Is the 4-Factor Model of Symptomology Equivalent Across Bipolar Disorder Subtypes?

Norm O'Rourke, Andrew Sixsmith, Tal Michael, Yaacov Bachner

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background Research with the BDSx (Bipolar Disorder Symptom Scale) suggests a 4-factor structure of responses: two depression (cognitive, somatic) and two hypo/mania factors (elation/loss of insight, affrontive symptoms). The two depression and two hypo/mania factors are correlated; and affrontive symptoms of hypo/mania (e.g., furious, disgusted, argumentative) are positively correlated with both depression factors suggesting pathways for mixed symptom presentation. This grouping of affrontive symptoms of hypo/mania organically emerged in exploratory research and has subsequently been supported in confirmatory analyses between samples and over time. The BDSx has been clinically validated with BD outpatients. Results Over 19 days, we recruited an international sample of 784 adults with BD using micro-targeted, social media advertising (M = 44.48 years, range 18–82). All participants indicated that they had BD (subtype, if known) and had been diagnosed with BD (month, year). This sample size was sufficient to confirm the 4-factor model across subtypes and compare the three (BD I, BD II, BD NOS). Responses to 19 of 20 BDSx items were psychometrically consistent across BD subtypes. Only responses to the ‘hopeless’ item were significantly higher for those with BD II. Conclusions When comparing models, it appears that affrontive symptoms are significantly and uniformly associated with hypo/mania and both depression factors across subtypes. In contrast to BD diagnostic criteria, this suggests that affrontive symptoms are central to the clinical presentation of hypo/mania and mixed symptomology across BD subtypes.
Original languageEnglish
Article number24
Number of pages9
JournalInternational Journal of Bipolar Disorders
StatePublished - 2 Aug 2021


  • Affrontive symptoms
  • BD subtypes
  • BDS
  • Bipolar disorder
  • Invariance analyses
  • Scale validation

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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