Background This study looked to investigate the interaction between exercise and approach motivation (AM) levels in a non-clinical sample as a first step towards investigating the impact of acute exercise upon hypomanic states within Bipolar Disorder. The Behavioural Activation System (BAS) dysregulation theory proposes that AM levels in individuals with Bipolar Disorder, are hyper-reactive to relevant cues and prone to fluctuation such that excessive levels underpin hypomania/mania. We hypothesise that exercise may interact with high AM levels to further increase AM levels in both the general population and individuals with BD, with this effect being exacerbated in the latter group. As an initial test of this theory we explore the impact of moderate and vigorous exercise and sedentary activity upon AM in an unselected student sample. We also tested the extent to which hypomania vulnerability predicts the impact of exercise. Method Participants were recruited from a University student population. After completing a measure of hypomanic personality traits, 61 participants completed a task designed to induce higher levels of AM before taking part in one of three 15 min activities (sedentary, moderate exercise or vigorous exercise). AM levels as well as variables relevant to hypomanic symptoms were measured prior to and post AM induction, at 5 min intervals during the activities and twice during a recovery period. Results Vigorous exercise significantly increased individuals' AM levels in comparison to moderate or no exercise. No association was found between hypomania vulnerability and exercise impact. Conclusions These results provide a first step in investigating the possible risks associated with engaging in different intensities of exercise during a hypomanic episode. Any recommendations within this study should however be taken in light of the limitations identified. Further research replicating these results with a larger sample and among individuals with Bipolar Disorder is recommended.

Bipolar Disorders affect a substantial minority of the population and result in significant personal, social and economic costs. Understanding of the causes of, and consequently the most effective interventions for, this condition is an area requiring development. Drawing upon theories of Bipolar Disorder that propose the condition to be underpinned by dysregulation of systems governing behavioural activation or approach motivation, we present a mathematical model of the regulation of behavioural activation. The model is informed by non-linear, dynamical principles and as such proposes that the transition from "non-bipolar" to "bipolar" diagnostic status corresponds to a switch from mono- to multistability of behavioural activation level, rather than an increase in oscillation of mood. Consistent with descriptions of the behavioural activation or approach system in the literature, auto-activation and auto-inhibitory feedback is inherent within our model. Comparison between our model and empirical, observational data reveals that by increasing the non-linearity dimension in our model, important features of Bipolar Spectrum disorders are reproduced. Analysis from stochastic simulation of the system reveals the role of noise in behavioural activation regulation and indicates that an increase of nonlinearity promotes noise to jump scales from small fluctuations of activation levels to longer lasting, but less variable episodes. We conclude that further research is required to relate parameters of our model to key behavioural and biological variables observed in Bipolar Disorder.

Background: Bipolar affective disorder (BPAD) is characterised by a lifelong vulnerability to develop episodes of depressed or elevated mood in response to stressful life events involving achievement or failure. We hypothesised that this latent vulnerability can manifest as reactivity of affect and self-esteem to experimentally induced experiences of success and failure and is shaped by history of childhood adversity. Methods: Twenty-four people with remitted BPAD and twenty-four healthy controls underwent anagram-solving tasks designed to generate experiences of success and failure in two separate sessions. Positive and negative affect and implicit and explicit self-esteem were measured before and after each task. Early adversity was measured by Childhood Trauma Questionnaire. Results: People with BPAD showed larger reactivity of affect and explicit self-esteem in response to experimental success and failure than did healthy controls. There were no significant differences in reactivity of implicit self-esteem. History of childhood trauma predicted increased affective reactivity to failure but not to success. Limitations: We used a convenience sample. Conclusions: the present experimental paradigm reveals reactivity of affect and self-esteem as features of BPAD, which are present even during good remission and thus are accessible as targets of interventions aiming at relapse prevention. Differential associations with childhood adversity indicate aetiological heterogeneity, with reactivity to failure influenced by early trauma and reactivity to success driven by other mechanisms. © 2011 Elsevier B.V. All rights reserved.

Problem: Despite calls for physical activity (PA) to be prescribed to individuals with Bipolar Disorder (BD) as a means of improving physical and mental health there has been no systematic review of the potential health risks and benefits of increased PA for individuals with BD. This paper presents the first such review. Method: Systematic searches of six databases were conducted from database inception until January 2009, using a range of search terms to reflect both PA and BD. Studies were subsequently considered eligible if they reported on quantitative studies investigating the effect of PA upon some aspect of physical or mental health in individuals with BD. Results: of the 484 articles retrieved, six studies met the inclusion criteria. Discussion: Few studies have considered how PA may impact on the physical and mental health of people with BD. Nevertheless existing studies do suggest that physical activity interventions may be feasible and have a role in promoting mental health in this population. We discuss methodological, practical and ethical challenges to research in this area, and outline three research questions that future work should seek to address. Conclusions: Research into the efficacy and safety of PA as an intervention in BD is required to support the development of detailed, population-specific guidelines. © 2009 Elsevier Ltd. All rights reserved.

The current study tests a prediction of the behavioral activation system (BAS) dysregulation theory of bipolar disorder, namely that following high levels of reward or frustration, individuals with bipolar disorder will take longer than will healthy controls to recover to baseline levels of BAS activity. Eighty individuals (40 with bipolar I disorder, currently euthymic; 40 with no history of affective disorder) completed a daily diary over a 28 day period. No differences were found between the 2 groups in terms of the relation among levels of reward or frustration experienced, magnitude of initial response, or time taken to recover. However, examination of the relation between number of previous episodes and time to recover revealed that history of mania was associated with prolonged activation following reward, whereas history of both mania and depression were associated with prolonged recovery following frustration. The findings do not support an association between lifetime diagnosis of bipolar disorder and slow recovery of BAS activity. Nevertheless, they offer tentative support for an association between number of previous episodes and slow recovery of BAS activity.

This study investigated the possibility that, in remitted bipolar I affective disorder, dysfunctional attitudes
are mood-state dependent. Participants were 120 individuals with remitted bipolar I disorder, remitted
unipolar depression, or no history of affective disorder. The Dysfunctional Attitudes Scale (DAS;
Weissman, 1979) was completed before and after positive or negative mood challenge. Following mood
increase, the bipolar group changed significantly less in DAS total score than did the other 2 groups, and
in goal-striving and achievement attitudes relative to the unipolar group. These findings did not provide
clear support for the mood-state dependency theory in bipolar disorder, arguing instead for the presence
in bipolar I disorder of dysfunctional cognitions that show characteristic resilience in the face of minor
positive mood increase.

Behavioural Activation (BA) is associated with a substantial evidence base for treatment of acute unipolar depression, and has promise as an easily disseminable psychological intervention for bipolar depression. Using a randomised multiple baseline case series design we examined the feasibility and acceptability of an adapted version of BA in a U.K. outpatient sample of 12 adults with acute bipolar depression. Participants were allocated at random to a 3–8 week wait period before being offered up to 20 sessions of BA. They completed outcome measures at intake, pre- and post-treatment and weekly symptom measures across the study period. Retention in therapy was high (11/12 participants completed the target minimum number of sessions), and all participants returning acceptability measures reported high levels of satisfaction with the intervention. No therapy-related serious adverse events were reported, nor were there exacerbations in manic symptoms that were judged to be a result of the intervention. The pattern of change on outcome measures is consistent with the potential for clinical benefit; six of the nine participants with a stable baseline showed clinically significant improvement on the primary outcome measure. The findings suggest adapted BA for bipolar depression is a feasible and acceptable approach that merits further investigation.

Background
The healthiness of children’s diets, and the success of interventions seeking to improve them, are hindered by children’s preferences for foods high in fat, salt and/or sugar over healthier options such as fruit and vegetables. Children’s food choices are often driven by hedonic factors such as taste rather than considerations of health and nutrition, meaning that educational approaches are unlikely to be successful on their own. Food Go/No-Go training (which sits in the family of motor response training and inhibition training tasks) is a computerised intervention that appears to target the automatic processes driving food choice (e.g. food liking/reward responses, and automatic motor responses) by requiring participants to inhibit their responses to certain foods in the context of a reaction time game. Chapter One presents an overview of the food Go/No-Go training literature.
Aims
In a series of experimental and feasibility studies, we aimed to answer the following questions: (i) can food Go/No-Go training lead to healthier food choices among children aged 4-11 years, (ii) how do variations in food Go/No-Go training tasks (e.g. different response signals, different delivery methods) impact the effectiveness of training on children’s food choices in relatively controlled settings, and (iii) how acceptable and feasible are different delivery methods of food Go/No-Go training for implementing in real-world environments?
Methods
Chapter Two presents four early experimental studies in a school setting, comparing the effects of food Go/No-Go training against a control task on children’s food choices in a hypothetical choice task. Chapter Three presents an experimental study (also in a school setting) exploring whether using evaluative response signals (happy and sad faces) enhances training effects on children’s food choices compared to neutral signals (green and red symbols). Chapter Four presents two feasibility studies exploring the delivery of computer-based Go/No-Go training to families via the internet. Chapter Five presents an experimental study in a school setting, comparing computer-based training and touchscreen-compatible app-based training against a control task. Chapter Six explores the feasibility of delivering app-based Go/No-Go training to families in a mixed-methods feasibility study taking a randomised controlled design. Finally, Chapter Seven presents a qualitative study, using a thematic analysis method to explore the experiences of parents in the UK who were engaged in family healthy eating efforts during the coronavirus pandemic. Chapter Eight summarises the research presented here, presents the results of mini meta-analyses of the studies included in this thesis, and suggests avenues for future research.
Results
In Chapter Two, children selected a significantly higher number of healthy foods after playing food Go/No-Go training compared to two different control tasks. In Chapter Three, no effect of food Go/No-Go training was observed (regardless of whether response signals were evaluative or neutral) which may have been due to large group sizes during testing (e.g. higher distraction and social influence during food choice). Attrition was high in the feasibility studies of Chapter Four, and feedback from parents suggested that the training would benefit from gamification and adaptation for touch-screens. In Chapter Five, computer-based (but not touch-screen app-based food Go/No-Go training) led to children choosing significantly higher numbers of healthy foods versus control - low statistical power may have masked an effect of app-based training. The feasibility study in Chapter Six met the majority of continuation criteria for feasibility and acceptability of the intervention and methods, however some families engaged very little with the food Go/No-Go training, and parent feedback indicated a number of ways the training could be optimised to enhance engagement. Chapter Seven revealed a number of challenges faced by parents during the UK lockdown in March 2020 (e.g. increased influence of children’s food requests on feeding decisions), reiterating why accessible interventions directly targeting children’s food preferences are needed in the wider toolkit of family-targeted healthy eating interventions. The mini meta-analyses in Chapter Eight suggested that both computer-based and app-based food Go/No-Go training significantly impact children’s food choices, but that the effect size for computer-based training is twice as large as that for app-based training, in line with research with this specific app with adult samples.

Conclusions
Overall, these studies indicate that food Go/No-Go training is a feasible, acceptable and effective tool that could be used to encourage healthier food choices among children. Further research should be undertaken to understand why the app-based training used in these studies yielded a smaller effect size than computer-based training, and whether an optimised, app-based intervention can be developed that both engages children and encourages them towards healthier food choices.

A broad range of evidence indicates that negative affect is a key motivator and a major risk factor in the development and maintenance of dependence. Consequently, modern psychological therapies approaches seek to address this motivational process. Three therapeutic approaches that specifically aim to disrupt the relationship between negative affect and drug choice have been identified: Cognitive Behavioural Therapy (CBT), Mindfulness Based Interventions (MBIs) and Affect Regulation Therapy (ART0. However, the active ingredients of these interventions are poorly understood while at the same time these interventions are costly and often time consuming. Consequently, there is a need for brief, evidence-based interventions which isolates the active ingredient which targets negative mood-induced drug motivation that can easily be delivered in different settings. To this end, this thesis tested a range of ‘therapeutic’ manipulations for their capacity to abolish the effect of laboratory negative affect induction on measures of alcohol motivation. This thesis trialled three potential interventions inspired by CBT, MBIs and ART. A CBT inspired intervention which paired negative affect drinking triggers with adaptive strategies in undergraduate student drinkers showed no evidence of limiting stress-induced alcohol motivation. A brief negative affect focused functional imagery intervention in which participants paired their own personalised negative affect triggers and adaptive strategies did abolish stress-induced alcohol motivation in the laboratory and increased self-efficacy of control over negative affect drinking in hazardous student drinkers online over a 2-week period. To further isolate the active ingredients four experiments tested whether the core component of MBIs, breath counting would abolish negative affect alcohol motivation. In all four experiments, breath counting attenuated negative affect-induced alcohol choice and craving in hazardous community drinkers. However, our last study showed that the effects of breath counting on stress-induced alcohol motivation were not superior to that of a visual distraction task, suggesting that the therapeutic effects of breath counting may stem from cognitive load. These findings provide preliminary evidence for the efficacy of these interventions and would justify future trials to explore their clinical utility in modifying actual drinking or relapse outcomes. The potential of acute interventions to modify drinking in the natural environment is challenged by the broad spectrum of environmental stressors which hazardous drinkers are subjected to.

A secondary analysis of the COBRA randomized controlled trial was conducted to examine how well Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA) repair anhedonia. Patients with current major depressive disorder (N = 440) were randomized to receive BA or CBT, and anhedonia and depression outcomes were measured after acute treatment (six months) and at two further follow up intervals (12 and 18 months). Anhedonia was assessed using the Snaith Hamilton Pleasure Scale (SHAPS; a measure of consummatory pleasure). Both CBT and BA led to significant improvements in anhedonia during acute treatment, with no significant difference between treatments. Participants remained above healthy population averages of anhedonia at six months, and there was no further significant improvement in anhedonia at 12-month or 18-month follow up. Greater baseline anhedonia severity predicted reduced repair of depression symptoms and fewer depression-free days across the follow-up period following both BA and CBT. The extent of anhedonia repair was less marked than the extent of depression repair across both treatment arms. These findings demonstrate that CBT and BA are similarly and only partially effective in treating anhedonia. Therefore, both therapies should be further refined or novel treatments should be developed in order better to treat anhedonia.

Depression is a debilitating and recurrent mental health problem. Although there are a number of effective psychological treatments for adult depression, around 50% of individuals do not recover (Cuijpers et al. 2021). To improve the effectiveness of these treatments we need to understand how they work. Previous research has identified times in treatment when there are patterns of discontinuous depression change and these times have been used to examine processes of change to further understand how treatments lead to depression change. The aim of this thesis was to build upon this research to further understand discontinuous depression changes in and outside of treatment, the processes of change surrounding these times of depression variability, and how they relate to treatment outcomes. This thesis primarily focused on two patterns of discontinuous change; rapid improvements in depression symptoms, known as ‘sudden gains’ (Tang & DeRubeis, 1999) and ‘depression spikes’ which are transient increases in depression symptoms (Hayes, Feldman, Beevers, et al. 2007). To examine this four studies were conducted. Study one investigated the rates, timing, and association with treatment outcomes of sudden gains and depression spikes in a large scale clinical practice dataset. Study two explored client cognitive and behavioural processes of change surrounding sudden gains in cognitive behavioural therapy (CBT) and behavioural activation (BA), and their association with treatment outcomes in a trial dataset. Study three used the same trial dataset to explore predictors of depression spikes in CBT and BA, and their relation to treatment outcomes. Study four focused on how cognitive and behavioural avoidance are associated with depression variability outside of treatment across a stressful life period in a student sample. The thesis ends with a discussion of the methodological,
theoretical, and clinical implications of the findings and suggestions for future research.

Behavioural experiments are an important component of cognitive-behavioural therapy. However, there exists little up-to-date guidance on how to conduct these in people with a diagnosis of bipolar disorder. This paper provides recommendations on how to conduct behavioural experiments in this population. The aim is to upskill and empower clinicians to conduct behavioural experiments. The paper combines the expertise of senior clinicians working in the United Kingdom. The article starts by providing general advice on conducting behavioural experiments in people with bipolar disorder. It then offers specific examples of behavioural experiments targeting cognitions around the uncontrollability and danger of affective states, and related behavioural strategies, which have been implicated in the maintenance of bipolar mood swings. The article finishes by providing examples of behavioural experiments for non-mood related difficulties that commonly occur with bipolar experiences including perfectionistic thinking, need for approval, and intrusive memories. Behavioural experiments offer a useful therapeutic technique for instigating cognitive and behavioural change in bipolar disorder. Conducted sensitively and collaboratively, in line with people's recovery-focused goals, behavioural experiments can be used to overcome mood- and non-mood related difficulties.

BACKGROUND: We sought to evaluate the acceptability of a psychological therapy programme (Therapy for Inter-episode Mood Variability in Bipolar Disorder (ThrIVe-B)) for individuals with ongoing bipolar mood instability and the feasibility and acceptability of potential trial procedures. We also evaluated the performance of clinical and process outcome measures and the extent to which the programme potentially represents a safe and effective intervention. METHOD: We conducted an open (uncontrolled) trial in which 12 individuals with a bipolar spectrum diagnosis commenced the ThrIVe-B programme after completing baseline assessments. The programme comprised 16 group skills training sessions plus individual sessions and a supporting smartphone application. Follow-up assessments were at therapy end-point and 6 months post-treatment. RESULTS: Nine participants completed treatment. Ten provided end-of-treatment data; of these, nine were satisfied with treatment. Interviews with participants and clinicians indicated that the treatment was broadly feasible and acceptable, with suggestions for improvements to content, delivery and study procedures. Exploration of change in symptoms was consistent with the potential for the intervention to represent a safe and effective intervention. CONCLUSIONS: Conducting further evaluation of this approach in similar settings is likely to be feasible, whilst patient reports and the pattern of clinical change observed suggest this approach holds promise for this patient group. Future research should include more than one study site and a comparison arm to address additional uncertainties prior to a definitive trial. TRIAL REGISTRATION: Trial Registration: ClinicalTrials.gov NCT02637401; registered 22.12.15 (retrospectively registered).

Abstract
Background
Anxiety is highly prevalent in people diagnosed with bipolar disorder (BD), and can persist between acute episodes of mania and depression. Recent studies indicate that people with BD are prone to experiencing frequent, intrusive and emotional mental images which further fuel their levels of anxiety and mood instability. These intrusive emotional mental images represent a specific target for treatment for this disorder with the potential to reduce anxiety and improve mood stability. A new brief structured psychological intervention for BD called Imagery Based Emotion Regulation (IBER) has been developed, which translates experimental work in the area of imagery and emotion into a skills training programme to improve the regulation of intrusive and distressing emotional mental images in BD. A feasibility trial is required in order to assess whether a full randomised controlled trial is indicated in order to evaluate this approach.

Methods
The design is a two-arm feasibility randomised controlled trial (RCT), with 1:1 randomisation stratified by trial site and minimised on medication status and anxiety severity. Participants are 60 individuals diagnosed with bipolar disorder and experiencing at least a mild level of anxiety. Sites are defined by the geographical boundaries of two National Health Service (NHS) Trusts, with recruitment from NHS teams, GP surgeries and self-referral. The intervention is up to 12 sessions of Imagery Based Emotion Regulation within 16 weeks. The comparator is NHS standard care. The primary aim is to assess the feasibility of conducting a powered multi-site RCT to evaluate effectiveness. Measures of anxiety, depression, mania, mood stability and health care use will be conducted at baseline, end of treatment and at 16-week follow-up.

Discussion
This is the first feasibility trial of an imagery-based intervention for the treatment of anxiety in bipolar disorder. If the trial proves feasible, a large multi-site trial will be required.

Trial registration
ISRCTN16321795. Registered on October 16, 2018. 10.1186/ISRCTN16321795

Self-compassion and its cultivation in psychological interventions are associated with improved mental health and well-being. However, the underlying processes for this are not well understood. We randomly assigned 135 participants to study the effect of two short-term self-compassion exercises on self-reported-state mood and psychophysiological responses compared to three control conditions of negative (rumination), neutral, and positive (excitement) valence. Increased self-reported-state self-compassion, affiliative affect, and decreased self-criticism were found after both self-compassion exercises and the positive-excitement condition. However, a psychophysiological response pattern of reduced arousal (reduced heart rate and skin conductance) and increased parasympathetic activation (increased heart rate variability) were unique to the self-compassion conditions. This pattern is associated with effective emotion regulation in times of adversity. As predicted, rumination triggered the opposite pattern across self-report and physiological responses. Furthermore, we found partial evidence that physiological arousal reduction and parasympathetic activation precede the experience of feeling safe and connected.

Depression is a common and costly problem. Behavioral Activation (BA)is an effective treatment for depression when delivered 1:1, but group treatments often do not perform as well as 1:1 treatments. One way to begin to understand how group treatments perform is to assess the process of change during treatment. This study examined trajectories of change across 10-session group BA for individuals with severe, chronic, or recurrent forms of depression. We also tested whether individuals who had associated sudden gains or depression spikes had better outcomes than those who did not have these change patterns. We examined psychological and sociodemographic predictors of the patterns of change. Participants were 104 individuals who met diagnostic criteria for major depressive disorder and participated in one of 10 BA groups, provided over a 2-year period. A linear, but not quadratic or cubic, rate of change fit the data and the effect size for the change in mood symptoms from baseline to posttreatment was large, Cohen's d = 1.25. Although 34% (26 of the 77 who provided outcome data)of individuals had a sudden gain and 10% (7/77)had a depression spike, neither sudden gains nor depression spikes predicted posttreatment outcomes. None of the demographic or psychological factors (rumination, behavioral activation)predicted the pattern of change. These results suggest that although group BA may help to reduce depressive symptoms in individuals with severe, recurrent, and/or chronic forms of depression, the overall linear pattern of change is different from quadratic patterns of change reported for 1:1 BA.

BACKGROUND: in bipolar spectrum disorder, some individuals experience ongoing, frequent fluctuations in mood outside of affective episodes. There are currently no evidence-based psychological interventions designed to address this. This feasibility study is a phase II evaluation of a dialectical behavioural therapy-informed approach (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). It seeks to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. METHODS/DESIGN: Patients will be randomised 1:1 to either treatment as usual only (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points will be at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point for the candidate primary outcome measures. We aim to recruit 48 individuals meeting diagnostic criteria for a bipolar spectrum disorder and reporting frequent mood swings outside of acute episodes, through primary and secondary care services and self-referral. To evaluate feasibility and acceptability, we will examine recruitment and retention rates, completion rates for study measures and feedback from participants on their experience of study participation and therapy. DISCUSSION: Proceeding to a definitive trial will be indicated if the following criteria are met: (1) trial participation does not lead to serious negative consequences for our participants; (2) any serious concerns about the acceptability and feasibility of the trial procedures can be rectified prior to a definitive trial; (3) follow-up data at 9 months are available for at least 60% of participants; (4) at least 60% of patients in the ThrIVe-B arm complete treatment. TRIAL REGISTRATION: ISRCTN, ISRCTN54234300. Registered on 20 July 2017.

BACKGROUND: Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative. OBJECTIVES: to determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments. DESIGN: Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation. SETTING: Three community mental health services in England. PARTICIPANTS: Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services. INTERVENTIONS: BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists. OUTCOMES: Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months. RESULTS: We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p 

OBJECTIVE: to explore participant views on acceptability, mechanisms of change and impact of behavioural activation (BA) delivered by junior mental health workers (MHWs) versus cognitive behavioural therapy (CBT) delivered by professional psychotherapists. DESIGN: Semistructured qualitative interviews analysed using a framework approach. PARTICIPANTS: 36 participants with major depressive disorder purposively sampled from a randomised controlled trial of BA versus CBT (the COBRA trial). SETTING: Primary care psychological therapies services in Devon, Durham and Leeds, UK. RESULTS: Elements of therapy considered to be beneficial included its length and regularity, the opportunity to learn and not dwelling on the past. Homework was an important, although challenging aspect of treatment. Therapists were perceived as experts who played an important role in treatment. For some participants the most important element of therapy was having someone to talk to, but for others the specific factors associated with BA and CBT were crucial, with behavioural change considered important for participants in both treatments, and cognitive change unsurprisingly discussed more by those receiving CBT. Both therapies were considered to have a positive impact on symptoms of depression and other areas of life including feelings about themselves, self-care, work and relationships. Barriers to therapy included work, family life and emotional challenges. A subset (n=2) of BA participants commented that therapy felt too simple, and MHWs could be perceived as inexperienced. Many participants saw therapy as a learning experience, providing them with tools to take away, with work on relapse prevention essential. CONCLUSIONS: Despite barriers for some participants, BA and CBT were perceived to have many benefits, to have brought about cognitive and behavioural change and to produce improvements in many domains of participants' lives. To optimise the delivery of BA, inexperienced junior MHWs should be supported through good quality training and ongoing supervision. TRIAL REGISTRATION NUMBER: ISRCTN27473954, 09/12/2011.

We report the construction of the Inventory of Responses to Positive Affective States (IRPAS), a trait, self-report measure of response to positive affect. The IRPAS differs from existing measures by addressing a broad set of responses to positive affect, including but not limited to affect regulation strategies, and by considering relevance to a range of positive affective states. In Study 1, qualitative interviews were conducted with 21 individuals to inform item content. In Study 2, factor analysis of the final item set was conducted using data from 540 individuals. Study 3 investigated convergent and divergent validity and test–retest reliability of the resulting 59-item IRPAS. The IRPAS was found to be reliable and valid, and to make a unique contribution to the literature on response to positive mood. Further validation studies should be conducted; potential applications include exploration of positive affect functioning in both clinical and non-clinical populations.

Thought speed and variability are purportedly common features of specific psychological states, such as mania and anxiety. The present study explored the independent and combinational influence of these variables upon condition-specific symptoms and affective state, as proposed by Pronin and Jacobs’ (Perspect Psychol Sci, 3:461–485, 2008) theory of mental motion. A general population sample was recruited online (N = 263). Participants completed a thought speed and variability manipulation task, inducing a combination of fast/slow and varied/repetitive thought. Change in mania and anxiety symptoms was assessed through direct self-reported symptom levels and indirect, processing bias assessment (threat interpretation). Results indicated that fast and varied thought independently increased self-reported mania symptoms. Affect was significantly less positive and more negative during slow thought. No change in anxiety symptoms or threat interpretation was found between manipulation conditions. No evidence for the proposed combinational influence of speed and variability was found. Implications and avenues for therapeutic intervention are discussed.

Background This study looked to investigate the interaction between exercise and approach motivation (AM) levels in a non-clinical sample as a first step towards investigating the impact of acute exercise upon hypomanic states within Bipolar Disorder. The Behavioural Activation System (BAS) dysregulation theory proposes that AM levels in individuals with Bipolar Disorder, are hyper-reactive to relevant cues and prone to fluctuation such that excessive levels underpin hypomania/mania. We hypothesise that exercise may interact with high AM levels to further increase AM levels in both the general population and individuals with BD, with this effect being exacerbated in the latter group. As an initial test of this theory we explore the impact of moderate and vigorous exercise and sedentary activity upon AM in an unselected student sample. We also tested the extent to which hypomania vulnerability predicts the impact of exercise. Method Participants were recruited from a University student population. After completing a measure of hypomanic personality traits, 61 participants completed a task designed to induce higher levels of AM before taking part in one of three 15 min activities (sedentary, moderate exercise or vigorous exercise). AM levels as well as variables relevant to hypomanic symptoms were measured prior to and post AM induction, at 5 min intervals during the activities and twice during a recovery period. Results Vigorous exercise significantly increased individuals' AM levels in comparison to moderate or no exercise. No association was found between hypomania vulnerability and exercise impact. Conclusions These results provide a first step in investigating the possible risks associated with engaging in different intensities of exercise during a hypomanic episode. Any recommendations within this study should however be taken in light of the limitations identified. Further research replicating these results with a larger sample and among individuals with Bipolar Disorder is recommended.

BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. METHODS/DESIGN: COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. DISCUSSION: the clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN27473954.

Bipolar Disorders affect a substantial minority of the population and result in significant personal, social and economic costs. Understanding of the causes of, and consequently the most effective interventions for, this condition is an area requiring development. Drawing upon theories of Bipolar Disorder that propose the condition to be underpinned by dysregulation of systems governing behavioural activation or approach motivation, we present a mathematical model of the regulation of behavioural activation. The model is informed by non-linear, dynamical principles and as such proposes that the transition from "non-bipolar" to "bipolar" diagnostic status corresponds to a switch from mono- to multistability of behavioural activation level, rather than an increase in oscillation of mood. Consistent with descriptions of the behavioural activation or approach system in the literature, auto-activation and auto-inhibitory feedback is inherent within our model. Comparison between our model and empirical, observational data reveals that by increasing the non-linearity dimension in our model, important features of Bipolar Spectrum disorders are reproduced. Analysis from stochastic simulation of the system reveals the role of noise in behavioural activation regulation and indicates that an increase of nonlinearity promotes noise to jump scales from small fluctuations of activation levels to longer lasting, but less variable episodes. We conclude that further research is required to relate parameters of our model to key behavioural and biological variables observed in Bipolar Disorder.

Background: Bipolar affective disorder (BPAD) is characterised by a lifelong vulnerability to develop episodes of depressed or elevated mood in response to stressful life events involving achievement or failure. We hypothesised that this latent vulnerability can manifest as reactivity of affect and self-esteem to experimentally induced experiences of success and failure and is shaped by history of childhood adversity. Methods: Twenty-four people with remitted BPAD and twenty-four healthy controls underwent anagram-solving tasks designed to generate experiences of success and failure in two separate sessions. Positive and negative affect and implicit and explicit self-esteem were measured before and after each task. Early adversity was measured by Childhood Trauma Questionnaire. Results: People with BPAD showed larger reactivity of affect and explicit self-esteem in response to experimental success and failure than did healthy controls. There were no significant differences in reactivity of implicit self-esteem. History of childhood trauma predicted increased affective reactivity to failure but not to success. Limitations: We used a convenience sample. Conclusions: the present experimental paradigm reveals reactivity of affect and self-esteem as features of BPAD, which are present even during good remission and thus are accessible as targets of interventions aiming at relapse prevention. Differential associations with childhood adversity indicate aetiological heterogeneity, with reactivity to failure influenced by early trauma and reactivity to success driven by other mechanisms. © 2011 Elsevier B.V. All rights reserved.

Objectives: Despite some encouraging outcomes and shared
components of psychological therapies specific to bipolar disorders, not
all studies found conclusively that the addition of a psychosocial
intervention to pharmacological interventions improves outcomes. There
was some tentative evidence from post hoc analyses that patients with
more than 12 previous episodes did not benefit from psychoeducation or
cognitive therapy. This paper presents a systematic review and metaanalysis
which examines the overall efficacy of bipolar disorder-specific
psychological therapies and the impact of the number of previous
episodes on the efficacy of psychological therapies in relapse prevention.
Methods: Systematic literature searches of electronic databases and
reference lists of existing reviews were carried out. The number of
participants experiencing relapse in randomized, controlled studies was
combined in a meta-analysis to determine the overall treatment effect in
relapse prevention. Metaregression modeling was used to examine
whether the number of previous episodes confounded the number of
relapses experienced by participants by the end of treatment.
Results: Meta-analysis of relapse calculated an overall relative risk of
0.74 [95% confidence interval (CI): 0.64–0.85] with some heterogeneity
present (I2 = 43.3%). Metaregression of six studies showed no
relationship between number of episodes and number of relapses by
endpoint.
Conclusion: Psychological therapy specifically designed for bipolar
disorder is effective in preventing or delaying relapses in bipolar
disorders, and there is no clear evidence that the number of previous
episodes moderated the effect.

The current study describes the development and validation of a new subscale to be used with the
BIS/BAS scales (Carver & White, 1994). This subscale measures lowered approach motivation following
nonreward. Factor analysis of the new subscale was carried out within a sample of 308 University students,
test–retest reliability was established within a sample of 62 individuals, and construct validity
was explored in a sample of 86 individuals by comparing scores on the new subscale with those on an
existing self-report measure of apathy and on a behavioural measure of persistence. Reliability and validity
of the new frustrative nonreward responsiveness subscale was found to be adequate within the populations
studied. The findings are discussed in relation to theoretical accounts of BAS and BIS sensitivity.

Problem: Despite calls for physical activity (PA) to be prescribed to individuals with Bipolar Disorder (BD) as a means of improving physical and mental health there has been no systematic review of the potential health risks and benefits of increased PA for individuals with BD. This paper presents the first such review. Method: Systematic searches of six databases were conducted from database inception until January 2009, using a range of search terms to reflect both PA and BD. Studies were subsequently considered eligible if they reported on quantitative studies investigating the effect of PA upon some aspect of physical or mental health in individuals with BD. Results: of the 484 articles retrieved, six studies met the inclusion criteria. Discussion: Few studies have considered how PA may impact on the physical and mental health of people with BD. Nevertheless existing studies do suggest that physical activity interventions may be feasible and have a role in promoting mental health in this population. We discuss methodological, practical and ethical challenges to research in this area, and outline three research questions that future work should seek to address. Conclusions: Research into the efficacy and safety of PA as an intervention in BD is required to support the development of detailed, population-specific guidelines. © 2009 Elsevier Ltd. All rights reserved.

A number of accounts of shame and guilt emphasise an association between shame and
anger difficulties, and it has been suggested that shame and rage may promote one
another. The shame anger relationship may be particularly relevant to the study of
forensic populations, as the fact of having committed a criminal offence has the potential
to be a highly shame-provoking experience. The current study investigates the prediction
that shame and guilt reactions to an offence are differentially related to the propensity to
experience and ability to control anger. A measure of offence-related shame and guilt
and a measure of anger experience and control was completed by 60 men detained in
forensic psychiatric units. The results supported the prediction that offence-related
shame is associated with elevated levels of anger difficulties, whilst offence-related guilt is
associated with ability to control anger. The findings of the current study are consistent
with those of previous investigations of shame, guilt and anger. Specific implications for
the understanding and prevention of violent offending are discussed.

The current study tests a prediction of the behavioral activation system (BAS) dysregulation theory of bipolar disorder, namely that following high levels of reward or frustration, individuals with bipolar disorder will take longer than will healthy controls to recover to baseline levels of BAS activity. Eighty individuals (40 with bipolar I disorder, currently euthymic; 40 with no history of affective disorder) completed a daily diary over a 28 day period. No differences were found between the 2 groups in terms of the relation among levels of reward or frustration experienced, magnitude of initial response, or time taken to recover. However, examination of the relation between number of previous episodes and time to recover revealed that history of mania was associated with prolonged activation following reward, whereas history of both mania and depression were associated with prolonged recovery following frustration. The findings do not support an association between lifetime diagnosis of bipolar disorder and slow recovery of BAS activity. Nevertheless, they offer tentative support for an association between number of previous episodes and slow recovery of BAS activity.

There is substantial evidence that shame and guilt are distinct emotions. Within the field of forensic psychology, it has been suggested that feelings of shame and guilt about a crime differ in their implications for the offender's behaviour. However, investigation of this issue is hampered by the absence of separate, dedicated measures of offence-related guilt and shame. The aim of this study was to develop and validate a preliminary measure of shame and guilt about a crime. The Offence-Related Shame and Guilt Scale was completed by 60 men detained on forensic psychiatric units, as were two existing general measures of shame and guilt. Exploratory factor analysis revealed the existence of two substantive shame and guilt dimensions. The resulting scales were found to have adequate internal consistency and test - retest reliability. Overall the results of this study suggest that while there is considerable overlap between the two emotions, shame and guilt represent distinct emotional responses to an offence.

This study investigated the possibility that, in remitted bipolar I affective disorder, dysfunctional attitudes
are mood-state dependent. Participants were 120 individuals with remitted bipolar I disorder, remitted
unipolar depression, or no history of affective disorder. The Dysfunctional Attitudes Scale (DAS;
Weissman, 1979) was completed before and after positive or negative mood challenge. Following mood
increase, the bipolar group changed significantly less in DAS total score than did the other 2 groups, and
in goal-striving and achievement attitudes relative to the unipolar group. These findings did not provide
clear support for the mood-state dependency theory in bipolar disorder, arguing instead for the presence
in bipolar I disorder of dysfunctional cognitions that show characteristic resilience in the face of minor
positive mood increase.

OBJECTIVE: in a previous randomized controlled study, the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year. This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months. METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent relapses were randomly assigned into a cognitive therapy plus medication group or a control condition of medication only. Independent raters, who were blind to patient group status, assessed patients at 6-month intervals. RESULTS: over 30 months, the cognitive therapy group had significantly better outcome in terms of time to relapse. However, the effect of relapse prevention was mainly in the first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to 189) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the last 18 months. Multivariate analyses of variance showed that over the last 18 months, the cognitive therapy group exhibited significantly better mood ratings, social functioning, coping with bipolar prodromes, and dysfunctional goal attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled. However, the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period. Further studies should explore the effect of booster sessions or maintenance therapy.

INTRODUCTION: Cognitive therapy (CT) for bipolar disorder emphasizes the monitoring and regulation of mood, thoughts and behaviour. The Sense of Hyper-Positive Self Scale (SHPSS) measures the extent to which bipolar patients value themselves and perceive themselves to possess personal attributes (e.g. dynamism, persuasiveness and productiveness) associated with a state of being 'mildly high', which does not reach the severity of clinical hypomania. It is hypothesized that patients who score highly on the SHPSS do not respond well to cognitive therapy. METHOD: One hundred and three bipolar-I patients were randomized into CT and control groups. The SHPSS was administered at baseline and at a 6-month follow-up. RESULT: the SHPSS had good test-retest reliability after 6 months. At baseline, the Goal-Attainment Dysfunctional Attitudes contributed significantly to the SHPSS scores after the mood measures were controlled for in a regression analysis. There was a significant interaction between baseline SHPSS scores and group allocation in predicting relapse during therapy. Patients who scored highly on the SHPSS had a significantly increased chance of relapse after controlling for mood scores, levels of social functioning at recruitment, and the previous number of bipolar episodes. CONCLUSION: Not all patients benefited from CT. For patients with high SHPSS scores, CT was less efficacious. The results also indicate that future studies could evaluate targeting these attributes and dysfunctional beliefs with intensive cognitive behavioural techniques.

BACKGROUND: Despite the use of mood stabilizers, a significant proportion of patients with bipolar affective disorder experience frequent relapses. A pilot study of cognitive therapy (CT) specifically designed to prevent relapses for bipolar affective disorder showed encouraging results when used in conjunction with mood stabilizers. This article reports the outcome of a randomized controlled study of CT to help prevent relapses and promote social functioning. METHODS: We randomized 103 patients with bipolar 1 disorder according to the DSM-IV, who experienced frequent relapses despite the prescription of commonly used mood stabilizers, into a CT group or control group. Both the control and CT groups received mood stabilizers and regular psychiatric follow-up. In addition, the CT group received an average of 14 sessions of CT during the first 6 months and 2 booster sessions in the second 6 months. RESULTS: During the 12-month period, the CT group had significantly fewer bipolar episodes, days in a bipolar episode, and number of admissions for this type of episode. The CT group also had significantly higher social functioning. During these 12 months, the CT group showed less mood symptoms on the monthly mood questionnaires. Furthermore, there was significantly less fluctuation in manic symptoms in the CT group. The CT group also coped better with manic prodromes at 12 months. CONCLUSION: Our findings support the conclusion that CT specifically designed for relapse prevention in bipolar affective disorder is a useful tool in conjunction with mood stabilizers.