Journal of Affective Disorders Reports 2 (2020) 100031

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Journal of Affective Disorders Reports

journal homepage: www.elsevier.com/locate/jadr

Review Article

Understanding bipolar disorder within a biopsychosocial emotion

dysregulation framework
M.A. Koenders a,b,∗, A.L. Dodd c, A. Karl d, M.J. Green e,f, B.M. Elzinga b, K. Wright d
a
PsyQ Rotterdam, Outpatient treatment department of Bipolar Disorders, Rotterdam, Netherlands
b
Department of Clinical Psychology, Leiden University, Leiden, Netherlands
c
Department of Psychology, Faculty of Health & Life Sciences, Northumbria University, Newcastle –upon Tyne, United Kingdom
d
University of Exeter, Exeter, Devon, United Kingdom
e
School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
f
Neuroscience Research Australia, Sydney, NSW, Australia

a r t i c l e i n f o a b s t r a c t

Keywords: Bipolar disorder is characterized by extreme mood fluctuations and ongoing affective instability. Mechanisms in-
bipolar disorder volved in emotion regulation (ER) seem to be a contributing factor, however the nature and extent of these are not
mania clear yet. The aim of the current review is to contribute to a comprehensive model that covers the full scope of the
depression
emotion regulation processes in BD, in order to understand the psychological mechanisms that could contribute
emotion regulation
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 regu-
lation 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 strate-
gies 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.

1. Introduction The mechanisms involved in emotion regulation seem pertinent to

this endeavour. In the field of major depressive disorder (MDD) it has al-
Bipolar disorder (BD) is characterized by extreme fluctuations of ready been proposed that people who are prone to becoming depressed
mood, including depressed, hypomanic, manic and mixed mood states. do not necessarily experience more negative emotions, such as sadness,
The lifetime prevalence of BD is estimated around 1% for bipolar I but instead face challenges in regulating these emotions, resulting in
disorder (BDI) and between 1 and 2% for bipolar II disorder (BDII) longer periods of negative emotion that contribute to depressed mood
(Merikangas et al., 2011). One of the main goals in the treatment of (Joormann and Stanton, 2016). It is likely that there are comparable dif-
bipolar disorder is to stabilize mood and diminish these extreme fluctu- ficulties experienced by people with BD, with the important difference
ations. Despite evidence-based pharmacological and psychosocial inter- that periods of both extreme negative and extreme positive mood states
ventions, complete stability is only reached by a very small proportion may be prolonged with dysregulation.
of people who have BD, with over 90% of BD patients relapsing into new Currently, the idea that difficulty in regulating affective states rep-
mood episodes during their lifetime (Angst et al., 2003). Furthermore, resents an underlying mechanism of BD is captured in two distinct psy-
a substantial subgroup of people with BD report frequent switches be- chological models that are relatively well studied: The behavioural acti-
tween low and high mood states, outside of full episodes (Judd et al., vation system (BAS) dysregulation theory (e.g. Depue and Iacono, 1989;
2003, 2002). Given the co-occurrence of these different patterns of af- Urosevic et al., 2008) and the Integrative Cognitive Model (ICM)
fective instability within BD, a challenge for research is to characterise (Mansell et al., 2007). The BAS theory predominantly focuses on the
their distinctiveness, causation, inter-relatedness and implications. (hypo-) manic episodes in patients with BD. The theory states that indi-
viduals with BD are overly sensitive and reactive to goal- and reward-

∗
Corresponding author.
E-mail address: m.a.koenders@fsw.leidenuniv.nl (M.A. Koenders).

https://doi.org/10.1016/j.jadr.2020.100031
Received 20 October 2020; Received in revised form 30 October 2020; Accepted 7 November 2020
Available online 12 November 2020
2666-9153/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

relevant stimuli, which leads to excessive approach-related and reward between emotion regulation strategies according to the phase of emo-
motivation, which in turn precipitates manic symptoms. There is sub- tional processing in which they occur. The model starts with antecedent-
stantial evidence that, at least for a subgroup of bipolar patients, such focused strategies that occur before full activation of emotion-response
mechanisms play an important role in the development of manic symp- tendencies. Within this category, situation selection involves avoiding or
toms (Ironside et al., 2020). However, the development of recurrent approaching particular situations (e.g., things or people) to regulate
depressive episodes is less well explained by this theory, but could be emotion, and situation modification describes adapting the situation to
explained by dysregulation of the behavioural inhibition system (BIS), change its emotional effects. Selecting particular aspects of the situation
which could be seen as the opposite of the BAS. The BIS drives inhibitory to focus upon is referred to as attentional deployment, whilst ascribing a
and avoidance behaviours and is associated with depression, avoidance, particular meaning to these aspects to shape emotion response is termed
and heightened sensitivity to non-reward in the general population and cognitive change. Response-focused strategies, known as response modu-
populations with ‘bipolar characteristics’ (e.g. hypomanic personality, lation, represent attempts to change the course of the emotion response
depressive symptoms) (Carver and Johnson, 2009; Dempsey et al., 2017; tendency once it has begun. In the following sections these different
Jones and Day, 2008), but is less well studied in bipolar populations. emotion regulation stages will be discussed in the light of BD. Findings
The ICM (Mansell et al., 2007) states that the underlying mechanism are summarized in Table 1.
of both depressive and manic mood fluctuations could be explained by
the extreme negative and positive appraisals of internal affective fluctu- 2. Method
ations. For instance, patients can have extreme positive appraisals about
activated states (‘when I feel energetic I am the best version of myself’) Because we had to cover such a broad scope of the emotion regu-
or extreme negative appraisals (‘when I feel energetic I lose all control’). lation domain and its different stages we were not able to adopt a sys-
Consequently, behaviour is guided by the content of the appraisal. For tematic review method/PRISMA guidelines (Moher et al., 2009). How-
instance, engaging in stimulating activities to upregulate the energetic ever, we did perform a broad literature search using the followng search
state (ascent behaviour) runs the risk of developing a (hypo-) manic terms to identify relevant articles published until October 2019: bipo-
state. Alternatively, social withdrawal to downregulate this state (de- lar (disorder/depression), mania/manic/hypomania, manic depress∗ ,
scent behaviour) has the possible consequence of enhancing depressed hypomanic AND emotion regulation, emotion, emotion dysregulation,
mood. These different appraisal styles could also apply to negative af- emotional processing, emotion self-regulation, affective regulation, af-
fective states. fective dysregulation, OR dysfunctional beliefs, cognitive appraisal, re-
In summary, one model predominantly explains the onset of manic sponse styles, cognitive response, cognitive style, coping OR behavioural
episodes on a behavioural level and the other explains both mood states approach/inhibition/BIS/BAS, goal regulation, reward.
on a predominantly cognitive level, where interpretations of current The first search string (referring to bipolar) was limited to title and
states have direct bearing on subsequent regulatory strategies that can abstract. We used Web of Science and Pubmed. This led to 4159 pa-
be cognitive or behavioural. However, one of the most commonly used pers that were selected for further screening. Based on title 2365 were
emotion regulation models in the literature – the Process Model of Emo- excluded in the first screening round (for reasons such as not English, re-
tion Regulation proposed by James Gross (1998) – posits that attentional view papers, non-bipolar sample, case study etc.). The remaining 1394
processes are important to emotion regulation, alongside behavioural papers were excluded (1098) or subdivided into the categories ‘Cogni-
and cognitive processes. Hence, both the formerly discussed psycholog- tive Style and mood appraisal’ (57), ‘Structural/functional experimen-
ical models do not fully cover the complete emotion regulation process. tal’ (120), ‘emotion regulations problems (39) and ‘behavioural inhibi-
The aim of the current review is to contribute towards a more com- tion/approach and reward’ (80). These papers were used to inform the
prehensive model that covers the full scope of the emotion regulation review and also to identify additional relevant literature.
processes, in order to fully characterise the psychological mechanisms The second part of the current review on potential vulnerability fac-
that could contribute to the onset of both manic and depressive states. tors associated with emotion regulation processes in bipolar disorder
was mainly based on meta-analyses and reviews on these specifics do-
1.1. Aim of the paper mains.

In the first part of this review we summarise each stage of the process 3. Stages of the process model of emotion regulation in bipolar
model in relation to the extant literature on mood or emotion-linked re- disorder
sponses in BD. To do so, we draw upon empirical studies of biases in cog-
nition, behaviour and attention that have compared individuals with BD 3.1. Situation selection & modification
to those with other mental health conditions, or with no mental health
condition. This includes studies which have tested bipolar participants Situation selection, as well as the modification of situations, by defi-
in the euthymic phase, as well as during depression and (hypo)mania. nition involves behavioural choices on the part of the individual. These
For the sake of brevity, we do not draw upon literature about broader behaviours may reflect organised, goal-directed activity that brings one
cognitive functioning in individuals with BD (such as overall deficits in closer to sources of positive reinforcement which may be novel or in-
sustained attention, for example), unless this has been studied directly herently stimulating.
as part of the response to emotional stimuli or with respect to emotion According to the BAS theory, individuals with BD are overly sensi-
regulation. tive and reactive to goal- and reward-relevant stimuli, leading to ex-
In the latter part of the review we consider potential vulnerability cessive approach-related and reward motivation, and, in turn, manic
factors for the emotion regulation patterns described and briefly sum- symptoms. In theory, motivational systems such as the BAS are highly
marise the empirical literature on the relationship between emotion reg- likely to be involved in situation selection (approach versus avoid-
ulation difficulties and biological and genetic factors, personality style ance). Approach and avoidance behaviour can be thought of as oper-
and life events. Finally, we synthesise the material discussed with in- ating at several different levels. Considering first the higher level cog-
sights from clinical practice to suggest a tentative classification of emo- nitive task of goal-setting, several self-report studies have found people
tion regulation style in people with BD for future investigation. with BD to report stronger achievement and goal-attainment attitudes
(Fletcher et al., 2013a; Perich et al., 2014) and to endorse higher ambi-
1.2. Process model of emotion regulation
tions then unaffected controls (Johnson et al., 2012). Two further studies
(Carver et al., 2009; Tharp et al., 2016) have found that BD patients with
As an organising framework, we refer to the Process Model of emo-
more ambitious goals have a higher risk of developing manic episodes
tion regulation (Gross, 1998) (see Table 1). This model distinguishes
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

Table 1
Emotion regulation problems in BD according to different models.

Gross model BAS model of BD ICM model of BD Current review

Situation Avoiding or approaching Increased approaching Increased approach or • Increased approach-behaviour of goal- and
selection and particular situations, things of goal- and reward avoidant behaviour reward related situations, substance (ab-)
modification or people to regulate related situations use∗ ; increased interaction with novel
emotion and adapting the environments∗ ∗
situation to change its • Some evidence for increased inhibition and
emotional effects avoidance of reward related situations.∗ ∗
Attentional Selecting particular aspects Increased focus on Increased focus on internal • Overall no bias to both negative and
deployment of the situation to focus rewarding or goal changes positive stimuli in euthymia (only during
upon directed stimuli mood states)∗ .
• Some evidence for increased attention to
emotional stimuli. ∗
Cognitive Ascribing a particular Increased positive Increased extreme positive Cognitive traits
change meaning to the aspects of a appraisal of rewarding or negative appraisal of • No convincing evidence for overall
situation to shape emotion situations internal state increased dysfunctional attitudes. ∗ ∗
response • More extreme positive and negative
appraisals of internal feelings of activation. ∗ ∗
Cognitive strategies
• Less effective use of positive strategies
(reappraisal). ∗
• Less use of positive strategies, but may be a
function of depressive symptom level ∗
• Elevated use of negative cognitive strategies
(catastrophizing and self-blame), but may be
a function of depressive symptom level. ∗
Response The specific emotion that is Increased positive, Increased positive or • Some evidence for increased emotional
tendency felt and/or expressed, its energetic, active affect negative affect responses based on self-report∗
intensity and duration • No convincing evidence for increased
emotional reactivity and peripheral
psychophysiological responses∗
• Based on neuro-imaging studies abnormally
elevated activity in limbic structures in
response to emotional stimuli∗
Response Attempts to change the Upregulate positive Ascent or descent • Heightened negative∗ and positive ∗ ∗ .
modulation emotion response tendency mood by goal directed behaviours rumination
once it has begun behaviour • Increased dampening of positive and
negative affect∗
• Risk-taking and emotion-based impulsivity
(urgency) in response to positive affect∗
Note. ∗ From studies comparing individuals with Bipolar Disorder to unaffected control participants; ∗∗
From studies comparing individuals with Bipolar
Disorder to unaffected control participants, and to other patient group(s).

prospectively. Additionally, individuals with BD who score high on goal- theory). A small number of studies have examined avoidance tenden-
attainment were more likely to engage in stimulating and activating cies in people with BD. There is some indication of greater self-reported
behaviour that potentially induces a (hypo-) manic episode (Lee et al., behavioural inhibition in those with BD compared to HC’s and MDD pa-
2010), reported experiencing more BAS-relevant events such as goal- tients (Meyer et al., 2001; Weinstock et al., 2018; Yechiam et al., 2008).
striving, opportunity to obtain goals or rewards, overcoming challenges These studies examined self-reported passive avoidance of threat. In one
(Boland et al., 2016) and are more likely to engage in substance abuse further study the majority of participants with BD reported avoiding at
behaviour (Abbasi et al., 2016; Alloy et al., 2009). least one rewarding activity as a means of preventing mania, suggesting
Further, when individuals with BD made good progress towards a deliberate situation selection as a means of regulating affect (Edge et al.,
goal, they increased their effort towards this goal, whereas healthy 2013).
controls (HC’s) decreased effort in the same situation (Fulford et al., Besides selecting ‘actual or real situations or events’ one could also
2010). Conversely, when those with BD made lower than expected goal mentally go (back) to specific situations, which is known as ‘mental im-
progress, they decreased their effort towards that goal significantly less agery’ or ‘seeing with the mind’s eye’ (Kosslyn et al., 2001). Holmes and
than control participants did. Two other studies also indicate that in- colleague (Holmes et al., 2008) proposed that mental imagery might
dividuals with BD put more effort in more rewarding and challenging play a role as an amplifier of bipolar mood instability, and could specif-
tasks than do HC’s (Harmon-Jones et al., 2008; Hayden et al., 2008). ically explain both the increased rate of anxiety in BD patients and the
At a more basic level of behavioural organisation, locomotion is a occurrence of elevated mood. It seems that bipolar patients report more
core output of BAS (Grillner et al., 1997). Indeed, findings suggest that vivid imagery of future events and higher levels of intrusive imagery
both motor activity and the tendency to interact with novel objects is compared to patients with stable mood, and comparable to subjects with
elevated in BD during manic and euthymic states (Henry et al., 2008; depression and anxiety (Ivins et al., 2014) (Di Simplicio, Renner, Black-
Minassian et al., 2011; Perry et al., 2010). This is in keeping with a well et al., 2016; Holmes et al., 2011). Although this is a promising
number of studies demonstrating increased rates of both rapid-response theory, evidence is limited and it is unclear which causal relation the
and reward-delay impulsive behaviour (preference for a smaller imme- heightened imagery in BD has with mood: is it caused by depressed or
diate reward relative to a larger delayed reward) within manic episodes (hypo-) manic mood, or is it a trigger for mood disturbances?
(Swann, 2010), whilst self-report measures of impulsivity, but less so In conclusion, with respect to situation selection, there is evi-
behavioural indices, suggest this may remain elevated during euthymia dence that bipolar patients have an increased tendency to seek chal-
(Newman and Meyer, 2014). lenges/goals and novelty. Additionally they there is evidence for avoid-
The above described mechanisms especially account for potential ap- ance of threat, but it is unclear to what extent depressive mood con-
proach mechanisms but not avoidance mechanisms (as seen in the BIS tributes to this avoidance behaviour. Lastly, bipolar patients seem to
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

have more vivid images of past and future situations and events. Again requires other explanations to be ruled out (for a discussion of the
the role of mood is not fully clear in this increased imagery in BD. role of non-attentional processes in delayed stimulus disengagement see
Clarke et al., 2013).
4. Attentional bias Regardless, the relatively small amount of research conducted on
attentional bias suggests that compared to HC’s, individuals with BD
Attentional bias occurs when an individual preferentially attends show greater attention to threat stimuli, with attention towards general
to one class of stimuli in the environment relative to another. Hetero- emotional stimuli more consistently found in mania than in euthymia.
geneity between studies in methodology (e.g. emotional Stroop task, In bipolar depression, the pattern of attention may be characterised by
spatial cueing tasks using emotional words or faces and eye-tracking bias both toward and away from emotional stimuli, possibly as a func-
paradigms) and in the mood state of participants makes it difficult to tion of response latency and the type of emotion represented. Outside of
draw strong conclusions about the nature of attentional biases in BD. manic episodes there is reason to suspect that if there is attentional bias
Here we consider studies that attempted to measure bias in attention. towards positive or rewarding stimuli, this is most likely to be detected
Two studies report a bias towards threatening stimuli in BD par- in the early, automatic stages of processing. Further comparisons with
ticipants, regardless of whether currently euthymic or in an affective individuals with MDD are required to determine the extent to which
episode, relative to control participants (Garcia Blanco et al., 2014a; patterns of bias may be specific to BD.
Garcia Blanco, Salmeron, and Perea, 2015), whilst another reports
greater attentional interference in individuals with euthymic BD rel- 4.1. Cognitive change
ative to control participants when exposed to negative or affectively
neutral faces. However, in general, studies have tended not to report The ‘Cognitive change-domain’ is the most well studied domain of
biases towards positive or more general negative stimuli in euthymic Gross’ Process model in BD. Cognitive change (as an aspect of emotion
individuals using behavioural paradigms (Broch-Due et al., 2018; Gar- regulation) refers to modifying the meaning of situations or events. The
cia Blanco et al., 2015; Garcia Blanco, Salmeron, Perea et al., 2014b; meaning one ascribes to an experience in the first place will most likely
Peckham et al., 2016). Studying the event-related brain electrical activ- reflect enduring cognitive styles, beliefs and attitudes, and appraisals of
ity to reward stimuli in a gambling task allows more fine-grained inves- internal states. We will first describe these characteristics, before going
tigation of attentional biases during euthymia. In particular, one study into the strategies that may be mood dependant.
found increased early attentional network activation around 100 ms (as Several studies investigated whether bipolar patients displayed a
indicated by the N1 component) in euthymic individuals relative to a different cognitive profile (e.g. cognitive strategies that are specifi-
matched control group in response to gains and losses. This heightened cally used by BD patients) compared to HC’s and MDD patients. When
attention to reward stimuli indicates a reward-related bias at an early, taking current affective state into account, the majority of the stud-
automatic stage which interestingly predicted later aspects of reward ies found no differences in cognitive strategies between BD and HC’s
processing such as risk monitoring (Mason et al., 2016). (Fletcher et al., 2013b; Fuhr et al., 2014; Jabben et al., 2012; Jones et al.,
A number of studies report differences in patterns of attention to 2005; Lex et al., 2011, 2008; Mansell et al., 2011; Scott and Pope, 2003;
emotional stimuli in bipolar depression relative to mania and euthymia. Tzemou and Birchwood, 2007; Wright et al., 2005) or between those
The direction of these effects tends to vary across studies, with some re- with BD and MDD (Fletcher et al., 2013b; Fuhr et al., 2014; Jabben et al.,
porting a bias towards negative information relative to euthymia (Garcia 2012; Jones et al., 2005; Lex et al., 2011, 2008; Mansell et al., 2011;
Blanco et al., 2013) [emotional stroop task using words]; (Garcia Blanco Scott et al., 2003; Tzemou et al., 2007; Wright et al., 2005). Never-
et al., 2014b) [antisaccade task using faces]), away from negative in- theless, two studies report elevated levels of dysfunctional attitudes
formation (Jongen et al., 2007) [dot-probe task using words] or away in those with BD relative to HC’s (Fletcher et al., 2013b; Jones et al.,
from positive information (Garcia Blanco et al., 2014b) [eyetracking us- 2005), and a small number have reported greater endorsement of spe-
ing pictures] and Jabben et al. (2012) [dot probe task using words]. In cific types of cognitive style (goal attainment, need for approval in BD
addition, a further study making this comparison found reduced disen- relative to those with MDD (Batmaz et al., 2013; Fletcher et al., 2013b;
gagement from positive and anger stimuli in the bipolar depressed group Stange et al., 2015).
at short latencies (Leyman et al., 2009). This indicates that disruption It also appears that people with BD who do have extreme neg-
in the allocation of attention to emotional stimuli appears to be associ- ative attributions and attitudes are at greater risk of developing fu-
ated with bipolar depression. amongst those studies testing individuals ture depressed and (hypo-) manic episodes (Stange et al., 2015;
during mania relative to bipolar depression or euthymia, there is some Stange et al., 2013a) and have longer time until recovery of mood
evidence favouring an attentional bias toward positive material (Garcia- episodes (Stange et al., 2013b). In line with the ICM model, BD pa-
Blanco et al., 2013; Garcia Blanco et al., 2013; Garcia Blanco et al., tients seem to have more extreme positive self-relevant appraisals of the
2015). At the same time, several studies have found increased attention feelings of activation than HC’s and MDD patients (Jones et al., 2006;
to negative material and to threat amongst individuals experiencing ma- Mansell and Jones, 2006; Mansell et al., 2011; Tosun et al., 2015) even
nia (Garcia Blanco et al., 2013; Garcia Blanco et al., 2015; Lyon et al., after controlling for current mood. Kelly et al. (2011) showed that posi-
1999), although one small study found residual manic symptoms to be tive appraisal about activated states predicted BD (in a sample with BD,
associated with gazing away from negative material (Broch-Due et al., MDD and HC) only when in combination with high levels of negative
2018). appraisals of the same states. The authors suggested these contradicting
It is not straightforward to determine whether bias in allocation of appraisals might lead to conflicting attempts to up-regulate and down-
attention represents an emotion-regulation strategy or an automatic pro- regulate their mood states, leading to mood disturbances. Furthermore,
cess that feeds into an aberrant response tendency that requires effortful the number of future relapses appeared to be associated with beliefs
regulation. Indeed, it is possible that both early and late-stage attentional about lack of controllability of affective states, negative consequences
biases may be operating in people with BD. Measurement methods that and greater concern about mood swings (independent of current mood
allow exploration of effects at very short versus longer post-stimulus severity) (Lobban et al., 2013).
latencies can help to shed light on this issue. For example, the early- Besides these enduring cognitive strategies, there are also particu-
phase differences in brain activity reported by Mason et al. (2016) dur- lar meaning-altering strategies that are brought to bear in the moment.
ing outcome anticipation suggest that at least some bias in attention Below we will describe whether BD appears to be associated with par-
associated with BD may be automatic in nature. It is tempting to view ticular types of cognitive change strategies.
findings of bias effects at longer latencies in behavioural tasks as evi- Use of reappraisal has been associated with better mental health out-
dence of differences in strategic regulation of attention; however, this comes in the general population (Hu et al., 2014); hence, it has been
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

of particular interest to those understanding emotion regulation in BD. It has been hypothesized that heightened emotionality is an endur-
Using self-report measures of reappraisal, some studies have found in- ing characteristic of BD (Henry et al., 2008), meaning that people with
dividuals with BD to report reduced levels of reappraisal (Kanske et al., BD experience more intense negative and positive emotions (apart from
2015; Wolkenstein et al., 2014) whilst others have not (Green et al., their mood episodes) that fluctuate more frequently. One way to define
2011). Self-reported reappraisal deficits in individuals with BD were emotional responses is by ‘emotional reactivity’, which is defined by
found to disappear when negative mood was taken into account sta- the magnitude of change from an emotional baseline state in response
tistically (Johnson et al., 2016). Rather than measuring an enduring to emotion-eliciting stimuli (Gross, 1998). The evidence on emotional
tendency (i.e., trait-like) use of reappraisal, Gruber et al. (2012) exam- reactivity in BD is deeply divided. There are indications that people with
ined spontaneous reappraisal in people with euthymic BD whilst watch- BD show stronger self-reported emotional reactivity compared to HC’s
ing emotionally evocative film clips, in comparison to HC’s. The group (Aas et al., 2014, 2015; Aminoff et al., 2012; Henry et al., 2008), or
with BD reported engaging in a greater amount of reappraisal (trying specifically report more anger and frustration during euthymic states
harder) but felt that their emotion regulation attempts were less suc- (Dutra et al., 2014; Johnson and Carver, 2016), but again contradictory
cessful. A comparable study found similar rates of reappraisal in people findings have been reported (Edge et al., 2015).
with and without BD, and similar affective, facial and physiological re- Studies using frequent momentary assessments show that euthymic
activity (Gruber et al., 2014). Interestingly, differences in neural activa- BD patients report more overall negative affect (Gruber et al., 2013;
tion patterns have been observed in people with BD during reappraisal, Havermans et al., 2010) and more fluctuations in both negative and posi-
compared to those without (Kanske et al., 2015; Townsend et al., 2013). tive emotionality compared to HC’s (Knowles et al., 2007). However, the
These studies showed that BD patients, when actively trying to regulate majority of laboratory studies that measure self-reported negative emo-
emotions, have significantly decreased activation of frontal structures tional intensity after mood induction or emotional stimuli fail to find dif-
and decreased connectivity between the amygdala, and specific pre- ferences in reactivity in euthymic BD compared to HC’s (Aminoff et al.,
frontal regions involved in emotion regulation (also during euthymia). 2011; Edge et al., 2015; Gruber et al., 2014; Lemaire et al., 2015;
Thus, it may be that individuals with BD can engage in reappraisal to the M’Bailara et al., 2009; Mansell and Lam, 2006; Ruggero and John-
same extent as unaffected individuals, with similar emotional-expressive son, 2006; Wright et al., 2005) although some studies did find increased
consequences, but that there are some differences in the neural net- reactivity in BD patients (Gruber et al., 2011b; Pavlova et al., 2011). Re-
works that are recruited during this process, perhaps reflected in the sults are also conflicting with respect to positive stimuli, with some lab-
felt sense of effort. Alternatively, BD patients might overcompensate by oratory studies finding increased self-reported reactivity (Gruber et al.,
trying harder because brain circuitries can’t be recruited as effectively 2011a, 2009; Gruber et al., 2011b) whilst others do not (Farmer et al.,
(Toma et al., 2018). It is also possible that reappraisal is reduced in 2006; Gruber et al., 2014). There is some evidence that BD may be as-
more negative mood states, which has been reported in MDD patients sociated with increased self-reported positive responding to neutral and
(Joormann and Gotlib, 2010). negative stimuli in the form of film clips and pictures (Gruber et al.,
Other potentially helpful cognitive change strategies that have been 2011b; M’Bailara et al., 2009); but not consistently (Edge et al., 2015;
studied in BD include Putting into Perspective, Refocus on Planning, Pos- M’Bailara et al., 2012).
itive Refocusing and Acceptance. Studies comparing people with BD to Emotional reactivity has also been measured on a physiological
those without, and to other diagnostic groups, have tended not to find level in BD. For positive emotions, smaller decreases in respiratory
between-group differences on these subscales, with the exception of de- sinus arrhythmia and greater heart rate variability (both indices of
creased use of Putting into Perspective (Green et al., 2011; Rowland et al., parasympathetic activity and effective emotion regulation (Thayer and
2013; Wolkenstein et al., 2014), although not in Rowland et al. (2012). Lane, 2000)) in response to emotional film clips and personal mem-
Self-Blame and Catastrophising have been consistently found to be ories have been found in euthymic bipolar individuals compared to
elevated in people with BD relative to those without (Green et al., HC’s (Gruber et al., 2011b, 2014), although not in an earlier study
2011; Rowland et al., 2013, 2012; Wolkenstein et al., 2014); how- (Gruber et al., 2009). More indirect evidence for heightened reactiv-
ever, it does not seem to be the case that elevated scores are associ- ity was found in one study showing excessive startle reflexes in reaction
ated with BD in particular (Bayes et al., 2016; Rowland et al., 2013, to neutral stimuli (M’Bailara et al., 2009), although this may reflect the
2012; Wolkenstein et al., 2014). There does not seem to be a consistent way in which neutral stimuli are affectively evaluated rather than reac-
finding that Other Blame is elevated in those with BD relative to those tivity per se.
without (Bayes et al., 2016; Green et al., 2011; Rowland et al., 2013; Arguably, some evidence for differences has been found at a neuro-
Wolkenstein et al., 2014). logical level. Neuroimaging research shows abnormally elevated activity
In summary, there are some indications that BD patients use more in limbic structures (amygdala, hippocampus and insular cortex) in re-
dysfunctional strategies in the domains of approval, self-control and sponse to emotional stimuli (Morris et al., 2012; Perry et al., 2019). In
goal-attainment and that especially extreme positive and negative ap- summary, individuals with BD report experiencing elevated emotional
praisal of positive and negative affect is characteristic of BD patients. responses during daily life, which might be illustrated by abnormal neu-
However, it is difficult to separate this from mood dependant effects. rological emotional responses in BD patients, which are also subjectively
Examination of cognitive change processes in real time experimental experienced as such.
(for examples see Seeley et al., 2015) settings might allow researchers
to parse out these effects. At present though there does not seem 4.3. Response modulation
to be evidence for a particular profile of cognitive change strategies
that sets those with BD apart from those with other mental health Response modulation represent attempts to change the course of the
conditions. emotion response tendency once it has begun. In line with the ICM, ap-
praisals of internal states are related to BD, risk of developing BD, and
both clinical and subclinical symptoms of (hypo)mania and depression
4.2. Emotion response tendencies (Kelly et al., 2017). Further, Dodd et al. (2019) systematic review found
that, while there was some evidence for associations between specific
In this section we will summarize the neurocognitive and psycho- facets of cognitive change and outcomes in BD (e.g., reappraisal), the
logical evidence for emotion response tendencies in BD. This stage bulk of the evidence was for specific response modulation strategies for
represents the ‘output’ of the emotion regulation process: the spe- upregulating and downregulating both positive and negative affect. Pri-
cific emotion that is felt and/or expressed, including its intensity and marily, these were rumination (on both negative and positive affect),
duration. risk-taking and impulsive responding to positive affect, and dampening
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

positive affect. Similar findings for relationships between these strate- Findings from neuroimaging studies show structural brain differ-
gies and mania risk in non-clinical populations have been reviewed else- ences between BD patients and HC’s in brain regions relevant to emotion
where (McGrogan et al., 2019). regulation. A recent meta-analyses (Lu et al., 2019) shows that BD is as-
Published research has continued to support the findings of sociated with significantly decreased volume of brain areas (e.g., PFC
Dodd et al. (2019) review, in showing that self-reported negative ru- including the left DMPFC, left VLPFC, and right precentral) which are
mination is heightened in BD compared to non-clinical controls (e.g. strongly implicated in emotion regulation processes. In earlier sections
Oh et al., 2019), and there are similarities between BD and MDD in of this paper we reviewed evidence showing that decreased activation
tendencies to engage in negative rumination (Forgeard et al., 2018; of frontal regions during specific emotion regulation processes in BD
Weinstock et al., 2018). Whereas positive rumination (ruminating on patients have been observed, together with decreased connectivity be-
positive affect) may set BD apart from MDD as well as non-clinical tween the amygdala and frontal regions involved in downregulation of
groups (Hanssen et al., 2018; Weinstock et al., 2018). However, more re- emotions (Kanske et al., 2015; Townsend et al., 2013)
cently, and in contrast to much of the literature, brooding (a putatively One amongst many potential neurobiological factors contributing
maladaptive form of ruminating on negative affect) (Treynor et al., to aberrant emotion regulation in BD is HPA-axis dysfunction, which
2003) was unrelated to depressive symptoms in a recent study by has been explored in a number of studies, as described in the meta-
Peckham et al. (2019). analyses by Murri et al. (2016). According to this meta-analyses (in-
While positive rumination is a response modulation strategy de- cluding studies using a variety of approaches to test HPA-axis activity
signed to enhance or maintain positive affect (if that is the desired such as basal cortisol levels, diurnal profile, ACTH test, CRH stimulation
internal state; Mansell et al., 2007), dampening positive affect is also test or combined dexamethasone/CRH test (DEX/CRH)). HPA-axis hy-
theoretically and empirically linked to BD. With past experience of peractivity seems to be more prominent amongst patients in the manic
problematic high mood states, we would expect people with BD to phase, but is also present in the euthymic phase. Genes that are related
try to downregulate positive affect when this is appraised as an un- to HPA-axis activity do not seem to be specific risk factors for BD. How-
desirable state. The literature largely supports this, with more damp- ever, specific polymorphisms of HPA-related genes have been associated
ening in BD compared to controls, and dampening being linked to de- with clinical features of BD, indicating that genetic variations seem to
pressive symptoms (Dodd et al., 2019). Further work has largely sup- contribute to specific clinical representations of BD. The association be-
ported this (Weinstock et al., 2018), although interestingly a recent tween emotion regulation and HPA-axis functioning has not yet been
study (Hanssen et al., 2018) reported that those with MDD were more thoroughly studied. However, some studies have shown that positive
likely to dampen positive affect, whereas people with BD-II were more emotion regulation strategies like problem solving are associated with
likely to dampen compared to those with BD-I. This seems counterintu- long term lower cortisol levels (Hoyt et al., 2014; O’Donnell et al., 2008)
itive given it is those with BD-I who have experienced the most function- and with increased momentary cortisol responses (Denson et al., 2014;
ally disruptive high mood states. However, the dampening of positive af- Gilbert et al., 2017; Lam et al., 2009). Whether dysfunctions of HPA-axis
fect in BD II could also have a protective effect against developing more activity in BD are related to emotion regulation problems thus remains
severe manic episodes. This is in line with a previous study, indicating unclear. One of that factors that may affect both HPA-axis functioning
that some level of positive rumination is protective against depression, and emotion regulation is childhood or later life trauma, as discussed in
but at increasing levels it could put someone at risk of developing a the next section.
severely elevated state (Kraiss et al., 2019). In terms of genetic predisposition for emotion dysregulation, a re-
However, the literature does not suggest that people with BD are view by Van Rheenen and Rossell (2013) describes the role of common
unable to engage in putatively adaptive emotion regulation strategies. variation in the Catechol-O-Methyltransferase (COMT) and Tryptophan
A recent experience sampling study (Leung et al., 2019) reported that Hydroxylase 2 (TPH2) genes in contributing to abnormal prefrontal neu-
positive affect predicted subsequent adaptive coping (problem-solving rocognitive functioning, which in turn might lead to less control over
and distraction) and no differences were found between euthymic BD the regulation of emotions in BD patients. This thesis was also put for-
patients and HC’s in the use of distraction and in neural-activation of ward in an earlier review by Green, Cahill and Malhi (2007) with re-
involved brain regions (Kanske et al., 2015). spect to the role of neurocognitive and associated disturbances in brain
In summary, people with BD appear broadly similar to those with function in BD that might conceivably contribute to emotion regula-
MDD in the use of rumination and dampening, but show greater lev- tion difficulties. In line with these ideas, a recent systematic review by
els of positive rumination. The available evidence suggests that people Miskowiak et al. (2019) shows that affective cognitive functioning is
with BD do not show a deficit in their ability to engage in adaptive emo- impaired in BD, at least with respect to emotional facial recognition, at-
tion regulation strategies. Furthermore, within BD, research focused on tentional interference by emotional stimuli, and reward processing. In
‘response styles’ has overwhelmingly reported that poorer outcomes are summary, evidence points towards the existence of biological abnormal-
linked to tendencies to engage in risky and impulsive behaviours, damp- ities commonly reported in BD patients, which make them vulnerable to
ening as a response to positive or negative affect and in ruminative re- emotion regulation disturbances. However, because of the complexity of
sponses. It seems that people with BD may have tendencies to engage these individual systems, let alone in interaction with one another, no
in a range of response-modulation strategies designed to approach or causal links have been convincingly identified yet.
avoid that specific emotional experience, depending on their current
context. 5.2. Early life experiences

A number of studies have demonstrated an association between

5. Potential vulnerability factors associated with emotion trauma exposure in childhood and alterations in the different phases of
regulation processes in bipolar disorder emotion regulation. This includes emotion-modulated attentional biases
and disturbances in reward processing (Jaffee, 2017; Pechtel and Pizza-
5.1. Neurobiological factors galli, 2011). Rates of childhood abuse are elevated amongst those with
BD relative to the general population (Etain et al., 2010; Watson et al.,
There is a wealth of literature on biological vulnerabilities in BD, and 2014), similar to patients with MDD. It follows that at least some pat-
it is beyond the scope of this paper to provide an exhaustive overview terns of emotion regulation observed amongst people with BD may not
of the findings. Therefore we will only briefly summarize some impor- be specific to BD, but may reflect the impact of early life trauma. Fur-
tant biological findings from neuroimaging, stress biology, and genetic thermore, we would expect to see heterogeneity in emotion regulation
studies. patterns across the population of people with BD, partly as a conse-
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

quence of variation in early life experiences. Indeed, amongst people finding is that BD patients demonstrate higher neuroticism compared
with BD, experience of childhood trauma has been found to be asso- with HC’s (Bagby et al., 1997; Barnett et al., 2011; Bauer et al., 2016).
ciated with worse long term outcomes including earlier age of onset, However, neuroticism seem to reflect a predisposition to psychopathol-
greater number of bipolar episodes, increased risk of suicide and in- ogy in general and not bipolar specifically. Additionally, research re-
creased substance use difficulties (Etain et al., 2013). Several studies sults on extraversion are divided, reporting both higher and lower ex-
indicate that childhood trauma in BD (specifically emotional abuse) traversion scores in BD patients (Barnett et al., 2011; Jylha et al.,
seems to be related to later affective lability and more dysfunctional 2010). Also other big five personality traits like openness (Bagby et al.,
emotion regulation strategies in BD (Aas et al., 2014; Etain et al., 2008; 1997; Tackett et al., 2008) and low agreeableness (Murray et al., 2007;
Marwaha et al., 2016). Given the strong heritability of BD, the apparent Quilty et al., 2009) are associated with BD. However, a consistent BD
relation between early life trauma and BD may however be contami- profile cannot be identified based on these studies.
nated by genetic factors, affecting both parental abusive or neglectful The divergent results might indicate specific subtypes amongst those
behaviour in parents of BD patients and symptoms of bipolar disorder with BD; for instance, there may be some with a more depressive-prone
in (parents and) the offspring. or a more manic-prone disease course. Along these lines, it seems that
In addition to experiences of trauma, other chronic stressors in child- in BD higher neuroticism scores are especially associated with more
hood, for example stressors associated with family poverty, has been depressive symptomatology (Lozano and Johnson, 2001; Quilty et al.,
found to be associated with difficulties in self-regulation and adaptive 2009) and other traits such as high conscientiousness (particularly the
coping (Evans and Fuller-Rowell, 2013), and alterations in brain areas achievement striving facet), extraversion and low agreeableness predict
associated with emotion regulation (Kim et al., 2013). Young people increases in manic symptoms across time (Barnett et al., 2011; Kim et al.,
with a family history of BD have been found to experience higher levels 2012; Lozano et al., 2001; Quilty et al., 2009). However, these associa-
of chronic stress than individuals without a family history (Ostiguy et al., tions might be spurious, since they seem to be strongly related to base-
2009). Thus, individuals with BD may be vulnerable to particular emo- line symptoms and may reflect individuals with BD incorporating the
tion regulation issues as a consequence of elevated levels of chronic experience with their past illness course into their self‐reported person-
stress in childhood (including as a result of parental mental health dif- ality (Parker et al., 2004; Sparding et al., 2017).
ficulties and their impact on parenting behaviours, e.g. Clement et al., When studies look beyond the Big Five personality traits, it
2016). seems that bipolar patients report more personality features related
Both childhood trauma and chronic stress have been associated with to emotional instability, hostility, novelty seeking. A meta-analyses by
dysregulations of the HPA axis (Nemeroff, 2016) a process described as Zaninotto and colleagues shows that BD patients report higher scores on
allostatic load (Heim and Nemeroff, 2001, 2002): that is, a cumulative novelty seeking, self-transecendence and lower on harm avoidance com-
adverse effect on the body when an individual is exposed to repeated pared to healthy controls and MDD patients, although the exact effects
stressors and/or inadequate responses of physiological systems that are of (subclinical) mood symptoms are not clear. Levels of anxiety are also
involved in the adaptation to environmental challenges (Danese and elevated in BD, even in euthymia, and both compared to HC’s and MDD
McEwen, 2012; McEwen, 1998). Dysregulation of the stress axis also (Bagby et al., 1997; Loftus et al., 2008; Savitz et al., 2008; Young et al.,
has detrimental effects on function and structural integrity of brain 1995).
circuitries involved in emotional perception, memory and regulation A study by Qiu et al. (2017) offers a possible explanation for the
(Arnsten, 2009, 2015; McEwen and Gianaros, 2011; McEwen and Morri- somewhat contradictory findings in personality profiles. With cluster
son, 2013; Roozendaal et al., 2009), thus explaining the above-reported analyses based on different personality questionnaires they identified
abnormal cortisol and heart rate responses in BD to a psychosocial stres- three ‘subtypes’ of bipolar patients: the ‘anxious/depressed’ type charac-
sor (Wieck et al., 2013). Kapczinski et al. (2008) proposed a model in terized by an anxious/inhibited and dysthymic temperament; the ‘rela-
which the interplay between early life stress and the repeated episodes tively stable’ type characterised by low anxiety, and intermediate levels
of mood swings after BD onset, and potentially maladaptive symptom of persistence/drive, humour and impulsivity (associated with higher
management/emotion regulation approaches, lead to a perpetuating al- overall functioning, lower rates of rapid cycling and a more stable
lostatic load process. course); and a ‘manic type’, which is high on anxiety, but also on inse-
Future investigation of emotion regulation patterns that may be spe- curity, persistence/drive, spirituality, expressiveness and humour. The
cific to BD should consider the potential influence of early life trauma existence of possible different ‘subtypes’ of BD patients might account
and stress. Research should consider that this influence may be additive, for the contradicting findings we have found throughout this review.
but equally may be interactive, whereby experience of childhood trauma
in combination with a pre-disposition to BD shapes emotion regulation 6. Discussion
in particular ways. In later sections of this manuscript we propose that
the experience of childhood trauma in combination with BD vulnera- In this narrative review of emotion regulation in BD we have used
bility could either predispose for over-regulation of emotions (damp- Gross’ Process Model of emotion regulation as a framework within
ening) or upregulation of specifically positive emotions and/or manic which to consider studies of momentary emergence and regulation of
states. emotion in BD, guided by two contemporary theories of BD (BAS dysreg-
ulation model and the ICS). From the evidence reviewed it appears that
5.3. Personality style people with BD differ from unaffected participants in some aspects of
emotion regulation, but show substantial overlap with emotion regula-
There is increasing interest in identifying a personality profile of BD tion tendencies in MDD. Tendencies that may distinguish people with BD
that might (partly) explain the vulnerability to ongoing affective dysreg- from other groups include greater approach to challenge and novelty,
ulation. In the general population neuroticism has been linked to nega- and greater levels of positive rumination. Patterns observed in those
tive affect and increased reactivity to negative events, and both extraver- with BD appear inconsistent across studies. For example, there is evi-
sion and agreeableness are associated with positive affect, less mood dence of increase in both approach and avoidant behaviour, attentional
variability and reduced reactivity to negative stimuli (e.g. Bolger and biases towards and away from both positive and negative stimuli, and
Schilling, 1991; Gomez et al., 2000). We are not aware of BD-specific lit- a combination of positive and negative cognitive appraisal strategies. It
erature on specific personality traits and their link with emotion regula- may be important to recognise mood states as a potentially contribut-
tion in BD. Most literature focuses on distinguishing personality features ing to these inconsistent findings. Still, there seems to be evidence for a
of BD patients, HC’s and other clinical groups. When personality traits profile that is characterized by the tendency to upregulate positive af-
of BD patients are compared to healthy populations the most consistent fect, as well as a profile that tends to over-use downregulation strategies
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

Fig. 1. Emotion regulation processes in bipolar disorder for the ’avoidant’ and ’approach’ profiles.

for both positive and negative affect. This kind of heterogeneity is also acteristics of persistence, drive and expressiveness; and a stable subtype
seen when patterns of symptom course are investigated in BD. Based with more moderate traits.
on longitudinal studies, three rather clear subgroups have been identi- We thus propose that two distinct emotion regulation profiles could
fied: 1) a predominantly depressed group; 2) a cycling or episodic group apply to BD. In Fig. 1. we illustrate these profiles in detail, combin-
with alternating manic and depressed episodes; 3) a minimally impaired ing both the ICM and BAS hypotheses and the evidence in the cur-
or stable group (Kalbag et al., 1999; Koenders et al., 2015; Post et al., rent review. The first could be seen as predominantly “approach” orien-
2003; Solomon et al., 2009; Uher et al., 2013). One would expect that tated, and would be expected to be associated with positive appraisals
patients with a different longitudinal course have a different profile on about the (hypo-) manic features of BD. Within this profile, the indi-
other characteristics as well. Indeed, Qiu et al. (2017) found personality vidual would appear more reward sensitive, goal directed, and likely
profiles that overlap with groups of patients characterised by differences to seek novelty. They are likely to use stimulating or risk-taking be-
in course of illness: that is, an anxious/depressed subtype characterized haviours to elevate positive mood and escape negative mood; this pro-
by an anxious and inhibited temperament; a manic subtype with char- file would be expected to promote hypo (-manic) phases, as well as con-
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

Fig. 2. Descriptions of two clinical cases based on emotion regulation profile.

tribute to lows due to exhaustion, or extreme negative appraisal and in others to more risk-taking and externalizing behaviour (Jaffee, 2017).
self-blame in the absence of highly energetic states or rewarding situa- While these speculations are consistent with the different personality
tions. In contrast, those showing an “avoidance” profile are more likely profiles reported by Qiu et al. (2017), it is also possible that the ex-
to appraise any mood fluctuations negatively and engage in avoidant perience with BD itself might shape emotion regulation strategies. For
behaviour in order to prevent intense affective fluctuations; all emo- instance, very negative experiences with (the consequences of) manic
tional reactions are (extremely) negatively appraised and responded to episodes might lead to a more cautious approach to stimulating ac-
with rumination or dampening. Those with this more withdrawn and tivities or feelings, while a more positive experience with the manic
emotionally suppressed profile would be likely to experience a more elements of the disorder might lead to a profile in which the ‘manic
depressed mood course. These different profiles might be related to feelings’ are actively approached. This is reflected in the ICM whereby
early life experience, neurobiological vulnerabilities and the person- Mansell et al. (2007) propose that the individual’s affect regulation be-
ality of the patient. For instance, it is known that childhood trauma haviours have consequences that serve to strengthen the beliefs that led
could lead in some to harm-avoidance and internalizing behaviour but to these behaviours in the first place. To our knowledge this particular
M.A. Koenders, A.L. Dodd, A. Karl et al. Journal of Affective Disorders Reports 2 (2020) 100031

bidirectional relationship proposed in the ICM has not yet been tested comparing individuals across each phase of BD to HC’s and individuals
directly, nor has the possibility of a psychological staging process across with other mental health conditions in order to confirm the existence
the course of BD, whereby life experiences result in changes in emotion of these profiles. The current state of evidence on the role of emotion
regulation style over time which is in line also with the allostatic load dysregulation is currently too fragile to draw any firm conclusion on a
model of BD (Kapczinski et al., 2008). To allow for the possibility that specific BD profile. Especially the predominant use of self-report mea-
different emotion regulation styles could occur in the same individual sures in most studies and the difficulty to control for the effects of mood
over time, we refer to these as “profiles” rather than fixed personality state on such measures is a major concern. Further, since studies com-
types. paring those with BD to those with other diagnoses are relatively rare,
The current distinction we make between potentially different emo- we cannot conclude that the profiles observed are bipolar-specific rather
tion regulation profiles clearly requires more empirical investigation, than common to other groups who experience a mental health condi-
and we do not expect it captures the regulatory styles of all people tion. Our contention however is that they need not be disorder-specific:
with BD. Studies testing the validity of this model should go beyond emotion regulation profile arises as a consequence of the interaction of
self-report measures and should contain real-life assessment of emotion disorder-specific factors with individual differences.
regulation strategies, for instance in experimental settings (combining
self-report with physiological or (f)MRI data) and experienced sampling 7. Conclusion
methods to test ecological validity and interpersonal processes. These
mechanisms should also be tested across different phases and mood The current review considered evidence for aberrant emotion reg-
states of the disease. For more detailed suggestions on how emotion ulation strategies in BD, concluding that evidence for a single charac-
regulation research should be designed to be more ecologically valid teristic pattern of emotion regulation in BD is not evident, but that a
we refer to Aldao et al. (2013). small number of specific emotion regulation strategies are consistently
If meaningful subgroups, such as the currently proposed, can be iden- implicated in BD. Our review highlights that the field is hampered by ab-
tified, this could also guide psychological interventions. Currently, most sence of systematic comparisons between BD cases and other psychiatric
empirical studies in BD have tested aspects of the ‘approach profile’, of- comparison groups, as well as a lack of longitudinal research designs
ten linked to BAS dysregulation theory. Although not thoroughly inves- in well-powered cohorts. Nevertheless, the evidence to date supports a
tigated in BD, the ‘avoidant profile’ has important overlap with emotion model of emotion dysregulation in BD that builds on existing theories
regulation dysfunctions that are identified in MDD (Visted et al., 2018) (BAS and ICM); we articulate the potential for two distinct profiles of
and in BD this profile would also be associated with a more depressive emotion regulation styles in BD in an attempt to propose a more com-
prone course. As anxiety disorders are highly prevalent in BD patients prehensive psychological model that incorporates all stages of the emo-
(Merikangas et al., 2007), one would also expect that this specific co- tion regulation processes. We have also considered the role of childhood
morbidity is especially seen in patients with the avoidant profile. trauma, personality and neurobiological vulnerabilities in contributing
to these processes. Although evidence is still limited, this model could
6.1. Clinical implications have clinical relevance and help to identify problematic emotion regu-
lation patterns in BD patients that suffer from ongoing mood symptoms
In our experience, patients with BD who attend psychological ther- despite treatment according to clinical guidelines.
apy (in addition to pharmacotherapy and other guideline treatment ap-
proaches) are often seeking support with mood and emotion regulation.
Declaration of Competing Interest
Our review would suggest that therapists and patients should not select
emotion regulation targets and techniques based merely on diagnosis. It
All authors declare no conflict of interest.
is likely more informative and effective to consider what particular emo-
tion regulation difficulties the individual is experiencing. Our tentative
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