The psychosocial context of bipolar disorder: Environmental, cognitive, and developmental risk factorsMethodological requirements of psychosocial risk research and challenges posed by bipolar spectrum disordersCurrent environment and bipolar disorder: role of life events and social supportRecent life events and bipolar disorderPsychosocial treatment based on life events: interpersonal and social rhythm therapySocial support and bipolar disorderPsychosocial treatment based on social support/EE: family-focused psychoeducationSummary of current environment findingsCognitive styles and bipolar disordersCross-sectional studies: cognitive styles in a depressed stateCross-sectional studies: cognitive styles in a manic/hypomanic stateCross-sectional studies: cognitive styles in a remitted/euthymic stateCross-sectional studies: comparisons of cognitive styles across mood statesLongitudinal studies: stability of cognitive styles within individuals across moodsLongitudinal studies: cognitive styles as predictors of bipolar courseLongitudinal studies: cognitive vulnerability × stress predictors of bipolar coursePsychosocial treatment based on cognitions: cognitive behavioral therapySummary of cognitive style findingsDevelopmental factors and bipolar disorderParenting/attachment historiesMaltreatment historiesSummary of developmental findingsConclusionAcknowledgementsReferencesThe psychosocial context of bipolar disorder: Environmental,cognitive, and developmental risk factorsLauren B. Alloya,T, Lyn Y. Abramsonb, Snezana Urosevicb, Patricia D. Walshawa,Robin Nusslockb, Amy M. NeerenaaDepartment of Psychology, Temple University, 1701 N. 13th Street, Philadelphia, PA 19122, United StatesbUniversity of Wisconsin–Madison, United StatesReceived 13 October 2004; received in revised form 26 May 2005; accepted 13 June 2005AbstractIn 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 bipolarspectrum disorders. Our review is focused on the following overarching question: Do psychosocial factors trulycontribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also addresswhether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin bydiscussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posedby bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role ofrecent 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 therole of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolardisorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolardisorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude withan assessment of the state of the psychos ocial risk factors literature in bipolar disorder with regard to our guidingquestions.D 2005 Elsevier Ltd. All rights reserved.Keywords: Bipolar disorder; Environmental risk; Cognitive risk; Developmental risk0272-7358/$ - see front matter D 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.cpr.2005.06.006T Corresponding author. Tel.: +1 215 2047326.E-mail address: [email protected] (L.B. Alloy).Clinical Psychology Review 25 (2005) 1043–1075bMy temperament, moods, and illness clearly, and deeply, affected the relationships I had withothers and the fabric of my work. But my moods were themselves powerfully shaped by the samerelationships and work. The challenge was in learning to understand the complexity of this mutualbeholdenness...Q (Jamison, 1995, p. 88)Like the disorder itself, empirical and theoretical work on bipolar disorder has bseesawedQ back andforth between psychological and biological conceptualizations. Despite the early pioneering work ofKraepelin (1921) emphasizing the psychosocial context of the disorder, conceptions of bipolar disorderas a genetically based, biological illness dominated over the past century. Family, twin, and adoptionstudies suggesting that bipolar disorder has a strong genetic predisposition (Goodwin & Jamison, 1990;Nurnberger & Gershon, 1992) and pharmacotherapy trials indicating the effectiveness of lithium andanticonvulsive drugs in controlling the cycling of bipolar disorder (e.g., Keck & McElroy, 1996) shiftedthe focus to the disorder’s biological underpinnings. However, in the past decade and a half, there hasbeen resurgence of interest in the role of psychosocial processes in the onset, course, expression, andtreatment of bipolar spectrum disorders. This swing of the seesaw back again toward the inclusion ofpsychosocial factors in bipolarity research is largely attributable to researchers’ dual recognition thatgenetic and biological processes are unable to fully account for differences in the expression, timing, andpolarity of symptoms (O’Connell, 1986) and that lithium’s and other drugs’ prophylactic effects arelimited. In fact, a 1990 NIMH workshop report (Prien & Potter, 1990) called for further exploration ofthe impact that psychosocial factors have on the course of bipolar disorder as well as the development ofpsychosocial 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), anunderstanding of the role of psychosocial factors in the onset, course, expression, and treatment of thisdisorder has great importance.Consequently, in this article, we review empirical research on individuals’ current environmentalcontexts, cognitive/personality styles, and developmental histories as psychosocial risk factors for theonset, course, and expression of bipolar disorder, as well as psychosocial treatments based on theseputative risk factors. The overarching question that provides the foundation for our review is: Dopsychosocial factors truly