Cognitive attentional syndrome and metacognitive beliefs as potential treatment targets for metacognitive therapy in bipolar disorder

Table 1 Examples of the components of the cognitive attentional syndrome and dysfunctional metacognitive beliefs in bipolar disorder

	Depressive phase	Hypo/manic phase
Perseverative thinking	“Why am I so depressed? What is the point in living any more? What is the root cause of my depression? Why can’t I just snap out of this feeling?”	“I can do whatever I like, I have never been stronger! I feel so great, and this feeling must last forever.”
	“What if I never get better? Will I always feel like this? What if I have a recurrence?”	“How dare they think that I should not be doing the things I want to? Nobody has the right to tell me what I am allowed to do.”
		“What if my mood deteriorates? What if I start to feel depressed again? Will my health never be like everyone else’s?”
Attentional biases and threat monitoring	Constant mood monitoring, self-focused attention, focusing on any changes in depressive symptomatology, checking energy levels, body scanning for early warning signs of recurrence	Constant mood monitoring, self-focused attention, focusing on any changes in hypo/manic symptomatology, checking energy levels, body scanning for early warning signs of recurrence
Dysfunctional coping strategies	Thought control, inactivity, self-harm, alcohol/substance use, emotional avoidance, social withdrawal	Thought control, hyperactivity, impulsivity, alcohol/substance use, emotional overindulgence, increased social interaction
Negative metacognitive beliefs	“Rumination is uncontrollable. Worrying will harm me. If my energy level changes during the day, this means that I am about to get depressed.”	“Rumination is out of my control. Worrying too much might harm me. I have a broken brain. My genes are responsible for my disorder, and there is no way to cure it.”
	“My friends will leave me because of my never-ending rumination.”	“I can not form stable relationships because of my bipolar disorder. This has ruined my life.”
Positive metacognitive beliefs	“Rumination will help me identify the cause of my depression. Worrying keeps me prepared for any unwanted consequences. Checking my mood will tell me when I am at risk for depression.”	“Thinking about my positive mood will make my day better. The more time I spend time on my heightened energy, the less probable that I fall back to my depression. Worrying that I may experience a relapse will help me identify any early warning signs.”