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Lorelei Simpson Rowe, Ph.D.
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Nia Parson, Ph.D.
A WEEKLY DIARY STUDY OF ARGUMENTS AND INTIMATE PARTNER
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August 3, 2012
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Mullen DeBoer, Kacy B.A., Valparaiso University, 2005
M.A., Southern Methodist University, 2010
one specific aspect of relationship functioning in the context of BPD: Intimate partner
violence (IPV). However, relatively little is known about when incidents of IPV are most
likely to occur among couples in which a partner has BPD. The current study examines
the longitudinal association between fluctuations in depressive and manic symptoms and
occurrence of psychological and physical IPV over 6 months among 38 couples in which
one partner had BPD. Results indicated that couples were more likely to engage in
psychological IPV during weeks when the partner with BPD had greater depressive
symptoms and total depression over the 6-month study period was associated with a
greater likelihood of any instance of physical IPV. In addition, individuals with bipolar
disorder were more likely to experience episodes of psychological IPV during weeks
when they both used drugs and had reduced manic symptoms. Overall, the results
LIST OF TABLES p. v
LIST OF FIGURES p. vi
ACKNOWLEDGEMENTS p. vii
Chapter
1. INTRODUCTION p. 1
Manic Symptoms
Methodological Advancements
2. METHODOLOGY p. 8
Participants
Procedures
Measures
Data Analysis
3. RESULTS p. 17
Hypothesis Testing
4. DISCUSSION p. 22
REFERENCES p. 31
iv
LIST OF TABLES
Table Page
v
LIST OF FIGURES
Figure Page
vi
ACKNOWLEDGEMENTS
and humbled by God’s grace and mercy. First and foremost, my husband, Davis, has
consistently demonstrated patience, kindness, grace, and sacrificial love, all in his own
quiet and humble manner that has not only made me a better graduate student, but a
better wife and mother. My son, Elias, whose timing into this world could have only
been orchestrated through God’s providence and who has provided me daily with joy,
laughter, and love. It is my prayer that my work in graduate school will have not only
sharpened my research and clinical skill, but also my daily practice as a mother. My
parents, Jim and Marcine, for believing in my academic abilities long before I believed in
them myself and for moving to Dallas to get us through the final stretch.
committee members: Renee McDonald, David Rosenfield, and Nia Parson. Without their
vii
dissertation would have not been possible. My clinical supervisors, including Leslie
Powers, Kimberly Doyle, Jim Harris, Reed Robinson, Jeffrey Dodds, Lynnora Ratliff,
and professional.
empathy provided by my wonderful research lab mates and friends. I cannot express my
gratitude for the opportunity to work with such incredibly smart, talented, kind, and fun
research lab mates as Cora and Anne. I would also like to thank several other graduate
school students for their friendship including Mary Clare, Catherine, Gabby, Erica, and
Erica.
viii
Chapter 1
INTRODUCTION
Bipolar disorder (BPD) is a chronic, severe, and disabling illness that affects
hypomania) and, in the majority of cases, depression (Judd et al., 2003; Judd et al., 2002).
(e.g., Cooke, Robb, Young, &Joffe, 1996; Dion, Tohen, Anthony, & Waternaux, 1988)
typically has a chronic course with high rates of residual symptoms between acute mood
episodes (Müller-Oerlinghausen et al., 2002), even when patients are compliant with
Goldberg, Grossman, & Meltzer, 1990; Gitlin, Swendsen, Heller, & Hammen, 1995).
romantic partners, and other family members, which in turn can affect the course of the
illness. For example, although many individuals with BPD receive mental health services
(Narrow, Reiger, Rae, Manderscheid, & Locke, 1993), significant others and family
members often still serve an informal care-giving role. As a result, emotional distress
and “caregiver burden” are common among the loved ones of those with BPD (e.g.,
1
Perlick, Rosenheck, Clarkin, Maciejewski, Sirey, Struening, & Link, 2004). Such
Clarkin, Kaczynski, & Rosenheck, 2005). Relationship distress and dissolution are also
common among couples in which a partner has BPD (Perlick et al., 2004; Whisman,
2007). On the other hand, the presence of strong, supportive couple/family relationships
is related to a number of positive outcomes for individuals with BPD. These include
greater employment stability (Hammen, Gitlin, & Altshuler, 2000) and medication
adherence (Demers & Davis, 1971; Lesser, 1983), fewer acute mood episodes (e.g.,
Brugha, 1995), and reduced service utilization (Perlick et al., 2005), all of which may
Given the importance of stable and supportive relationships for those with BPD,
may be of particular importance in BPD. Research suggests that IPV specifically, and
relationship conflict more broadly, may be more common among couples in which a
partner has BPD (Dore & Romans, 2001; Hoover & Fitzgerald, 1981; Lam, Donaldson,
Brown, & Malliaris, 2005). Moreover, individuals with BPD are at risk for anger attacks
(Perlis, Smoller, Fava, Rosenbaum, Nierenberg, & Sachs, 2004) and impulsivity (Swann,
Lijffijt, Lane, Steinberg, & Moeller, 2009), both of which have been linked to aggressive
Conklin, 2003). Additionally, one of the most commonly reported concerns among
2
partners is a fear that the individual with BPD will engage in violence, particularly during
episodes of hypomania or mania (Dore & Romans, 2001; Lam et al., 2005). Moreover,
research in non-BPD samples shows that high levels of conflict and relationship
aggression are associated with relationship distress and instability (Lawrence &
Bradbury, 2001; Rogge & Bradbury, 1999; Stith, Green, Smith, & Ward, 2008), physical
injury (Archer, 2000), psychological distress (Straus, Cerulli, McNutt, Rhodes, Conner,
Kemball, Kaslow, & Houry, 2009) and harm to children (see Kitzman, Gaylord, Holt, &
sociocultural predictors of violence (Capaldi & Kim, 2007; DeMaris, Benson, Fox, Hill,
& Van Wyk, 2003). Theorists have divided these factors into proximal influences–those
contextual factors that set the stage for a specific incident of IPV, and distal influences–
factors that predict the presence and frequency of IPV (DeMaris et al., 2003). Although
Babcock, Miller, & Siard, 2003; Bookwala, Frieze, Smith, & Ryan, 1992; Earls, 1994;
Holtzworth-Munroe & Stuart, 1994; Lee, 2000; Loeber & Farrington, 2000; Miles-Doan,
1998; O’Leary, Slep, & O’Leary, 2007; Simkins & Katz, 2002; Tweed & Dutton, 1998;
White & Humphrey, 1994), knowledge about proximal factors remains primarily
theoretical (see Frye & Karney, 2006 for an exception). However, identification of
important proximal factors has the potential to inform prevention and intervention efforts
to target the specific contexts when IPV is most likely to occur. The purpose of the
current study is to examine two potential proximal predictors of IPV that are particularly
likely to occur in the distal context of BPD: manic symptoms and substance abuse.
3
Manic Symptoms
Although less frequent and shorter in duration than depressive episodes (Judd et
al., 2002; Perlis et al., 2006), manic episodes are often associated with greater distress
sometimes aggressive behavior (Cassidy, Ahearn, & Carroll, 2002; Simon, Swann,
Powell, Potter, Kresnow, & O’Carroll, 2001; Swann, Stokes, Secunda, Maas, Bowden,
Berman, & Koslow, 1994). Among individuals with BPD, higher state impulsivity has
been linked to mania (Swann, Anderson, Dougherty, & Moeller, 2001; Swann, Pazzaglia,
Nicholls, Dougherty, & Moeller, 2003) which may place the person with BPD at higher
risk for perpetrating violence (Simon et al., 2001). Indeed, based on the reports of
spouses of individuals with BPD, manic symptoms appear to be associated with incidents
of IPV, specifically (Dore & Romans, 2001). Moreover, mixed episodes (defined by the
Pirozzi, Magliano, & Bartoli, 2003). Thus, we will test the hypotheses that 1) IPV will
be more likely to occur during weeks when manic symptoms are elevated and 2)
elevations in both depressive and manic symptoms in the same week will be more
strongly associated with occurrence of IPV than elevations in only depressive or manic
symptoms.
use. Substance use disorders (SUDs) are prominent in BPD, with rates as high as 60%
(Cassidy et al., 2002; Reiger, Farmer, Rae, Locke, & Keith, 1990), and are highly
4
correlated with impulsivity (Brady, Myrick, & McElroy, 1998; Swann, Dougherty,
Pazzaglia, Pham, & Moeller, 2004). Furthermore, SUD comorbidity is associated with a
more severe course of BPD (Feinman & Dunner, 1996) and greater cognitive impairment
(Martinez-Aranet al., 2004), which may place a person at greater risk for engaging in
IPV (Kantor & Straus, 1987; Leonard & Senchak, 1996; Schafer, Caetano, & Cunradi,
2004; Stuart, Moore, Gordon, Ramsey, & Kahler, 2006). Established models of IPV
suggest that substance use may provide an immediate context that makes psychological
and physical aggression more likely by reducing inhibitions and contributing to negative
perceptions of partner behavior (e.g., Foran & O’Leary, 2008). Within BPD samples,
findings indicate that acute manic episodes accompanied by substance use are associated
with greater mood lability, impulsivity, and general violence (Salloum et al., 2002)
hypothesize that 3) substance use will be associated with greater likelihood of IPV
occurrence, and 4) substance use in the context of elevated manic symptoms will be
Methodological Advancements
some methodological limitations in the existing literature. First, the majority of research
on IPV has relied upon cross-sectional designs (e.g., Dore & Romans, 2001), longitudinal
designs in which assessments are spaced at least several months apart (e.g., Barlow,
Grenyer, Ilkiw-Lavalle, 2000), or retrospective reports of IPV (e.g., Lam et al., 2005).
5
By examining the week-to-week association between the hypothesized proximal
predictors and the occurrence of IPV, we will be better able to determine how
fluctuations in symptoms and substance use are related to the occurrence of violence.
whether certain predictors are uniquely related to either psychological or physical IPV.
Previous studies (e.g., Barlow et al., 2000; Dore & Romans, 2001; Lam et al., 2005) often
examining the weekly associations between proximal predictors and psychological and
physical IPV, we will be better able to focus prevention and intervention efforts for
specific types of IPV. Furthermore, as there is strong and consistent evidence that a
partner’s aggressive acts are an important proximal context that increases the risk for
committing IPV (Capaldi, Shortt, & Crosby, 2003), we will examine the occurrence of
couple IPV (whether either partner endorsed engaging in an act of IPV during each week)
instead of focusing solely on acts of IPV committed by the participant with BPD. In
focusing on couple-level IPV as an outcome variable, we will be able to account for the
influence of a partner’s acts of IPV on the participant’s IPV as well as the possibility that
Third, we will control for two important confounds: relationship adjustment and
associated with IPV over time (Lawrence & Bradbury, 2001; Lawrence & Bradbury,
2007) in clinical and community samples, therefore we will test the above hypotheses
controlling for the individual with BPD’s relationship satisfaction. In addition, results of
6
several studies examining the proximal context for episodes of IPV indicate that verbal
(Cascardi & Vivian, 1995; Dobash & Dobash, 1979; Fenton & Rathus, 2010; Hamberger,
Lohr, Bonge, & Tolin, 1997); consequently, we will also test the above hypotheses
7
Chapter 2
METHODOLOGY
Participants
Thirty-eight individuals with BPD (n = 34, 89.5%, met criteria for Bipolar I; n =
4, 10.5%, met criteria for Bipolar II) and their heterosexual partners were recruited from
a larger metropolitan area in the southwest region of the U.S. through print, radio,
clinics and peer support groups. All couples met the following eligibility criteria: a) both
partners were between 25-65 years of age, b) the partners had been living together for at
least one year, c) both partners had completed at least a 10th grade education, d) both
partners could read and speak English well enough to complete interviews and
questionnaires, e) only one partner met DSM-IV criteria for Bipolar I or II disorder, f)
neither partner met DSM-IV diagnostic criteria for a primary psychotic disorder (i.e.
symptoms solely in the context of a mood episode were not an exclusionary criterion, and
g) the couple was not currently enrolled in couple therapy and did not plan to engage in
8
Participants (individuals with BPD) and their partners were, on average, in their
mid-40s (MParticipants= 44, SD = 10; MPartners= 46, SD = 11), had some college education (M
= 15,SD = 3), and had relatively high levels of relationship satisfaction (MParticipants= 108,
SD = 21; MPartners= 108, SD = 15; DAS scores > 97; Funk & Rogge, 2007). The majority
were White (92.1% of participants and 84.2% of their partners) with most of the
remaining sample reporting their race/ethnicity as Latino (5.3% of participants and 7.9%
of their partners). Fifty percent of participants and 76 percent of their partners were
employed; median couple income was $4,500 per month ($54,000 per year). The
At the time of the initial assessment, 31% of participants met criteria for a manic
or hypomanic episode, 54% of participants met criteria for a major depressive episode,
and 15% met criteria for both a major depressive episode and a manic/hypomanic episode
in the past month. Additionally, about a quarter (26%) of participants currently met
criteria for other Axis I disorders. Eleven percent (n = 4) of participants met criteria for a
substance use disorder and 21% (n = 8) met criteria for an anxiety disorder. When
examining lifetime diagnoses, a majority (75%) of participants met criteria for an Axis I
met criteria for a lifetime substance use disorder, 50% (n = 19) met criteria for an anxiety
disorder, and 11% (n = 4) met criteria for another diagnosis (e.g., eating disorder, pain
disorder).
Procedure
All study procedures were approved by the Institutional Review Board at the
university where the data were collected. Couples were recruited from community
9
mental health agencies, online advertisements (e.g., Craigslist), and local bipolar and
functioning among couples in which one partner had BPD. Previous research by Judd
and colleagues (2002) indicates that individuals with BPD report shifts in polarity more
than three times a year, on average; thus, the 6-month period of the study was designed to
participants. Potential participants contacted the research lab by phone and a research
assistant provided them with information about the study procedures and screened them
for study eligibility. Once both partners contacted the lab and were confirmed to be
eligible for the study, a research assistant scheduled them for the initial assessment.
functioning, and intimate partner violence, among others not relevant to the current study.
Additionally, doctoral students in clinical psychology who were trained and supervised
Structured Clinical Interview for the DSM-IV-TR, Research Version (SCID-I; First,
Spitzer, Gibbon, & Williams, 2002) to confirm that one, and only one, partner had a
Bipolar I or II diagnosis and confirm that all other eligibility requirements were met.
Couples then completed additional measures and tasks not related to the current study,
including the remaining Axis I modules of the SCID. Participants were reimbursed $125
each ($250 total per couple) for completion of the initial assessment.
Participants and their partners then completed brief weekly questionnaires for 6
months (26 weeks total) assessing relationship satisfaction, arguments between partners,
10
psychological and physical aggression, mood symptoms, and substance use. At the initial
Participants were asked to complete their weekly diaries independently from each other
and not to share their answers with one another. They were provided with one month’s
worth of weekly diaries (four at a time) and self-addressed, stamped envelopes and were
instructed to complete a weekly diary on the same day each week and mail it within five
days. Participants were reimbursed $5 for each diary they completed and returned to the
lab by its due date, paid in monthly installments. Participants and their partners
completed, on average, twenty weekly diaries across the six months of assessment. The
lowest number of weekly diaries completed was 2 while the highest number was 28.
Measures
TR Axis I Disorders, Research Version (SCID-I; First et al., 2002) is a well-validated and
reliable semi-structured interview for diagnosing the major DSM-IV-TR Axis I disorders.
It was administered to both partners at the initial assessment by trained doctoral graduate
student interviewers and was used to confirm that one partner had a diagnosis of Bipolar I
or II, to assess for any comorbid diagnoses for the partner with BPD, and to assess the
psychiatric history of the partner without BPD. All diagnoses were made by consensus
with the PI, an experienced diagnostician. Thirty percent of all interviews (n = 23) were
re-scored to examine inter-rater agreement. Agreement was acceptable for both current
indicate higher levels of satisfaction and a cut-off score of 97.5 has been validated as an
indicator of relationship distress (e.g., Funk & Rogge, 2007). It is highly correlated with
other measures of relationship satisfaction (Spanier, 1976) and in this sample, the internal
consistency of this measure was high for both participants with BPD (coefficient α = .95)
IPV. The Conflict Tactics Scale, Revised (CTS-2; Straus, Hamby, Boney-
McCoy, & Sugarman, 1996) is a well-validated and reliable measure of IPV that consists
of 78 items, on which participants rate their own and their partner’s behavior on five
and Injury). For the current study, the Psychological (8 items) and Physical Aggression
(12 items) subscales were used. Additionally, given that many individuals under-report
their own violence on self-report measures (Archer, 1999; Arias & Beach, 1987; Riggs,
Murphy, & O’Leary, 1989), the highest report of IPV from either reporter was used to
calculate prevalence and frequency estimates; that is, if a participant said that he/she had
engaged in an act 2 times, but his/her partner reported that the participant had engaged in
the act 4 times, a score of 4 was recorded for that act. Prevalence of psychological and
physical IPV in the past year were calculated by scoring 1 if the participant or their
partner reported at least one act of IPV in the past year; scores of 0 were given if the
participant or partner did not report any violent acts in the past year. Frequency of
the past year, but it did happen before) to be 0. Scores were then recoded based on
recommendations by Straus and colleagues (1996) as follows: Once in the past year = 1,
12
Twice in the past year = 2, 3-5 times in the past year = 4, 6-10 times in the past year = 8,
11-20 times in the past year = 15, and More than 20 times in the past year = 25. All
frequency items of the psychological aggression subscale were summed and reported as a
one-year frequency of psychological aggression. Cronbach’s alpha for the current sample
of individuals with BPD was .74 for the psychological aggression subscale and .55 for the
physical aggression subscale; internal consistency for the current sample of partners
without BPD was .64 for the psychological aggression subscale and .77 for the physical
aggression subscale.
To assess occurrence of IPV over the 6-month period of the study, selected items
from the CTS-2 (Straus et al., 1996) measuring mild psychological and mild physical
aggression were included in the weekly diary. Participants were asked to report how
frequently each of the following had occurred in the past week in open-ended questions:
investigations, the behaviors assessed in the selected items are the most common of all
items on the CTS-2 (e.g., Frye & Karney, 2006). As with the full CTS-2, the highest
report by either partner was used to calculate estimates. Frequency of the single-item
psychological aggression measure at baseline (on the weekly diary) was correlated (r =
.80, p< .01) with the frequency score from the CTS-2 psychological aggression subscale
in the current sample. Prevalence of the single-item physical aggression measure (on the
weekly diary) at baseline was associated with the prevalence of the CTS-2 physical
with their partner over the past week in an open-ended item “In the past week, how many
arguments did you have with your partner?” Due to positive skew, the data were recoded
so that responses of 7 or higher were scored as “7”; thus, scores ranged from 0 (no
arguments) to 7 arguments. In the current study, frequency of arguments from the first
weekly diary were correlated, r =.88; p< .01, with baseline psychological IPV from the
CTS-2.
Spitzer, & Williams, 2001) is a self-report, 9-item measure of depressive symptoms in the
past week that was administered in each weekly diary measure. It is based on the nine
DSM-IV-TR criteria for a Major Depressive Episode and has good internal consistency
(α = .85 in the current sample, from baseline administration). In the current study, PHQ-
9 scores from the first weekly diary were correlated with clinician-ratings on the
Hamilton Rating Scale for Depression (Hamilton, 1960), r = .82; p< .01, and with
participant self-report on the Beck Depression Inventory, Revised (Beck, Steer, &
Brown, 1996), r = .76; p< .01, both obtained at the baseline assessment.
Manic symptoms. The ASRM (Altman, Hedeker, Peterson, & Davis, 1997) is a
5-item self-report measure of manic symptoms in the past week that participants
completed as part of the weekly diaries. Scores from the first weekly diary correlated
positively with clinician-ratings on the Young Mania Rating Scale (Young, Biggs,
Ziegler, & Meyer, 1978), r = .51, p< .01, and the measure showed good internal
14
Alcohol and drug use. Participants were asked to report on their own alcohol
and drug use over the past week using open-ended items:“In the past week, how many
alcoholic drinks did you have?” and “In the past week, how many times did you use
illegal drugs or a prescription drug in a way other than was prescribed?”Weekly reports
estimations of alcohol/substance use over longer periods of time because it reduces recall
over a circumscribed time period (Del Boca & Darkes, 2004; Lemmens, Tan, & Knibbe,
1992). Number of alcoholic drinks reported in the initial diary was correlated with
baseline SCID-I alcohol abuse symptoms in the past month (r = .71, p< .01) in the current
sample.
Data Analysis
and occurrence of psychological and physical aggression were the dependent variables,
psychological aggression, r= .76, and physical aggression, r=.63, were all highly
correlated (all p’s < .001).Due to the highly positively skewed distribution of both
psychological and physical IPV in the current sample, prevalence, rather than frequency
use, and drug use) and their interactions (Manic Symptoms × Depressive Symptoms,
Manic Symptoms × Alcohol Use and Manic Symptoms × Drug Use) were included at
15
level-1 as a time-varying covariate. Within-participant average manic symptoms,
depressive symptoms, alcohol use and drug use over the study period were controlled at
statistics indicate the degree to which weekly scores for the IVs were related to weekly
scores for the DVs, controlling for the average effect of each IV at level-2.For example, a
positive and significant coefficient for level-1 manic symptoms would indicate that
during weeks when participants reported higher levels of manic symptoms, they were
also more likely to experience IPV; conversely, a positive and significant coefficient for
with higher average manic symptoms were more likely to experience IPV over the course
of the 6-month assessment period. A statistics expert was consulted about conducting a
power analysis to determine an appropriate sample size for the current study. The expert
concluded that the current sample size (n = 38 individuals with bipolar disorder)
16
Chapter 3
RESULTS
one act of physical IPV in the past year, committed by either partner. Across the six
months of assessment, only five couples (13.2%) experienced an act of physical IPV
committed by either partner; each couple only endorsed IPV during one week of the
assessment period. Thus, because the base rate of physical IPV was so low, we were
examination of between-couples differences across the six months revealed that there
were no differences on study predictors (e.g., manic symptoms, substance use) among
couples endorsing physical IPV compared to those not endorsing physical IPV, with two
exceptions. When examining the cross-sectional initial assessment data, participants with
BPD in a couple relationship reporting physical IPV over the past year were more
depressed than were participants with bipolar disorder in a relationship not reporting
physical IPV. Additionally, as expected, at the initial assessment participants with BPD
in a couple relationship reporting physical IPV over the past year reported lower
reporting physical IPV. Finally, when examining the mean scores across the six months
17
of data, among couples reporting physical IPV, participants with BPD reported a lower
average frequency of alcoholic drinks (M = .14, SD = .26) than did participants with
BPD in a relationship not reporting physical IPV. See Table 1 for a summary of
between-couple comparisons.
at least one act of psychological IPV in the past year, committed by either partner.
Across the six months of assessment, twenty-six couples (68.4%) experienced at least one
act of psychological IPV committed by either partner and thirty-three couples (87%)
reported at least one argument during the 6-month study period. The average number of
weeks in which psychological IPV occurred was 5.42 (SD = 6.23) and the average
frequency of psychological IPV across all weeks was 1.00 (SD = 2.85), with thirty acts of
psychological IPV as the highest number reported on any given week. Average
frequency of arguments across all weeks was 1.20 (SD = 1.80), with seven arguments as
reported having consumed alcohol at least once during the 6-month study period with a
mean of 1.69 drinks per week (SD = 3.85). Number of drinks ranged from 0 to 30 per
week across the sample and the average number of drinking weeks was 6.50 (SD = 8.88).
Twenty-six percent (n = 10) of participants reported illegal drug use and/or prescription
drug abuse during the study period with a mean frequency of weekly drug use of .39 (SD
= 1.60). Because drug use was strongly positively skewed, we examined whether the
individual used drugs during a given week, rather than the frequency of drug use each
18
week; the average number of weeks participants reported using illegal drugs and/or
(indicating a high probability of manic or hypomanic episode; Altman et al., 1997) during
at least one week over the 6-month period. The average ASRM score across the six
months was 2.11 (SD = 3.35) and scores ranged from 0 to 20. The average number of
weeks with an ASRM score greater than 6 was 2.45 (SD = 3.97).For depressive
symptoms, 89% (n = 33) of participants had a PHQ-9 score greater than 5 (indicating at
least mild depressive symptoms; Kroenke et al., 2001) during at least one week over the
study period. The average PHQ-9 score was 7.18 (SD = 6.86) and scores ranged from 0
to 27; the average number of weeks with a PHQ-9 score greater than 5 was 9.47 (SD =
Hypothesis Testing
To test the hypothesis that IPV would be more likely to occur during weeks when
manic symptoms were elevated, we conducted logistic multi-level models in which the
occurrence of psychological IPV was regressed onto weekly manic symptoms, weekly
level-1, controlling for initial relationship adjustment (DAS) and average manic
symptoms at level-2. All level-1 variables were group-mean centered and level-2
errors and the Odds Ratio are reported in Table 3.Only weekly depressive symptoms
were related to psychological IPV, such that during weeks when the individual with BPD
19
was more depressed, the couple was more likely to experience psychological IPV. The
hypotheses that manic symptoms would be associated with IPV and that there would be a
Next, we tested the hypothesis that IPV would be more likely to occur during
weeks when manic symptoms were elevated and the participant had used substances.
Because alcohol and drug use were not correlated, we examined these variables
individually. The same process of model testing was followed as above, in which
substance use was added as a level-1 time varying covariate and then the interaction
terms were examined (see Table 4).Results revealed that none of the hypothesized
however, a Manic Symptoms × Drug Use interaction was revealed, although not in the
hypothesized direction. Further probing of the interaction revealed that low levels of
manic symptoms were associated with increased psychological IPV during weeks when
participants with BPD had used drugs. Contrary to our hypothesis, when manic
symptoms were above average, drug use was associated with lower rates of psychological
To determine if the results were specific to psychological IPV or were relevant for
arguments between partners more broadly, we replicated the above models with
symptoms were related to frequency of couple arguments, such that during weeks when
the individual with BPD was more depressed, the couple reported more frequent
indicating that couples in which the participant with BPD had higher average manic
20
symptoms across the study period reported more frequent arguments. Finally, although
the predicted Manic Symptoms × Depressive Symptoms interaction was not supported in
the model predicting psychological IPV, it was supported in the model predicting
frequency of couple arguments. Further probing of the interaction revealed that elevated
manic symptoms were only associated with increased arguments during weeks when
depressive symptoms were also elevated. In fact, when depressive symptoms were below
average, increased manic symptoms were associated with lower rates of arguments (see
Figure 2).
arguments regressed onto manic symptoms and participant substance use (see Table 6).
Results revealed that none of the hypothesized predictors (alcohol or drug use) were
Use interaction.
Finally, we entered all predictors with a significant main effect in the above
models predicting psychological IPV, including weekly manic and depressive symptoms
and weekly drug use and the Manic Symptoms × Drug Use interaction as level-1 time
varying predictors, and controlling for weekly frequency of couple arguments (see Table
7). Results revealed that the main effect of weekly depressive symptoms and the Manic
Symptoms × Drug Use interaction were retained after controlling for weekly arguments.
21
Chapter 4
DISCUSSION
individuals and couples coping with BPD has relied on retrospective reports of the
patient’s aggressive behavior provided by caregivers, with much less attention focused on
the range and frequency of acts of IPV among couples coping with BPD. Given that
previous research indicates that intimate partners are more likely to be exposed to the
patient’s aggressive behavior (Dore & Romans, 2001) than other types of caregivers, the
current study was designed to address this gap in the literature. Several methodological
features of the present study differentiate it from previous studies and support the
strength of its findings: the use of prospective measures of affective symptoms and
episodes of IPV, the use of a measure of specific acts of psychological and physical IPV,
and the self-report of arguments, psychological and physical IPV, mood symptoms, and
substance use by both the participants with BPD and their partners.
Our results indicate that couples coping with BPD in the current study reported
BPD and their partners/caregivers (Barlow et al., 2000; Lam et al., 2005). Additionally,
the current sample reported a prevalence of physical IPV (23.7%) that is comparable to
both similar clinical (Dore & Romans, 2001) and more general community (Archer,
22
2000) samples. Further, couples in the current study reported rates of psychological and
physical IPV that is comparable to distressed couples (Friend, Bradley, Thatcher, &
Gottman, 2011), despite the relatively low levels of relationship distress in this sample.
Finally, at the bivariate level, there was a near perfect correlation between patient and
partner IPV (both physical and psychological) indicating that, in the current sample,
participants with bipolar disorder were both the perpetrators and victims of IPV. This is
consistent with other studies of IPV in both clinical and community samples which
suggest that among couples who report experiencing relatively infrequent and mild IPV,
both partners are likely to perpetrate IPV (e.g., Straus & Gelles, 1986).
Additionally, the current findings indicate that weekly depressive symptoms are
associated with both frequency of arguments and occurrence of psychological IPV across
First, previous research has indicated that bipolar depressive episodes are related
problems, including aggression (Perlis et al., 2004). Further, research conducted by Judd
among individuals with bipolar disorder indicated that depressive symptoms occur
between 31.9 and 50.3% of weeks while manic/hypomanic symptoms only occur
between 1.3 to 8.9% of weeks. The greater frequency of depressive symptoms and the
couple arguments and occurrence of psychological and physical IPV in the current study.
between hostile and critical close others and increased depressive symptomatology
Interestingly, and inconsistent with our results, the few studies (Dore & Romans,
2001; Lam et al., 2005) that have examined aggressive behavior among people with
symptoms. Based on our data, fluctuations in manic symptoms over time were not
associated with the occurrence of psychological IPV, although greater average manic
findings indicate that psychological IPV is not more likely to occur during weeks when
people with bipolar disorder are experiencing an increase in manic symptoms; however,
greater frequency of arguments is more likely to occur among couples in which the
disorder (e.g., Akiskal et al., 2006; Vazquez, Gonda, Zaratiegui, Lorenzo, Akiskal, &
Akiskal, 2010). Research on affective temperaments supports the current findings that
individuals with bipolar disorder often experience subthreshold manic symptoms between
affective episodes. The present data may be reflective of individuals with temperamental
traits that do not meet the threshold for a manic episode, but consistently report some
24
manic symptoms over time such as an irritability and labile mood. This is an important
finding because it indicates that manic symptoms over time are associated with greater
Future studies should focus on identifying which affective temperamental traits are
related to arguments and relationship conflict and if these traits contribute to a consistent
given the low rates of manic symptoms across the six months in the current study, future
research should focus on the association between IPV and manic symptoms in a more
Further, some researchers have described couples coping with BPD as having
Stewart, Davenport, Ketchum, & Kupfer, 1981), indicating that they are stable much of
the time but can be threatened during periods where the partner with BPD is
relationship between manic symptoms and arguments, support the notion that couples
coping with BPD experience increased conflict and hostility when the individual with
Contrary to our hypotheses, the interaction between weekly manic symptoms and
weekly drug use is not consistent with previously existing evidence that drug use and
manic symptoms are related to episodes of violence. Current results indicated that
participants who used drugs and reported more manic symptoms were least likely to
25
experience episodes of psychological IPV. Past empirical studies have demonstrated that
both mania and drug use lead to increased impulsivity and that when they occur at the
same time, impulsivity is greater than when they occur in isolation (Martinez-Aran et al.,
which may have affected their weekly report of symptoms. Previous research supports
including racing thoughts or depression (Weiss, Kolodziej, Griffin, Najavits, Jacobson, &
Greenfield, 2004). Potentially, the participant’s with bipolar disorder use of substances
may have resulted in an overall lower experience of manic symptoms over the course of
the six months. However, since the type of illegal substances used by the participants
with bipolar disorder was not collected, only the weekly frequency of drug use, it is
difficult to draw conclusions about the affects specific substances may have had on the
Future research should focus not only on obtaining information regarding the
participant with bipolar disorder and their partner’s IPV, but also on collecting greater
detail regarding the immediate context surrounding episodes of IPV. For example, it will
be useful to gather data that specified which partner engaged in an act of IPV first and
what types and amount of illegal substances were used on a weekly basis. Therefore,
collecting prospective, longitudinal data that is less vulnerable to recall error than
episodes of IPV.
Finally, the two couple level factors that were examined in the current study,
addition to partner’s IPV, participant satisfaction was related to psychological IPV over
the six months and physical IPV at the initial assessment. Overall, participants with
bipolar disorder with lower levels of satisfaction at the initial assessment reported more
arguments across the six months and were more likely to report that either they or their
partner had engaged in psychological IPV. These findings support a dyadic model of
important to understand the bipolar-specific risk factors for IPV among individuals with
especially the association between the patient and their partner’s IPV and overall
relationship satisfaction.
What implications do the current data have for clinicians working with couples
coping with bipolar disorder? Often, individuals with bipolar disorder receive individual
bipolar disorder tend to share several common characteristics: the model of therapy is
shared with the patient and his/her family and offers a specific individualized
conceptualization of the presenting problems, clear rationale for the techniques used are
provided to the patient, psychoeducation and skill development are core components, and
change is seen as a result of the patient’s efforts (Miklowitz et al., 2009). Typically, such
27
interventions do not address IPV or conflict management strategies; however, the current
results highlight the importance of assessing for and addressing conflict and
psychological IPV among couples coping with bipolar disorder. Interestingly, there is a
growing body of research examining the use of conjoint therapy with couples reporting
relatively infrequent, mild, and bidirectional IPV (Stith et al., 2004), which emphasizes
the therapy plans to meet the needs of the individuals in the couple relationship (Harris,
2006). This conjoint format may be a useful approach in intervening with couples
reporting arguments and psychological IPV who are also coping with BPD.
Also, the current data indicate that there is a need to intervene in substance use at
the individual level with patients with bipolar disorder. Existing research indicates that
comorbid substance use and bipolar disorder are more difficult to treat than bipolar
(Himmelhoch & Garfinkel, 1986; Goldberg, Garno, Leon, Kocsis, & Portera, 1999).
However, based on the findings of a few studies examining treatment effectiveness for
recommended to treat comorbid bipolar and SUD. Group based cognitive behavioral
therapy has been shown to decrease medical service utilization and increase
pharmacotherapy compliance among individuals with bipolar and substance use disorders
(Schmitz, Averill, Sayre, McCleary, Moeller, & Swann, 2002; Weiss, Najavits, &
role of substances in episodes of IPV (McCollum, Stith, Miller, & Ratcliffe, 2011). The
28
current data highlights the value of intervening in substance abuse among individuals
Limitations
When considering the results of the current study, several factors limit the
interpretation of the current findings. First, the study has a small sample size that limits
the power to detect differences between the study variables. Second, although the
longitudinal data allows for conclusions about the relationship between variables, causal
relationships cannot be determined. Third, the current sample was drawn from the
community, which means that although almost all participants with bipolar disorder were
actively receiving treatment (e.g., psychotropic medications), many were not acutely ill
during the six months of assessment. Next, the current sample was primarily White
andpartners were in their mid-40s, on average, indicating that they may be less likely to
engage in IPV than younger samples (e.g., Pan, Neidig, & O’Leary, 1994). Finally, the
inclusion criteria for the current study required that participating couples must have been
living together for at least one year. Therefore, couples in the current study may
represent more stable relationships that have effectively managed the impact of bipolar
disorder on their couple functioning. This suggests that couples in the current study may
possess certain individual and/or relationship characteristics that might not be found in
couples coping with bipolar disorder who are not able to maintain cohabitation for 1 year
or longer.
indicating that conflict and psychological IPV are serious issues affecting many couples
coping with bipolar disorder. Our current interventions for bipolar disorder and partner
29
violence may not be addressing the role that affective symptoms and drug use have on
research should focus on how best to intervene with couples coping with bipolar disorder
30
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Table 1: Between-Couple Differences among Couples Reporting Physical IPV and
Couples t df d
(n = 5) IPV
(n = 33)
Initial Assessment
(DAS)
Note. * p < .05, ** p < .01, *** p < .001. Standard Deviations appear in parentheses
adjacent to means
45
Table 2: Descriptive Statistics and Bivariate Correlations between Study Variables
1. 2. 3. 4. 5. 6. M (SD)
1. Relationship - 107.97
Weeks)
.50***
7. Drug Use (% Weeks) -.07 .26 .18 .17 .28 -.02 10.73 (23.53)
* p< .05, ** p < .01, *** p < .001; DAS = Dyadic Adjustment Scale, ASRM = Altman
46
Table 3: Occurrence of Psychological IPV by Manic and Depressive Symptoms
β (SE) OR
47
Table 4: Occurrence of Psychological IPV by Manic Symptoms and Substance Use
β (SE) OR β (SE) OR
Use
* p< .05, ** p < .01, *** p < .001; OR = Odds Ratio, DAS = Dyadic Adjustment Scale,
48
Table 5: Couple Arguments by Manic and Depressive Symptoms
β (SE)
49
Table 6: Couple Arguments by Manic Symptoms and Substance Use
β (SE) β (SE)
50
Table 7: Predictors of Psychological IPV, Controlling for Couple Arguments
β (SE) OR
51
Figure 1. Odds of psychological IPV by manic symptoms and drug use.
52