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Are dysfunctional attitudes elevated and linked to mood in bipolar disorder? A meta- analysis and systematic review Post Graduate Conference 2022 Chloe Woods

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Chloe Woods at University of Southampton
Chloe Woods
Thomas Richardson at University of Southampton
Thomas Richardson
Emma Palmer-Cooper at University of Southampton
Emma Palmer-Cooper
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Abstract

Describes a meta-analysis on dysfunctional assumptions in Bipolar Disorder.
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Are dysfunctional attitudes
elevated and linked to mood
in bipolar disorder? A meta-
analysis and systematic
review
Post Graduate Conference 2022
Chloe Woods
Supervisors Thomas Richardson and Emma
Palmer-Cooper.
23rd June 2022
2
Overview
•Introduction
–What are DA and how they present in Bipolar
–Aims of the review
•Method
•Results
–Meta-analysis
–Narrative synthesis
•Discussion
•Clinical implication & Limitations
•Questions
3
What are Dysfunctional Attitudes?
If others dislike
you, you cannot
be happy
A person should
do well at
everything he
undertakes
I am nothing if a
person I love
doesn’t love me
My life is wasted
unless I am a
success
DAS-24, Power et al.,
1994
4
Dysfunctional Attitudes in Depression
•Elevated (Keller, 1983) and linked to more depressive
episodes (Otto Et al., 2007).
•DA can predict future depressive symptoms and severity
(Kërqeli et al., 2013; Wang et al., 2010).
•Characteristic (Fresco et al., 2006) or mood dependent in
depression (Pearson & Miranda, 2002)?
5
Dysfunctional Attitudes in Bipolar
•Mixed findings about the prevalence of DA in BD
–Higher scores for ‘goal attainment’ DA for Bipolar (Lam et al., 2004)
–DA scores higher in BD population vs unipolar depressed and HC
(Batmaz, et al., 2013).
–No significant difference in DAS scores between BD, UP and HC
(Alatiq et al., 2010).
•Mixed findings about the influence of mood
–Goldberg et al., (2008) reported significant associations between
mania symptoms and increased DA scores. (not dep)
My life is
wasted unless
I am a success
6
Aims
1. explore the presence DA in BD vs a comparison group
2. identify any associations and provide a narrative review of DA
in BD and reported relationships between mood & DA
3. to review the methodological quality of the studies;
4. explore evidence for psychological therapy on DA in BD
5. to reflect upon current research/ implications/
recommendations for future research in BD and DA.
7
Method
•Databases = Medline, PsycInfo and Web of Science
•Search terms =
–‘bipolar’ AND
–“dysfunctional attitude*” or “dysfunctional belie*” or
“dysfunctional assum*” or “negative cognitions” or
“maladaptive belie*”
8
Method- Inclusion/ Exclusion
Inclusion Exclusion
Any study design
Reviews, meta
-analyses,
abstracts, commentaries
Participants diagnosed with BD
No formal diagnosis (DSM, ICD)
Participants 18+
Child/ adolescent studies
Peer reviewed journal
Non standardised
Written in English
Data collected during or post
intervention
Standardised measure for DA +
Mood (means + SD)
Statistical results not raw data
(means, SD, sample size)
At least two group (BDI vs BDII /
BD vs HC)
9
Method- PRISMA
Total Papers Produced
N = 323
Titles/Abstracts screening
N = 161
Full paper screening
N = 77
Total papers included
N = 47
Meta-analysis
N = 23
Narrative review
N = 47
10
Method
•Quality assessment tool
–National Heart Lung and Blood Institute (NHLBI; 2014) Quality
Assessment Tool for Observational Cohort and Cross-Sectional
Studies
•Effect size computation
–Random effects meta-analysis using RevMan (2020) to identify
SMD between groups
–Group means, SD and sample size (Borenstien et al. 2009).
–DAS total scores to avoid Type I error.
11
Results- Meta-analysis
•No difference was observed between BD and unipolar
participants (d= -0.16).
•A significant mean difference was found between BD and
healthy controls (d= 0.70).
12
Results- Meta-analysis
•Mood state in BD- a SMD was found between DA scores for
euthymic vs. depressed participants (d= -0.71).
•3 studies included in the meta-analysis were suggestive of
lower DA in those who had engaged in psychological therapy
compared to TAU.
13
Results- Narrative Synthesis
•DA are a characteristic of BD that is not as prevalent in
healthy populations
•Initial studies are in support of psychological therapies being
effective at reducing DA in BD.
•DA are higher in depressed individuals with BD when
compared to other mood states (euthymic, manic, mixed).
•Using the DAS mania does not correlate with increased DA
14
Discussion
•DA are not unique to unipolar depression as previously
thought (Keller, 1983; Abela & D'Alessandro, 2002), but also
are not more extreme in bipolar depressive episodes.
•The severity of DA are dependent on a individuals state,
rather than just a trait of their diagnosis (Person & Miranda,
2002).
•Remains mixed evidence whether DA can predict mood
episode in BD
•High heterogeneity of studies
15
Limitations
•Limited hand searching
•Data extraction for full papers reviewed
•Fair or poor quality studies
•Lack of longitudinal studies
•No analysis of subscales (DAS)
Clinical implications/ Future research
•DA are most active when individuals are depressed,
treatment targeting this phase of illness
•Limited understanding of DA and mania phase of BD
•Need for further longitudinal studies
16
References
Abela, J. R., & D'Alessandro, D. U. (2002). Beck's cognitive theory of depression: A test of
the diathesis‐stress and causal mediation components. British Journal of Clinical
Psychology, 41(2), 111-128.
Alatiq, Y., Crane, C., Williams, J. M. G., & Goodwin, G. M. (2010). Dysfunctional beliefs in
bipolar disorder: Hypomanic vs depressive attitudes. Journal of Affective Disorders, 122(3),
294- 300. https://doi:10.1016/j.jad.2009.08.021
Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy,
1(1), 5–37.
Borenstein, M., Hedges, L. V., Higgins, J. P., & Rothstein, H. R. (2021). Introduction to
metaanalysis. John Wiley & Son.
Fresco, D. M., Heimberg, R. G., Abramowitz, A., & Bertram, T. L. (2006). The effect of a
negative mood priming challenge on dysfunctional attitudes, explanatory style, and
explanatory flexibility. British Journal of Clinical Psychology, 45(2), 167-183.
https://doi.org/10.1348/014466505X35137
Goldberg, J. F., Gerstein, R. K., Wenze, S. J., Welker, T. M., & Beck, A. T. (2008).
Dysfunctional attitudes and cognitive schemas in bipolar manic and unipolar depressed
outpatients: Implications for cognitively based psychotherapeutics. Journal of Nervous and
Mental Disease, 196(3), 207-210. https://doi:10.1097/NMD.0b013e3181663015
Keller, K. E. (1983). Dysfunctional attitudes and the cognitive therapy for depression.
Cognitive therapy and research, 7(5), 437-444.https://doi.org/10.1007/BF01187171
17
Kërqeli, A., Kelpi, M., & Tsigilis, N. (2013). Dysfunctional attitudes and their effect on
depression. Procedia-Social and Behavioral Sciences, 84, 196-
204.https://doi.org/10.1016/j.sbspro.2013.06.534
Lam, D., Wright, K., & Smith, N. (2004). Dysfunctional assumptions in bipolar disorder.
Journal of affective disorders, 79(1-3), 193-199. https://doi.org/10.1016/S0165-
0327(02)00462-7
Otto, M. W., Teachman, B. A., Cohen, L. S., Soares, C. N., Vitonis, A. F., & Harlow, B. L.
(2007). Dysfunctional attitudes and episodes of major depression: Predictive validity and
temporal stability in never-depressed, depressed, and recovered women. Journal of
abnormal psychology, 116(3), 475. https://doi.org/10.1037/0021-843X.116.3.475.
Persons, J. B., & Miranda, J. (2002). Treating dysfunctional beliefs: Implications of the mood-
state hypothesis. Clinical advances in cognitive psychotherapy: Theory and application, 62-
74
Power, M. J., Katz, R., McGuffin, P., Duggan, C. F., Lam, D., & Beck, A. T. (1994). The
Dysfunctional Attitude Scale (DAS): A comparison of forms A and B and proposals for a new
subscaled version. Journal of research in personality, 28(3), 263-276.
https://doi.org/10.1006/jrpe.1994.1019.
Review Manager Web (RevMan Web). Version 5.4. The Cochrane Collaboration, (2020).
Available at revman.cochrane.org
Wang, C. E., Halvorsen, M., & Eisemann, M. (2010). Stability of dysfunctional attitudes and
early maladaptive schemas: A 9-year follow-up study of clinically depressed subjects.
Journal of behavior therapy and experimental psychiatry, 41(4), 389-396.
https://doi.org/10.1016/j.jbtep.2010.04.002
References cont.
YOUR QUESTIONS
ResearchGate has not been able to resolve any citations for this publication.
Treating dysfunctional beliefs: Implications of the mood-state hypothesis
Article
Full-text available
  • Jan 1991
  • J Cognit Psychother
The mood-state hypothesis proposes that underlying dysfunctional beliefs are more available for therapeutic interventions when patients are in a negative mood state than when they are in a positive mood state. After briefly reviewing evidence supporting the mood-state hypothesis, this article offers recommendations for treating dysfunctional beliefs. First, when patients begin therapy in a clinically depressed state, we recommend working on underlying dysfunctional beliefs early in treatment when the presence of negative mood enhances the patient's ability to report the beliefs. Second, when symptoms have remitted, mood is positive, and underlying beliefs are not readily reported, we discuss four ways to obtain information about the underlying beliefs: direct accessing strategies, the therapeutic relationship, homework, and the case formulation. Finally, when patients experience recurrent pronounced mood shifts, we recommend teaching them to anticipate corresponding shifts in thinking.
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Dysfunctional Attitudes and Their Effect on Depression
Article
Full-text available
  • Jul 2013
An experimental design attempted to examine changes in the dysfunctional attitudes in participants with and without depressive symptomatology following negative and positive mood induction and tested whether dysfunctional attitudes predicted symptoms of depression after one month. In the study took part one-hundred sixty undergraduate students in Kosovo. Results indicated that there was a slight decrease after negative mood priming in the level of dysfunctional attitudes for both groups of participants; however, after positive mood priming there was an increase for both groups. Nonetheless, hierarchical regression analysis results revealed that the model of prediction with the level of dysfunctional attitudes after both priming conditions and the group of depressive symptomatology explains a proportion of variance in depression 28.7% (ΔR2= .24, Fchange(3, 91) =10.655, p < .001). Findings suggest that negative mood priming is not a successful procedure in eliciting dysfunctional attitudes and that there is no difference based on depressive symptomatology in the increase of dysfunctional attitudes after mood priming. Further attention needs to be paid to the effects of positive mood priming. Nevertheless dysfunctional attitudes predict symptoms of depression, thus supporting Beck‘s model but the level of dysfunctional attitudes assessed after positive mood priming predicted symptoms of depression in a negative linear direction pointing to differences in findings and questioning the universality of the cognitive model of depression across cultures.
View
Dysfunctional Attitudes and Episodes of Major Depression: Predictive Validity and Temporal Stability in Never-Depressed, Depressed, and Recovered Women
Article
Full-text available
  • Aug 2007
In a large, community-based sample of women (N = 750), the authors examined the nature of associations between dysfunctional attitudes and depression. Dysfunctional attitudes were evaluated both as a vulnerability factor for depression and as a consequence of depression. A link was found between past depression and baseline elevations in dysfunctional attitudes that was independent of current subsyndromal symptoms, but intensification of dysfunctional attitudes following prospectively evaluated episodes of depression (depressive "scarring") was not observed. Although baseline dysfunctional attitudes predicted an episode of major depression over 3 years of prospective study, this prediction, considered alone or in interaction with negative life events, was redundant with that offered by history of past depression. Further, no significant prediction was evident for the Dysfunctional Attitude Scale (A. N. Weissman & A. T. Beck, 1978) when the formerly depressed and never-depressed cohorts were considered separately. Implications for cognitive theories are discussed.
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Cognitive models of depression
Article
  • Nov 1986
  • J Cognit Psychother
Argues that the variety of ways in which cognitive processes in depression have been conceptualized warrant the presentation of 6 models. The cross-sectional model states that the systematic negativity that pervades the cognitive processes is a necessary (but not sufficient) component of depression. The structural model stipulates that certain negatively biased schemas become hypervalent in depression and produce a systematic bias in the abstraction and interpretation of data. The stressor-vulnerability model stipulates that specific patterns of schemas make a person sensitive to specific stressors. The reciprocal-interaction model focuses on interaction with key figures. The psychobiological model integrates cognitive processes and biological processes as different sides of the same coin. The evolutionary model views depression as an atavistic mechanism or program that may have been adaptational in a prehistoric environment but is not adaptive in our current milieu. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Dysfunctional Attitude Scale (DAS): A Comparison of Forms A and B and Proposals for a New Subscaled Version
Article
  • Sep 1994
Presents 2 studies which attempt to produce a scaled version of the DAS (A. N. Weissman and A. T. Beck, 1979). In the 1st study, a combined sample of depressed and formerly depressed Ss (aged 18–65 yrs) and the Ss 1st-degree relatives completed either Form A or B of the DAS. Factor analyses of the 2 sets of data suggest that the 2 versions of the DAS are not equivalent when a wide range of respondents are sampled. A 2nd study presents information about a 24-item version of the DAS which can be used to rate achievement, dependency, and self-control. Such subscales may be the preferred way of pursuing possible vulnerability factors, rather than seeking more global effects. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Dysfunctional attitudes and cognitive therapy for depression
Article
  • Oct 1983
Nineteen depressed community volunteers received a replication of the cognitive therapy group treatment used by Shaw (1977). Two groups were created based upon a median split of pretreatment scores on the Dysfunctional Attitude Scale (Weissman & Beck, Note 1). The Beck Depression Inventory, Hamilton Rating Scale for Depression, Hopelessness Scale, and Social Adjustment Scale were administered prior to and following a 4-week treatment and following a 4-week follow-up. Subjects with higher initial levels of dysfunctional attitudes evidenced a poorer response to the treatment than their attitudinally more functional counterparts. This result was robust and held over a residual gain scoring procedure. Results lend support to the hypothesis that dysfunctional attitude level acts as a general psychopathological indicator.
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Stability of dysfunctional attitudes and early maladaptive schemas: A 9-year follow-up study of clinically depressed subjects
Article
  • Apr 2010
The Dysfunctional Attitude Scale (DAS) and the Young Schema Questionnaire (YSQ) have been suggested as relatively stable vulnerability markers for depression and entrenched psychological disorders, respectively. One-hundred-and-forty-nine clinically depressed (CDs), previously depressed (PDs) and never-depressed subjects (NDs) completed the DAS, the YSQ and the Beck Depression Inventory in the index study and were followed-up nine years later. Results showed: (1) Elevated scores in CDs and PDs as compared to NDs; (2) Some stability of depressive symptoms; (3) Significant moderate test-retest correlations for DAS scales and YSQ scales Disconnection and Impaired Limits, also after controlling for depression severity; (4) A significant reduction in mean score for DAS total, Approval by Others and YSQ scales Disconnection and Impaired Limits; (5) Significant correlations between DAS and YSQ scales. Our results support a state-trait vulnerability model of depression comprising stable differences in availability of dysfunctional attitudes and early maladaptive schemas, but also fluctuating differences in accessibility of those schemas during the course of depression. The findings point to the significance of the YSQ scales as vulnerability markers for depression in addition to the more established DAS scales.
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Dysfunctional beliefs in bipolar disorder: Hypomanic vs. depressive attitudes
Article
  • Sep 2009
To date the effect of cognitive behavioural therapy modified for bipolar disorder has been inconsistent and sometimes disappointing. However studies exploring cognitive style in bipolar disorder have not identified the unique patterns of beliefs specific to bipolar disorder. The current study examines whether Mansell's hypomania-related dysfunctional belief scale specifically identifies bipolar disorder patients. Forty remitted bipolar patients, twenty remitted unipolar patients and twenty healthy controls completed the Hypomanic Attitudes and Positive Prediction Inventory (HAPPI) and the Dysfunctional Attitude Scale (DAS). The remitted bipolar group scored higher than the unipolar and healthy control groups on the HAPPI scale overall score and on three subscales that measured self-catastrophic beliefs, beliefs related to negative responses from other people when in elevated mood and beliefs related the response style to activation and elevation. The study finds evidence of unique dysfunctional beliefs elevated only in remitted bipolar patients. Such findings could be used to inform the development of a specific cognitive behavioural therapy for bipolar disorder.
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Beck's cognitive theory of depression: A test of the diathesis-stress and causal mediation components
Article
  • Jul 2002
This prospective study tested the diathesis-stress and causal mediation components of Beck's (1967, 1983) cognitive theory of depression. In order to allow for a stringent test of the aetiological component of Beck's theory, we used a short-term longitudinal design in which participants' dysfunctional attitudes were assessed prior to the occurrence of a negative event. In all, 136 high school seniors applying to the University of Pennsylvania completed measures of depressed mood and dysfunctional attitudes 1-8 weeks before receiving their admissions decision (Time 1). The assessment of dysfunctional attitudes was preceded by a priming task designed to activate latent depressogenic schemata. Participants also completed measures of depressed mood, negative views of the self, and negative views of the future shortly after they received their admissions decision (Time 2) and four days later (Time 3). Consistent with the diathesis-stress component of Beck's theory, dysfunctional attitudes predicted increases in depressed mood immediately following a negative admissions outcome (Time 2). In addition, consistent with the causal mediation component of the theory, in negative outcome students, the relationship between dysfunctional attitudes and increases in depressed mood was mediated by negative views of the future. Contrary to predictions, however, this relationship was not mediated by negative views of the self. In addition, contrary to predictions, dysfunctional attitudes did not predict enduring depressed mood after a negative outcome (Time 3). Individuals with dysfunctional attitudes are likely to show increases in depressed mood following the occurrence of negative events. The relationship between dysfunctional attitudes and increases in depressed mood following the occurrence of negative events is mediated by negative views of the future.
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The effect of a negative mood priming challenge on dysfunctional attitudes, explanatory style, and explanatory flexibility
Article
  • Jul 2006
Ninety-seven undergraduates, 48 of whom had a history of self-reported major depression, completed measures of mood and cognitive style (e.g. explanatory style, explanatory flexibility, dysfunctional attitudes) prior to and directly after a negative mood priming challenge that consisted of listening to sad music and thinking about an upsetting past event. Eighteen of the previously depressed participants endorsed baseline levels of depression, explanatory style for negative events, and dysfunctional attitudes higher than levels reported by never depressed participants or euthymic participants with a history of depression. All three groups (never depressed participants, dysphoric participants with a history of depression, euthymic participants with a history of depression) demonstrated increases in dysphoria and dysfunctional attitudes in response to the negative mood priming challenge. Dysphoric participants with a history of depression, but not the other two groups, evidenced modest increases in explanatory style following the negative mood priming challenge. Finally, euthymic participants with a history of depression, but not the other two groups, evidenced drops in explanatory flexibility. Findings from the present study suggest that the cognitive theories of depression may benefit from examining both cognitive content and cognitive flexibility when assessing risk for depression.
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