toarmino D, et al. Measuring experiential avoidance: A preliminary test of a working model. Psychol Rec 2004; 54:553- 578.
55. McCracken LM, Gutiérrez-Martínez O. Processes of change in psychological flexibility in an interdisciplinary groupbased treatment for chronic pain based on Acceptance and Commitment Therapy. Behav Res Ther 2011; 49:267-274.
56. Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: A study of treatment effectiveness and Process. J Consult Clin Psychol 2008; 76:397-407.
57. Berghoff CR, Forsyth JP, Ritzert TR, Sheppard SC. Comparing paths to quality of life: Contributions of ACT and cognitive therapy intervention targets in two highly anxious samples. J Contextual Behav Sci 2014; 3:89-97.
58. Han J, Liu JE, Su YL, Qiu H. Effect of a group-based acceptance and commitment therapy (ACT) intervention on illness cognition in breast cancer patients. J Context Behav Sci 2019; 14:73-81.
59. O’Donoghue E, Clark A, Richardson M, Hodsoll J, Nandha S, Morris E, et al. Balancing ACT: Evaluating the effectiveness of psychoeducation and Acceptance and Commitment Therapy (ACT) groups for people with bipolar disorder: Study protocol for pilot randomised controlled trial. Trials. 2018; 19:436.
60. Pankowski S, Adler M, Andersson G, Lindefors N, Svanborg C. Group acceptance and commitment therapy (ACT) for bipolar disorder and co-existing anxiety–an open pilot study. Cogn Behav Ther 2017; 46:114-128.
61. Altshuler LL, Post RM, Black DO, Keck PE, Nolen WA, Frye MA, et al. Subsyndromal depressive symptoms are associated with functional impairment in patients with bipolar disorder: Results of a large, multisite study. J Clin Psychiatry 2006; 67:1551-1560.
62. Yan-Meier L, Eberhart NK, Hammen CL, Gitlin M, Sokolski K, Altshuler L. Stressful life events predict delayed functional recovery following treatment for mania in bipolar disorder. Psychiatry Res 2011;186:267-271.
63. Karatepe H, Aktepe M. The effect of acceptance, values and mindfulness on functionality in bipolar disorder. Psychiatry Clin Psychopharmacol 2020; 30:186-192.
64. Apaydin ZK, Atagun MI. Relationship of functionality with impulsivity and coping strategies in bipolar disorder. Dusunen Adam 2018; 31:21-29.