Revisiting the “manic defence hypothesis”: assessing explicit and implicit cognitive biases in euthymic bipolar disorder

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ABSTRACT Objective: The manic defence theory of bipolar disorder suggests that manic symptoms arise from an attempt to overcompensate for underlying depression. This depression avoidance may also be active in euthymia, raising concerns about the accuracy of explicit self-report measurement, and, more importantly, the presence of underlying negative cognitions. Methods: Ninety-six individuals identifying as bipolar-depressed, bipolar-euthymic, unipolar-depressed, unipolar-euthymic (based on self-reported diagnosis and mood state), and 53 non-psychiatric controls completed a series of online questionnaires assessing explicit and implicit measures of activated negative schemata. These included the Dysfunctional Attitudes Scale and the Young Schema Questionnaire, and an implicit measure, the Pragmatic Inference Task. Results: When assessed explicitly, bipolar-euthymic individuals endorsed negative schema content at a level intermediate between depressed individuals (bipolar and unipolar) and controls. However, when assessed implicitly, bipolar-euthymic individuals endorsed the highest levels of negative schema content of all groups. Conclusions: These findings indicate depression avoidance during euthymia, suggesting that implicit measurement may have a role in understanding latent negative cognitions in bipolar euthymia. The results have clinical implications as they suggest that reliance upon explicit self-report may overlook underlying and unconscious affective instability. KEY POINTS (1) People with bipolar euthymia reported low levels of explicit negative schemas, but high implicit signs of negative/depressive cognitions. (2) This implicit negative schema activation was higher than that seen in depression. (3) Bipolar euthymia may not represent wellness but suppression of negative cognitions.