Emotion regulation in the ups and downs of bipolar disorder

Author: Dr Alyson Dodd

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Psychologists spend an awful lot of time theorising and researching emotion regulation – why we do it, how we do it, what’s effective and what’s not. One of the main reasons that psychologists are so interested in emotion regulation is because it’s important for understanding how we can navigate everyday life and achieve our goals. It influences our performance across a number of domains including work, sport and exercise, and relationships. It’s also important for our mental health and well-being. Some emotion regulation strategies are helpful, such as problem-solving, engaging in pleasant distracting activities, or thinking differently about the situation. Yet others are unhelpful, such as suppressing how we feel, or ruminating (focusing on negative emotions and their consequences). This is my particular interest – looking at how the ways in which people think about and respond to their moods and emotions can become problematic.

Bipolar disorder is characterised by mood fluctuation and the experience of both low mood (depression) and high mood (hypomania or mania). Elated moodis a key feature of hypomania and mania. My collaborator Dr June Gruber at UC Boulder in the States has even argued that there is a dark side to happiness. Work from her lab suggests that mania arises from a phenomenon called positive emotion persistence, particularly emotions related to reward and achievement. Irritability is also commonly experienced in these mood states, as is feeling activated – doing more, speaking more, racing thoughts, sleeping less, engaging in risky behaviours, and inflated self-esteem.

As you can imagine, mania can cause a lot of problems for people – with relationships, finances, education and work, and hospitalisation. Yet some aspects of hypomania, which is less extreme, can feel good, and be seen as driving productivity and creativity. Coupled with this, there is evidence that bipolar disorder is characterised by an overly sensitive reward system, and making excessively ambitious goals for the future – meaning people with bipolar disorder are more likely to approach rewarding situations when available.

What happens when someone wants to experience the elation and energy of high mood, but fears a manic relapse? My research has found that that people with bipolar disorder have mixed and even conflicting views about their high mood, seeing both positive and negative aspects. On one hand, they might feel like the world is full of unlimited opportunities and they can achieve more when they feel high, whereas on the other hand, they might think they are losing control of their mind and are about to have a breakdown. Coupled with this, while not wanting to become depressed, low mood may be seen as keeping them safe from losing control. People can become hypervigilant to their emotions, and interpret these as the first signs of mood episodes.

To give examples, if someone with bipolar disorder is feeling happy and full of energy, and believes this is driving their creativity and productivity, they might try to amplify positive emotions by focusing on and savouring it, or engaging in more activities that make them feel good. However, if they fear they are becoming too high, they might try to dampen positive emotions by thinking they don’t deserve to feel happy or focusing on negatives. To avoid depression, people with bipolar disorder might take risks, suppress their feelings, or ruminate. Our systematic review of emotion regulation strategies in bipolar disorder found that people with bipolar disorder tend to respond to negative and positive emotions with unhelpful emotion regulation strategies more than people from a healthy population group, and that these strategies are related to heightened mood symptoms and poorer functioning and quality of life. 

A common misconception is that people with bipolar disorder ‘swing’ very quickly from one extreme to the other. This is not generally the case, but many people with bipolar disorder do report day-to-day fluctuation in how they feel. Recent psychological approaches to treating bipolar disorder – including our hot off the press Thrive-BD programme – have aimed to help people to manage this ongoing fluctuation (or instability). Part of this is about normalising and accepting emotions, identifying that a ‘healthy’ emotional response is not mania or depression, and understand where they are responding to emotions in ways that become problematic.

Such approaches have the potential to complement traditional psychological interventions for bipolar disorder that focus on preventing relapse into a full-blown mood episode, by helping people to manage everyday emotional fluctuation. Myself and collaborators Dr Manja Koenders and Dr Kim Wright recently ran a workshop on psychological treatment for emotion regulation problems in bipolar disorder at the International Society for Bipolar Disorders conference. As Kim put it, people should be allowed to grieve for things that are lost without it being depression, and get fired up about projects without it being mania. We need more research, but supporting people to regulate their emotions more effectively might help them to not get too tangled up in them that we can’t do the things we want to do and achieve the things we want to achieve – and that is true for all of us.

About the Author

Dr Alyson Dodd is an Associate Professor in the Department of Psychology and a member of the Psychopathologies subgroup of our Health and Wellbeing Research Group

References

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.

Dodd, A. L., Mansell, W., Morrison, A. P., & Tai, S. (2011). Extreme appraisals of internal states and bipolar symptoms: The Hypomanic Attitudes and Positive Predictions Inventory. Psychological Assessment, 23(3), 635.

Johnson, S. L., Fulford, D., & Carver, C. S. (2012). The double‐edged sword of goal engagement: consequences of goal pursuit in bipolar disorder. Clinical Psychology & Psychotherapy, 19(4), 352-362.

Wright, K., Dodd, A., Warren, F., Medina-Lara, A., Dunn, B., Harvey, J., … & Lynch, T. (2021). Psychological Therapy for Mood Instability within Bipolar Spectrum Disorder: A Randomised, Controlled Feasibility Trial of a Dialectical Behaviour Therapy-Informed Approach (the ThrIVe-B Programme).