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Psychological approaches to bipolar disorders: A theoretical critique
M.J. Power T
Section of Clinical and Health Psychology, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, UK Received 21 September 2004; received in revised form 6 May 2005; accepted 13 June 2005
Abstract An outline is presented of five main psychological models of the bipolar disorders. These approaches include the Behavioural Activation/Inhibition Systems model, the Cognitive Therapy model, the Interpersonal and Social Rhythm Therapy model, the Interacting Cognitive Subsystems model, and the SPAARS model. Strengths and weaknesses are highlighted for each approach. It is concluded that although there is no model that can adequately account for even the key features of the bipolar disorders (such as periodicity, shifts in the valence of the selfconcept, mixed affective states, and patterns of recovery and relapse), nevertheless, more recently developed multilevel approaches to emotion offer more sophisticated possibilities for modeling these complex disorders. D 2005 Elsevier Ltd. All rights reserved.
1. Introduction Bipolar disorders occur in approximately 1% of the population (Cavanagh, 2004; Weissman & Myers, 1978). They are characterized by a series of affective highs and lows with some states combining feelings of mania, depression and other moods or emotions concurrently. These disturbances are thought to recur throughout the lifetime of 80–95% of those affected (Goodwin & Jamison, 1990). Bipolar disorders can have devastating consequences for individual sufferers and their families. An estimated 9 years of life, 12 years of normal health and 14 years of major activities such as schooling, work and child rearing may be lost to the average 25-year-old woman diagnosed with the disorder (Prien & Potter,
T Tel.: +44 131 651 3943. E-mail address: firstname.lastname@example.org. 0272-7358/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2005.06.008
M.J. Power / Clinical Psychology Review 25 (2005) 1101–1122
1990). A high mortality risk is associated with the affective episodes with approximately one quarter of bipolar disorder individuals attempting suicide (Prien & Potter, 1990). Different theories exist as to the aetiology of bipolar disorders. Psychobiological theories propose a diathesis-stress model, in which stress from life events interacts with predisposed biological, biochemical and neurological instabilities to induce the illness in vulnerable individuals. Whilst many such models are a useful reminder that increased stress levels are linked to the onset of a variety of disorders, the models themselves rarely move beyond a simple level of descriptiveness. Additional research has linked factors such as lack of social support, family environment (Miklowitz, Goldstein, Neuchterlein, Snyder, & Mintz, 1988), lifestyle and sleep irregularity (Wehr, Sack, & Rosenthal, 1987), and increased sensitivity with each episode (Post, 1992) to illness instigation and relapse. However, with one or two exceptions, there has been little work carried out on psychological aspects of bipolar disorders such as research that addresses the self-concept or emotion in bipolar disorders. Furthermore, many of the models of the bipolar disorders simplify the clinical characteristics of the disorders almost beyond recognition; for example, many accounts of hypomania/mania would imply that the goaldirected engagement and activity leads only to positive emotions, whereas the actual emotional experience of mania typically includes considerable dysphoria, anxiety, and irritability, with emotional lability being a characteristic feature. Goodwin and Jamison (1990) reported that 70–80% of patients with mania presented with this mixed state picture; Cassidy, Forest, Murry, and Carroll’s (1998) largescale exploratory factor analysis of manic symptoms showed that bdysphoric moodQ was the first major factor in their data; and bipolar disorders show considerable co-morbidity with anxiety disorders, drug and alcohol abuse, etc (see Papolos, 2003, for a recent summary). Despite the surprising lack of psychological research on bipolar disorders, there are now several psychological models that have been offered in order to provide an account of at least part of the phenomena of the bipolar disorders. These models are either adaptations of existing approaches to psychological disorders, as in the case of the adaptations of the Cognitive Therapy and Interpersonal Psychotherapy Models, or they are based on more general frameworks as in the adaptations of the Interacting Cognitive Sub-systems (ICS) and the Schematic-Propositional-Analogical-AssociationistRepresentation-Systems (SPAARS) approaches. However, before these approaches are reviewed, the adaptation of Jeffrey Gray’s Behavioural Activation/Behavioural Inhibition Systems (BAS/BIS) model will be considered. For each of the models, three simple tests can be run: (1) Does the model account for some or all of the unique clinical features of the disorders such as periodicity, mixed affective states, extreme shifts in the valence of mood and self-concept, and patterns of recovery and relapse? (2) What is the explanatory power of the theory? Does it focus on one category of symptom at the expense of others? Does the theory make testable predictions? Does the theory make unique predictions? (3) Is the theory relevant to normal functioning or is it a stand-alone and disorder-specific approaches? Can it account for other types of psychopathology and place the bipolar disorders in a general framework of psychopathology? These three sets of tests will not be applied in a formulaic way as we proceed through each of the models, but the models will be described in their own appropriate ways first, before returning to these questions so that they will be used to structure the final summary and conclusions.
In the presence of such stimuli. 1) detects mismatches between predicted events that do not occur. with its focus on behavioural inhibition and predicted aversiveness. 1982) identified two key behavioural systems. motivation. and Seligman’s (1975) Learned Helplessness theory and its subsequent reformulations. in which a postulated comparator (see Fig. Rolls. which focuses on stimuli that have come to be conditioned to punishment or frustrative non-reward. there is also a relevant tradition within mood and affect from at least Osgood’s semantic differential approach (e. Clark. 1999. Anxiety therefore was considered to be a consequence of activity in the BIS. 1957) of examining a two-dimensional approach (e. The behavioural activation/behavioural inhibition systems (BAS/BIS) model The BAS/BIS model can be considered in the context of dimensional approaches to personality. which is accompanied by increased arousal and attention to the environment. & Tannenbaum. to the interruption of ongoing activity. the Behavioural Activation System (BAS) focuses on approach behaviour in which positive stimuli. First. however. Russell & Carroll. unpredicted events that do occur. that is. 1. & Tellegen. First. The BAS is therefore closely associated with incentive motivation and with motor programmes related to approach. Although in many ways derived from and related to Eysenck’s (1967) two dimensions of extraversion–introversion and normality-neuroticism (also called bemotionalityQ). or novel stimuli which may come to be associated with unconditioned responses (UCRs). Gray (1976. or reward. Watson. Gray’s comparator model. the BAS/BIS approach will be outlined before returning to some of the generic problems shared by these two-dimensional approaches. and predicted punishments and non-rewards that occur. though there is a clear overlap between Gray’s account of the BIS. Nevertheless. . a Pavlovian conditioning based system.g.M. In his theory of anxiety. The application of Gray’s BAS/BIS model to mood disorders has tended to focus on the role of the BAS rather than the BIS (see later for some exceptions to this generalisation). Suci. 1999. lead to approach and engagement. Power / Clinical Psychology Review 25 (2005) 1101–1122 1103 2. and emotion.g. Although Gray (1990) STORED REGULARITIES THE WORLD COMPARATOR PREDICTIONS PLANS Fig. 1988). Osgood. a Behavioural Inhibition System (BIS).J. the BIS leads to behavioural inhibition.
focussed in particular on normal levels of cortisol production and the change in cortisol production under stress in both cyclothymic and bipolar individuals (e. and Winters (2000) reported an increase in manic symptoms after the attainment of an important goal. Fun Seeking. Depue suggested that the high arousal. Power / Clinical Psychology Review 25 (2005) 1101–1122 thought that only the BIS was clearly identified with the emotion of anxiety. Depue et al. Although in the Carver and White approach the BIS scale has remained much as conceptualised by Gray in its focus on punishment sensitivity. and Johnson (2004) found that hypomania was linked with an overlyoptimistic future goal-oriented pattern. 1995). who can be considered to have a milder variant of a bipolar disorder. they have further developed and modified the BAS scale to include subscales that assess Drive (i. retardation. and Carver (1999) found that in mood-disorder prone students. whereas low levels of BAS activity. 1987. & Iwata. though it should be cautioned that patterns of over-investment in some goals and under-investment in others are characteristic of unipolar depression also (Champion & Power. Meyer. Sandrow. Meyer. Turner. the BIS fluctuated with levels of depression but was not predictive of . Goplerud & Depue. Johnson. In an analogue study with students that included the Carver and White BIS/BAS scales. whereas both high BIS and low BAS Reward Responsiveness were related to depression symptom scores. thereby raising the possibility that both dimensions could be involved in mood disorders rather than only the BAS and therefore contrary to authors such as Depue and others (e. & Spoont.g. 2004) who have focussed only on the BAS in bipolar disorders. 1985) has proposed that BAS-type systems are poorly regulated both in bipolar disorder individuals and in cyclothymic individuals. On the basis of these and related findings. etc.g. 2003). Johnson. Johnson. Depue (Depue. including disengagement from rewarding activities. In this vein. and that such individuals reported future goals as being less stressful and less difficult than did control individuals. whereas normal individuals tend to aim for some moderation of the positive affect for example by bcoastingQ. 2001) followed up a group of 59 Bipolar 1 individuals over an average of 20 months. others have been bolder and developed emotion models based on the BAS. 1987. Johnson. This preliminary study therefore offered some support for the Carver and White modification of the BIS/BAS model. Depue et al. Stern and Berrenberg (1979) reported that on the illusion of control laboratory task individuals with a history of hypomania predicted higher rates of success after success feedback in comparison to controls. The work of Carver and White (1994) in their operationalisation of Gray’s approach has offered a selfreport BIS/BAS scale for the assessment of BIS and BAS sensitivities. Carver and White also considered the BAS to be linked to positive affect and the BIS to negative affect. 1985).1104 M. In an analogue study with students reporting hypomanic or depressed symptomatology. high goal-directed activity. & Winters. higher scores on the BAS Fun Seeking scale were related to higher mania symptom scores. they found hypersecretion of cortisol and slower recovery to normal cortisol levels. In contrast.J. Krauss. Meyer.. though questions have necessarily been asked about whether this self-report measure does measure the same construct as the psychophysiological and behavioural measures of BIS/BAS that have been used in the laboratory (cf. There is some evidence therefore in support of the claim that goal attainment and goal loss or interruption are hyper-valenced in the bipolar disorders..e. They found that the BAS (especially Reward Responsiveness) was predictive of increases in manic symptoms over time but was not predictive of changes in depression. Goplerud & Depue. in particular in the combination of both BAS and BIS in the correlation with depression scores. are characteristic of the depressed phase. and high positive emotions are characteristic of high levels of BAS activity and of hypomania. Beevers. with the additional feature that bipolar individuals continue to attempt to increase positive affect after goal attainment with increased goal pursuit. A subsequent study from the same research group (Meyer. For example. the pursuit of desired goals). and Reward Responsiveness. Wright & Lam.
A further inconsistent finding was reported in an epidemiological study of over 1800 19–21 year olds (Johnson et al. 2005) that. contrary to the current classification of bipolar disorders. A similar analysis of affect space is proposed by Watson et al. (1988). Perhaps the major limitation can be highlighted when the theory is placed in the context of other two-dimensional approaches to motivation and affect. is what exactly are the two dimensions. but none of the expected differences were found on the BAS scales. However. whereas the phenomena of the emotional disorders suggest otherwise (e. There are a number of major limitations of the BAS/BIS approach in addition to some of the issues already raised. to more sophisticated emotion-based theories which will be returned to later (see e. 1999). which would indicate that the BIS is simply a state marker but not a vulnerability factor. Carver and White’s (1994) analysis argues that BAS is related to positive affect and BIS to negative affect and that these two dimensions are orthogonal to each other. Gray developed his comparator model illustrated above (see Fig. an alternative option might be to argue as Johnson et al. in addition to the question of whether or not the self-report measure correctly operationalises the construct. Lane & Nadel. Russell & Carroll. Even within the study of self-reported affect.g. in which the function of consciousness is that of an error-detector for the interruption of automatic processes (e. Although there are still recent equivalents of the BAS/BIS such as in Rolls (1999) reinforcement-based theory of emotion. The evidence for this complexity is wide-ranging in the areas of emotion and motivation. For example. The Meyer et al (2001) clinical study needs of course to be replicated in a larger sample. such an approach simplifies the concept of the self and of consciousness. Ekman.g. Dalgleish & Power. but there still remains the problem for the BIS/BAS approach of why neither BIS nor BAS were predictive of depression. dominant in the 1950s and 1960s. in which the two orthogonal dimensions are explicitly labeled Positive Affect and Negative Affect. but. it does question the relevance of the BIS/BAS approach to bipolar disorders.J. which share some of the same limitations. the evidence is far from clear-cut that any of the two-dimensional approaches are sufficient.g.g. 1992) and increasing evidence of specific-emotion linked neuroanatomical circuits that underlie different emotions but which are not capturable simply by a positive-negative distinction (e. 2004a).. which found significantly higher levels of BIS in respondents with a lifetime-ever diagnosis of depression. Notwithstanding these contradictions within the two-dimensional approach is the problem that although the self-report of conscious affect might be captured by dimensions such as Valence and Arousal. with each varying from High to Low. for a dramatic example of such a change). 2000). 1966. mania and depression are not inherently linked but simply show high levels co-morbidity. However. like with the other two-dimensional approaches. in press). Power / Clinical Psychology Review 25 (2005) 1101–1122 1105 later levels of depression. the underlying functional and neuroanatomical systems may be far more complex and not best described by such systems. & Winters. The question therefore for the BIS/BAS approach. Cuellar. Johnson. 2003). but includes work in favour of basic emotions (e. Gray. 1) to include a theory of consciousness and the self.g. a contrary approach is that Positive–Negative (or Pleasant–Unpleasant) forms a single bipolar dimension with Arousal or Activation as the second orthogonal dimension (e. 1991. in this case. for example.M. . the linking of BAS to mania but not depression would be consistent.g. and how do they deal with the contradictory evidence base? The limitations of the BIS/BAS approach are also paralleled in the shift from the all-embracing concept of stress. Again. Lazarus. with the assumption that both are unitary constructions. have done subsequently (e.g. how do they map onto emotion and mood. 1999). these approaches simplify the complex phenomena which they attempt to explain. contrary to many of the assumptions to date (Power. together with the other inconsistent findings.
Reilly-Harrington. and Whitehouse (1999) found that the interaction between negative life events and cognitive style as measured by the Attributional Style Questionnaire or the Dysfunctional Attitudes Scale (DAS) was predictive of both depressive symptoms and manic symptoms at 1-month follow-up. Shaw. in the sense that they assume the basic cognitive therapy model outlined in Fig. Jones. Beck. 2002) and by Lam et al. Fresco. 1979). . that is. may lead to bactivationQ of the dysfunctional schema in that the person no longer believes that he or she is lovable. Wright & Lam. ReillyHarrington. (2002) have argued in bipolar disorders that schemas act in a bbidirectionalQ way. Rush. for example. events that lead to sleep disruption or to successful goal pursuits may be more likely to trigger mania. the polarity of the schema shifts with mood state and life events from one extreme to the other. criticism and rejection from parents) FORMULATION OF DYSFUNCTIONAL ASSUMPTIONS (e.J. bipolar disorders. 2. In a study of students with lifetime-ever diagnosis of bipolar disorders. The two main presentations of the adaptation to bipolar disorders by Beck et al. from at one time representing that they are totally unlovable to another time representing that everybody loves them. for example. Beck’s Cognitive Therapy model. loss events) ACTIVATION OF ASSUMPTION NEGATIVE AUTOMATIC THOUGHTS DEPRESSION Fig. which in turn cause the onset of the relevant mood such as the depressed state in the vulnerable individual. and. schizophrenia. 2 (based on Beck. Alloy. Power / Clinical Psychology Review 25 (2005) 1101–1122 3. & Emery. 1999. Newman et al. 2004) are both relatively informal. Leahy. personality disorders. bI am a failureQ. (Lam.g. The activation of the dysfunctional beliefs causes the production of negative automatic thoughts (e. & Gyulai. etc. In summary. Hayward. with the main differences being the types of dysfunctional attitudes or schemas that are implicated.1106 M. (Newman. more recently. This classic Cognitive Therapy model of unipolar depression has now been adapted to a number of different disorders that include anxiety disorders. unless I am loved I am worthless) CRITICAL INCIDENTS (e. model is therefore also a diathesis-stress model in which different types of life events may be related to different manic or depressive states. in the transition from adolescence to adulthood.g. & Bright. A EARLY EXPERIENCE (e. The Newman et al. even though a schema might focus on lovability.g. 2. or believes that he or she has been a failure throughout life. bI am unlovableQ. The cognitive therapy model An outline of the classic Cognitive Therapy model of unipolar depression is presented in Fig. childhood experiences lead to the development of dysfunctional schemas that centre around themes such as the need to be loved or the need to achieve.).g. Disconfirming experiences or life events later in life.
One can only feel sorry for the sheer amount of work that poor dysfunctional attitudes (and this is not to deny the role of other cognitive processes such as memory.g. which has focussed on specific subsets of dysfunctional attitudes. infallibility of predictions. success in which is postulated to lead to euphoria (see Fig. However. The second main cognitive therapy model has been presented by Lam et al. on the Rosenberg SelfEsteem Scale hypomanic participants were found to score somewhat higher on both the Positive Esteem and the Negative Esteem subscales in comparison to the remitted and depressed bipolar participants. attention. The hypomanic participants were found to score at intermediate levels between the remitted and the depressed groups on dysfunctional attitudes. but the authors reported that cognitive factors such as the DAS are not predictive of changes in manic symptoms. eventually there will be a disorder for each dysfunctional attitude! The serious points here are summarised in the following points. However. (2000) offer support for the proposal that specifically goal-attainment life events rather than positive events in general are related to increases in manic symptoms. bI do not need the approval of other people to be happyQ). 1994). Criticisms of the Cognitive Therapy model. (1) The classic Cognitive Therapy framework has too simple a monolithic view of the self-concept. 2003) compared bipolar participants who were either remitted. and disruption of normal routines. like with the BAS/BIS approach. Wright. bIf I try hard enough. the dysfunctional attitudes that are characteristic in bipolar disorder include goal-striving. including those attitudes related to Perfectionism or goal-attainment. and reasoning) are having to do as the Cognitive Therapy model is extended to more and more disorders (and I make this criticism as a one-time fan of dysfunctional attitudes—see e.M.. In order to test the model. exploratory factor analysis suggested factors that included bgoal-attainmentQ (e. and Scott. Power et al. findings such as these suggest that the name bbipolar disorderQ is a misnomer in itself. as noted in the BAS comments above. A further study by Scott (Scott & Pope. hypomanic or depressed at the time of the assessment. and control over outcomes. A positive feedback loop in vulnerable individuals leads to attempts to enhance positive mood state with increasingly driven goal-attainment behaviour. it is unclear how a single schema would change its content and processing features so . Johnson et al. two factors that distinguished the bipolar patients from a comparison sample of unipolar patients. These findings again. this problem is highlighted in the need for bbidirectional schemasQ in the adaptation for bipolar disorders. Moreover. nor do they report the relevant analyses that would have fully tested the predictor models.g. have to begin with a focus on the simplicity of the model. I should be able to excel at anything I attemptQ) and bantidependencyQ (e. Lam. manic individuals tend to be brisk-loversQ in which their decision-making processes assume unlimited resources. Consistent therefore with the proposals for the BAS approach discussed above.g. their results for mania are inconclusive because they did not examine subscales of the DAS. Stanton. and Smith (2004) used the Dysfunctional Attitude Scale with a sample of 143 Bipolar Type 1 patients. (1999). which can either be overly positive or overly negative according to context and mood. As Leahy (1999) has proposed. Garland. demonstrate that the hypomanic/manic phases of bipolar disorders are not simply the positive opposite of the negative depressed phases. disregard of feedback from others (exacerbated by activation of the bantidependencyQ beliefs). Indeed.J. Power / Clinical Psychology Review 25 (2005) 1101–1122 1107 further study by Johnson and Fingerhut (2004) of 60 Bipolar 1 individuals reported support for the DAS being predictive of depressive symptomatology at 6 month follow-up. and Ferrier (2000) found that euthymic bipolar individuals continued to show elevated scores on dysfunctional attitudes related to Perfectionism in addition to continuing to display social problemsolving difficulties (as measured by the Means-Ends Problem-Solving procedure). 3).
I should be happy all the time 2. see Power & Dalgleish.g. (2) The classic Cognitive Therapy framework has a single level of information processing (as do many other classic models of stress and emotion. the approach is neutral on what emotions are. Power / Clinical Psychology Review 25 (2005) 1101–1122 DYSFUNCTIONAL ATTITUDES Goal Attainment: 1. which will be presented later. in Clark’s. whether they can combine or be in conflict with each other. Nevertheless. model of panic). and so on. dramatically in order at one time to be excessively positive and at a later time to be excessively negative. (2002). whether or not they relate to each other or stand alone. though of necessity feedback loops have been added into cognition-emotion cycles in subsequent cognitive therapy models (e. The main tenet of the original model was that cognition (e. (3) The Cognitive Therapy approach has an overly cognitive and inadequate theory of emotion. In other .J.1108 M. which limits the explanatory power of the model and which weakens it in comparison to modern multi-level information processing approaches such as ICS and SPAARS. 1986. A more elegant solution would be to consider the more complex self-concept structures that have been considered in social cognitive psychology (see later). 1997). 3.g. nor is this problem tackled by Newman et al. A person should do well at everything he undertakes MOOD Euphoric or dysphoric Mood BIOLOGICAL Genetic predisposition to manic depressive illness BEHAVIOUR Relating to Mania: Highly driven behaviour Lack of routine etc Relating to Depression: Self-blame for failure to meet standards Rumination about negative implications of depressive symptoms etc Fig. Negative Automatic Thoughts) causes emotion. Lam’s Dysfunctional Attitude model. how they develop.
(4) Adaptations only to the content of schemas/attitudes are insufficient to capture the actual differences between the full range of psychological disorders (Power & Champion. The approach basically draws on social-psychodynamic models that reflect for example the influence of the social psychoanalytic approach of Harry Stack Sullivan (1953) in the US. Grief—the loss of a significant other. The IPT approach to depression was originally developed as a control intervention in a pharmacotherapy trial for unipolar depression. there is no theory of emotion within Cognitive Therapy. the elevation of negative emotions as well as positive. 2000) for the treatment of unipolar depression. the transition from adolescence to adulthood. Power / Clinical Psychology Review 25 (2005) 1101–1122 1109 words. Frank. Nevertheless. 1988.g. the elevation of negative beliefs and negative self-esteem as well as positive beliefs and positive self-esteem. together with a circadian rhythm model developed by the IPT group at the University of Pittsburgh (Ehlers. & Kupfer. Role Transitions—for example.J. . & Chevron. The first phase focuses on assessment and formulation. 2004). it is possible to begin to locate the approach theoretically in a post-hoc fashion as it has developed into an evidence-based approach for unipolar depression. Power & Dalgleish. Swartz. 1990. retirement. but bemotionsQ are givens within the model that do not need further theoretical deconstruction. The second phase of therapy selects one of four focus areas on which to base the intervention: 1) 2) 3) 4) Interpersonal Role Disputes—for example. 1989). IPT includes the so-called Interpersonal Inventory which is an interview assessment of the social network and social support of the client. Weismann. Rounsaville. In addition to history and diagnostic interviewing. The complex phenomenology of manic episodes cannot simply be accounted for by successful goal-attainment leading to the activation of positive goal-attainment schema. Goodwin & Jamison. combined with the equal influence in the US of the social psychiatrist Adolf Meyer (1957). 4. 1984.M. IPT works with three phases in therapy. Markowitz. 1997). Frank. The findings also add weight to the view that mania is not the polar opposite of depression. 1988. Klerman. marital conflict. 1986. It is deliberately pragmatic rather than theoretical in its approach. Weissman. The presentation of the model is therefore necessarily different to the other models in this paper because of the originators explicit disavowal of theory in favour of practitioners’ anecdotal accounts of what worked for them in therapy. problems at work. Spielvogle. et al. but they have been the only group to have developed it into a framework in which to understand bipolar disorders combined with a clinical intervention. all point to the need for more sophisticated models of the type to be considered later. & Kupfer. The interpersonal and social rhythm therapy (IPSRT) approach The IPSRT approach to bipolar disorders combines the Interpersonal Psychotherapy approach developed by Weissman. The Pittsburgh group have of course not been the only researchers and clinicians to have identified the significance of circadian rhythm disruption in bipolar disorders (see e. in that Weissman and Klerman interviewed expert colleagues about how they worked in practice with their depressed clients. & Klerman. The focus therefore will be on the IPSRT model rather than the earlier circadian dysrhythmia models. Interpersonal Deficits problems in establishing and maintaining relationships. (Klerman. A theory of emotional disorder that does not provide a theory of emotion is sadly lacking in its scope. Healy & Williams.
but again is also a feature of other bipolar interventions (SIGN. multi-system approaches. in contrast to some of the earlier models discussed above. it is unclear how the four focus areas of IPT derived for unipolar depressions map onto bipolar disorders given evidence from elsewhere pointing to for example the importance of goal-related events rather than positive or negative events in general (Johnson. which vary from occasion to occasion and from emotion to emotion. one cannot simply point at the model and say this is the bemotion boxQ: emotion is a process distributed over many subsystems and represents a high-level integration of a variety of such processes. or when certain prodromes or early warning signs of a manic or depressive episode are identified (a feature that is now also characteristic of most CBT approaches to bipolar disorders and is of proven efficacy. & Ritenour. the strengths of IPSRT and CBT approaches are in the boundaries they set for other more theoretically-driven approaches to bipolar disorders. 2002). 1985. Power / Clinical Psychology Review 25 (2005) 1101–1122 The third and final phase of the therapy is the Termination phase in which the therapist works to establish therapeutic gains and to deal with the issues arising from the ending of therapy. just as it would be possible to do this with Cognitive Behaviour Therapy (Power. Frank. However. 2004. the second set is the . see Lam et al. Similar to Cognitive Therapy therefore.1110 M. 1993) is a recent exemplar of one of a class of multi-level. in addition to their potential application to emotion. Other weaknesses of the IPSRT approach follow from this lack of theory. Barnard & Teasdale. 1991. The plan then is to regularise social rhythms. Perry et al. SIGN. relapse. can provide accounts of a wide variety of cognitive skills and processes. The link between cognition and emotion is not easily pinned down in such models. to monitor mood. it would be possible to map IPSRT onto one of several viable theories. so in many ways the theoretical base of the approach is seen as secondary to the question of whether or not the intervention works. which. good science requires good theory for the development and testing of hypotheses. 2004. especially under circumstances of vulnerability for the individual. Schwannauer. Because of the focus on application and intervention. Kupfer. 2000). IPSRT is primarily a treatment-driven approach to bipolar disorders. The Social Rhythm Metric (SRM) (Monk. We will turn therefore to two multilevel cognitive approaches to emotion. and the periodicity of the disorders. 1991) is completed as part of the assessment. thus. The SRM seeks to identify specific triggers that are likely to disrupt normal social rhythms for the individual. 2005). The interacting cognitive subsystems (ICS) approach The Interacting Cognitive Subsystems (ICS) approach (Barnard. 1999. Teasdale & Barnard. maintenance. The second main feature of IPSRT is its focus on social circadian rhythms. Weissman et al. and for the clinical insights that they offer into factors associated with onset. 5. Other characteristics of the therapy include its short-term here-and-now focus (see Klerman et al.. because the relationship is seen as complex and interactive and so. recovery. 1999. and to monitor social interactions.J. Psychoeducation about bipolar disorders is also a key component. both of which have been derived as more general frameworks but both of which have recently been adapted specifically for bipolar disorders. 2005)... thus. 1984. there is a loose mapping between theory and practice. it is unclear how important circadian and other dysrhythmias are for both mania and depression and to what extent they can account for all features of symptomatology. 2005).. There are nine main cognitive subsystems in Teasdale and Barnard’s (1993) ICS approach: the first set of subsystems is sensory-related and includes the Acoustic and Visual subsystems. The lack of an explicit theoretical base for IPT and for IPSRT has to be therefore its major weakness.
Rather than provide a detailed description of all subsystems however. Johnson-Laird. Teasdale and Barnard’s ICS model. the Implicational. Although ICS is not alone in considering emotion to be the result of processing in multiple cognitive systems (see for example Leventhal and Scherer’s. and the Propositional subsystems. the higher level semantic representations at the Implicational level in ICS are referred to as dschematic modelsT. the phrases dTony BlairT or dGeorge BushT do not have truth values in themselves but are merely names about which nothing is asserted. Power / Clinical Psychology Review 25 (2005) 1101–1122 1111 Central subsystems and includes the Morphonolexical. the Body State. namely. 4. and the Object subsystems.M. the focus will be one those that are especially important in the occurrence of emotion. schematic models combine information from a variety of sources and are more generic and holistic and integrate information from other subsystems. Only when they are included in larger units such as dTony Blair eats British beefT or dGeorge Bush is a fine politicianT do the units become propositional because they are either true or false. Teasdale and Barnard argue that much of the challenging of negative thoughts and beliefs in standard Cognitive Therapy occurs at the propositional level and may often ignore the higher level PROPOSITIONAL SUB-SYSTEM VISUAL SUB-SYSTEM IMPLICATIONAL SUB-SYSTEM BODY STATE SUB-SYSTEM Fig. it provides one of the most detailed and elegant multi-system approaches to the understanding of emotion. and the Limb subsystems. Power. the Propositional. These two systems represent a common distinction made in psycholinguistics because of the need to have both multiple levels and multiple representations in models of the comprehension and production of language (e.g. model). In the approach therefore emotion is treated as a distributed phenomenon that is the result of the combination within the Implicational subsystem of outputs from a number of cognitive subsystems rather than simply being the output from a specific cognitive appraisal. 1983). we have highlighted three possible inputs to the Implicational subsystem from the Visual. that Cognitive Therapy focuses on a single level of meaning. thus. whereas profit can be had from considering two levels of meaning such as propositions and mental models. 4. In relation to emotion.g. 1987. In contrast. In the simplified example shown in Fig. Teasdale and Barnard (1993) also extend an earlier criticism of Cognitive Therapy made by Power and Champion (1986). so. The units of representation in the Propositional subsystem are propositions.J. These subsystems process information partly in parallel and partly sequentially according to the type of task and other requirements acting on the overall system. within ICS. 4. 1986). the Body State. These four subsystems together are the most important ones in the production of emotion in the ICS approach. schematic models draw upon the whole range of other subsystems feeding information into the Implicational subsystem. the key subsystems are the so-called Propositional and Implicational. and the third set is Affector subsystems and includes the Articulatory. Like the more commonly used dmental modelsT approach (e. . which are the smallest semantic units that can have a truth value. as illustrated in Fig.
but becomes more depressed rather than less depressed because for example a higher level model is confirmed in which the individual is always wrong. Barnard considers variation in four sets of processes: (1) (2) (3) (4) the the the the content of semantic representations. Cooper. rate of change in mental images. 2004). thus. the subsystems could be treated as functional modules within a modular processing system. Sheppard and Teasdale (2000) have replicated this . In depression. not just its account of bipolar disorders. or. the Implicational and Propositional systems are considered to enter a state of interlock. inconsistent with each other. in which schematic models continually generate negative propositions which in turn feedback to the Implicational system thereby regenerating the original schematic model. it could be argued that the cognitive subsystems were simply a functional description of a set of processes that were instantiated in the brain in a radically different fashion (see Gazzaniga. In the extension of ICS to a range of psychopathology. in such states. it is too soon to judge the ICS approach to bipolar disorders because of its recent and only sketchy development. there is some flexibility about which particular theory a framework can instantiate. Taylor. However. there is a degree to which it is not falsifiable. alternatively.1112 M. it remains to be seen how useful the ICS approach is from both the empirical point of view and the clinical point of view. 1988. for an excellent discussion of this issue in relation to modularity). but under more extreme circumstances can lead to delusional models. Overall. and Paykel (1995) who found that depressed patients completed sentence stems with positive words or phrases consistent with high-level schematic models rather than simply offering negative sentence completions which might be predicted by theories such as Beck’s or Bower’s. Hayhurst. there is little or no reflection on specific propositional meanings. which then has consequences for the integration of information arising from other subsystems. some interesting preliminary supporting data for the ICS account of unipolar depression have been presented by Teasdale. Schizophrenia is considered to arise from desynchrony between schematic and propositional levels of meaning. in mania the opposite occurs and propositional and implicational meanings are said to enter a brunaway stateQ. the low level cognitive architecture for ICS could be based on connectionist networks. which under optimal conditions can lead to imaginative thinking.J. The adaptation of the ICS approach to bipolar disorders has recently been outlined by Barnard (2003. In relation to emotion. the net outcome of such a process can be that the individual is browbeaten into rejecting the negative proposition. ICS is of course a general cognitive model that will stand or fall on how useful an account it provides of a wide range of cognitive processes. Barnard proposes that the same mechanism may underlie the production of delusions in mania when combined with the fast rate of processing. which permits the development of models and meanings that are unscrutinised. but it could be based on a viable alternative. synchronization of the processes that generate meaning. For example. Because it is in part a framework and in part a theory. Power / Clinical Psychology Review 25 (2005) 1101–1122 Implicational meaning. By contrast to this low rate of change in depression. mode in which processes operate. In contrast therefore to the depressed state in which propositional and implicational meanings become binterlockedQ. Partial products from fast changing schematic models might then combine to form new schematic models. in which he also considers its application to schizophrenia. schematic models are seen to have a high rate of change in mania and involve the processing of positive or mixed schematic models but with largely unevaluated propositional representations thereby remaining outside of focal awareness. and rapidly changing.
1976) in which. ICS appears to swim against the tide of current goal-based appraisal theories of emotion that we have highlighted elsewhere (Power & Dalgleish. emotion is considered to be integrative across multiple processes and systems and not identifiable with any one of them. analogical. an appraisal of the interpretation especially in relation to goal relevance. if any. while not disputing that it is advantageous to make distinctions between different levels of meaning. the auditory. 1997). nor is it clear what unique implications. However. nor can emotion be equated with the physiology and overt behaviour. with the possible exceptions of conscious awareness and overt behaviour. The schematic. associative representation systems (SPAARS) approach On the basis of more recent philosophical and psychological models (Power & Dalgleish. the Associative and the Analogical). less positive way. a number of components of emotion can be identified. For the present however we believe that the tide is running in the right direction and will provide the direction that will be taken in the next section. an action potential or tendency to action. Swimming against the tide is obviously not a criticism in itself and may.M. but it lacks a sophisticated theory of emotion. and associative levels may occur in parallel in a manner comparable to Leventhal’s (e. The SPAARS cognitive model of emotion is summarised in Fig. the approach has for therapeutic practice with the bipolar disorders. 1997). the proprioceptive. The importance of such systems in emotions and emotional disorders is clearly evident for example in Post Traumatic Stress Disorder (Dalgleish & Power. such a process is not an explicit feature of the ICS approach in contrast to the SPAARS model to be considered next. an interpretation. In this manner therefore. ICS incorporates a highly sophisticated cognitive theory. 2004b) in which certain sights. indeed. As with ICS. 1980) early influential multi-level theory. All of these components are present normally in an emotion episode. mood-improved patients presented completed sentence stems in a more functional.J. the Propositional. emotion is generated in ICS via a pattern-matching process. 6. 5 (the letters are merely a mnemonic for the different types of representation systems—the Schematic Model. in SPAARS the processing of the schematic. It would of course be possible for these representation systems to be ordered sequentially thereby forming a single level along the lines of the original cognitive therapy model (Beck. prove to be remarkably percipient. The approach is multi-level and includes four different levels of representation. thus. the tactile. propositional. and overt behaviour. and the olfactory which we have grouped together and termed the Analogical representation system. an initiating event (external or internal). We might note however that the central distinction between the Propositional and the Implicational levels of meaning may not be as clear-cut in practice as it appears. Power / Clinical Psychology Review 25 (2005) 1101–1122 1113 finding and have also shown that at 2 months follow-up. schemas produce negative automatic thoughts (propositional representations) which then cause the emotion.g. albeit a sophisticated set of such processes. of course. for example. a physiological reaction. sounds or other bodily sensations may become . The initial processing of stimuli occurs through a number of mode-specific or sensory-specific systems such as the visual. we have suggested that the concept of demotionT is a holistic one that typically includes all of these components. propositional. although it might be argued that goal-based discrepancies can be modeled within ICS. Ultimately. but that emotion is not identifiable with any one component. This approach is contrary to prior theories that have equated emotion for example with the conscious bfeelingQ (as in the so-called bfeeling theoriesQ). but which in practice also constitute a set of parallel processing modules. conscious awareness.
a level that is designed to integrate information in a flexible and dynamic fashion in combination with the advantages of the more traditional schema approach. The term is taken from Teasdale and Barnard (1993). the emotion-laden nature of which may become acutely apparent to the individual following for example bereavement when names and places associated with the loved one can trigger overwhelming feelings of sadness. but instead argue that they feed either through appraisals at the schematic model level or directly through the associative route (in contrast to Teasdale & Barnard. or Williams. 5. for further discussion of bcognitive architecturesQ). For example. Although such propositional representations have played a key role in the generation of emotion in a number of theories. could take the form of a number of modularised connectionist networks (see e.1114 M. 1993). illustrated above in Fig.g. 5. which provides a good account of repetitive and invariant relationships . anger. The output from analogical processing then feeds into the three representation systems that operate in parallel. Power / Clinical Psychology Review 25 (2005) 1101–1122 SCHEMATIC MODEL LEVEL Route 1 EVENT ANALOGICAL SYSTEM ASSOCIATIVE LEVEL Route 2 PROPOSITIONAL LEVEL Fig. 1953). MacLeod. & Mathews. Power & Dalgleish.J. such as the role of propositional level automatic thoughts in Beck’s Cognitive Therapy discussed earlier. Watts. The highest level of semantic representation. 1993). swear words come in a whole range of culture-specific forms. 1998. 1999). Each individual accumulates a set of unique personal words and phrases which may also directly access emotion through the associative route: significant names and significant places provide two such examples (cf. 1997. At the lower level there is an associative system which. 1983). is labeled the Schematic Model level. thus. Cherry. in terms of possible architectures. it is designed to capture the advantages of a mental model level of representation (Johnson-Laird. the classic dcocktail party phenomenonT of hearing one’s name spoken whilst engaged in another conversation. Power and Dalgleish’s SPAARS model. inherent parts of the memory and experience of a traumatic event. These words and phrases are normally designed to elicit an emotional reaction in the recipient. we propose that there is no direct route from propositions to emotion (in agreement with Teasdale & Barnard. The intermediate level of semantic representation within SPAARS is the Propositional level. which is typically through the direct access associative route. and other emotions (Power. This is the most language-like level of representation. particular words or phrases may become directly linked to emotion for certain individuals.
Basic emotions are also considered to be the building blocks from which more complex emotions are derived. Power & Dalgleish. For example. currently depressed bipolar patients gave characteristic self-related attributions for negative events. Although this line of work might be interpretable in the light of the purported psychodynamic defense mechanism. 5). Kahneman & Miller. in which mania is seen to be a defense against an underlying state of depression (see studies by Winters & Neale.M. has gone largely unrecognised in relation to both the emotional disorders and a number of other drive-related disorders (Power & Dalgleish. 1997). 1986). In relation to emotion. they are typically considered to originate in innate systems. 1997). the Schematic Model level is extremely important because it is at this level that the generation of emotion occurs through the process of effortful appraisal (shown as Route 1 in Fig. or goals. For example. the processes become autonomous and encapsulated and are not easily interruptable) around particular self-aspects such as certain emotions. Startup. Watson & Clark. and Bentall (1999) found that on an explicit test of attributional style. Ekman. Although previous theorists have derived depression from other combinations.e. Fear and Disgust and that all other emotions can be derived from this basic set. and to appear early during the infant’s development (e. Lewin. whereas currently manic patients gave normal attributions. 1992). whether of external or internal origin. Anger. roles. turns disgust against the self because of perceived inadequacy or culpability. SPAARS follows the proposal made by Oatley & Johnson-Laird (1987) that there are five basic emotions of Sadness. some forms of unipolar depression may occur from the coupling of Sadness and Disgust in which the individual feels both sad because of some actual or imagined loss. that two or more emotions can be produced in parallel by the different Schematic and Associative routes.g. 1991.J. 1951). and the summary in Bentall & Kinderman. The advantage of a multi-level system such as SPAARS can be illustrated by reference to particular empirical and clinical findings that originate from work with the bipolar disorders. the currently manic patients showed the same negative biases that the depressed patients showed. A similar proposal has been made by Showers (1992) in her notion of bcompartmentalizationQ which shares some similarities with the modularisation . there now exist a number of models that have been applied to the normal self-concept and to the self-concept in unipolar depression that can be applied fruitfully to bipolar disorders. 2003). 1992). 1997). Lyon. Happiness. for example. 1997) has argued that the selfconcept can become bmodularisedQ (i. In relation to the self-concept. Power (1987. a process that leads to a state referred to as the bAmbivalent SelfQ. on implicit tests such as naming latencies and recall. 1987. 1985. according to the basic appraisal processes considered elsewhere (Oatley & Johnson-Laird. Power / Clinical Psychology Review 25 (2005) 1101–1122 1115 between concepts but which is weakest therefore where more flexible representations are needed (cf.g. or may involve the coupling of different semantic levels within an emotion module. The proposal in relation to a number of emotional disorders is that in many cases the coupling of two or more of these basic emotions provides the basis of the disorder. or that one emotion or mood state may replace another that is experienced more aversively (Power & Dalgleish. The key processes through this route include therefore the interpretation and appraisal of any relevant input. In contrast. 1999. An important feature of emotional disorder follows from the proposal in SPAARS that some of the disorders may be derived from the coupling of two or more basic emotions. but. there have been a number of studies following in the psychoanalytic tradition of the bmanic defenseQ (e. in addition. as will be discussed in detail later. as in SPAARS. be universal in their expression. it is suggested that disgust’s crucial role. it could equally be argued that. Freud (1917) derived Melancholia from Sadness and Anger. especially in the form of self-disgust. and more recent theorists have proposed that the comorbidity of depression and anxiety has theoretical implications (e.g. or in Bentall. Power & Dalgleish. For example.
bI’m a pretty good tennis player. This change at the Analogical level then feeds into the Schematic Model. Even in individuals with hypomania.e. as we have suggested recently. etc. there are raised levels of both positive and negative self-esteem on a straightforward self-report measure. and my serve could do with improving. Jones (2001) adaptation of SPAARS for bipolar disorders provides an excellent starting point within which to model some of the phenomena of the bipolar disorders. being a tennis player. so an account based on schematic and automatic processes seems preferable to one based solely on a defensive process. and implicit. as Scott and Pope (2003) have shown.). Such processes would appear to operate for example as if there was a bmanic defenseQ. and so on. and Lloyd (2002) used Shower’s card sort task to explore the self-concept in individuals with bipolar disorders.) are almost always entirely positive or entirely negative in their content. the bdepression defenseQ against mania if the same logic was followed. effortless. can begin to exacerbate and set up positive feedback loops around all of the systems. . the experience of a positive event. and Propositional Levels. 1997). it is clear that in bipolar individuals this dysfunctional self-organization represents part of the recurring vulnerability to the disorder. or simply a relief that a depressed episode has finished. models of feeling superior. In the meantime.g. being a lawyer. in bipolar disorders key self-aspects (e. the Associative level in SPAARS).e. That is.g. 1997) is that not only do positive feedback loops arise within emotion modules but that they can also arise between modules such that emotions themselves can . Two studies reported in Power. Part of the original SPAARS formulation (Power & Dalgleish.g. At the Associative level automatic appraisals and biases learned from previous experiences feed into the creation and perception of further experiences (e. but my backhand is a bit weak. it is easy to see how the currently dominant self-aspect would be part of a feedback system that maintained overly positive or overly negative mood states. . For example. whilst at the Propositional level propositions of the form bI feel good. being a lover. 6. at the Schematic Model level a positive model of hypomania. the SPAARS proposal is that so-called phenomena such as the bmanic defenseQ merely reflect multi-level processes in which some processes are conscious effortful and explicit. However. Power and Schmidt (2004) have also tried to develop the emotion theory side of SPAARS in order to cover additional aspects of bipolar disorders.Q abound and again form part of the positive feedback loops that serve to maintain and exacerbate the initial state of change at the Analogical level. .1116 M. being a mother. being a student. an increase in energy. the dominance of a positive self-aspect (i. . further enforced sleep deprivation and drug and alcohol abuse in an attempt to maintain the positive high whilst reducing negative aspects arising from exhaustion. the Analogical system becomes disrupted in a number of ways such as through circadian rhythms changing. a summary of which is presented in Fig. the dominant active Schematic Model in SPAARS) in mania would not prevent automatic processes occurring in currently non-dominant negative self-aspects (i. but SPAARS would equally predict the opposite bdefenseQ. whereas in parallel other processes are automatic. The results suggested that in Showers’ (1992) terms of bcompartmentalisationQ and in our two terms of bambivalent selfQ and bmodularisationQ (Power & Dalgleish. furthermore. Association. . etc. there is good replicable evidence that the self-concept is organised differently in bipolar disorders. The clinical and psychotherapeutic implications are likely to be considerable and well worth further exploration. .Q). Jones has suggested that within SPAARS.J. attractive. One explicit proposed application of the SPAARS model to bipolar disorders has been made by Steven Jones (2001). creative. it is clearly not the whole story. de Jong.Q as opposed to bI’m such a fantastic tennis player who should have been at Wimbledon. Power / Clinical Psychology Review 25 (2005) 1101–1122 proposal. With such modularised extreme self-aspects. Rather than go down this line however. whereas in non-bipolar controls the equivalent self-aspects are more often described with mixed positive and negative content (e.
rather. but these emotions tend to be experienced in an bimmersedQ way rather than in a selfreflective way (Dalgleish & Power.M. happiness and anxiety. We are currently engaged in an assessment of basic emotions in bipolar disorders that should address these predictions.g.g. episodes of mania may be better analysed as couplings of happiness and anger. the proposal in SPAARS is that the correct level of description of emotional disorders should begin with the basic emotions and their tendency to couple with each other. equivalently.. One of the possible implications of the coupling proposal in SPAARS is that. biases MANIA-LINKED EMOTIONS PROPOSITIONAL “I feel good.g. Part of the therapeutic endeavour in working .g. anxiety in dysphoric mania. One further point that can be made about the SPAARS approach to mania is that the fast-changing appraisals that occur because of high risk taking and self-created events may lead to fast-changing emotion couplings. Jones’ adaptation of the SPAARS model for bipolar disorders. In other words both mania and depression clearly can occur without each other (e. 6. or whatever. 2004a). included the proposal that unipolar depression may consist of the coupling of sadness and disgust. but. thereby reflecting the fact noted in the Introduction that most so-called manic states are actually bmixed statesQ when symptoms are carefully assessed (Cassidy et al. Power / Clinical Psychology Review 25 (2005) 1101–1122 SCHEMATIC MODEL Positive view of mania Feelings of superiority MANIA-LINKED EMOTIONS 1117 ANALOGICAL SYSTEM EVENT Circadian System Disruption. bdeath by panicQ in which automatic sequences are dominant). just as episodes of depression may be analysed within SPAARS as couplings of sadness and disgust or sadness and anxiety. become coupled and set up positive feedback loops between each other. We have recently argued that the conscious experience of emotion can vary according to whether the individual retains a self-reflective capacity during the emotion experience (e. noted above. attractive . creative.. the correlation of mania and depression may not represent the nosological entity that the terms bbipolar disorderQ or bmanic-depressionQ imply. In the case of mania.J. Our original analysis.” Fig. 1998). may simply represent co-morbidity. Increased Energy ASSOCIATIVE LEVEL Automatic appraisals. so. approximately 25% of individuals diagnosed with bipolar disorders never experience significant depression). have recently suggested (e. 2005). such as sadness in mixed states.. then happiness (elation) can become coupled with one or more other basic emotions.. and anger in irritable/aggressive episodes. Cuellar et al. as Johnson et al. a high level schematic model of bI am now having a panic attackQ) versus becomes completely immersed in the emotion and does not maintain a reflective capacity (e.
Moreover. the real test of the usefulness of SPAARS as a theory will be whether or not it makes testable empirical predictions. the ICS and the SPAARS models. In terms of the limitations of the SPAARS approach. there are many other criteria. it remains to be seen therefore whether or not it merely provides a very flexible framework in which to re-describe the phenomena of bipolar disorders. similar to the ICS model. but at the same time the unique clinical features of the bipolar disorders have not yet been clearly and explicitly modeled. however. 7. The SPAARS approach does at least begin to offer the level of intricacy needed for complex disorders such as the bipolar disorders. Final points and conclusions A very crude attempt to summarise some of the strengths and weaknesses of each model has been presented in Table 1. whether it has implications for clinical practice. their recent applications to these and to other disorders illustrate the potential strengths. with each of the 5 main models assessed against the three overarching criteria listed in the Introduction. Power / Clinical Psychology Review 25 (2005) 1101–1122 psychologically with mania must be therefore to help reinstate self-reflective schematic models of the self in order to interrupt the automatic positive appraisals and action sequences that Barnard (2003. It is clear that different models have different strengths and weaknesses and. these multi-level Table 1 A summary of the adequacy of the 5 main theories evaluated in terms of three summary criteria Clinical features of BD BIS/BAS Cognitive Therapy IPSRT ICS SPAARS Low Medium High Medium Medium Theoretical adequacy Low Medium Low High High Applicability to normal and abnormal High Medium Low High High . As apparent from Table 1. and the nosological derivation of emotional disorders.J. At a theoretical level. we believe that there are important empirical and clinical implications of the SPAARS model for both unipolar and bipolar disorders. the implications for the self-concept. provide the best ways forward for the foreseeable future. the application of SPAARS to the bipolar disorders is recent. specifically. though work by Jones (2001) has presented an important first step in this direction. Although neither ICS nor SPAARS were specifically developed to account for the bipolar disorders. we are not of the view that it is unfalsifiable in that key components and putative processes lead to very clear predictions about emotional conflict. the fact that it has so much explanatory power in that it can be applied to all normal emotions and to all emotional disorders might make it unfalsifiable as a framework because different specific theories can be incorporated. equally.1118 M. whether it adds to our understanding of these disorders. empirical predictions. ultimately. our conclusion is that current multi-level models of cognition and emotion. the coupling of emotions. or more detailed criteria against which the models can be tested. Nevertheless. 2004) has also recently commented on in the ICS approach. and therapeutic implications that these models may have. and. but these implications remain to be fully tested. the modularisation of emotions. As Power and Schmidt (2004) have suggested.
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