Protocol of a feasibility randomised controlled trial of Empowered Conversations: training family carers to enhance their relationships and communication with people living with dementia.

Background: Communication difficulties can cause frustration, low mood, and stress for people living with dementia and their carer. Carers should be offered training on adapting their communication skills. However, it is not common for skills-based education to examine emotional aspects of care and the effect of dementia on relationships. The Empowered Conversations (EC) training course was developed in response to a gap in service provision and has been adapted to a virtual format (Zoom). It addresses the specific psychological, relationship, and communication needs of informal and family dementia carers. The primary aim of the study is to investigate the feasibility of conducting a multi-centre randomised controlled evaluation trial of EC. Secondary aims include exploring the acceptability of delivering the intervention online and examining the optimum way of establishing cost-effectiveness. Methods: The feasibility trial uses a pragmatic data-collector blind parallel two-group RCT design with two arms (EC intervention plus treatment as usual, and treatment as usual waitlist control). There will be a 2:1 allocation in favour of the EC-training intervention arm. 75 participants will complete baseline outcome measures exploring their role as a carer, including their physical and mental health, attitudes to caring, quality of life, and use of health and social care services. These will be repeated after six-months. Participants allocated to the treatment group who complete the course will be invited to participate in a qualitative interview discussing their experience of EC. Conclusions: The study will investigate recruitment pathways (including facilitators and barriers to recruitment), estimate retention levels and response rates to questionnaires, obtain additional evidence regarding proof of concept, and consider the most appropriate primary outcome measures and methods for evaluating cost-effectiveness. The results of the feasibility study will be used to inform the development of a multicentre randomised controlled trial in the United Kingdom. Registration: ISRCTN15261686 (02/03/2022).

There are 700,000 family and informal carers for people living with dementia in the UK alone. Sixty-four percent of informal carers in England say they have limited support for the range of psychological and social needs they experience. It can be difficult to keep communicating well due to thinking and memory changes that caused by dementia. This can lead to frustration, low-mood and stress for both people living with dementia and their carers. The 6-session online Empowered Conversations course is designed to enable carers to maintain and improve good communication and relationships with those they support. Course facilitators are trained to provide specific communication techniques, ways of managing conflicts, and working with difficult emotions. The course has been tried out over the last 4-years and changes made. Feedback from informal carers indicates it is in an optimum form and we are ready to test it further in a large trial. Before this is done, it is necessary to complete a smaller 'feasibility' trial to check whether such a larger trial is possible. This article explains how the feasibility trial will be carried out. Our 'feasibility' trial will check several things. We want to make sure that carers would be willing to have an only 66% chance of receiving the course straight away, because it is essential to have a comparison group. The remaining 33% of carers would be offered the course 6-months later. We want to ensure that our design is good enough to identify any improvement in carers' well-being, relationships and communication. We will also ask carers to take part in a one-to-one interview about their experiences of the course, including their views on the course being delivered on Zoom.

An Artificial Therapist (Manage Your Life Online) to Support the Mental Health of Youth: Co-Design and Case Series.

BACKGROUND: The prevalence of child and adolescent mental health issues is increasing faster than the number of services available, leading to a shortfall. Mental health chatbots are a highly scalable method to address this gap. Manage Your Life Online (MYLO) is an artificially intelligent chatbot that emulates the method of levels therapy. Method of levels is a therapy that uses curious questioning to support the sustained awareness and exploration of current problems. OBJECTIVE: This study aimed to assess the feasibility and acceptability of a co-designed interface for MYLO in young people aged 16 to 24 years with mental health problems. METHODS: An iterative co-design phase occurred over 4 months, in which feedback was elicited from a group of young people (n=7) with lived experiences of mental health issues. This resulted in the development of a progressive web application version of MYLO that could be used on mobile phones. We conducted a case series to assess the feasibility and acceptability of MYLO in 13 young people over 2 weeks. During this time, the participants tested MYLO and completed surveys including clinical outcomes and acceptability measures. We then conducted focus groups and interviews and used thematic analysis to obtain feedback on MYLO and identify recommendations for further improvements. RESULTS: Most participants were positive about their experience of using MYLO and would recommend MYLO to others. The participants enjoyed the simplicity of the interface, found it easy to use, and rated it as acceptable using the System Usability Scale. Inspection of the use data found evidence that MYLO can learn and adapt its questioning in response to user input. We found a large effect size for the decrease in participants' problem-related distress and a medium effect size for the increase in their self-reported tendency to resolve goal conflicts (the proposed mechanism of change) in the testing phase. Some patients also experienced a reliable change in their clinical outcome measures over the 2 weeks. CONCLUSIONS: We established the feasibility and acceptability of MYLO. The initial outcomes suggest that MYLO has the potential to support the mental health of young people and help them resolve their own problems. We aim to establish whether the use of MYLO leads to a meaningful reduction in participants' symptoms of depression and anxiety and whether these are maintained over time by conducting a randomized controlled evaluation trial.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial.

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

An integrative control theory perspective on consciousness.

An integrative account of consciousness should have a number of properties. It should build upon a framework of nonconscious behavior in order to explain how and why consciousness contributes to, and addresses the limitations of, nonconscious processes. It should also encompass the primary (phenomenal), secondary (access), and tertiary (self-awareness) aspects of consciousness. A number of accounts have proposed a role for consciousness in the prediction of sensory input, yet these proposals do not address how organisms deal with multiple, unpredictable, disturbances to maintain control. According to perceptual control theory (PCT), purposiveness is the control of hierarchically organized perceptual variables via changes in output that counteract disturbances which would otherwise increase error between the current value and the reference value (goal state) of each perceptual variable. In PCT, reorganization is the process required for the adaptive modification of control systems in order to reduce the error in intrinsic systems that control essential, largely physiological, variables. The current article proposes that primary consciousness emerges from this system, and is sustained as secondary consciousness through a number of processes including the control of the integration rate of novel information via exploratory behavior, attention, imagination, and altering the mutation rate of reorganization. Tertiary consciousness arises when internally sustained perceptual information is associated with specific symbols that form a parallel, propositional system for the use of language, logic, and other symbolic systems. The hypotheses and initial research designs to test this account are provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The positive and negative sleep appraisal measure: Towards a clinical validation of sleep spectrum cognitions.

BACKGROUND: Sleep disturbance is considered a transdiagnostic process due to high comorbidity with mental health difficulties. In particular, sleep disturbances are a feature of mood disorders. To advance transdiagnostic psychological interventions targeting sleep, the Positive and Negative Sleep Appraisal Measure (PANSAM) was developed. The PANSAM is a theory-driven measure based on an Integrative Cognitive Sleep Model and proposes that positive and negative sleep appraisals for excessively long and short sleep durations play a key role in the development of insomnia, hypersomnia, and reduced need for sleep. This study evaluated clinical validity of this new measure. METHODS: Participants were those who met bipolar at risk criteria and bipolar diagnoses (bipolar spectrum group) (N = 22), major depressive disorder (unipolar depression group) (N = 18), and a nonclinical group (N = 22). To compare against previous insomnia and bipolar disorder relevant research, administered measures included the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) and the Hypomanic and Positive Predictions Inventory (HAPPI). RESULTS: Analysis of variance (ANOVA) tests revealed that the clinical groups scored significantly higher on the PANSAM. The same was shown for the DBAS and HAPPI. Post hoc analyses showed that the PANSAM scale and subscales had significant correlations with all clinical measures. Effect sizes are reported due to sample size limitations. CONCLUSION: This study has initially validated the PANSAM with clinical populations and highlighted its applicability to a transdiagnostic approach.

The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness.

OBJECTIVES: This paper aims to identify potential areas for refinement in existing theoretical models of suicide, and introduce a new integrative theoretical framework for understanding suicide, that could inform such refinements. METHODS: Literature on existing theoretical models of suicide and how they contribute to understanding psychological processes involved in suicide was evaluated in a narrative review. This involved identifying psychological processes associated with suicide. Current understanding of these processes is discussed, and suggestions for integration of the existing literature are offered. RESULTS: Existing approaches to understanding suicide have advanced the current knowledge of suicide in various ways. They have guided valuable research in the following areas: motivations for suicide and the psychological distress which influences suicide attempts; ambivalence about suicide; suicidal individuals' focus of attention; and ways in which individuals who contemplate suicide differ from individuals who attempt suicide. We outline a new theoretical framework as a means to integrating all of these concepts into the three principles of control, conflict, and awareness. Within this framework, suicide is regarded as occurring due to a long standing conflict between an individual's personal goals, culminating in an episode of acute loss of control. The new framework posits that the individual then strives to regain control through the means of suicide because of a narrowed awareness of consequences of their actions on other valued goals. This psychological mechanism of limited awareness is posited to be the common pathway by which individuals make a suicide attempt, regardless of which risk factors are present. CONCLUSION: This article introduces a theoretical framework that generates several hypotheses for future research, and focuses on psychological processes occurring during immediate crisis. One of the key hypotheses resulting from our predictions on how individuals progress from contemplating to attempting suicide will be tested in an ongoing program of research: Individuals who attempt suicide have a significantly reduced awareness of consequences of suicide, which would negatively impact on their important life goals, values, principles, or ideals, compared to individuals who contemplate suicide. Therapy guided by the new framework may be more flexible, immediate, and client-focused than other therapies for suicidal individuals.

A Thematic Analysis of Multiple Pathways Between Nature Engagement Activities and Well-Being.

Research studies have identified various different mechanisms in the effects of nature engagement on well-being and mental health. However, rarely are multiple pathways examined in the same study and little use has been made of first-hand, experiential accounts through interviews. Therefore, a semi-structured interview was conducted with seven female students who identified the role of nature engagement in their well-being and mental health. After applying thematic analysis, 11 themes were extracted from the data set, which were: "enjoying the different sensory input," "calm nature facilitates a calm mood," "enhancing decision making and forming action plans," "enhancing efficiency and productivity," "alleviating pressure from society's expectations regarding education," "formation of community relations," "nature puts things into perspective," "liking the contrast from the urban environment," "feel freedom," "coping mechanism," and "anxious if prevented or restricted." The results indicate complementary mechanisms for how nature-related activities benefit mental health and well-being that may occupy different levels of experience within a hierarchical framework informed by perceptual control theory.

The perceptual control model of psychopathology.

Perceptual control theory states that behaviour controls perception; we act against disturbances in the environment to align hierarchically organised perceived aspects of the self and the world with neurally specified reference values. The diverse symptoms of psychopathology are each examples of loss of control, which are maintained by conflicting control systems, and effective interventions shift and sustain awareness to the source of the conflict to allow trial-and-error changes (reorganisation) in the parameters of the superordinate system to the conflict, until control is restored. Experimental, phenomenological, therapeutic and computational research has examined its mechanisms, and its mode of delivery has extended it from a client-led psychotherapy (method of levels) to brief training, group interventions and computerised modalities.

Sensorimotor delays in tracking may be compensated by negative feedback control of motion-extrapolated position.

Sensorimotor delays dictate that humans act on outdated perceptual information. As a result, continuous manual tracking of an unpredictable target incurs significant response delays. However, no such delays are observed for repeating targets such as the sinusoids. Findings of this kind have led researchers to claim that the nervous system constructs predictive, probabilistic models of the world. However, a more parsimonious explanation is that visual perception of a moving target position is systematically biased by its velocity. The resultant extrapolated position could be compared with the cursor position and the difference canceled by negative feedback control, compensating sensorimotor delays. The current study tested whether a position extrapolation model fit human tracking of sinusoid (predictable) and pseudorandom (less predictable) targets better than the non-biased position control model, Twenty-eight participants tracked these targets and the two computational models were fit to the data at 60 fixed loop delay values (simulating sensorimotor delays). We observed that pseudorandom targets were tracked with a significantly greater phase delay than sinusoid targets. For sinusoid targets, the position extrapolation model simulated tracking results more accurately for loop delays longer than 120 ms, thereby confirming its ability to compensate for sensorimotor delays. However, for pseudorandom targets, this advantage arose only after 300 ms, indicating that velocity information is unlikely to be exploited in this way during the tracking of less predictable targets. We conclude that negative feedback control of position is a parsimonious model for tracking pseudorandom targets and that negative feedback control of extrapolated position is a parsimonious model for tracking sinusoidal targets.

Why Do We Need Computational Models of Psychological Change and Recovery, and How Should They Be Designed and Tested?

Traditional research methodologies typically assume that humans operate on the basis of an "open loop" stimulus-process-response rather than the "closed loop" control of internal state. They also average behavioral data across repeated measures rather than assess it continuously, and they draw inferences about the working of an individual from statistical group effects. As such, we propose that they are limited in their capacity to accurately identify and test for the mechanisms of change within psychological therapies. As a solution, we explain the advantages of using a closed loop functional architecture, based on an extended homeostatic model of the brain, to construct working computational models of individual clients that can be tested against real-world data. Specifically, we describe tests of a perceptual control theory (PCT) account of psychological change that combines the components of negative feedback control, hierarchies, conflict, reorganization, and awareness into a working model of psychological function, and dysfunction. In brief, psychopathology is proposed to be the loss of control experienced due to chronic, unresolved conflict between important personal goals. The mechanism of change across disorders and different psychological therapies is proposed to be the capacity for the therapist to help the client shift and sustain their awareness on the higher level goals that are driving goal conflict, for sufficiently long enough to permit a trial-and-error learning process, known as reorganization, to "stumble" upon a solution that regains control. We report on data from studies that have modeled these components both separately and in combination, and we describe the parallels with human data, such as the pattern of early gains and sudden gains within psychological therapy. We conclude with a description of our current research program that involves the following stages: (1) construct a model of the conflicting goals that are held by people with specific phobias; (2) optimize a model for each individual using their dynamic movement data from a virtual reality exposure task (VRET); (3) construct and optimize a learning parameter (reorganization) within each model using a subsequent VRET; (3) validate the model of each individual against a third VRET. The application of this methodology to robotics, attachment dynamics in childhood, and neuroimaging is discussed.

Behavioral anatomy of a hunt : Using dynamic real-world paradigm and computer vision to compare human user-generated strategies with prey movement varying in predictability.

It is commonly thought that the mind constructs predictive models of the environment to plan an appropriate behavioral response. Therefore a more predictable environment should entail better performance, and prey should move in an unpredictable (random) manner to evade capture, known as protean motion. To test this, we created a novel experimental design and analysis in which human participants took the role of predator or prey. The predator was set the task of capturing the prey, while the prey was set the task of escaping. Participants performed this task standing on separate sides of a board and controlling a marker representing them. In three conditions, the prey followed a pattern of movement with varying predictability (predictable, semi-random, and random) and in one condition moved autonomously (user generated). The user-generated condition illustrated a naturalistic, dynamic environment involving a purposeful agent whose degree of predictability was not known in advance. The average distance between participants was measured through a video analysis custom-built in MATLAB. The user-generated condition had the largest average distance. This indicated that, rather than moving randomly (protean motion), humans may naturally employ a cybernetic escape strategy that dynamically maximizes perceived distance, regardless of the predictability of this strategy.

Agents of change: Understanding the therapeutic processes associated with the helpfulness of therapy for mental health problems with relational agent MYLO.

OBJECTIVE: To understand the therapeutic processes associated with the helpfulness of an online relational agent intervention, Manage Your Life Online (MYLO). METHODS: Fifteen participants experiencing a mental health related problem used Manage Your Life Online for 2 weeks. At follow-up, the participants each identified two helpful and two unhelpful questions posed by Manage Your Life Online within a single intervention session. Qualitative interviews were conducted and analyzed using thematic and content analysis to gain insight into the process of therapy with Manage Your Life Online. RESULTS: MYLO appeared acceptable to participants with a range of presenting problems. Questions enabling free expression, increased awareness, and new insights were key to a helpful intervention. The findings were consistent with the core processes of therapeutic change, according to Perceptual Control Theory, a unifying theory of psychological distress. Questions that elicited intense emotions, were repetitive, confusing, or inappropriate were identified as unhelpful and were associated with disengagement or loss of faith in Manage Your Life Online. CONCLUSIONS: The findings provide insight into the likely core therapy processes experienced as helpful or hindering and outlines further ways to optimize acceptability of Manage Your Life Online.

The development of a theoretically derived measure exploring extreme appraisals of sleep in bipolar disorder: a Delphi study with professionals.

BACKGROUND: Sleep and mood are known to be linked and this is particularly evident in people with a diagnosis of bipolar disorder (BD). It has been proposed that psychological interventions improving sleep can be a pathway for improving mood. In order for a psychological sleep intervention to be appropriate, the common cognitive processes maintaining the range of sleep disturbances need to be investigated. AIM: This study aimed to explore and identify expert consensus on positive and negative sleep appraisals in the context of low and high mood states, using the Integrative Cognitive Model as a theoretical guide. METHOD: A Delphi approach was utilized to allow clinical and research professionals, with experience in the field of BD, to be anonymously consulted about their views on sleep appraisals. These experts were invited to participate in up to three rounds of producing and rating statements that represented positive and negative sleep appraisals. RESULTS: A total of 38 statements were developed and rated, resulting in a final list of 19 statements that were rated as 'essential' or 'important' by >80% of the participants. These statements represent the full range of extreme sleep appraisals this study had set out to explore, confirming the importance of better understanding and identifying positive and negative sleep cognitions in the context of high and low mood. CONCLUSION: The statements reviewed in this study will be used to inform the development of a sleep cognition measure that may be useful in cognitive therapy addressing sleep disturbances experienced along the bipolar spectrum.

A systematic evaluation of the evidence for perceptual control theory in tracking studies.

Perceptual control theory (PCT) proposes that perceptual inputs are controlled to intentional 'reference' states by hierarchical negative feedback control, evidence for which comes from manual tracking experiments in humans. We reviewed these experiments to determine whether tracking is a process of perceptual control, and to assess the state-of-the-evidence for PCT. A systematic literature search was conducted of peer-review journal and book chapters in which tracking data were simulated with a PCT model (13 studies, 53 participants). We report a narrative review of these studies and a qualitative assessment of their methodological quality. We found evidence that individuals track to individual-specific endogenously-specified reference states and act against disturbances, and evidence that hierarchical PCT can simulate complex tracking. PCT's learning algorithm, reorganization, was not modelled. Limitations exist in the range of tracking conditions under which the PCT model has been tested. Future PCT research should apply the PCT methodology to identify control variables in real-world tasks and develop hierarchical PCT architectures for goal-oriented robotics to test the plausibility of PCT model-based action control.

The 4Ds of Dealing With Distress - Distract, Dilute, Develop, and Discover: An Ultra-Brief Intervention for Occupational and Academic Stress.

The Covid-19 crisis has clarified the demand for an ultra-brief single-session, online, theory-led, empirically supported, psychological intervention for managing stress and improving well-being, especially for people within organizational settings. We designed and delivered "4Ds for Dealing with Distress" during the crisis to address this need. 4Ds unifies a spectrum of familiar emotion regulation strategies, resilience exercises, and problem-solving approaches using perceptual control theory and distils them into a simple four-component rubric (Distract-Dilute-Develop-Discover). In essence, the aim is to reduce distress and restore wellbeing, both in the present moment through current actions (distract or dilute), and through expressing longer-term goal conflicts (e.g., through talking, writing, and drawing) to discover new perspectives that arise spontaneously after sufficient time and consideration. The intervention is user-led in that it draws on users' own idiosyncratic and pre-existing experiences, knowledge, skills and resources to help them apply an approach, or combination of approaches, that are proportionate and timed to the nature and context of the stress they are experiencing. In this article we review the empirical basis of the approach within experimental, social, biological and clinical psychology, illustrate the novel and time-efficient delivery format, describe its relevance to sports and exercise, summarise feedback from the recipients of the intervention to date, and describe the directions for future evaluation.

'It's nice to think somebody's listening to me instead of saying "oh shut up"'. People with dementia reflect on what makes communication good and meaningful.

WHAT IS KNOWN ON THE SUBJECT?: People with dementia experience cognitive decline which can affect their ability to communicate with others and consequently getting their needs met. Loneliness and social isolation are associated with depression and anxiety, while difficulties communicating may magnify such difficulties. Enhancing meaningful interactions may support maintenance of valued relationships and positive wellbeing. Although previous research has examined communicative experiences, this has been from the perspectives of professionals or caregivers. Exploring meaningful communication from the perspectives of people with dementia is crucial in supporting relationships and wellbeing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: People with dementia can be active participants in research. They are aware of their cognitive impairments as well as social interactions and features constituting meaningful communications. People with dementia recognized carers' attempts to understand and empathize with them; allowing them to feel valued and heard, empowering them to maintain interactions. Alternatively, feeling dismissed, inferior or pressured to provide 'correct' responses deterred them from further conversations. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: People with dementia have an awareness of their relationships, communications and preferences. Thus, it is imperative to respect this population and make attempts to understand their communication as they sense this effort even when miscommunications occur. Embrace qualities that facilitate person-centred care within communications is vital as this can preserve valued relationships, support one's needs and enhance wellbeing. Such features include active listening, empathizing, being physically and mentally present, spending time to know the individual and sharing experiences, thoughts and emotions. Abstract Introduction Social isolation can be problematic for people with dementia; understanding what makes communication meaningful may reduce such risk. Scientific rationale Previous research has examined caregivers' or professionals' experiences of meaningful communication. Understanding this from the perspectives of people with dementia could enhance their interactions and wellbeing. Aim Exploring what makes communication meaningful from the perspective of people with dementia. Methods Nine dyadic interactions between a person with dementia and a family carer were filmed. Individuals with dementia watched the footage and reflected on their communications in semi-structured interviews. Results Three superordinate themes emerged. Themes 'sharing moments of emotional connection' and 'empowering one's ability to communicate' related to the experience of feeling connected, understood, valued and heard, allowing further communication. Conversely, 'inhibitors to communication' related feeling disempowered and reduced interactions. Discussion Even when carers could not understand what people with dementia attempted to communicate, their efforts to interact with them were valued and considered meaningful as they reinforce their sense of connectedness. Implications for practice Embracing a person-centred approach by actively attuning to the person and continuously attempting to empathize and understand persons with dementia can help preserve important relationships and allow the person to feel valued and interpersonally connected.

Communication Empowerment Framework: An integrative framework to support effective communication and interaction between carers and people living with dementia.

OBJECTIVES: To demonstrate the power of integrating three theoretical perspectives (Mentalization Theory, Perceptual Control Theory and the Communicative Impact model), which jointly illuminate the communication challenges and opportunities faced by family carers of people with dementia. To point the way to how this framework informs the design and delivery of carer communication and interaction training. METHOD: Conceptual synthesis based on a narrative review of relevant literature, supported by examples of family carers. RESULTS: We use the conceptual models to show how the capacity to mentalize ("holding mind in mind") offers a greater sense of control over internal and external conflicts, with the result that they can be deescalated in pursuit of mutual goals. CONCLUSIONS: The integrative conceptual framework presented here highlights specific psychological and relational mechanisms that can be targeted through carer training to enhance communication with a person living with dementia.

What is the relationship between post-traumatic stress disorder, extreme appraisals of internal state and symptoms in bipolar disorder?

BACKGROUND: It is important to understand the factors associated with more severe mood symptoms in bipolar disorder. The integrative cognitive model of bipolar disorder proposes that extreme appraisals of changes to internal states maintain and exacerbate mood symptoms. AIMS: The current study aimed to investigate if post-traumatic stress disorder (PTSD) is related to current depressive and manic bipolar symptoms, and whether this relationship is mediated by appraisals of internal state. METHOD: Participants with bipolar disorder (n = 82) from a randomized controlled trial of cognitive therapy for bipolar disorder (the TEAMS trial) completed self-reported questionnaires assessing appraisals of internal state, generalized anxiety symptoms, and self-reported and observer-rated depressive and manic symptoms. Clinical interviews assessed PTSD co-morbidity. RESULTS: Participants with bipolar and co-morbid PTSD (n = 27) had higher depressive symptoms and more conflicting appraisals than those without PTSD. Regression analyses found PTSD to be associated with depressive symptoms but not manic symptoms. Conflicting appraisals were found to be associated only with manic symptoms meaning that the planned mediation analysis could not be completed. CONCLUSIONS: Findings provide partial support for the integrative cognitive model of bipolar disorder and highlight the need for transdiagnostic treatments in bipolar disorder due to the prevalence and impact of trauma and co-morbidity. Working on trauma experiences in therapy may impact on depressive symptoms for those with bipolar disorder and co-morbid PTSD.