Metacognıtıons and emotıonal schemas: A new cognıtıve perspectıve for the dıstınctıon between unıpolar and bıpolar depressıon Sedat Batmaz, Semra Ulusoy Kaymak, Sibel Kocbiyik, Mehmet Hakan Turkcapar PII: DOI: Reference:

S0010-440X(14)00134-5 doi: 10.1016/j.comppsych.2014.05.016 YCOMP 51321

To appear in:

Comprehensive Psychiatry

Received date: Revised date: Accepted date:

4 May 2014 22 May 2014 22 May 2014

Please cite this article as: Batmaz Sedat, Ulusoy Kaymak Semra, Kocbiyik Sibel, Turkcapar Mehmet Hakan, Metacognıtıons and emotıonal schemas: A new cognıtıve perspectıve for the dıstınctıon between unıpolar and bıpolar depressıon, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.016

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ACCEPTED MANUSCRIPT METACOGNITIONS AND EMOTIONAL SCHEMAS: A NEW COGNITIVE PERSPECTIVE FOR THE DISTINCTION

Sedat BATMAZa*, MD.

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BETWEEN UNIPOLAR AND BIPOLAR DEPRESSION

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Semra ULUSOY KAYMAKb, MD.

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Sibel KOCBIYIKc, MD.

Mehmet Hakan TURKCAPARd, MD, PhD.

Affiliation of the authors:

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Psychiatrist, Psychiatry Clinic, Mersin State Hospital, Mersin / Turkey.

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a

Associate Professor of Psychiatry, Psychiatry Clinic, Ataturk Training and Research Hospital, Ankara / Turkey. c

Professor of Psychiatry, Department of Psychology, Hasan Kalyoncu University, Gaziantep / Turkey.

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d

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Psychiatrist, Psychiatry Clinic, Ataturk Training and Research Hospital, Ankara / Turkey.

Running Head:

METACOGNITIONS AND EMOTIONAL SCHEMAS IN UNIPOLAR AND BIPOLAR DEPRESSION

Total Word Count: 4869 (Excluding references) *Correspondence address:

Sedat BATMAZ, MD Basak Sok. 48/6 Kucukesat, 06660 Ankara / Turkey. Tel: 90 – 505 – 780 26 76 e-mail: [email protected]

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ACCEPTED MANUSCRIPT ABSTRACT Introduction: Clinicians need to make the differential diagnosis of unipolar and

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bipolar depression to guide their treatment choices. Looking at the differences

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observed in the metacognitions, and the emotional schemas, might help with this differentiation, and might provide information about the distinct psychotherapeutical

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targets.

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Methods: Three groups of subjects (166 unipolar depressed, 140 bipolar depressed, 151 healthy controls) were asked to fill out the Metacognitions Questionnaire-30 (MCQ-30), and the Leahy Emotional Schema Scale (LESS). The clinicians diagnosed the volunteers according to the criteria of DSM-IV-TR with a structured clinical

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interview (MINI), and rated the moods of the subjects with the Montgomery Asberg

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Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS). Statistical analyses were undertaken to identify the group differences on the MCQ-

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30, and the LESS.

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Results: The bipolar and unipolar depressed patients’ scores on the MCQ-30 were significantly different from the healthy controls, but not from each other. On the LESS dimensions of guilt, duration, blame, validation, and acceptance of feelings, all three groups significantly differed from each other. There were no statistically different results on the LESS dimensions of comprehensibility, consensus, and expression. The mood disordered groups scored significantly different than the healthy controls on the LESS dimensions of simplistic view of emotions, numbness, rationality, rumination, higher values, and control. Conclusion: These results suggest that the metacognitive model of unipolar depression might be extrapolated for patients with bipolar depression. These results 2

ACCEPTED MANUSCRIPT are also compatible to a great extent with the emotional schema theory of

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depression.

Key Words: unipolar depression, bipolar depression, metacognition, emotional

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schema, cognitive behavioral therapy

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ACCEPTED MANUSCRIPT Introduction:

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Since the revolutionary conceptualization of depression as a disorder of dysfunctional

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cognitions rather than an emotional disorder [1], the cognitive theory of depression has evolved and broadened its scope with a variety of new therapy approaches [2-7],

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including metacognitive therapy [8] and emotional schema therapy [9]. Although the cognitive model of unipolar depression is extensively studied [1, 10-11], little is known

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about the distinctive features of the cognitive model of bipolar depression [12-15]. Clinical and demographic variables may be helpful to some extent in the distinction between these two different phenomenological syndromes [16-18], but there still is a

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high rate of misdiagnosis [19-21].

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From the view point of a cognitive behavioural psychotherapist, bipolar depression seems to be very similar to unipolar depression, as observed by previous

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researchers [14, 22-24]. Some of these similarities can be summarized as increased

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rumination, an implicit pessimistic attributional style, low self-esteem, and dysfunctional attitudes towards the self [15, 22, 24-26]. Thus, bipolar patients have been described as having (1) concerns with perfectionism, autonomy and selfcriticism, (2) complex patterns of self-esteem that depend upon the phase of illness, (3) pronounced short-term fluctuations in mood and self-esteem, and (4) an increased need for social approval [15, 23-24, 27-28]. Furthermore, as noted in a study by Van der Gucht [29], negative cognitive styles observed in bipolar patients, which are characterized by sociotropy, autonomy, behavioural inhibition and rumination, are mostly evident during the depressive phase, but may still be present in an attenuated form even during the euthymic period. Although these cognitive

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ACCEPTED MANUSCRIPT styles and the similarities between unipolar and bipolar depression have been reported for a long time, little reserach has been undertaken to investigate the

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between group differences of depressed individuals.

Research involving the cognitive structure of bipolar disorder has generally focused

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on the content of irrational beliefs, i.e. automatic thoughts, dysfunctional attitudes and core beliefs [14; 30-33]. Yet, cognitions consist of more elements than simply the

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above mentioned ones, e.g. metacognitions [8]. Metacognition is defined as “an orchestra conductor, who appraises, monitors or controls cognitions” [34]. It is postulated that people have positive or negative beliefs (metacognitions) of their appraisal of the events they encounter, and such metacognitions are believed to be

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the underlying process of the maintenance of psychopathology [8, 34-35]. In a

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disorder like bipolar disorder, which has two opposite poles regarding its clinical phenomenology, it is of great importance to investigate the specific metacognitions.

is written

in

English)

comparing unipolar and

bipolar depression’s

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them

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Nonetheless, there are yet just two studies in the literature [36-37] (and only one of

metacognitions. These studies have shown that the metacognitions, as measured by the metacognitions questionnaire, differ between the mood disordered groups on some metacognitive aspects [36], and that some of the metacognitions of bipolar type II depressed patients might be predictive of their dysfunctional attitudes [37].

As cognitive theory’s scope broadened, emotions have become a more respected area of research, and this has led to the birth of an innovative therapy approach, i.e. emotional schema therapy [9]. Leahy (2002) has built upon the metacognitive information processing model of Wells [38-39], and named the plans, modalities and

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ACCEPTED MANUSCRIPT strategies to an emotion as emotional schemas [40]. According to Leahy’s emotional schema model, the differences in individuals’ interpretations, evaluations, action

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tendencies, and behavioral strategies for their emotions may result in negative beliefs

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about their emotions, such as the belief that their emotions do not make sense, that they will last indefinitely and overwhelm them, that they are shameful and unique to

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them, that they can not be expressed, and that they will never be validated. These individuals are more likely to utilize problematic and maladaptive coping styles, such

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as rumination, worry, avoidance, drinking, bingeing, or dissociating [9]. In one of the pivotal articles on his model of emotional schemas, Leahy (2007) states that “although noticing, labeling, and differentiating emotions are part of an essential first step in emotional processing, individuals also differ in their interpretations and

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strategies of their own emotions once they recognize that they have an emotion” [41].

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Furthermore, as Pennebaker et al. suggest (1997) emotional processing reflects the disinhibition of emotions, and allows for increased self-undestanding, and positive

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self-reflection. They continue to conclude that simply emotional expression per se

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may not be enough, and that facilitating acceptance, understanding, decreasing guilt, and differentiating emotions have a greater impact on consequent depression [4042]. Emotional schemas, therefore, may be of interest in differentiating various types of psychopathology, e.g. unipolar depression and bipolar depression. Yet, no study can be found in the literature focusing on this distinction.

This study primarily focuses on the distinction of unipolar and bipolar depression in terms of metacognitions and emotional schemas, thereby intending to make some yet rarely illustrated contribution to the literature on how to differentiate these two separate clinical conditions. 6

ACCEPTED MANUSCRIPT Methods:

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Sample:

Outpatients who presented to the psychiatry clinics of Ankara Oncology Training and

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Research Hospital (Ankara, Turkey), Ataturk Training and Research Hospital (Ankara, Turkey), and Mersin State Hospital (Mersin, Turkey) between August 2009

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and April 2013 were invited to take part in this study.

Three groups were formed according to the study design. The first group consisted of 166 patients who were diagnosed with unipolar depressive disorder. The second

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group consisted of 140 patients who were diagnosed with bipolar (type I) depressive

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disorder. The third group consisted of 151 healthy controls, who were either referred for routine psychiatric evaluation prior to a job application, or acquaintances of the

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mood disordered participants, who were not diagnosed with, nor had any history of,

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any axis – I psychiatric disorder. None of the subjects were offered any compensation for their participation in the study. All diagnoses were based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) version IV-TR [43]. A diagnostic interview with at least one significant other of the patients for collateral information gathering purposes, and to prevent any recall bias of the past previous manic / hypomanic episodes, was conducted. Also with the patients, specifically a clinical diagnostic interview focusing on any previous manic / hypomanic episodes, and screening for any risk factors known to be related to bipolarity, e.g. family history of bipolar disorder, characteristics of the depressive episodes, response to any previous antidepressant treatment (if relevant), age of

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ACCEPTED MANUSCRIPT onset, etc., was conducted, so as to minimise the risk of misdiagnosis of the unipolar

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depressive patients.

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Participants were included in the study if they were between 18 and 65 years old, had no comorbid psychiatric axis I disorder, were not using any substances (smoking

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up to one pack of cigarettes was an exception), had no uncontrolled medical condition, had no history of head trauma or neurosurgery, were never treated by

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electroconvulsive therapy, were at least graduates of secondary school (at least 8 years of education), were not pregnant or breastfeeding at the time of the clinical interview, and had not been receiving any kind of psychiatric treatment, i.e. psychopharmacologic or psychotherapeutic, for at least 12 weeks at the time of the

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interview. Because of these stringent inclusion criteria, e.g. no comorbidity allowance

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for the clinically depressed groups, the study took almost four years.

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All participants provided written informed consent prior to study enrollment. Approval

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of the local ethics committee was also obtained.

Instruments of Assessment:

1. Sociodemographic Data Form: This form was developed by the researchers and the sociodemographic data, i.e. age, gender, level of education, marital status, obtained from the patients was recorded onto it. 2. Mini International Neuropsychiatric Interview (MINI): Developed by Sheehan and Lecrubier (1998), the MINI is a structured clinical interview for

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ACCEPTED MANUSCRIPT Axis - I disorders [44]. In this study, the Turkish version of the scale for the DSM – IV version was used [45].

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3. Montgomery – Asberg Depression Rating Scale (MADRS): This is a

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clinician administered scale that is used to rate the cognitive and emotional aspects of depression [46]. The higher the score, the more severe the

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disorder. The Turkish version of the scale was used in this study [47]. 4. Young Mania Rating Scale (YMRS): This is a clinician administered scale

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which is used to identify the core symptoms of mania and is helpful in rating the severity of the disorder [48]. Participants were required to get a score less than seven in order to be considered manic or hypomanic symptomatology free. Any participants scoring higher than this cut-off score were excluded from

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the study, because they were thought to be in a manic or mixed episode. The

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Turkish version of the YMRS was used in this study [49]. 5. The Metacognitions Questionnaire – 30 (MCQ-30): This is the short version

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of the Metacognitions Questionnaire [35, 50], which is rated on a 4 – point

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Likert scale, and consists of the five identical factors of the original version of the scale. These five factors are: (1) positive beliefs about worry, (2) cognitive confidence, (3) uncontrollability and danger, (4) cognitive self-consciousness, and (5) the need to control thoughts. MCQ is based on psychopathological conditions and is therefore appropiate for assessing metacognitions related to them [35]. The MCQ-30 has good reliability and validity. Cronbach coefficient alphas for the subscales range from 0.72 to 0.93. Tosun and Irak investigated the psychometric characteristics of the scale, adapted it in a Turkish sample and determined its validity and reliability. The Turkish language version of the form was found to be valid and reliable [51]. Although there are obviously

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ACCEPTED MANUSCRIPT other aspects of metacognitions, e.g. rumination, this study was solely relying on the meatcognitive aspects determined by the MCQ-30.

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6. Leahy Emotional Schema Scale (LESS): This scale consists of items that

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are used to determine how a person thinks about and copes with his own emotions. It has fourteen dimensions, which are related to both functional and

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dysfunctional attitudes towards emotions that might be interfering with a therapeutic change during the psychotherapy process [40, 52]. In this study,

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the Turkish version of the scale was used [52], but the original scale’s dimensions were retained. Also a composite score for the adaptive, more flexible emotional schemas was computed, and this subscale was named “adaptive emotional schemas”. This subscale consisted of the following

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emotional schema dimensions: Validation, comprehensibility, higher values,

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control, consensus, expression, and acceptance of feelings. Another composite score for the rigid, less adaptive emotional schemas was

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computed, and this subscale was named “rigid emotional schemas”. The

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dimensions included in this subcale were as follows: Guilt, simplistic view of emotions, numbness, rationality, duration, rumination, and blame. Finally, a composite score for the total “negative beliefs about emotions” was calculated by reversing the points for adaptive emotional schemas, i.e. scores for the dimensions of invalidation, low comprehensibility, lack of higer values, loss of control, low consensus, lack of acceptance of feelings, and lack of expression, and adding up with the score for the rigid emotional schemas. The adaptive and rigid emotional schemas, and the negative belief about emotions composite scores were computed in the way reported in previous studies [5354]. Details about the dimensions of the LESS can be found elsewhere [40].

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ACCEPTED MANUSCRIPT Other ways to cope with emotions, and to interpret them, may be measured using other scales, but this study was focusing on the predetermined LESS

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dimensions, and the aforementioned subscale scores of it to compare the

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unipolar and bipolar depressed groups with each other, and the healthy

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controls.

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Statistical Analysis:

SPSS for Windows v. 17.0 (Chicago, Illinois, USA) was used to analyse the data. Descriptive statistics for constant variables were shown by mean ± standard deviation, whereas for categorical variables, the statistics were shown by the number

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of cases and by percentage. The significance of the difference of mean age, and of

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the mean scores of the clnical scales between the groups were analysed by analysis of variance (one-way ANOVA). If a significant difference was detected by the one-

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way ANOVA, post-hoc Tukey HSD test was used to identify the responsible cases.

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Effect size (ES) index (as partial eta-squared, η2) for one-way ANOVA is computed using a general linear model procedure. For this index, cut-off scores of .01, .06 and .14 are, by convention, interpreted as small, medium, and large effect sizes, respectively. Categorical variables were analysed by Pearson’s Chi-Square. Bivariate correlational analyses between the scales were undertaken. Pearson correlation coefficients (CC) of less than .30 were regarded as very low, .30 – .49 as low, .50 – .69 as moderate, .70 – .89 as high, and .90 – 1.00 as very high [55]. p values < .05 were regarded as significant.

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Results:

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A total of 457 participants were recruited for the study. There was no statistically

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significant difference between the groups regarding age, gender, marital status, or level of education. Sociodemographic data of the participants are shown in Table 1. The severity of depressive symptoms was assessed by using the MADRS. The mood disordered groups scored significantly higher on this scale than the healthy controls,

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but they did not differ from each other. The YMRS was used to determine the severity

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of manic symptoms, and to rule out any participants in a manic or mixed episode. Both of the mood disordered groups scored significantly higher than the healthy

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control group on the YMRS, and the bipolar depressed group scored higher than the

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unipolar depressed group. These findings are summarized in Table 1.

Table 1 to be placed about here

Statistically significant differences were determined between the groups in terms of negative beliefs about worry concerning uncontrollability and danger (large ES = .177), lack of cognitive confidence (small ES = .020), beliefs about the need to control thoughts (medium ES = .118), and cognitive self-consciousness (small ES = .032) mean subscale scores. All these subscale scores were higher in the unipolar

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ACCEPTED MANUSCRIPT and bipolar depressed groups than in the controls, but there was no difference between the unipolar and bipolar depression groups. No difference was determined

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between the groups in terms of positive beliefs about worry mean subscale scores.

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The MCQ – 30 mean total scores were also statisticaly higher in the mood disordered groups than in the healthy controls (medium ES = .088). Yet the mood disordered

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groups did not differ from each other on this score (Table 2).

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None of the groups were distinguishable from each other on the mean scores of the LESS dimensions of comprehensibility, consensus, and expression. On the mean LESS dimension scores of guilt (large ES = .302), duration (large ES = .146), blame (large ES = .286), validation (large ES = .192), and acceptance of feelings (large ES

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= .288), all three groups were statistically different. Among these LESS dimensions, healthy controls were found to score higher in the validation, and acceptance of

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feelings than the mood disordered groups. The healthy controls scored lower than

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the mood disordered groups on the LESS dimensions of guilt (large ES = .302), duration (large ES = .146), and blame (large ES = .286). For all the aforementioned

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LESS dimensions, the bipolar depressed group scored in between the unipolar depressed group and the healthy controls. The mood disordered groups scored statistically different from the healthy controls, but not from each other, on the LESS dimensions of simplistic view of emotions (large ES = .346), numbness (large ES = .242), rationality (medium ES = .090), rumination (large ES = .256), higher values (medium ES = .070), and control (medium ES = .110). Relevant to these findings, the healthy controls scored higher in the higher values, and control dimensions of the LESS; and lower on the simplistic view of emotions, numbness, rationality, and rumination dimensions of the LESS (Table 2).

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ACCEPTED MANUSCRIPT Table 2 to be placed about here

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The MCQ total and MCQ subscale mean scores were found to be positively correlated with the total depression and mania mean scores, with the exception of the

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positive beliefs about worry subscale mean score with the mean MADRS total score. The adaptive emotional schemas subscale mean scores were negatively correlated

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with all of the metacognitive scale mean scores (very low to low, negative CC), whereas the subscale mean scores of the rigid emotional schemas and the negative beliefs about emotions were positively correlated with all of the metacognitive scale mean scores (low to moderate, positive CC). Other correlations regarding the scales

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are shown in Table 3.

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Table 3 to be placed about here

Discussion and Conclusions:

Although there is growing evidence regarding the distinction between unipolar and bipolar depression in terms of clinical, phenomenological and imaging studies [16-18, 56], only a small number of research has focused solely on the differences in the cognitive structure of these two disorders, and these studies tend to look for differences in the automatic thoughts, dysfunctional assumptions and schemas of the subjects [22, 33]. The literature search on the distinction between these two disorders

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ACCEPTED MANUSCRIPT in terms of metacognitions or emotional schemas revealed few results [36-37]. This study is one of the few studies focusing on this specific area of interest.

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Results of this study revealed no statistically significant differences between the

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mood disordered groups in terms of their metacognitions. This result might have been found not only because the same metacognitive processes may be underlying

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these disorders, but also possibly because the scale used in this study to identify the

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metacognitions may not be statistically powerful enough to differentiate between the mood disordered groups. For this reason, it may be of great importance to use metacognitive scales specific to depressive disorders, e.g. the Positive Beliefs about Rumination Scale (PBRS) [38; 57-58], and the Negative Beliefs about Rumination

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Scale (NBRS) [39, 57-58], in subsequent studies to look for differences between unipolar and bipolar depressed groups. As previously reported, the PBRS scores

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reflect the positive beliefs about rumination, and the NBRS scores reflect the beliefs

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about the uncontrollability and harmful nature of rumination, and the beliefs about the social and interpersonal consequences of ruminating [58]. Moreover, previous

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studies concluded that the scores of the PBRS are correlated with the positive beliefs about worry subscale score of the MCQ, and the scores of the NBRS are correlated with the uncontrollability and danger, and cognitive confidence subscale scores of the MCQ [57]. Therefore, the first possibility we mentioned above may still be relevant while interpreting our results. Another aspect to keep in mind is that it has repeatedly been shown that the concepts of rumination and worry may not be distinguishable from each other, and that they may be representing a negative way of repetitive thinking in general [36, 57, 59-63]. This could be one explanation why the scores of the so called depression specific metacognitive rating scales show correlations with a

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ACCEPTED MANUSCRIPT more generic metacognition scale scores [57], as has been reported in our study as well.

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The only subscale score of the MCQ which failed to differentiate the mood disordered

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groups from the healthy controls was found to be the positive beliefs about worry subscale, which was also previously reported in the literature [36]. In that study,

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which is also the only other study published in English comparing unipolar to bipolar

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depressed patients on the scores of metacognitions, very similar results to ours were reported. The two contrasting results of their study to ours are on the subscale scores of the cognitive confidence, and the cognitive self-consciousness. Our result of the cognitive confidence subscale score is more consistent with the metacognitive model

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of depression [34, 58], as cognitive confidence actually reflects another way of interpreting the negative consequences of ruminating. On the other hand, as pointed

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out by Wells [64], cognitive self-consciousness, i.e. directing attention to one’s

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thought processes, is an index of unhelpful monitoring of internal mental events, which presents itself as threat montioring in depressed individuals. Thus, scoring

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higher on this subscale would probably be more consistent with the metacognitive model as well [34, 58]. The conflicting results between our study and the other study may at least partly be explained by the small number of participants the other investigators recruited for their study. Still, further research in this area might clarify this issue. The other research article on the metacognitive profile of bipolar patients comes from Iran, and to the best of our knowledge, that article concludes that the negative beliefs about uncontrollability and danger, and the need to control thoughts are found to be important predictors of dysfunctional attitudes [37]. This study, however, lacks any control group, let alone any comparison to unipolar patients, and the participants are 16

ACCEPTED MANUSCRIPT all diagnosed with bipolar disorder type II, which may limit the generalizability of their results. Another important limitation of this study is the small number of participants.

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Nonetheless, this study seems to be the first published article ever looking into the

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metacognitions of bipolar patients, and therefore needs to be acknowledged. Although there are reports on the emotional schema dimensions of unipolar

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depression [40], it is questionnable whether those results can be extrapolated to

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bipolar depressive patients, since previous studies on the cognitive structure of these patient groups demonstrated some important differences [22-33]. Our study is the first one focusing on the differences about emotional schemas of unipolar and bipolar depression. Thus, these results may provide some evidence for the therapists

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interested in the management of bipolar patients.

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Firstly, as expected, the healthy controls scored significantly higher on the composite

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score of adaptive emotional schemas subscale than the mood disordered groups, and the bipolar patients had statistically higher scores on this subscale than the

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unipolar depressed ones. Regarding the composite score of the rigid emotional schemas, and the more general negative belief about emotions composite score, the complete opposite results were obtained. These results suggest that unipolar and bipolar depressed patients differ in terms of their appraisals of emotional states, which is an essential point to consider during psychotherapy. On the other hand, as previously noted in the literature, bipolar patients tend to inherit some implicit cognitive processes which can not be ruled out by self-report measures, and which may consequently be resulting in a biased interpretation of the results of direct, explicit measures [26, 65-67].

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ACCEPTED MANUSCRIPT Secondly, regarding the dimensions of the emotional schema scale, no statistically differences were found between the mood disordered patients and the healthy

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controls on the comprehensibility, consensus, and expression dimensions. Except for

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the expression dimension (which has some mixed data in the literature as well [41]), this result contradicts the early findings of Leahy [40]. In his article, depression was

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found to be related to less comprehensibility, and less consensus. He further suggested that making sense of one’s feelings is a central element in emotional

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processing, and that believing that others shared the same feeling as the individual resulted in less depression. On the other hand, the preliminary analysis of that study revealed that there were some differences when gender was taken into account, and specifically women less likely believed that they had consensus about their feelings

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with others. Also his study population was rather small, and consisted of patients with

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quite low depression scores. Low scores on the depression scale, and the proprotion of the women enrolled in these two studies may be a direct reason of this

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discrepancy. Yet another explanation may be reached when noticing that the Leahy

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study had no comparison group, so we can not conclude if the patients would differ from healthy controls regarding these dimensions. Another aspect which may be related to this inconsistency between the two studies is the various cultural factors regarding the concept of emotions [68-70]. One approach to an emotion in a Western culture may not be the same in an Eastern one, and vice versa. Therefore, individuals may be feeling the same about expressing their emotions regardless of feeling depressed, but may differ in their interpretations of comprehensibility or the sameness of their feelings in different cultures.

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ACCEPTED MANUSCRIPT Thirdly, with the exception of the above mentioned dimensions, the healthy control group differed significantly on the scores related to the dimensions reflecting

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adaptive, more flexible emotional schemas, i.e. validation, acceptance, higher values,

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and control. Similarly, on all the dimensions reflecting rigid, less adaptive emotional schemas, the healthy control group statistically differed from the mood disordered

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patients. These results are totally consistent with the emotional schema theory of Leahy, where e.g. individuals are thought to believe that other people will validate or

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be receptive to their emotions, that emotional experiences provide insight to their values, that they have control over their emotions, and that they can accept their emotional experiences [9, 40-41].

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Fourthly, apart from statistically differing from the healthy controls, some dimensions

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of the LESS also signified that unipolar and bipolar patients may have differing levels of beliefs in their appraisal of emotions, i.e. guilt, duration, blame, validation, and

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acceptance. The unipolar depressed patients represented a group with higher

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shame, guilt, and embarrasment of their emotions than the bipolar depressed ones. Also they tended to believe that, which is also consistent with the hopelessness model of depression [71-72], their emotions will last longer, which in turn adds to current depression. The unipolar depressed patients also used blaming others and the self for having that emotion more than the bipolar patients. They also accepted their feelings less, which may be a direct consequence of longer duration expectancy [40], and felt less validated by others, compared to the bipolar depressed participants. These results suggest that there is far more to be considered when trying to differentiate unipolar and bipolar patients than simply relying on clinical factors, or diagnostic criteria.

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Some limitations of the present study can be summarized as follows: Due to the

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cross-sectional design of the study, it is not possible to draw any causal relationships

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between the scales and depression. Also, it would be more reliable to use depression specific metacognitive scales rather than a generic scale. Another limitation is the

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use of self-report measures, which are open to manipulation, and known to be

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affected by the implicit cognitive style of bipolar patients.

The strengths of the study involves the inclusion of a large sample, the comparison of the emotional schemas between two depressive groups for the first time, the addition of information to the subject of metacognitions in this patient population, and the

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availability of a healthy control group. The results also have clinical implications for

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the psychotherapy of bipolar depression, especially focusing on the metacognitions and emotional schemas. This study points out to the possibility of using the same

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metacognitive therapy principles applied for unipolar depression to the depressive

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phase of bipolar disorder. Also the emotional schema differences provide a detailed profile for bipolar depression, which may be stressed and the appropriate techniques be utilized during emotionally focused cognitive therapy sessions.

In conclusion, since the treatment of bipolar depression has changed drastically in the past two decades, and now that there are more options in choosing the right psychopharmacological agent for the disorder, research has also grown in the area of psychotherapy. Of note, cognitive behavioural therapy has shown promise for bipolar disorder. The distinction of unipolar and bipolar depression is therefore still awating more clues from research. The cognitive structure of these disorders, and the

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ACCEPTED MANUSCRIPT differences between them, may be helpful in identifying and choosing the right

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treatment modality.

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Acknowledgments:

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We would like to thank all the participants who agreed to be part of the study, and filled out the forms we handed out. We also would like to thank Mr. Murat BATMAZ, MA, English Instructor at Yeditepe University in Istanbul, Turkey, for his proofreading and English editing of the manuscript. We are grateful to the anonymous reviewers

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for their valuable comments on our manuscript.

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Declaration of Interest:

This paper has not received any funds from any agency. The authors do not have an affiliation with, or any financial interest in, the psychopharmacological industry that might pose a conflict of interest for this paper. The authors alone are responsible for the content and writing of the paper. An earlier version of this manuscript was presented as an open paper, and nominated as one of the best presentations, at the 48th National Psychiatric Congress of the Psychiatric Association of Turkey, held between October 9th and 13th, 2012, in Bursa, Turkey.

21

ACCEPTED MANUSCRIPT References:

RI P

T

1. Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive Therapy of Depression. New York, The Guilford Press, 1987.

Behav Ther 2013 Jun;44(2):199-212.

SC

2. Hofmann SG, Asmundson GJ, Beck AT: The science of cognitive therapy.

MA NU

3. Beck AT: The current state of cognitive therapy: a 40-year retrospective. Arch Gen Psychiatry 2005 Sep;62(9):953-9.

4. Kahl KG, Winter L, Schweiger U: The third wave of cognitive behavioural

Nov;25(6):522-8.

ED

therapies: what is new and what is effective? Curr Opin Psychiatry 2012

PT

5. Brown LA, Gaudiano BA, Miller IW: Investigating the similarities and differences between practitioners of second- and third-wave cognitive-

CE

behavioral therapies. Behav Modif 2011 Mar;35(2):187-200. 6. Hayes SC, Villatte M, Levin M, Hildebrandt M: Open, aware, and active:

AC

contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annu Rev Clin Psychol 2011;7:141-68. 7. Ost LG: Efficacy of the third wave of behvioral therapies: a systematic review and meta-analysis. Behav Res Ther 2008 Mar;46(3):296-321. 8. Wells A: Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester, Wiley, 2000. 9. Leahy RL, Tirch D, Napolitano LA: Emotion Regulation in Psychotherapy: A Practitioner’s Guide. New York, The Guilford Press, 2011.

22

ACCEPTED MANUSCRIPT 10. Disner SG, Beevers CG, Haigh EA, Beck AT: Neural mechanisms of the cognitive model of depression. Nat Rev Neurosci 2011 Jul 6;12(8):467-77.

T

11. Beck AT: The evolution of the cognitive model of depression and its

RI P

neurobiological correlates. Am J Psychiatry 2008 Aug;165(8):969-77.

SC

12. Batmaz S, Ulusoy Kaymak S, Soygur AH, Ozalp E, Turkcapar MH: The distinction between unipolar and bipolar depression: A cognitive theory

MA NU

perspective. Compr Psychiatry 2013 Oct;54(7):740-9.

13. Johnson SL, Fingerhut R: Negative cognitions predict the course of bipolar depression, not mania. J Cogn Psychotherapy 2004;18:149-162.

ED

14. Scott J, Stanton B, Garland A, Ferrier IN: Cognitive vulnerability in patients

PT

with bipolar disorder. Psychol Med 2000;30:467-72. 15. Scott J, Pope M: Cognitive styles in individuals with bipolar disorders. Psychol

CE

Med 2003;33:1081-8.

AC

16. Bowden CL: A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord 2005;84:117-25. 17. Cuellar AK, Johnson SL, Winters R: Distinctions between bipolar and unipolar depression. Clin Psychol Rev 2005;25:307-39. 18. Forty L, Smith D, Jones L, Jones I, Caesar S, Cooper C, et al: Clinical differences

between

bipolar

and

unipolar

depression.

Br J

Psychiatry

2008;192:388-9. 19. Hirschfeld RM, Lewis L, Vornik LA: Perceptions and impact of bipolar disorder: How far have we really come? Results of the National Depressive and 23

ACCEPTED MANUSCRIPT Manic-Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003;64(2):161-74.

T

20. Ghaemi SN, Sachs GS, Chiou AM, Pandurangi AK, Goodwin FK: Is bipolar

RI P

disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord

SC

1999;52:135-44.

21. Yatham LN, Kennedy SH, O’Donovan C, Parikh S, MacQueen G, McIntyre R,

MA NU

et. al: Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.

ED

22. Jones B, Scott J, Haque S, Gordon-Smith K, Heron J, Caesar S, Cooper C, Forty L, Hyde S, Lyon L, Greening J, Sham P, Farmer A, McGuffin P, Jones I,

PT

Craddock N: Cognitive style in bipolar disorder. Br J Psychiatry 2005;187:431-

CE

437.

23. Alloy LB, Abramson LY, Walshaw PD, Neeren AM: Cognitive vulnerability to

AC

unipolar and bipolar mood disorders. J Soc Clin Psychol 2006;25:729-754. 24. Pavlickova H, Varese F, Turnbull O, Scott J, Morriss R, Kinderman P, Paykel E, Bentall RP: Symptom-specific self-referential cognitive processes in bipolar disorder: a longitudinal analysis. Psychol Med 2013 Sep;43(9):1895-907. 25. Thomas J, Knowles R, Tai S, Bentall RP: Response styles in bipolar disorder. J Affect Disord 2007;100:249-252. 26. Lyon H, Startup M, Bentall RP: Social cognition and the manic defense. J Abnorm Psychol 1999;108:273-282.

24

ACCEPTED MANUSCRIPT 27. Knowles R, Tai S, Jones SH, Highfield J, Morriss R, Bentall RP: Stability of self-esteem in bipolar disorder: comparison among remitted bipoar patients,

T

remitted unipolar patients and helathy controls. Bipolar Disord 2007;6:490-495.

RI P

28. Pardoen D, Bauwens F, Tracy A, Martin F, Mendlewicz J: Self-esteem in

SC

recovered bipolar and unipolar outpatients. Br J Psychiatry 1993;163:755-762. 29. van der Gucht E, Morriss R, Lancaster G, Kinderman P, Bentall RP:

MA NU

Psychological processes in bipolar affective disorder: negative cognitive style and reward processing. Br J Psychiatry 2009;194:146-151. 30. Ak M, Lapsekili N, Haciomeroglu B, Sutcigil L, Turkcapar H. Early maladaptive

ED

schemas in bipolar disorder. Psychol Psychother 2012;85(3):260-7. 31. Lex C, Meyer TD, Marquart B, Thau K: No strong evidence for abnormal

PT

levels of dysfunctional attitudes, automatic thoughts, and emotional information-

CE

processing biases in remitted bipolar I affective disorder. Psychol Psychother 2008;81:1-13.

AC

32. Wright K, Lam D, Newsom-Davis I: Induced mood change and dysfunctional attitudes

in

remitted

bipolar

I

affective

disorder.

J

Abnorm

Psychol

2005;114(4):689-96. 33. Tzemou E, Birchwood M: A prospective study of dysfunctional thinking and the regulation of negative intrusive memories in bipolar I disorder: implications for affect regulation theory. Psychol Med 2007;37:689-98. 34. Wells A: Metacognitive Therapy for Anxiety and Depression. New York, The Guilford Press, 2011.

25

ACCEPTED MANUSCRIPT 35. Cartwright-Hatton S, Wells A: Beliefs about worry and intrusions: the MetaCognitions Questionnaire and its correlates. J Anxiety Disord 1997 May-

T

Jun;11(3):279-96.

RI P

36. Sarisoy G, Pazvantoglu O, Ozturan DD, Ay ND, Yilman T, Mor S, Korkmaz IZ, Kacar OF, Gumus K: Metacognitive beliefs in unipolar and bipolar A

comparative

study.

J

Psychiatry

DOI:

MA NU

10.3109/08039488.2013.814710.

Nord

SC

depression:

37. Kazemi H, Ghorbani M: Evaluation of relationship between metacognition components and dysfunctional attitudes in outpatients with bipolar mood

ED

disorder II. J Shahid Sadoughi Univ Med Sci 2012 Mar-Apr;20(1):90-100. 38. Papageorgiou C, Wells A: Metacognitive beliefs about rumination in major

PT

depression. Cogn Behav Pract 2001a;8:160-163.

CE

39. Papageorgiou C, Wells A: Positive beliefs about depressive rumination: Development and preliminary validation of a self-report scale. Behav Ther

AC

2001b;32:13-26.

40. Leahy RL: A model of emotional schemas. Cogn Behav Pract 2002;9:177190. 41. Leahy RL: Emotional schemas and resistance to change in anxiety disorders. Cogn Behav Pract 2007;14:36-45. 42. Pennebaker JW, Mayne TJ, Francis ME: Linguistic predictors of adaptive bereavement. J Pers Soc Psychol 1997;72:863-871.

26

ACCEPTED MANUSCRIPT 43. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, text revision. Washington, American Psychiatric

T

Association, 2000.

RI P

44. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janus J, Weiller E, Hergueta T, Baker R, Dunbar GC: The Mini-International Neuropsychiatric

SC

Interview (MINI): the development and validation of a structured diagnostic

MA NU

interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(20):22-23. 45. Engeler A: MINI International Neuropsychiatric Interview – Turkish Version 5.0.0. Ed: Sheehan DV, Lecrubier Y. Istanbul, GSK, 2004.

ED

46. Montogmery SA, Asberg M: A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382-9.

PT

47. Ozer SK, Demir B, Tugal O, Kabakci E, Yazici K: Montgomery and Asberg

CE

Depression Rating Scale: interrater validity and reliablity study. Turk Psikiyatri Derg 2001;12(3):185-94.

AC

48. Young RC, Biggs JT, Ziegler VE: A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35. 49. Karadag F, Oral ET, Yalcin FA, Erten E: Reliability and validity of Turkish translation of Young Mania Rating Scale. Turk Psikiyatri Derg 2002;13:107-14. 50. Wells A, Cartwright-Hatton S: A short form of the Metacognitions Questionnaire: Properties of the MCQ-30. Behav Res Ther 2004;42:385-96.

27

ACCEPTED MANUSCRIPT 51. Tosun A, Irak M: Adaptation, validity, and reliability of the Metacognition Questionnaire-30 for the Turkish population, and its relationship to anxiety and

T

obsessive-compulsive symptoms. Turk Psikiyatri Derg 2008;19(1):67-80.

RI P

52. Yavuz KF, Turkcapar MH, Demirel B, Karadere E: Adaptation, validity and reliability of the Leahy Emotional Schema Scale Turkish version based on

SC

Turkish university students and workers. Dusunen Adam The Journal of

MA NU

Psychiatry and Neurological Sciences 2011;24:273-82. 53. Silberstein LR, Tirch D, Leahy RL, McGinn L: Mindfulness, psychological flexibility and emotional schemas. Int J Cogn Ther 2012;5(4):406-19.

ED

54. Tirch DD, Leahy RL, Silberstein LR, Melwani PS: Emotional schemas, psychological flexibility, and anxiety: the role of flexible response patterns to

PT

anxious arousal. Int J Cogn Ther 2012;5(4):380-91.

CE

55. Hinkle DE, Wiersma W, Jurs SG: Applied Statistics for the Behavioral Sciences. New York, Houghton Mifflin Company, 1998.

AC

56. da Almeida JR, Phillips ML: Distinguishing between unipolar and bipolar depression: current and future clinical and neuroimaging perspectives. Biol Psychiatry 2013;73(2):111-8. 57. Roelofs J, Huibers M, Peeters F, Arntz A, van Os J: Positive and negative beliefs about depressive rumination: a psychometric evaluation of two self-report scales and a test of a clinical metacognitive model of rumination and depression. Cognit Ter Res 2010;34(2):196-205. 58. Papageorgiou C, Wells A: Depressive Rumination: Nature, Theory, and Treatment. Chisester, Wiley, 2003. 28

ACCEPTED MANUSCRIPT 59. McEvoy PM, Watson H, Watkins ER, Nathan P: The relationship between worry, rumination, and comorbidity: evidence for repetitive negative thinking as a

T

transdiagnostic construct. J Affect Disord 2013 Oct;151(1):313-20.

SC

and anxiety. Front Psychol 2012 Feb 13;3:20.

RI P

60. Sorg S, Vogele C, Furka N, Meyer AH: Perseverative thinking in depression

61. Segerstrom SC, Stanton AL, Flynn SM, Roach AR, Testa JJ, Hardy JK:

MA NU

Episodic repetitive thought: dimensions, correlates, and consequences. Anxiety Stress Coping 2012 Jan;25(1):3-21.

62. Rood L, Roelofs J, Bogels SM, Alloy LB: Dimensions of negative thinking

ED

and the relations with symptoms of depression and anxiety in children and adolescents. Cognit Ther Res 2010 Aug;34(4):333-42.

PT

63. D’Hudson G, Saling LL: Worry and rumination in older adults: differentiating

CE

the processes. Aging Ment Health 2010 Jul;14(5):524-34. 64. Wells A, Fisher P, Myers S, Wheatley J, Patel T, Brewin CR: Metacognitive

AC

therapy in recurrent and persistent depression: a multiple-baseline study of a new treatment. Cognit Ther Res 2009;33:291-300. 65. Hartlage S, Alloy L, Vazquez C, Dykman B: Automatic and effortful processing in depression: Psychol Bull 1993;113:247-278. 66. Haeffel GJ, Abramson LY, Brazy PC, Shah JY, Teachman BA, Nosek BA: Explicit and implicit cognition: a preliminary test of a dual-process theory of cognitive vulnerability to depression. Behav Res Ther 2007;45:1155-1167.

29

ACCEPTED MANUSCRIPT 67. Winters KC, Neale JM: Mania and low self-esteem. J Abnorm Psychol 1985;94:282-90.

T

68. Zhu Z, Ho SM, Bonanno GA: Cultural similarities and differences in the

RI P

perception of emotional valence and intensity: a comparison of Americans and

SC

Hong Kong Chinese. Am J Psychol 2013 Fall;126(3):261-73. 69. Kayyal MH, Russell JA: Americans and Palestinians judge spontaneous

MA NU

facial expressions of emotion. Emotion 2013 Oct;13(5):891-904. 70. Hofmann SG: The pursuit of happiness and its relationship to the metaexperience of emotions and culture. Aust Psychol 2013 April 1;48(2):94-97.

ED

71. Greene SM: The relationship between depression and hopelessness.

May;154:650-9.

PT

Implications for current theories of depression. Br J Psychiatry 1989

CE

72. Alloy LB, Abramson LY, Metalsky GI, Hartlage S: The hopelessness theory

AC

of depression: attributional aspects. Br J Clin Psychol 1988 Feb;27(Pt1):5-21.

30

ACCEPTED MANUSCRIPT Table 1. Demographic and Clinical Data BPD

(n=166)

Mean age in years (SD)

HC (n=151)

Statistics

(n=140)

Post-hoc

size

comparisons

(ηp2)

(Tukey HSD)

(ᵡ /F)

37.64 (12.27)

37.92 (11.87)

40.07

100 (60.2)

80 (57.1)

96 (63.6)

F = 1,796; p =.167 2

Marital Status

-

RI P

(12.60) Gender, female (%)

Effect

2

T

UPD

ᵡ = 1,260; p = .533

-

2

-

ᵡ = 3,858; p = .426 50 (30.1)

43 (30.7)

49 (32.5)

Married (%)

92 (55.4)

86 (61.4)

87 (57.6)

Other* (%)

24 (14.5)

11 (7.9)

15 (9.9)

SC

Single (%)

2

Level of education

-

ᵡ = 5,041; p = .080

89 (53.6)

58 (41.4)

78 (51.7)

≥ 8 years (%)

77 (46.4)

82 (58.6)

73 (48,3)

MADRS (SD)

33.08

31.98

3.34

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Up to 8 years (%)

b

c

(4.47) YMRS (SD)

(5.36)

b,c

(2.94)

F = 2289,205;

2.14

2.86

0.26

F = 174,148;

(1.51)a,c

(0.76)b,c

p < .001

ED

UPD = BPD > HC

.434

BPD > UPD > HC

p < .001

(1.33)a,b

*Separated, widowed or divorced.

.910

UPD: Unipolar Depressed Patients, BPD: Bipolar Depressed Patients, HC: Healthy Control Subjects, n: Number of 2

2:

participants, SD: Standard deviation, ηp : Partial eta squared, ᵡ Chi-square, F: One-Way ANOVA, HSD: Highly significant a

b

PT

difference, MADRS: Montgomery-Asberg Depression Rating Scale, YMRS: Young Mania Rating Scale, :Statistically significant c

AC

CE

between UPD and BPD, :Statistically significant between UPD and HC, :Statistically significant between BPD and HC.

31

ACCEPTED MANUSCRIPT Table 2. Mean scores of the scales according to the groups

UPD M

BPD SD

M

2.66

12.97

2.71

16.69

c c

HC SD

M

3.55

12.74

F

Cognitive Confidence

14.12

b

2.76

14.10

3.83

13.11

Need to Control Thoughts

15.41b

3.02

15.41c

3.30

12.80b,c

Cognitive Self-Consciousness

14.41b

2.45

14.70c

3.84

13.30b,c

Uncontrollability and Danger

MCQ-30 Total

72.42

b

10.20

73.86

c

3.69

12.81

4.23

b,c

14.33

64.76

LESS

T

3.36

b,c

.410

4.600

.020

UPD = BPD > HC

.011

3.74

30.506

.118

UPD = BPD > HC

< .001

b,c

3.43

7.614

.032

UPD = BPD > HC

.001

13.86

21.824

.088

UPD = BPD > HC

< .001

.192

HC > BPD > UPD

< .001

-

.933

3.24

11.58b,c

2.99

53.822

Comprehensibility

15.05

3.13

15.05

3.67

14.93

2.46

.069

4.52

b,c

17.08

Higher Values

11.07b

Control

11.95

Numbness

7.27

Rationality

b

b

12.27

b

7.19a,b

Duration Consensus

13.62

3.73

12.71

2.96

16.35

c

2.54

11.44c

3.12

12.11

c

2.14

c

7.08

3.66

98.279

.302

UPD > BPD > HC

< .001

4.46

11.42

b,c

2.92

120.269

.346

UPD = BPD > HC

< .001

3.24

12.77b,c

2.18

17.065

.070

HC > UPD = BPD

< .001

3.43

b,c

3.19

28.130

.110

HC > UPD = BPD

< .001

2.46

72.275

.242

UPD = BPD > HC

< .001

2.77

8.13

14.44 4.25

b,c

2.31

12.74

c

2.16

10.76

3.36

22.354

.090

UPD = BPD > HC

< .001

2.09

6.47a,c

2.00

5.03b,c

2.49

38.832

.146

UPD > BPD > HC

< .001

2.88

13.16

3.51

13.88

-

.148

ED

Simplistic View of Emotions

b

MA NU

9.84a,c

14.19

< .001

3.41

1.92

Guilt

.664

UPD = BPD > HC

8.39a,b

a.c

-

.177

Validation

a,b

p

48.698

SC

15.84

b

RI P

12.64

Post-hoc comparisons (Tukey HSD)

SD

MCQ-30 Positive Beliefs

Effect size (ηp2)

b,c

3.16

1.920

29.11

b,c

5.73

91.987

.288

HC > BPD > UPD

< .001

3.16

14.86

b,c

3.98

78.024

.256

UPD = BPD > HC

< .001

2.85

7.80

2.53

.582

-

.559

3.13

91.122

.286

UPD > BPD > HC

< .001

9.28

93.167

.291

HC > BPD > UPD

< .001

13.96

179.371

.441

UPD > BPD > HC

< .001

Negative Beliefs About Emotions‡ 179.36a,b 14.25 172.50a,c 22.76 152.89b,c 16.45

91.072

.286

UPD > BPD > HC

< .001

21.12

Rumination

19.59

Expression

b

8.09

9.07

Adaptive Emotional Schemas*

24.15

89.30

a,b

86.66

a,b

a,c

3.80

19.22

2.08

7.90

2.05

7.93

8.18 11.44

c

a,c

93.65

a,c

82.49

a,c

5.87

2.88

5.05

b,c

12.75 104.52 15.26

59.51

b,c

b,c

AC

Rigid Emotional Schemas†

a,b

CE

Blame

4.19

PT

Acceptance of Feelings

a,b

*Composite score for adaptive emotional schemas, †Composite score for rigid emotional schemas, ‡Composite score for negative beliefs about emotions UPD: Unipolar Depressed Patients, BPD: Bipolar Depressed Patients, HC: Healthy Control Subjects, M: Mean score, SD: 2

Standard deviation, ηp : Partial eta squared, F: One-Way ANOVA, HSD: Highly significant difference, MCQ-30: a

Metacognitions Questionnaire – 30, LESS: Leahy Emotional Schema Scale, :Statistically significant between UPD and BPD, b

c

:Statistically significant between UPD and HC, :Statistically significant between BPD and HC.

32

ACCEPTED MANUSCRIPT Table 3. Correlational analyses

.641** 1

MCQUD .420** .234** .406** 1

MCQCConf .202** .135** .305** .462** 1

MCQNCT .354** .207** .468** .765** .417** 1

MCQCCoun .220** .138** .543** .504** .429** .592** 1

MCQ-T

Val

Comp

Gui

Simp

.336** .216** .692** .834** .676** .852** .789** 1

-.439** -.294** -.290** -.458** -.455** -.386** -.372** -.512** 1

.007 .015 -.136** .019 .067 .007 -.041 -.018 .023 1

.548** .365** .371** .505** .316** .526** .407** .556** -.516** .104* 1

.583** .355** .196** .458** .305** .398** .410** .465** -.517** .063 .581** 1

T

MADRS 1 YMRS PB UD CConf NCT CCoun T Val Comp Gui Simp High Cont Numb Ratio Dur Cons Accep Rum Exp Bla Adapt Rigid Neg *p < .05, ** p < .01

MCQPB .056 .102* 1

RI P

YMRS

ED

MA NU

SC

MADRS

AC

CE

PT

MADRS: Montgomery-Asberg Depression Rating Scale, YMRS: Young Mania Rating Scale, MCQ-PB: Metacognition Questionnaire Positive Beliefs, MCQ-UD: Metacognition Questionnaire Uncontrollability and Danger, MCQ-CConf: Metacognition Questionnaire Cognitive Confidence, MCQ-NCT: Metacognition Questionnaire Need to Control Thoughts, MCQ-CCoun: Metacognition Questionnaire Cognitive SelfConsciousness, MCQ-T: Metacognition Questionnaire Total Score, Val: Validation, Comp: Comprehensibility, Gui: Guilt, Simp: Simplistic View of Emotions, High: Higher Values, Cont: Control, Numb: Numbness, Ratio: Rationality, Dur: Duration, Cons: Consensus, Accep: Acceptance of Feelings, Rum: Rumination, Exp: Expression, Bla: Blaming Others, Adapt: Adaptive Emotional Schemas, Rigid: Rigid Emotional Schemas, Neg: Negative Beliefs About Emotions

33

ACCEPTED MANUSCRIPT Table 3 (Continued). Correlational analyses Cons -.088

.363**

.168**

.258**

.006

.254**

.246**

.198**

.152**

UD

-.030

-.071

.553**

.342**

.251**

.120*

CConf

-.065

.064

.518**

.133**

.295**

.111*

NCT

.098*

-.065

.432**

.292**

.257**

.201**

CCoun

.013

-.007

.341**

.223**

.262**

.191**

T

.027

-.007

.552**

.325**

.328**

.200**

Val

.123**

.217**

.180** .038

.094* -.098*

.316** .040 .426**

.302** .180** .583**

-.009

Comp Gui

.534** .045 .496**

.143** .124**

Simp

-.040

.529**

.522**

.405**

.055

High

1

.186** .142**

-.044

.096*

-.034

.188**

-.004 .749** .652** .044

1

.134** 1

-.060

.118*

.122**

.137**

.465**

.404**

.023

1

.364**

.045

1

.214**

.514** .467** .527** -.088 1

Numb Ratio

PT

Dur

Rum

Exp .013

Bla .530**

.245**

-.068

.318**

.203**

-.101*

.248**

.468**

.455**

.124** .135** -.067

.241**

-.060

.334**

.431**

.127** -.020

.498**

.260**

.471** .039 .431**

Rigid Neg *p < .05, ** p < .01

.504** .264** .538**

.048 -.061

.576** .200** .677**

.524**

.169**

.563**

-.090

.147**

-.025

.148** .395**

.178** -.057

.201** .436**

.241**

.076

.252**

.207**

.043

.417**

-.051 .481** 1

.036 .015

.059 .632** .489**

-.029 1

AC

Exp Bla Adapt

1

CE

Cons Accep

Rum .483**

MA NU

Cont

ED

YMRS

Accep .507** .284** .406** .540** .338** .569** .446** .601** .607**

T

Dur .355**

RI P

Ratio .291**

SC

Cont .310** .204** .070

Numb .522**

PB

High .258** .122** .095*

MADRS

.048 1

Adapt .541** .317** .258** .412** .268** .348** .297** .416** .658** .379** .492** .466** .452** .464** .445** .280** .212** .340** .701** .442** .215** .460** 1

Rigid .662**

Neg .554**

.410**

.287**

.339**

.407**

.612**

.574**

.403**

.449**

.581**

.514**

.442**

.430**

.625**

.621**

.642** .124** .841**

.717** -.120* .732**

.829**

.717**

-.022 .155** .706**

.154** .205** .653**

.612**

.533**

.622**

.435**

.083 .798** .685**

-.103* .831** .618**

.034 .765**

-.120* .674**

.565** 1

.790** .868** 1

MADRS: Montgomery-Asberg Depression Rating Scale, YMRS: Young Mania Rating Scale, MCQ-PB: Metacognition Questionnaire Positive Beliefs, MCQ-UD: Metacognition Questionnaire Uncontrollability and Danger, MCQ-CConf: Metacognition Questionnaire Cognitive Confidence, MCQ-NCT: Metacognition Questionnaire Need to Control Thoughts, MCQ-CCoun: Metacognition Questionnaire Cognitive SelfConsciousness, MCQ-T: Metacognition Questionnaire Total Score, Val: Validation, Comp: Comprehensibility, Gui: Guilt, Simp: Simplistic View of Emotions, High: Higher Values, Cont: Control, Numb: Numbness, Ratio: Rationality, Dur: Duration, Cons: Consensus, Accep: Acceptance of Feelings, Rum: Rumination, Exp: Expression, Bla: Blaming Others, Adapt: Adaptive Emotional Schemas, Rigid: Rigid Emotional Schemas, Neg: Negative Beliefs About Emotions

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