ElevatedAmbitionsforFameAmongPersonsDiagnosedWithBipolarIDisorderSheri - PDF document

ElevatedAmbitionsforFameAmongPersonsDiagnosedWithBipolarIDisorderSheriL.JohnsonUniversityofCalifornia,BerkeleyCharlesS.CarverUniversityofMiamiIanH.GotlibStanfordUniversityAgrowingbodyofevidencesuggeststhatpeoplewithbipolardisorderarehighlygoal-oriented.Comparedtootherpersons,theyexpendmoreefforttoattainrewardsandviewgoalpursuitasmoreimportanttotheirself-worth.Personsatriskformaniaandthosediagnosedwithbipolarspectrumdisordershavebeenshowntoendorsehighlyambitiouslifegoals,suchasbecomingamultimillionaireorachievingfame.ThisstudyisthefirstexaminationofwhethersuchelevatedgoalscharacterizepersonsdiagnosedwithbipolarIdisorder.Wealsoexaminedwhetherelevatedambitionspredictedsymptomchangeovertime.Ninety-twopersonswithbipolarIdisorderand81age-andsex-matchedcontrolscompletedtheWillinglyApproachedSetofStatisticallyUnlikelyPursuits,ameasureofextremelyhighlifeambitions.Asubsetofthebipolarparticipantscompleteda3-monthfollow-upinterview.Participantswithbipolardisorderendorsedhigherambitionsforpopularfamethandidcontrols;moreover,height-enedambitionsforpopularfameandfinancialsuccesspredictedincreasesinmanicsymptomsinthosewithbipolardisorderoverthenextthreemonths.Discussionfocusesongoalregulationinbipolarbipolardisorder,mania,goalregulation,ambitionOverthepastdecade,aseriesoffindingssuggestthatpeoplewithbipolardisorderhavehighlevelsofrewardsensitivity(e.g.,Meyer,Johnson,&Winters,2001).ThesefindingshavecomefromstudiesofbipolarIdisorder(Lam,Wright,&Smith,2004;Salavertetal.,2007;VanderGucht,Morriss,Lancaster,Kinder-man,&Bentall,2009;butseeJones,Tai,Evershed,Knowles,&Bentall,2006foranonreplication),bipolarspectrumdisorders(Alloy&Abramson,2010;Alloyetal.,2006,2008,2009),andsamplesatriskfordisorderbyvirtueofahistoryofsubsyndromalmanicsymptoms(Carver&Johnson,2009;Fulford,Johnson,&Carver,2008;Gruber&Johnson,2009;Johnson&Carver,2006;Meyer,Beevers,Jonson,&Simmons,2007;Meyer&Hofmann,2005;Meyer,Johnson,&Carver,1999).Mostofthesestudiesreliedontheself-reportBehavioralApproachSystemscales(Carver&White,1994)toassessrewardsensitivity,butelevationsonbehavioralandpsychophysiologicalmeasuresofrewardsensi-tivityhavealsobeenfoundamongstudentsatriskformania(Harmon-Jonesetal.,2008;Haydenetal.,2008;Sutton&John-son,2002).Theelevationinrewardsensitivityhasalsobeenfoundtobepresentandconstantevenasmanicsymptomsfluctuate(Meyer,Johnson,&Winters,2001)andthereforedoesnotappeartobeduesimplytobeinginasymptomaticstate.Therewardsensitivitymodelhasbeenfoundtobeusefulinpredictingthecourseofmania;indeed,increasesinmaniaovertimehavebeenpredictedbyself-reportedrewardsensitivity(Alloy&Abramson,2010;Meyer,Johnson,&Winters,2001),lifeeventsinvolvingreward(Johnsonetal.,2000,2008;Nus-slock,Abramson,Harmon-Jones,Alloy,&Hogan,2007),andelevationsinbehaviorfocusedonattainingrewardandgoals(Lozano&Johnson,2001).Elevationsofrewardsensitivityhavealsobeenfoundtopredicttheonsetofbipolardisorder(Alloy,etal.,inpress).Despitethissupportforthemodel,itisimportanttonotethatrewardsensitivityisabroadconcept.Increasingly,modelsoftherewardsystemdifferentiateamongspecificprocessesandmecha-nismsinvolvedingoalregulation(Johnson,Edge,Holmes,&Carver,inpress).Thus,evidenceconcerningmorespecificpro-cesseshasbeensought.Peoplewithbipolardisorderappeartovaluegoalpursuitmorethandootherpeople(Alloyetal.,2009;Fulford,Johnson,&Tuchman,2009;Scott,Stanton,Garland,&Ferrier,2000;Spielberger,Parker,&Becker,1963;Wright,Lam,&Newsom-Davis,2005).Theyreportbothviewinggoalattain-mentascentraltotheirsenseofworth(Lam,Wright,&Sham,2005;Scott,Stanton,Garland,&Ferrier,2000)andpursuingtheir ThisarticlewaspublishedOnlineFirstNovember21,2011.SheriL.Johnson,DepartmentofPsychology,UniversityofCalifornia,Berkeley;CharlesS.Carver,DepartmentofPsychology,UniversityofMiami;andIanGotlib,DepartmentofPsychology,StanfordUniversity.SupportedbytheNationalInstituteofMentalHealth(GrantRO1076021).WethankJessicaJayneYuforherhelpinpreparingtherefer-encesandtables.WethankLoriEisner,DanielFulford,TerrenceKetter,ChristopherMiller,JenniferNam,BaileySmith,SarahVictor,andMeggyWangfortheirassistanceinconductingthisstudy,andKathleenHolmesforhercommentsonanalyses.CorrespondenceconcerningthisarticleshouldbeaddressedtoSheriL.Johnson,DepartmentofPsychology,3210TolmanHall,UniversityofCalifornia,Berkeley,CA94720.E-mail:sljohnson@berkeley.eduJournalofAbnormalPsychology©2011AmericanPsychologicalAssociation2012,Vol.121,No.3,602–6090021-843X/11/$12.00DOI:10.1037/a0026370 goalsinamoreeffortfulandperfectionisticmanner(Morrison,2003;Spielberger,Parker,&Becker,1963).Severallaboratorystudiessuggestthatpersonswithbipolardisorderexpendmoreefforttowardrewardthandohealthycon-trols.Forexample,Haydenetal.(2008)foundthatpeoplewithbipolardisorderperformedfasterthandidhealthycontrolswhengivenanopportunitytoearnrewardonacard-sortingtask;thesedifferencesdidnotemergeinanonrewardcondition.Harmon-Jonesetal.(2008)suggestedthathighapproachmotivationmightleadpeoplediagnosedwithbipolardisordertosustaineffortandremainengagedastasksbecomemoredifficult,butonlyfortasksinvolvingreward(asopposedtopunishment).Harmon-Jonesetal.usedleftfrontalcorticalactivation(asmeasuredbyelectroenceph-alogram)toindextaskengagement.Whenpresentedwithana-gramsofvaryingdifficultylevels(easy,medium,difficult)andachanceeithertowinmoneyifsolvedcorrectly(“reward”trial)ortolosemoneyifnotsolvedcorrectly(“punishment”trial),peoplewithbipolardisordershowedgreaterrelativeleftfrontalcorticalactivationinpreparationforthedifficultrewardtrials,butnotforthedifficultpunishmenttrials.Consideredcollectively,findingssuggestthatpeoplediagnosedwithbipolardisorderareparticu-larlywillingtoexpendefforttoearnrewardondifficulttasks.Willingnesstoexpendefforttowardgoalsalsoisalsomani-festedonself-reportscales.Severalstudieshavefoundthatpeoplewithdiagnosesofbipolardisorder,aswellasthoseatriskforbipolardisorder,sethighlyambitiousgoals.Forexample,riskforbipolardisorder,indexedbyscoresontheHypomanicPersonalityScale(Eckblad&Chapman,1986),hasbeenfoundtocorrelatewithperceptionsthatonewasgoingtomakemoremoneyandachievehighacademicgrades(Meyer&Krumm-Merabet,2003).Toexaminethisissuefurther,JohnsonandCarver(2006)de-velopedtheWillinglyApproachedSetofStatisticallyUnlikelyPursuits(WASSUP),aself-reportmeasureofextremelyambitious(difficulttoachieve)lifegoals,suchasbecomingthefocusofbooksandTVshows,orbecomingthebest-lovedparentofalltime.TheWASSUPwasdesignedtoincludegoalsrelatedtoextrinsicrecognition,suchasachievingfame,wealth,orpoliticalinfluence,aswellasgoalsthataremoreintrinsicallymotivated,suchasfamilyandfriendshipgoals.Intwovalidationstudies,studentsatriskformaniaendorsedhigheraspirationsonWASSUPsubscalesrelatedtoextrinsicmotivation,independentofcurrentlevelsofmanicsymptoms(Johnson&Carver,2006).SeveralstudieshavesincereplicatedtheprofileofriskformaniabeingstronglycorrelatedwithextrinsicWASSUPsubscales(Fulford,Johnson,&Carver,2008;Gruber&Johnson,2009;Johnson&Jones,2009).Johnson,Eisner,andCarver(2009)foundfurtherthatstudentsdiagnosedwithbipolarspectrumdisordershadsig-nificantlyhigherscoresonWASSUPsubscalesassessingextrin-sicallyorientedgoalsthandidhealthycontrolsorpersonsdiag-nosedwithmajordepressivedisorder,evenaftercontrollingforsubsyndromalsymptoms.Thus,aseriesofinvestigationssuggeststhatpeopleatriskformaniaandthosewithbipolarspectrumdisorderendorsehighlyambitiousgoals.Todate,however,researchershavenotexaminedambitiouslifegoalsinasampleofpersonslimitedtothosediagnosedwithbipolarIdisorder.TheseveresymptomsofbipolarIdisorder,aswellastherepeatedexperiencesofmanicepisodes,mightdampenambitiousgoal-setting.BipolarIdisorderisassociatedwithpro-foundlyhighratesofunemployment,maritaldissolution,legaldifficulties,andevenhomelessness—levelsofstressthatmightbeexpectedtocrushoptimismaboutdifficultlifegoals.Hence,inoneaimofthisstudywastoconsidertheeffectsofillnesshistoryonambitiousgoalsettinginasampleofbipolarIpersons.Asecondaimofthisstudywastoconsiderwhetherhighgoalsettingmightberelatedtoincreasesinmanicsymptomsovertime.Activationisrobustlycorrelatedwithmania(Akiskal&Benazzi,2005;Wehr,Goodwin,Wirz-Justice,Breitmaier,&Craig,1982);indeed,increasedphysicalactivationappearstobeaprodromalsignalofmania(Lam&Wong,1997).Signsofheightenedgoalengagement,suchassettingnewgoalsandspendingmoreeffortonthosegoals,predictincreasesinmania(Lozano&Johnson,2001).Highgoalsettingmaysetthestageforperiodsofoverac-tivity,whichwouldthenintensifytheriskformania(Johnson,WehypothesizedthatpersonswithbipolarIdisorderwouldreporthighlyambitiouslifegoals,particularlyforgoalsrelatedtoextrinsicrecognition,comparedtothosewithnomooddisorder,andthatWASSUPscoresrelatedtoextrinsicrecognitionwouldalsopredictincreasesinmaniaovertime.Toexaminethesequestions,werecruitedcommunitysamplesofpersonsdiagnosedwithbipolarIdisorderandofage-andsex-matchedcontrolpar-ticipantswithnohistoryofmooddisorders.AllcompletedtheWASSUP.ParticipantsdiagnosedwithbipolardisordercompletedtheWASSUPafterbeingfolloweduntiltheyachievedsymptomremission.Asubsetof33personswithbipolardisorderalsocompletedstandardizedsymptominterviewsata3-monthfollow-upsession.ParticipantswererecruitedfromtheMiamiandPaloAltoareasusingadvertisementsinthenewspaper,ontheweb,andonpublictransportationsites,aswellasflyersplacedinlocalmentalhealthclinics.Theparticipantswere92personswhometcriteriaforbipolarIdisorder(AmericanPsychiatricAssociation,2000),asverifiedbytheStructuredClinicalInterviewfor(SCID;First,Gibbon,Spitzer,&Williams,1997)forAxisIdisorders,and81controlparticipantswithnohistoryofmoodParticipantswereeligibleiftheymetcriteriaforbipolarIdisorderor,forthecontrolgroup,iftheyhadnohistoryofmajordepressionoranybipolarspectrumdisorder.ParticipantswererequiredtohavespokenEnglishforatleast10yearsandtobebetween18and65yearsofage.Exclusioncriteriaforallpartic-ipantsincludedmeetingdiagnosticcriteriaforsubstanceabuseordependenceinthepastyear,aprimarypsychoticdisorderduringthelifetime,ageneralmedicalconditionofthecentralnervoussystem,suchasbraininjury,vasculardisease,degenerativedisor-der,ahistoryofseriousheadinjury,oranydevelopmentaldis-abilityorlanguageproblemsthatcouldinterferewithunderstand-ingorcompletinginformedconsentormeasures.BipolarIandcontrolparticipantswerematchedbyageandsex.Tomaximizeourabilitytostudytheimportantcomorbidconditionsofanxietydisordersandsubstance-relateddisorders,someInternetandcom-munityadvertisementstargetedpeoplewiththeseconditions.AbouthalfofthebipolarparticipantsmetdiagnosticcriteriaforELEVATEDAMBITIONSINBIPOLARDISORDER lifetimeanxietydisordersandabouthalfforlifetimesubstance-relateddisorders.Aboutaquarterofthecontrolparticipantsmetdiagnosticcriteriaforeitheranxietydisordersorsubstance-relatedAtthefirstface-to-facevisit,allpotentialparticipantscompletedwritteninformedconsentprocedures.Participantswerepaidanhourlyrateforcompletingmeasures.AllmeasuresandprocedureswereapprovedbytheinstitutionalreviewboardsattheUniversityofMiamiandStanfordUniversity.TheSCID.TheSCIDisthemostcommonlyusedstructuredinterviewforassessinglifetimeandcurrentTheinterviewincludesstandardizedprobesforassessingdiagnos-ticcriteria,aswellasguidelinesforevaluatingeachsymptom.Demographiccharacteristics,suchasemploymentstatusandhis-tory,weregatheredduringtheinterview,andinterviewerscodedwhetherparticipantswerecurrentlyabletowork.Courseparam-etersforeachcondition,suchasthenumberofepisodesandhospitalizations,werealsoassessedaspartoftheinterview.Be-causesomeparticipantsreportedthattheycouldnotreliablyesti-matethenumberofepisodesorageofonset,courseparametersaremissingforsomeparticipants.BeforeadministeringtheSCID,researchassistantsandgraduatestudentsinclinicalpsychologyreceivedextensivetrainingfromtheleadauthorJohnson.Interraterreliabilitywasassessedbyrating10randomlyselectedaudiointerviews.Theratingswerecomparedtoaseriesofcriterion-standardaudiointerviews.Interraterreliabilitywas1.0forboththemaniaanddepressionmodules.TheBech-RafaelsonManiaScale.TheBech-RafaelsonMa-niaScaleBRMS;Bech,Bolwig,Kramp,&Rafaelsen,1979)wasusedtoassesstheseverityofmanicsymptoms.This11-iteminterview-basedmeasureassessestheseverityofmanicsymptomssuchaselevatedmood,decreasedneedforsleep,increasedverbalactivity,increasedmotoractivity,flightofthoughts,andincreasedsexualinterest.Eachitemisscoredona5-pointratingscale,anditemsaresummedtoyieldatotal(higherscoresindicatemoreseveresymptoms).Thescalehasbeenshowntobesensitivetochangesinclinicalstatusandhasbeenwidelyusedtoassesstreatmentoutcomes(Bech,2008).Scoresof16andaboveindicatemoderatemaniaandscoresof28oraboveindicateseveremania(Bech,2008).Weusedasetofstandardizedprobesandobtainedhighinterraterreliability(intraclasscorrelationcoefficientcoefficient.93inasampleof14randomlyselectedaudiotapes)andinternalconsistency(.94).Thescaledistinguishesbetweenpersonswithandwithoutcurrentmania,andcorrelateshighlywithothermeasuresofcurrentmania(Bech,2008).TheModifiedHamiltonRatingScaleforDepression.ModifiedHamiltonRatingScaleforDepression(MHRSD;Miller,Bishop,Norman,&Maddever,1985)wasusedtoassesstheseverityofdepressivesymptoms.ThissemistructuredinterviewwasdesignedtoallowparaprofessionalstomakevalidandreliableratingsofdepressionseveritybyprovidingstandardizedprobesandbehavioralanchorstosupplementtheinitialHamiltonRatingScaleforDepression(Hamilton,1980).Eachitemcoversonesymptomofdepression,withratingsrangingfrom0to2or4.Itemsaresummedtoyieldapossibletotalscoreof52.Scoresbelow7indicateremission,whilescoresof17andmoreareinterpretedasindicativeofadepressiveepisode.Thisscalehasexcellentinterraterreliability(ICC.93inpublishedarticlesandamongourresearchteammembersforasetof14audiotapedinterviews)andinternalconsistency(.92).TheMHRSDissensitivetochangesinclinicalstatus,correlateshighlywithothermeasuresofcurrentdepression,andhasbeenvalidatedinbipolardisorder(Johnsonetal.,2000,2008).TheWASSUP.TheWASSUP(Johnson&Carver,2006)isa30-itemself-reportmeasuredesignedtoassesshighlyambitiouslifegoals.Respondentsinthisstudyratedhowlikelytheyweretoseteachgoalforthemselves.Responseoptionswereratedfrom1nochanceIwillsetthisgoalformyself)to5(definitelyWILLsetthisgoalformyself).Therearesevenfactor-analyticallyderivedsubscales:PopularFame(e.g.,“youwillappearregularlyonTV”),Friendships(idealizedfriendships,e.g.,“everyoneyouknowwillloveyou”),WorldWell-Being(e.g.,“youwillcreateworldpeace”),PoliticalInfluence(e.g.,“youwillbeimportantinpolit-icalcircles”),Family(idealizedfamilyrelationships,e.g.,“yourrelationshipwillbemoreromanticthanRomeoandJuliet”),Fi-nancialSuccess(e.g.,“youwillhave$20millionormore”),andasubscalewithitemsreflectingCreativityandself-actualization.Inthisstudy,alphasweremoderatefortheCreativity,FinancialSuccess,andPoliticalInfluencesubscales(.69),andwerehighfortheFriends,Family,WorldWell-Being,andPopularFamesubscales(.80).Correlationsamongsubscalesrangedfrom.22to.59.Inpreviousresearch,personsatriskformaniaandthosediagnosedwithbipolarspectrumdisorderhaveendorsedhighaspirationsonthePopularFameandFinancialSuccesssub-scales(Carver&Johnson,2009;Johnson&Carver,2006;Fulford,Johnson,&Carver,2008;Gruber&Johnson,2009;Johnson&Jones,2009).Beforeparticipation,individualswhocontactedthestudystaffwerebrieflyscreenedoverthephoneforpotentialstudyeligibilityondemographic,medical,andpsychiatriccriteria.ThosewhowerepotentiallyeligiblewereinvitedtotheUniversityofMiamiorStanfordUniversityforadiagnosticinterview.Afterdiagnosisandotherinclusioncriteriawereconfirmed,participantscompletedthemeasuresdescribedabove.ParticipantswithbipolardisorderwhowereexperiencingsignificantsymptomswerefolloweduntiltheyachievedremissionasassessedwiththeMHRSDandBRMS.TheWASSUPwascompletedonceremissionwasachieved.Theyreturnedtotheuniversityforseparatesessionstocompleteothermeasuresnotdescribedhere.Toexaminewhetherbaselinevariablespredictedchangeinsymptoms,33oftheparticipantswerecontactedbytelephonefora3-monthsymptomseverityinterviewthatincludedtheBRMSandtheMHRSD.Telephoneinterviewshavebeenshowntobeareliableandvalidmannerofgatheringsymptomseveritydata(Potts,Daniels,Burnam,&Wells,1990;Simon,Revicki,&VonKorff,1993).(Onlyasubsampleofparticipants,alldrawnfromtheMiamisite,wascontactedforfollow-upduetolimitationsinstaffavailability.)AnalyseswereconductedusingStatisticalPackagefortheSo-cialSciences,Version19.Itemsweremissingfor24participantsJOHNSON,CARVER,ANDGOTLIB forWASSUPscalesduetoanerrorincopyingonesideoftheform.Thesedatawereconsideredtobemissingatrandom,andsowereimputedusingPSAS,Version19,multipleregressionimpu-tationprocedures,restrictingtheimputedvariablestotheoriginalrangeoftheWASSUPsubscales.Beforeconductingprimaryanal-yses,univariatedistributionsofkeyvariableswereexamined(seeTable1).Allvariablesdemonstratednormality,withtheexceptionoftheWASSUPPoliticalInfluenceandWorldWell-beingsub-scales—veryfewpeopleendorsedhighscoresonthesescales.Squareroottransformationswerecomputedforthesetwovari-ables;however,thesetransformationshadnoeffectsonthepri-maryanalyses,soanalysesofrawscoresarereportedhere.ComparisonsBetweentheBipolarandControlGroupsAsshowninTable1,thebipolarandcontrolgroupsdidnotdifferonage,sex,ethnicity,oreducationlevels.Participantsinthebipolargroupweremorelikelytobeunemployedorunabletoworkthanwereparticipantsinthecontrolgroup.Althoughthebipolargroupreportedaseverehistoryofrecurrentmoodepisodesandmanyhospitalizations,allparticipantsreportedextremelylowlevelsofcurrentmanicanddepressivesymptoms.Nonetheless,asnotedinTable1,thebipolargrouphadsignificantlyhighermaniascores(BRMS)scoresatbaselineandgreaterlikelihoodofsubstance-relatedandanxietydiagnosesthandidthecontrolpar-AsshowninTable2,thebipolargrouphadsignificantlyhigherscoresontheWASSUPPopularFamesubscaleandlowerscoresontheFriendsandFamilysubscalesthandidthecontrolgroup.ThetwogroupsdidnotdifferonotherWASSUPsubscalescores.Toensurethatthesedifferencesdidnotresultfromtheslightlyhighermaniascoresinthebipolargroup,analysesofcovariancewereconductedcontrollingforBRMSscores.Intheseanalyses,groupdifferencesremainedsignificantforeachofthesethreescales,PopularFamesubscale,(1,128).05,Family(1,128).05,andtheFriendssubscale,PredictorsoftheWASSUPSubscalesWithintheBipolarSampleAsdiscussedintheintroduction,wealsoconsideredwhetheramoresevereillnesscoursemightrelatetolowerWASSUPscoresinthebipolarsample.AsshowninTable3,therewasnoevidencethatamoreseverecourseofdisordercorrelatedwithloweraspi-rationswithinthebipolargroup.Wealsoexaminedwhetherahistoryofasubstance-relateddiagnosisorofanxietydisorderscorrelatedwithdiminishedWASSUPscores.Thesevariables,too,didnotcorrelatewithWASSUPscores.Wewerealsointerestedinhowoneotherillness-relatedconse-quence—inabilitytowork—relatedtotheWASSUPsubscales.Becauseonly2.5%ofthecontrolgroupreportedinabilitytowork,weexaminedthiswithinthebipolargroup.Thatis,aseriesofone-wayanalysesofvariancewereusedtoexaminetheeffectofemploymentstatus(employed,unemployed,orunabletowork)onWASSUPsubscaleswithinthebipolargroup.EmploymentstatuscorrelatedsignificantlywiththeWealthsubscale.PersonswhowereunabletoworkreportedlowerambitionsforFinancialSuc-18,thandidpersonswhowere55,andthosewerecurrently17.(Notethatthemeanscoreevenamongthosewithbipolardisorderwhowereabletoworkwaslowerthanthemeanscoreofhealthycontrols.)TherewasanonsignificanttendencyforemploymentstatustoberelatedtoWorldWell-Being,(2,87).05.EmploymentstatusdidnotcorrelatesignificantlywithotherWASSUPsub-Table1SampleCharacteristicsbyDiagnosticGroup BipolarI)or%)or%Age(y)37.8(11.61)35.0(12.1)Sex(%male)40.248.0Yearsofeducation14.8(2.0)14.5(2.1)EmploymentstatusEmployedorhomemaker(%)61.186.4Unabletowork20.02.5Unemployed18.911.1Ethnicminoritystatus20.917.3Lifetimediagnosisofalcoholorsubstanceabuse/dependence53.326.6Lifetimediagnosisofanxiety52.225.92.5(2.7)1.0(1.4)MHRSD3.3(4.3)2.0(3.2)PreviousMDEs10.8(11.5)PrevioushospitalizationsforMDE1.2(2.3)AgeofMDEonset18.3(8.7)Previousmanicepisodes9.4(10.2)Previoushospitalizationsformania1.6(3.0)Ageofmaniaonset22.0(9.0).BRMSBechRafaelsenManiaScale;MHRSDHamiltonRatingScaleforDepression;MDEmajordepressiveepisodeperSCIDinterview.Groupdifferencesoncategoricalvariablessuchassex,ethnicity,employment,andcomorbiddiagnosticstatuswereexaminedusingchi-squaretests;allothergroupdifferenceswereassessedusingaTable2GroupDifferencesonElevatedAmbitions(WASSUP) PopularFame1.77(.82)1.50(.57)Friends2.25(.89)2.57(1.06)2.18*WorldWell-Being1.54(.81)1.62(.97).59PoliticalInfluence1.34(.52)1.42(.79).81Family2.87(1.11)3.24(1.14)2.17*FinancialSuccess2.05(1.02)2.24(.91)1.29Create2.79(.92)2.68(.94)Note.df171exceptPopularFame,ELEVATEDAMBITIONSINBIPOLARDISORDER ProspectivePredictionofManiaSymptomsOurfinalgoalwastoexaminewhetherelevatedaspirationsmightpredictincreasesinmanicsymptomsatthe3-monthfollow-upassessmentamongthosewithbipolardisorder.AsshowninTable4,thePopularFameandFinancialSuccesssub-scalesweresignificantpredictorsoffollow-upBRMSscoresamongbipolarIparticipants,aftercontrollingforbaselinesymp-tomratings.NoWASSUPsubscalesignificantlypredicteddepres-sionscores(MHRSD).Wealsoconductedanalysestoexaminewhetherthosewhocompletedthefollow-upassessmentdifferedfromthosewhodidnotcompletethefollow-upassessment.AmongthebipolarItestssuggestedthatthosewhodid(33)anddidnotcomplete(27)follow-upassessmentsdidnotdifferonthenumberofepisodesofmaniaanddepression,thenumberofhospitalizationsformaniaanddepression,theseverityofmanicordepressivesymptomsatstudyentry,age,oryearsofeducation.Chi-squareanalysesindicatedthatthosewhodidanddidnotcompletefollow-upassessmentsdidnotdifferongender,sub-stanceusehistory,oranxietydisorders.Thosewhocompletedfollow-upassessmentsreportedalaterageofonsetofmania,Toconsiderwhetherageofmaniaonsetoperatedasapotentialconfound,weexaminedthepartialcorrelationsofPopularFameandFinancialSuccesssubscaleswithfollow-upBRMSscoresaftercontrollingforbothbaselinesymptomratingsandageofmaniaonset.Bothcorrelationsremainedsubstantialandsignificantwhencontrollingforageofmaniaonsetalongwithbaselinemaniaratings(bothpartialThisstudyprovidesthefirstexaminationofwhetherpersonsdiagnosedwithbipolarIdisorderarecharacterizedbyhighlyambitiouslifegoals,andwhethersuchelevatedaspirationspredictincreasesinmaniaovertime.Althoughambitiouslifegoalshavebeendocumentedamongthosewithbipolarspec-trumdisorder,existingliteraturehadnottestedwhetherthemoresevereconsequencesofbipolarIdisorderwoulddampentendenciestowardheightenedambitions.WefoundthatpersonswithbipolarIdisorderendorsedsignificantlyhigherambitionsforpopularfamethandidcontrolparticipants.Theseeffectsdidnotappeartobeduetoage,sex,oreducationlevels,asgroupswerematchedonthesecharacteristics.Norwerecurrentmanicsymptomsresponsiblefortheseeffects.Thecurrentfindingsextendpreviousresultswithmilderformsofdisorderinindi-catingthattheambitionsofpersonswithbipolarIdisorderareextremelyhigh.Indeed,aspirationsforpopularfamewerehighinthebipolarsampleevenamongthosewithmoreextensivehistoriesofepisodes,morepsychiatrichospitalizations,comor-bidanxietyandsubstanceabusedisorders,andamongthosewhowereunemployed.Alsoashypothesized,greaterambitionsforpopularfameandfinancialsuccesspredictedincreasesinmanicsymptomsovertime,controllingforbaselinesymptoms.Thisisthefirststudytoshowthattheseelevatedambitionscanpredictmanicsymptoms.Inthisstudy,personswithbipolardisorderreportedloweraspirationsforintrinsicallymotivatedgoalsregardingfamilyandfriendshipsthandidcontrolparticipants.Thisprofilehasalsobeennotedinsamplesatriskforbipolardisorder(Gruber&Johnson,2009).Oneexceptiontothisprofileofextrinsicallyorientedam-bitionsisnoted—unlikefindingswithmildersamples,peoplewithbipolardisorderdidnotendorsehighaspirationsforfinancialsuccess,evenwhenthosewhowereunabletoworkwereexcluded.Itmaybethatfinancialaspirationsarenotsustainedasthecon-Table3CorrelationsofWASSUPSubscalesWithIllnessHistoryParameters(asAssessedbySCID)WithintheBipolarGroup( NumberofdepressedepisodesNumberofhospitalizationsforNumberofmanicepisodesNumberofformaniaHistoryofalcoholorsubstanceHistoryofanxietydisorderPopularFame.049.005.109.041.098.013.112.013.107.023.047WorldWell-Being.066.103.041.148.088PoliticalInfluence.075.077.014.018.080.008.027.034.088FinancialSuccess.028.028.016.098Create.009.039.038.026.107.055Noneofthecorrelationsattainedsignificance.Table4CorrelationsofWASSUPSubscalesWithManiaandDepressionat3-MonthFollow-UpWithintheBipolarSample,AfterControllingforBaselineSymptoms( Follow-upmania(BRMS)controllingforbaselineBRMSFollow-updepressioncontrollingforbaselineMHRSDPopularFame.483Friends.006WorldWell-Being.048.123PoliticalInfluenceFinancialSuccess.488Create.115BechRafaelsenManiaScale;MHRSDHamiltonRatingScaleforDepression.JOHNSON,CARVER,ANDGOTLIB sequencesofthedisorderbecomemoresevere,eventhoughwewerenotabletoidentifyvariablesthatrelatedtolowerfinancialaspirationsinthebipolargroup.Onthewhole,findingsregardinghighaspirationsforpopularfameandlowaspirationsforfriendshipsandfamilysuggestthatpeoplewithbipolardisorderadoptextrinsicallyratherthanintrin-sicallymotivatedgoals.Aspursuingextrinsicgoalshasbeenrelatedtoadesireforsocialdominance(Duriez,Vansteenkiste,Soenens,&DeWitte,2007),thesefindingsfitwithothersinsuggestingthatbipolardisorderisrelatedtoaheighteneddesireforpower(Gilbert,McEwan,Hay,Irons,&Cheung,2007;Gilbertetal.,2009).Despitesupportforhypotheses,itisimportanttonoteseverallimitationsinthisstudy.RegardingtheWASSUPscale,itemsonthePoliticalInfluencesubscalewererarelyendorsedinthissampleandothersamples(cf.Johnson,Eisner,&Carver,2009),andperhapsasaconsequence,thescaledidnotcorrelatewithexpectedoutcomes,ashasbeenobservedinpreviousstudies.Asaself-reportscale,theWASSUPscaleisalsovulnerabletobiasesinresponsestyles.Futurestudiesofgoal-settinginbipolardisordershouldintegratebehavioralmeasuresofwillingnesstopursuedifficultgoals(Harmon-Jonesetal.,2008;Haydenetal.,2008).Moreover,findingsregardingthepredictionofmanicsymptomsovertimemustbeinterpretedcautiously,asthefollow-upsub-samplewassmall,andfewparticipantsreportedseveremanicsymptomsatfollow-up.Further,amongpersonswithbipolardis-order,thosewhocompletedthefollow-upreportedalateronsetofmaniacomparedtothosewhodidnotcompletethefollow-upNotwithstandingtheselimitations,thisstudyextendspreviousworkbyshowingthatevenpersonswithamoreseverehistoryofmanicsymptomsendorseambitiousgoal-setting,andthatthisambitiousgoal-settingpredictsmoreseveresymptomsofmaniaovertime.Otherfindingssuggestthatoverlypositiveviewsoftheself(Lam,Wright,&Sham,2005),BehavioralApproachSystemsensitivity(Meyer,Johnson,&Winters,2001),beliefsabouttheimportanceofgoals(Alloyetal.,2009;Francis-Raniere,Alloy,&Abramson,2006),andgoalengagement(Lozano&Johnson,2001)canpredictincreasesinmania.Evidenceacrossthesestudiessuggestsanimportantroleforcognitiveandpersonalityvariablesrelatedtogoaldysregulationaspredictorsofthecourseofmanicsymptoms.Findingsofthecurrentstudy,then,augmentagrowingliteraturethatsuggeststhatmaniaisrelatedtoadistinctsetofcognitiveprocessesregardinggoals,whicharerelevantforunder-standingthecourseofmanicsymptoms.Acoregoalforfutureresearchwillbetounderstandthebiological,social,andperson-alityvariablesthatcontributetogoaldysregulationwithinbipolarSeveralearlystudiessuggestthatabetterunderstandingofgoaldysregulationmightberelevantfortreatmentplanning.Whensurveyed,manypersonswithbipolarIdisorderhavereportedthattheytrytoavoidoverlystimulatinggoal-relevantactivitiesasawayofpreventingmanicepisodes(Lam&Wong,1997).Useofthesestrategieswasfoundtopredictlessriskofmaniaovertime(Lam,Wong,&Sham,2001).Wehavede-signedamaniatreatmentthatinvolvestechniquesformodulat-inghighgoalsetting.Overthecourseoftheintervention,participantsdemonstratedsignificantdecreasesinWASSUPscoresandinterviewerratingsofmanicsymptomseverity(Johnson&Fulford,2009).Henceforpersonswithbipolardisorder,agreaterawarenessofhowgoaldysregulationrelatestothecourseofdisorder,alongwithstrategiesforavoidingoverlyintensegoalpursuit,mightbehelpful.Akiskal,H.S.,&Benazzi,F.(2005).OptimizingthedetectionofbipolarIIdisorderinoutpatientprivatepractice:Towardasystematizationofclinicaldiagnosticwisdom.JournalofClinicalPsychiatry,66,914–921.Alloy,L.B.,Abramson,L.Y.,Walshaw,P.D.,Cogswell,A.,Grandin,L.D.,Hughes,M.E.,...Hogan,M.E.(2008).BehavioralApproachSystemAndBehavioralInhibitionSystemsensitivitiesandbipolarspec-trumdisorders:Prospectivepredictionofbipolarmoodepisodes.larDisorders,10,310–322.doi:10.1111/j.1399-5618.2007.00547.xAlloy,L.B.,Abramson,L.Y.,Walshaw,P.D.,Cogswell,A.,Smith,J.M.,Neeren,A.M.,...Nusslock,R.(2006).Behavioralapproachsystem(BAS)sensitivityandbipolarspectrumdisorders:Aretrospectiveandconcurrentbehavioralhigh-riskdesign.MotivationandEmotion,30(2),143–155.doi:10.1007/s11031-006-9003-3Alloy,L.B.,Abramson,L.Y.,Walshaw,P.D.,Gerstein,R.K.,Keyser,J.D.,Whitehouse,W.G.,...Jones,E.(2009).Behavioralapproachsystem(BAS)–relevantcognitivestylesandbipolarspectrumdisorders:Concurrentandprospectiveassociations.JournalofAbnormalPsychol-ogy,118,459–471.doi:10.1037/a0016604Alloy,L.B.,&Abramson,L.Y.(2010).Theroleofthebehavioralapproachsystem(BAS)inbipolarspectrumdisorders.CurrentDirec-tionsinPsychologicalScience,19,189–194.doi:10.1177/Alloy,L.B.,Bender,R.E.,Whitehouse,W.G.,Wagner,C.A.,Liu,R.T.,Grant,D.A.,...Abramson,L.Y.(inpress).HighBehavioralApproachSystem(BAS)sensitivity,rewardresponsiveness,andgoal-strivingpre-dictfirstonsetofbipolarspectrumdisorders:Aprospectivebehavioralhigh-riskdesign.JournalofAbnormalPsychologyAmericanPsychiatricAssociation.(2000).TheDiagnosticandStatisticalManualofMentalDisorders,FourthEdition,TextRevision(DSM-IV-.Washington,DC:Author.Bech,P.(2008).Useofratingscalesinaffectivedisorders.PsychiatricReview,1,6–10.Bech,P.,Bolwig,T.G.,Kramp,P.,&Rafaelsen,O.J.(1979).TheBech-RafaelsenManiaScalean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