Research paperCoping with amplified emotionality among people with bipolar disorder: A longitudinal study
Introduction
Bipolar disorder (BD) is a serious mental illness characterized by chronic and recurrent mood fluctuations between depression and mania. According to worldwide mental health surveys, BD is the second highest ranking cause of missed work or school days (Alonso et al., 2011), which indicates a disability or role limitation in carrying out daily activities (Mall et al., 2015, Merikangas et al., 2007). In general, persistent psychosocial disability in individuals with BD fluctuates in parallel with changes in affective symptoms (Judd et al., 2005), concomitant with a high relapse rate and a chronic recurrent course (Miziou et al., 2015, Reinares et al., 2014, Yatham et al., 2009). On the other hand, amplified emotionality (Gruber et al., 2013) can be another crucial characteristic of BD. Behavioral Approach System (BAS) dysregulation theory (Alloy and Abramson, 2010) can help to illustrate. Having a high BAS sensitivity level (Nusslock et al., 2009, Urosevic et al., 2008), people with BD tend to be overresponsive in relation to BAS-activating or goal-striving life events that easily result in manic/hypomanic mood symptoms (Johnson et al., 2008, Johnson et al., 2016, Nusslock et al., 2007). In addition to this overresponsiveness to life events, poor emotion regulation (Green et al., 2007, Johnson et al., 2007, Phillips and Vieta, 2007) further leads to the maintenance of elevated mood states (Farmer et al., 2006). Thus, finding ways to cope with amplified emotionality and extreme mood changes is vital for people with BD to manage their illness.
Instead of focusing on symptom reduction or relapse prevention in clinical recovery, a paradigm shift is placing more emphasis on personal recovery (Tse et al., 2014a) in which there is more focus on goal setting or self-empowerment (Tse et al., 2014b). Goal setting serves as an important element in the mental health recovery process (Clarke et al., 2009) and an integral component of strengths-based interventions, which self-directed empowerment can facilitate (Shanks et al., 2013, Tse et al., 2014b, Tse et al., 2016). Capitalizing on the individual's own vision of recovery, goal setting can even promote hope and enhance motivation (Clarke et al., 2012, Michalak et al., 2012). Goal setting can lead to the enhancement of positive emotions (Greenglass and Fiksenbaum, 2009, McCarthy et al., 2010) or vice versa (Marien et al., 2012, Orehek et al., 2011). However, goal pursuit could intertwine with emotional response for people with BD (Gilbert and Gruber, 2014). Specifically, ambitious or excessive goal striving may easily elicit a manic mood in people with BD (Alloy et al., 2012, Stange et al., 2013, Tharp et al., 2016). This dilemma is quite challenging, especially when people with BD have difficulties in regulating their positive emotions. Thus, further investigation is needed to fill this research gap and to see if any dilemma-breaking means can help people with BD to achieve the set goals and go through a personal recovery process.
Coping with BAS-activating life events appears to be an outlet to counter the emergence of manic symptoms. In essence, coping is a dynamic process that changes according to the varying demands and appraisals of situations over time or from stage to stage (Carver et al., 1989, Holahan et al., 1996). Therefore, a flexible coping mechanism is necessary (Cheng, 2001, Cheng et al., 2014). Individuals’ experience and cognition change over time. The cognitive interpretation of an experience sets the coping process in motion (Folkman et al., 1986, Roesch et al., 2002). Specifically, perceived controllability is seen as a key element in a cognitive appraisal with implications for how an individual determines his or her available personal or interpersonal resources for responding to a situation (Cheng, 2001, Folkman et al., 1986). These processes emerge and reemerge, influencing the selection and use of coping strategies (Lazarus, 1993). Therefore, repeated measures of appraisal and coping are necessary to identify both changing and relatively stable variables (Cheng and Cheung, 2005, Lazarus, 2000, Ptacek and Pierce, 2003). The use of longitudinal studies to identify the unknown issue of stability in coping flexibility, especially the temporal effect of the BAS response to experimentally manipulated BAS-relevant stimuli (Urosevic et al., 2008), has been suggested (Cheng, 2001, Lazarus, 1999). Thus, further investigation is needed to fill this research gap.
Moreover, the coping flexibility model has just been applied to the normal population, but it has never been applied to people with mental health concerns (Cheng et al., 2014). Coping flexibility may apply differently to people with BD than to people without BD. First, individual affective states may color the judgment of an appraisal or coping response (Forgas and Eich, 2013). Second, the presumed effective coping in a normal population may be of no use to people with BD during their mood episodes (Urosevic et al., 2008, Wright et al., 2009). Further investigation is warranted. In addition, most previous studies focused only on coping with general stressors or prodromes (Lam et al., 2001, Wong and Lam, 1999) rather than life events. Detailed investigation of the impact of different styles of coping in relation to life events, particularly those that are BAS relevant, has yet to take place.
An exploration of how individuals cope with life events is relevant to the management of amplified emotionality, especially when taking the effects of individuals’ BAS sensitivity and psychosocial functioning levels into account as well. Coping may play a role between mood states and an individual's BAS sensitivity level (Alloy and Abramson, 2010, Alloy et al., 2009) or psychosocial functioning level (Weinstock and Miller, 2008, Weinstock and Miller, 2010). A BAS hypersensitivity trait (Nusslock et al., 2009, Urosevic et al., 2008) and psychosocial functional impairment (Nolen et al., 2004, Weinstock and Miller, 2008, Weinstock and Miller, 2010) can be significant risk factors for affective symptoms in BD. Therefore, further investigation can identify the role of coping, on top of BAS hypersensitivity and psychosocial functioning, in predicting mood symptoms.
This study had two aims. First, we examined the differences in the stability of mood states and coping flexibility across a year between participants with and without BD. Second, we investigated time-invariant variables (BAS sensitivity level and psychosocial functioning level) and time-varying variables (different components of coping flexibility) as predictors of changes, if any, in mood states over time. We hypothesized that coping should play a crucial role in managing amplified emotionality in people with BD. A 12-month longitudinal follow-up study design examined the stability in coping flexibility and mood states across time. Within the prospective analyses, corresponding measures occurring at two subsequent follow-up time points, 6 months and 12 months after the initial baseline measurement, indicated changes.
Section snippets
Participants
Ninety participants diagnosed with BD I or II by a regional hospital and 90 healthy controls from the community were recruited through convenient sampling. The participants were fluent in Chinese, aged 18–65, and had a primary level of education or above. The participants with BD had to have been in a state of full remission for more than two months (Tohen et al., 2009). Exclusion criteria included a comorbid diagnosis of schizophrenia, schizoaffective disorder, substance misuse, organic brain
Linear and quadratic growth model
A total of 172 participants completed the entire process of the study. About 60% of the participants were female in both groups. Relatively, the people in the control group were younger with higher socio-occupational functioning. Detailed descriptive information is presented in Table 1. The baseline affective symptoms were comparable between the two groups at the beginning (t = 1.870, p = .063 for MHRSD; t = 1.684, p = .094 for BRMS), and this similarity remained at the final time point (t
Discussion
This study examined the longitudinal changes or stability of mood states and coping flexibility by comparing the differences between people with and without BD. Conceptually, to the best of the authors’ knowledge, the present study is the first study to extend the application of the coping flexibility model to a clinical population, that is, people with bipolar illness. As demonstrated by the individual growth models in this study, coping flexibility took precedence over both BAS sensitivity
Limitations and conclusions
First, there was no breakdown of the BD group into the two different subtypes in this study. Considering substantial differences in BAS sensitivity and its association with mood variability have been quantified in BD I and BD II (Fletcher et al., 2013), it is suggested that although a similar pattern of functional impairment may be observed in both groups (Rosa et al., 2010), the different degrees of amplified emotionality and subsequent coping of individuals with BD I and BD II should lead to
Funding body agreements and policies
None
Conflict of interest
None
Acknowledgments
We thank the participants who kindly took part in this research study.
Contributors
Author (Sunny H.W. Chan) designed the study, managed the literature searches, data collection, data analyses, and wrote the first draft. Author (Samson Tse) supervised the entire work and edited the manuscript. All authors contributed to and have approved the final manuscript.
Appendix
Abbreviations used in this study: AA = Behavioral-activation/emotion-amplifying; ACT = Activation; AIC = Akaike information criterion; AR1 = autoregressive covariance structure; BAS = Behavioral Approach System; BD = Bipolar disorders; BRMS = Bech-Rafaelsen Mania Scale; CTR = Perceived controllability; DD = Behavioral-deactivation/emotion-diminishing; EF = Emotion-focused; FAST = Functioning Assessment Short Test; Fit1/Fit2 = Fit index; HLM = hierarchical linear modeling; ISS = Internal State
References (93)
- et al.
People with bipolar I disorder report avoiding rewarding activities and dampening positive emotion
J. Affect. Disord.
(2013) - et al.
Behavioral activation system (BAS) differences in bipolar I and II disorder
J. Affect. Disord.
(2013) - et al.
The cognitive and neurophysiological basis of emotion dysregulation in bipolar disorder
J. Affect. Disord.
(2007) Mania and dysregulation in goal pursuit: a review
Clin. Psychol. Rev.
(2005)- et al.
The bipolar recovery questionnaire: psychometric properties of a quantitative measure of recovery experiences in bipolar disorder
J. Affect. Disord.
(2013) - et al.
"I won't do what you tell me!": elevated mood and the assessment of advice-taking in euthymic bipolar I disorder
Behav. Res. Ther.
(2006) - et al.
Being flexible or rigid in goal-directed behavior: when positive affect implicitly motivates the pursuit of goals or means
J. Exp. Soc. Psychol.
(2012) Cognitive Processing in bipolar disorder conceptualized using the interactive cognitive subsystems (ICS) model
Clin. Psychol. Rev.
(1990)- et al.
The modified Hamilton rating scale for depression: reliability and validity
Psychiatry Res.
(1985) - et al.
Psychosocial interventions in bipolar disorder: What, for Whom, and When
J. Affect. Disord.
(2014)
Functional impairment in bipolar II disorder: is it as disabling as bipolar I?
J. Affect. Disord.
Dysregulation of the behavior approach system (BAS) in bipolar spectrum disorders: review of theory and evidence
Clin. Psychol. Rev.
Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar disorder
Compr. Psychiatry
Principles of good practice for the translation and cultural adaptation process for patient-reported outcome (PRO) measures: report of the ISPOR task force for translation and cultural adaptation
Value Health
The development and validation of the coping inventory for prodromes of mania
J. Affect. Disord.
Reduced approach motivation following nonreward: extension of the BIS/BAS scales
Personal Individ. Differ.
The role of the behavioral approach system (BAS) in bipolar spectrum disorders
Curr. Dir. Psychol. Sci.
Longitudinal predictors of bipolar spectrum disorders: a behavioral approach system perspective
Clin. Psychol.
High behavioral approach system (BAS) sensitivity, reward responsiveness, and goal-striving predict first onset of bipolar spectrum disorders: a prospective behavioral high-risk design
J. Abnorm. Psychol.
Days out of role due to common physical and mental conditions: results from the WHO world mental health surveys
Mol. Psychiatry
Diagnostic and Statistical Manual of Mental Disorders
Independent assessment of manic and depressive symptoms by self-rating
Arch. Gen. Psychiatry
The Bech-Rafaelsen mania scale and the Hamilton depression scale: Evaluation of homogeneity and inter-observer reliability
Acta. Psychiatr. Scand.
Augmenting behavioral activation treatment with the behavioural activation and inhibition scales
Behav. Cogn. Psychother.
Multimodel inference: understanding AIC and BIC in model selection
Soc. Methods Res.
You want to measure coping but your protocol's too long: consider the brief COPE
Int. J. Behav. Med.
Assessing coping strategies: a theoretically based approach
J. Personal. Soc. Psychol.
Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment: the BIS/BAS scales
J. Personal. Soc. Psychol.
Assessing coping flexibility in real-life and laboratory settings: a multimethod approach
J. Personal. Soc. Psychol.
Cognitive and motivational processes underlying coping flexibility: a dual-process model
J. Personal. Soc. Psychol.
Psychological responses to outbreak of severe acute respiratory syndrome: a prospective, multiple time-point study
J. Personal.
Coping flexibility and psychological adjustment to stressful life changes: a meta-analytic review
Psychol. Bull.
Flexible coping psychotherapy for functional dyspeptic patients: a randomized controlled trial
Psychosom. Med.
Do goal-setting interventions improve the quality of goals in mental health services?
Psychiatr. Rehabil. J.
Recovery in mental health: a movement towards well-being and meaning in contrast to an avoidance of symptoms
Psychiatr. Rehabil. J.
Psychological mechanisms and the ups and downs of personal recovery in bipolar disorder
Br. J. Clin. Psychol.
A pilot study of positive mood induction in euthymic bipolar subjects compared with healthy controls
Psychol. Med.
Discovering Statistics Using SPSS
Appraisal, coping, health status, and psychological symptoms
J. Pers. Soc. Psychol.
Affective influences on cognition: Mood congruence, mood dependence, and mood effects on processing strategies
Depressive personality styles and bipolar spectrum disorders: prospective test of the event congruency hypothesis
Bipolar Disord.
The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions
Am. Psychol.
Flexibility and negative affect: examining the associations of explanatory flexibility and coping flexibility to each other and to depression and anxiety
Cognit. Ther. Res.
Emotion regulation of goals in bipolar disorder and major depression: a comparison of rumination and mindfulness
Cognit. Ther. Res.
Proactive coping, positive affect, and well-being: testing for mediation using path analysis
Eur. Psychol.
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Reconsideration of the factorial structure of the Barratt Impulsiveness Scale (BIS-11): Assessment of impulsivity in a large population of euthymic bipolar patients
2019, Journal of Affective DisordersCitation Excerpt :This phenomenon could contribute to explain why suicide is frequent in patients with bipolar disorder. These patients often present two particularly dangerous features when associated: an acute awareness of psychological pain during depression, associated with a general hyper-emotionality (Chan and Tse, 2018; Henry et al., 2013) and a strong tendency to act impulsively (Etain et al., 2013; Olié et al., 2015). These two characteristics (general emotional dysregulation and impulsivity) have been found associated with suicidal behavior in a general population of 2295 students among which were 108 past suicidal attempters (Ammerman et al., 2015).