Behavioural and Cognitive Psychotherapy, 2007, 35, 515–539Printed in the United Kingdom First published online 27 June 2007 doi:10.1017/S1352465807003827

The Interpretation of, and Responses to, Changes in InternalStates: An Integrative Cognitive Model of Mood Swings

and Bipolar Disorders

Warren Mansell and Anthony P. Morrison

University of Manchester, UK

Graeme Reid and Ian Lowens

Early Intervention Services, Bolton, Salford & Trafford Mental Health NHS Trust, UK

Sara Tai

University of Manchester, UK

Abstract. A cognitive approach to understanding mood swings and bipolar disorders isprovided, with the interpretation of changes in internal state as a central explanatory factor.The model explains how attempts at affect regulation are disturbed through the multipleand conflicting extreme personal meanings that are given to internal states. They promptexaggerated efforts to enhance or exert control over internal states, which paradoxicallyprovoke further internal state changes, thereby feeding into a vicious cycle that can maintainor exacerbate symptoms. Counterproductive attempts at control are classified as eitherascent behaviours (increasing activation), or descent behaviours (decreasing activation). Itis suggested that appraisals of extreme personal meaning are influenced by specific sets ofbeliefs about affect and its regulation, and about the self and relations with others, leading toan interaction that raises vulnerability to relapse. Pertinent literature is reviewed and foundto be compatible with such a model. The clinical implications are discussed and compared toexisting interventions.

Keywords: Mania, hypomania, depression, cognitive behavioural therapy, informationprocessing, goal conflict.

Introduction

Bipolar disorder typically represents a severe and enduring mental health problem involvingperiods of extreme disruptions to mood, behaviour and cognitive functioning. People with the

Reprint requests to Warren Mansell, Lecturer in Psychology, School of Psychological Sciences, Coupland I, Universityof Manchester, Oxford Road, Manchester M13 9PL, UK. E-mail: warren.mansell@manchester.ac.uk

© 2007 British Association for Behavioural and Cognitive Psychotherapies

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disorder typically experience periods of severe depression, mania or hypomania, in additionto periods of relatively stable mood. However, even during periods of so-called “remission”sufferers can still display mood swings and sub-clinical symptoms (Judd et al., 2002, 2003).Rates of relapse remain high, despite use of medication, with approximately 50% of individualsrelapsing within a year (Solomon, Keitner, Miller, Shea and Keller, 1995).

Bipolar I disorder, characterized by a history of mania and depression, is thought to have aprevalence of at least 1.5% (American Psychiatric Association, 1994; Bebbington and Ramana,1995), although some argue that as many as 6.5% of the population have symptoms that aresevere enough to cause significant disruption to daily living, and would qualify for a diagnosisof a bipolar spectrum disorder, which includes bipolar II disorder, cyclothymia and bipolardisorder not-otherwise-specified (Angst, 1998). A significant number of those with the disorderexperience a severe decline in occupational and social functioning, potentially leading to greatpersonal and financial loss. The overall impact can be vast for sufferers, their relatives, and thewider community. For example, it is estimated that within the UK, the cost of bipolar disorderto society in 2001 amounted to £2 billion, 85% of which can be accounted for through indirectcosts such as unemployment and premature mortality (Das Gupta and Guest, 2002).

Despite the impact of bipolar disorders, current understanding of the mechanisms involvedis limited. Several commentators have noted that primacy has been given to hypotheticalbiological factors in attempts to provide an understanding of causal factors (e.g. Scott, 1995).However, increasing evidence has emerged that emphasizes the importance of psychologicalfactors in the development and maintenance of the disorder. We aim to briefly summarizefour of the most prominent accounts (which overlap with one another to some degree), moveon to explain a novel approach built upon the previous theories, followed by a focus uponimplications for a focused psychological intervention.

From the 1980s onwards (Depue et al., 1981; Depue, Krauss and Spoont, 1987; Johnsonet al., 2000), a series of authors have proposed that bipolar disorders can be explained by theincreased sensitivity of a neuropsychological system governing reward-seeking behaviour:termed the behavioural activation system (BAS; Gray, 1972, 1994). It is proposed thatindividuals vulnerable to the disorders have more sensitive and reactive regulatory systems,leading to increased vulnerability to extreme mood variations. Johnson and colleagues (Lozanoand Johnson, 2001; Johnson et al., 2000; Johnson, Ruggero and Carver, 2005) have suggestedthat “goal-attainment life events” are likely to trigger this system, resulting in increases inmanic symptoms; they provide some evidence to support this proposal. In turn, several authorshave proposed that dysfunctional beliefs relating to extreme goal-attainment, perfectionismand need for approval may interact with these life events and further raise the risk of an episode(Johnson et al., 2005; Wright and Lam, 2004).

A second approach has focused on the disruption of circadian rhythms: biological cyclesgoverning sleep, activity levels and other intrinsic drives. Disruption is thought to occur whenthe environmental cues that influence the pattern of the cycles are disturbed by the disruptionof normal routines as a result of pharmacological, environmental or interpersonal events, asmight occur following stressful life events (Meyer, Johnson and Winters, 2001; Wehr, Sack,Rosenthal, Duncan and Gillin, 1983; Wehr, Sack and Rosenthal, 1987). The consequence isthought to be a neuropsychological state characterized by elevated arousal and psychomotoragitation. Extending circadian rhythms theory, Jones (2001) provided an elaborate cognitiveframework that expanded upon an early proposition by Healy and Williams (1989). Jones(2001) suggested that during the development of mania, neuropsychological symptoms may

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be appraised in ways that are positive and self-dispositional rather than situational (e.g. “Myfast thinking is a sign of my inherent intelligence and creativity”), thus leading to behavioursthat further disrupt rhythms and feed into a vicious cycle of escalating symptoms.

In a third line of work, Bentall and colleagues (Bentall, 2003; Lyon, Startup and Bentall,1999) further examined the idea of cognitive style in bipolar disorders, reviving a modified formof the manic-defence hypothesis (Abraham, 1911). Abraham initially stated that depressionand mania represented different response styles to a common problem, with people becomingmanic in the process of trying to avoid the experience of depression (Bentall, 2003). Accordingto this approach, depressed and bipolar patients have a similar ruminative style of coping withdepression, but people with bipolar disorders also tend to employ the additional strategy ofbehavioural risk-taking, which is thought to contribute to the specific symptoms of mania (e.g.Knowles, Tai, Christensen and Bentall, 2005; Knowles, Tai, Jones, Morriss and Bentall, 2006;Thomas and Bentall, 2002).

In a fourth line of work, clinicians have noted the tendency for cognitive style during maniato be opposite to that of depression; for example, the self is perceived as creative, talentedand superior in contrast to slow, worthless and unlovable, and the perception of unlimitedfuture possibilities replaces a view of the future that is hopeless and pessimistic (Beck, 1967;Leahy and Beck, 1988). It is proposed that the cognitive biases have subsequent effects onmood and behaviour that contribute to manic symptoms. In a related account, Leahy (1999)has articulated how biases of this kind can be viewed within a theory of decision-making(portfolio theory) as examples of high risk-preference.

Each of the above approaches has advanced the understanding of the role of psychologicalmechanisms in bipolar disorders, and informed the related psychological interventions (e.g.Basco and Rush, 1996; Lam, Jones, Hayward and Bright, 1999; Leahy, 2005; Newman,Leahy, Beck, Reilly-Harrington and Gyulai, 2002; Scott, Stanton, Garland and Ferrier, 2000).However, many of the constructs implicated in these models remain hypothetical and offerplausible but incomplete accounts of the wide range of symptoms involved in the disorder. Forexample, there is a difficulty with theories placing an emphasis on behavioural components(such as behavioural activation, disruption to daily rhythms, and coping strategies) withoutspecifying the role of the implicated cognitive mechanisms. Emphasis has also been placedon explaining mechanisms leading to mania that do not adequately explain how people maketransition from one phase to another (e.g. from mania to depression), or account for theprocesses involved in mixed episodes. Furthermore, the complexity of these models potentiallylimits the extent to which they can be applied in clinical situations to help people become moremindful of their cycles of mood, cognition and behaviour. Consequently, we aim to outlinean approach grounded in existing cognitive behavioural theory, which is sufficiently simpleto ease the process of creating collaborative formulations, while being versatile enough toaccount for the multiple experiences associated with bipolar disorders. We first summarize themodel and then elaborate in detail on each component and the evidence relating to it.

Interpretations of and responses to changes in internal state: an integrative model

Recent developments in the cognitive conceptualization of anxiety disorders and psychosishave incorporated the occurrence and interpretation of intrusions. These advances in theoreticalunderstanding have resulted in new and refined clinical approaches to intervention. In additionto the seminal work of Beck (1967) and the more recent work of leading theorists in the

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anxiety disorders field (e.g. Clark, 1999; Salkovskis, 1991; Wells and Matthews, 1994), ourapproach has been specifically influenced by two further recent theoretical developments: themetacognitive conceptualization of psychosis (Morrison, 2001) and the conceptualizationsof cognitive and behavioural processes common to a range of psychological disorders(“transdiagnostic” processes: Harvey, Watkins, Mansell and Shafran, 2004). These approachesto the cognitive conceptualization of mental health problems suggest that such difficulties(whether psychotic or not) are characterized by similar themes: intrusions into awareness(such as body state information, affect, thoughts and images, or external sensory input)that are appraised in a problematic manner (commonly involving some kind of catastrophicmisinterpretation). These appraisals, which are influenced by beliefs that have been formedas the result of life experiences, also influence the selection of potentially unhelpful strategiesfor self-regulation, which may consequently contribute to mood destabilization.

We aim to apply these conceptualizations to the phenomenology of mood swings byproposing a new cognitive model of bipolar disorders. This model is not, and cannot bepurely disorder-specific, as it specifies a mechanism for the maintenance and escalation ofmood fluctuations that vary dynamically over time. Thus, although the model would mostclosely apply to bipolar disorders, it would also help to explain sub-clinical mood swings andmood fluctuations in other conditions such as anxiety disorders. We suggest that the mannerin which mood fluctuations express themselves over time will determine the diagnosis thatthe individual receives at that stage. Consistent with this approach, longitudinal studies revealthat a diagnosis of bipolar disorder is relatively unstable over time (Chen, Swann and Johnson,1998; Forrester, Owens and Johnstone, 2001). Furthermore, while mood fluctuations clearlycharacterize bipolar spectrum disorders, they are also significant features of schizoaffectivedisorder (APA, 1994), borderline personality disorder (APA, 1994), some anxiety disorders(e.g. Bowen, South and Hawkes, 2004), and sub-clinical hypomanic populations (e.g. Hofmannand Meyer, 2006). Therefore we would expect the model to be useful when working with eachof these groups, in addition to conceptualizing mood fluctuations in superficially non-affectivepsychoses (cf. Krabbendam and van Os, 2005). We regard this transdiagnostic utility as astrength of the model, considering the increasing evidence that the key cognitive mechanismsmaintaining psychological symptoms are common to a range of disorders (Harvey et al., 2004).For the sake of simplicity we will refer to “bipolar disorder” throughout this paper from thispoint onwards, but the model applies to a much wider population.

In the first stage of the model, intrusions into awareness (i.e. changes in internal state inphysiological, emotional or cognitive domains) are misinterpreted as signifying extreme per-sonal meaning. Not only are these appraisals extreme, but they are multiple and contradictory,and therefore unresolved with respect to one another. Only one appraisal occupies awarenessat any one time, but they have the capacity to switch with one another as the cycle evolves.In this respect, the model is consistent with dynamic models of behaviour, cognition and theenvironment that emphasize reciprocal change over time (e.g. Bandura, 1977).

The appraisals include interpretations of the internal state as a sign of an imminentcatastrophe, a personal success, or a personal weakness. Feared catastrophes may often focusupon concerns regarding the personal consequences of an impending episode of depression ormania. Predictions of imminent personal success typically involve the potential triumph overprevious experiences of depression, adversity and failure. Appraisals of personal weaknesstypically involve attacks directed at the self that relate to the state of activation, e.g. “I shouldbe ashamed of myself for getting so agitated”.

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According to the model, the appraisals of internal states as signifying extreme personalmeaning trigger immediate efforts at exerting control to either prevent the catastrophe,reach safety, or attain personal success. These behaviours interfere with any opportunitiesto reappraise the internal state or to resolve the conflicting appraisals with respect to oneanother.1 Individuals may literally feel as though their “self ” is changing as they switchbetween these contradictory personal appraisals.

The responses can be conceptualized in several ways. First, in relation to negative predictions(i.e. either catastrophic views of depression or manic episodes) such coping responses couldbe defined as safety-seeking behaviours (Salkovskis, 1991). While these behaviours wouldbe intended to avoid catastrophic events, they can be counterproductive, as in the case of“antidepressive behaviours” (see Morrison, Peyton and Nothard, 2003). However, in additionto this explanation, behavioural responses may also be conceptualized as either “ascent”behaviours (Mansell and Lam, 2003) or “descent” behaviours. Ascent behaviours are carriedout to try to enhance or control the activation level of the internal state and they contributeto increases in activation levels. Examples include increased involvement in activities andprojects, risk-taking, alcohol and other drug use, extended wakefulness, seeking of socialstimulation, and the dismissal of others’ attempts to moderate behaviour. Descent behavioursare carried out to try to enhance or control the activation level of the internal state and contributeto decreases in activation levels. Examples include social withdrawal and isolation, extendedsleep, rumination and self-critical thinking.

The model proposes that the appraisal of changes in internal state, and the associateduse of ascent/decent behaviours, are influenced by a range of factors, including: personalbeliefs regarding the self and others; procedural beliefs regarding information processingstrategies (e.g. the advantages and disadvantages of rumination); and beliefs about affectiveand physiological states (e.g. positive and/or negative beliefs about depression: Reid, 2005).Such beliefs are likely to be affected by past life experiences, and ongoing current events.

The model is illustrated graphically in Figure 1. The inter-relationships between thecomponents demonstrate how escalation of symptoms occur, with a cycle of change in internalstate, distorted appraisal, and attempts to control or enhance that contribute to further alterationsin internal state, leading eventually to experiences that confirm dysfunctional beliefs. Itis suggested that the cycle develops via an iterative process, with each factor becomingprogressively amplified, manifesting as escalating symptoms within affective, physiological,cognitive and behavioural domains. Thus, at different phases (e.g. remission, prodromes,depression, mania, mixed states), the components of the model will vary in degree and content.Each part of the model will now be elaborated in detail with a discussion of evidence relevantto each component.

Changes in internal state

The model is dynamic, and driven by the individual and so can be “entered” at any point(see Figure 1). However, it makes most sense clinically and for descriptive purposes to start

1A more elaborate model of conflict and control in psychopathology is beyond the scope of this paper, but readersare referred to Mansell (2005) for an explanation of how the CBT approach can be conceptualized under a broaderconceptual framework, known as Perceptual Control Theory (Powers, 1973, 2005).

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Figure 1. A cognitive model of mood swings and bipolar disorders

at the top of the diagram with an event that triggers a change in internal state. For example,the opportunity provided by a carnival in town could prompt a reaction of excitement, or theingestion of several cups of coffee could prompt an increase in arousal. The nature of thetrigger can be varied; it is the change in internal state that it prompts or allows that is key.The change in state might be a change in mood, arousal, cognition (e.g. thoughts racing) orperceived behaviour (see Table 1).

The model suggests that people with bipolar disorder would experience fluctuations intheir internal state prior to episodes of intense affect change, and this fluctuation increasesthe likelihood of a cognitively driven cycle of escalating symptoms. As such, the modelis consistent with evidence that people with bipolar disorder experience considerable affectchange outside episodes of clear mania or depression (Judd et al., 2002, 2003; Perugi, Toni,Travierso and Akiskal, 2003).

We emphasize that the changes in internal state experienced by people with bipolar disordersare on a continuum with mood fluctuations found in other clinical samples and non-clinicalpopulations. For example, hypomanic experiences are reported by a range of individualswith no clinical conditions, including undergraduate students (Depue, Krauss, Spoont andArbisi, 1989; Udachina and Mansell, 2007), individuals with a “hypomanic personality style”(Eckblad and Chapman, 1986), naturally short sleepers (Monk, Buysee, Welsh, Kennedy andRose, 2001) and high functioning individuals past the peak age of onset of bipolar disorder(Seal, Mansell and Mannion, in press).

The above proposal needs to be qualified to some degree. The cyclical, escalating, natureof the model predicts that internal state, in tandem with escalations in appraisal and behaviour

Cognitive

modelofbipolar

disorders521

Table 1. The key components of the cognitive model of mood swings and bipolar disorders

Name of component Definition Subcategories Examples

Change in internalstate

Intrusions into awareness of the current qualityof perception of the mind or body

MoodPhysiologyCognition

“High”, “low”, “sad”, “irritable”“Buzzy”, “restless”, “agitated”“Thoughts racing”, “moving quicker”

Appraisal of extremepersonal meaning

Attaching extreme personal significance tocurrent changes in internal state

Self-successSelf-criticalSocial approvalOther-NegativeCatastrophic

“I have the energy to do anything I want”“I am making a fool of myself ”“I can make everyone around me admire me”“Other people are trying to control me”“I am about to lose control of my mind”

Ascent behaviours Behaviours aimed at enhancing or controllinginternal states (because of their extremepersonal meaning) that have the effect ofincreasing the state of activation

InternalPhysicalBehaviourSocial

Recurrent goal setting and ideation, worryIngest stimulating substances, extended wakefulnessDo things quicker, act on spur of momentSeek out people to influence, ignore advice

Descent behaviours Behaviours aimed at enhancing or controllinginternal states (because of their extremepersonal meaning) that have the effect ofdecreasing the state of activation

InternalBehaviourSocial

Rumination, self-critical thinking, suppressionReduce activityWithdraw from other people, increased dependence

Beliefs about affectregulation, theself and others

Underlying metacognitive beliefs that areformed from experience, accessible duringdifferent states, and influence on-lineappraisals of internal states

Affect regulation

Self

Others

“I cannot cope feeling sad even for a short while”“If I feel good, I must act on the feeling straight way”“When I am energized I know that I am a very

important person”“When I feel good, other people do not understand me”

Life experiences Events in the outside world that contribute tobeliefs, changes in internal state, and areinfluenced by the observable effects ofascent and descent behaviours

Early

Ongoing

Trauma, failure experiences, experiences of “hypingself up” to overcome adversity

Other peoples responses to changes in behaviour, e.g.encouragement, worry, neglect, anger, constraint

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change, could reach proportions that appear qualitatively different, yet emanate from a similardynamic cycle to those that contribute to minor mood swings. At extreme states of mood andarousal, information processing may become biased considerably and further contribute to aperson’s difficulties in stepping outside the cycle (cf. Steel, Fowler and Holmes, 2005; Clarkand Sahakian, 2006). For example, heightened distractibility associated with arousal may beincompatible with the sustained, controlled attention necessary to engage in the contextualprocessing of experiences. These potential neuropsychological factors are beyond the scopeof the current article, yet demonstrate an integrative capacity of the model on which we aim toelaborate in future work. A further consideration is whether certain genetic factors predisposeto more pronounced changes in internal state that raise the risk for developing bipolar disorder.This possibility would be consistent with the model.

Changes in internal state interpreted as having extreme personal meaning

In the next stage of the model (see Figure 1), a change in internal state is subject to interpretationby the individual. This interpretation is characterized by extreme positive and negative personalmeanings that have a significant propensity for conflict. These appraisals are at the heart of themodel; they direct behavioural responses that are themselves perceived and appraised, servingas the “online” mediators of underlying beliefs.

As described earlier, Healy and Williams (1989) were the first to highlight the findings thatcircadian rhythm disruption leading to a state of psychomotor activation and agitation couldthen form the basis of self-relevant appraisals. They focused on appraisals relating to positivepersonal traits. For example, an increase in the subjective rate of the speed of thinking could beinterpreted as a sign of great intelligence, wit and natural intuition. Until recently, no studieshave tested this hypothesis.

Our current model is consistent with Healy and Williams’s (1989) approach, but emphasizesa wider range of extreme, conflicting, self-relevant appraisals. It is proposed that extremepersonal appraisals are not limited to states of high activation, but that states of relative lowactivation such as tiredness and fatigue may also activate important beliefs (e.g. “Withoutthe energy to do important things, my life has no purpose”: see also Jones, 2001), as mightfeelings of sadness (“I cannot cope with being sad even for a short while”). In addition toextreme positive meanings, states of high activation may receive self-critical and catastrophicpersonalized meanings (“When I get overexcited, I am always arrogant and overbearing” and“When I feel happy it is a sign I am about to lose control of my mind”). Note that these appraisalsmay, or may not turn out to have some truth in them: people with bipolar disorders do relapse.However, the model suggests that these appraisals are nonetheless functionally disruptivebecause they contribute to a cycle of escalating processes and can become self-fulfilling.Moreover, many individuals with bipolar disorder make these catastrophic predictions basedon limited evidence, such as a brief change in energy levels, rather than basing them ona balanced, contextualized analysis of their experiences. It is the consistency between theappraisal and the evidence used to support it that is extreme rather than the absolute, potentialtruth value of the statement.

It is also likely that idiosyncratic meanings would be invoked by other feelings, such asfrustration (e.g. “When I feel irritated I am convinced that other people are trying to controlme”). Thus, the model suggests that multiple, conflicting appraisals of internal states areavailable; therefore the appraisals change over time in tandem with the dynamic changes in

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internal state, behaviour and responses from others. The extreme appraisals often reflect animage of an “imminent possible self ” derived from earlier experiences stored in memory, ina similar way to those reported in other conditions such as social phobia and agoraphobia (foran overview, see Holmes and Hackmann, 2004). For example, Mansell and Lam (2004) foundthat people with bipolar disorder reported recurrent, distressing memories of themselves whenthey were in the depths of depression, or feeling viewed as a failure by others. The empiricalevidence for the sensory self-relevant information associated with the appraisals of extremepersonal meaning within the model is elaborated further in another article (Mansell andHodson, in preparation).

The direct evidence for the appraisals proposed in the model will be reviewed here. Mansell(2006) selected five categories: Self-Activation, Self-Catastrophic, Other-Positive, Other-Negative and Response-Style. Each of these categories had a good level of internal consistency.They formed the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI). The firsttwo categories directly involve extreme personal appraisals of internal states (e.g. “When I feelmore active I realise that I am a very important person”; “When I feel agitated and restless itmeans that I am about to have a breakdown”). The two categories of beliefs about others werealso of extreme personal relevance (e.g. “When I feel really good, people don’t understandme”; “When I feel excited I know that other people desire me”). Individuals with bipolardisorder scored higher on this scale, and each of the subscales, than a matched non-clinicalcontrol sample. This finding was replicated in a more extensive study that controlled for currentsymptoms (Mansell and Jones, 2006).

Jones, Mansell and Waller (2006) tested a similar hypothesis with a scale that they coinedthe Hypomanic Interpretations Questionnaire (HIQ). This scale measures the tendency forindividuals to make personal attributions for the signs and symptoms of hypomania (e.g. “IfI felt in high spirits and full of energy, I would probably think it was because I am a talentedperson with lots to offer”). Individuals vulnerable to bipolar disorder, and those reportinga diagnosis of bipolar disorder, were found to score significantly higher on this scale thanmatched non-clinical controls.

Behavioural components

Ascent behaviours

Ascent behaviours (see Figure 1) are triggered by extreme personal appraisals of alterationsin internal state. They contribute to heightened activation levels that are themselves perceivedand appraised. Ascent behaviours are critical to the capacity of the cycle to escalate symptoms.For example, a person who experienced racing thoughts and who subsequently believed thatthey are extremely intelligent would be more likely to dominate social interactions and ignorenegative feedback from others. Ascent behaviours are goal-focused; yet they contribute to thedevelopment of manic symptoms (Mansell and Lam, 2003). For example, a person’s reactionto the consequences of dominating social interactions is likely to be affected by a confirmatorybias associated to their primary interpretation (e.g. “I am supremely intelligent; other peoplehave to struggle to keep up”). Other people may consequently be viewed as incompetent,and the normal processing of social cues that might moderate extreme behaviour (e.g. looksof disquiet; explicit requests to slow down) will be disrupted. Other examples of ascentbehaviours include: extended wakefulness; increased rate of activity; generating multiple

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ideas and goals, the seeking of social stimulation; and the dismissing of others’ attemptsto moderate behavioural changes. Similarities exist in the concept of ascent behaviours andexamples of poor coping strategies (e.g. “continue to move about and take on more tasks”)that have been associated with relapse into mania (Lam, Wong and Sham, 2001).

Research into antidepressive behaviours (behaviours intended to prevent depression) appearsto provide some evidence for our central assertion of a specific tendency for amplifiedbehavioural responses to internal states in people with bipolar disorder. For example, Morrisonet al. (2003) reported associations between self-reported frequencies of antidepressivebehaviours and predisposition to mania in a non-patient sample. Increased reports of activecoping (e.g. keeping busy) and social coping (e.g. talking to a friend) were also associatedwith a greater predisposition to mania. In addition, Morrison et al. (2003) reported that“active coping” as a solution to low mood was negatively correlated with current symptomsof depression, suggesting that these antidepressive behaviours may be effective in reducingnegative affect. This finding was replicated in a clinical sample (Morrison et al., 2006). Thelatter study found that currently depressed individuals with a bipolar diagnosis and non-patientsreported higher frequency of active coping than a unipolar-depressed group of participants.Although of considerable interest, further studies are required in order to explore the degreeof specificity of particular types of active coping to people with bipolar disorder.

Within the model, increased risk-taking would be viewed as a further example of ascentbehaviour. In non-clinical samples, hypomanic personality has been associated with self-reported risk-taking as method of coping with negative moods (Knowles et al., 2005, 2006;Thomas and Bentall, 2002). Although consistent with the model, further evidence would beneeded to clarify whether this coping style increased levels of subsequent activation and thusthe possibility of an episode of mania.

In most of the studies mentioned, the behavioural responses in bipolar disorder have beenassessed with self-report questionnaires. In contrast, Mansell and Lam (2006) investigateda specific ascent behaviour (i.e. the tendency for people with bipolar disorder when in anelevated mood state to ignore or dismiss advice) using an experimental paradigm. Participantswere either individuals with remitted bipolar disorder, remitted unipolar depression, or neverdepressed controls. They took part in a computerized paradigm assessing the use of adviceduring a goal-directed task before and after either a positive or negative mood induction. Peoplewith bipolar disorder were found to use less advice to inform their decisions after the positivemood induction, in contrast to never depressed controls and people with remitted unipolardepression. This study provides tentative evidence that certain ascent behaviours have the effectof reducing the influence of social feedback, which, if attended to, would serve the functionof assisting a person to moderate their feelings and behaviour according to the social context.

Descent behaviours

The alternative responses that could follow from extreme personal appraisals are behavioursthat contribute to lowered mood state, identified within the model as descent behaviours (seealso Mansell, Colom and Scott, 2005). These can form a further vicious cycle; for example,some people may appraise their feelings of sadness in an extreme way (“I will look pathetic andbe rejected by my friends”), contributing to a descent behaviour of avoiding social situations.Others may believe “I can only be productive when I am full of energy”, leading to otherdescent behaviours such as ceasing any activity and the initiation of prolonged periods of

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sleep. Such responses reduce the possibility of the discovery of disconfirmatory evidence,which contributes to their continued use. Our model would indicate that the behaviouralsymptoms that characterize bipolar depression are often the result of attempts to overcomeperceived aversive consequences of high or low mood states.

Recent research on unipolar depression has emphasized the role of “response style” inincreasing symptom severity and precipitating relapse. In particular, there is evidence thatrumination in response to low mood predicts increased severity of depressive symptoms(Nolen-Hoeksema and Morrow, 1991; Watkins, Teasdale and Williams, 2000; Watkins andTeasdale, 2001). Rumination involves recurrent thinking about the causes and implications ofnegative affect for the self. Several studies have found that vulnerability to bipolar disorders,as assessed by either self-report scales or familial risk, is correlated with high levels of self-reported rumination (Jones et al., 2006; Knowles et al., 2005, 2006; Thomas and Bentall, 2002).

Beliefs about self, world, others, affect and affect regulation

The beliefs illustrated in Figure 1 remain latent but can be accessed through introspection,questioning or situational context. The arrows in Figure 1 indicate that beliefs can determineboth the “online” appraisals during different internal states and the choice of behaviours used tocontrol, sustain or enhance them. Furthermore, life experiences and everyday events contributeto these beliefs in an ongoing fashion.

Regarding beliefs about the self, world and others, several studies have shown thatindividuals with bipolar disorder report attitudes that are equivalent to those of people withunipolar depression (Lam, Wright and Smith, 2004; Scott et al., 2000; Scott and Pope, 2003;see Mansell and Scott, 2006, for a thorough review). It is of particular interest as to whether aproportion of these beliefs are more specific to bipolar disorder, and would therefore contributeto the appraisals that drive the central aspect of our model. Some evidence exists indicatingthat these beliefs focus upon extreme personal goals. For example, Lam et al. (2004) foundthat individuals with bipolar disorder scored higher on goal-attainment beliefs than a unipolarsample. In a separate study, such beliefs were maintained in individuals with remitted bipolardisorder after a positive mood induction, whereas they dropped in individuals with a historyof unipolar depression, indicating that extreme personal beliefs may have a capacity to endurethrough states of elevated mood, a finding that does not apply to people without bipolardisorder (Wright, Lam and Strachan, 2006). Lam, Wright and Sham (2005) assessed theextent to which patients with bipolar disorder value and perceive that they possess a range ofpositive self-dispositional traits (e.g. dynamic, creative, successful) using a new measure - theSense of Hyper-Positive Self Scale. They found that patients who had scored higher on thisscale prior to treatment showed increased rates of relapse of hypomania or mania. Finally, inan analogue study, Johnson and Carver (2006) found that individuals who are vulnerable tomania report higher aspirations for fame, wealth, and political influence.

In the model, beliefs regarding internal states are thought to guide appraisals of internalchanges, leading to the further alterations in affect, and the activation of procedurally guidedbehavioural responses. The role of beliefs about affect and its regulation has received relativelylittle attention in the research literature to date. However some supportive evidence exists.

In a non-clinical sample, Reid (2005) found correlations between predisposition to mania (asmeasured by the Hypomanic Personality Questionnaire; Ekblat and Chapman, 1986; Kwapilet al., 2000), and both negative and positive beliefs about depression (e.g. “If I get depressed I

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will never achieve anything”; “When I get depressed I see the world as it really is”). Negativebeliefs about emotion such as “My emotions can be harmful”, and “My emotions are incontrol of me” were also found to be associated with a greater predisposition to mania. This isconsistent with our suggestion that global beliefs regarding affect, rather than beliefs limitedto depression, may contribute to affect instability.

In focusing upon the influence of procedural beliefs upon behavioural responses, Mansell(2006) found that a set of beliefs concerning “response style” differentiated people withbipolar disorder and non-clinical controls. This scale included items such as “When I feelgood, I must keep ‘on the go’ all the time or things will fall apart around me”, and “I need tohave complete control over my moods in order to prevent myself from having a breakdown”.Such beliefs would be predicted to be triggered by changes in internal state and contribute tothe maintenance behaviours in the model.

Morrison et al. (2003) found that current depression was associated with low levels ofbelief in the use of social coping as a way of preventing depression in a non-clinical sample.Interestingly, this study failed to find any associations between self-reported beliefs aboutantidepressive behaviours and predisposition to mania, despite having found associationsbetween frequencies of antidepressive behaviours and predisposition to mania, as discussedearlier. In contrast, Morrison et al. (2006) found that people with bipolar disorder weremore likely to believe that both distraction and active coping would prevent depression whencompared to people with unipolar depression and non-patient participants.

In relation to unipolar depression, there is evidence of associations between metacognitivebeliefs and ruminative thinking (e.g. Papageorgiou and Wells, 2003). There is also someevidence that procedural beliefs about cognitions are implicated in bipolar disorder. Taylor,Morrison and Bentall (2006) examined whether there were differences between manic,depressed and remitted bipolar participants (and non-patient controls). They found that bipolar-depressed and bipolar-manic participants showed higher levels of unhelpful thought controlstrategies (as assessed by the Thought Control Questionnaire; TCQ; Wells and Davies, 1994)when compared with non-patients. In addition, bipolar-depressed participants and, to a lesserextent, bipolar-manic participants showed higher levels of dysfunctional metacognitive beliefs(as assessed by the Metacognitive Cognitions Questionnaire; MCQ; Cartwright-Hatton andWells, 1997), in comparison with remitted bipolar participants and non-patient controls.

Perhaps unsurprisingly, there are some inconsistencies in the findings of studies examiningprocedural beliefs. Procedural subroutines often operate outside of awareness and maytherefore be difficult for people to identify and report (Wells and Mathews, 1994). In clinicalpractice, it can often be necessary to infer (via guided discovery) the content of proceduralbeliefs by observing consistencies in response styles to particular stimuli.

Life experiences and current environment (including the reactions of other people)

Our model incorporates life events that occur at three different stages: early independent eventsthat contribute to dysfunctional beliefs (starting from the box labelled life events in Figure 1);partially independent events that follow on from the effects of ascent and descent behavioursand contribute to internal state changes and beliefs (arrows to and from the box in Figure 1);and dependent events that occur as a consequence of the spiralling of the vicious cycle overmany iterations (i.e. occur as a result of an episode of significantly heightened, or loweredmood).

Cognitive model of bipolar disorders 527

Early independent life events

As with “severe mental illness” in general (e.g. Mueser et al., 1998), a history of early traumais common amongst people with bipolar disorder (e.g. Hyun, Friedman and Dunner, 2000;Kennedy et al., 2002; Leverich et al., 2002; Fox, 2005). Typically, such research has focusedon childhood physical and sexual abuse, with a common finding that increased severity ofabuse history appears to be associated with poorer clinical outcomes (e.g. Leverich et al.,2002; Neria, Bromet, Carlson and Naz, 2005).

Recently, evidence has emerged that a wider range of adverse early experiences may beassociated with the development of bipolar symptoms. In a non-clinical sample, Reid (2005)found that predisposition to mania was associated with a history of childhood emotional abuse,physical abuse, emotional neglect and physical neglect. Of these factors, reports of emotionalabuse were found to be the best predictor of predisposition to mania. Interestingly, there wasno association between a history of childhood sexual abuse and predisposition to mania.

In a clinical study, Fox (2005) studied childhood trauma and parental bonding in three groupsof individuals: those with a history of mania with positive symptoms of psychosis; those witha history of mania without such symptoms; and a non-patient control group. Seventy-onepercent of the clinical sample reported a history of childhood abuse, compared to 20% in thecontrol group. Low levels of maternal care and protection were found to significantly predictlifetime prevalence of mania, with emotional abuse approaching significance as predictor oflifetime prevalence.

Partially independent life events

These are events that emerge during the cycle of escalating symptoms within the model.Reviews of the literature on stressful life events leading up to episodes in bipolar disorderindicate that they precede relapse at similar rates to that found in unipolar depression (seeJohnson, 2005; Johnson and Roberts, 1995). Our model proposes a finer differentiation ofthe role of life events in that it is important to differentiate two different pathways throughwhich experiences contribute to the cycle (see Figure 1). This is either by direct influenceupon internal state (the dotted line in Figure 1), or through confirmation of extreme personalappraisals of the internal state (the unbroken line in Figure 1). Experiences of the first typewould include events that disrupt circadian rhythms (e.g. night-shift work), events that involvethe ingestion of psychoactive substances (e.g. substance use), and experiences of heightenedexternal stimulation (e.g. nightclubs). A retrospective study found that mania was significantlymore likely to be preceded by events that disrupt circadian rhythms than depression (Malkoff-Schwartz et al., 1998).

Experiences of the second kind include attainment or failure at personal goals (e.g. gettingmarried, losing a job), and the negative and positive responses of others (e.g. criticism, praise).Importantly, behaviour from others that also reflects an extreme appraisal that is personalisedto the individual would have the capacity to feed into the cycle. For example, close familymembers may appraise small changes in behaviour as signalling an imminent breakdownand respond in critical or overprotective fashion. This kind of response in family membershas been found to predict relapse (Miklowitz, Goldstein, Nuechterlein, Snyder and Mintz,1988). Other individuals, often recent acquaintances, may appraise the change in behaviourin an extremely positive manner, responding in ways that appear to endow the individual

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with high status and power. In response, the individual’s current appraisals are polarized intoeither sharing or contradicting those of others, but rarely are the appraisals directly tested forevidence or integrated with one another. This aspect of the model also helps explain how thecurrent appraisals are maintained and change dynamically over time.

Dependent life events

When a person has experienced the vicious cycle illustrated in Figure 1 many times, thistypically constitutes an “episode”. This leaves in its wake a series of potentially damaginglife events, such as hospital admission, broken relationships, and stigmatization. According tothe model, these experiences trigger further belief changes. For example, information given toservice users about the diagnosis, and poorly implemented psychological interventions, mayconfirm or amplify catastrophic beliefs about affect change, and encourage hypervigilancefor changes in internal states that have been identified as “early warning signs”. Catastrophicinterpretations based on limited evidence, the consequent affect, and the subjective senseof either success or failure of behavioural responses may lead to intensification of affect,as previously outlined in the model. A similar process has been described in the psychosisliterature (see Gumley et al., in press).

Summary of the model

We have proposed a new cognitive model of mood swings and bipolar disorders in somedetail, alongside relevant evidence. Individuals with bipolar disorders experience changesin their internal state that are then appraised as having one of a range of extreme positiveand negative personal meanings. Within an escalating cycle, appraisals can be activating(ascent behaviours) or deactivating (descent behaviours), with consequent impact on mood.Thus appraisals and the subsequent selection of behavioural response are determined byunderlying beliefs about the self, the world, others, and also affect and its regulation. Thesebeliefs have their origins in early independent life experiences, but are subject to changeover time through life experiences, some of which occur as a consequence of the behaviouralresponses. As the cycle escalates in a self-perpetuating manner, these life experiences caninclude the damaging social effects of an episode of mood disorder. The model allows bothfor individual differences in genetic predisposition to internal state changes, and describespotential alterations in information processing style as individuals move round the cycle, yetit is the underlying beliefs and the conflict between them that is seen to drive mood swingsand the development of mood symptoms. The nature of current symptoms will be a complexresult of the previous experience of going through past vicious cycles, the nature of differentunderlying beliefs available, and the current environment.

How does the model account for the course and symptom profile of bipolar disorder?

Models of bipolar disorder need to address certain key features: the symptom profile of mania,including mixed states and psychosis; symptoms of depressive episodes; the temporary resol-ution of manic symptoms; and the occurrence of sub-clinical symptoms between episodes. Asa full explanation of our model has been provided, we will now focus upon exploring its abilityto coherently account for these specific points. Ultimately, an accurate prediction of the course

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and symptoms of bipolar disorders would only be possible from dynamic simulations of themodel over time; however, the following section provides some of the more likely associations.

Symptom profile of mania

There is emerging consensus that there are multiple dimensions of manic symptoms thatextend beyond the classic diagnostic symptoms. Factor analytic investigations have identifiedbetween four and seven components of mania that are very similar between studies (e.g.Akiskal, Azorin and Hantouche, 2003; Cassidy, Forest, Murry and Carroll, 1998; Rossi et al.,2001). For example, one well-controlled study identified five factors: dysphoria (includinganxiety); psychomotor agitation/activation; irritability/aggression; elevated hedonic tone; andpsychosis (Cassidy et al., 1998). Even studies that have excluded mixed states have identifieda similar factor structure (Akiskal et al., 2003; Rossi et al., 2001). Thus, it is clear that thestate of mania involves a heterogenous mixture of emotional states, both positive and negative,although there appears to be a core internal state of high activation.

As mentioned, our model is based on the notion that people with bipolar disorder makeextreme personal appraisals of changes in their internal state, and respond by striving toexert control. Many of these appraisals (as related to mania) are based on beliefs that statesof high activation lead to extreme personal success and the ability to overcome major lifeproblems. The central consequence of these appraisals is to trigger behaviours that increaselevels of activation, which explains these individuals’ specific vulnerability to this core featureof mania. However, a further set of beliefs, likely to be shared with other disorders, involvesthe intolerance or catastrophic appraisal of depressed mood and other negative affective states.Thus, individuals will strive to suppress these feelings with states of high activation and positiveaffect (in a way that is consistent with the depression-avoidance hypothesis). Nevertheless,whether current affect is positive, negative, or a mixture of each will depend upon the extremepersonal appraisals that are made of the current situation.

According to our model, it is likely that mixed states of affect are the norm rather thanthe exception, as differing components of the model can be present simultaneously. Forexample, extreme negative beliefs about the consequences of depressed mood could co-occurwith ascent behaviours directed at raising mood, such as striving to amuse other people, ortaking substances that raise mood temporarily. Similarly, states of high activation, appraisedas signalling extreme success leading to elevated mood, can co-exist with irritability andaggression stemming from interpreting others’ comments as controlling rather than caring.The model states that individuals with bipolar disorder have mixed, conflicting beliefs abouttheir internal states (e.g. that activated feelings indicate both possible future success andcatastrophe) rather than having one maladaptive belief. The fact that different features of themodel can occur simultaneously also explains findings of mixed positive and negative selfesteem during hypomania (Scott and Pope, 2003) and explicit high self-esteem co-occurringwith implicit low self esteem (Lyon et al., 1999).

In relation to psychotic experiences/symptoms, it is expected that voices/unusual beliefs arelikely to develop in people who made specific kinds of appraisals about the content of theirthoughts during the vicious cycle, especially when they have the opportunity to spiral roundunchecked, thereby exacerbating the changes in internal state, extreme personal meaning andbehaviour. Morrison (2001) has proposed that the identification of psychosis is characterized bythe person holding culturally unacceptable (and potentially extremely distressing) appraisals

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of their intrusions, which would be likely to trigger a further vicious cycle of appraisal,behaviour and subsequent further intrusions. Morrison’s (2001) model serves as a supplementto the current model in attempting to explain the psychotic features of mania. There are alsolikely to be neurophysiological consequences of the spiralling process that increase the risk ofpsychosis (e.g. deficits in sustained attention), but we propose that these deficits are insufficientto fully explain psychotic symptoms (see also Kapur, 2003; Steel et al., 2005).

The temporary resolution of mania

Currently, episodes of mania tend to be identified and addressed relatively quickly by healthservices with psychotropic medication and, in extremes, forced constraint. Subsequently, dueto such rapid responses, little is known about whether manic episodes naturally “burn out” ifleft untreated. The model predicts that the core components to treat in order to lead to long-termresolution of symptoms are the beliefs that feed into the extreme personal appraisals of thechanges in internal state. However, most interventions focus on either reducing the emissionof overt (but not internal mental) behaviours (i.e. constraint) or calming the internal state(i.e. medication). These interventions are sufficient to circumvent the vicious cycle of ascentand reduce symptoms of mania in the short to medium term. However, such interventionspermit internal mental behaviours (e.g. rumination) about the now de-activated internal stateto continue (see also Mansell et al., 2005). The experience of lack of control in the faceof threat (i.e. of relapse) is likely to lead to a sense of entrapment, which has been shownto be highly associated with depression in a non-clinical sample (Gilbert and Allan, 1998).These individuals would remain vulnerable to another episode of mania when they experienceincreases in activation in the future; the high risk of relapse even with medication supportsthis view (e.g. Solomon et al., 1995). In contrast, the model suggests that people who manageto circumvent their ascent into mania by addressing the extreme appraisals will considerablylower the probability of further relapse.

Symptoms of depressive episodes

First, it is important to note a proportion of individuals within the general population (whotherefore have not come to the attention of clinical services) fulfil the criteria for a diagnosis ofbipolar disorder yet do not report episodes of depression, i.e. they have unipolar mania (Kessler,Rubinow, Holmes, Abelson and Zhao, 1997). For some individuals, the lack of depression hasbeen confirmed when they are followed-up over long periods (Solomon et al., 2003). Classicbipolar disorder is thought to oscillate between depression and mania, yet there is emergingevidence that these two kinds of episodes are relatively independent (for a review, see Cuellar,Johnson and Winters, 2005). For many people, such as those diagnosed with bipolar II disorder,their condition is dominated by depression interspersed with episodes of hypomania (Juddet al., 2003). Our model is able to accommodate these findings, as it can provide an explanationof mood changes independent of depression, and yet its components have the capacity to clarifyhow depression can be maintained and exacerbated when triggered. Also, it is worth notingthat individuals who have never experienced depression may nevertheless have dysfunctionalbeliefs about states of negative affect, which form part of the model. The vulnerability todepression depends on the specific beliefs of the individual. Those who specifically appraisechanges in internal states in ways that trigger descent behaviours (e.g. rumination over the

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causes of low mood, or isolation in order to attempt to prevent a relapse) would be predictedto experience depressive symptoms (see also Mansell et al., 2005).

Sub-syndromal symptoms

Prospective studies over several years have indicated that individuals with bipolar disorderexperience depressive symptoms between 30 to 50% of every day, in addition to occasionalsubclinical hypomanic symptoms (Judd et al., 2002; 2003). Our model suggests that the lack ofresolution of past episodes (i.e. the preservation of key dysfunctional beliefs regarding internalstates) accounts for the occurrence of these sub-syndromal experiences. As long as a personcan remain within a relatively narrow range of changes in internal state, they can prevent fullescalation of the cycle leading to relapse. However, a range of symptoms, including anxiety,depression, and occasional hypomania would also be predicted as the cycle switches betweenascent and descent behaviours while in between episodes. This may account for the mixedpattern of explicit positive and implicit negative self esteem found during remitted states(Winters and Neale, 1985). It is proposed that most individuals in between episodes preventthe onset of mania by descent behaviours, such as social withdrawal, self-critical rumination,excessive dependency, or taking excessively high levels of medication. Sub-clinical depressivesymptoms, in addition to anxiety symptoms, are likely to follow from the use of these kinds ofdescent behaviours. Of course, using descent behaviours to prevent relapse could be regardedas considerably more functional than risking a manic relapse, although the model indicatesthat they contribute to the long-term maintenance of sub-clinical symptoms.

Clinical implications of the model

There are several clinical implications of the model that will be summarized here.

Existing interventions within CBT

The cognitive model presented here is consistent with the use of some strategies alreadyemployed in CBT for bipolar disorder, but we suggest that they may currently have limitedeffectiveness. For example, the identification of prodromes and coping strategies can be veryconstructive if close attention is paid to the differences between normal changes in internal stateand genuine clinical symptoms, and if attention is paid to whether the client feels confidentregarding their ability to follow detailed action plans. However, if the distinction is blurred orambiguous, or the client lacks confidence, then people may instead receive evidence for theirdysfunctional belief that all moods need to be controlled for fear of imminent relapse. In turn,they would engage in ascent or descent behaviours to try control normal changes in internalstate, and paradoxically escalate symptoms. The model is also consistent with the developmentof strategies to achieve goals that do not require high levels of activation, such as problem-solving and activity scheduling. However, without directly testing the belief that internal statessignal imminent success or catastrophe, then clients may again remain vulnerable to ascentand descent behaviours when these states are triggered following relevant life events.

In contrast to many existing approaches, the cognitive model presented here indicates theuse of a range of experiential interventions that can target the underlying beliefs and relatedbehaviours that are maintaining the disorder. These interventions do not, however, attempt to

532 W. Mansell et al.

change mood or reduce symptoms directly. In accordance with the model this can reinforce thedysfunctional belief that internal states must be controlled or a catastrophic outcome will occur.We propose that problems emerge from the vicious cycle between internal state, appraisal,behaviour and experience, rather than from any one of these factors in isolation.

Assessment and formulation

The first stage of intervention that directly follows from this model is the joint development ofthe formulation itself, which provides a perspective on clinical symptoms that will be new tomost patients and normalizing in its continuity with everyday experiences. This first stage isclearly critical because it allows the therapist and client to map out the key factors and agree onthem before direct interventions is carried out. Indeed, part of the inspiration for this model it-self has been drawn from collaborative formulations with clients (e.g. Mansell and Lam, 2003).

Cognitive techniques

There are a range of relatively simple interventions that are derived from the formulation usingSocratic dialogue. For example, the therapist and client can discuss the conflicted beliefs aboutinternal states, e.g. comparing pros and cons of being in a high, energetic mood. The aim isnot for the therapist to get the client to give up high moods altogether, but to encourage themto notice and take responsibility for their contradictory beliefs about them. The appraisals ofinternal states can be directly addressed by allowing the client to describe the internal state indetail and generate less extreme interpretations. Often it is helpful to explore the origins of theextreme beliefs to consider how they were formed, and whether they still apply now, or whetherthere are exceptions. For example, one client learned that her agitation was a consequence ofher attempts to control her anxiety by pacing around.

Cognitive-experiential techniques

The key experiential intervention is very similar to cognitively-oriented exposure in anxietydisorders (see Clark, 1999; Bennett-Levy et al., 2004). We suggest that the key to effectivetreatment is to help the client to learn to accept normal fluctuations in internal state bychallenging their extreme appraisals, and by helping the client experiment with replacingascent and descent behaviours with responses that do not contribute to escalating symptoms(these could be termed “balance” behaviours). For depression this may involve continuing withtheir normal routine rather than isolating themselves and ruminating and observing the long-term effects. For hypomania, this may involve practising inhibiting ascent behaviours and, forexample, allowing other people to take control of challenging situations to test the outcome.

The role of attention to internal states is very important within treatment adhering to thismodel. Clients are encouraged to acknowledge their internal state during problematic situationsand focus on it without attempting to control it. A behavioural response may therefore involveactively choosing not to act, and to mindfully experience the change in mood. This “mindful”stance may promote the spontaneous reorganization of internal experience, and can often revealother intrusive material that can be tackled with techniques such as imagery, restructuring,and narrative formation (see Arntz and Weertman, 1999; Grey, Young and Holmes, 2002;Hackmann and Holmes, 2004).

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It should be stressed that at all stages the treatment is collaborative and formulation-led.The current model is therefore best applied during euthymia, anxiety states, depression andmild hypomania, but not during acute mania. Clients in states of acute risk, such as duringmania, who may be experiencing suicidal ideation, aggressive behaviour and counterproductivelevels of substance-abuse would be treated using therapeutic approaches specifically designedto target these behaviours. Nevertheless, outside immediate situations implicating risk, thecurrent model can be used to address the beliefs and behavioural patterns that may contributeto states of acute risk in the long-term. Additional research and development is required toevaluate and further refine these techniques.

A full illustration of the model in use within a single case is provided in the associated web-based document on the journal website (available online in the table of contents for this issue:http://journals.cambridge.org/jid_BCP) and in a recent published case study (Mansell, 2007).

Conclusions

The present model provides a coherent framework that can be used to help clients meaningfullyintegrate the various factors associated with potentially chaotic experiences related with bipolardisorder. While it is consistent with earlier psychological accounts and draws on each ofthem to some degree, it provides a novel, highly focused account to guide formulation-basedtreatment. Key beliefs regarding internal state changes have been identified as contributing tothe occurrence of complex patterns, cycles of affect, and behavioural change. It is hoped thatour model will provide therapists with increased confidence in relation to understandingand intervening in ways that will minimize clients’ hopelessness and entrapment, andmaximize the probability of successful recovery. Over time, we hope that CBT based onthis conceptualization will allow clients to tolerate a greater variation in their internal states,and therefore broaden the “bandwidth” of situations in which they feel comfortable. We wouldlike to see clients benefit from the improvement in functioning that this would entail. Further,we hope that the model will evoke further discussion and provide multiple avenues for futureresearch.

Acknowledgements

Many people gave useful feedback and kind support to the first author on an earlier relatedmodel. They were: Jan Scott, Sheri Johnson, Richard J. Brown, Pasco Fearon, Steve Jones,Luke Clark, Phil Barnard, David M. Clark, Anke Ehlers, Frances Marshall, Geraldine Owen,Daniel Freeman, Elizabeth Kuipers, Dominic Lam, Paul Salkovskis, Jan Van Niekerk, andEdward Watkins. The authors would like to thank Nicholas Tarrier, Richard Bentall, theUniversity of Manchester and Bolton, Salford and Trafford Mental Health NHS Trust for theirfinancial and pastoral support.

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