Background Bipolar disorder (BD) presents with complex clinical features. While factor models have elucidated dimensional psychopathology in BD, they have overlooked the interplay between premorbid psychosocial deficits, long-term outcomes, and transdiagnostic genetic influences. Identifying these underlying dimensions is crucial for personalised interventions.

Aims This observational study aimed to identify a comprehensive dimensional model of BD psychopathology integrating premorbid psychosocial deficits and poorer outcomes (reduced inter-episode remission, chronicity), to investigate their association with the genetic burden of BD and related transdiagnostic disorders, schizophrenia (SCZ), major depression (MDD), attention-deficit and hyperactivity disorder (ADHD), and anxiety (ANX). We hypothesised, psychosocial deficits correlate with worse BD outcomes.

Method We employed Inverse Probability Weighting (IPW) on a sample of 4992 participants to minimise bias. Exploratory Factor Analysis (EFA) of 77 OPCRIT items identified four symptom dimensions. Confirmatory Factor Analysis (CFA) validated a 20-item, four-factor model. Polygenic Risk Scores (PRSs) for five psychiatric disorders were calculated, and Structural Equation Modelling (SEM) was used to analyse genetic contributions to these dimensions.

Results The CFA demonstrated a good fit for the four-factor model, comprising ‘mania,’ ‘psychosis,’ ‘depression,’ and a novel ‘psychosocial functioning’ dimension. SEM revealed distinct genetic liabilities: BD PRS primarily predicted ‘mania,’ SCZ PRS ‘psychosis,’ and MDD PRS ‘depression.’ Notably, the ‘psychosocial functioning’ dimension, characterised by premorbid psychosocial deficits and poorer outcomes, showed positive associations with ADHD and anxiety PRSs, and an inverse correlation with BD PRS.

Conclusions This study provides a novel dimensional model of BD that integrates premorbid psychosocial factors and outcomes, revealing a link between genetic burden of ADHD and anxiety with a ’psychosocial functioning’ dimension associated with poorer BD outcomes. This suggests a biological basis for the complex interplay between factors, highlighting the potential for early identification and targeted interventions for individuals at higher risk for a more challenging illness trajectory.

Key terms: bipolar disorder, ADHD, anxiety, psychosocial, dimensions, polygenic risk scores

The authors declare funding from the Stanley Center for Psychiatric Research at the Broad Institute for the genotyping of the control samples. Authors AM and NB were supported by the UCLH NIHR BRC. Author TV is supported in part by the National Institutes of Health (NIH) Graduate Partnership Program (GPP). These are non-profit/governmental institutions that support research in this area. The authors declare that this funding did not influence the design, conduct, or reporting of this research.

This study was partially funded by the Stanley Center for Psychiatric Research at the Broad Institute for the genotyping of the control samples. Authors AM and NB were funded by the UCLH NIHR BRC. Author TV is funded in part by the National Institutes of Health (NIH) Graduate Partnership Program (GPP).

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Ethics committee of NHS Metropolitan Multi-centre Research(MREC/03/11/090) gave ethical approval for this work

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