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The two depression and two hypo\/mania factors are correlated; and affrontive symptoms of hypo\/mania (e.g., furious, disgusted, argumentative) are positively correlated with both depression factors suggesting pathways for mixed symptom presentation. This grouping of affrontive symptoms of hypo\/mania organically emerged in exploratory research and has subsequently been supported in confirmatory analyses between samples and over time. The BDS<jats:sub>x<\/jats:sub> has been clinically validated with BD outpatients.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Over 19\u00a0days, we recruited an international sample of 784 adults with BD using micro-targeted, social media advertising (M \u2009=\u2009 44.48\u00a0years, range 18\u201382). All participants indicated that they had BD (subtype, if known) and had been diagnosed with BD (month, year). This sample size was sufficient to confirm the 4-factor model across subtypes and compare the three (BD I, BD II, BD NOS). Responses to 19 of 20 BDS<jats:sub>x<\/jats:sub> items were psychometrically consistent across BD subtypes. Only responses to the \u2018hopeless\u2019 item were significantly higher for those with BD II.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>When comparing models, it appears that affrontive symptoms are significantly and uniformly associated with hypo\/mania and both depression factors across subtypes. In contrast to BD diagnostic criteria, this suggests that affrontive symptoms are central to the clinical presentation of hypo\/mania and mixed symptomology across BD subtypes.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s40345-021-00229-1","type":"journal-article","created":{"date-parts":[[2021,8,2]],"date-time":"2021-08-02T02:02:43Z","timestamp":1627869763000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Is the 4-factor model of symptomology equivalent across bipolar disorder subtypes?"],"prefix":"10.1186","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5100-427X","authenticated-orcid":false,"given":"Norm","family":"O\u2019Rourke","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew","family":"Sixsmith","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tal","family":"Michael","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yaacov G.","family":"Bachner","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2021,8,2]]},"reference":[{"key":"229_CR1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.books.9780890425596","volume-title":"Diagnostic and statistical manual of mental disorders (DSM-5)","author":"American Psychiatric Association","year":"2013","unstructured":"American Psychiatric Association. 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