A WEEKLY DIARY STUDY OF ARGUMENTS AND INTIMATE PARTNER

VIOLENCE AMONG COUPLES COPING WITH BIPOLAR DISORDER

Approved by:

__________________________
Lorelei Simpson Rowe, Ph.D.

__________________________
Renee McDonald, Ph.D.

_________________________
David Rosenfield, Ph.D.

_________________________
Nia Parson, Ph.D.
A WEEKLY DIARY STUDY OF ARGUMENTS AND INTIMATE PARTNER

VIOLENCE AMONG COUPLES COPING WITH BIPOLAR DISORDER

A Dissertation Presented to the Graduate Faculty of

Dedman College

Southern Methodist University

in

Partial Fulfillment of the Requirements

for the degree of

Doctor of Philosophy

with a

Major in Clinical Psychology

by

Kacy Mullen DeBoer

(B.A., Valparaiso University)

(M.A., Southern Methodist University)

August 3, 2012
 UMI Number: 3524426

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Mullen DeBoer, Kacy B.A., Valparaiso University, 2005
M.A., Southern Methodist University, 2010

A Weekly Diary Study of Arguments and Intimate Partner

Violence among Couples Coping with Bipolar Disorder

Advisor: Professor Lorelei Simpson Rowe

Doctor of Philosophy conferred August 3, 2012

Dissertation completed January 18, 2012

Bipolar disorder (BPD) is a chronic illness associated with significant impairment

in multiple areas of functioning, including development and maintenance of intimate

relationships. Increasingly, research supports the prevalence and problematic nature of

one specific aspect of relationship functioning in the context of BPD: Intimate partner

violence (IPV). However, relatively little is known about when incidents of IPV are most

likely to occur among couples in which a partner has BPD. The current study examines

the longitudinal association between fluctuations in depressive and manic symptoms and

occurrence of psychological and physical IPV over 6 months among 38 couples in which

one partner had BPD. Results indicated that couples were more likely to engage in

psychological IPV during weeks when the partner with BPD had greater depressive

symptoms and total depression over the 6-month study period was associated with a

greater likelihood of any instance of physical IPV. In addition, individuals with bipolar

disorder were more likely to experience episodes of psychological IPV during weeks

when they both used drugs and had reduced manic symptoms. Overall, the results

suggest a potentially important association between mood symptoms and occurrence of

IPV among couples in which one partner has BPD.

iii
 TABLE OF CONTENTS

LIST OF TABLES p. v

LIST OF FIGURES p. vi

ACKNOWLEDGEMENTS p. vii

Chapter

1. INTRODUCTION p. 1

Manic Symptoms

Comorbid Alcohol and Substance Use

Methodological Advancements

2. METHODOLOGY p. 8

Participants

Procedures

Measures

Data Analysis

3. RESULTS p. 17

Descriptive Statistics and Preliminary Analyses

Hypothesis Testing

4. DISCUSSION p. 22

REFERENCES p. 31

iv
 LIST OF TABLES

Table Page

1. Between-Couple Differences among Couples Reporting Physical IPV 45

and Couples Not Reporting Physical IPV

2. Descriptive Statistics and Bivariate Correlations between Study Variables 46

3. Occurrence of Psychological IPV by Manic and Depressive Symptoms 47

4. Occurrence of Psychological IPV by Manic Symptoms and Substance Use 48

5. Couple Arguments by Manic and Depressive Symptoms 49

6. Couple Arguments by Manic Symptoms and Substance Use 50

7. Predictors of Psychological IPV, Controlling for Couple Arguments 51

v
 LIST OF FIGURES

Figure Page

1. Odds of psychological IPV by manic symptoms and drug use 52

2. Couple arguments by manic and depressive symptoms 53

vi
 ACKNOWLEDGEMENTS

When I reflect on the number of people that have sustained me throughout my

graduate work and on this dissertation, in particular, I am overwhelmed with gratitude

and humbled by God’s grace and mercy. First and foremost, my husband, Davis, has

been a never-ending source of stability, encouragement, and wisdom. He has

consistently demonstrated patience, kindness, grace, and sacrificial love, all in his own

quiet and humble manner that has not only made me a better graduate student, but a

better wife and mother. My son, Elias, whose timing into this world could have only

been orchestrated through God’s providence and who has provided me daily with joy,

laughter, and love. It is my prayer that my work in graduate school will have not only

sharpened my research and clinical skill, but also my daily practice as a mother. My

parents, Jim and Marcine, for believing in my academic abilities long before I believed in

them myself and for moving to Dallas to get us through the final stretch.

Professionally, my advisor, Lorelei Simpson Rowe, has been a dedicated mentor

throughout my years in graduate school. I would also like to thank my dissertation

committee members: Renee McDonald, David Rosenfield, and Nia Parson. Without their

collaboration, assistance, and incredible knowledge of research and statistics, my

vii 
 
dissertation would have not been possible. My clinical supervisors, including Leslie

Powers, Kimberly Doyle, Jim Harris, Reed Robinson, Jeffrey Dodds, Lynnora Ratliff,

and Alina Suris, have contributed immeasurably to my growth as a clinician, researcher,

and professional.

Finally, I am truly grateful for the continuous support, encouragement, and

empathy provided by my wonderful research lab mates and friends. I cannot express my

gratitude for the opportunity to work with such incredibly smart, talented, kind, and fun

research lab mates as Cora and Anne. I would also like to thank several other graduate

school students for their friendship including Mary Clare, Catherine, Gabby, Erica, and

Erica.

viii 
 
 Chapter 1

INTRODUCTION

Bipolar disorder (BPD) is a chronic, severe, and disabling illness that affects

approximately 1% of the population (Müller-Oerlinghausen, Berghöfer, & Bauer, 2002).

The illness is defined by mood disturbances including intense elevation (mania or

hypomania) and, in the majority of cases, depression (Judd et al., 2003; Judd et al., 2002).

In addition to affective instability, BPD is associated with poor psychosocial functioning

(e.g., Cooke, Robb, Young, &Joffe, 1996; Dion, Tohen, Anthony, & Waternaux, 1988)

and significant impairment in multiple areas of functioning (Miklowitz, 2007). BPD

typically has a chronic course with high rates of residual symptoms between acute mood

episodes (Müller-Oerlinghausen et al., 2002), even when patients are compliant with

medications and receive empirically-supported psychosocial treatments (Harrow,

Goldberg, Grossman, & Meltzer, 1990; Gitlin, Swendsen, Heller, & Hammen, 1995).

Unsurprisingly, BPD poses significant functional difficulties for patients, their

romantic partners, and other family members, which in turn can affect the course of the

illness. For example, although many individuals with BPD receive mental health services

(Narrow, Reiger, Rae, Manderscheid, & Locke, 1993), significant others and family

members often still serve an informal care-giving role. As a result, emotional distress

and “caregiver burden” are common among the loved ones of those with BPD (e.g.,

1
 Perlick, Rosenheck, Clarkin, Maciejewski, Sirey, Struening, & Link, 2004). Such

caregiver distress is related to greater depressive symptoms and more frequent

psychological services utilization among partners/family members (Perlick, Hohenstein,

Clarkin, Kaczynski, & Rosenheck, 2005). Relationship distress and dissolution are also

common among couples in which a partner has BPD (Perlick et al., 2004; Whisman,

2007). On the other hand, the presence of strong, supportive couple/family relationships

is related to a number of positive outcomes for individuals with BPD. These include

greater employment stability (Hammen, Gitlin, & Altshuler, 2000) and medication

adherence (Demers & Davis, 1971; Lesser, 1983), fewer acute mood episodes (e.g.,

Brugha, 1995), and reduced service utilization (Perlick et al., 2005), all of which may

influence the social and economic costs of the illness.

Given the importance of stable and supportive relationships for those with BPD,

research that improves our understanding of specific aspects of relationship functioning

has considerable relevance for psychosocial interventions. There is increasing evidence

that one particular aspect of relationship functioning–intimate partner violence (IPV)–

may be of particular importance in BPD. Research suggests that IPV specifically, and

relationship conflict more broadly, may be more common among couples in which a

partner has BPD (Dore & Romans, 2001; Hoover & Fitzgerald, 1981; Lam, Donaldson,

Brown, & Malliaris, 2005). Moreover, individuals with BPD are at risk for anger attacks

(Perlis, Smoller, Fava, Rosenbaum, Nierenberg, & Sachs, 2004) and impulsivity (Swann,

Lijffijt, Lane, Steinberg, & Moeller, 2009), both of which have been linked to aggressive

behavior (Barratt, 1991; Stanford, Houston, Mathias, Villemarette-Pittman, Helfritz, &

Conklin, 2003). Additionally, one of the most commonly reported concerns among
2
partners is a fear that the individual with BPD will engage in violence, particularly during

episodes of hypomania or mania (Dore & Romans, 2001; Lam et al., 2005). Moreover,

research in non-BPD samples shows that high levels of conflict and relationship

aggression are associated with relationship distress and instability (Lawrence &

Bradbury, 2001; Rogge & Bradbury, 1999; Stith, Green, Smith, & Ward, 2008), physical

injury (Archer, 2000), psychological distress (Straus, Cerulli, McNutt, Rhodes, Conner,

Kemball, Kaslow, & Houry, 2009) and harm to children (see Kitzman, Gaylord, Holt, &

Kenny, 2003 for review).

Recent theories of IPV suggest a number of intrapersonal, dyadic, and

sociocultural predictors of violence (Capaldi & Kim, 2007; DeMaris, Benson, Fox, Hill,

& Van Wyk, 2003). Theorists have divided these factors into proximal influences–those

contextual factors that set the stage for a specific incident of IPV, and distal influences–

factors that predict the presence and frequency of IPV (DeMaris et al., 2003). Although

an extensive body of literature has focused on identifying distal influences (e.g.,

Babcock, Miller, & Siard, 2003; Bookwala, Frieze, Smith, & Ryan, 1992; Earls, 1994;

Holtzworth-Munroe & Stuart, 1994; Lee, 2000; Loeber & Farrington, 2000; Miles-Doan,

1998; O’Leary, Slep, & O’Leary, 2007; Simkins & Katz, 2002; Tweed & Dutton, 1998;

White & Humphrey, 1994), knowledge about proximal factors remains primarily

theoretical (see Frye & Karney, 2006 for an exception). However, identification of

important proximal factors has the potential to inform prevention and intervention efforts

to target the specific contexts when IPV is most likely to occur. The purpose of the

current study is to examine two potential proximal predictors of IPV that are particularly

likely to occur in the distal context of BPD: manic symptoms and substance abuse.
3
Manic Symptoms

Although less frequent and shorter in duration than depressive episodes (Judd et

al., 2002; Perlis et al., 2006), manic episodes are often associated with greater distress

and impairment because of the consequences of impulsive, uncontrolled, irritable, and

sometimes aggressive behavior (Cassidy, Ahearn, & Carroll, 2002; Simon, Swann,

Powell, Potter, Kresnow, & O’Carroll, 2001; Swann, Stokes, Secunda, Maas, Bowden,

Berman, & Koslow, 1994). Among individuals with BPD, higher state impulsivity has

been linked to mania (Swann, Anderson, Dougherty, & Moeller, 2001; Swann, Pazzaglia,

Nicholls, Dougherty, & Moeller, 2003) which may place the person with BPD at higher

risk for perpetrating violence (Simon et al., 2001). Indeed, based on the reports of

spouses of individuals with BPD, manic symptoms appear to be associated with incidents

of IPV, specifically (Dore & Romans, 2001). Moreover, mixed episodes (defined by the

simultaneous presence of a major depressive episode and a manic episode) are

characterized by particularly high levels of irritability and aggressive behavior (Maj,

Pirozzi, Magliano, & Bartoli, 2003). Thus, we will test the hypotheses that 1) IPV will

be more likely to occur during weeks when manic symptoms are elevated and 2)

elevations in both depressive and manic symptoms in the same week will be more

strongly associated with occurrence of IPV than elevations in only depressive or manic

symptoms.

Comorbid Alcohol and Substance Use

A second factor likely to be predictive of incidents of IPV in BPD is substance

use. Substance use disorders (SUDs) are prominent in BPD, with rates as high as 60%

(Cassidy et al., 2002; Reiger, Farmer, Rae, Locke, & Keith, 1990), and are highly
4
correlated with impulsivity (Brady, Myrick, & McElroy, 1998; Swann, Dougherty,

Pazzaglia, Pham, & Moeller, 2004). Furthermore, SUD comorbidity is associated with a

more severe course of BPD (Feinman & Dunner, 1996) and greater cognitive impairment

(Martinez-Aranet al., 2004), which may place a person at greater risk for engaging in

partner aggression (Salloum, Cornelius, Mezzich, & Kirisci, 2002).

Studies of substance abuse in non-BPD samples support a strong association with

IPV (Kantor & Straus, 1987; Leonard & Senchak, 1996; Schafer, Caetano, & Cunradi,

2004; Stuart, Moore, Gordon, Ramsey, & Kahler, 2006). Established models of IPV

suggest that substance use may provide an immediate context that makes psychological

and physical aggression more likely by reducing inhibitions and contributing to negative

perceptions of partner behavior (e.g., Foran & O’Leary, 2008). Within BPD samples,

findings indicate that acute manic episodes accompanied by substance use are associated

with greater mood lability, impulsivity, and general violence (Salloum et al., 2002)

compared to periods of either substance use or manic episodes alone. Thus, we

hypothesize that 3) substance use will be associated with greater likelihood of IPV

occurrence, and 4) substance use in the context of elevated manic symptoms will be

associated with greater likelihood of IPV than either alone.

Methodological Advancements

In addition to testing the theoretical hypotheses described above, we will address

some methodological limitations in the existing literature. First, the majority of research

on IPV has relied upon cross-sectional designs (e.g., Dore & Romans, 2001), longitudinal

designs in which assessments are spaced at least several months apart (e.g., Barlow,

Grenyer, Ilkiw-Lavalle, 2000), or retrospective reports of IPV (e.g., Lam et al., 2005).
5
By examining the week-to-week association between the hypothesized proximal

predictors and the occurrence of IPV, we will be better able to determine how

fluctuations in symptoms and substance use are related to the occurrence of violence.

Second, we will examine psychological and physical IPV separately to determine

whether certain predictors are uniquely related to either psychological or physical IPV.

Previous studies (e.g., Barlow et al., 2000; Dore & Romans, 2001; Lam et al., 2005) often

focus on either psychological or physical IPV, or do not distinguish between them. By

examining the weekly associations between proximal predictors and psychological and

physical IPV, we will be better able to focus prevention and intervention efforts for

specific types of IPV. Furthermore, as there is strong and consistent evidence that a

partner’s aggressive acts are an important proximal context that increases the risk for

committing IPV (Capaldi, Shortt, & Crosby, 2003), we will examine the occurrence of

couple IPV (whether either partner endorsed engaging in an act of IPV during each week)

instead of focusing solely on acts of IPV committed by the participant with BPD. In

focusing on couple-level IPV as an outcome variable, we will be able to account for the

influence of a partner’s acts of IPV on the participant’s IPV as well as the possibility that

affective symptoms or substance use could contribute to a partner’s aggression (e.g.,

through arguments or frustration with symptoms).

Third, we will control for two important confounds: relationship adjustment and

frequency of arguments. There is strong evidence that relationship satisfaction is

associated with IPV over time (Lawrence & Bradbury, 2001; Lawrence & Bradbury,

2007) in clinical and community samples, therefore we will test the above hypotheses

controlling for the individual with BPD’s relationship satisfaction. In addition, results of
6
several studies examining the proximal context for episodes of IPV indicate that verbal

arguments and/or confrontations are common immediate precipitants of violence

(Cascardi & Vivian, 1995; Dobash & Dobash, 1979; Fenton & Rathus, 2010; Hamberger,

Lohr, Bonge, & Tolin, 1997); consequently, we will also test the above hypotheses

controlling for the frequency of couple arguments.

7
 Chapter 2

METHODOLOGY

Participants

Thirty-eight individuals with BPD (n = 34, 89.5%, met criteria for Bipolar I; n =

4, 10.5%, met criteria for Bipolar II) and their heterosexual partners were recruited from

a larger metropolitan area in the southwest region of the U.S. through print, radio,

internet, and newspaper advertisement distributed widely and to targeted psychiatric

clinics and peer support groups. All couples met the following eligibility criteria: a) both

partners were between 25-65 years of age, b) the partners had been living together for at

least one year, c) both partners had completed at least a 10th grade education, d) both

partners could read and speak English well enough to complete interviews and

questionnaires, e) only one partner met DSM-IV criteria for Bipolar I or II disorder, f)

neither partner met DSM-IV diagnostic criteria for a primary psychotic disorder (i.e.

Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, Delusional

Disorder, Brief Psychotic Disorder, or Psychotic Disorder NOS), although psychotic

symptoms solely in the context of a mood episode were not an exclusionary criterion, and

g) the couple was not currently enrolled in couple therapy and did not plan to engage in

couple therapy during the 6-month study period.

8
 Participants (individuals with BPD) and their partners were, on average, in their

mid-40s (MParticipants= 44, SD = 10; MPartners= 46, SD = 11), had some college education (M

= 15,SD = 3), and had relatively high levels of relationship satisfaction (MParticipants= 108,

SD = 21; MPartners= 108, SD = 15; DAS scores > 97; Funk & Rogge, 2007). The majority

were White (92.1% of participants and 84.2% of their partners) with most of the

remaining sample reporting their race/ethnicity as Latino (5.3% of participants and 7.9%

of their partners). Fifty percent of participants and 76 percent of their partners were

employed; median couple income was $4,500 per month ($54,000 per year). The

majority of participants with bipolar disorder were women (71.1%).

At the time of the initial assessment, 31% of participants met criteria for a manic

or hypomanic episode, 54% of participants met criteria for a major depressive episode,

and 15% met criteria for both a major depressive episode and a manic/hypomanic episode

in the past month. Additionally, about a quarter (26%) of participants currently met

criteria for other Axis I disorders. Eleven percent (n = 4) of participants met criteria for a

substance use disorder and 21% (n = 8) met criteria for an anxiety disorder. When

examining lifetime diagnoses, a majority (75%) of participants met criteria for an Axis I

disorder in addition to bipolar disorder. More specifically, 63% (n = 24) of participants

met criteria for a lifetime substance use disorder, 50% (n = 19) met criteria for an anxiety

disorder, and 11% (n = 4) met criteria for another diagnosis (e.g., eating disorder, pain

disorder).

Procedure

All study procedures were approved by the Institutional Review Board at the

university where the data were collected. Couples were recruited from community
9
mental health agencies, online advertisements (e.g., Craigslist), and local bipolar and

depression support groups for a 6-month longitudinal study examining relationship

functioning among couples in which one partner had BPD. Previous research by Judd

and colleagues (2002) indicates that individuals with BPD report shifts in polarity more

than three times a year, on average; thus, the 6-month period of the study was designed to

capture sufficient mood fluctuation to test the hypotheses without overburdening

participants. Potential participants contacted the research lab by phone and a research

assistant provided them with information about the study procedures and screened them

for study eligibility. Once both partners contacted the lab and were confirmed to be

eligible for the study, a research assistant scheduled them for the initial assessment.

At the initial assessment, participants provided informed consent and separately

completed questionnaires covering topics including current symptoms, relationship

functioning, and intimate partner violence, among others not relevant to the current study.

Additionally, doctoral students in clinical psychology who were trained and supervised

by an experienced diagnostician administered the mood and psychosis modules of the

Structured Clinical Interview for the DSM-IV-TR, Research Version (SCID-I; First,

Spitzer, Gibbon, & Williams, 2002) to confirm that one, and only one, partner had a

Bipolar I or II diagnosis and confirm that all other eligibility requirements were met.

Couples then completed additional measures and tasks not related to the current study,

including the remaining Axis I modules of the SCID. Participants were reimbursed $125

each ($250 total per couple) for completion of the initial assessment.

Participants and their partners then completed brief weekly questionnaires for 6

months (26 weeks total) assessing relationship satisfaction, arguments between partners,
10
psychological and physical aggression, mood symptoms, and substance use. At the initial

assessment, participants were instructed in how to complete the weekly diaries.

Participants were asked to complete their weekly diaries independently from each other

and not to share their answers with one another. They were provided with one month’s

worth of weekly diaries (four at a time) and self-addressed, stamped envelopes and were

instructed to complete a weekly diary on the same day each week and mail it within five

days. Participants were reimbursed $5 for each diary they completed and returned to the

lab by its due date, paid in monthly installments. Participants and their partners

completed, on average, twenty weekly diaries across the six months of assessment. The

lowest number of weekly diaries completed was 2 while the highest number was 28.

Measures

DSM-IV-TR Axis I Diagnoses. The Structured Clinical Interview for DSM-IV-

TR Axis I Disorders, Research Version (SCID-I; First et al., 2002) is a well-validated and

reliable semi-structured interview for diagnosing the major DSM-IV-TR Axis I disorders.

It was administered to both partners at the initial assessment by trained doctoral graduate

student interviewers and was used to confirm that one partner had a diagnosis of Bipolar I

or II, to assess for any comorbid diagnoses for the partner with BPD, and to assess the

psychiatric history of the partner without BPD. All diagnoses were made by consensus

with the PI, an experienced diagnostician. Thirty percent of all interviews (n = 23) were

re-scored to examine inter-rater agreement. Agreement was acceptable for both current

mood episode (κ = .89), and mood diagnosis (κ = .83).

Relationship satisfaction. The Dyadic Adjustment Scale (DAS; Spanier, 1976)

is a well-validated, 32-item self-report measure of relationship adjustment with four

11
subscales assessing satisfaction, cohesion, affection, and consensus. Higher scores

indicate higher levels of satisfaction and a cut-off score of 97.5 has been validated as an

indicator of relationship distress (e.g., Funk & Rogge, 2007). It is highly correlated with

other measures of relationship satisfaction (Spanier, 1976) and in this sample, the internal

consistency of this measure was high for both participants with BPD (coefficient α = .95)

and their partners (coefficient α = .90).

IPV. The Conflict Tactics Scale, Revised (CTS-2; Straus, Hamby, Boney-

McCoy, & Sugarman, 1996) is a well-validated and reliable measure of IPV that consists

of 78 items, on which participants rate their own and their partner’s behavior on five

scales (Negotiation, Psychological Aggression, Physical Aggression, Sexual Coercion,

and Injury). For the current study, the Psychological (8 items) and Physical Aggression

(12 items) subscales were used. Additionally, given that many individuals under-report

their own violence on self-report measures (Archer, 1999; Arias & Beach, 1987; Riggs,

Murphy, & O’Leary, 1989), the highest report of IPV from either reporter was used to

calculate prevalence and frequency estimates; that is, if a participant said that he/she had

engaged in an act 2 times, but his/her partner reported that the participant had engaged in

the act 4 times, a score of 4 was recorded for that act. Prevalence of psychological and

physical IPV in the past year were calculated by scoring 1 if the participant or their

partner reported at least one act of IPV in the past year; scores of 0 were given if the

participant or partner did not report any violent acts in the past year. Frequency of

psychological aggression was calculated by recoding scores of 0 (Never) and 7 (Not in

the past year, but it did happen before) to be 0. Scores were then recoded based on

recommendations by Straus and colleagues (1996) as follows: Once in the past year = 1,
12
Twice in the past year = 2, 3-5 times in the past year = 4, 6-10 times in the past year = 8,

11-20 times in the past year = 15, and More than 20 times in the past year = 25. All

frequency items of the psychological aggression subscale were summed and reported as a

one-year frequency of psychological aggression. Cronbach’s alpha for the current sample

of individuals with BPD was .74 for the psychological aggression subscale and .55 for the

physical aggression subscale; internal consistency for the current sample of partners

without BPD was .64 for the psychological aggression subscale and .77 for the physical

aggression subscale.

To assess occurrence of IPV over the 6-month period of the study, selected items

from the CTS-2 (Straus et al., 1996) measuring mild psychological and mild physical

aggression were included in the weekly diary. Participants were asked to report how

frequently each of the following had occurred in the past week in open-ended questions:

“I insulted/swore at/yelled at my partner”, “My partner insulted me/swore at me/yelled at

me”, “My partner pushed/slapped me or forcefully grabbed me in anger”, and “I

pushed/slapped my partner or forcefully grabbed him/her in anger.” In other

investigations, the behaviors assessed in the selected items are the most common of all

items on the CTS-2 (e.g., Frye & Karney, 2006). As with the full CTS-2, the highest

report by either partner was used to calculate estimates. Frequency of the single-item

psychological aggression measure at baseline (on the weekly diary) was correlated (r =

.80, p< .01) with the frequency score from the CTS-2 psychological aggression subscale

in the current sample. Prevalence of the single-item physical aggression measure (on the

weekly diary) at baseline was associated with the prevalence of the CTS-2 physical

aggression subscale, χ2 (1)= 4.14, p < .05.

13
 Arguments. Participants were asked to report on the frequency of arguments

with their partner over the past week in an open-ended item “In the past week, how many

arguments did you have with your partner?” Due to positive skew, the data were recoded

so that responses of 7 or higher were scored as “7”; thus, scores ranged from 0 (no

arguments) to 7 arguments. In the current study, frequency of arguments from the first

weekly diary were correlated, r =.88; p< .01, with baseline psychological IPV from the

CTS-2.

Depressive symptoms. The Patient Health Questionnaire-9 (PHQ-9; Kroenke,

Spitzer, & Williams, 2001) is a self-report, 9-item measure of depressive symptoms in the

past week that was administered in each weekly diary measure. It is based on the nine

DSM-IV-TR criteria for a Major Depressive Episode and has good internal consistency

(α = .85 in the current sample, from baseline administration). In the current study, PHQ-

9 scores from the first weekly diary were correlated with clinician-ratings on the

Hamilton Rating Scale for Depression (Hamilton, 1960), r = .82; p< .01, and with

participant self-report on the Beck Depression Inventory, Revised (Beck, Steer, &

Brown, 1996), r = .76; p< .01, both obtained at the baseline assessment.

Manic symptoms. The ASRM (Altman, Hedeker, Peterson, & Davis, 1997) is a

5-item self-report measure of manic symptoms in the past week that participants

completed as part of the weekly diaries. Scores from the first weekly diary correlated

positively with clinician-ratings on the Young Mania Rating Scale (Young, Biggs,

Ziegler, & Meyer, 1978), r = .51, p< .01, and the measure showed good internal

consistency (coefficient α = .85 in the current sample).

14
 Alcohol and drug use. Participants were asked to report on their own alcohol

and drug use over the past week using open-ended items:“In the past week, how many

alcoholic drinks did you have?” and “In the past week, how many times did you use

illegal drugs or a prescription drug in a way other than was prescribed?”Weekly reports

of frequency of alcohol and substance use are well-validated and preferable to

estimations of alcohol/substance use over longer periods of time because it reduces recall

errors by asking individuals to report an exact amount of alcohol/substance consumption

over a circumscribed time period (Del Boca & Darkes, 2004; Lemmens, Tan, & Knibbe,

1992). Number of alcoholic drinks reported in the initial diary was correlated with

baseline SCID-I alcohol abuse symptoms in the past month (r = .71, p< .01) in the current

sample.

Data Analysis

We used 2-level hierarchical linear models to examine within- and between-

subject variability in aggressive behavior. Couple-level estimates of argument frequency,

and occurrence of psychological and physical aggression were the dependent variables,

because partner reports of argument frequency, r = .63, and partner perpetration of

psychological aggression, r= .76, and physical aggression, r=.63, were all highly

correlated (all p’s < .001).Due to the highly positively skewed distribution of both

psychological and physical IPV in the current sample, prevalence, rather than frequency

of IPV was used as the dependent variable.

Each proximal predictor (i.e., manic symptoms, depressive symptoms, alcohol

use, and drug use) and their interactions (Manic Symptoms × Depressive Symptoms,

Manic Symptoms × Alcohol Use and Manic Symptoms × Drug Use) were included at
15
level-1 as a time-varying covariate. Within-participant average manic symptoms,

depressive symptoms, alcohol use and drug use over the study period were controlled at

level-2, as was participant relationship satisfaction (baseline DAS). Thus, level-1

statistics indicate the degree to which weekly scores for the IVs were related to weekly

scores for the DVs, controlling for the average effect of each IV at level-2.For example, a

positive and significant coefficient for level-1 manic symptoms would indicate that

during weeks when participants reported higher levels of manic symptoms, they were

also more likely to experience IPV; conversely, a positive and significant coefficient for

Average Mania (level-2) would indicate a between-subjects effect, where participants

with higher average manic symptoms were more likely to experience IPV over the course

of the 6-month assessment period. A statistics expert was consulted about conducting a

power analysis to determine an appropriate sample size for the current study. The expert

concluded that the current sample size (n = 38 individuals with bipolar disorder)

multiplied by the number of weeks of data collected (M = 20.68, SD = 8.07) provided

sufficient power to detect the hypothesized effects.

16
 Chapter 3

RESULTS

Descriptive Statistics and Preliminary Analyses

At the baseline assessment, nine couples (23.7%) reported experiencing at least

one act of physical IPV in the past year, committed by either partner. Across the six

months of assessment, only five couples (13.2%) experienced an act of physical IPV

committed by either partner; each couple only endorsed IPV during one week of the

assessment period. Thus, because the base rate of physical IPV was so low, we were

unable to examine predictors of specific occurrences of aggression. However,

examination of between-couples differences across the six months revealed that there

were no differences on study predictors (e.g., manic symptoms, substance use) among

couples endorsing physical IPV compared to those not endorsing physical IPV, with two

exceptions. When examining the cross-sectional initial assessment data, participants with

BPD in a couple relationship reporting physical IPV over the past year were more

depressed than were participants with bipolar disorder in a relationship not reporting

physical IPV. Additionally, as expected, at the initial assessment participants with BPD

in a couple relationship reporting physical IPV over the past year reported lower

relationship satisfaction than participants with bipolar disorder in a relationship not

reporting physical IPV. Finally, when examining the mean scores across the six months

17
of data, among couples reporting physical IPV, participants with BPD reported a lower

average frequency of alcoholic drinks (M = .14, SD = .26) than did participants with

BPD in a relationship not reporting physical IPV. See Table 1 for a summary of

between-couple comparisons.

In contrast, at the baseline assessment, thirty couples (79%) reported experiencing

at least one act of psychological IPV in the past year, committed by either partner.

Across the six months of assessment, twenty-six couples (68.4%) experienced at least one

act of psychological IPV committed by either partner and thirty-three couples (87%)

reported at least one argument during the 6-month study period. The average number of

weeks in which psychological IPV occurred was 5.42 (SD = 6.23) and the average

frequency of psychological IPV across all weeks was 1.00 (SD = 2.85), with thirty acts of

psychological IPV as the highest number reported on any given week. Average

frequency of arguments across all weeks was 1.20 (SD = 1.80), with seven arguments as

the highest number reported on any given week.

Regarding the independent variables, 55% (n = 21) of individuals with BPD

reported having consumed alcohol at least once during the 6-month study period with a

mean of 1.69 drinks per week (SD = 3.85). Number of drinks ranged from 0 to 30 per

week across the sample and the average number of drinking weeks was 6.50 (SD = 8.88).

Twenty-six percent (n = 10) of participants reported illegal drug use and/or prescription

drug abuse during the study period with a mean frequency of weekly drug use of .39 (SD

= 1.60). Because drug use was strongly positively skewed, we examined whether the

individual used drugs during a given week, rather than the frequency of drug use each

18
week; the average number of weeks participants reported using illegal drugs and/or

prescription drug use was 1.66 (SD = 5.11).

Finally, 61% (n = 23) of participants had an ASRM score greater than 6

(indicating a high probability of manic or hypomanic episode; Altman et al., 1997) during

at least one week over the 6-month period. The average ASRM score across the six

months was 2.11 (SD = 3.35) and scores ranged from 0 to 20. The average number of

weeks with an ASRM score greater than 6 was 2.45 (SD = 3.97).For depressive

symptoms, 89% (n = 33) of participants had a PHQ-9 score greater than 5 (indicating at

least mild depressive symptoms; Kroenke et al., 2001) during at least one week over the

study period. The average PHQ-9 score was 7.18 (SD = 6.86) and scores ranged from 0

to 27; the average number of weeks with a PHQ-9 score greater than 5 was 9.47 (SD =

8.72). Bivariate correlations and within-participant average scores across weekly

assessments for all variables are shown in Table 2.

Hypothesis Testing

To test the hypothesis that IPV would be more likely to occur during weeks when

manic symptoms were elevated, we conducted logistic multi-level models in which the

occurrence of psychological IPV was regressed onto weekly manic symptoms, weekly

depressive symptoms, and the Manic Symptoms × Depressive Symptoms interaction at

level-1, controlling for initial relationship adjustment (DAS) and average manic

symptoms at level-2. All level-1 variables were group-mean centered and level-2

variables were grand-mean centered. Population-average estimates with robust standard

errors and the Odds Ratio are reported in Table 3.Only weekly depressive symptoms

were related to psychological IPV, such that during weeks when the individual with BPD
19
was more depressed, the couple was more likely to experience psychological IPV. The

hypotheses that manic symptoms would be associated with IPV and that there would be a

Manic Symptoms × Depressive Symptom interaction were not supported.

Next, we tested the hypothesis that IPV would be more likely to occur during

weeks when manic symptoms were elevated and the participant had used substances.

Because alcohol and drug use were not correlated, we examined these variables

individually. The same process of model testing was followed as above, in which

substance use was added as a level-1 time varying covariate and then the interaction

terms were examined (see Table 4).Results revealed that none of the hypothesized

predictors (alcohol or drug use) was related to psychological IPV independently;

however, a Manic Symptoms × Drug Use interaction was revealed, although not in the

hypothesized direction. Further probing of the interaction revealed that low levels of

manic symptoms were associated with increased psychological IPV during weeks when

participants with BPD had used drugs. Contrary to our hypothesis, when manic

symptoms were above average, drug use was associated with lower rates of psychological

IPV (see Figure 1).

To determine if the results were specific to psychological IPV or were relevant for

arguments between partners more broadly, we replicated the above models with

frequency of couple arguments as the DV. As shown in Table 5, weekly depressive

symptoms were related to frequency of couple arguments, such that during weeks when

the individual with BPD was more depressed, the couple reported more frequent

arguments. Interestingly, a between-subjects effect for manic symptoms emerged,

indicating that couples in which the participant with BPD had higher average manic
20
symptoms across the study period reported more frequent arguments. Finally, although

the predicted Manic Symptoms × Depressive Symptoms interaction was not supported in

the model predicting psychological IPV, it was supported in the model predicting

frequency of couple arguments. Further probing of the interaction revealed that elevated

manic symptoms were only associated with increased arguments during weeks when

depressive symptoms were also elevated. In fact, when depressive symptoms were below

average, increased manic symptoms were associated with lower rates of arguments (see

Figure 2).

Next, we replicated the above model examining the frequency of couple

arguments regressed onto manic symptoms and participant substance use (see Table 6).

Results revealed that none of the hypothesized predictors (alcohol or drug use) were

related to frequency of couple arguments, including the Manic Symptoms × Substance

Use interaction.

Finally, we entered all predictors with a significant main effect in the above

models predicting psychological IPV, including weekly manic and depressive symptoms

and weekly drug use and the Manic Symptoms × Drug Use interaction as level-1 time

varying predictors, and controlling for weekly frequency of couple arguments (see Table

7). Results revealed that the main effect of weekly depressive symptoms and the Manic

Symptoms × Drug Use interaction were retained after controlling for weekly arguments.

21
 Chapter 4

DISCUSSION

To date, most of the research on psychological and physical aggression among

individuals and couples coping with BPD has relied on retrospective reports of the

patient’s aggressive behavior provided by caregivers, with much less attention focused on

the range and frequency of acts of IPV among couples coping with BPD. Given that

previous research indicates that intimate partners are more likely to be exposed to the

patient’s aggressive behavior (Dore & Romans, 2001) than other types of caregivers, the

current study was designed to address this gap in the literature. Several methodological

features of the present study differentiate it from previous studies and support the

strength of its findings: the use of prospective measures of affective symptoms and

episodes of IPV, the use of a measure of specific acts of psychological and physical IPV,

and the self-report of arguments, psychological and physical IPV, mood symptoms, and

substance use by both the participants with BPD and their partners.

Our results indicate that couples coping with BPD in the current study reported

rates of psychological IPV (68.4%) comparable to other samples of participants with

BPD and their partners/caregivers (Barlow et al., 2000; Lam et al., 2005). Additionally,

the current sample reported a prevalence of physical IPV (23.7%) that is comparable to

both similar clinical (Dore & Romans, 2001) and more general community (Archer,

22
2000) samples. Further, couples in the current study reported rates of psychological and

physical IPV that is comparable to distressed couples (Friend, Bradley, Thatcher, &

Gottman, 2011), despite the relatively low levels of relationship distress in this sample.

Finally, at the bivariate level, there was a near perfect correlation between patient and

partner IPV (both physical and psychological) indicating that, in the current sample,

participants with bipolar disorder were both the perpetrators and victims of IPV. This is

consistent with other studies of IPV in both clinical and community samples which

suggest that among couples who report experiencing relatively infrequent and mild IPV,

both partners are likely to perpetrate IPV (e.g., Straus & Gelles, 1986).

Additionally, the current findings indicate that weekly depressive symptoms are

associated with both frequency of arguments and occurrence of psychological IPV across

time. Furthermore, a between-subject, cross-sectional examination of physical IPV also

indicated a higher level of depressive symptoms among participants in violent

relationships. There are several possible explanations for these findings.

First, previous research has indicated that bipolar depressive episodes are related

to increased episodes of anger or irritability that may contribute to interpersonal

problems, including aggression (Perlis et al., 2004). Further, research conducted by Judd

and colleagues (2002) on the frequency of depressive versus hypomanic/manic symptoms

among individuals with bipolar disorder indicated that depressive symptoms occur

between 31.9 and 50.3% of weeks while manic/hypomanic symptoms only occur

between 1.3 to 8.9% of weeks. The greater frequency of depressive symptoms and the

evidence that behavior related to depressive symptoms (e.g., withdrawal, behavioral

disengagement) has been shown to be highly problematic for relationship functioning

23
may explain the association between depressive symptoms and greater frequency of

couple arguments and occurrence of psychological and physical IPV in the current study.

Alternatively, greater arguments and psychological IPV may contribute to depressive

symptoms. Indeed, there is a well-established body of research supporting an association

between hostile and critical close others and increased depressive symptomatology

(Miklowitz & Johnson, 2009) among individuals with BPD.

Interestingly, and inconsistent with our results, the few studies (Dore & Romans,

2001; Lam et al., 2005) that have examined aggressive behavior among people with

bipolar disorder indicate a relationship between aggressive behavior and manic

symptoms. Based on our data, fluctuations in manic symptoms over time were not

associated with the occurrence of psychological IPV, although greater average manic

symptoms were associated with increased frequency of couple arguments. These

findings indicate that psychological IPV is not more likely to occur during weeks when

people with bipolar disorder are experiencing an increase in manic symptoms; however,

greater frequency of arguments is more likely to occur among couples in which the

partner with bipolar disorder experiences more manic symptoms overall.

Previous studies have identified the presence of affective temperaments

(subaffective manifestations of an affective episode) among individuals with bipolar

disorder (e.g., Akiskal et al., 2006; Vazquez, Gonda, Zaratiegui, Lorenzo, Akiskal, &

Akiskal, 2010). Research on affective temperaments supports the current findings that

individuals with bipolar disorder often experience subthreshold manic symptoms between

affective episodes. The present data may be reflective of individuals with temperamental

traits that do not meet the threshold for a manic episode, but consistently report some
24
manic symptoms over time such as an irritability and labile mood. This is an important

finding because it indicates that manic symptoms over time are associated with greater

arguments, regardless of whether a person is experiencing an acute manic episode.

Future studies should focus on identifying which affective temperamental traits are

related to arguments and relationship conflict and if these traits contribute to a consistent

report of subthreshold manic symptoms across assessment time points. Additionally,

given the low rates of manic symptoms across the six months in the current study, future

research should focus on the association between IPV and manic symptoms in a more

severely symptomatic sample.

Further, some researchers have described couples coping with BPD as having

relationships that are “intermittently incompatible” (Frank, Targum, Gershon, Anderson,

Stewart, Davenport, Ketchum, & Kupfer, 1981), indicating that they are stable much of

the time but can be threatened during periods where the partner with BPD is

symptomatic. Current data regarding the cross-sectional and longitudinal association

between psychological IPV and depressive symptoms, as well as the longitudinal

relationship between manic symptoms and arguments, support the notion that couples

coping with BPD experience increased conflict and hostility when the individual with

BPD is experiencing an increase in mood symptoms. Subsequently, this may make

couples coping with BPD more vulnerable to relationship instability.

Contrary to our hypotheses, the interaction between weekly manic symptoms and

weekly drug use is not consistent with previously existing evidence that drug use and

manic symptoms are related to episodes of violence. Current results indicated that

participants who used drugs and reported more manic symptoms were least likely to
25
experience episodes of psychological IPV. Past empirical studies have demonstrated that

both mania and drug use lead to increased impulsivity and that when they occur at the

same time, impulsivity is greater than when they occur in isolation (Martinez-Aran et al.,

2004). In turn, this increase in impulsivity is thought to be related to greater violence;

therefore, the current results are somewhat difficult to interpret.

However, it is possible that participants with bipolar disorder used illegal

substances or abused prescription medication to self-medicate and stabilize their mood

which may have affected their weekly report of symptoms. Previous research supports

the use of substances as an attempt to self-treat specific bipolar-related symptoms,

including racing thoughts or depression (Weiss, Kolodziej, Griffin, Najavits, Jacobson, &

Greenfield, 2004). Potentially, the participant’s with bipolar disorder use of substances

may have resulted in an overall lower experience of manic symptoms over the course of

the six months. However, since the type of illegal substances used by the participants

with bipolar disorder was not collected, only the weekly frequency of drug use, it is

difficult to draw conclusions about the affects specific substances may have had on the

expression of affective symptoms.

Future research should focus not only on obtaining information regarding the

participant with bipolar disorder and their partner’s IPV, but also on collecting greater

detail regarding the immediate context surrounding episodes of IPV. For example, it will

be useful to gather data that specified which partner engaged in an act of IPV first and

what types and amount of illegal substances were used on a weekly basis. Therefore,

collecting prospective, longitudinal data that is less vulnerable to recall error than

traditional measurement methods is essential in clarifying the relationship between

26
psychiatric symptomatology, illegal substance use and prescription drug abuse, and

episodes of IPV.

Finally, the two couple level factors that were examined in the current study,

relationship satisfaction and arguments, were both related to incidents of IPV. In

addition to partner’s IPV, participant satisfaction was related to psychological IPV over

the six months and physical IPV at the initial assessment. Overall, participants with

bipolar disorder with lower levels of satisfaction at the initial assessment reported more

arguments across the six months and were more likely to report that either they or their

partner had engaged in psychological IPV. These findings support a dyadic model of

IPV where both partners participate in episodes of IPV. Therefore, although it is

important to understand the bipolar-specific risk factors for IPV among individuals with

bipolar disorder, it is also critical to consider variables related to their relationship,

especially the association between the patient and their partner’s IPV and overall

relationship satisfaction.

What implications do the current data have for clinicians working with couples

coping with bipolar disorder? Often, individuals with bipolar disorder receive individual

or family therapy that focuses on medication adherence, mood charting, and

psychoeducation regarding the illness. Empirically supported psychotherapies specific to

bipolar disorder tend to share several common characteristics: the model of therapy is

shared with the patient and his/her family and offers a specific individualized

conceptualization of the presenting problems, clear rationale for the techniques used are

provided to the patient, psychoeducation and skill development are core components, and

change is seen as a result of the patient’s efforts (Miklowitz et al., 2009). Typically, such
27
interventions do not address IPV or conflict management strategies; however, the current

results highlight the importance of assessing for and addressing conflict and

psychological IPV among couples coping with bipolar disorder. Interestingly, there is a

growing body of research examining the use of conjoint therapy with couples reporting

relatively infrequent, mild, and bidirectional IPV (Stith et al., 2004), which emphasizes

improving conflict management skills, learning problem-solving techniques, and tailoring

the therapy plans to meet the needs of the individuals in the couple relationship (Harris,

2006). This conjoint format may be a useful approach in intervening with couples

reporting arguments and psychological IPV who are also coping with BPD.

Also, the current data indicate that there is a need to intervene in substance use at

the individual level with patients with bipolar disorder. Existing research indicates that

comorbid substance use and bipolar disorder are more difficult to treat than bipolar

disorder alone, as substance abuse appears to contribute to lithium resistance

(Himmelhoch & Garfinkel, 1986; Goldberg, Garno, Leon, Kocsis, & Portera, 1999).

However, based on the findings of a few studies examining treatment effectiveness for

both disorders, both pharmacological and disorder specific psychotherapy are

recommended to treat comorbid bipolar and SUD. Group based cognitive behavioral

therapy has been shown to decrease medical service utilization and increase

pharmacotherapy compliance among individuals with bipolar and substance use disorders

(Schmitz, Averill, Sayre, McCleary, Moeller, & Swann, 2002; Weiss, Najavits, &

Greenfield, 1998). Interestingly, more recent approaches to couples treatment of IPV

have included a one-session motivational interviewing based intervention to address the

role of substances in episodes of IPV (McCollum, Stith, Miller, & Ratcliffe, 2011). The
28
current data highlights the value of intervening in substance abuse among individuals

with bipolar disorder who engage in IPV.

Limitations

When considering the results of the current study, several factors limit the

interpretation of the current findings. First, the study has a small sample size that limits

the power to detect differences between the study variables. Second, although the

longitudinal data allows for conclusions about the relationship between variables, causal

relationships cannot be determined. Third, the current sample was drawn from the

community, which means that although almost all participants with bipolar disorder were

actively receiving treatment (e.g., psychotropic medications), many were not acutely ill

during the six months of assessment. Next, the current sample was primarily White

andpartners were in their mid-40s, on average, indicating that they may be less likely to

engage in IPV than younger samples (e.g., Pan, Neidig, & O’Leary, 1994). Finally, the

inclusion criteria for the current study required that participating couples must have been

living together for at least one year. Therefore, couples in the current study may

represent more stable relationships that have effectively managed the impact of bipolar

disorder on their couple functioning. This suggests that couples in the current study may

possess certain individual and/or relationship characteristics that might not be found in

couples coping with bipolar disorder who are not able to maintain cohabitation for 1 year

or longer.

In sum, there is a growing body of research, including the current study,

indicating that conflict and psychological IPV are serious issues affecting many couples

coping with bipolar disorder. Our current interventions for bipolar disorder and partner
29
violence may not be addressing the role that affective symptoms and drug use have on

these important, and potentially dangerous, aspects of couple functioning. Future

research should focus on how best to intervene with couples coping with bipolar disorder

who also report a history of and/or current experience of IPV.

30
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44
Table 1: Between-Couple Differences among Couples Reporting Physical IPV and

Couples Not Reporting Physical IPV

Couples t df d

Physical IPV No Physical

(n = 5) IPV

(n = 33)

Initial Assessment

Depression (BDI-II) 22.85 (9.03) 13.09 (8.57) -2.94** 35 1.11

Relationship Satisfaction 92.06 (14.49) 111.99 (29.61) 2.73* 35 .85

(DAS)

Across Six Months

Weekly Alcoholic Drinks .14 (.26) 1.61 (2.06) 3.89*** 36 1.00

Note. * p < .05, ** p < .01, *** p < .001. Standard Deviations appear in parentheses
adjacent to means

45
Table 2: Descriptive Statistics and Bivariate Correlations between Study Variables

1. 2. 3. 4. 5. 6. M (SD)

1. Relationship - 107.97

Adjustment (DAS) (20.99)

2. Average Arguments -.41** - 1.45 (1.72)

3. Psychological IPV (% -.37* .88*** - 35.18 (32.66)

Weeks)

4. Average ASRM -.10 .36* .22 - 2.38 (2.26)

5. Average PHQ-9 - .22 .28 .20 - 7.37 (5.28)

.50***

6. Average Drinks .15 .05 .16 -.08 -.16 - 1.41 (1.98)

7. Drug Use (% Weeks) -.07 .26 .18 .17 .28 -.02 10.73 (23.53)

* p< .05, ** p < .01, *** p < .001; DAS = Dyadic Adjustment Scale, ASRM = Altman

Self-Rating Scale for Mania, PHQ-9 = Patient Health Questionnaire

46
Table 3: Occurrence of Psychological IPV by Manic and Depressive Symptoms

β (SE) OR

Intercept -.63 (.19)** .53

Initial DAS -.02 (.01)* .98

Average ASRM .09 (.07) 1.10

Average PHQ-9 .04 (.04) 1.04

Weekly ASRM .01 (.03) 1.01

Weekly PHQ-9 .06 (.01)*** 1.06

Weekly ASRM × PHQ-9 .003 (.003) 1.00

OR = Odds Ratio; * p < .05, ** p < .01, *** p < .001

47
Table 4: Occurrence of Psychological IPV by Manic Symptoms and Substance Use

Alcohol Use Drug Use

β (SE) OR β (SE) OR

Intercept -.64 (.18)*** .53 -.62 (.19)** .54

Initial DAS -.03 (.01)*** .97 -.03 (.01)*** .97

Average ASRM .09 (.07) 1.10 .09 (.07) 1.09

Average Substance Use .15 (.11) 1.16 -.002 (.01) 1.00

Weekly ASRM -.01 (.03) .99 -.01 (.02) .99

Weekly Substance Use .02 (.06) 1.02 .16 (.29) 1.18

Weekly ASRM × Substance -.005 (.006) .99 -.14 (.05)** .87

Use

* p< .05, ** p < .01, *** p < .001; OR = Odds Ratio, DAS = Dyadic Adjustment Scale,

ASRM = Altman Self-Rating Scale for Mania

48
Table 5: Couple Arguments by Manic and Depressive Symptoms

β (SE)

Intercept 1.42 (.22)***

Initial DAS -.02 (.01)***

Average ASRM .19 (.07)**

Average PHQ-9 .02 (.03)

Weekly ASRM -.02 (.02)

Weekly PHQ-9 .07 (.02)**

Weekly ASRM × PHQ-9 .01 (.004)*

* p< .05, ** p < .01, *** p < .001

49
Table 6: Couple Arguments by Manic Symptoms and Substance Use

Alcohol Use Drug Use

β (SE) β (SE)

Intercept 1.41 (.22)*** 1.41 (.22)***

Initial DAS -.03 (.01)** -.03 (.01)**

Average ASRM .19 (.12) .19 (.13)

Average Substance Use .12 (.10) .01 (.01)

Weekly ASRM -.05 (.03) -.02 (.02)

Weekly Substance Use -.02 (.06) .08 (.21)

Weekly ASRM × Substance Use -.01 (.01) -.07 (.09)

* p< .05, ** p < .01, *** p < .001

50
Table 7: Predictors of Psychological IPV, Controlling for Couple Arguments

β (SE) OR

Intercept -.61 (.13)*** .54

Initial DAS .01 (.01) 1.01

Average Arguments 1.03 (.08)*** 2.80

Average ASRM .04 (.06) 1.04

Average PHQ-9 .03 (.03) 1.04

Average Drug Use .0005 (.003) 1.00

Weekly ASRM .02 (.02) 1.02

Weekly PHQ-9 .04 (.02)* 1.04

Weekly Drug Use .05 (.25) 1.05

Weekly Arguments .66 (.08)*** 1.93

Weekly ASRM × Drug -.15 (.07)* .86

OR = Odds Ratio; * p < .05, ** p < .01, *** p < .001

51
Figure 1. Odds of psychological IPV by manic symptoms and drug use.

52