Understanding bipolar disorder within a biopsychosocial emotion dysregulation framework

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.