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Clinical Psychology Review 25 (2005) 1101 1122

Psychological approaches to bipolar disorders: A theoretical critique


M.J. Power T
Section of Clinical and Health Psychology, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, UK Received 21 September 2004; received in revised form 6 May 2005; accepted 13 June 2005

Abstract An outline is presented of five main psychological models of the bipolar disorders. These approaches include the Behavioural Activation/Inhibition Systems model, the Cognitive Therapy model, the Interpersonal and Social Rhythm Therapy model, the Interacting Cognitive Subsystems model, and the SPAARS model. Strengths and weaknesses are highlighted for each approach. It is concluded that although there is no model that can adequately account for even the key features of the bipolar disorders (such as periodicity, shifts in the valence of the selfconcept, mixed affective states, and patterns of recovery and relapse), nevertheless, more recently developed multilevel approaches to emotion offer more sophisticated possibilities for modeling these complex disorders. D 2005 Elsevier Ltd. All rights reserved.

1. Introduction Bipolar disorders occur in approximately 1% of the population (Cavanagh, 2004; Weissman & Myers, 1978). They are characterized by a series of affective highs and lows with some states combining feelings of mania, depression and other moods or emotions concurrently. These disturbances are thought to recur throughout the lifetime of 8095% of those affected (Goodwin & Jamison, 1990). Bipolar disorders can have devastating consequences for individual sufferers and their families. An estimated 9 years of life, 12 years of normal health and 14 years of major activities such as schooling, work and child rearing may be lost to the average 25-year-old woman diagnosed with the disorder (Prien & Potter,
T Tel.: +44 131 651 3943. E-mail address: mjpower@staffmail.ed.ac.uk. 0272-7358/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2005.06.008

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1990). A high mortality risk is associated with the affective episodes with approximately one quarter of bipolar disorder individuals attempting suicide (Prien & Potter, 1990). Different theories exist as to the aetiology of bipolar disorders. Psychobiological theories propose a diathesis-stress model, in which stress from life events interacts with predisposed biological, biochemical and neurological instabilities to induce the illness in vulnerable individuals. Whilst many such models are a useful reminder that increased stress levels are linked to the onset of a variety of disorders, the models themselves rarely move beyond a simple level of descriptiveness. Additional research has linked factors such as lack of social support, family environment (Miklowitz, Goldstein, Neuchterlein, Snyder, & Mintz, 1988), lifestyle and sleep irregularity (Wehr, Sack, & Rosenthal, 1987), and increased sensitivity with each episode (Post, 1992) to illness instigation and relapse. However, with one or two exceptions, there has been little work carried out on psychological aspects of bipolar disorders such as research that addresses the self-concept or emotion in bipolar disorders. Furthermore, many of the models of the bipolar disorders simplify the clinical characteristics of the disorders almost beyond recognition; for example, many accounts of hypomania/mania would imply that the goaldirected engagement and activity leads only to positive emotions, whereas the actual emotional experience of mania typically includes considerable dysphoria, anxiety, and irritability, with emotional lability being a characteristic feature. Goodwin and Jamison (1990) reported that 7080% of patients with mania presented with this mixed state picture; Cassidy, Forest, Murry, and Carrolls (1998) largescale exploratory factor analysis of manic symptoms showed that bdysphoric moodQ was the first major factor in their data; and bipolar disorders show considerable co-morbidity with anxiety disorders, drug and alcohol abuse, etc (see Papolos, 2003, for a recent summary). Despite the surprising lack of psychological research on bipolar disorders, there are now several psychological models that have been offered in order to provide an account of at least part of the phenomena of the bipolar disorders. These models are either adaptations of existing approaches to psychological disorders, as in the case of the adaptations of the Cognitive Therapy and Interpersonal Psychotherapy Models, or they are based on more general frameworks as in the adaptations of the Interacting Cognitive Sub-systems (ICS) and the Schematic-Propositional-Analogical-AssociationistRepresentation-Systems (SPAARS) approaches. However, before these approaches are reviewed, the adaptation of Jeffrey Grays Behavioural Activation/Behavioural Inhibition Systems (BAS/BIS) model will be considered. For each of the models, three simple tests can be run: (1) Does the model account for some or all of the unique clinical features of the disorders such as periodicity, mixed affective states, extreme shifts in the valence of mood and self-concept, and patterns of recovery and relapse? (2) What is the explanatory power of the theory? Does it focus on one category of symptom at the expense of others? Does the theory make testable predictions? Does the theory make unique predictions? (3) Is the theory relevant to normal functioning or is it a stand-alone and disorder-specific approaches? Can it account for other types of psychopathology and place the bipolar disorders in a general framework of psychopathology? These three sets of tests will not be applied in a formulaic way as we proceed through each of the models, but the models will be described in their own appropriate ways first, before returning to these questions so that they will be used to structure the final summary and conclusions.

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2. The behavioural activation/behavioural inhibition systems (BAS/BIS) model The BAS/BIS model can be considered in the context of dimensional approaches to personality, motivation, and emotion. Although in many ways derived from and related to Eysencks (1967) two dimensions of extraversionintroversion and normality-neuroticism (also called bemotionalityQ), there is also a relevant tradition within mood and affect from at least Osgoods semantic differential approach (e.g. Osgood, Suci, & Tannenbaum, 1957) of examining a two-dimensional approach (e.g. Rolls, 1999; Russell & Carroll, 1999; Watson, Clark, & Tellegen, 1988). First, however, the BAS/BIS approach will be outlined before returning to some of the generic problems shared by these two-dimensional approaches. In his theory of anxiety, Gray (1976, 1982) identified two key behavioural systems. First, a Behavioural Inhibition System (BIS), a Pavlovian conditioning based system, which focuses on stimuli that have come to be conditioned to punishment or frustrative non-reward, or novel stimuli which may come to be associated with unconditioned responses (UCRs). In the presence of such stimuli, the BIS leads to behavioural inhibition, that is, to the interruption of ongoing activity, which is accompanied by increased arousal and attention to the environment. Anxiety therefore was considered to be a consequence of activity in the BIS, in which a postulated comparator (see Fig. 1) detects mismatches between predicted events that do not occur, unpredicted events that do occur, and predicted punishments and non-rewards that occur. The application of Grays BAS/BIS model to mood disorders has tended to focus on the role of the BAS rather than the BIS (see later for some exceptions to this generalisation), though there is a clear overlap between Grays account of the BIS, with its focus on behavioural inhibition and predicted aversiveness, and Seligmans (1975) Learned Helplessness theory and its subsequent reformulations. Nevertheless, the Behavioural Activation System (BAS) focuses on approach behaviour in which positive stimuli, or reward, lead to approach and engagement. The BAS is therefore closely associated with incentive motivation and with motor programmes related to approach. Although Gray (1990)
STORED REGULARITIES

THE WORLD

COMPARATOR PREDICTIONS

PLANS

Fig. 1. Grays comparator model.

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thought that only the BIS was clearly identified with the emotion of anxiety, others have been bolder and developed emotion models based on the BAS. For example, Depue (Depue, Krauss, & Spoont, 1987; Goplerud & Depue, 1985) has proposed that BAS-type systems are poorly regulated both in bipolar disorder individuals and in cyclothymic individuals, who can be considered to have a milder variant of a bipolar disorder. Depue et al. focussed in particular on normal levels of cortisol production and the change in cortisol production under stress in both cyclothymic and bipolar individuals (e.g. Goplerud & Depue, 1985); they found hypersecretion of cortisol and slower recovery to normal cortisol levels. On the basis of these and related findings, Depue suggested that the high arousal, high goal-directed activity, and high positive emotions are characteristic of high levels of BAS activity and of hypomania, whereas low levels of BAS activity, including disengagement from rewarding activities, retardation, etc., are characteristic of the depressed phase. In this vein, Johnson, Sandrow, Meyer, and Winters (2000) reported an increase in manic symptoms after the attainment of an important goal, with the additional feature that bipolar individuals continue to attempt to increase positive affect after goal attainment with increased goal pursuit, whereas normal individuals tend to aim for some moderation of the positive affect for example by bcoastingQ. In an analogue study with students reporting hypomanic or depressed symptomatology, Meyer, Beevers, and Johnson (2004) found that hypomania was linked with an overlyoptimistic future goal-oriented pattern, and that such individuals reported future goals as being less stressful and less difficult than did control individuals. Stern and Berrenberg (1979) reported that on the illusion of control laboratory task individuals with a history of hypomania predicted higher rates of success after success feedback in comparison to controls. There is some evidence therefore in support of the claim that goal attainment and goal loss or interruption are hyper-valenced in the bipolar disorders, though it should be cautioned that patterns of over-investment in some goals and under-investment in others are characteristic of unipolar depression also (Champion & Power, 1995). The work of Carver and White (1994) in their operationalisation of Grays approach has offered a selfreport BIS/BAS scale for the assessment of BIS and BAS sensitivities, though questions have necessarily been asked about whether this self-report measure does measure the same construct as the psychophysiological and behavioural measures of BIS/BAS that have been used in the laboratory (cf. Johnson, Turner, & Iwata, 2003). Although in the Carver and White approach the BIS scale has remained much as conceptualised by Gray in its focus on punishment sensitivity, they have further developed and modified the BAS scale to include subscales that assess Drive (i.e. the pursuit of desired goals), Fun Seeking, and Reward Responsiveness. Carver and White also considered the BAS to be linked to positive affect and the BIS to negative affect, thereby raising the possibility that both dimensions could be involved in mood disorders rather than only the BAS and therefore contrary to authors such as Depue and others (e.g. Depue et al., 1987; Wright & Lam, 2004) who have focussed only on the BAS in bipolar disorders. In an analogue study with students that included the Carver and White BIS/BAS scales, Meyer, Johnson, and Carver (1999) found that in mood-disorder prone students, higher scores on the BAS Fun Seeking scale were related to higher mania symptom scores, whereas both high BIS and low BAS Reward Responsiveness were related to depression symptom scores. This preliminary study therefore offered some support for the Carver and White modification of the BIS/BAS model, in particular in the combination of both BAS and BIS in the correlation with depression scores. A subsequent study from the same research group (Meyer, Johnson, & Winters, 2001) followed up a group of 59 Bipolar 1 individuals over an average of 20 months. They found that the BAS (especially Reward Responsiveness) was predictive of increases in manic symptoms over time but was not predictive of changes in depression. In contrast, the BIS fluctuated with levels of depression but was not predictive of

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later levels of depression, which would indicate that the BIS is simply a state marker but not a vulnerability factor. A further inconsistent finding was reported in an epidemiological study of over 1800 1921 year olds (Johnson et al., 2003), which found significantly higher levels of BIS in respondents with a lifetime-ever diagnosis of depression, but none of the expected differences were found on the BAS scales. The Meyer et al (2001) clinical study needs of course to be replicated in a larger sample, but, together with the other inconsistent findings, it does question the relevance of the BIS/BAS approach to bipolar disorders, in addition to the question of whether or not the self-report measure correctly operationalises the construct. However, an alternative option might be to argue as Johnson et al. have done subsequently (e.g. Cuellar, Johnson, & Winters, 2005) that, contrary to the current classification of bipolar disorders, mania and depression are not inherently linked but simply show high levels co-morbidity; in this case, the linking of BAS to mania but not depression would be consistent, but there still remains the problem for the BIS/BAS approach of why neither BIS nor BAS were predictive of depression. There are a number of major limitations of the BAS/BIS approach in addition to some of the issues already raised. Perhaps the major limitation can be highlighted when the theory is placed in the context of other two-dimensional approaches to motivation and affect, which share some of the same limitations. Carver and Whites (1994) analysis argues that BAS is related to positive affect and BIS to negative affect and that these two dimensions are orthogonal to each other. A similar analysis of affect space is proposed by Watson et al. (1988), in which the two orthogonal dimensions are explicitly labeled Positive Affect and Negative Affect, with each varying from High to Low. However, a contrary approach is that PositiveNegative (or PleasantUnpleasant) forms a single bipolar dimension with Arousal or Activation as the second orthogonal dimension (e.g. Russell & Carroll, 1999). Notwithstanding these contradictions within the two-dimensional approach is the problem that although the self-report of conscious affect might be captured by dimensions such as Valence and Arousal, the underlying functional and neuroanatomical systems may be far more complex and not best described by such systems. The evidence for this complexity is wide-ranging in the areas of emotion and motivation, but includes work in favour of basic emotions (e.g. Ekman, 1992) and increasing evidence of specific-emotion linked neuroanatomical circuits that underlie different emotions but which are not capturable simply by a positive-negative distinction (e.g. Lane & Nadel, 2000). Even within the study of self-reported affect, the evidence is far from clear-cut that any of the two-dimensional approaches are sufficient, contrary to many of the assumptions to date (Power, in press). The question therefore for the BIS/BAS approach, like with the other two-dimensional approaches, is what exactly are the two dimensions, how do they map onto emotion and mood, and how do they deal with the contradictory evidence base? The limitations of the BIS/BAS approach are also paralleled in the shift from the all-embracing concept of stress, dominant in the 1950s and 1960s, to more sophisticated emotion-based theories which will be returned to later (see e.g. Lazarus, 1966, 1991, for a dramatic example of such a change). Although there are still recent equivalents of the BAS/BIS such as in Rolls (1999) reinforcement-based theory of emotion, these approaches simplify the complex phenomena which they attempt to explain. For example, Gray developed his comparator model illustrated above (see Fig. 1) to include a theory of consciousness and the self, in which the function of consciousness is that of an error-detector for the interruption of automatic processes (e.g. Gray, 1999). Again, such an approach simplifies the concept of the self and of consciousness, for example, with the assumption that both are unitary constructions, whereas the phenomena of the emotional disorders suggest otherwise (e.g. Dalgleish & Power, 2004a).

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3. The cognitive therapy model An outline of the classic Cognitive Therapy model of unipolar depression is presented in Fig. 2 (based on Beck, Rush, Shaw, & Emery, 1979). In summary, childhood experiences lead to the development of dysfunctional schemas that centre around themes such as the need to be loved or the need to achieve. Disconfirming experiences or life events later in life, for example, in the transition from adolescence to adulthood, may lead to bactivationQ of the dysfunctional schema in that the person no longer believes that he or she is lovable, or believes that he or she has been a failure throughout life. The activation of the dysfunctional beliefs causes the production of negative automatic thoughts (e.g. bI am unlovableQ, bI am a failureQ, etc.), which in turn cause the onset of the relevant mood such as the depressed state in the vulnerable individual. This classic Cognitive Therapy model of unipolar depression has now been adapted to a number of different disorders that include anxiety disorders, schizophrenia, personality disorders, and, more recently, bipolar disorders. The two main presentations of the adaptation to bipolar disorders by Beck et al. (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2002) and by Lam et al. (Lam, Jones, Hayward, & Bright, 1999; Wright & Lam, 2004) are both relatively informal, in the sense that they assume the basic cognitive therapy model outlined in Fig. 2, with the main differences being the types of dysfunctional attitudes or schemas that are implicated. Newman et al. (2002) have argued in bipolar disorders that schemas act in a bbidirectionalQ way, that is, even though a schema might focus on lovability, the polarity of the schema shifts with mood state and life events from one extreme to the other, from at one time representing that they are totally unlovable to another time representing that everybody loves them. The Newman et al. model is therefore also a diathesis-stress model in which different types of life events may be related to different manic or depressive states; for example, events that lead to sleep disruption or to successful goal pursuits may be more likely to trigger mania. In a study of students with lifetime-ever diagnosis of bipolar disorders, ReillyHarrington, Alloy, Fresco, and Whitehouse (1999) found that the interaction between negative life events and cognitive style as measured by the Attributional Style Questionnaire or the Dysfunctional Attitudes Scale (DAS) was predictive of both depressive symptoms and manic symptoms at 1-month follow-up. A
EARLY EXPERIENCE (e.g. criticism and rejection from parents) FORMULATION OF DYSFUNCTIONAL ASSUMPTIONS (e.g. unless I am loved I am worthless)

CRITICAL INCIDENTS (e.g. loss events)

ACTIVATION OF ASSUMPTION NEGATIVE AUTOMATIC THOUGHTS

DEPRESSION

Fig. 2. Becks Cognitive Therapy model.

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further study by Johnson and Fingerhut (2004) of 60 Bipolar 1 individuals reported support for the DAS being predictive of depressive symptomatology at 6 month follow-up, but the authors reported that cognitive factors such as the DAS are not predictive of changes in manic symptoms. However, their results for mania are inconclusive because they did not examine subscales of the DAS, nor do they report the relevant analyses that would have fully tested the predictor models. The second main cognitive therapy model has been presented by Lam et al. (1999), which has focussed on specific subsets of dysfunctional attitudes. In order to test the model, Lam, Wright, and Smith (2004) used the Dysfunctional Attitude Scale with a sample of 143 Bipolar Type 1 patients; exploratory factor analysis suggested factors that included bgoal-attainmentQ (e.g. bIf I try hard enough, I should be able to excel at anything I attemptQ) and bantidependencyQ (e.g. bI do not need the approval of other people to be happyQ), two factors that distinguished the bipolar patients from a comparison sample of unipolar patients. Consistent therefore with the proposals for the BAS approach discussed above, the dysfunctional attitudes that are characteristic in bipolar disorder include goal-striving, success in which is postulated to lead to euphoria (see Fig. 3). A positive feedback loop in vulnerable individuals leads to attempts to enhance positive mood state with increasingly driven goal-attainment behaviour, disregard of feedback from others (exacerbated by activation of the bantidependencyQ beliefs), and disruption of normal routines. As Leahy (1999) has proposed, manic individuals tend to be brisk-loversQ in which their decision-making processes assume unlimited resources, infallibility of predictions, and control over outcomes. Johnson et al. (2000) offer support for the proposal that specifically goal-attainment life events rather than positive events in general are related to increases in manic symptoms; and Scott, Stanton, Garland, and Ferrier (2000) found that euthymic bipolar individuals continued to show elevated scores on dysfunctional attitudes related to Perfectionism in addition to continuing to display social problemsolving difficulties (as measured by the Means-Ends Problem-Solving procedure). A further study by Scott (Scott & Pope, 2003) compared bipolar participants who were either remitted, hypomanic or depressed at the time of the assessment. The hypomanic participants were found to score at intermediate levels between the remitted and the depressed groups on dysfunctional attitudes, including those attitudes related to Perfectionism or goal-attainment. Moreover, on the Rosenberg SelfEsteem Scale hypomanic participants were found to score somewhat higher on both the Positive Esteem and the Negative Esteem subscales in comparison to the remitted and depressed bipolar participants. These findings again, as noted in the BAS comments above, demonstrate that the hypomanic/manic phases of bipolar disorders are not simply the positive opposite of the negative depressed phases. Indeed, findings such as these suggest that the name bbipolar disorderQ is a misnomer in itself. Criticisms of the Cognitive Therapy model, like with the BAS/BIS approach, have to begin with a focus on the simplicity of the model. One can only feel sorry for the sheer amount of work that poor dysfunctional attitudes (and this is not to deny the role of other cognitive processes such as memory, attention, and reasoning) are having to do as the Cognitive Therapy model is extended to more and more disorders (and I make this criticism as a one-time fan of dysfunctional attitudessee e.g. Power et al., 1994); eventually there will be a disorder for each dysfunctional attitude! The serious points here are summarised in the following points. (1) The classic Cognitive Therapy framework has too simple a monolithic view of the self-concept; this problem is highlighted in the need for bbidirectional schemasQ in the adaptation for bipolar disorders, which can either be overly positive or overly negative according to context and mood. However, it is unclear how a single schema would change its content and processing features so

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DYSFUNCTIONAL ATTITUDES
Goal Attainment: 1. I should be happy all the time 2. A person should do well at everything he undertakes

MOOD
Euphoric or dysphoric Mood

BIOLOGICAL
Genetic predisposition to manic depressive illness

BEHAVIOUR
Relating to Mania: Highly driven behaviour Lack of routine etc Relating to Depression: Self-blame for failure to meet standards Rumination about negative implications of depressive symptoms etc

Fig. 3. Lams Dysfunctional Attitude model.

dramatically in order at one time to be excessively positive and at a later time to be excessively negative, nor is this problem tackled by Newman et al. (2002). A more elegant solution would be to consider the more complex self-concept structures that have been considered in social cognitive psychology (see later). (2) The classic Cognitive Therapy framework has a single level of information processing (as do many other classic models of stress and emotion; see Power & Dalgleish, 1997), which limits the explanatory power of the model and which weakens it in comparison to modern multi-level information processing approaches such as ICS and SPAARS, which will be presented later. (3) The Cognitive Therapy approach has an overly cognitive and inadequate theory of emotion. The main tenet of the original model was that cognition (e.g. Negative Automatic Thoughts) causes emotion, though of necessity feedback loops have been added into cognition-emotion cycles in subsequent cognitive therapy models (e.g. in Clarks, 1986, model of panic). Nevertheless, the approach is neutral on what emotions are, whether or not they relate to each other or stand alone, how they develop, whether they can combine or be in conflict with each other, and so on. In other

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words, there is no theory of emotion within Cognitive Therapy, but bemotionsQ are givens within the model that do not need further theoretical deconstruction. A theory of emotional disorder that does not provide a theory of emotion is sadly lacking in its scope. (4) Adaptations only to the content of schemas/attitudes are insufficient to capture the actual differences between the full range of psychological disorders (Power & Champion, 1986; Power & Dalgleish, 1997). The complex phenomenology of manic episodes cannot simply be accounted for by successful goal-attainment leading to the activation of positive goal-attainment schema; the elevation of negative emotions as well as positive, the elevation of negative beliefs and negative self-esteem as well as positive beliefs and positive self-esteem, all point to the need for more sophisticated models of the type to be considered later. The findings also add weight to the view that mania is not the polar opposite of depression.

4. The interpersonal and social rhythm therapy (IPSRT) approach The IPSRT approach to bipolar disorders combines the Interpersonal Psychotherapy approach developed by Weissman, Klerman, et al. (Klerman, Weismann, Rounsaville, & Chevron, 1984; Weissman, Markowitz, & Klerman, 2000) for the treatment of unipolar depression, together with a circadian rhythm model developed by the IPT group at the University of Pittsburgh (Ehlers, Frank, & Kupfer, 1988; Swartz, Frank, Spielvogle, & Kupfer, 2004). The Pittsburgh group have of course not been the only researchers and clinicians to have identified the significance of circadian rhythm disruption in bipolar disorders (see e.g. Goodwin & Jamison, 1990; Healy & Williams, 1988, 1989), but they have been the only group to have developed it into a framework in which to understand bipolar disorders combined with a clinical intervention. The focus therefore will be on the IPSRT model rather than the earlier circadian dysrhythmia models. The IPT approach to depression was originally developed as a control intervention in a pharmacotherapy trial for unipolar depression. It is deliberately pragmatic rather than theoretical in its approach, in that Weissman and Klerman interviewed expert colleagues about how they worked in practice with their depressed clients. The presentation of the model is therefore necessarily different to the other models in this paper because of the originators explicit disavowal of theory in favour of practitioners anecdotal accounts of what worked for them in therapy. Nevertheless, it is possible to begin to locate the approach theoretically in a post-hoc fashion as it has developed into an evidence-based approach for unipolar depression. The approach basically draws on social-psychodynamic models that reflect for example the influence of the social psychoanalytic approach of Harry Stack Sullivan (1953) in the US, combined with the equal influence in the US of the social psychiatrist Adolf Meyer (1957). IPT works with three phases in therapy. The first phase focuses on assessment and formulation. In addition to history and diagnostic interviewing, IPT includes the so-called Interpersonal Inventory which is an interview assessment of the social network and social support of the client. The second phase of therapy selects one of four focus areas on which to base the intervention: 1) 2) 3) 4) Interpersonal Role Disputesfor example, marital conflict, problems at work; Role Transitionsfor example, the transition from adolescence to adulthood, retirement; Griefthe loss of a significant other; Interpersonal Deficits problems in establishing and maintaining relationships.

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The third and final phase of the therapy is the Termination phase in which the therapist works to establish therapeutic gains and to deal with the issues arising from the ending of therapy. Other characteristics of the therapy include its short-term here-and-now focus (see Klerman et al., 1984; Weissman et al., 2000). The second main feature of IPSRT is its focus on social circadian rhythms. The Social Rhythm Metric (SRM) (Monk, Kupfer, Frank, & Ritenour, 1991) is completed as part of the assessment. The SRM seeks to identify specific triggers that are likely to disrupt normal social rhythms for the individual, to monitor mood, and to monitor social interactions. The plan then is to regularise social rhythms, especially under circumstances of vulnerability for the individual, or when certain prodromes or early warning signs of a manic or depressive episode are identified (a feature that is now also characteristic of most CBT approaches to bipolar disorders and is of proven efficacy; see Lam et al., 1999; Perry et al., 1999; Schwannauer, 2004; SIGN, 2005). Psychoeducation about bipolar disorders is also a key component, but again is also a feature of other bipolar interventions (SIGN, 2005). Similar to Cognitive Therapy therefore, IPSRT is primarily a treatment-driven approach to bipolar disorders, so in many ways the theoretical base of the approach is seen as secondary to the question of whether or not the intervention works. Because of the focus on application and intervention, there is a loose mapping between theory and practice; thus, it would be possible to map IPSRT onto one of several viable theories, just as it would be possible to do this with Cognitive Behaviour Therapy (Power, 2002). The lack of an explicit theoretical base for IPT and for IPSRT has to be therefore its major weakness; good science requires good theory for the development and testing of hypotheses. Other weaknesses of the IPSRT approach follow from this lack of theory; thus, it is unclear how important circadian and other dysrhythmias are for both mania and depression and to what extent they can account for all features of symptomatology; it is unclear how the four focus areas of IPT derived for unipolar depressions map onto bipolar disorders given evidence from elsewhere pointing to for example the importance of goal-related events rather than positive or negative events in general (Johnson, 2005). However, the strengths of IPSRT and CBT approaches are in the boundaries they set for other more theoretically-driven approaches to bipolar disorders; and for the clinical insights that they offer into factors associated with onset, maintenance, relapse, recovery, and the periodicity of the disorders. We will turn therefore to two multilevel cognitive approaches to emotion, both of which have been derived as more general frameworks but both of which have recently been adapted specifically for bipolar disorders.

5. The interacting cognitive subsystems (ICS) approach The Interacting Cognitive Subsystems (ICS) approach (Barnard, 1985, 2004; Barnard & Teasdale, 1991; Teasdale & Barnard, 1993) is a recent exemplar of one of a class of multi-level, multi-system approaches, which, in addition to their potential application to emotion, can provide accounts of a wide variety of cognitive skills and processes. The link between cognition and emotion is not easily pinned down in such models, because the relationship is seen as complex and interactive and so, in contrast to some of the earlier models discussed above, one cannot simply point at the model and say this is the bemotion boxQ: emotion is a process distributed over many subsystems and represents a high-level integration of a variety of such processes, which vary from occasion to occasion and from emotion to emotion. There are nine main cognitive subsystems in Teasdale and Barnards (1993) ICS approach: the first set of subsystems is sensory-related and includes the Acoustic and Visual subsystems; the second set is the

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Central subsystems and includes the Morphonolexical, the Propositional, the Implicational, and the Object subsystems; and the third set is Affector subsystems and includes the Articulatory, the Body State, and the Limb subsystems. These subsystems process information partly in parallel and partly sequentially according to the type of task and other requirements acting on the overall system. Rather than provide a detailed description of all subsystems however, the focus will be one those that are especially important in the occurrence of emotion. In relation to emotion, the key subsystems are the so-called Propositional and Implicational, as illustrated in Fig. 4. These two systems represent a common distinction made in psycholinguistics because of the need to have both multiple levels and multiple representations in models of the comprehension and production of language (e.g. Power, 1986). The units of representation in the Propositional subsystem are propositions, which are the smallest semantic units that can have a truth value; thus, the phrases dTony BlairT or dGeorge BushT do not have truth values in themselves but are merely names about which nothing is asserted. Only when they are included in larger units such as dTony Blair eats British beefT or dGeorge Bush is a fine politicianT do the units become propositional because they are either true or false. In contrast, the higher level semantic representations at the Implicational level in ICS are referred to as dschematic modelsT. Like the more commonly used dmental modelsT approach (e.g. Johnson-Laird, 1983), schematic models combine information from a variety of sources and are more generic and holistic and integrate information from other subsystems; so, within ICS, schematic models draw upon the whole range of other subsystems feeding information into the Implicational subsystem. In the simplified example shown in Fig. 4, we have highlighted three possible inputs to the Implicational subsystem from the Visual, the Body State, and the Propositional subsystems. These four subsystems together are the most important ones in the production of emotion in the ICS approach. In the approach therefore emotion is treated as a distributed phenomenon that is the result of the combination within the Implicational subsystem of outputs from a number of cognitive subsystems rather than simply being the output from a specific cognitive appraisal. Although ICS is not alone in considering emotion to be the result of processing in multiple cognitive systems (see for example Leventhal and Scherers, 1987, model), it provides one of the most detailed and elegant multi-system approaches to the understanding of emotion. Teasdale and Barnard (1993) also extend an earlier criticism of Cognitive Therapy made by Power and Champion (1986); namely, that Cognitive Therapy focuses on a single level of meaning, whereas profit can be had from considering two levels of meaning such as propositions and mental models. Teasdale and Barnard argue that much of the challenging of negative thoughts and beliefs in standard Cognitive Therapy occurs at the propositional level and may often ignore the higher level
PROPOSITIONAL SUB-SYSTEM

VISUAL SUB-SYSTEM

IMPLICATIONAL SUB-SYSTEM

BODY STATE SUB-SYSTEM

Fig. 4. Teasdale and Barnards ICS model.

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Implicational meaning; the net outcome of such a process can be that the individual is browbeaten into rejecting the negative proposition, but becomes more depressed rather than less depressed because for example a higher level model is confirmed in which the individual is always wrong. The adaptation of the ICS approach to bipolar disorders has recently been outlined by Barnard (2003, 2004), in which he also considers its application to schizophrenia. In the extension of ICS to a range of psychopathology, Barnard considers variation in four sets of processes: (1) (2) (3) (4) the the the the content of semantic representations; rate of change in mental images; mode in which processes operate; synchronization of the processes that generate meaning.

In depression, the Implicational and Propositional systems are considered to enter a state of interlock, in which schematic models continually generate negative propositions which in turn feedback to the Implicational system thereby regenerating the original schematic model. By contrast to this low rate of change in depression, schematic models are seen to have a high rate of change in mania and involve the processing of positive or mixed schematic models but with largely unevaluated propositional representations thereby remaining outside of focal awareness. Schizophrenia is considered to arise from desynchrony between schematic and propositional levels of meaning, which then has consequences for the integration of information arising from other subsystems; Barnard proposes that the same mechanism may underlie the production of delusions in mania when combined with the fast rate of processing. Partial products from fast changing schematic models might then combine to form new schematic models, which under optimal conditions can lead to imaginative thinking, but under more extreme circumstances can lead to delusional models. In contrast therefore to the depressed state in which propositional and implicational meanings become binterlockedQ, in mania the opposite occurs and propositional and implicational meanings are said to enter a brunaway stateQ; in such states, there is little or no reflection on specific propositional meanings, which permits the development of models and meanings that are unscrutinised, inconsistent with each other, and rapidly changing. Overall, it is too soon to judge the ICS approach to bipolar disorders because of its recent and only sketchy development. ICS is of course a general cognitive model that will stand or fall on how useful an account it provides of a wide range of cognitive processes, not just its account of bipolar disorders. Because it is in part a framework and in part a theory, there is a degree to which it is not falsifiable; thus, there is some flexibility about which particular theory a framework can instantiate. For example, the low level cognitive architecture for ICS could be based on connectionist networks, but it could be based on a viable alternative; the subsystems could be treated as functional modules within a modular processing system, or, alternatively, it could be argued that the cognitive subsystems were simply a functional description of a set of processes that were instantiated in the brain in a radically different fashion (see Gazzaniga, 1988, for an excellent discussion of this issue in relation to modularity). In relation to emotion, it remains to be seen how useful the ICS approach is from both the empirical point of view and the clinical point of view. However, some interesting preliminary supporting data for the ICS account of unipolar depression have been presented by Teasdale, Taylor, Cooper, Hayhurst, and Paykel (1995) who found that depressed patients completed sentence stems with positive words or phrases consistent with high-level schematic models rather than simply offering negative sentence completions which might be predicted by theories such as Becks or Bowers. Sheppard and Teasdale (2000) have replicated this

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finding and have also shown that at 2 months follow-up, mood-improved patients presented completed sentence stems in a more functional, less positive way. We might note however that the central distinction between the Propositional and the Implicational levels of meaning may not be as clear-cut in practice as it appears, while not disputing that it is advantageous to make distinctions between different levels of meaning. Ultimately, of course, emotion is generated in ICS via a pattern-matching process, albeit a sophisticated set of such processes; thus, ICS incorporates a highly sophisticated cognitive theory, but it lacks a sophisticated theory of emotion, nor is it clear what unique implications, if any, the approach has for therapeutic practice with the bipolar disorders. In this manner therefore, ICS appears to swim against the tide of current goal-based appraisal theories of emotion that we have highlighted elsewhere (Power & Dalgleish, 1997); although it might be argued that goal-based discrepancies can be modeled within ICS, such a process is not an explicit feature of the ICS approach in contrast to the SPAARS model to be considered next. Swimming against the tide is obviously not a criticism in itself and may, indeed, prove to be remarkably percipient. For the present however we believe that the tide is running in the right direction and will provide the direction that will be taken in the next section.

6. The schematic, propositional, analogical, associative representation systems (SPAARS) approach On the basis of more recent philosophical and psychological models (Power & Dalgleish, 1997), a number of components of emotion can be identified; an initiating event (external or internal), an interpretation, an appraisal of the interpretation especially in relation to goal relevance, a physiological reaction, an action potential or tendency to action, conscious awareness, and overt behaviour. All of these components are present normally in an emotion episode, with the possible exceptions of conscious awareness and overt behaviour; we have suggested that the concept of demotionT is a holistic one that typically includes all of these components, but that emotion is not identifiable with any one component. This approach is contrary to prior theories that have equated emotion for example with the conscious bfeelingQ (as in the so-called bfeeling theoriesQ), nor can emotion be equated with the physiology and overt behaviour. As with ICS, emotion is considered to be integrative across multiple processes and systems and not identifiable with any one of them. The SPAARS cognitive model of emotion is summarised in Fig. 5 (the letters are merely a mnemonic for the different types of representation systemsthe Schematic Model, the Propositional, the Associative and the Analogical). The approach is multi-level and includes four different levels of representation. It would of course be possible for these representation systems to be ordered sequentially thereby forming a single level along the lines of the original cognitive therapy model (Beck, 1976) in which, for example, schemas produce negative automatic thoughts (propositional representations) which then cause the emotion. However, in SPAARS the processing of the schematic, propositional, and associative levels may occur in parallel in a manner comparable to Leventhals (e.g. 1980) early influential multi-level theory. The initial processing of stimuli occurs through a number of mode-specific or sensory-specific systems such as the visual, the auditory, the tactile, the proprioceptive, and the olfactory which we have grouped together and termed the Analogical representation system, but which in practice also constitute a set of parallel processing modules. The importance of such systems in emotions and emotional disorders is clearly evident for example in Post Traumatic Stress Disorder (Dalgleish & Power, 2004b) in which certain sights, sounds or other bodily sensations may become

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SCHEMATIC MODEL LEVEL

Route 1

EVENT

ANALOGICAL SYSTEM

ASSOCIATIVE LEVEL

Route 2

PROPOSITIONAL LEVEL

Fig. 5. Power and Dalgleishs SPAARS model.

inherent parts of the memory and experience of a traumatic event. The output from analogical processing then feeds into the three representation systems that operate in parallel. At the lower level there is an associative system which, in terms of possible architectures, could take the form of a number of modularised connectionist networks (see e.g. Power & Dalgleish, 1997, or Williams, Watts, MacLeod, & Mathews, 1998, for further discussion of bcognitive architecturesQ). The intermediate level of semantic representation within SPAARS is the Propositional level. This is the most language-like level of representation. Although such propositional representations have played a key role in the generation of emotion in a number of theories, such as the role of propositional level automatic thoughts in Becks Cognitive Therapy discussed earlier, we propose that there is no direct route from propositions to emotion (in agreement with Teasdale & Barnard, 1993), but instead argue that they feed either through appraisals at the schematic model level or directly through the associative route (in contrast to Teasdale & Barnard, 1993). For example, particular words or phrases may become directly linked to emotion for certain individuals; thus, swear words come in a whole range of culture-specific forms. These words and phrases are normally designed to elicit an emotional reaction in the recipient, which is typically through the direct access associative route. Each individual accumulates a set of unique personal words and phrases which may also directly access emotion through the associative route: significant names and significant places provide two such examples (cf. the classic dcocktail party phenomenonT of hearing ones name spoken whilst engaged in another conversation; Cherry, 1953), the emotion-laden nature of which may become acutely apparent to the individual following for example bereavement when names and places associated with the loved one can trigger overwhelming feelings of sadness, anger, and other emotions (Power, 1999). The highest level of semantic representation, illustrated above in Fig. 5, is labeled the Schematic Model level. The term is taken from Teasdale and Barnard (1993); it is designed to capture the advantages of a mental model level of representation (Johnson-Laird, 1983), a level that is designed to integrate information in a flexible and dynamic fashion in combination with the advantages of the more traditional schema approach, which provides a good account of repetitive and invariant relationships

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between concepts but which is weakest therefore where more flexible representations are needed (cf. Kahneman & Miller, 1986). In relation to emotion, the Schematic Model level is extremely important because it is at this level that the generation of emotion occurs through the process of effortful appraisal (shown as Route 1 in Fig. 5). The key processes through this route include therefore the interpretation and appraisal of any relevant input, whether of external or internal origin, according to the basic appraisal processes considered elsewhere (Oatley & Johnson-Laird, 1987; Power & Dalgleish, 1997). An important feature of emotional disorder follows from the proposal in SPAARS that some of the disorders may be derived from the coupling of two or more basic emotions, or may involve the coupling of different semantic levels within an emotion module. Basic emotions are also considered to be the building blocks from which more complex emotions are derived; they are typically considered to originate in innate systems, be universal in their expression, and to appear early during the infants development (e.g. Ekman, 1992). SPAARS follows the proposal made by Oatley & Johnson-Laird (1987) that there are five basic emotions of Sadness, Happiness, Anger, Fear and Disgust and that all other emotions can be derived from this basic set. The proposal in relation to a number of emotional disorders is that in many cases the coupling of two or more of these basic emotions provides the basis of the disorder. For example, some forms of unipolar depression may occur from the coupling of Sadness and Disgust in which the individual feels both sad because of some actual or imagined loss, but, in addition, turns disgust against the self because of perceived inadequacy or culpability. Although previous theorists have derived depression from other combinations, for example, Freud (1917) derived Melancholia from Sadness and Anger, and more recent theorists have proposed that the comorbidity of depression and anxiety has theoretical implications (e.g. Watson & Clark, 1992), it is suggested that disgusts crucial role, especially in the form of self-disgust, has gone largely unrecognised in relation to both the emotional disorders and a number of other drive-related disorders (Power & Dalgleish, 1997). The advantage of a multi-level system such as SPAARS can be illustrated by reference to particular empirical and clinical findings that originate from work with the bipolar disorders. For example, there have been a number of studies following in the psychoanalytic tradition of the bmanic defenseQ (e.g. Lewin, 1951), in which mania is seen to be a defense against an underlying state of depression (see studies by Winters & Neale, 1985, and the summary in Bentall & Kinderman, 1999, or in Bentall, 2003). Lyon, Startup, and Bentall (1999) found that on an explicit test of attributional style, currently depressed bipolar patients gave characteristic self-related attributions for negative events, whereas currently manic patients gave normal attributions. In contrast, on implicit tests such as naming latencies and recall, the currently manic patients showed the same negative biases that the depressed patients showed. Although this line of work might be interpretable in the light of the purported psychodynamic defense mechanism, it could equally be argued that, as in SPAARS, that two or more emotions can be produced in parallel by the different Schematic and Associative routes, or that one emotion or mood state may replace another that is experienced more aversively (Power & Dalgleish, 1997), as will be discussed in detail later. In relation to the self-concept, there now exist a number of models that have been applied to the normal self-concept and to the self-concept in unipolar depression that can be applied fruitfully to bipolar disorders. For example, Power (1987, 1991; Power & Dalgleish, 1997) has argued that the selfconcept can become bmodularisedQ (i.e. the processes become autonomous and encapsulated and are not easily interruptable) around particular self-aspects such as certain emotions, roles, or goals, a process that leads to a state referred to as the bAmbivalent SelfQ. A similar proposal has been made by Showers (1992) in her notion of bcompartmentalizationQ which shares some similarities with the modularisation

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proposal. Two studies reported in Power, de Jong, and Lloyd (2002) used Showers card sort task to explore the self-concept in individuals with bipolar disorders. The results suggested that in Showers (1992) terms of bcompartmentalisationQ and in our two terms of bambivalent selfQ and bmodularisationQ (Power & Dalgleish, 1997), there is good replicable evidence that the self-concept is organised differently in bipolar disorders. That is, in bipolar disorders key self-aspects (e.g. being a student, being a mother, being a lawyer, being a lover, being a tennis player, etc.) are almost always entirely positive or entirely negative in their content, whereas in non-bipolar controls the equivalent self-aspects are more often described with mixed positive and negative content (e.g. bIm a pretty good tennis player, but my backhand is a bit weak, and my serve could do with improving. . .Q as opposed to bIm such a fantastic tennis player who should have been at Wimbledon. . .Q). With such modularised extreme self-aspects, it is easy to see how the currently dominant self-aspect would be part of a feedback system that maintained overly positive or overly negative mood states; furthermore, the dominance of a positive self-aspect (i.e. the dominant active Schematic Model in SPAARS) in mania would not prevent automatic processes occurring in currently non-dominant negative self-aspects (i.e. the Associative level in SPAARS). Such processes would appear to operate for example as if there was a bmanic defenseQ, but SPAARS would equally predict the opposite bdefenseQ, the bdepression defenseQ against mania if the same logic was followed. Rather than go down this line however, the SPAARS proposal is that so-called phenomena such as the bmanic defenseQ merely reflect multi-level processes in which some processes are conscious effortful and explicit, whereas in parallel other processes are automatic, effortless, and implicit. Even in individuals with hypomania, as Scott and Pope (2003) have shown, there are raised levels of both positive and negative self-esteem on a straightforward self-report measure, so an account based on schematic and automatic processes seems preferable to one based solely on a defensive process. In the meantime, it is clear that in bipolar individuals this dysfunctional self-organization represents part of the recurring vulnerability to the disorder. The clinical and psychotherapeutic implications are likely to be considerable and well worth further exploration. One explicit proposed application of the SPAARS model to bipolar disorders has been made by Steven Jones (2001), a summary of which is presented in Fig. 6. Jones has suggested that within SPAARS, the Analogical system becomes disrupted in a number of ways such as through circadian rhythms changing, an increase in energy, the experience of a positive event, and so on. This change at the Analogical level then feeds into the Schematic Model, Association, and Propositional Levels. For example, at the Schematic Model level a positive model of hypomania, models of feeling superior, or simply a relief that a depressed episode has finished, can begin to exacerbate and set up positive feedback loops around all of the systems. At the Associative level automatic appraisals and biases learned from previous experiences feed into the creation and perception of further experiences (e.g. further enforced sleep deprivation and drug and alcohol abuse in an attempt to maintain the positive high whilst reducing negative aspects arising from exhaustion, etc.); whilst at the Propositional level propositions of the form bI feel good, creative, attractive. . .Q abound and again form part of the positive feedback loops that serve to maintain and exacerbate the initial state of change at the Analogical level. Jones (2001) adaptation of SPAARS for bipolar disorders provides an excellent starting point within which to model some of the phenomena of the bipolar disorders. However, it is clearly not the whole story, as we have suggested recently. Power and Schmidt (2004) have also tried to develop the emotion theory side of SPAARS in order to cover additional aspects of bipolar disorders. Part of the original SPAARS formulation (Power & Dalgleish, 1997) is that not only do positive feedback loops arise within emotion modules but that they can also arise between modules such that emotions themselves can

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SCHEMATIC MODEL Positive view of mania Feelings of superiority MANIA-LINKED EMOTIONS

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ANALOGICAL SYSTEM EVENT Circadian System Disruption; Increased Energy ASSOCIATIVE LEVEL Automatic appraisals, biases MANIA-LINKED EMOTIONS

PROPOSITIONAL I feel good, creative, attractive ...

Fig. 6. Jones adaptation of the SPAARS model for bipolar disorders.

become coupled and set up positive feedback loops between each other. Our original analysis, noted above, included the proposal that unipolar depression may consist of the coupling of sadness and disgust. In the case of mania, then happiness (elation) can become coupled with one or more other basic emotions, such as sadness in mixed states, anxiety in dysphoric mania, and anger in irritable/aggressive episodes. One of the possible implications of the coupling proposal in SPAARS is that, as Johnson et al. have recently suggested (e.g. Cuellar et al., 2005), the correlation of mania and depression may not represent the nosological entity that the terms bbipolar disorderQ or bmanic-depressionQ imply, but, rather, may simply represent co-morbidity. In other words both mania and depression clearly can occur without each other (e.g. approximately 25% of individuals diagnosed with bipolar disorders never experience significant depression); the proposal in SPAARS is that the correct level of description of emotional disorders should begin with the basic emotions and their tendency to couple with each other; just as episodes of depression may be analysed within SPAARS as couplings of sadness and disgust or sadness and anxiety, so, equivalently, episodes of mania may be better analysed as couplings of happiness and anger, happiness and anxiety, or whatever, thereby reflecting the fact noted in the Introduction that most so-called manic states are actually bmixed statesQ when symptoms are carefully assessed (Cassidy et al., 1998). We are currently engaged in an assessment of basic emotions in bipolar disorders that should address these predictions. One further point that can be made about the SPAARS approach to mania is that the fast-changing appraisals that occur because of high risk taking and self-created events may lead to fast-changing emotion couplings, but these emotions tend to be experienced in an bimmersedQ way rather than in a selfreflective way (Dalgleish & Power, 2004a). We have recently argued that the conscious experience of emotion can vary according to whether the individual retains a self-reflective capacity during the emotion experience (e.g. a high level schematic model of bI am now having a panic attackQ) versus becomes completely immersed in the emotion and does not maintain a reflective capacity (e.g. bdeath by panicQ in which automatic sequences are dominant). Part of the therapeutic endeavour in working

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psychologically with mania must be therefore to help reinstate self-reflective schematic models of the self in order to interrupt the automatic positive appraisals and action sequences that Barnard (2003, 2004) has also recently commented on in the ICS approach. In terms of the limitations of the SPAARS approach, similar to the ICS model, the application of SPAARS to the bipolar disorders is recent; it remains to be seen therefore whether or not it merely provides a very flexible framework in which to re-describe the phenomena of bipolar disorders. At a theoretical level, the fact that it has so much explanatory power in that it can be applied to all normal emotions and to all emotional disorders might make it unfalsifiable as a framework because different specific theories can be incorporated; however, we are not of the view that it is unfalsifiable in that key components and putative processes lead to very clear predictions about emotional conflict, the coupling of emotions, the modularisation of emotions, the implications for the self-concept, and the nosological derivation of emotional disorders. The SPAARS approach does at least begin to offer the level of intricacy needed for complex disorders such as the bipolar disorders, but at the same time the unique clinical features of the bipolar disorders have not yet been clearly and explicitly modeled, though work by Jones (2001) has presented an important first step in this direction. Nevertheless, the real test of the usefulness of SPAARS as a theory will be whether or not it makes testable empirical predictions, whether it adds to our understanding of these disorders, and, ultimately, whether it has implications for clinical practice. As Power and Schmidt (2004) have suggested, we believe that there are important empirical and clinical implications of the SPAARS model for both unipolar and bipolar disorders, but these implications remain to be fully tested.

7. Final points and conclusions A very crude attempt to summarise some of the strengths and weaknesses of each model has been presented in Table 1, with each of the 5 main models assessed against the three overarching criteria listed in the Introduction. It is clear that different models have different strengths and weaknesses and, equally, there are many other criteria, or more detailed criteria against which the models can be tested. As apparent from Table 1, our conclusion is that current multi-level models of cognition and emotion, specifically, the ICS and the SPAARS models, provide the best ways forward for the foreseeable future. Although neither ICS nor SPAARS were specifically developed to account for the bipolar disorders, their recent applications to these and to other disorders illustrate the potential strengths, empirical predictions, and therapeutic implications that these models may have. Moreover, these multi-level

Table 1 A summary of the adequacy of the 5 main theories evaluated in terms of three summary criteria Clinical features of BD BIS/BAS Cognitive Therapy IPSRT ICS SPAARS Low Medium High Medium Medium Theoretical adequacy Low Medium Low High High Applicability to normal and abnormal High Medium Low High High

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approaches provide explanations or readily incorporate other phenomena such as the bmanic-defenseQ, circadian dysrhythmias, mixed affective states, changes in the self-concept, and so on. In summary, psychological approaches to bipolar disorders have reached the starting line; it is hoped that something of both the potential and the excitement for developments in this area have been conveyed in this paper. For too long, the bipolar disorders have been abandoned to simplistic biological approaches. In place of this simplicity, there is now the opportunity to look at the complex interactions between biological, psychological, and social processes, for indeed all three types of processes are closely involved in the vulnerability, onset, recovery, relapse, and periodicity in these disorders. There is one area of research that integrates the biological, the psychological, and social better than any other, and that is in the study of emotion. At one and the same time emotions are essentially biological for they are rooted in the biology of our own and other species, they are psychological and can preoccupy consciousness like no other experience, and they are social in that they arise in social situations more than in any other. It is hoped that the summary of these five different psychological approaches to the bipolar disorders has conveyed something of the strengths and weaknesses of each, while providing pointers to future directions that this burgeoning area of research and clinical need should take.

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