Psychiatry Research 219 (2014) 248–254

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Review article

The role of social relationships in bipolar disorder: A review

Sarah Greenberg, Katherine L. Rosenblum, Melvin G. McInnis, Maria Muzik n
Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48105, USA

art ic l e i nf o a b s t r a c t

Article history: Social relationships and attachment are core developmental elements of human existence and survival
Received 15 November 2013 that evolve over the lifetime of an individual. The internal and external factors that influence them
Received in revised form include the presence of illness in the individual or in their immediate environment. The developmental
9 May 2014
aspects of attachment and social relationships have become increasingly of interest and relevance in
Accepted 22 May 2014
Available online 4 June 2014
light of early developmental epigenetic modification of gene expression patterns that may influence
subsequent behavioral patterns and outcomes. This review examines extant literature on attachment
Keywords: and social relationships in bipolar cohorts. Despite many methodological challenges, the findings
Mood disorder indicate that social relationships and capacity for attachment are significantly compromised in
Attachment
individuals with bipolar disorder compared to other mood disorders and normal controls. Though
Social support
extant research is limited, research clearly points toward the importance of social relationships on the
Parent–child relationship
etiology, course, and consequences of bipolar disorder. We highlight a number of key considerations for
future research.
& 2014 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
3.1. Child attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
3.2. Adult attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
3.3. Social support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

1. Introduction reviews the literature on the role of social relationships in

Studies examining social relations among individuals with
bipolar disorder diagnoses suggest that these individuals are more
likely to report insecure attachment relationships and poor social
support. This association may be highly relevant for the indivi-
duals’ course of illness and life trajectory, as studies in the general
population have shown that supportive relationships may buffer
against life's stressful experiences. This paper comprehensively
n
Corresponding author. Tel.: þ 1 734 232 0206; fax: þ1 734 764 4031.
E-mail address: muzik@med.umich.edu (M. Muzik).
emotional wellness across the life cycle in persons with bipolar
disorder. The data presented are organized in the framework of
Social Convoy Theory.
Bipolar disorder is characterized by a lifelong pattern of
pathological mood swings ranging from the energized states with
misguided volition and intoxicating euphoria (or irritability) of the
manic phases, to the spectrum of depression with compromised
energy, volition, and slowed cognition, concentration, and physical
activity. There are overt and covert debilitating consequences,
socially, personally, and vocationally, placing bipolar disorder
among the top ten causes of years lost to disability (Murray and
Lopez, 1997). Even euthymic and remitted bipolar individuals

http://dx.doi.org/10.1016/j.psychres.2014.05.047
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
 S. Greenberg et al. / Psychiatry Research 219 (2014) 248–254
report lower functioning and well-being compared to patients
with chronic medical illness, major depressive disorder (Cooke
et al., 1996), or the general population (Arnold et al., 2000). Two
years following the first onset of bipolar mania, only a third of
individuals return to their former level of functioning (Tohen et al.,
2000; Duffy et al., 2007).
Individuals with bipolar disorder generally have trouble with
relationships across the lifespan. Disrupted life domains in those
with bipolar disorder include self-expression/self-improvement,
family relationships, other social relationships, and work relations;
these disruptions are observed even when the individuals with
bipolar disorder are euthymic at the time of assessment (Robb
et al., 1997). The social cost of bipolar disorder is thought to be
considerable, but there are relatively few studies that address the
social burden of this illness. Angst (1998) reported that the divorce
rate is three- to six-folds higher in bipolar II versus controls.
Family members and caregivers are reported to be considerably
burdened, and their burden is frequently associated with the level
of depression in the affected person (Ostacher et al., 2008). Thus,
not surprisingly, individuals with bipolar disorder are more likely
to be living alone, yet they are also noted to be more likely poor,
less educated, or unemployed (or if employed more likely to have
missed days), compared to those with major depression or no
affective disorder (Shippee et al., 2011). The social limitations of
this illness are compounded in part by the chaotic episodic nature
of the disorder, but also based on the diluted capacity of affected
individuals to establish healthy attachments that serve as tem-
plates for enduring relationships.
The causes of bipolar disorder are not yet fully elucidated, but it
is widely accepted within the field that an interaction between
biological susceptibility and environmental influences contribute
to its etiology (McInnis et al., 2007). Environmental factors,
including social context, may shape biological mechanisms that
are genetically determined, or influence genetic function (expres-
sion) within the individual over the course of development. There
is evidence of at least three associated genetic polymorphisms in
those diagnosed with bipolar disorder (Clayton-Smith et al., 2010;
Cohen-Woods et al., 2010; Cannon et al., 2011). The implications of
these genetic variations, including abnormalities in cell structure,
and dysregulation of cellular transmitters or receptors, are among
the biological consequences related to these genetic polymorph-
isms that may explain some, but in reality very little, of the
phenotypic aspects of bipolar disorder. The field that studies the
non-genetic biology of gene expression is epigenetics, investigat-
ing how environment influences gene functionality. Epigenetics
has been proposed responsible for some of the phenotypic varia-
tions in bipolar disorder course and illness severity that genetics
or environmental effects alone are unlikely to explain (Petronis,
2003). Epigenetic studies suggest that early social context, most
importantly early caregiving experiences, is a potentially crucial
modifier of the associations between genetic vulnerability and
development of mental health risks, and underscores the critical
importance of secure child–parent attachment relationships as
foundation for lifelong health (Miller et al., 1997; Francis et al.,
1999). The stress that an infant experiences when exposed to
inadequate parenting, leading to the establishment of an insecure
attachment relationship pattern, has been found to hold mean-
ingful biological and social implications for gene expression and is
related to poor behavioral adaptation later in life (for a review, see
Champagne and Curley (2005))
DNA methylation exemplifies an epigenetic mechanism that
involves modulating gene expression as a consequence of early
caregiving that may hinder the offspring's responsiveness (i.e.
social responsivity) later in life. Most of this work has been
demonstrated in animal studies. For example, Champagne et al.
(2003) showed that rodent offspring reared in poor quality
249
environments (i.e., low maternal licking/grooming) increased
methylation of the glucocorticoid receptor (GR) gene, which is
associated with decreased expression of this GR gene in the
hippocampus area, leading to an increased and dysregulated stress
response in the offspring. Conversely, being reared in high quality
caregiving (i.e., high maternal licking/grooming) was associated
with a decreased GR gene methylation, increased GR expression in
the hippocampal area and decreased stress response. This research
illustrates the effect of maternal care from one generation to next
– maternal care given to offspring shapes offspring biological and
behavioral outcomes. DNA methylation, along with other environ-
mental factors, has similarly been proposed as epigenetic mechan-
isms that contribute to intergenerational influences in humans.
Current research and clinical indicators are consistent with a
complex interplay between environmental and biological factors
in the developmental trajectory of bipolar disorder (McGowan and
Kato, 2008). It is postulated that environmental factors may evoke
or protect against biological vulnerabilities in bipolar disorder, a
combination of a genetic diathesis and stress (environment) (Post,
1992). The genetic diathesis–stress model may be helpful in
understanding why close relationships may be so severely
impacted by bipolar disorder; children of affected parents are
not only genetically predisposed, but parental disorder may also
increase the risk though an unpredictable caregiving environment,
which in turn may interfere with the offspring's development of a
secure attachment. Disrupted early caregiving may be an environ-
mental risk that may potentiate genetic and epigenetic vulner-
abilities. These factors may, in turn, create a deteriorating cycle –
early close relationships may be affected by parental disorder, and
if the children develop the disorder, their disorder may further
interfere with and complicate their future relationships.
Few studies have focused on the role of interpersonal relation-
ships on the presentation or course of bipolar disorder, or
conversely, the impact of bipolar disorder on close relationships.
There are three central domains of close relationships, including
(a) early childhood child–parent attachment, (b) adult attachment
(including romantic partnership), and (c) social support. Associa-
tions have been described between these domains and other
psychiatric disorders including psychotic (Breier and Strauss,
1984) and depressive disorders (for a review see Wai Wan and
Green (2009)), borderline personality disorder (for a review of the
attachment literature, see Agrawal et al. (2004)), social anxiety
disorder (Eng et al., 2001), and general psychiatric symptomatol-
ogy (Hipwell et al., 2000; Shorey and Snyder, 2006).
Attachment Theory is a conceptual framework initially pro-
posed by Bowlby (1969), a psychiatrist and ethologist who aimed
to elucidate the evolutionary purpose underlying the formation of
early social bonds between parents and offspring. Bowlby pro-
posed that offspring are neurologically hardwired to form long-
lasting emotional attachments to their caregivers for the purpose
of proximity seeking in times of perceived danger, thus promoting
survival of the species. Bowlby postulated this as a universal
principle for all mammalian species. His follower, Mary Ainsworth,
later specified that while attachments are universal for mamma-
lian species, in humans, the quality of the attachment bond is
unique for each dyad and is shaped by the cumulative experience
of day-to-day interactions over the first year between the baby and
the caregiver. She demonstrated that the quality of attachment can
be measured in an experimental paradigm, the Strange Situation
Paradigm (SSP) (Ainsworth and Wittig, 1969) The SSP classifies
attachment styles as secure, insecure–avoidant, insecure–ambiva-
lent, and disorganized through coding of behavioral indicators of
approach and comfort seeking in a reunion episode following
separation from the caregiver. The attachment style is thought to
develop over the first year of life as consequence to the parents’
caregiving style. Later in life, during adolescence and adulthood,
250 S. Greenberg et al. / Psychiatry Research 219 (2014) 248–254
the measurement of attachment is through a person's narratives of
childhood caregiving experiences during times that would elicit
attachment behaviors, such as separations from caregivers, illness,
or emotional and physical hurt (Obegi and Berant, 2010). Such
narratives of attachment relevant memories are also called “inter-
nal working models of relationships,” and are thought of as
memory templates that guide relational and social experiences
across the lifespan (Main et al., 1985). Most interviews that tap
into adult attachment working models tend to measure an adult's
attachment to his or her family of origin instead of adult romantic
relations (Jacobvitz et al., 2002). Finally, early attachment experi-
ences can also be tapped into through retrospective self-report
measures that ask an adult to report on their relationships with
one or both parents when growing up (Parker et al., 1979). There
are several self-report attachment measures available and vali-
dated (Armsden and Greenberg, 1987; Collins and Read, 1990;
Bartholomew and Horowitz, 1991; Brennan et al., 1998). In
summary, attachment is an established construct in developmen-
tal psychology known to contribute to a person's adjustment and
developmental trajectory across the life span.
Most studies of social support seem to use semi-structured
interviews or self report measures to elicit information about
perceived social support and functional support, such as instru-
mental support, emotional support, or companionship. For exam-
ple, the Interpersonal Support Evaluation List (Cohen and Wills,
1985) is a commonly used self-report scale that measures func-
tional or perceived social support. The use of semi-structured
interviews to elicit social support information is seemingly less
common. One concern in measuring social support information,
whether through interview or self-report, is the potential for
reporting bias; in particular, the risk that current mood states
may shape the respondent's evaluation of their social support.
While reporting biases is a concern for any study with any
population that solely uses self-report measures, this is a parti-
cular concern for studies involving psychiatric populations, given
that one's perspective of social support or attachment could be
affected by their current mood. In spite of this issue, however, self-
report measures do give valuable insight into participants’ percep-
tions of their social relationships, and have been found to be valid
and reliable.
Several prescient studies on bipolar disorder, summarized
briefly in subsequent sections of this paper, hint at the important
role that may be played by close relationships. The paucity of
research on close attachment relationships and bipolar disorder
represents a significant gap in the literature, in particular in view
of the emerging interest in epigenetic influence on human devel-
opment (Szyf, 2011).
The Social Convoy Model characterizes the role of close
relationships across the lifespan (Kahn and Antonucci, 1980), and
is useful for considering the importance of close relationships over
the lifetime of individuals affected with bipolar disorder. This
model provides a conceptual framework to integrate early attach-
ment relationships with primary caregivers and social support
provided by friends and romantic partners later in life, under-
scoring the lifelong importance of attachment and social support
needs. According to this model, relationships across the lifespan
are continuations of relationships that were formed in childhood
based on formative experiences with early attachment caregivers.
From this perspective, support provided by parents in early child-
hood plays a critical role as an infant begins life within a social
convoy and his or her parents are typically the primary available
social relationships. Sensitive support is likely to yield higher
levels of attachment security in children. Secure children trust
their caregivers, and are able to use them both as a “secure base”
as they explore the world, and as a “safe haven” for comfort and
regulation in times of distress (Bowlby, 1988). Early attachment
security, in turn, provides children with subsequent increased
sense of self-esteem and efficacy, and more trusting, well-
regulated friendships with peers (Rosenblum et al., 2009). As the
infant matures, the social convoy grows and changes as he or she
forms close relationships with others, such as friends or romantic
partners. As the child develops into an adult, he or she continues
to exist within a social convoy. Paralleling secure attachment
patterns in infancy and early childhood when interacting with
caregivers, secure adult attachment reflects a balance between inti-
macy and independence, whereby the adult is able to establish and
maintain closeness and intimacy, and yet does not unduly worry about
acceptance by others. High levels of perceived social support provide
the “secure base” and “safe haven” for an adult, allowing for optimal
functioning. The link between attachment and social support is that
perceptions of attachment figures are associated with perceptions of
support from those same figures (Asendorpf and Wilpers, 2000).
Research supports that for adults, the presence of at least one
supportive close relationship is more important than who the specific
relationship is with (e.g., parent, romantic partner etc.) (Levitt, 1991).
Thus, the Social Convoy Model suggests that both social support and
attachment theories reflect an underlying, evidence-based assumption
that “crisesþ support/coping¼increased wellbeing” (Antonucci and
Akiyama, 1994, p. 40).
The Social Convoy Model facilitates understanding how indivi-
duals, regardless of age or partnership status, experience support
from others, and the impact that this support has on their
functioning and wellbeing. In the current review we use a Social
Convoy framework to organize the extant literature on bipolar
disorder and close relationships from a lifespan perspective,
drawing from research on both attachment and social support.
2. Methods
This literature review reports on the results of a systematic review conducted
with the PubMed, Medline, and PsycINFO search engines. We used the following
key words: “bipolar” (used in all searches), “attachment,” “parenting”, “marriage”,
“relationship”, and/or “social support.” Titles and abstracts of the articles listed
through this search were individually reviewed to determine if they met the
following additional methodological criteria:
1. original empirical study published in a peer-reviewed journal;
2. sample includes adults with bipolar disorder;
3. analysis focused on bipolar sample (i.e., analyses did not simply reflect group-
ing bipolar with other psychiatric illness); and
4. measures of aspects of the social convoy (i.e. adult or child attachment, social
support).
This search yielded 23 studies, 15 regarding social support and bipolar disorder,
and eight regarding attachment and bipolar disorder (three children, five adults).
Results of this search are listed in Table 1 and are summarized in the following
sections.
3. Results
In the following sections we provide a summary of the extant
literature on close social relationships and bipolar disorder,
reporting findings separately for bipolar disorder and child attach-
ment, adult attachment, and social support.
3.1. Child attachment
Studies of psychosocial functioning in the offspring of parents
with bipolar disorder have focused primarily on assessments of
behavior and psychopathology of the child (Chang et al., 2003a,
2003b; Duffy et al., 2007; Bella et al., 2011; Diler et al., 2011), while
relatively few have addressed specific elements of attachment
between children and their parents. Radke-Yarrow et al. (1985)
 S. Greenberg et al. / Psychiatry Research 219 (2014) 248–254 251

Table 1
Methodological characteristics among studies.

Domain Study Relationship(s) Total Bipolar n Controls? Other Study Measure of Measure
measured N psych designa relationshipb typec
dx?

Child attachment Radke-Yarrow et al. Child 99 BP offspring Yes Yes CS SS O

(1985) n ¼14
Zahn-Waxler et al. Child 27 BP offspring Yes No CS SS O
(1984) n ¼7
Gilbert et al. (2007) General 40 BP n¼ 40 No No CS AAS SR
Joyce (1984) Parents 158 BP n¼ 58 Yes No CS PBI SR

Adult attachment Kökçü and Kesebir General 163 BP n¼ 44 Yes No CS AAS SR

(2010)
Marazziti et al. (2007) Romantic partner 126 BPI n¼ 31; BPII No Yes CS ECR SR
n ¼31
Morriss et al. (2009) Friends, family 148 BPI n¼ 107 Yes No CS BHRQ SR
Rosenfarb et al. (1994) Parents, peers 156 BP n¼ 25 Yes Yes CS IPPA, PCRQ SR
Beyer et al. (2003) General 141 BP n¼ 85 Yes No CS DSSI SR
Cohen et al. (2004) Best friend, parent, romantic 52 BPI n¼ 52 No No L SI SR
partner
Dorz et al. (2003) General 163 BP n¼ 31 No Yes CS SSQ SR
Gutiérrez-Rojas et al. General 108 BP n¼ 108 No No CS SASS SR
(2011)
Johnson et al. (1999) General 59 BPI n¼ 59 No No L ISEL, ISSI CI, SR

Social support Johnson et al. (2000) General 31 BPI n¼ 31 No No L ISEL SR

Johnson et al. (2003) General 94 BPI n¼ 71; BPII No No L ISEL, ISSI CI, SR
n ¼23
Kulhara et al. (1999) General 118 BP n¼ 118 No No L SSQ SR
O'Connell et al. (1985) General 60 BPI n ¼ 60 No No L PRI CI
Romans and McPherson General 284 BPI n¼ 52 Yes Yes CS ISSI CI
(1992)
Sanchez-Moreno et al. General 88 BP n¼ 88 No No CS MSPSS SR
(2010)
Staner et al. (1997) Social network 77 BP n¼ 27 Yes Yes L SSNI SR
Stefos et al. (1996) General 21 BP n¼ 21 No No L SSNI SR
Strauss and Johnson Treatment provider, general 58 BPI n¼ 58 No No L WAI, ISEL SR
(2006)
Weinstock and Miller General 92 BPI n¼ 92 No No L ISEL SR
(2010)

a
CS ¼ Cross-Sectional, L¼ Longitudinal.
b
SS ¼Strange Situation, AAS ¼ Adult Attachment Scale, PBI ¼ Parental Bonding Instrument, ECR ¼Experiences in Close Relationships, BHRQ ¼Bartholomew–Horowitz
Relationship Questionnaire, IPPA ¼Inventory of Parent and Peer Attachment, PCRQ ¼Parent-Child Relations Questionnaire, DSSI ¼ Duke Social Support Index, SI ¼Five-item
Scale of Supportive Interactions, SSQ ¼Social Support Questionnaire, SASS¼ Social Adaptation Self-Evaluation Scale, ISEL ¼ Interpersonal Support Evaluation List, ISSI ¼Inter-
view Schedule for Social Interaction, PRI¼Personal Resources Inventory, MSPSS ¼Multidimensional Scale of Perceived Social Support, SSNI ¼ Social Support Network
Inventory, WAI ¼Working Alliance Inventory.
c
SR ¼Self-Report Questionnaire, O ¼ Observational, CI ¼ Clinician-Rated Interview.

and Zahn-Waxler et al. (1984) studied attachment in children of
adults with bipolar disorder using the standard paradigm, the SSP
(Ainsworth and Wittig, 1969). Both studies were limited by small
samples, such that the two studies combined only included 21
children of mothers with bipolar disorder. Nonetheless, the results
were remarkable – 19 of 21 children at two- or three-years old had
an insecure attachment style. Though the sample sizes were
extremely small, the results of these two studies strongly suggest
that parent–child attachment should be examined further in
parents with bipolar disorder. A more recent study of parent–
child interactions that included 60 families (30 bipolar and 30
controls) found that parent–child relationships in the bipolar
group were characterized by significantly less warmth, affection,
and intimacy, and there are more quarreling and forceful punish-
ment (Schenkel et al., 2008).
Close examination of the qualities of early caregiving environ-
ments provided by symptomatic parents with bipolar disorder is
likely to be of considerable importance. Parents with bipolar
disorder may be hindered in their ability to provide an appropriate
and predictable response to a child, not only due to the extreme
“highs” of mania and the “lows” of depression, but also because of
the vicissitudes and turmoil of the sub-threshold symptoms that
characterize the chronicity of bipolar disorder. These types of
challenges to the caregiving environment and childhood attach-
ment security may both directly contribute to difficulties in child
behavioral and emotional self regulation, as parents struggle to
provide effective co-regulation, but also may interfere with effec-
tive childhood learning of social sills including capacity for secure
emotional attachment (Bowlby, 1988), which have implications for
relationships later in life.
3.2. Adult attachment
Patterns of attachment in bipolar disorder may be considered
in several dimensions, the most common contemporal context
being either a focus on adult attachment to other adults (i.e.
romantic partners and friends), or with a focus on adult attach-
ment that reflects their current state of mind about their own
family of origin (i.e., current mental representations of early
experiences with one's own mother or father in early childhood).
Our search identified five studies published on adult attachment in
bipolar cohorts; however, the type of attachment relationship that
each study measured differed from one other. The different
constructs of attachment reduces comparative analysis to a qua-
litative perspective with a challenge to the field for a systematic
approach in the future. In addition, all five studies used different
252 S. Greenberg et al. / Psychiatry Research 219 (2014) 248–254
self-report measures to assess attachment. Four studies engaged a
healthy control group to compare attachment among individuals
with bipolar disorder to healthy controls; one study (Joyce, 1984)
examining adults’ retrospective accounts of their relationship to
their parents using the Parental Bonding Instrument (Parker et al.,
1979) found no difference in attachment styles between the two
groups. The remaining three studies found more insecure attach-
ment styles in individuals with bipolar disorder compared to the
non-affected controls (Rosenfarb et al., 1994; Morriss et al., 2009;
Kökçü and Kesebir, 2010). For example, Morriss et al. (2009), who
examined attachment to family and friends using the Bartholo-
mew–Horowitz Relationship Questionnaire (Bartholomew and
Horowitz, 1991) found that most (79%) of bipolar individuals
reported an insecure attachment, as opposed to only 32% of
controls. However, this difference may be explained by the
presence of a psychiatric diagnosis in general and not be specific
to bipolar disorder; the two studies that compared other psychia-
tric diagnoses with bipolar disorder found a preponderance of
insecure attachment relationships independent of diagnosis
(Rosenfarb et al., 1994; Marazziti et al., 2007). To control for
reporting biases from symptomatic subjects, three studies
included only participants with bipolar disorder (Joyce, 1984;
Gilbert et al., 2007; Kökçü and Kesebir, 2010) and one separated
subjects into groups based on current mood state (Morriss et al.,
2009). The latter study found that attachment was affected by
mood; for example, scores for secure attachment were no different
between manic patients and healthy controls but depressed and
euthymic individuals with history of bipolar disorder were more
likely to report insecure attachment.
3.3. Social support
Five cross-sectional and 10 prospective studies focused on
social support and bipolar disorder. Several concluded that lower
levels of perceived social support were related to unfavorable
outcomes in bipolar disorder. In this section we summarize the
primary findings of these studies with regards to social support
and bipolar disorder.
The five published cross-sectional studies indicate that, as a
group, individuals with bipolar disorder experience a lower level
of social support than controls (Romans and McPherson, 1992;
Beyer et al., 2003), but that the level of social support is similar to
that of patients with other psychiatric diagnoses (Romans and
McPherson, 1992; Dorz et al., 2003). This finding is similar to
studies of adult attachment, where any psychiatric diagnosis
predicted insecure attachment. Sanchez-Moreno et al. (2010) and
Gutiérrez-Rojas et al. (2011) found that social support is negatively
correlated with current depressive symptoms and previous num-
ber of depressive episodes. Conversely, Romans and McPherson
(1992) found that manic episodes were more detrimental to social
support.
In contrast to cross-sectional studies, longitudinal studies
provide insight on temporal relationships, including recurrence
of mood episodes, symptoms severity, impairment, and levels of
social support. In the extant literature, findings are mixed: social
support does not influence episode relapse (Staner et al., 1997),
social support influences manic or depressive episode relapse
(O'Connell et al., 1985; Stefos et al., 1996; Kulhara et al., 1999,
Johnson et al., 2003), social support only influences depressive
episode relapse (Johnson et al., 1999, 2000; Cohen et al., 2004;
Weinstock and Miller, 2010), and social support influences manic
episode relapse (Strauss and Johnson, 2006). Two studies identi-
fied by our approach examined social support and lithium out-
come, and found that strong social support significantly predicted
good lithium outcome (O'Connell et al., 1985; Kulhara et al., 1999).
The sole study that measured treatment alliance as a form of social
support found that a strong treatment alliance is related to strong
social support and that treatment alliance is negatively correlated
with depressive symptoms (Strauss and Johnson, 2006). These
studies may have been limited not only by a small sample size, but
a small period of follow-up time (seven out of 10 longitudinal
studies had a follow-up period of 1 year or less) which may be too
short of a time to measure episode recurrence, especially manic
episode recurrence.
4. Discussion
Social relationships and attachments are core to human exis-
tence and survival. From birth until death, humans exist within a
social convoy that has implications for well-being. The relevance
to bipolar disorder is established in the association of current
metrics of recurrence and severity with evidence of poor social
support and relationships patterns. This leads to the conclusion
that social convoys play a significant role in the outcome of the
illness; however, there are a number of inconsistencies in the
findings primarily due to the low overlap in the specific methods
that each study operationalized the relevant constructs (e.g.,
illness severity could be defined by age of onset, duration of
illness, number of hospitalizations, etc for bipolar disorder). Most
studies do not control for reporting biases based on the current
mood state of the individual. It is highly probable that one's
perspective of perceived social support or attachment could be
affected based on current mood state, and this variation, when left
unaccounted, may attenuate effects observed for social support on
bipolar symptomatology. Several studies do not distinguish
between depressive and manic episodes. Studies also differed on
how they coded non-traditional relationships. For example, Cohen
et al. (2004) coded the lowest level of support for missing
relationships (e.g., no romantic partner, deceased parents) and
Morriss et al. (2009) excluded for non-traditional parenting (i.e. if
a subject was raised by more or less than two parents). This
eliminates the possibility that a missing or non-traditional rela-
tionship has a different effect on close relationships than a mere
low level of support or an insecure attachment. Additionally, no
studies currently take into account the high level of heritability of
bipolar disorder. This is relevant because family members who
may (or may not) provide social support may also suffer from a
diagnosis of bipolar disorder, and in this regard, it would be
helpful to know more about the characteristics of study partici-
pants’ ‘social convoy’. Finally, sampling issues pose significant
methodological constraints on the conclusions that can be drawn
from these studies. Most have small sample sizes, some recruit
only severely ill patients (e.g., recruiting from an acute psychiatric
ward), some only analyze bipolar I patients, and some group
bipolar I and II patients together, and many lack a control group.
It has been well established that adults with bipolar disorder
often have trouble with social cognition or emotion perception,
especially nonverbal emotion processing (Van Rheenen and
Rossell, 2013). This is important given that emotion perception
may be a skill that is first learned and practiced in early childhood
and affects an individual throughout the lifespan (Cole et al., 1994),
and that deficits in emotion perception have implications for
quality of life (Fulford et al., 2014). Early caregiving experiences
in early childhood underlie the development of relationship
templates (or attachment-relevant working models), which in
turn serve as emotion regulators in the context of social interac-
tions and communications across the life span (Rosenblum et al.,
2006). Thus, early caregiving experiences in individuals with
genetic vulnerability for bipolar disorder could modify, possibly
through epigenetic mechanisms, the expression of genes underlying
neuro-circuitry relevant for emotion processing, and either ameliorate
 S. Greenberg et al. / Psychiatry Research 219 (2014) 248–254
or heighten emotion understanding or processing deficits. Such
epigenetic shaping of emotion regulation patterns early in life could
have implications throughout the lifespan for individuals with bipolar
disorder, and while speculative at this point, investigation of such
processes would be innovative and relevant.
Although limited, the extant literature regarding the frame-
work of social convoys and how early attachment shapes subse-
quent relational security seems to have clinical implications
regarding the establishment of a secure working alliance. In
general, people seeking psychiatric services have better outcomes
when they have a good relationship with providers (Martin et al.,
2000). This holds true for people with bipolar disorder (Berk et al.,
2004; Zeber et al., 2008). When patients come for treatment, it is
likely that their attitudes they hold towards treatment and their
providers are shaped by previous relationship experiences, more
specifically, their attachment relationships and social support
expectations. Their previous relationships may have influenced
how trusting they are; this could have implications for the quality
of the working alliance they establish with a treatment provider. It
is also important for clinicians to consider relational factors when
assessing their patients’ quality of relationships, whether roman-
tic, with their children, or with others. This is in line with current
evidence-based therapeutic approaches that emphasize the whole
family perspective (Eisner and Johnson, 2008; Luciano et al., 2012;
Miklowitz et al., 2013). The clinical implication of how social
convoys affect treatment with individuals suffering bipolar dis-
order is an area that needs further research.
5. Conclusion
Social relationships are fundamental to human nature, and
decades of research support that early caregiving experiences
shape how individuals understand and process cognitions and
emotions relevant for social interactions, which subsequently may
impact the quality of all social relationships across the life span.
Individuals with bipolar disorder have impairments in social
relationships, as described in parenting contexts, romantic and
family relationships and broader societal functioning. Epigenetic
processes where own early caregiving experiences interact with
genetic sensitivity could contribute to the establishment of such
social processing and communication impairments. The limited
current data on attachment quality and social convoys in indivi-
duals with bipolar disorder supports the notion that more atten-
tion to this area of research is needed.
Acknowledgments
This research was supported by the Heinz C. Prechter Bipolar
Research Fund at the University of Michigan Depression Center.
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