Previous research on functional outcome in bipolar disorder (BD) has uncovered various factors that exacerbate psychosocial disability over the course of illness, including genetics, illness severity, stress, anxiety, and cognitive impairment. This paper presents an integrated view of these findings that accounts for the precipitous decline in psychosocial functioning after illness onset. The proposed model highlights a number of reciprocal pathways among previously studied factors that trap people in a powerful cycle of ailing forces. The paper discusses implications to patient care as well as the larger social changes required for shifting the functional trajectory of people with BD from psychosocial decline to growth. 1. Introduction Psychosocial functioning in bipolar disorder (BD) runs the full gamut of human potential. Whereas some people with BD accomplish historical landmarks in human achievement [1–3], others experience significant difficulties in managing tasks of daily living [4]. The remarkable functional variability in BD highlights an inherent prognostic complexity [5–7], which is not immediately evident in the diagnosis [8]. Many studies have illuminated various aspects of illness progression in BD [9–11], yet significant improvement to functional outcome may require further theoretical and clinical advancement [12]. The astounding functional differences among people with BD present one of the toughest challenges to this effort, as these emerge across the entire spectrum of human development [7, 13–16]. Early emotional abnormalities and poor premorbid functioning tend to occur in BD [17–19]; however, adequate psychosocial adjustment prior to the first manic episode is also common [20–22]. Furthermore, after illness onset, many people with BD regain psychosocial functioning [13, 23], yet others suffer inordinate functional decline, which progresses from a state of psychosocial adjustment to a state of disability [23, 24]. The latter group is of particular interest to clinical research. Understanding the nature of the sometimes dysfunctional trajectory of BD may help to diminish it, and thereby reduce suffering and cost. This paper examines the strongest predictors of functional outcome in BD, which have been separately summarized in multiple previous reviews. In this regard, the paper does not aim to provide a comprehensive review of studies linking each of the factors under discussion to psychosocial functioning in BD. Instead, it offers an integrated view on previously reviewed findings and discusses potential implications for prevention
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