The Role of Emotional Regulation in Bipolar Personality Disorder

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August 20, 2022 / By thadmin2

The Role of Emotional Regulation in Bipolar Disorder

 

What is Bipolar Disorder?

Bipolar Disorder, formerly known as manic depression, is a mental health condition wherein an individual displays extreme mood swings including emotional highs (mania or hypomania) and lows (depression) (“Bipolar Disorder – Symptoms and causes”, 2021).

The main features of Bipolar Disorder are the drastic fluctuations between manic and depressive moods. A core feature of depressive episodes is the loss of interest or pleasure in nearly all activities. Depressive episodes might also trigger feelings of anxiousness and affect our sleep (Kennedy, 2008).

Bipolar Disorder occurs equally in males and females (although depressive episodes are more common in women than men). It usually begins in adolescence and young adulthood, around the ages of 18 to 22 years (Hooley et al., 2017). According to the Singapore Mental Health Study done by the Institute of Mental Health in 2016, about 1.6% of the adult population, or 1 in every 63 people, has experienced Bipolar Disorder in their lifetime (Gan, 2020)

 

Types of Bipolar Disorder

Bipolar Disorder can be classified into 4 types: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and Bipolar Disorder not otherwise specified (Phillips & Kupfer, 2013). People with Bipolar I have had at least one manic episode whereas people with Bipolar II have had depressive and hypomanic episodes (Hilty et al., 2006). Bipolar II disorder is equally or somewhat more common than bipolar I disorder.

Bipolar I Disorder

  • Person has full-blown mania
  • Person experiences episodes of mania and periods of depression

Bipolar II Disorder

  • Person experiences period of hypomania, but the symptoms are below that of a full-blown mania
  • Person experiences periods of depressed mood that meet the criteria for depression

Cyclothymic Disorder

Refers to the repeated experience of hypomanic symptoms for at least 2 years. this is a less severe version of a full-blown Bipolar Disorder as it lacks the extreme 

Symptoms of cyclothymic disorder varies according to the respective phases:

  1. Hypomanic phase
    1. The person may become especially creative and productive because of increased physical and mental energy.
  2. Depressed phase
    1. The individual feels sad, and experiences a marked loss of interest or satisfaction in usual activities and hobbies.
    2. The person may exhibit low energy, feelings of inadequacy, social withdrawal, and a pessimistic, brooding attitude.

Bipolar Disorder Not Otherwise Specified (NOS)

A form of diagnosis for individuals who display some symptoms of Bipolar Disorder but does not necessarily meet all the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders. For instance, one may rapidly alternate between manic and depressive episodes, or have hypomanic episodes without depressive episodes.

In general, children and adolescents are most frequently diagnosed with NOS as they are least likely to have a past history of mood dysfunction.

 

Comparing bipolar and unipolar disorder

Bipolar Disorders differ from unipolar disorders by the presence of manic or hypomanic episodes, which are nearly always preceded or followed by periods of depression. 

A person experiencing a manic episode has a markedly elevated, euphoric, and expansive mood, often interrupted by occasional outbursts of intense irritability or even violence—especially when others refuse to go along with the person’s wishes and schemes.

 

Mania vs Hypomania – Similarities and Differences

Mania Hypomania
Duration At least one week At least 4 days, up to one week
Intensity Severe Mild to moderate
Functional Impairment Significant impairment in work and interpersonal relationships No impairment
Symptoms
  • Increased energy activity levels, and restlessness
  • Racing thoughts, distractibility, pressured speech, inflated sense of self-esteem (aka grandiosity)
  • Decreased need for sleep, sexual arousal or pleasure
  • Irritability
  • Aggression
  • Similar to that of mania but mild enough such that the person can resume daily functioning of activities
Need for hospitalisation Yes No

 

A manic episode occurs when one experiences behavioral changes that largely affect their functioning. These could include increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation (Dailey & Saadabadi, 2022).  Hypomania is a less severe form of mania, lasting for at least 4 days. Mania is typically diagnosed as part of bipolar I disorder, whereas hypomania is a part of bipolar II disorder. People with bipolar I disorder tend to have more depressive episodes, more mixed episodes (wherein depression is combined with mania), higher hospitalisation rates, and higher risk of suicide than those with bipolar II disorder.

 

Bipolar Disorder: Causal Factors (Butcher et al., 2017)

Biological Factors

  • Genetic Influence
    First-degree relatives of a person with Bipolar Disorder have a greater risk for unipolar major depression (although the reverse is not true). It is also studied that genes account for approximately 80-90% variance in the likelihood of a person developing bipolar I disorder.

 

  • Neurochemical Factors
    Studies support that during manic episodes, there is an increase in norepinephrine activity, which results in increased alertness, arousal and attention. Although there is less consistent evidence for lowered norepinephrine activity (lower levels of alertness, arousal, and attention) during depressive episodes. Serotonin, which helps in regulation of one’s moods, appear to be low in both depressive and manic phases.

Dopamine is another hormone involved in regulating one’s mood states. The evidence for the role of dopamine stems from research showing that elevated levels of dopamine in several regions of the brain may be related to manic symptoms of hyperactivity. High doses of drugs such as cocaine and amphetamines can produce dopamine, triggering manic-like behaviour. Conversely, drugs such as lithium reduce dopaminergic activity and are antimanic.

 

  • Abnormalities of Hormonal Regulatory System

Cortisol levels increase in bipolar depression but are usually not elevated during manic episodes.

  • Neurophysiological and Neuroanatomical Influences
    Blood flow to the left prefrontal cortex, which is an area that is responsible for executive functions such as establishing positive emotions, is reduced during depressive phases, whereas it is increased in certain other parts of the prefrontal cortex, responsible for formation of negative emotions, during mania. As such, there is a fluctuation in brain activity during mania and depressed versus normal moods. Studies find that there are deficits in the prefrontal cortex activity in Bipolar Disorder. These deficits are likely related to neuropsychological deficits that individuals with Bipolar Disorder experience, namely problem solving, planning, working memory, attention shifting and sustaining of attention on cognitive tasks. 

 

  • Sleep and Other Biological Rhythms
    During manic episodes, individuals with Bipolar Disorder tend to sleep very little. During depressive episodes, they tend toward hypersomnia. This suggests disturbances of seasonal biological rhythms. This disturbance seems to be true for bipolar individuals as they appear to be especially sensitive to, and easily disturbe by any changes in their daily cycles which require a resetting of their biological clocks.

 

Social/Environmental Factors

  • Low Social Support

Poor social support may increase the risk of relapse in Bipolar Disorder (Johnson et al., 2003).  Individuals with Bipolar Disorder tend to have more depressive recurrences after 1 year, independent of the effects of stressful life events.

 

Psychological Factors

  • Stressful life events

According to the diathesis-stress model stressful life events are responsible for the onset of bipolar episodes by activating the underlying vulnerability. The reason for that is the destabilising effects that such stressful events may have on critical biological rhythms.

  • Adulthood stressors

Friendship problems, problems with one’s partner, and financial hardship increase the likelihood of developing Bipolar Disorder and one’s chance of having relapse.

  • Personality traits and cognitive styles

These factors may interact with stressful life events in the likelihood of a relapse. Neuroticism is associated with symptoms of depression and mania, and also predicts increases in depressive symptoms in people with Bipolar Disorder. Personality variables associated with high levels of achievement striving and increased sensitivity to rewards in the environment are likely to result in manic symptoms. Individuals with a pessimistic attributional style who had also experienced negative life events are more likely to exhibit greater depressive symptoms.

Emotion Regulation for Bipolar Disorder

People with Bipolar Disorder have a greater tendency to employ maladaptive emotion regulation (ER) strategies such as rumination, self-blame, suppression and catastrophizing, thereby negatively affecting their mood (Dodd et al., 2019). The use of adaptive emotion regulation strategies, such as reappraisal, predicts less depression over time, suggesting that emotion regulation interventions developed to address emotionality in anxiety and depressive disorders could help reduce the significant burden of depression observed within BD (Johnson et al., 2016). It is also studied that distraction and mindfulness contributed to lower ruminative tendencies compared to problem-solving.

ER is defined as effortful and automatic attempts to downregulate, upregulate or sustain antecedent-based or response-focused emotions, both positive and negative.

 

ER strategies to regulate one’s emotions include (Siqueira Rotenberg et al., 2020):

  1. Cognitive Reappraisal
    1. Changing one’s (usually negative) way of thinking about something, leading to a change in response.
    2. Drawing on cognitive control and executive functioning to reframe one’s thoughts.
  2. Problem Solving
    1. Refers to how an individual interprets and evaluates a given situation in the most appropriate manner.
    2. Requires one to have the ability to perceive and adapt accordingly.
  3. Acceptance
    1. Acknowledging that difficulties exist and learning to accept the reality of circumstances.
  4. Cognitive Flexibility, Self-Awareness and Mindfulness
    1. Using context-appropriate strategies, being adaptable and resourceful to different strategies.
    2. Increasing awareness of personal strengths and understanding personal goals.
    3. Cultivating positive relationships, learning self-compassion, and relaxation techniques help one to cope with their emotions better.

 

It is important to note that the main purpose of  ER strategies is to prevent a relapse of bipolar episodes (Siqueira Rotenberg et al. , 2020).

 

Psychotherapy options for Bipolar Disorder

 

  • Cognitive Therapy

This mode of therapy Involves educating the individual about Bipolar Disorder, developing a comprehensive understanding of the individual’s fluctuating emotions and thoughts, and teaching them to effectively manage their mood and cognitions. All cognitive therapy manuals include the psychoeducation component pertaining to the aetiology (causes) of Bipolar Disorder, the (possible) need for medications, and early warning signs of symptoms. They also include identifying maladaptive, negative thoughts about the self, and teaching clients ways to overcome negative cognitions that may be present during depressive episodes, and target overly positive thoughts that may be present during manic episodes.

 

  • Family Focused Therapy (FFT)

FFT is a modification of the family-focused therapy originally developed for the treatment of schizophrenia (Goldstein & Miklowitz, 1995). It involves group psychoeducation for the immediate family members about the symptoms and causes of Bipolar Disorder, as well as the possible need for medical adherence. Families are taught to identify and respond to emergent symptoms earlier, and they will learn to adopt the best coping responses. Since it is widely researched that excessively negative family interactions can trigger relapse of Bipolar Disorder, families will also learn communication and problem-solving skills to reduce conflict and resolve family problems. It is important to note that variations of family therapy other than FFT do not seem to show changes in manic or depressive symptoms. The FFT differs from the other approaches in terms of its structured exercises that involve family communication, more education about Bipolar Disorder, and more specific strategies to respond to symptoms.

 

  • Interpersonal and Social Rhythm Therapy (IPSRT)

The IPSRT is a form of therapy designed to help individuals improve their moods by understanding and working in tandem with their biological rhythms. Clients will be taught techniques to enhance the regularity of daily routines and schedules. The interpersonal component of IPSRT also focuses on resolution of current interpersonal problems, such as unresolved grief, interpersonal disputes, role transitions, and interpersonal isolation. Using the IPSRT, clients can learn how to regulate their emotions with mood-changing activities, so as to increase mood stability and the awareness of highly emotional triggers. Acute IPSRT (i.e. weekly sessions over several months) was shown to result in significant improvements in symptoms compared to maintenance IPSRT (i.e. treatment on a monthly basis for two years).


Conclusion

 

Bipolar Disorder can be a great source of emotional and mental distress for individuals struggling with it as they are perpetually experiencing fluctuating moods between mania and depression. As such, it is crucial to identify the symptoms of Bipolar Disorder early, and seek help as soon as possible. For those whose loved ones are experiencing the symptoms of Bipolar Disorder, it is important to encourage them to seek treatment, and also be aware of emotional triggers that may cause them to fall into a relapse. It is crucial to embrace your loved ones and let them know you are there for them, and understanding of the struggles they are going through. Treatment options such as Cognitive Therapy and Family-Focused Therapy should be adopted, with the aim to minimise the symptoms of Bipolar Disorder as much as possible. 

 

At Thrive Psychology Clinic, we are committed to providing effective and efficient support for every child, adolescent and adult in their mental health. If you believe that your friends or loved ones around you may be struggling with behavioural/mental health issues, encourage them to seek professional help. Feel free to contact us via email: info@thrivepsychology.com.sg or call: 6962 9753 and we will be happy to assist you.

 

References

Bipolar Disorder – Symptoms and causes. Mayo Clinic. (2021). Retrieved 3 June 2022, from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955.

Butcher, J., Hooley, J., Mineka, S., & Nock, M. (2017). Abnormal Psychology, Global Edition (17th ed., pp. 270-282). Pearson Education Limited.

Dailey, M. W., & Saadabadi, A. (2022, May 2). Mania . National Library of Medicine. Retrieved May 27, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK493168/

Dodd, A., Lockwood, E., Mansell, W., & Palmier-Claus, J. (2019). EMOTION REGULATION STRATEGIES IN Bipolar Disorder: A systematic and Critical Review. Journal of Affective Disorders, 246, 262–284. https://doi.org/10.1016/j.jad.2018.12.026

Gan, E. (2020). ‘There’s a lot of suffering’: Bipolar disorder disrupts life but recovery is possible, says a survivor. today. Retrieved 3 June 2022, from https://www.todayonline.com/singapore/theres-lot-suffering-bipolar-disorder-disrupts-life-recovery-possible-says-survivor.

Goldstein, M. J., & Miklowitz, D. J. (1995). The effectiveness of psychoeducational family therapy in the treatment of schizophrenic disorders. Journal of Marital and Family Therapy, 21, 361-376.

Hilt, L. M., & Pollak, S. D. (2012, October). Getting out of rumination: Comparison of three brief interventions in a sample of Youth. Journal of abnormal child psychology. Retrieved May 21, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432145/

Hilty, D. M., Leamon, M. H., Lim, R. F., Kelly, R. H., & Hales, R. E. (2006, September). A review of bipolar disorder in adults. Psychiatry (Edgmont (Pa. : Township)). Retrieved May 27, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963467/ 

Johnson, L., Lundström, O., Åberg-Wistedt, A., & Mathé, A. (2003). Social support in bipolar disorder: its relevance to remission and relapse. Bipolar Disorders, 5(2), 129-137. https://doi.org/10.1034/j.1399-5618.2003.00021.x

Johnson, S., Tharp, J., Peckham, A., & McMaster, K. (2016). Emotion in Bipolar I Disorder: Implications for Functional and Symptom Outcomes. Journal Of Abnormal Psychology, 125(1), 40-52. https://doi.org/10.1037/abn0000116

Phillips, M., & Kupfer, D. (2013). Bipolar disorder diagnosis: challenges and future directions. The Lancet, 381(9878), 1663-1671. https://doi.org/10.1016/s0140-6736(13)60989-7

Siqueira Rotenberg, L., Cohab Khafif, T., Nascimento, C., & Lafer, B. (2020). Emotion Regulation and Bipolar Disorder: Strategies during the COVID‐19 Pandemic. Bipolar Disorders, 22(8), 879-882. https://doi.org/10.1111/bdi.13001