Self-Referential Thinking, Suicide, and Function of the Cortical Midline Structures and Striatum in Mood Disorders: Possible Implications for Treatment Studies of Mindfulness-Based Interventions for Bipolar Depression
Bipolar depression is often refractory to treatment and is frequently associated with anxiety symptoms and elevated suicide risk. There is a great need for adjunctive psychotherapeutic interventions. Treatments with effectiveness for depressive and anxiety symptoms as well as suicide-related thoughts and behaviors would be particularly beneficial. Mindfulness-based interventions hold promise, and studies of these approaches for bipolar disorder are warranted. The aim of this paper is to provide a conceptual background for such studies by reviewing key findings from diverse lines of investigation. Results of that review indicate that cortical midline structures (CMS) appear to link abnormal self-referential thinking to emotional dysregulation in mood disorders. Furthermore, CMS and striatal dysfunction may play a role in the neuropathology underlying suicide-related thoughts and behaviors. Thus, combining studies of mindfulness interventions targeting abnormal self-referential thinking with functional imaging of CMS and striatal function may help delineate the neurobiological mechanisms of action of these treatments. 1. Introduction The neurobiology of bipolar spectrum disorders is incompletely characterized . Further, current medication treatments are only partially effective , and 73% of patients receiving pharmacotherapy relapse within 5 years . Thus, there is a compelling need for effective adjunctive psychotherapy interventions [4, 5]. Cognitive-behavioral therapy is an effective intervention for depression [4, 6–9] but seems to be of less benefit for bipolar spectrum illness . Bipolar disorder is highly comorbid with anxiety [11, 12], and therefore interventions that also target anxiety might be of particular benefit . Mindfulness-based psychotherapies are being increasingly used to target both depressive and anxiety symptoms in a variety of clinical populations [14–16]. However, few studies [17–19] have investigated these interventions for bipolar spectrum disorders. Furthermore, an integrated conceptual framework for such studies has not been published. Mindfulness interventions target aberrant self-referential thinking . Increasing evidence suggests that alterations in self-referential thinking may be associated with a number of mood and anxiety spectrum disorders. For example, investigations indicate an association between aberrant self-concept and/or self-schemas and unipolar depression [21–25], generalized anxiety disorder , obsessive-compulsive disorder [27, 28], PTSD [29–31], social phobia [32, 33], and panic
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