Abstract
• On all levels of the emotion regulation model there are seemingly contradictory findings in BD, with evidence for a profile that is characterized by the tendency to upregulate positive affect, as well as a profile that tends to over-use downregulation strategies for both positive and negative affect. • These profiles could be characterized by different emotion regulation mechanisms, personality profiles and biological and psychological vulnerability factors. • Based on these findings we tentatively identify two emotion regulation profiles in BD (reflecting ‘approach’ and ‘avoidant’ behaviours respectively). Bipolar disorder is characterized by extreme mood fluctuations and ongoing affective instability. Mechanisms involved in emotion regulation (ER) seem to be a contributing factor, however the nature and extent of these are not clear yet. The aim of the current review is to contribute to a comprehensive model that covers the full scope of the emotion regulation processes in BD, in order to understand the psychological mechanisms that could contribute to the onset of both manic and depressive states. To this end we review each stage (attentional, behavioural and cognitive processes) of the Process Model of Emotion Regulation in relation to the extant literature on mood or emotion-linked responses in BD. Additionally, potential vulnerability factors (e.g. biological, genetic, personality) for dysfunctional emotion regulation patterns are described. We conclude that on all levels of the emotion regulation model there are seemingly contradictory findings in BD, with evidence for a profile that is characterized by the tendency to upregulate positive affect, as well as a profile that tends to over-use downregulation strategies for both positive and negative affect. These profiles could be characterized by different emotion regulation mechanisms, personality profiles and biological and psychological vulnerability factors. Based on these findings we tentatively identify two emotion regulation profiles in BD (reflecting ‘approach’ and ‘avoidant’ behaviours respectively) and discuss clinical implications and different treatment approaches. To illustrate the latter, we present two clinical cases of both ER profiles and their different treatment approaches.
Highlights
Bipolar disorder (BD) is characterized by extreme fluctuations of mood, including depressed, hypomanic, manic and mixed mood states
In earlier sections of this paper we reviewed evidence showing that decreased activation of frontal regions during specific emotion regulation processes in BD patients have been observed, together with decreased connectivity between the amygdala and frontal regions involved in downregulation of emotions (Kanske et al, 2015; Townsend et al, 2013)
The current review considered evidence for aberrant emotion regulation strategies in BD, concluding that evidence for a single characteristic pattern of emotion regulation in BD is not evident, but that a small number of specific emotion regulation strategies are consistently implicated in BD
Summary
Bipolar disorder (BD) is characterized by extreme fluctuations of mood, including depressed, hypomanic, manic and mixed mood states. The lifetime prevalence of BD is estimated around 1% for bipolar I disorder (BDI) and between 1 and 2% for bipolar II disorder (BDII) (Merikangas et al, 2011). One of the main goals in the treatment of bipolar disorder is to stabilize mood and diminish these extreme fluctuations. Despite evidence-based pharmacological and psychosocial interventions, complete stability is only reached by a very small proportion of people who have BD, with over 90% of BD patients relapsing into new mood episodes during their lifetime (Angst et al, 2003). A substantial subgroup of people with BD report frequent switches between low and high mood states, outside of full episodes (Judd et al, 2003, 2002). Given the co-occurrence of these different patterns of affective instability within BD, a challenge for research is to characterise their distinctiveness, causation, inter-relatedness and implications
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