Elsevier

Journal of Affective Disorders

Volume 239, 15 October 2018, Pages 303-312
Journal of Affective Disorders

Research paper
Coping with amplified emotionality among people with bipolar disorder: A longitudinal study

https://doi.org/10.1016/j.jad.2018.07.025Get rights and content

Highlights

  • Amplified emotionality characteristics of bipolar disorder is confirmed.

  • Reducing perceived controllability can help in regulating elevated mood states.

  • Less use of behavioral-activation coping is crucial in managing elevated mood.

  • Eliminating the use of emotion-amplifying coping is crucial in manic mood regulation.

Abstract

Background

The amplified emotionality characteristics of bipolar disorder (BD) may interfere with goal pursuit in the recovery process. This is the first study to test the coping flexibility model empirically among people with BD. Finding ways to cope with goal-striving life events should shed light on managing elevated mood states.

Methods

Using a 12-month longitudinal follow-up design, this study examined the stability in coping flexibility with experimentally-devised Behavioral Approach System (BAS) activating life events and mood states at 6- and 12-month time points for individuals with BD (n = 83) and healthy controls (n = 89). Hierarchical linear modeling tested the individual growth model by studying the longitudinal data.

Results

The findings showed fluctuations in different components of coping flexibility and mood states across time. They confirmed the amplified emotionality characteristics of BD. Moreover, coping flexibility took precedence over BAS sensitivity and psychosocial functioning levels in predicting mood states.

Limitations

Measurements of BAS sensitivity may focus on trait nature only and prone to subjective bias. The assessment of mood or coping flexibility may not accurately capture actual experience in daily life. Lack of respective data on bipolar subtypes and significant differences in some dimensions between the BD and control groups are further limitations of the study.

Conclusions

The study's findings have implications for coping with amplified emotionality within the personal recovery process for people with BD. Judicious application of coping strategies and adjustment of perceived controllability are crucial for individuals to reach goals pertinent to personal recovery and manage potential manic mood symptoms.

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

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