Clinical Psychology Review 25 2005 1043 1075 The psychosocial context of bipolar disorder Environmental cognitive and developmental risk factors Lauren B Alloy a T Lyn Y Abramson b Snezana Urosevic b Patricia D Walshaw a Robin Nusslock b Amy M Neeren a a Department of Psychology Temple University 1701 N 13th Street Philadelphia PA 19122 United States b University of Wisconsin Madison United States Received 13 October 2004 received in revised form 26 May 2005 accepted 13 June 2005 Abstract In this article we review empirical research on the role of individuals current environmental contexts cognitive styles and developmental histories as risk factors for the onset course and expression of bipolar spectrum disorders Our review is focused on the following overarching question Do psychosocial factors truly contribute risk to the onset course or expression of bipolar disorders As a secondary issue we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research Next we review the extant studies on the role of recent life events and supportive and nonsupportive social interactions current environment in bipolar disorders as well as psychosocial treatments designed to remediate these current environmental factors We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events including studies of cognitive behavioral therapies for bipolar disorder Finally we review studies of parenting and maltreatment histories in bipolar disorders We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions D 2005 Elsevier Ltd All rights reserved Keywords Bipolar disorder Environmental risk Cognitive risk Developmental risk T Corresponding author Tel 1 215 2047326 E mail address lalloy temple edu L B Alloy 0272 7358 see front matter D 2005 Elsevier Ltd All rights reserved doi 10 1016 j cpr 2005 06 006 1044 L B Alloy et al Clinical Psychology Review 25 2005 1043 1075 bMy temperament moods and illness clearly and deeply affected the relationships I had with others and the fabric of my work But my moods were themselves powerfully shaped by the same relationships and work The challenge was in learning to understand the complexity of this mutual beholdenness Q Jamison 1995 p 88 Like the disorder itself empirical and theoretical work on bipolar disorder has bseesawedQ back and forth between psychological and biological conceptualizations Despite the early pioneering work of Kraepelin 1921 emphasizing the psychosocial context of the disorder conceptions of bipolar disorder as a genetically based biological illness dominated over the past century Family twin and adoption studies suggesting that bipolar disorder has a strong genetic predisposition Goodwin Jamison 1990 Nurnberger Gershon 1992 and pharmacotherapy trials indicating the effectiveness of lithium and anticonvulsive drugs in controlling the cycling of bipolar disorder e g Keck McElroy 1996 shifted the focus to the disorder s biological underpinnings However in the past decade and a half there has been resurgence of interest in the role of psychosocial processes in the onset course expression and treatment of bipolar spectrum disorders This swing of the seesaw back again toward the inclusion of psychosocial factors in bipolarity research is largely attributable to researchers dual recognition that genetic and biological processes are unable to fully account for differences in the expression timing and polarity of symptoms O Connell 1986 and that lithium s and other drugs prophylactic effects are limited In fact a 1990 NIMH workshop report Prien Potter 1990 called for further exploration of the impact that psychosocial factors have on the course of bipolar disorder as well as the development of psychosocial treatments as an adjunct to pharmacotherapy Given that bipolar disorder is often a severe recurrent or unremitting illness with significant impairment including alcohol abuse suicide divorce and erratic work history Goodwin Jamison 1990 that affects about 1 5 of the U S population Hyman 2000 and between 0 5 and 3 5 of the world population Kleinman et al 2003 an understanding of the role of psychosocial factors in the onset course expression and treatment of this disorder has great importance Consequently in this article we review empirical research on individuals current environmental contexts cognitive personality styles and developmental histories as psychosocial risk factors for the onset course and expression of bipolar disorder as well as psychosocial treatments based on these putative risk factors The overarching question that provides the foundation for our review is Do psychosocial factors truly contribute to the onset course or expression of bipolar disorders Do they do so above and beyond the role of genetic predisposition Given that much of the research on the role of psychosocial factors in the psychopathology and treatment of bipolar disorders has evolved out of work on unipolar depression we also address a secondary question in our review Are the psychosocial factors that contribute risk to bipolar disorder similar or dissimilar to those found to be important in unipolar depression Research has provided support for a continuum or spectrum of severity within the bipolar category ranging from the milder subsyndromal Cyclothymia to Bipolar II disorder to full blown Bipolar I disorder Akiskal Djenderedjian Rosenthal Khani 1977 Akiskal Khani Scott Strauss 1979 Cassano et al 1999 Depue et al 1981 Goodwin Jamison 1990 Klein Depue Slater 1985 Waters 1979 Consequently our review covers studies on the full range of bipolar spectrum disorders We begin our article by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for such endeavors Next we review the extant studies on the role of recent life events and supportive and non supportive social interactions current environment in bipolar disorders as well as psychosocial treatments L B Alloy et al Clinical Psychology Review 25 2005 1043 1075 1045 designed to remediate these