2012. Vol.3, No.4, 364-369
Published Online April 2012 in SciRes (
Copyright © 2012 SciRes.
Bipolar Spectrum Disorders and Self-Concept among Males
and Females with Parenting Roles
Frank J. Prerost1*, Sharon Song2
1Department of Fam ily Medicine, Midwestern University, Downers Grove, USA
2Department of Biomedical Sciences, Midwestern University, Downers Grove, USA
Email: *
Received February 2nd, 2012; revised February 28th, 2012; accepted March 29th, 2012
Bipolar spectrum disorders have been found to produce significant psychosocial costs for individuals and
society. Although a number of studies have examined various psychosocial and psychological aspects as-
sociated with the bipolar spectrum disorders, the research literature has been extremely limited when fo-
cused on the parenting role. This current study examined the self-concept among parents who have been
diagnosed with a bipolar spectrum disorder. A group of male and female parents with a diagnosis of a bi-
polar spectrum disorder were assessed using the Tennessee Self-Concept Scales-2. Another group of
males and females without a diagnosis of a bipolar spectrum disorder were also assessed for comparison
using the same assessment tool. Compared to the non-bipolar parent group, results showed that partici-
pants with a diagnosis of a bipolar spectrum disorder showed a significantly lower self-concept marked
with doubts, concerns about academic/work performance, and perceptions of being physically diminished,
inadequate, alienated, and unworthy of the family role. Findings from this study showed that parents with
a bipolar spectrum disorder expressed negative perceptions related to inadequacy as a person across a
number of self-concept dimensions. The results expanded upon current descriptions of the psychological
dimensions found among individuals diagnosed with a bipolar spectrum disorder.
Keywords: Self-Concept; Bipolar Disorders; Parenting
The Mood Disorders described in the Diagnostic and Statis-
tical Manual of Mental Disorders, Fourth Edition Text Revision
(DSM-IV-TR) are identified to be commonly occurring psychi-
atric disorders (Bebbington & Ramana, 1995). The possible
long-term consequences of the mood disorders have been found
to range from spontaneous remission to a chronic presentation
of symptoms (Galione & Zimmerman, 2010). The diagnostic
separation of the mood disorders into Depressive Disorders and
Bipolar Disorders used in the DSM-IV-TR has proved to be
clinically and diagnostically useful (Perlis, Uher, Ostacher,
Goldberg, Trivedi, Rush, & Fava, 2010). Support for this sepa-
ration came from family studies, twin studies, and biological
studies. Additional support has been garnered from the finding
of differential clinical responses to treatment and long term
outcomes found among persons diagnosed with depressive and
bipolar disorders (Johnson, Meyer, Winett, & Small, 2000).
Bipolar spectrum disorders have been characterized through
abnormal mood swings that compose different levels of mood
states including mania, hypomania, major depression and
mixed states. Research has found that patients diagnosed with
the bipolar spectrum disorders such as bipolar I disorder, bipo-
lar II disorder, and cyclothymia, share many similarities in
symptomatic presentation (Hirschfeld, 2001). Although the
lifetime prevalence rate of bipolar I disorder has been reported
to be approximately 1%, the prevalence of all of the bipolar
spectrum disorders has been found to be substantially higher
and impacts on a significant number of persons in our society
(Hirschfeld, 2001).
Research efforts have investigated a wide range of factors
associated with the bipolar spectrum disorders including the
causal factors for bipolar disorder, the personal and societal
costs, psychosocial functioning, and effectiveness of various
treatment and management modalities (Michalak & Murray,
2010). Yet a critical examination of the self-concept of parents
who have been diagnosed with a bipolar spectrum disorder has
been lacking in the scientific literature. Few studies have ex-
plored the perceptions that individuals have developed about
the bipolar disorder, and none have specifically examined how
the notations about the psychiatric disorder have influenced
developmental, behavioral or mental health concerns about their
offspring or the actual parenting behaviors perfo rmed.
Many studies have shown that bipolar spectrum disorders are
associated with high rates of relapse that produced significant
psychosocial, social and economic costs to society (Freeman,
Freeman, & McElroy, 2002). Although many of the most per-
sonally and socially destructive behaviors of bipolar spectrum
disorders have been controlled through the application of psy-
choactive medication, compliance has continued to be a sig-
nificant problem (Perlis, Uher, Ostacher, Goldberg, Trivedi,
Rush, & Fava, 2010). Bipolar spectrum disorders have been
found to exact substantial financial, psychological, and societal
costs even when individuals have received appropriate phar-
macotherapy. Individuals with bipolar spectrum disorders have
been considered to be prone to recurrences of problematic
symptoms (Miklowitz & Alloy, 1999). Research has docu-
mented substantial personal costs to the bipolar patients such as
financial strain, occupational instability, and increased mortal-
*Corresponding author.
ity rate (Psbu, Brandt, Correia, Ekbom, & Sparen, 2001).
Most individuals with bipolar spectrum disorders have been
diagnosed during a depressive episode, but have showed great-
est noncompliance with treatment when the depressed mood
has dissipated (Angst & Marneros, 2001; Querques & Kontos,
2010). Researchers have found that a majority of patients with
bipolar disorder have not achieved complete functional recov-
ery (Pradham, Sinha, & Singh, 1999). Approximately 25% of
persons diagnosed with bipolar spectrum disorders have not
achieved full recovery (Pradham, Sinha, & Singh, 1999). Ge-
netic factors, biological and cognitive vulnerabilities have been
acknowledged in extended family studies to be significant in
the etiology of bipolar spectrum disorder (Blackwood, Visscher,
& Muir, 2001; Klimes-Dougan, Long, Lee, Ronsaville, Gold, &
Martinez, 2010). Family and linkage studies have provided
evidence for overlapping genetic susceptibility between bipolar
spectrum disorders and schizophrenia (Bramon & Sham, 2001).
This genetic component in the etiology of bipolar spectrum
disorders has been readily reported in the media making the
information readily accessible to individuals who are parenting
offspring. Approximately half of the adult children who had a
parent with a history of serious psychiatric disorder were found
to display major psychological or substance abuse problems
(Mowbrary, Bybee, Oysterman, MacFarlane, & Bowersox,
Stressful life events and disturbances in social-familial sup-
ports systems have been known to influence the cycling of the
bipolar spectrum disorders (Rush, 2003; Leboyer & Kupfer,
2010). This continual triggering of the mood cycling has served
to preserve negative ideas about the psychiatric condition
(Bramon & Sham, 2001). Social support has been considered to
be an important predictor of the frequency of mood cycling.
Enhanced self-esteem that was bolstered through a strengthened
social support system positively impacted on the clinical course
of bipolar spectrum disorders (Kilbourne, Teh, Welsh, Pincus,
Lasky, Perron, & Bauer, 2010). Effective psychosocial inter-
ventions have improved adherence to medications, enhanced
social-occupational functioning, and expanded the capacity of
individuals to cope with environmental stressors (Johnson, Me-
yer, Winett, & Small, 2000).
Researchers and clinicians have called for an enhanced un-
derstanding of the possible factors that may lead to improved
psychosocial interventions among individuals with bipolar spe-
ctrum disorders (Craighead & Miklowitz, 2000). Researchers
have also emphasized the importance of trying to identify the
factors that have prevented or impeded persons with bipolar
spectrum disorder from seeking effective treatments (Struening,
Perlick, Link, Hellman, Herman, & Sirey, 2001).
Offspring and Parentin g C o nsideration s
Persons who have been diagnosed with a bipolar spectrum
disorder have often shown an intellectual curiosity about pedi-
atric onset bipolar disorders. Many individuals have expressed
the opinion that their diagnosis was missed in their youth
(Wozniak, Biederman, & Richards, 2001). Up to sixteen per-
cent of pediatric psychiatric referrals have been found with a
presentation of symptoms associated with mania (Schraaufnael,
Brumback, Harper, & Weinberg, 2001). Bipolar spectrum dis-
orders have been recognized as a significant problem in all age
groups with various indicators of bipolar spectrum disorders
even recognized among prepubertal children (McNamara, Nan-
dagopal, Strakowski, & DelBello, 2010). Treatment for bipolar
spectrum disorders in children and adolescents has focused on a
multimodal approach with an emphasis on psychosocial inter-
ventions combined with pharmacotherapy (James & Javaloyes,
2001). At a roundtable convened by the National Institute of
Mental Health, it was recommended that children with prepu-
bertal bipolar spectrum disorders require particular monitoring
of treatments and outcomes (Hyman, 2000).
Assortative mating has been described as the tendency for
individuals with similar phenotypes to form relationships. This
phenomenon has been found to be a recurrent outcome among
persons with bipolar spectrum disorders as individuals form
intimate relationships and have had children (Mathews & Reus,
2010). But current research has not concluded if these couples
have experienced any particular difficulty with their family
roles and responsibilities.
Using interviews and critical discourse analysis, it has been
found that parents diagnosed with bipolar disorders reported a
heightened need to monitor and moderate their emotions while
teaching their children to do the same (Wilson & Crowe, 2009).
Parents with bipolar spectrum disorder were found to endorse
negative communication styles that produced limited personal
expression in their children (Vance, Jones, Espie, Bentall, &
Tai, 2009). Problems in communication were also described
among parents with bipolar spectrum disorder in the context of
not providing their children with an optimal environment for
learning communicative skills (Oyserman, Mowbray, Meares,
& Firminger, 2000).
This current research endeavor was designed to assess self-
concept among parents diagnosed with a bipolar spectrum. It
was hypothesized that parents diagnosed with a bipolar spe-
ctrum disorder would have a significantly lessened overall self-
concept and diminished family self-concept in comparison to
parents without a bipolar spectrum disorder. Further it was
proposed that the bipolar parents would have lower self-concept
and satisfaction in their life with enhanced conflict compared to
those without a diagnosis of a bipolar spectrum disorder.
Thirty adults (25 women and 5 men) who had at least one
child and had been diagnosed with a bipolar spectrum disorder
volunteered for participation in this study. The participants
were recruited from the community with radio and newspaper
advertisements, and announcements at meetings of a regional
support group for persons with bipolar spectrum disorders. The
volunteers with bipolar disorder were paid $25.00 in considera-
tion of their time and effort to participate in the study. Only
adults who were 18 years and older, had children, and had re-
ceived a formal diagnosis of a bipolar spectrum disorder were
accepted into the study and assigned to the bipolar parent group.
These 30 participants had a mean of 2.16 children and the fol-
lowing characteristics: 23 Euro-American, 6 African-American,
1 Hispanic; 12 married, 9 divorced, 3 separated, 6 si ngle; 2 had
not graduated from high school, 24 had earned some college
Participants in the non-bipolar parent group were recruited
from the surrounding community. Thirty-eight adults (25 women
and 13 men) volunteered for participation in the study. Inclu-
sion into the non-bipolar parent group required an absence of a
Copyright © 2012 SciRes. 365
bipolar spectrum disorder, having children and being 18 years
or older at the time of data collection. The non-bipolar parent
group participants had a mean of 1.92 children and had the
following characteristics: 31 Euro-American, 2 African-Ame-
rican, 4 Hispanic, and 1 Asian; 35 had earned at least some
college credit. The non-bipolar parent group participants did
not receive any financial remuneration for volunteering to be
part of the study.
Before participation in this study, all the participants signed
an informed consent form approved by the Midwestern Univer-
sity Institutional Review Board (IRB). All procedures, materi-
als, advertisements, and announcements used in this study were
IRB approved.
All of the participants completed a demographic question-
naire, and the Tennessee Self-Concept Scale-2, TSCS-2 (Fitts
& Warren, 1996). The TSCS-2 was selected for this study be-
cause it is comprised of self-concept scales that reflect directly
on the issues being examined in this study and it has an estab-
lished history of usage. The TSCS-2 was developed to examine
self-concepts in 1988 and the current edition was revised in
1996. The TSCS-2 has been standardized on nationwide sam-
ples from 7 to 90 years of age. The adult form used in this study
is written at the third grade reading level and is designed for
persons between the ages of 19 - 90 years. A five-point
Likert-ty pe scale (1 = always fal se, 2 = mostly false, 3 = partly
false and partly true, 4 = most ly true, 5 = always true) is used t o
respond to 82 self-report questionnaire items that assess how
individuals feel about them selves.
The TSCS-2 is considered to have good psychometric prop-
erties with coefficient alphas reported to range from .81 to .95.
The test-retest reliability estimates for the TSCS-2 scale scores
ranged from .62 to .82 (Lowe, Peyton, & Reynolds, 2007).
High validity correlations between the TSCS-2 scales and those
of other well known measures have been obtained (Lowe, Pey-
ton, & Reynolds, 2007).
The paper and pencil AutoScore Form of the TSCS-2 was
used in this study. Scoring of each TSCS-2 AutoScore Form
required approximately 10 minutes and provided 15 scores for
each participant in the study. The TSCS-2 is made up of 4 va-
lidity measures (inconsistent responding, self-criticism, faking
good, response distribution), 6 measures of self-concept (phy-
sical, moral, personal, family, social, academic/work), 2 sum-
mary self-concept measures (total self-concept, conflict), and 3
supplementary measures (iden tity, satisfaction, behavior).
Validity Scores
The Inconsistent Responding (INC) score identifies if there is
an unusually wide discrepancy in the person’s responses to 9
pairs of items with similar content. An example of an INC pair
would be: “I have a healthy body” “I take good care of myself
physically”. The Self-Criticism (SC) score indicates the degree
to which a peson endorses mildly derogatory statements. It
assesses whether a person is willing to admit to having com-
mon frailties such as: “I am not as smart as the people around
me.” Responses to nine statements make up the SC score. Fak-
ing Good (FG) is an indicator of the tendency to project a
falsely positive self-concept and make a favorable impression.
An example of the 7 items of the FG score is: “I feel good most
of the time”. The Response Distribution (RD) score is a meas-
ure of certainty about self-perception and is designed to assess
how extreme the responses were on the TSCS-2. The number of
extreme rati ngs of “1” and “5” is calculated across all quest ions
on the TSCS-2.
Self-Concept Scores
Physical Self-Concept (PHY) score represents the person’s
view of physical health, sexuality, physical skill, and appea-
rance. Fourteen items comprise the PHY score and includes the
statement: “I am an attractive person”. The Moral Self-Concept
(MOR) score describes the self from a moral/ethical perspective
and measures a person’s satisfaction with personal conduct and
control of impulses. The 14 items in the MOR score includes:
“I am an honest person”. Personal Self-Concept (PER) score
reflects the individual’s sense of personal worth, adequacy, and
personal adjustment. There are 12 items in the PER score in-
cluding: “I am a nobody”. The Family Self-Concept (FAM)
score taps into the person’s feelings of adequacy and value as a
family member. There are 12 statements for the FAM score and
includes: “I am a member of a happy family.” The Social Self-
Concept (SOC) score refers to the sense of adequacy and worth
in relation to social interactions including peers apart from
family and close friends. The 12 statements making up the SOC
score includes: “I do not feel at ease with other people.” The
Academic/Work Self-Concept (ACA) score measures self-per-
ceptions in the context of school and work settings. There 12
items in the ACA score and includes: “Math is hard for me.”
Summary Scores
The Conflict (CON) score compares the extent of differentia-
tion between self-concept through assertion versus disagree-
ment with negative items. The CON score reflects ambivalence
and is taken from 16 statements including: “I’ll never be as
smart as other people.” The Total Self-Concept (TOT) score
measures an individual’s overall self-esteem. The TOT score
gives an indication if a person holds a generally positive or
negative self-concept. Seventy-four statements in the TSCS-2
produce the TOT score and include the following statement: “I
see something good in everyone I meet”.
Supplementary Scores
The Identity (IDN) score measures basic identity and how
persons describe themselves. There are 21 statements in the
IDN score and includes: “I am a friendly person”. The Satisfac-
tion (SAT) score refers to the individual’s sense of self-satis-
faction and degree of contentment with the self. There are 21
statements that make up the SAT score and include: “I wish I
could be more trustworthy”. The Behavior (BHV) score meas-
ures a person’s perception of actions and reflects on how indi-
viduals describe themselves when referring to their behavior.
The BHV score includes 20 items on the TSCS-2 including: “I
do not act the way my family thinks I should”.
Each participant was seen individually in an interview room
where an informed consent form was reviewed and signatures
collected before data collection began. Following completion of
the demographic questionnaire, the participants completed the
Copyright © 2012 SciRes.
TSCS-2. The responses the participants provided on the demo-
graphic questionnaire and the TSCS-2 were coded in a manner
to assure anonymity.
The data collected on the TSCS-2 was analyzed to test the
hypothesis that individuals in the bipolar parent group would
have a significantly diminished overall self-concept. Dimin-
ished family self-concept in comparison to the non-bipolar
parent group of participants without a bipolar spectrum disorder
was also expected. Further, it was anticipated that the bipolar
parent group would show lower levels of self-concept related to
satisfaction in their life and enhanced conflict compared to the
non-bipolar parent group. The Cronbach’s alpha reliability
coefficients for the TOT score and subscales ranged from 0.727
to 0.855 which when compared to previously published guide-
lines are in the good to acceptable categories (George &
Mallery, 2003).
The mean TOT score on the Tennessee Self-Concept Scales-
2 for the bipolar parent group was 39.77 with an 8.61 standard
deviation. The non-bipolar parent group presented with a mean
TOT score of 54.87 with a standard deviation of 8.42. An
analysis of variance revealed a significant main effect (bipolar
parent group compared to non-bipolar parent group), F = 7.23,
p = 0.001 supporting the hypothesis that bipolar parent group
participants would have a diminished self-concept. Multiple
post-hoc t-tests on all of the TSCS-2 self-concept and supple-
mental scales revealed significant support for the hypotheses
related to family and satisfaction. The bipolar parent group
participants showed lower life satisfaction (SAT), t = 7.92, p =
0.0001 and family self-concept (FAM), t = 6.77, p = 0.0001.
Although a significant difference was not found for the CON
Score, t = 0.30, p = 0.7651; significant findings for the Physical
Self-Concept (PHY), t = 4.68, p = 0.0001; Moral/Ethical Self-
Concept (MOR), t = 3.31, p = 0.0015; Personal Self-Concept
(PER), t = 5.70, p = 0.0001; Social Self-Concept (SOC), t =
4.55, p = 0.0001; Academic/Work Self-Concept (ACA), t =
4.18, p = 0.0001; Identity (IDN), t = 5.85, p = 0.0001; and Be-
havior (BHV), t = 4.85, p = 0.0001 lend support to the pro-
posed negative impact of bipolar disorder on different aspects
of self-concept among the bipolar parent group.
The t-scores, means and standard deviations for all the valid-
ity, self-esteem, and supplemental scales for the non-bipolar
parent group and bipolar parent group are presented in Table 1.
The pattern of outcomes on the validity scales, INC, SC, FB,
and RD scores were indicative of good validity for the scores
across the TSCS-2 self-concept and supplementary measures
(Fitts & Warren, 1996).
The results indicated that parents with a bipolar spectrum
disorder showed a consistent and significant lessening of the
self-concept across various dimensions compared to the non-
bipolar parent group. The differences reached significance over
several aspects of self-concept including total, physical, moral,
personal, family, academic, identity, satisfaction and behavior.
Feelings of inadequacy as related to self-concept appeared to be
common among parents with a bipolar spectrum disorder. As
related to self-concept these individuals questioned their abili-
Table 1.
Comparison of bipolar parent group with non-bipolar parent group on
the Tennessee Self-Concept Scales-2 (TSCS-2) showing means, stan-
dard deviations, t-scores and p values.
Bipolar Paren t
Group M (SD)
Parent Gro u p
M (SD) t p-value
Responding 57.93 (10.30) 48.79 (7.712) 2.470.0161
Self-criticism 45.90 (13.14) 46.18 (9.302) 0.010.9921
Faking Goo d 41.80 (9.443) 54.34 (9.346) 3.180.0022
Distribution 47.03 (12.69) 51.24 (9.960) 0.890.37 67
Physical 41.23 (9.895) 54.37 (12.54) 4.680.0001
Moral 44.37 (12.59) 52.45 (8.497) 3.310.0015
Personal 39.93 (10.95) 54.63 (10.07) 5.700.00 01
Family 40.00 (8.506) 52.82 (6.974) 6.770.0001
Social 44.10 (9.15 4) 53.34 (7.570) 4.550.0001
Academic 45.57 (10.09) 54.13 (6.625) 4.180.0001
Conflict 55.80 (13.99) 53.89 (9.003) 0.300.7651
Total 39.77 (8.5 67) 54.87 (8.418) 4.370.0001
Identity 38.93 (9.2 89) 53.29 (10.57) 5.850.0001
Satisfaction 38.63 (7.3 54) 52.66 (7.121) 7.920.0001
Behavior 42.77 (10.71) 53.89 (8.049) 4.850.0001
ties to succeed in the various settings.
Parents with a bipolar spectrum disorder reported a sense of
inadequacy that questioned their value as a family member.
This finding may be considered to be an expansion on previ-
ously reported research outcomes in which parents with bipolar
disorder did not achieve full management of their symptoms
during the course of the bipolar spectrum disorder. Without
feeling in full control of the bipolar spectrum disorder constel-
lation of symptoms, the parents may have questioned their
value as a fully functioning family member. The results of the
current study have shown a diminished physical self-concept
that may have served as an impediment to perceiving the self as
a fully functioning family member. This may have promoted a
sense of alienation from th e fa mily.
Previous research that used a structured interview format
found that parents with bipolar disorder expressed a heightened
need to monitor their emotional state (Wilson & Crowe, 2009).
This need could be reflected in the impact on family self-con-
cept in the form of alienation. The need to carefully monitor
one’s emotional state may have set the parents apart from other
family membe rs and contributed to a feeling of separateness or
alienation from the m.
Previous research has shown that individuals with bipolar
disorder routinely experienced a reoccurrence of problematic
symptoms that lessened their overall sense of well being (Mik-
lowitz & Alloy, 1999). The current research showed that when
compared to the participants who did not have a bipolar spec-
trum disorder, the bipolar parent group reported a significantly
diminished physical self-concept. Seemingly they saw them-
selves as less physically well than others. It could be suggested
that the experience of emotional cycling with the need for con-
Copyright © 2012 SciRes. 367
tinuous use of mood stabilizing medications may have contrib-
uted to an unhealthy view of the self. These current findings
could be used to frame the previously reported outcomes that
persons with a bipolar spectrum disorder had described them-
selves as “broken” or less well than other people (Miklowitz &
Alloy, 1999).
Research has found poor social functioning among persons
with bipolar disorder and this was believed to be related to
diminished self-esteem (Johnson, Meyer, Winett, & Small,
2000). The current results revealed a low level of social and
personal self-concept among the bipolar parent group. These
individuals reported a low capacity to interact effectively in
social situations in comparison to the non-bipolar parent group.
Individuals with a bipolar spectrum disorder have expressed
problems with communication that contributed to an environ-
ment lacking in stimulation for the development of this skill in
their children (Oyserman, Mowbray, Meares, & Firminger,
2000). The diminished personal self-concept found in this study
among the bipolar parent group coincided with this previous
research. The low self-concept may have inhibited meaningful
communication with family members as well as with other per-
sons. Research has marked the importance of having strong
psychosocial and medical support systems for individuals di-
agnosed with bipolar disorder (Craighead & Miklowitz, 2000).
The findings in the current study which showed a diminished
level of personal self-concept may be connected to a limited
level of social support.
The bipolar parent group scored lower on moral/ethical self-
concept than the non-bipolar parent group. This may have been
a reflection on the perception that they were a “bad” person and
not a “good” one, and could have been related to the social
stigma that has been associated with mental illness in our soci-
Many studies have concluded that persons with bipolar dis-
order benefit from early diagnosis (Wozniak, Biederman, &
Richards, 2001) and a multimodal approach to treatment (James
& Javaloyes, 2001). Since the current study showed that vari-
ous aspects of self-concept were diminished among the bipolar
parent group, multimodal treatments could address the psycho-
social components of bipolar disorder and assist with enhancing
self-concept. Adult children of parents with bipolar disorder
have been found to exhibit a high incidence of psychiatric and
substance abuse problems (Mowbray, Bybee, Oysteman, Mac-
Farlane, & Bowersox, 2006). The treatment modalities used for
bipolar disorder may also be improved with the inclusion of
parenting support interventions.
Although the study obtained significant results the current
research is limited through the sample size. But the significant
outcomes suggest that future research efforts could be directed
into the self-perceptions among parents with bipolar spectrum
disorders in relationship to specific parenting skills. The con-
cerns found among these participants about the adequacy of
their self-concept and physical self may influence parenting
behavior and attitudes. Future research could focus on parent-
ing behaviors as the research variable among parents and non-
parents with a bipolar spectrum disorder.
This research was supported in part through a grant from the
Tsang Foundation. The authors wish to thank Erenee Sirinian,
DO for her assistance in the project.
Angst, J., & Marneros, A. (2001). Bipolarity from ancient to modern
times: Conception, birth and rebirth. Journal of Affective Disorders,
67, 3-19. doi:10.1016/S0165-0327(01)00429-3
Bebbington, P., & Ramana, R. (1995). The epidemiology of bipolar
affective disorder. Social Psychiatry and Psychiatric Epidemiology,
30, 279-292. doi:10.1007/BF00805795
Blackwood, D., Visscher, P., & Muir, W. (2001). Genetic studies of
bipolar affective disorder in large families. British Journal of Psy-
chiatry Supplement, 41 , 134-136. doi:10.1192/bjp.178.41.s134
Bramon, E., & Sham, P. (2001). The common genetic liability between
schizophrenia and bipolar disorder: A review. Current Psychiatry
Reports, 3, 332-337. doi:10.1007/s11920-001-0030-1
Craighead, W., & Miklowitz, D. (2000). Psychosocial interventions for
bipolar disorder. Jour na l of Cl in ic al Psychiatry, 61, 58-64.
Fitts, W. H., & Warren, W. L. (1996). Tennessee self-concept scale
(TSCS-2) manual . Los Angeles: Western Psychological Services.
Freeman, M., Freeman, S., & McElroy, S. (2002). The comorbidity of
bipolar and anxiety disorders: Prevalence, psychobiology, and treat-
ment issues. Journal o f Affective Disorders, 68, 1-23.
Galione, J., & Zimmerman, M. (2010). A comparison of depressed
patients with and without borderline personality disorder: Implica-
tions for interpreting studies of the validity of the bipolar spectrum.
Journal of Personalit y Disorders, 24, 763-772.
George, D., & Mallery, P. (2003). SPSS for Windows step by step: A
simple guide and referen c e (4th ed.). Boston: Allyn & Bacon.
Hirschfeld, R. (2001). Bipolar spectrum disorder: Improving its recog-
nition and diagnosis. J ou rn al of C l in ical Psychiatry, 62, 5-9.
Hyman, S. E. (2000). Goals for research on bipolar disorder: The view
from NIMH. Biological Psychiatry, 48, 436-441.
James, A., & Javaloyes, A. (2001). The treatment of bipolar disorder in
children and adolescents. Journal of Child Psychology and Psychia-
try, 42, 439-449. doi:10.1111/1469-7610.00738
Johnson, S., Meyer, B., Winett, C., & Small, J. (2000). Social support
and self-esteem predict changes in bipolar depression but not mania.
Journal of Affective Disor d ers, 58, 79-86.
Kilbourne, A. M., The, C., Welsh, D., Pincus, H. A., Lasky, E., Perron,
B., & Bauer, M. S. (2010). Implementing composite quality metrics
for bipolar disorder: Towards a more comprehensive approach to
quality measurement. General Hospital Psychiatry, 32, 636-643.
Klimes-Dougan, B., Long, J. D., Lee, C. Y., Ronsaville, D., Gold, P.
W., & Martinez, P. E. (2010). Continuity and cascade in offspring of
bipolar parents: A longitudinal study of externalizing, internalizing
and thought problems. Bipolar Disorders, 12, 627-637.
Leboyer, M., & Kupfer, D. J. (2010). Bipolar disorder: New perspec-
tives in health care and prevention. Journal of Clinical Psychiatry,
71, 1689-1695. doi:10.4088/JCP.10m06347yel
Lowe, P., Peyton, V., & Reynolds, C. (2007). Test score stability and
the relationship of adult manifest anxiety scale-college version scores
to external variables among graduate students. Journal of Psy-
choeducational Assessment, 25, 69-81.
Mathews, C., & Reus, D. (2010). Assortative mating in the affective
disorders: A systematic review and meta-analysis. Comprehensive
Psychiatry, 42, 257- 262. doi:10.1053/comp.2001.24575
McNamara, R. K., Nandagopal, J. J., Strakowski, S. M., & DelBello, M.
P. (2010) Preventative strategies for early-onset bipolar disorder:
Towards a clinical staging model. Central Nervous System Drugs, 24,
Michalak, E. E., & Murray, G. (2010). Development of the QOL.BD: A
disorder-specific scale to assess quality of life in bipolar disorder.
Bipolar Disorders, 12, 727-740.
Miklowitz, D., & Alloy, L. (1999). Psychosocial factors in the course
and treatment of bipolar disorder. Journal of Abnormal Psychology,
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 369
108, 558-588. doi:10.1037/0021-843X.108.4.555
Mowbrary, C., B ybee, D., O ysteman, D., MacFarl ane, P., & Bo wersox,
N. (2006). Psychosocial outcomes for adult children of parents with
severe mental illnesses: Demographic and clinical history predictors.
Health and Social Work , 31, 99-108. doi:10.1093/hsw/31.2.99
Osby, U., Brandt , L., Correia, N., Ekbom, A., & Sparen, P. (2001).
Excess mortality in bipolar and unipolar disorder. Archives of Gen-
eral Psychiatry, 58, 844-850. doi:10.1001/archpsyc.58.9.844
Oyserman, D., Mowbray, C., Meares, P., & Firminger, K. (2000). Par-
enting among mothers with a serious mental illness. American Jour-
nal of Orthopsychiatry, 70, 296-315. doi:10.1037/h0087733
Pradham, S., Sinha, V., & Singh, T. (1999). Psychosocial dysfunctions
in patients after recovery from mania and depression. International
Journal of Rehabilitation Re se arch, 22, 303-309.
Perlis, R. H., Uher, R., Ostacher, M., Goldberg, J. F., Trivedi, M. H.,
Rush, A. J., & Fava, M. (2010). Association between bipolar spec-
trum features and treatment outcomes in outpatients with major de-
pressive disorder. Journa l of Affective Disorders, 17, 30-45.
Querques, J., & Kontos, N. (2010). An approach to the patient with
dysregulated mood: Major depression and bipolar disorder. Devel-
opmental Psychopathology, 22, 849-866.
Rush, A. (2003). Toward an understanding of bipolar disorder and its
origin. Journal of Clinical Psychiatry, 64, 4-8.
Schraaufnael, C., Brumback, R., Harper, C., & Weinberg, W. (2001).
Affective illness in children and adolescents: Patterns of presentation
in relation to pubertal maturation and family history. Journal of
Child Neurology, 16, 553-561.
Struening, E., Perlick, D., Link, B., Hellman, F., Herman, D., & Sirey, J.
(2001). Stigma as a barrier to recovery: The extent to which caregiv-
ers believe most people devalue consumers and their families. Psy-
chiatry Service, 52, 1633-1638. doi:10.1176/
Vance, Y., Jones, S., Espie, J., Bentall, R., & Tai, S. (2009). Parental
communication style and family relationships in children of bipolar
parents. British Journal of Clinical Psychology, 47, 355-359.
Wilson, L., & Crowe, M. (2009). Parenting with a diagnosis bipolar
disorder. Journal of Advanced Nursing, 65, 877-884.
Wozniak, J., Biederman, J., & Richards, J. (2001). Diagnostic and
therapeutic dilemmas in the management of pediatric onset bipolar
disorder. Journal of Clin i ca l Psychiatry, 62, 10-15.