Thought Suppression in Patients With Bipolar Disorder
David J. Miklowitz
University of California, Los Angeles,
and University of Oxford
Yousra Alatiq, John R. Geddes, Guy M. Goodwin,
and J. Mark G. Williams
University of Oxford
Suppression of negative thoughts has been observed under experimental conditions among patients with
major depressive disorder (MDD) but has never been examined among patients with bipolar disorder
(BD). Patients with BD (n ? 36), patients with MDD (n ? 20), and healthy controls (n ? 20) completed
a task that required unscrambling 6-word strings into 5-word sentences, leaving out 1 word. The extra
word allowed the sentences to be completed in a negative, neutral, or “hyperpositive” (manic/goal-
oriented) way. Participants completed the sentences under conditions of cognitive load (rehearsing a
6-digit number), reward (a bell tone), load and reward, or neither load nor reward. We hypothesized that
patients with BD would engage in more active suppression of negative and hyperpositive thoughts than
would controls, as revealed by their unscrambling more word strings into negative or hyperpositive
sentences. Under conditions of load or reward and in the absence of either load or reward, patients with
BD unscrambled more negative sentences than did controls. Under conditions of reward, patients with
BD unscrambled more negative sentences than did patients with MDD. Patients with BD also reported
more use of negative thought suppression than did controls. These group differences in negative biases
were no longer significant when current mood states were controlled. Finally, the groups did not differ
in the proportion of hyperpositive sentence completions in any condition. Thought suppression may
provide a critical locus for psychological interventions in BD.
Keywords: thought suppression, reward, hyperpositive thinking, mental control theory, cognitive biases
Most cognitive theories of mood disorder assume that there are
critical cognitive vulnerabilities that are an enduring feature of
people with a history of depressive disorders, even when in remis-
sion. However, in major depressive disorder (MDD), it has been
difficult to confirm the presence of negative schemas when pa-
tients are no longer depressed (Ingram, Miranda, & Segal, 1998).
Instead, negative schemas are most reliably observed when remit-
ted patients with a history of depression start to experience a
worsening of mood (Miranda & Persons, 1988). Wenzlaff and
Bates (1998) have argued that the negative schemas characteristic
of depression are being actively suppressed in a process of mental
control when patients with MDD are in remission. Patients with
MDD often report that they try to suppress negative thoughts to
maintain a desirable mood or repair an undesirable one (Wegner &
Wenzlaff, 1996; Wenzlaff, 1993).
interaction between two systems: (a) an intentional operating process
that seeks to promote preferred emotional states and direct attention
away from unwanted material and (b) an ironic monitoring system
that searches for signs of failure to reach the intended state. When the
capacity of the operating system is occupied or distracted by stress or
challenge, the monitoring system takes over, filling consciousness
itself, bringing to mind unwanted contents. Correspondingly, the
detection of negative cognition requires disruption of the process of
mental control (Wenzlaff & Bates, 1998).
In a study of depressed, at-risk, and nondepressed college stu-
dents, Wenzlaff and Bates (1998) asked participants to unscramble
six-word strings into five-word sentences, leaving one word out.
The sentences could be completed with either a positive or a
negative valence (e.g., “looks the future bright very dismal”).
Students at risk for depression could not be distinguished from
control participants on the proportion of negative sentences pro-
duced during the task. However, when a cognitive load was
introduced—students were required to rehearse a six-digit number
while unscrambling the sentences—the at-risk students produced
more negative sentences than did the control participants. At-risk
students also reported a greater use of thought suppression as a
coping mechanism. Thus, experimental disruption of mental con-
trol by introducing a cognitive load may reveal latent cognitive
vulnerabilities among persons with or at risk for depression. In the
current article, we aim to investigate whether similar processes
operate in bipolar disorder (BD).
Little is known about the role of thought suppression in patients
with BD. In a study of acutely ill patients with BD (Lyon, Startup,
David J. Miklowitz, Department of Psychiatry, Semel Institute, Univer-
sity of California, Los Angeles (UCLA), and Department of Psychiatry,
University of Oxford, Oxford, England; Yousra Alatiq, John R. Geddes,
Guy M. Goodwin, and J. Mark G. Williams, Department of Psychiatry,
University of Oxford.
This research was supported by Grant 067797 to J. Mark G. Williams from
the Wellcome Trust, National Institute of Mental Health Grant MH073871 to
David Miklowitz, and a faculty fellowship to David Miklowitz from the
University of Colorado’s Council on Research and Creative Work. We thank
Catherine Crane and Wendy Swift for their assistance.
Correspondence concerning this article should be addressed to David J.
Miklowitz, Division of Child and Adolescent Psychiatry, UCLA Semel
Institute, David Geffen School of Medicine at UCLA, 760 Westwood
Plaza, Room 58-217, Los Angeles, CA 90024-1759. E-mail:
Journal of Abnormal Psychology
2010, Vol. 119, No. 2, 355–365
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& Bentall, 1999), manic patients endorsed more positive words to
describe themselves than did bipolar depressed patients, and they
had higher internality, stability, and globality scores for positive
situations. Nonetheless, on a free-recall task, they recalled as many
negative words as did bipolar depressed patients. Winters and
Neale (1985) found that remitted BD patients reported levels of
self-esteem similar to those of control participants. Indirect mea-
surements, however, demonstrated that patients with BD were
more likely than controls to attribute failure situations to them-
selves, a style frequently observed among patients with MDD
(e.g., Alloy et al., 1999). In a study of students at risk for BD,
negative attributional styles and dysfunctional attitudes interacted
with life events to predict increases in depressed or hypomanic
symptoms (Reilly-Harrington, Alloy, Fresco, & Whitehouse,
People at high risk for mania use more defensive responses to
threatening experimental tasks (e.g., writing about one’s own
mortality) than do those at low risk for mania (Johnson, Joiner, &
Ballister, 2005). Goldberg, Gerstein, Wenze, Welker, and Beck
(2008) found that core beliefs among bipolar patients appear to be
negativistic even during manic phases. These results can be inter-
preted in light of the manic defense theory, in which manic
symptoms are seen as protecting the patient from depressive
thoughts or feelings of loss. The manic defense may represent an
extension of the process of thought suppression observed in pa-
tients with MDD. Thought suppression may achieve the immediate
goal of masking and avoiding negative thoughts, which, among
patients with BD, may lead to mood elevation, excessive opti-
mism, and feelings of invulnerability. However, the ironic process
of thought suppression may intensify negative cognitions under
conditions of stress or challenge (Wegner, 1994; Wegner & Wen-
Our first objective in this study was to compare the thought
suppression process in remitted and partially remitted patients with
BD, patients with a history of MDD, and healthy control (HC)
participants using a modified version of Wenzlaff and Bates’s
(1998) scrambled sentence task (SST). We hypothesized that both
patients with BD and patients with MDD would engage in active
suppression of negative thoughts as a way of gaining control over
their mood states. This tendency would be revealed in their un-
scrambling of more sentences in the negative valence (rather than
neutral or positive valence) than controls under conditions of
cognitive load. We also predicted that BD and MDD patients
would report more use of negative thought suppression in their
day-to-day lives than would controls and that those who reported
more negative thought suppression would unscramble more neg-
ative sentences on the SST.
The second aim was to determine whether the thought-
suppression/ironic process hypothesis could be extended to the
phenomenon of “hyperpositive thinking.” Patients with BD are
thought to overestimate the rewards and underestimate the risks of
a challenging situation (e.g., investing in a new business scheme)
because these situations may engage the behavioral activation
system (Alloy et al., 2006; Johnson, 2005; Lam, Wright, & Smith,
2004). We hypothesized that patients with BD, when in remission
or partial remission, would suppress thoughts that signal great
accomplishment, excessive optimism, or risk underestimation
(e.g., “I like doing risky things”; “I always reject others’ advice”)
because these thoughts may signal the onset of a new manic or
hypomanic episode. These thoughts would be expected to become
more frequent under conditions of cognitive load. To test this
hypothesis, we extended the SST to include sentences that could be
completed in a neutral or a hyperpositive (manic, grandiose) way.
The third aim concerns the moderating effects of reward on
thought suppression. Elevated reward sensitivity (Johnson, Ful-
ford, & Eisner, 2009; Meyer, Johnson, & Winters, 2001) and
heightened ambitions (Johnson, Eisner, & Carver, 2009) have been
observed among patients with BD during periods of euthymia. Life
events involving goal attainment (Johnson et al., 2008; Johnson,
Sandrow, et al., 2000), overly confident views of self (Lam,
Wright, & Sham, 2005), and excessive goal engagement (Lozano
& Johnson, 2001) are prospectively associated with elevations in
manic symptoms within bipolar I samples. Consequently, we pre-
dicted that among outpatients with BD, but not among patients
with MDD, negative or hyperpositive thought suppression would
be more frequent under conditions of reward opportunity. To test
this hypothesis, we added an additional condition in which partic-
ipants were rewarded for completing sentences during the SST.
The participants (N ? 76) were 36 patients with remitted or
partially remitted bipolar I or II disorder, 20 patients with a history
of MDD, and 20 HC participants. Patients with BD were recruited
from the outpatient mood disorders clinic of the Warneford Hos-
pital, Oxford University, Oxford, United Kingdom, or from com-
munity advertisements posted in the city of Oxford or on the
Internet. Patients with MDD and HC participants were recruited
from community advertisements or Internet postings. This study
was approved by the Oxfordshire Research Ethics Committee.
Patients with BD met the following eligibility criteria: (a) age
18–70 years; (b) good understanding and comprehension of En-
glish; (c) a Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.; DSM–IV–TR; American Psychiatric Associa-
tion, 2000) referral diagnosis of bipolar I or bipolar II disorder, as
verified by a trained clinical psychologist using the Mini-
International Neuropsychiatric Interview (MINI; Sheehan et al.,
1998); (d) no fully syndromal mood episodes or substance abuse or
dependence disorders in the past 3 months; and (e) a score below
16 on the Hamilton Rating Scale for Depression (HRSD; Hamil-
ton, 1960) and below 12 on the Young Mania Rating Scale
(YMRS; Young, Biggs, Ziegler, & Meyer, 1978). Hence, patients
could have mild to moderate symptoms but could not be in an
acute mood episode. The patients with MDD met the same eligi-
bility criteria, with the exception that the MINI diagnosis was
lifetime MDD by the DSM–IV–TR and current HRSD scores were
below 16. The HC participants had no current or past history of a
Of 40 patients with diagnoses of BD who were referred by their
psychiatrists, 24 consented to the study and were included. Addi-
tionally, 29 patients with BD responded to community advertise-
ments; of these, 16 consented and were included. The procedures
were piloted with the first four patients with BD who were not
included in the final sample (N ? 36; 17 with bipolar I disorder,
19 with bipolar II disorder). For the MDD and control groups, 141
volunteers initially contacted the research team; of these, 96 were
MIKLOWITZ, ALATIQ, GEDDES, GOODWIN, AND WILLIAMS
no longer interested after receiving the study information sheet.
Thus, 45 volunteers were interviewed and met the inclusion crite-
ria for the MDD or HC groups. An additional 5 were excluded on
the basis of the first interview (e.g., HRSD scores ? 16), leaving
20 in the MDD group and 20 in the HC group.
All study volunteers arrived at a research office and read and
signed a university ethics committee–approved informed consent
form. Demographic information such as age, marital status, occu-
pation, current medications, and history of psychiatric treatments
was obtained. Next, a trained doctoral-level research diagnostician
administered the MINI diagnostic interview, the HRSD, the
YMRS, and the modified SST (see below).
The MINI is a structured interview with screening
questions regarding each of the DSM–IV major Axis I disorders
(e.g., mood, psychotic, substance abuse, anxiety, attention-deficit/
hyperactivity disorder), followed by yes–no questions about each
individual symptom. The MINI has strong reliability and validity
data in relation to the Structured Clinical Interview for DSM
Diagnoses (Sheehan et al., 1998), with interrater reliabilities rang-
ing from .89–1.0 (kappas) for the diagnoses of MDD and BD (N ?
HRSD and YMRS.
After the MINI was completed, the diag-
nostician conducted semistructured interviews concerning the par-
ticipant’s mood state in the past 1–2 weeks, including probes
regarding how frequently each symptom had occurred, its dura-
tion, and its severity. The HRSD contains 17 items scaled from 0
to 4. The YMRS contains 11 items scaled from 0 to 8. The
interrater agreement between two doctoral-level independent eval-
uators (David J. Miklowitz and Yousra Alatiq) based on 15 con-
joint ratings of patients and controls in this sample was high
(HRSD items, ? ? .73; YMRS items, ? ? .82).
The SST, a paper-and-pencil task, consisted of six-word
strings that the participant was asked to unscramble to form
five-word sentences, leaving one word out. The original 60 sen-
tences (Wenzlaff & Bates, 1998) could be completed such that the
resulting five-word sentences conveyed either negative/depressive
content or neutral/mildly positive content (e.g., “am life improving
my ruining I”). We constructed an additional 60 sentences with
hyperpositive (manic/goal-directed) content for this study by con-
sulting self-report scales of manic cognition (e.g., Beck, Colis,
Steer, Madrak, & Goldberg, 2006; Mansell & Jones, 2006). These
new sentences could be completed in either a negative or a hyper-
positive way (“Am winner born am loser I”; “Hopeless feel now-
adays powerful I very”) or a hyperpositive or a neutral way (“Very
ideas appropriate my original are”; “Always works taking some-
times chances out”). Figure 1 illustrates these distinctions.
All 120 sentences were then reclassified by four raters as neg-
ative/neutral (53 of the 60 sentences from the Wenzlaff & Bates,
1998, set), negative/hyperpositive (33 sentences, including three
reclassified from the Wenzlaff & Bates, 1998, set), and 29 hyper-
positive/neutral sentences. The interrater reliability for these clas-
sifications was 92% (? ? .87). Five sentences were excluded
because their affective valence was ambiguous, leaving a final set
of 115 sentences. After the sentences were scrambled, they were
randomly organized within four tasks, each consisting of between
28 and 30 sentences and each containing equal proportions of
sentences with negative/neutral (46%), negative/hyperpositive
(29%), or hyperpositive/neutral (25%) content, ?2(6) ? 3.09,
p ? .80.
The research diagnostician began by reading the following
You will be asked to unscramble sentences to form statements. Each
of the scrambled sentences contains six words. Unscramble five of the
words in each sentence by placing a number over each of the five
words indicating the proper order [example given]. Each sentence can
be unscrambled into more than one statement, but you should choose
only one statement to unscramble—the first one which comes to mind.
The four SST conditions were then presented to participants in
counterbalanced order, with the following instructions given be-
fore each sentence set. Participants were given up to 6 min to
complete each set.
Condition 1, No Load/No Reward (NL/NR).
were instructed to unscramble as many sentences as possible, as
quickly as they could (as above).
Condition 2, No Load/Reward (NL/R).
identical to the NL/NR condition except the participants were told,
“You will hear a reward bell for every four items you finish. Try
to work fast so you can achieve as many bell sounds as you can.”
The experimenter then chimed a “mindfulness bell” (a bell with a
pleasing tone) after every four sentence completions.
Condition 3, Load/No Reward (L/NR).
“I will give you a six-digit number to remember. Keep this number
in mind as you work on your sentences. You will be asked to recall
it later.” Participants were then given a six-digit number (e.g.,
The instructions were
Participants were told,
Sentences With Negative
- I am ruining my life
- Often I feel like crying
115 Five-Word Sentences
Sentences With Hyperpositive
-My ideas are very original
- I am a born winner
Add Extra Word
- I’m in control of everything/nothing
- I am a born winner/loser
- My ideas are very original/
- I am ruining/improving my life
Construction of the Scrambled Sentence Task set.
THOUGHT SUPPRESSION IN BIPOLAR DISORDER
469827) and asked to complete another sentence set. At the end of
the task, they were asked to recall the number. The experimenter
recorded the number of digits recalled in the correct order.
Condition 4, Load/Reward (L/R).
perform as in Condition 2 and were given reward bells after
completing every fourth sentence. They were simultaneously
asked to hold a different six-digit number in mind. Once again,
they were asked to recall the number after completing the sen-
On completing the SST, participants proceeded to make some
additional ratings. Participants rated the frequency of their use of
negative thought suppression as a coping strategy using Likert-
type scales ranging from 1 to 7 (where 1 ? never, 7 ? all the time)
in response to the question, “In the past month, how often have you
tried to suppress (i.e., keep out of mind) unwanted negative
thoughts and feelings?” Participants also rated the success of
negative thought suppression as a strategy (where 1 ? not at all
successful, 7 ? very successful), responding to the question, “In
the past month, how successful have you been in suppressing (i.e.,
keeping out of mind) unwanted negative thoughts and feelings?”
Participants also made ratings on 1–7 scales of the frequency or
success of positive thought suppression (i.e., keeping out of mind
any cheerful, optimistic, or highly confident thoughts) over the
Participants were asked to
The patients with BD were older (M ? 40.8 years, SD ? 13.3)
than the HC participants (M ? 29.6 years, SD ? 16.0; p ? .02) but
did not differ in age from the patients with MDD (see Table 1).
The HC participants were more likely (75%) to be students than
were the participants with BD (28%) or MDD (30%; p ? .003).
The patients with BD were more likely than patients with MDD to
be taking psychiatric medications (77% vs. 25%; p ? .001). No
differences were found between the groups in general cognitive
ability as assessed by Raven’s Progressive Matrices (see Table 1).
There were no differences between the bipolar I (n ? 17) and II
(n ? 19) patients on any of the demographic or symptom variables
in Table 1. Thus, the bipolar I and II patients were combined into
one group (n ? 36) for the primary analyses.
Number of Sentences Completed on the SST
First, we examined the overall number of sentences completed
under the four experimental conditions using a 2 (no load, load) ?
2 (no reward, reward) ? 3 (BD, MDD, or HC) factorial analysis of
variance (ANOVA). There was a main effect of the load manip-
ulation, F(1, 73) ? 67.25, p ? .001. Post hoc comparisons using
the Holm–Bonferroni sequential rejective method (Holm, 1979)
indicated that regardless of diagnostic group, participants com-
pleted more sentences under no-load as compared with load con-
ditions (p ? .05). There was also a main effect of reward, F(1,
73) ? 8.37, p ? .005, indicating that participants completed more
sentences under reward conditions than under nonreward condi-
tions. Number of sentence completions was treated as the denom-
inator when comparing groups on the proportion of negative or
hyperpositive sentence completions.
Negative and Hyperpositive Sentence Completion
For each participant, two proportion variables were calculated:
(a) the proportion of negative sentence completions in each SST
condition, calculated as the number of negative/hyperpositive and
negative/neutral word strings completed in the negative (depres-
sive) direction, divided by the total number of completed sentences
in that condition, and (b) the proportion of hyperpositive sentences
completed in each condition, calculated as the number of hyper-
positive/neutral sentences completed in the hyperpositive (manic)
direction, divided by the total number of completed sentences in
the relevant condition.
Sample Description (N ? 76)
ValueBD MDD HC
Age in years (SD)
Age in years on completing education (SD)
Gender, no. male (%)
Married, no. (%)
Occupation, no. (%)
Currently taking medication, no. (%)
Raven’s Progressive Matrices score
Age in years at illness onset (SD)
Depressive episodes, no. (SD)
Longest episode in months (SD)
.05 using Bonferroni-corrected post hoc comparisons. The p values refer to chi-square or t tests.
aRefers to the comparison of the BD and MDD groups only.
BD ? bipolar disorder; MDD ? major depressive disorder; HC ? healthy control. Means with different subscripts differed significantly at p ?
MIKLOWITZ, ALATIQ, GEDDES, GOODWIN, AND WILLIAMS
There was no effect of sentence type (negative/neutral vs. neg-
ative/hyperpositive) on the proportion of sentences completed in
the negative direction in any of the participant groups: Main effect
of sentence type, F(1, 73) ? 0.84, p ? .36; Sentence Type ?
Group interaction, F(2, 73) ? 0.45, p ? .64. However, there was
a main effect of sentence type (negative/hyperpositive vs. hyper-
positive/neutral), F(1, 73) ? 79.67, p ? .001, and a two-way
interaction between sentence type and group, F(1, 73) ? 12.06,
p ? .001, on hyperpositive sentence completions, indicating that
when given negative/hyperpositive sentences, HC participants
completed more in the hyperpositive direction than did participants
with BD (Holm–Bonferroni corrected p ? .05). To adjust for these
differences, we calculated the percentage of hyperpositive sen-
tences as the proportion of sentences completed in the hyperposi-
tive direction only when participants were given hyperpositive/
neutral options (e.g., “Superior most I’m others to equal”). The
negative/hyperpositive sentences were included only when calcu-
lating the total proportion of negative sentence completions. Nei-
ther negative nor hyperpositive completion scores were correlated
with participants’ age, gender, Raven’s Progressive Matrices
scores, or student or nonstudent status (for all, ps ? .05, N ? 76).
Was the Load Manipulation Successful?
Prior to testing the primary hypotheses, we examined whether
participants in the three groups differed in their ability to recall the
six-digit number after the L/NR or L/R tasks. A 2 (L/NR, L/R) ?
3 (BD, MDD, HC) factorial ANOVA showed that the BD patients
recalled fewer digits than did the controls in the L/NR condition,
F(2, 75) ? 3.08, p ? .05, but not in the L/R condition, F(2, 75) ?
1.84, p ? .10. Hence, we conducted secondary analyses comparing
the groups on the proportion of negative or hyperpositive sentence
completions in the load conditions using only the 54 participants
(BD, n ? 21/36 [58.3%]; MDD, n ? 15/20 [75.0%]; HC, n ?
18/20 [90.0%]) who recalled five or more digits.
Do Patients With BD Unscramble More Negative
Sentences Under Load and Reward Conditions?
The primary study hypothesis was that patients with BD would
complete proportionately more sentences in the negative direction
than would HC participants under conditions of cognitive load and
more sentences in the negative direction than either MDD or HC
participants under conditions of reward. To test this hypothesis, we
conducted a 2 ? 2 ? 3 ANOVA, with no load/load and no
reward/reward as within-subject variables and group (BD, MDD,
HC) as the between-subjects variable; the percentage of negative
sentence completions was the dependent variable.
There was a three-way interaction between load, reward, and
group, F(2, 73) ? 4.11, p ? .02, indicating that in the absence of
load and reward (the NL/NR condition), the participants with BD
produced a greater proportion of negative sentences than did the
HC participants (Holm–Bonferroni corrected p ? .05; Cohen’s d
statistic ? 0.87) but did not differ significantly from the partici-
pants with MDD (p ? .05; see Figure 2).1The BD participants
also produced a greater proportion of negative statements in the
NL/R condition than did the HC (corrected p ? .05, d ? 1.32) and
MDD participants (p ? .05, d ? 0.80). The MDD group did not
differ from the HC group in either the NL/NR or the NL/R
condition (ps ? .05).
Consistent with the hypotheses, in the L/NR condition, both the
BD and the MDD groups produced higher proportions of negative
sentences than did the HC group (BD vs. HC, d ? 1.49; MDD vs.
HC, d ? 0.83; corrected ps ? .05). The BD and MDD groups did
not differ significantly (p ? .05). Group differences were also
observed in the L/R condition, in which the BD and MDD groups
produced higher proportions of negative sentences than did the HC
group (BD vs. HC, p ? .05, d ? 1.33; MDD vs. HC, p ? .05, d ?
0.97) but did not differ from each other (p ? .05).
Were Differences in Negative Sentence Completions
Due to Baseline Levels of Negative Bias?
Responses to the NL/NR condition were conceptualized as each
participant’s baseline level of negative or hyperpositive bias dur-
ing the SST task. To rule out the possibility that significant
differences between groups in the load and reward conditions were
due to initial differences in baseline NL/NR scores, we calculated
an impairment index, a percentage difference score from the
NL/NR condition, for each participant in each of the remaining
three conditions (NL/R, L/NR, and L/R). For example, to deter-
mine the effect of reward on negative sentence completions in the
NL/R condition, a reward impairment index was calculated as the
percentage of negative completions in the NL/R condition sub-
tracted from the percentage of negative completions in the NL/NR
condition. The use of difference scores to control baseline differ-
ences is recommended over analyses of covariance when partici-
pants are not randomly assigned to groups (Dallal, 2005).
1Because proportional scores are often skewed, Lipsey and Wilson
(2001) recommended using arcsine transformations prior to conducting
ANOVAs. The three-way interaction between diagnostic group, load, and
reward for proportion scores was of similar magnitude when negative
completion scores were arcsine transformed, F(2, 73) ? 4.45, p ? .015.
Moreover, the effect size for the BD–HC comparison in the NL/NR
condition was virtually identical when using arcsine-transformed (Cohen’s
d ? 0.85) and untransformed scores (d ? 0.87; ps ? .05).
tences completed in the negative direction divided by total number of
sentences completed) by groups and task conditions. NL/NR ? no load/no
reward; NL/R ? no load/reward; L/NR ? load/no reward; L/R ? load/
reward; BD ? bipolar disorder; MDD ? major depressive disorder; HC ?
healthy control. There was a three-way interaction between load, reward,
and group, F(2, 73) ? 4.11, p ? .02.
Percentage of negative sentence completions (number of sen-
THOUGHT SUPPRESSION IN BIPOLAR DISORDER
Similar to the results of the factorial ANOVAs, there was a
to the load manipulation, F(2, 73) ? 3.68, p ? .03 (see Figure 3).
The omnibus difference remained significant after controlling for
age (p ? .05) and Raven’s Progressive Matrices scores (p ? .05).
Holm–Bonferroni corrected post hoc comparisons indicated that
the BD group showed a more depressive bias due to the load
manipulation than did the HC group (p ? .05; Cohen’s d ? 0.71),
but the MDD and HC groups did not differ (p ? .05). Participants
with BD and MDD did not differ in load impairment scores
(p ? .05).2
There was also a significant difference between the groups in
impairment due to the reward manipulation, F(2, 73) ? 4.02, p ?
.02 (see Figure 3). This omnibus result remained robust after
controlling for age (p ? .03) and Raven’s Progressive Matrices
scores (p ? .003). The group difference was attributable to the
higher reward impairment index scores in the BD than the HC
group (corrected p ? .05; d ? 0.79); the remaining pairwise group
comparisons did not reach significance (p ? .05). Finally, the
group comparison in impairment scores in the L/R condition did
not reach significance, F(2, 73) ? 2.70, p ? .07.3
Effects of Current Mood
The HRSD and YMRS scores were square root transformed to
adjust for positive skew. A comparison of the three groups re-
vealed an omnibus difference in transformed HRSD scores, F(2,
73) ? 20.74, p ? .0001. Pairwise group contrasts with Holm–
Bonferroni adjustments indicated that the BD (untransformed M ?
6.2, SD ? 5.4) and MDD (M ? 4.0, SD ? 2.9) groups each had
higher (p ? .05) HRSD scores than the HC group (M ? 0.65,
SD ? 1.1) but did not differ from each other (p ? .05). As
expected, the BD group had higher mean YMRS scores (untrans-
formed M ? 4.3, SD ? 4.4) than did the MDD (M ? 0.95, SD ?
1.4) and HC groups (M ? 0.40, SD ? 0.75), F(2, 75) ? 11.7, p ?
An analysis of covariance (ANCOVA) revealed that diagnosis
was no longer significantly associated with negative sentence
completion scores in the baseline NL/NR condition, F(2, 73) ?
1.61, p ? .21, once HRSD scores were covaried; HRSD scores
were independently associated with negative completion scores,
F(1, 72) ? 11.18, p ? .002. The group differences in the load
impairment index, F(2, 72) ? 2.36, p ? .10, and the reward
impairment index, F(2, 72) ? 2.52, p ? .09, were weakened by
inclusion of HRSD scores in the ANOVA models, although the
effect sizes for these pairwise comparisons were similar to
ANOVA comparisons that did not include HRSD scores as co-
variates (load impairment ? .70 vs. .71; reward impairment ? .77
YMRS scores bore no relationship to the negative sentence
completion variables (for all, p ? .10). The greater proportion of
negative sentence completions in the BD than the HC group within
the NL/NR condition was not affected by covarying YMRS scores,
F(2, 72) ? 5.23, p ? .01, d ? 0.94. However, the group differ-
ences in load impairment scores, F(2, 72) ? 2.38, p ? .10, d ?
0.50, and reward impairment scores, F(2, 75) ? 2.13, p ? .13, d ?
0.65, became nonsignificant once YMRS scores were covaried.
Do Patients With BD Unscramble More Hyperpositive
Sentences Under Load and Reward Conditions?
Next, we tested the hypothesis that, when given hyperpositive/
neutral sentence options, the BD patients would react to cognitive
load and reward by completing more sentences in the hyperposi-
tive direction. A 2 ? 2 ? 3 ANOVA was conducted with no
load/load and no reward/reward as within-subject variables and
group (BD, MDD, and HC) as the between-subjects variable. The
results show a main effect of reward, F(1, 73) ? 12.48, p ? .001.
Under reward conditions, all participants produced more hyper-
positive statements than they did under nonreward conditions.
However, no group differences or Group ? Condition interactions
were observed in this analysis (see Table 2). Inclusion of HRSD or
YMRS scores in ANCOVA models did not affect the results (all
ps ? .05).
Do Patients With BD Report Higher Levels of
Thought Suppression Than Do Comparison Groups?
There were significant differences between the groups in the
self-reported frequency of negative thought suppression, based on
a 1–7 Likert-type rating (see Table 3), F(2, 73) ? 4.87, p ? .01.
The BD group reported more frequent use of negative thought
suppression than did the HC group (corrected p ? .05) but not the
MDD group (p ? .05). There was also a significant difference
between groups in self-reported success in suppressing negative
thoughts, F(2, 72) ? 7.52, p ? .001, with both the BD group and
the MDD group (p ? .05) reporting less success than the HC
group. However, these differences could be largely attributed to
2When the group comparisons on the load conditions were repeated
using only the participants who correctly recalled five or more of the six
digits, the difference between the bipolar and HC groups in the load
impairment index remained significant (p ? .05).
3The pattern of group differences was identical when impairment scores
were arcsine transformed: For load impairment scores, F(2, 73) ? 3.66,
p ? .03; reward impairment scores, F(2, 73) ? 4.02, p ? .02; and
load/impairment scores, F(2, 73) ? 2.70, p ? .07.
lated as a percentage difference score between the load/no reward (L/NR), no
load/reward (NL/R), and load/reward (L/R) conditions and the no load/no
reward (NL/NR) condition. Load ? impairment index due to load (L/NR ?
NL/NR); Reward ? impairment index due to reward (NL/R ? NL/NR);
Load/Reward ? impairment index due to load and reward (L/R ? NL/NR).
due to the load manipulation, F(2, 75) ? 3.68, p ? .03, and the reward
manipulation, F(2, 75) ? 4.02, p ? .02.
Impairment indices by groups. Impairment indices were calcu-
MIKLOWITZ, ALATIQ, GEDDES, GOODWIN, AND WILLIAMS
current mood states: When depressive symptoms (HRSD) were
covaried, the group differences in frequency ratings, F(2, 72) ?
.25, p ? .10, and success ratings, F(2, 72) ? 2.13, p ? .10, were
no longer significant.
There was also a significant difference between groups in the
self-rated frequency of positive thought suppression, F(2, 73) ?
3.63, p ? .03. The patients with BD reported a significantly higher
frequency than did the patients with MDD (p ? .05) but not the
controls (p ? .05). The difference between BD and MDD patients
in the frequency of self-reported positive thought suppression was
no longer significant when YMRS scores were covaried, F(2,
72) ? 2.18, p ? .10.
Does Self-Reported Negative Thought Suppression
Predict Performance on the SST?
We predicted that (a) frequent use of negative thought suppres-
sion would be associated with a greater tendency to complete
negatively valenced sentences during the SST, and (b) these asso-
ciations would be strongest in the BD and MDD groups, especially
under load and reward conditions. We examined this hypothesis in
multiple regression models, in which the independent variables
were diagnosis and self-reported negative thought suppression
scores (centered) and their interaction. The dependent variables
were the proportion of negative sentences produced in the four
Indeed, greater self-reported frequency of negative thought sup-
pression was related to a greater proportion of negative sentence
completions across conditions, independent of diagnostic group,
F(1, 70) ? 12.62, p ? .001. In contrast, self-reported success in
suppressing negative thoughts was related to fewer negative sen-
tence completions across conditions and diagnoses, F(1, 69) ?
6.05, p ? .016. There were no significant interactions between
diagnosis and self-reported frequency or success of negative
thought suppression in predicting negative sentence completions in
any condition (all ps ? .10).
Next, we sought to determine whether the self-reported fre-
quency of thought suppression affected the observed group differ-
ences in the proportion of negative sentence completions. We used
ANCOVAs to compare the groups on the load and reward impair-
ment indices while including the frequency and, separately, the
success of negative thought suppression as covariates. The group
differences in the baseline (NL/NR) condition—in which BD
participants completed proportionately more negative sentences
than did the controls—remained significant when the frequency of
negative thought suppression was covaried, F(2, 72) ? 3.33, p ?
.04, d ? 0.58, but dropped to a level that approached significance
when success scores for negative thought suppression were covar-
ied, F(2, 71) ? 3.07, p ? .05, d ? 0.54.
The proportional difference between the BD and HC groups in
impairment due to the load manipulation was no longer significant
when the self-reported frequency of negative thought suppression
was covaried, F(2, 72) ? 2.29, p ? .11, d ? 0.57, but remained
significant when success ratings were covaried, F(3, 74) ? 3.40,
p ? .04, d ? 0.77. Finally, the finding of greater reward impair-
ment in the BD relative to the MDD or HC groups was weakened
by covarying the frequency of negative thought suppression, F(3,
75) ? 3.02, p ? .06, d ? 0.72. This group difference remained
statistically reliable when success ratings were covaried, F(2,
71) ? 4.41, p ? .016, d ? 0.89.
This study examined the role of thought suppression in masking
negative and hyperpositive thoughts among outpatients with BD.
Patients with BD produced more negative sentences during an
implicit, automatic processing task (the NL/NR SST condition)
than did HC participants, whereas patients with a history of MDD
did not differ from either group. However, when mental control
was disrupted by a cognitive load (rehearsing a six-digit number),
both the BD and the MDD patients completed more negatively
Percentage of Hyperpositive Completions by Groups Across
BD (n ? 36)MDD (n ? 20)HC (n ? 20)
M SDM SDMSD
load/no reward; L/R ? load/reward; BD ? bipolar disorder; MDD ?
major depressive disorder; HC ? healthy control.
NL/NR ? no load/no reward; NL/R ? no load/reward; L/NR ?
Group Comparisons on Self-Ratings of Thought Suppression
BD (n ? 36)MDD (n ? 20)HC (n ? 20)
differed significantly at p ? .05 using Holm–Bonferroni–corrected post hoc comparisons.
TS ? thought suppression; BD ? bipolar disorder; MDD ? major depressive disorder; HC ? healthy control. Means with different subscripts
THOUGHT SUPPRESSION IN BIPOLAR DISORDER
valenced sentences than did the controls. Thus, both groups of
patients with mood disorders were biased toward negative material
when mental control was depleted. These group differences were
no longer significant once mood state scores were covaried.
Although patients with BD reported more frequent use of neg-
ative thought suppression in the past month than did the controls,
they also reported being less successful in suppressing negative
material. Thus, the negative biases observed in BD might be the
result of ineffective mental control. This hypothesis is consistent
with the positive correlation in the full sample between the self-
reported frequency of negative thought suppression and the pro-
portion of negative sentence completions across conditions and the
inverse correlation between the self-reported success of negative
thought suppression and the proportion of negative sentence com-
pletions. Moreover, differences between patients with BD and HC
participants in negative sentence completions due to the load
manipulation became nonsignificant when the self-reported fre-
quency of negative thought suppression was covaried.
These findings add to a body of literature suggesting that, like
patients with MDD, patients with BD show negative cognitive
biases during implicit cognitive processing tasks (Kerr, Scott, &
Phillips, 2005; Lyon et al., 1999; Wenzlaff & Bates, 1998; Winters
& Neale, 1985). Future research should examine whether negative
thought suppression among patients with BD is the result of less
effective mental control or a greater negativity bias in attention or
memory relative to healthy persons or persons with other psychi-
The differences in negative thought suppression among the
groups were attributable in part to current mood symptoms. Se-
verity of concurrent mood symptoms cannot be fully disentangled
from DSM–IV diagnoses: Patients with BD rarely present for
treatment or research in full remission. Indeed, patients with BD
spend approximately half of the weeks of their lives in syndromal
or subsyndromal states of illness, particularly depression (Judd et
al., 2002). Other studies have found that the negativity of cognitive
styles is related to the severity of depression in both bipolar and
major depressive illness and that cognitions appear to be more
negative during depressive periods than euthymic periods (Cuellar,
Johnson, & Winters, 2005; Knowles, Tai, Christensen, & Bentall,
2005; Seligman et al., 1988; Thomas & Bentall, 2002). Further-
more, negative cognitive styles and low self-esteem predict in-
creases in depression over time among BD patients (Johnson &
Fingerhut, 2004; Johnson, Meyer, Winett, & Small, 2000). When
combined with residual mood symptoms, less effective mental
control—or, alternatively, a greater negativity bias—may put pa-
tients with BD at increased risk for earlier recurrences of depres-
A secondary purpose was to examine whether thought suppres-
sion extended to the hyperpositive thinking (excessive optimism,
extreme self-confidence, and risk underestimation) often charac-
teristic of BD. We predicted that patients with BD would suppress
hyperpositive thoughts, given that their presence could evoke
memories of prior manic, mixed, or hypomanic episodes. Indeed,
patients with BD reported more use of positive thought suppres-
sion than did patients with MDD, although this group difference
disappeared once concurrent levels of mood elevation (YMRS
scores) were controlled. In the SST, there were no differences
among the groups in the proportion of hyperpositive/neutral sen-
tences completed in the hyperpositive direction. In fact, when
asked to unscramble sentences with either negative or hyperposi-
tive content, the HC participants were more likely than the patients
with BD to complete the sentences in the hyperpositive direction.
Possibly, the hyperpositive sentences used in this study may
have reflected normative optimism and positive self-esteem rather
than manic grandiosity and inflated self-confidence. Alternatively,
the positively biased cognitions often described in BD may be
mainly a feature of the prodromal or active periods of mania or
hypomania rather than the remitted states. Current theories of
cognition in BD emphasize the interaction of positive and negative
information processing biases in predicting how different symp-
tom states (e.g., mania, mixed episodes, depression with hypoma-
nia) develop over time among different patients (Mansell & Ped-
Finally, we examined the role of rewards in the processing of
negative and positive information. Considerable evidence suggests
that BD patients experience greater cognitive reactivity to positive
stimuli than do members of other psychiatric or healthy compar-
ison groups (Johnson, 2005; Lam et al., 2004). BD patients or
students at risk for BD report higher levels of reward responsive-
ness and elevated success expectancies relative to controls (John-
son, Eisner, & Carver, 2009; Meyer, Johnson, & Carver, 1999),
which in turn are associated with increases in manic symptoms
over time (Johnson, Sandrow, et al., 2000; Meyer et al., 2001). We
found evidence to support our hypothesis that a simple reward—a
bell rung following every four sentence completions—would dis-
rupt mental control in the BD group and yield higher proportions
of negative sentence completions. Like the load manipulation,
reward may have increased the accessibility of negative thoughts
in the BD group. Unlike load, however, reward was associated
with a greater number of sentence completions in all groups.
Moreover, the proportion of hyperpositive/neutral sentences com-
pleted in the hyperpositive direction increased in the reward con-
ditions, suggesting that when faced with this choice, rewards bias
participants toward a more optimistic outlook.
These findings suggest that the effects of reward in increasing
negative cognition among BD patients cannot be easily explained
by mental control theory alone. Rewards may engage confidence
and goal pursuit among patients with BD but also bring to mind
memories of failure in achievement situations and feelings of low
self-worth (Alloy et al., 2005; Eisner, Johnson, & Carver, 2008).
Self-worth appears to be more reactive to sudden mood shifts
among persons with BD than among healthy persons (Johnson,
Some studies have found that individuals with BD or at risk for
BD are characterized by high drive/incentive motivation, ambi-
tious goal setting, conscientiousness, and perfectionism, and both
groups are more likely to become depressed under achievement
failure circumstances (Alloy et al., 2005; Lozano & Johnson,
2001). It is possible that reward activates self-discrepancy pro-
cesses (i.e., mismatches between actual self and idealized views of
the self; Higgins, Bond, Klein, & Strauman, 1986) and failure
beliefs when a goal is perceived to be difficult to obtain, which
may, in turn, lead to decreased goal setting, lower expectancies of
success, a reduction in goal-oriented behaviors, and negative
mood. Patients with BD may be more likely than HC participants
to engage in self-criticism to motivate themselves, which may
result in negatively biased thoughts during a reward task. The
small amount of evidence suggests that bipolar and unipolar pa-
MIKLOWITZ, ALATIQ, GEDDES, GOODWIN, AND WILLIAMS
tients are equally self-critical when in remission (Eisner et al.,
2008; Rosenfarb, Becker, Kahn, & Mintz, 1998). These issues
deserve further study, especially using laboratory paradigms that
go beyond self-report questionnaires to include implicit processing
tasks under conditions of reward or failure.
Several limitations of the study warrant comment. First, the SST
did not involve a direct manipulation of thought suppression. The
correlation between frequency of negative thought suppression and
the proportion of negative sentence completions in the SST sug-
gests some degree of consistency in the construct across measure-
ment methods. Nonetheless, it is possible that we simply measured
the conditions under which negative interpretation biases occur. In
an experimental manipulation, Beevers and Meyer (2008) ran-
domly assigned college students to a dysphoric mood induction or
a control condition and then gave thought suppression instructions
during a writing exercise (i.e., to not have negative thoughts during
the exercise vs. writing freely about a topic). The instructions to
suppress negative thoughts increased the accessibility of negative
thoughts even after the participants’ dysphoric mood had lifted.
Studies that directly manipulate thought suppression may clarify
the role of this process in bipolar and other clinical populations.
Second, it did not prove feasible to obtain a cross-sectional
sample of patients with BD or MDD who were entirely free of
symptoms. As is common in outpatient samples of bipolar I and II
patients (Judd et al., 2002; Perlis et al., 2006), the participants had
mild to moderate levels of subsyndromal depression. It remains
uncertain whether we would have found group differences in
negative thought suppression among patients who were asymp-
tomatic. Indeed, reward sensitivity diminishes when a person
experiences even mild depressive symptoms (Meyer et al., 2001).
Examining the longitudinal association between changes in
thought suppression, reward, and mood would clarify the direction
of effects between these domains of functioning in BD.
Third, the patients with BD were more likely to be undergoing
pharmacotherapy than the patients with MDD and may have been
more severely ill than their MDD counterparts. It was also not
possible to rule out the influential effects of common comorbid
conditions (or their correlated treatments), such as borderline per-
sonality disorder or attention-deficit/hyperactivity disorder, on task
performance. Moreover, the HC participants were younger and
more likely to be students than those in the mood disorder groups.
Although age and Raven’s Progressive Matrices scores did not
appear to explain the group differences, our design should be
replicated in studies that use patient and control samples matched
on a pairwise basis on demographic variables that might affect
performance on the SST.
Fourth, only 58% of the patients with BD achieved adequate
recall of the digits in the load task, which could imply failure to
engage with the task. Nonetheless, the key results concerning
negative thought suppression were observed in the subsample of
participants who recalled five or more of six digits. On the one
hand, it is possible that the patients with BD had more memory
impairment than did the MDD or HC participants, such that the
load demands of the task were satisfied in this subsample. On the
other hand, memory impairment may have generated greater frus-
tration and pessimistic attributions among the participants who had
difficulty recalling the digits in the load tasks. Indeed, BD patients
show significant neuropsychological impairment even when eu-
thymic (Clark, Kempton, Scarna `, Grasby, & Goodwin, 2005;
Schretlen et al., 2007). Cognitive load manipulations that do not
rely heavily on memory rehearsal strategies (e.g., distraction)
would test the generalizability of the present findings.
Finally, the reward bell, although containing a pleasing wind
chime tone, may not have been experienced as a positive incentive
stimulus by some of the participants. Our finding that all groups
completed more sentences under reward than nonreward condi-
tions does suggest that the bell served its function as a reward
(a stimulus that increases the frequency of a behavior). Nonethe-
less, in future studies, researchers should examine the effects of
more ecologically valid reward opportunities (e.g., praise, money,
public recognition, immediate success feedback)—some of which
have been successfully simulated in experimental studies of goal
pursuit (Johnson, 2005)—on the level of thought suppression
among BD and MDD patients. Including measures of reward
sensitivity (e.g., the Behavioral Activation Scales; Depue, Klein-
man, Davis, Hutchinson, & Krauss, 1985) may further clarify
important mediating variables in these reward pathways (Alloy et
al., 2008; Johnson, 2005).
Investigating treatments whose objective is to reduce thought
suppression may help clarify the role of these processes in recov-
ery from mood episodes or risk for recurrences. Controlled trials of
cognitive behavioral therapy for BD have yielded less consistent
results than trials of cognitive behavioral therapy for MDD, sug-
gesting that cognitive theories of depression cannot be automati-
cally translated into theories about the cognitive underpinnings of
BD (Hollon et al., 2002; Miklowitz & Scott, 2009). Preliminary
data suggest that mindfulness-based cognitive therapy may be
effective in alleviating depression and anxiety symptoms among
patients with BD (Miklowitz et al., 2009; Williams et al., 2008).
Mindfulness-based cognitive therapy is associated with reductions
in self-reported negative thought suppression among individuals
with past depression and suicidality (Hepburn et al., 2009). Dem-
onstrating that mindfulness-based cognitive therapy or similar
interventions reduce thought suppression in BD and in turn alle-
viate symptoms would help establish the primacy of this cognitive
process in the pathways between life stress and outcome in bipolar
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Received June 3, 2009
Revision received November 16, 2009
Accepted November 19, 2009 ?
THOUGHT SUPPRESSION IN BIPOLAR DISORDER