Journal of Affective Disorders 160 (2014) 92–97
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Research report
Cognitive emotion regulation in euthymic bipolar disorder Larissa Wolkenstein a,n, Julia C. Zwick a, Martin Hautzinger a, Jutta Joormann b a b
Department of Psychology, Clinical Psychology and Psychotherapy, University of Tübingen, Germany Department of Psychology, Northwestern University, Evanston, IL, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 5 July 2013 Received in revised form 12 December 2013 Accepted 13 December 2013 Available online 28 December 2013
Background: Based on findings indicating increased stress reactivity and prolonged stress recovery in individuals with bipolar disorder (BD), it has been proposed that emotion regulation (ER) deficits lie at the core of this disorder. Recent studies show an increased use of maladaptive ER strategies and a decreased use of adaptive ER strategies in BD. Whether this pattern is merely a correlate of affective episodes or might be a stable characteristic of BD, however, remains to be explored. In addition, it is unclear whether these deficits in ER are specific to people with a history of BD. Methods: We examined whether euthymic BD individuals differ from healthy controls (HC) and individuals with a history of Major Depressive Disorder (MDD) with respect to the cognitive ER strategies they habitually use (CERQ) in response to negative affect. The sample consisted of 42 bipolar patients, 43 patients with MDD and 39 HC. Results: Compared to HC, euthymic BD and MDD individuals reported increased use of rumination, catastrophizing, and self-blame alongside decreased use of positive reappraisal, and putting into perspective. No differences were found between BD and MDD groups. Limitations: These findings are based on self-reports reflecting the habitual use of ER-strategies. The use of more objective methods and the examination of the spontaneous use of ER-strategies in euthymic BD would be desirable. Conclusions: Deficits in the habitual use of ER strategies may characterize BD and MDD individuals even outside of an acute episode and thereby play a role in the recurrence of affective disorders. & 2014 Elsevier B.V. All rights reserved.
Keywords: Affective disorders Bipolar Depression Emotion regulation Euthymic CERQ
1. Introduction According to the World Health Organization, bipolar disorder (BD) is one of the most disabling psychiatric disorders and a leading cause of non-fatal burdens (World Health Organization, 2008). BD is characterized by recurrent episodes of depression, periods of sustained and abnormally elevated mood, and/or mixed states with co-occurring depressive and manic symptoms (American Psychiatric Association, 2000). It has been proposed that negative life events trigger increases in depressive symptoms whereas certain positive life events trigger (hypo-)manic symptoms (Johnson, 2005). Research has also shown that individuals with BD display prolonged recovery following a stressful life event (Goplerud and Depue, 1985). In addition, experimental studies suggest that bipolar spectrum disorders are associated with impairments in emotional recovery. Subclinical cyclothymic subjects compared to healthy controls (HC), for example, exhibited elevated cortisol levels 3 h after a stressful task indicating prolonged stress recovery (Depue et al., 1985). Taken together, these
n Correspondence to: Department of Clinical Psychology, University of Tübingen, Schleichstr. 4, 72076 Tübingen, Germany. Tel.: þ 49 70 7129 77184; fax: þ49 70 7129 5219. E-mail address: [email protected] (L. Wolkenstein).
0165-0327/$ - see front matter & 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.12.022
findings suggest deficits in regulatory processes in BD and various authors have proposed that difficulties in emotion regulation lie at the core of BD (Phillips and Vieta, 2007; Johnson et al., 2007; Gruber, 2011). According to Gross (1998) emotion regulation (ER) refers to processes by which individuals influence the appearance of emotions and how they experience and express these emotions. Some of these processes are implicit, automatic, and are performed without any consciousness or effort, whereas others are explicit, controlled, and are exerted consciously and with effort (Gyurak et al., 2011). Strategies that are performed consciously and effortfully can be subdivided into behavioral ER strategies (e.g., situation selection, expressive suppression) and cognitive ER strategies (e.g., cognitive reappraisal, rumination) (Gross and John, 2003; Garnefski and Kraaij, 2007). Although all ER strategies might be helpful in particular situations, studies suggest a general advantage of some ER strategies over others (e.g., Garnefski and Kraaij, 2007; Nezlek and Kuppens, 2008). Garnefski and Kraaij (2007), for example, showed that the use of catastrophizing, rumination, and self-blame is positively associated with symptoms of depression and anxiety whereas the use of positive reappraisal is negatively associated with these symptoms. Thus, ER strategies can be differentiated into (primarily) adaptive strategies and (primarily) maladaptive strategies.
L. Wolkenstein et al. / Journal of Affective Disorders 160 (2014) 92–97
Despite the fact that BD is defined by dysregulated emotional states (American Psychiatric Association, 2000), few studies to date have investigated the habitual use of ER strategies in BD. The majority of these studies used the Response Styles Questionnaire (RSQ; Nolen-Hoeksema et al., 1993) and highlighted that, in response to negative life events, remitted BD participants ruminate more than HC (Thomas et al., 2007; Van Der Gucht et al., 2009). Moreover, self-reported rumination has been associated with higher levels of depression and hypomania in adolescents at risk for BD (Knowles et al., 2005; Thomas and Bentall, 2002). The use of a revised version of the RSQ (Knowles et al., 2005) has further revealed that, in response to negative affect, depressed and remitted BD participants use adaptive coping strategies (i.e., distraction and problem solving) less frequently compared to manic BD participants (Thomas et al., 2007). Interestingly, manic BD participants reported to use adaptive coping strategies even more frequently than HC (Thomas et al., 2007). Compared to the RSQ and the revised version of the RSQ the Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski et al., 2001) samples a broader range of cognitive strategies used to regulate emotions in response to negative events. In addition to the habitual use of rumination, the CERQ also assesses the use of self-blame, blaming others, catastrophizing, putting into perspective, positive reappraisal, acceptance, positive refocusing, and refocus on planning. Within the context of BD, the CERQ has been previously used in two studies. The first study highlighted that, in addition to the more frequent use of rumination, bipolar individuals compared to HC report a more frequent use of catastrophizing and self-blame in response to negative events (Green et al., 2011). This was confirmed by the second study, that also showed a less frequent use of putting into perspective within the BD group (Rowland et al., 2013). Concerning the other cognitive ER strategies assessed by the CERQ, neither Green et al. (2011) nor Rowland et al. (2013) found any differences between bipolar patients and HC. However, the participation of the BD subjects in both studies was based on diagnoses given previously to the beginning of the study in question (in other studies). In other words, subjects0 current mood states were not assessed. Therefore, it is not unlikely that the inclusion of symptomatic individuals may have blurred differences between euthymic BD patients and HC: First, keeping in mind the symptoms of (hypo)-manic episodes, it is probable that individuals in a (hypo-) manic mood state are more likely to refocus on positive things, to positively reappraise, and to refocus on planning when being confronted with a negative event. Second, in the study by Thomas et al. (2007) manic BD participants reported a more frequent use of adaptive coping strategies as assessed by the RSQ not only compared to depressed and euthymic BD participants, but also compared to HC. To summarize, there is preliminary evidence that euthymic BD individuals show increased use of rumination in response to negative events. However, no study thus far has compared euthymic BD participants to HC in their habitual use of a broad range of cognitive ER strategies as assessed by the CERQ. That is, thus far we do not know whether deficits in the use of cognitive ER strategies that have been reported in BD (Green et al., 2011; Rowland et al., 2013) are merely a correlate of acute affective symptoms or are present independently of acute symptoms and might thus constitute a risk factor for future episodes. Studies specifically examining euthymic BD participants are of particular importance, given that recent models propose that maladaptive reactions to negative and positive affect underlie the downward and upward spirals, respectively, which in turn might result in a depressive or a manic episode in BD (Gruber, 2011; Johnson, 2005). It is therefore the main goal of this study to compare the habitual use of cognitive ER strategies of interepisode BD and HC. Furthermore, to examine whether our findings are specific to the bipolar spectrum of affective disorders or
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generalize to other affective disorders, we included a sample of remitted unipolar depressed patients. To our knowledge there is only one study thus far that has examined the habitual use of cognitive ER strategies in remitted depression. In this study, recovered depression was associated with an increased use of rumination and catastrophizing as well as a decreased use of putting into perspective compared to HC (Ehring et al., 2008). Due to the shared risk of remitted BD and remitted MDD for developing a depressive episode following a negative life event and based on previous studies that have examined the habitual use of ER in BD and MDD participants (Rowland et al., 2013; Green et al., 2011; Ehring et al., 2008; Van Der Gucht et al., 2009), we hypothesized that euthymic BD patients as well as remitted MDD patients display increased use of rumination and catastrophizing and decreased use of positive reappraisal and putting into perspective. Given that BD has repeatedly been associated with an increased use of self-blame (Green et al., 2011; Rowland et al., 2013), which has not been found in remitted MDD (Ehring et al., 2008), we further propose that euthymic BD patients, but not remitted MDD patients, display an increased use of self-blaming.
2. Methods 2.1. Participants One hundred and twenty-four participants were recruited through an outpatient clinic as well as through advertisements posted on the Internet and within the community. Participants were invited for an interview if they were deemed eligible based on screening conducted per telephone. To determine the diagnostic status of participants, trained interviewers administered the Structured Clinical Interview for DSM-IV (SCID; First et al., 1996). Participants with BD (n ¼42) either met the diagnostic criteria for remitted bipolar I disorder (62%) or for remitted bipolar II disorder (38%), based on the diagnostic criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000). Participants with MDD (n ¼43) either met DSM-IV criteria for recurrent MDD in remission (74.42%) or for an MDD single episode in remission (25.58%). Participants in the HC group (n ¼39) did not meet diagnostic criteria for any current or past Axis I disorder. Exclusion criteria for all participants were insufficient knowledge of the German language and age below 18 or above 69. Exclusion criteria for both clinical groups were lifetime psychotic symptoms (except moodcongruent delusions within affective episodes), current alcohol or substance dependency (if they met the lifetime diagnostic criteria they had to be abstinent for at least 24 months), current alcohol or substance abuse, cluster A personality disorders, borderline personality disorder, antisocial personality disorder, and current anorexia nervosa (BMI r18 kg/m²). Furthermore, participants in both clinical groups had to be remitted for at least 8 weeks and were required to take no medication or to take medication on a stable dosage for at least 4 weeks. Of the 42 BD participants 81% and of the 43 MDD participants 39.5% were on various medications at the time of the study (one participant in the HC group took antidepressants due to sleep disturbances). 2.2. Assessment of clinical symptoms To assess self-reported current symptom levels of depression, we used the Quick Inventory for Depressive Symptomatology Self-Report (QIDS-SR; Rush et al., 2003). The QIDS-SR comprises 16 items that assess presence and severity of 16 depression-related symptoms. It demonstrates high internal consistency with Cronbach0 s α ¼.86 (Rush et al., 2003) and has proven to be suitable not only for MDD
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L. Wolkenstein et al. / Journal of Affective Disorders 160 (2014) 92–97
Table 1 Demographic, neuropsychological and clinical characteristics of participants. Characteristic
Bipolar disorder %
Gender (female) University entrance diploma (yes) Age QIDS-SR HAM-D Age at first treatment SRMI YMRS
M
Major depressive disorder SD
61.90 69.05
%
M
Healthy controls SD
72.09 72.09 40.86 4.88 3.00 28.41 4.00 1.67
12.79 4.49 2.55 11.46 4.83 2.07
%
M
SD
42.18 1.15
13.27 1.27
58.97 64.10 36.91 4.40 3.58 28.37
13.35 3.24 2.40 12.37
Note: QIDS-SR ¼Quick Inventory of Depressive Symptomatology Self-Report; HAM-D ¼Hamilton Depression Rating Scale; SRMI ¼Self-Report Manic Inventory; YMRS¼ Young Mania Rating Scale.
but also for BD (Bernstein et al., 2010). The QIDS-SR demonstrated good internal consistency in the current sample (Cronbach0 s α ¼.80). As a clinician-rated instrument to assess the severity of current depressive symptoms we used the Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960), which comprises 21 items asking for the presence and severity of 20 depression-related symptoms. Good internal consistency of this scale has been proven over years (Trajković et al., 2011). Within the current sample the internal consistency was acceptable (Cronbach0 s α ¼.69). To assure the remitted mood state of the clinical groups, we required a score below 9 on the HAM-D for BD and MDD participants. Self-reported severity of manic symptoms within the BD group was assessed with the self-report manic inventory which comprises 48 true-false items (SRMI; Shugar et al., 1992). Within the current sample the internal consistency of the SRMI was high (Cronbach0 s α ¼ .85). To assess clinician-rated symptom levels of mania in the BD group, we used the Young Mania Rating Scale (YMRS; Young et al., 1978), which comprises 11 items asking for the presence and severity of different mania-associated symptoms. With Cronbach0 s α ¼ .45 the internal consistency of this scale was poor within our sample, which is probably not only due to the small sample size the calculation is based on (n ¼ 42) but also to the fact that all BD participants were remitted at the time of the study. To assure remission with respect to mania within the BD group, we required a score below 12 on the YMRS. 2.3. Cognitive emotion regulation questionnaire The CERQ is a 36-item self-report questionnaire which has been developed to measure the habitual use of nine cognitive ER strategies (Garnefski et al., 2001). The strategies characterize the individual0 s style of responding to negative events. Each of the nine conceptually distinct subscales consists of four items. Internal consistencies for the subscales have been reported to range from Cronbach0 s α ¼ 0.68 to Cronbach0 s α ¼0.83 (Garnefski et al., 2001). The internal consistencies in our sample where comparable with Cronbach0 s α ranging from 0.64 to 0.86. As in the study of Garnefski et al. (2001), only the internal consistency of one subscale was below 0.70 whereas five of the alphas were 0.80 or higher. In a next step we looked at each study group separately. Within the BD group Cronbach0 s α ranged from 0.71 to 0.90, within the MDD group it ranged from 0.59 to 0.83 and within the HC group Cronbach0 s α ranged from 0.56 to 0.85.
Participants who were deemed eligible through the phone screening were sent the SCID II screening questionnaire as well as the CERQ to complete at home and to bring to their diagnostic assessment session. During the diagnostic assessment session sociodemographic data were recorded before the interviewer administered the SCID-I and SCID-II (the latter if necessary), the YMRS (only BD participants), and the HDRS (only BD and MDD participants). Afterwards participants were asked to complete the QIDS-SR and the SRMI (only BD group). 2.5. Statistical analyses Group means were compared with a multivariate analysis of variance (MANOVA) and subsequent univariate analyses of variance (ANOVAs). Furthermore, post-hoc t-tests were conducted.
3. Results Demographic and clinical characteristics of the three groups are presented in Table 1. The three groups differed significantly only with respect to current depressive symptoms as assessed by the QIDS-SR, F(2, 121) ¼ 14.99, p o.001, η2 ¼ .20. Follow-up tests indicated that both, the BD group, t(48) ¼ 5.16, p o.001, as well as the MDD group, t(56) ¼ 6.07, po .001, had significantly higher QIDS-SR scores compared to HC. The two clinical groups, however, did not differ from each other, t(83) ¼0.57, p¼ .568.1 Even though both clinical groups differed from HC with respect to current depressive symptoms, the scores of all participants lay clearly below the clinical cutoff indicating that all patients fulfilled criteria for remission. In addition, the two clinical groups did not differ from each other with respect to their HAM-D scores or age at first treatment. 3.1. Group differences in cognitive emotion regulation strategies Our main hypotheses predicted group differences in the habitual use of particular ER strategies. Specifically, we predicted that euthymic BD patients as well as remitted MDD patients display an increased use of rumination and catastrophizing, and a decreased use of positive reappraisal and putting into perspective. Furthermore we expected that euthymic BD patients should display an increased use of self-blame compared to HC and MDD participants. Means and standard deviations are presented in Table 2. First, we conducted a MANOVA on the total scores of the nine CERQ
2.4. Procedure The procedures of the current study were approved by the local Ethical Committee and are in accordance with the Helsinki Declaration.
1 Within the whole sample the QIDS-SR was significantly correlated with all cognitive emotion regulation strategies (all rr .178 or rZ .254 and all p o .05). However, following the recommendations of Miller and Chapman (2001) we refrained from including the QIDS-SR as a covariate.
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Table 2 Means and standard deviations of all cognitive emotion regulation strategies for the three groups. CERQ subscale
Self-blame Blaming others Rumination Catastrophizing Putting into perspective Positive refocusing Positive reappraisal Acceptance Refocus on planning
Bipolar disorder
Major depressive disorder
Healthy controls
M
SD
M
SD
M
SD
10.81 7.33 11.36 8.14 10.36 8.64 11.36 11.74 10.57
3.71 2.93 3.79 3.59 3.31 3.60 3.80 3.46 3.58
10.93 7.19 12.16 7.63 11.14 9.19 11.77 12.21 11.21
4.03 2.40 3.55 3.01 3.10 3.47 4.17 3.11 2.87
7.53 6.29 7.21 5.24 14.42 10.42 13.74 11.84 11.97
1.91 2.10 2.71 1.57 3.48 3.61 3.71 3.33 3.32
Note: CERQ ¼ Cognitive Emotion Regulation Questionnaire. Italic values indicate all values that differed significantly between groups.
subscales which yielded a significant main effect of ‘group’, F(18, 226) ¼4.07, po .001, η2 ¼.245. Subsequent ANOVAs indicated a significant main effect of ‘group’ for self-blame, F(2, 120) ¼12.78, p o.001, η2 ¼.176, rumination, F(2, 120) ¼24.11, p o.001, η2 ¼.287, catastrophizing, F(2, 120) ¼11.37, p o.001, η2 ¼.159, putting into perspective, F(2, 120) ¼16.91, p o.001, η2 ¼ .220, and positive reappraisal, F(2, 120) ¼4.17, p ¼.018, η2 ¼ .065. There were no group differences with respect to blaming others, F(2, 120) ¼1.99, p¼ .141, positive refocusing, F(2, 120) ¼2.59, p¼ .079, acceptance, F(2, 120) ¼0.24, p ¼.788, or refocus on planning, F(2, 120) ¼1.84, p ¼.163. Follow-up t-tests were performed on the five significant CERQ subscales to examine specific group difference in the use of these strategies. Compared to HC, BD participants reported more frequent use of self-blame, t(63)¼ 5.04, po.001, rumination, t(74)¼ 5.67, po.001, and catastrophizing, t(57)¼ 4.77, po.001, as well as less frequent use of putting into perspective, t(78)¼5.35, po.001, and positive reappraisal, t(78)¼2.83, p¼.006. We found the same pattern for MDD participants. Compared to HC, they too showed an increased use of self-blame, t(62)¼ 4.95, po.001, rumination, t(79)¼ 6.98, po.001, and catastrophizing, t(65)¼ 4.56, po.001, alongside a decreased use of putting into perspective, t(79)¼ 4.49, po.001, and positive reappraisal, t(79)¼2.23, p¼.028. We did not find any significant differences between BD participants and MDD participants (all pZ.264). 3.2. Association between cognitive emotion regulation strategies and residual symptoms We further examined whether the habitual use of cognitive ER strategies is associated with self-reported residual symptoms separately for the BD and the MDD subsamples. Within the BD subsample we found a positive correlation between depressive residual symptoms as assessed by the QIDS and the use of blaming others (r ¼.541, p o.001). In contrast, acceptance was negatively correlated with depressive residual symptoms (r ¼ .354, p ¼.021). Manic residual symptoms as assessed by the SRMI were positively correlated with self-blame (r ¼ .359, p ¼ .020). Within the MDD subsample the QIDS sum score was negatively correlated with putting into perspective (r ¼ .378, p ¼.012). 3.3. Within-group differences in the BD group with respect to cognitive emotion regulation strategies As the BD group comprised n ¼ 26 BD-I participants and n ¼16 BD-II participants, we decided to explore whether BD-I and BD-II
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patients differed in their habitual use of cognitive emotion regulation strategies. First, we examined whether BD-I and BD-II patients differed in symptom levels. We did not find any withingroup differences on the QIDS-SR (t(40) ¼ 1.50, p ¼.149), HAM-D (t(40) ¼ 0,87, p ¼.389), SRMI (t(40) ¼0.56, p ¼.580), and YMRS (t(40) ¼ 1.47, p¼ .150). Second, we conducted a MANOVA on the total scores of the nine CERQ subscales. The main effect of ‘subgroup’ was not significant, F(9, 32) ¼0.22, p¼ .989, indicating that BD-I and BD-II patients do not differ with respect to their habitual use of cognitive emotion regulation strategies.
4. Discussion With the knowledge that dysregulated emotion is a defining characteristic of BD, this study examined whether euthymic BD individuals differ from HC with respect to their habitual use of ER strategies. To clarify whether deficits in ER are specific to the bipolar spectrum or generalize to affective disorders, we included a sample of unipolar depressed patients in remission in the study design. We hypothesized that compared to HC both, euthymic BD patients and remitted MDD patients, would display an increased use of rumination and catastrophizing as well as a decreased use of positive reappraisal and putting into perspective. Furthermore, we proposed that only remitted BD patients would display an increased use of self-blaming compared to HC. In line with our hypothesis, we found that BD as well as MDD, compared to HC, are associated with increased use of rumination and catastrophizing alongside decreased use of positive reappraisal and putting into perspective. In contrast to our hypotheses, we additionally found that both, remitted BD patients as well as remitted MDD patients, show an increased use of self-blame compared to HC. Indeed, our study yielded no differences between BD and MDD participants in self-reported habitual use of ER strategies. Furthermore, no group differences were found with respect to the use of blaming others, acceptance, positive refocusing, or refocus on planning. A heightened tendency to ruminate in response to negative events has repeatedly been reported in BD populations (Green et al., 2011; Thomas et al., 2007; Van Der Gucht et al., 2009). Studies have also shown that BD participants seem to ruminate to the same extent as participants suffering from MDD (Kim et al., 2012; Johnson et al., 2008). However, studies addressing the latter issue did not assess the current mood state of their participants. Thus, it remained unclear whether the increased use of rumination is also present in inter-episode BD or whether this finding is merely due to a subsample of acutely depressed BD participants. Our results show that euthymic BD participants ruminate to the same extent as participants with a history of MDD. Moreover, and in line with previous studies, we found that increased use of catastrophizing and decreased use of putting into perspective are associated with a history of both, MDD (Ehring et al., 2008) and BD (Green et al., 2011; Rowland et al., 2013). Notably, this is the first study to demonstrate that neither increased use of rumination and catastrophizing nor decreased use of putting into perspective are specific to BD or MDD, but rather seem to reflect a general marker of vulnerability to affective disorders. In addition, our results indicate that increased use of self-blame and decreased use of positive reappraisal are also markers of affective disorders, rather than being specific to either BD or MDD. However, this finding is in contrast to the results reported in a study by Ehring et al. (2008), in which neither increased selfblame nor decreased reappraisal was found in remitted MDD participants, as well as to the two studies including BD individuals, which did not find decreased use of positive reappraisal in BD (Green et al., 2011; Rowland et al., 2013).
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Differences in the samples may be responsible for differences in findings across the studies. Whereas the current study only included remitted bipolar patients, neither Green et al. (2011) nor Rowland et al. (2013) controlled for current mood state. Thus, while a decreased use of positive reappraisal may be characteristic of euthymic BD, the inclusion of symptomatic BD participants may have blurred this finding in previous studies. As outlined previously, it is possible that particularly (hypo-)manic BD participants make use of positive reappraisal, which might have led to non-significant findings in the studies of Green et al. (2011) and Rowland et al. (2013). This finding illustrates the importance of clearly defining the mood state of BD participants in studies looking at the habitual use of ER strategies. Whereas a decreased use of adaptive cognitive reframing techniques in remitted BD patients may reflect impaired capacities to set aside the significance of a negative event and to re-appraise, an increased use of these strategies in (hypo-)manic BD individuals may be indicative of their current symptoms. Whereas Ehring et al. (2008) did not find differences between recovered depressed participants and HC with respect to selfblame and positive reappraisal, we found increased use of selfblame and decreased use of reappraisal not only in euthymic BD but also in remitted MDD participants. Here, the difference in findings could be due to differences in depressive residual symptoms of the remitted MDD groups in the two studies, but it is unlikely. Whereas in the current study MDD differed from HC participants with respect to depressive symptoms, no such difference was reported in the study by Ehring et al. (2008). However, with a mean QIDS-SR score of 4.40 within the MDD group, the MDD participants in the current study were clearly remitted, as were the participants in the Ehring sample. Furthermore, we did not find any correlations between depressive residual symptoms and self-blame or positive reappraisal within our MDD subsample. Thus, it remains unclear what causes the differences between our findings and the findings of Ehring et al. (2008). However, studies in non-clinical samples consistently indicate significant relations between increased use of self-blame, rumination, and catastrophizing and decreased use of positive reappraisal and emotional problems (e.g., current and future depressive symptoms) (Garnefski and Kraaij, 2007, 2009). Thus, one would expect not only euthymic BD patients but also remitted MDD patients to display increased use of self-blame and decreased use of positive reappraisal, which is in line with our results. Future studies are necessary to replicate these findings. In addition to the group differences, correlational analyses revealed associations between depressive residual symptoms within the BD group and two strategies that did not differ between groups: Blaming others was positively correlated with depressive residual symptoms whereas acceptance was negatively correlated with depressive symptoms. It is possible that compared to HC, BD patients show a significantly increased extent of blaming others as well as a significantly decreased extent of acceptance only during acute depressive episodes. Future studies are required to directly investigate these hypotheses. Furthermore, an explorative within-group analysis yielded no significant difference between BD-I and BD-II patients with respect to their habitual use of cognitive emotion regulation strategies. As this analysis was based on a comparatively small sample size, replication studies using larger samples will be necessary to provide further support for this result. Our results demonstrate that it is vital to examine which ER strategies BD patients use while in a stable euthymic mood state as compared to their strategy selection in view of first affective symptoms of either polarity. It is possible, for example, that the strategy of positive refocusing is useful inter-episode as well as in the face of first depressive symptoms, whereas it might not be
useful when experiencing first (hypo-)manic symptoms. Gaining more insight into these selection processes will be useful for the development of appropriate intervention strategies. In this context it is worth mentioning that recent studies have demonstrated that euthymic BD individuals compared to HC report to expend increased effort to regulate their emotions independent of whether they watch an emotional or a non-emotional film-clip— suggesting that inter-episode BD individuals demonstrate a lessnuanced strategy selection with respect to the circumstances (Gruber et al., 2012). 4.1. Limitations While the findings of our study contribute significantly to our understanding of the habitual use of ER strategies within the context of euthymic BD and remitted MDD, there are a number of limitations of this study that should be kept in mind. The focus of this study was on the regulation of negative affect. Previous research, however, has pointed out that individual differences in responding to positive affect may play a critical role in BD (Johnson et al., 2008; Gruber et al., 2011; Alloy et al., 2009). Dampening or positive rumination, for example, have not only been shown to be associated with depressive symptoms but also with symptoms that might be of special relevance for elevated mood-states such as mania (Feldman et al., 2008). In contrast to depression, BD is not only associated with an increased tendency to ruminate in response to negative affect but also with an increased selfreported tendency to ruminate in response to positive affect (Johnson et al., 2008; Gruber et al., 2011). Whereas traitrumination in response to both negative and positive affect has been associated with higher life-time frequency of depression (Alloy et al., 2009; Gruber et al., 2011), only trait-rumination in response to positive affect has also been linked to higher lifetimefrequency of mania (Gruber et al., 2011). Furthermore, positive rumination has been found to be associated with symptoms of hypomania in a college student sample (Raes et al., 2009). Future studies should address this issue and broaden our knowledge about ER strategy use in euthymic BD patients by examining responding to negative as well as positive affect. Furthermore, even though the CERQ is frequently used to assess the habitual use of cognitive emotion regulation strategies (Ehring et al., 2008; Green et al., 2011), it has to be kept in mind that it is a self-report measure. Thus, it presumes a certain amount of introspective abilities to answer the questions of the CERQ. It is debatable whether subjects do have comprehensive access to their own cognitive processes and are able to give valid answers to such questions. There may be memory biases, for example, that distort participants0 response patterns. Thus, it will be interesting to extent the measures used to assess cognitive emotion regulation strategies in euthymic bipolar patients by integrating more objective measures in future studies. Of note, even though there are first studies demonstrating which brain networks are involved in particular emotion regulation strategies (McRae et al., 2008), our knowledge with respect to this question is limited. 4.2. Conclusions To summarize, euthymic BD as well as remitted MDD, is associated with an increased use of (primarily) maladaptive ER strategies and a decreased use of (primarily) adaptive ER strategies. Given that this pattern of ER strategy use is present during remission, i.e., it is not associated with the presence of acute affective symptoms, it may likely be a risk factor for the development of further affective episodes. Studies are needed that go beyond the examination of self-reported habitual use of ER strategies and assess whether the use of certain ER strategies predicts the
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recurrence of affective episodes and whether BD and MDD participants can be trained to effectively use adaptive ER strategies. In a recent study Gruber et al. (2012) found that bipolar patients report greater effort but less success in spontaneously regulating their emotions which suggests that besides the habitual use of certain ER strategies there may be other deficits influencing ER ability in patients suffering from affective disorders. Future studies are needed to clarify which processes underlie these deficits to successfully regulate emotions and to develop appropriate interventions. Furthermore, we need to examine whether ER deficits are specifically characteristic for remitted affective disorders or whether they characterize individuals with any lifetime psychiatric diagnosis. The latter would indicate that deficient ER constitutes a risk factor for the recurrence of either psychopathology. Role of funding source We had no funding for this study.
Conflict of interest All authors declare that they have no conflicts of interest.
Acknowledgements We thank Marjorie Kinney, who kindly assisted with the proof-reading of the manuscript.
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Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Cognitive emotion regulation in euthymic bipolar disorder Larissa Wolkenstein a,n, Julia C. Zwick a, Martin Hautzinger a, Jutta Joormann b a b
Department of Psychology, Clinical Psychology and Psychotherapy, University of Tübingen, Germany Department of Psychology, Northwestern University, Evanston, IL, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 5 July 2013 Received in revised form 12 December 2013 Accepted 13 December 2013 Available online 28 December 2013
Background: Based on findings indicating increased stress reactivity and prolonged stress recovery in individuals with bipolar disorder (BD), it has been proposed that emotion regulation (ER) deficits lie at the core of this disorder. Recent studies show an increased use of maladaptive ER strategies and a decreased use of adaptive ER strategies in BD. Whether this pattern is merely a correlate of affective episodes or might be a stable characteristic of BD, however, remains to be explored. In addition, it is unclear whether these deficits in ER are specific to people with a history of BD. Methods: We examined whether euthymic BD individuals differ from healthy controls (HC) and individuals with a history of Major Depressive Disorder (MDD) with respect to the cognitive ER strategies they habitually use (CERQ) in response to negative affect. The sample consisted of 42 bipolar patients, 43 patients with MDD and 39 HC. Results: Compared to HC, euthymic BD and MDD individuals reported increased use of rumination, catastrophizing, and self-blame alongside decreased use of positive reappraisal, and putting into perspective. No differences were found between BD and MDD groups. Limitations: These findings are based on self-reports reflecting the habitual use of ER-strategies. The use of more objective methods and the examination of the spontaneous use of ER-strategies in euthymic BD would be desirable. Conclusions: Deficits in the habitual use of ER strategies may characterize BD and MDD individuals even outside of an acute episode and thereby play a role in the recurrence of affective disorders. & 2014 Elsevier B.V. All rights reserved.
Keywords: Affective disorders Bipolar Depression Emotion regulation Euthymic CERQ
1. Introduction According to the World Health Organization, bipolar disorder (BD) is one of the most disabling psychiatric disorders and a leading cause of non-fatal burdens (World Health Organization, 2008). BD is characterized by recurrent episodes of depression, periods of sustained and abnormally elevated mood, and/or mixed states with co-occurring depressive and manic symptoms (American Psychiatric Association, 2000). It has been proposed that negative life events trigger increases in depressive symptoms whereas certain positive life events trigger (hypo-)manic symptoms (Johnson, 2005). Research has also shown that individuals with BD display prolonged recovery following a stressful life event (Goplerud and Depue, 1985). In addition, experimental studies suggest that bipolar spectrum disorders are associated with impairments in emotional recovery. Subclinical cyclothymic subjects compared to healthy controls (HC), for example, exhibited elevated cortisol levels 3 h after a stressful task indicating prolonged stress recovery (Depue et al., 1985). Taken together, these
n Correspondence to: Department of Clinical Psychology, University of Tübingen, Schleichstr. 4, 72076 Tübingen, Germany. Tel.: þ 49 70 7129 77184; fax: þ49 70 7129 5219. E-mail address: [email protected] (L. Wolkenstein).
0165-0327/$ - see front matter & 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.12.022
findings suggest deficits in regulatory processes in BD and various authors have proposed that difficulties in emotion regulation lie at the core of BD (Phillips and Vieta, 2007; Johnson et al., 2007; Gruber, 2011). According to Gross (1998) emotion regulation (ER) refers to processes by which individuals influence the appearance of emotions and how they experience and express these emotions. Some of these processes are implicit, automatic, and are performed without any consciousness or effort, whereas others are explicit, controlled, and are exerted consciously and with effort (Gyurak et al., 2011). Strategies that are performed consciously and effortfully can be subdivided into behavioral ER strategies (e.g., situation selection, expressive suppression) and cognitive ER strategies (e.g., cognitive reappraisal, rumination) (Gross and John, 2003; Garnefski and Kraaij, 2007). Although all ER strategies might be helpful in particular situations, studies suggest a general advantage of some ER strategies over others (e.g., Garnefski and Kraaij, 2007; Nezlek and Kuppens, 2008). Garnefski and Kraaij (2007), for example, showed that the use of catastrophizing, rumination, and self-blame is positively associated with symptoms of depression and anxiety whereas the use of positive reappraisal is negatively associated with these symptoms. Thus, ER strategies can be differentiated into (primarily) adaptive strategies and (primarily) maladaptive strategies.
L. Wolkenstein et al. / Journal of Affective Disorders 160 (2014) 92–97
Despite the fact that BD is defined by dysregulated emotional states (American Psychiatric Association, 2000), few studies to date have investigated the habitual use of ER strategies in BD. The majority of these studies used the Response Styles Questionnaire (RSQ; Nolen-Hoeksema et al., 1993) and highlighted that, in response to negative life events, remitted BD participants ruminate more than HC (Thomas et al., 2007; Van Der Gucht et al., 2009). Moreover, self-reported rumination has been associated with higher levels of depression and hypomania in adolescents at risk for BD (Knowles et al., 2005; Thomas and Bentall, 2002). The use of a revised version of the RSQ (Knowles et al., 2005) has further revealed that, in response to negative affect, depressed and remitted BD participants use adaptive coping strategies (i.e., distraction and problem solving) less frequently compared to manic BD participants (Thomas et al., 2007). Interestingly, manic BD participants reported to use adaptive coping strategies even more frequently than HC (Thomas et al., 2007). Compared to the RSQ and the revised version of the RSQ the Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski et al., 2001) samples a broader range of cognitive strategies used to regulate emotions in response to negative events. In addition to the habitual use of rumination, the CERQ also assesses the use of self-blame, blaming others, catastrophizing, putting into perspective, positive reappraisal, acceptance, positive refocusing, and refocus on planning. Within the context of BD, the CERQ has been previously used in two studies. The first study highlighted that, in addition to the more frequent use of rumination, bipolar individuals compared to HC report a more frequent use of catastrophizing and self-blame in response to negative events (Green et al., 2011). This was confirmed by the second study, that also showed a less frequent use of putting into perspective within the BD group (Rowland et al., 2013). Concerning the other cognitive ER strategies assessed by the CERQ, neither Green et al. (2011) nor Rowland et al. (2013) found any differences between bipolar patients and HC. However, the participation of the BD subjects in both studies was based on diagnoses given previously to the beginning of the study in question (in other studies). In other words, subjects0 current mood states were not assessed. Therefore, it is not unlikely that the inclusion of symptomatic individuals may have blurred differences between euthymic BD patients and HC: First, keeping in mind the symptoms of (hypo)-manic episodes, it is probable that individuals in a (hypo-) manic mood state are more likely to refocus on positive things, to positively reappraise, and to refocus on planning when being confronted with a negative event. Second, in the study by Thomas et al. (2007) manic BD participants reported a more frequent use of adaptive coping strategies as assessed by the RSQ not only compared to depressed and euthymic BD participants, but also compared to HC. To summarize, there is preliminary evidence that euthymic BD individuals show increased use of rumination in response to negative events. However, no study thus far has compared euthymic BD participants to HC in their habitual use of a broad range of cognitive ER strategies as assessed by the CERQ. That is, thus far we do not know whether deficits in the use of cognitive ER strategies that have been reported in BD (Green et al., 2011; Rowland et al., 2013) are merely a correlate of acute affective symptoms or are present independently of acute symptoms and might thus constitute a risk factor for future episodes. Studies specifically examining euthymic BD participants are of particular importance, given that recent models propose that maladaptive reactions to negative and positive affect underlie the downward and upward spirals, respectively, which in turn might result in a depressive or a manic episode in BD (Gruber, 2011; Johnson, 2005). It is therefore the main goal of this study to compare the habitual use of cognitive ER strategies of interepisode BD and HC. Furthermore, to examine whether our findings are specific to the bipolar spectrum of affective disorders or
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generalize to other affective disorders, we included a sample of remitted unipolar depressed patients. To our knowledge there is only one study thus far that has examined the habitual use of cognitive ER strategies in remitted depression. In this study, recovered depression was associated with an increased use of rumination and catastrophizing as well as a decreased use of putting into perspective compared to HC (Ehring et al., 2008). Due to the shared risk of remitted BD and remitted MDD for developing a depressive episode following a negative life event and based on previous studies that have examined the habitual use of ER in BD and MDD participants (Rowland et al., 2013; Green et al., 2011; Ehring et al., 2008; Van Der Gucht et al., 2009), we hypothesized that euthymic BD patients as well as remitted MDD patients display increased use of rumination and catastrophizing and decreased use of positive reappraisal and putting into perspective. Given that BD has repeatedly been associated with an increased use of self-blame (Green et al., 2011; Rowland et al., 2013), which has not been found in remitted MDD (Ehring et al., 2008), we further propose that euthymic BD patients, but not remitted MDD patients, display an increased use of self-blaming.
2. Methods 2.1. Participants One hundred and twenty-four participants were recruited through an outpatient clinic as well as through advertisements posted on the Internet and within the community. Participants were invited for an interview if they were deemed eligible based on screening conducted per telephone. To determine the diagnostic status of participants, trained interviewers administered the Structured Clinical Interview for DSM-IV (SCID; First et al., 1996). Participants with BD (n ¼42) either met the diagnostic criteria for remitted bipolar I disorder (62%) or for remitted bipolar II disorder (38%), based on the diagnostic criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000). Participants with MDD (n ¼43) either met DSM-IV criteria for recurrent MDD in remission (74.42%) or for an MDD single episode in remission (25.58%). Participants in the HC group (n ¼39) did not meet diagnostic criteria for any current or past Axis I disorder. Exclusion criteria for all participants were insufficient knowledge of the German language and age below 18 or above 69. Exclusion criteria for both clinical groups were lifetime psychotic symptoms (except moodcongruent delusions within affective episodes), current alcohol or substance dependency (if they met the lifetime diagnostic criteria they had to be abstinent for at least 24 months), current alcohol or substance abuse, cluster A personality disorders, borderline personality disorder, antisocial personality disorder, and current anorexia nervosa (BMI r18 kg/m²). Furthermore, participants in both clinical groups had to be remitted for at least 8 weeks and were required to take no medication or to take medication on a stable dosage for at least 4 weeks. Of the 42 BD participants 81% and of the 43 MDD participants 39.5% were on various medications at the time of the study (one participant in the HC group took antidepressants due to sleep disturbances). 2.2. Assessment of clinical symptoms To assess self-reported current symptom levels of depression, we used the Quick Inventory for Depressive Symptomatology Self-Report (QIDS-SR; Rush et al., 2003). The QIDS-SR comprises 16 items that assess presence and severity of 16 depression-related symptoms. It demonstrates high internal consistency with Cronbach0 s α ¼.86 (Rush et al., 2003) and has proven to be suitable not only for MDD
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L. Wolkenstein et al. / Journal of Affective Disorders 160 (2014) 92–97
Table 1 Demographic, neuropsychological and clinical characteristics of participants. Characteristic
Bipolar disorder %
Gender (female) University entrance diploma (yes) Age QIDS-SR HAM-D Age at first treatment SRMI YMRS
M
Major depressive disorder SD
61.90 69.05
%
M
Healthy controls SD
72.09 72.09 40.86 4.88 3.00 28.41 4.00 1.67
12.79 4.49 2.55 11.46 4.83 2.07
%
M
SD
42.18 1.15
13.27 1.27
58.97 64.10 36.91 4.40 3.58 28.37
13.35 3.24 2.40 12.37
Note: QIDS-SR ¼Quick Inventory of Depressive Symptomatology Self-Report; HAM-D ¼Hamilton Depression Rating Scale; SRMI ¼Self-Report Manic Inventory; YMRS¼ Young Mania Rating Scale.
but also for BD (Bernstein et al., 2010). The QIDS-SR demonstrated good internal consistency in the current sample (Cronbach0 s α ¼.80). As a clinician-rated instrument to assess the severity of current depressive symptoms we used the Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960), which comprises 21 items asking for the presence and severity of 20 depression-related symptoms. Good internal consistency of this scale has been proven over years (Trajković et al., 2011). Within the current sample the internal consistency was acceptable (Cronbach0 s α ¼.69). To assure the remitted mood state of the clinical groups, we required a score below 9 on the HAM-D for BD and MDD participants. Self-reported severity of manic symptoms within the BD group was assessed with the self-report manic inventory which comprises 48 true-false items (SRMI; Shugar et al., 1992). Within the current sample the internal consistency of the SRMI was high (Cronbach0 s α ¼ .85). To assess clinician-rated symptom levels of mania in the BD group, we used the Young Mania Rating Scale (YMRS; Young et al., 1978), which comprises 11 items asking for the presence and severity of different mania-associated symptoms. With Cronbach0 s α ¼ .45 the internal consistency of this scale was poor within our sample, which is probably not only due to the small sample size the calculation is based on (n ¼ 42) but also to the fact that all BD participants were remitted at the time of the study. To assure remission with respect to mania within the BD group, we required a score below 12 on the YMRS. 2.3. Cognitive emotion regulation questionnaire The CERQ is a 36-item self-report questionnaire which has been developed to measure the habitual use of nine cognitive ER strategies (Garnefski et al., 2001). The strategies characterize the individual0 s style of responding to negative events. Each of the nine conceptually distinct subscales consists of four items. Internal consistencies for the subscales have been reported to range from Cronbach0 s α ¼ 0.68 to Cronbach0 s α ¼0.83 (Garnefski et al., 2001). The internal consistencies in our sample where comparable with Cronbach0 s α ranging from 0.64 to 0.86. As in the study of Garnefski et al. (2001), only the internal consistency of one subscale was below 0.70 whereas five of the alphas were 0.80 or higher. In a next step we looked at each study group separately. Within the BD group Cronbach0 s α ranged from 0.71 to 0.90, within the MDD group it ranged from 0.59 to 0.83 and within the HC group Cronbach0 s α ranged from 0.56 to 0.85.
Participants who were deemed eligible through the phone screening were sent the SCID II screening questionnaire as well as the CERQ to complete at home and to bring to their diagnostic assessment session. During the diagnostic assessment session sociodemographic data were recorded before the interviewer administered the SCID-I and SCID-II (the latter if necessary), the YMRS (only BD participants), and the HDRS (only BD and MDD participants). Afterwards participants were asked to complete the QIDS-SR and the SRMI (only BD group). 2.5. Statistical analyses Group means were compared with a multivariate analysis of variance (MANOVA) and subsequent univariate analyses of variance (ANOVAs). Furthermore, post-hoc t-tests were conducted.
3. Results Demographic and clinical characteristics of the three groups are presented in Table 1. The three groups differed significantly only with respect to current depressive symptoms as assessed by the QIDS-SR, F(2, 121) ¼ 14.99, p o.001, η2 ¼ .20. Follow-up tests indicated that both, the BD group, t(48) ¼ 5.16, p o.001, as well as the MDD group, t(56) ¼ 6.07, po .001, had significantly higher QIDS-SR scores compared to HC. The two clinical groups, however, did not differ from each other, t(83) ¼0.57, p¼ .568.1 Even though both clinical groups differed from HC with respect to current depressive symptoms, the scores of all participants lay clearly below the clinical cutoff indicating that all patients fulfilled criteria for remission. In addition, the two clinical groups did not differ from each other with respect to their HAM-D scores or age at first treatment. 3.1. Group differences in cognitive emotion regulation strategies Our main hypotheses predicted group differences in the habitual use of particular ER strategies. Specifically, we predicted that euthymic BD patients as well as remitted MDD patients display an increased use of rumination and catastrophizing, and a decreased use of positive reappraisal and putting into perspective. Furthermore we expected that euthymic BD patients should display an increased use of self-blame compared to HC and MDD participants. Means and standard deviations are presented in Table 2. First, we conducted a MANOVA on the total scores of the nine CERQ
2.4. Procedure The procedures of the current study were approved by the local Ethical Committee and are in accordance with the Helsinki Declaration.
1 Within the whole sample the QIDS-SR was significantly correlated with all cognitive emotion regulation strategies (all rr .178 or rZ .254 and all p o .05). However, following the recommendations of Miller and Chapman (2001) we refrained from including the QIDS-SR as a covariate.
L. Wolkenstein et al. / Journal of Affective Disorders 160 (2014) 92–97
Table 2 Means and standard deviations of all cognitive emotion regulation strategies for the three groups. CERQ subscale
Self-blame Blaming others Rumination Catastrophizing Putting into perspective Positive refocusing Positive reappraisal Acceptance Refocus on planning
Bipolar disorder
Major depressive disorder
Healthy controls
M
SD
M
SD
M
SD
10.81 7.33 11.36 8.14 10.36 8.64 11.36 11.74 10.57
3.71 2.93 3.79 3.59 3.31 3.60 3.80 3.46 3.58
10.93 7.19 12.16 7.63 11.14 9.19 11.77 12.21 11.21
4.03 2.40 3.55 3.01 3.10 3.47 4.17 3.11 2.87
7.53 6.29 7.21 5.24 14.42 10.42 13.74 11.84 11.97
1.91 2.10 2.71 1.57 3.48 3.61 3.71 3.33 3.32
Note: CERQ ¼ Cognitive Emotion Regulation Questionnaire. Italic values indicate all values that differed significantly between groups.
subscales which yielded a significant main effect of ‘group’, F(18, 226) ¼4.07, po .001, η2 ¼.245. Subsequent ANOVAs indicated a significant main effect of ‘group’ for self-blame, F(2, 120) ¼12.78, p o.001, η2 ¼.176, rumination, F(2, 120) ¼24.11, p o.001, η2 ¼.287, catastrophizing, F(2, 120) ¼11.37, p o.001, η2 ¼.159, putting into perspective, F(2, 120) ¼16.91, p o.001, η2 ¼ .220, and positive reappraisal, F(2, 120) ¼4.17, p ¼.018, η2 ¼ .065. There were no group differences with respect to blaming others, F(2, 120) ¼1.99, p¼ .141, positive refocusing, F(2, 120) ¼2.59, p¼ .079, acceptance, F(2, 120) ¼0.24, p ¼.788, or refocus on planning, F(2, 120) ¼1.84, p ¼.163. Follow-up t-tests were performed on the five significant CERQ subscales to examine specific group difference in the use of these strategies. Compared to HC, BD participants reported more frequent use of self-blame, t(63)¼ 5.04, po.001, rumination, t(74)¼ 5.67, po.001, and catastrophizing, t(57)¼ 4.77, po.001, as well as less frequent use of putting into perspective, t(78)¼5.35, po.001, and positive reappraisal, t(78)¼2.83, p¼.006. We found the same pattern for MDD participants. Compared to HC, they too showed an increased use of self-blame, t(62)¼ 4.95, po.001, rumination, t(79)¼ 6.98, po.001, and catastrophizing, t(65)¼ 4.56, po.001, alongside a decreased use of putting into perspective, t(79)¼ 4.49, po.001, and positive reappraisal, t(79)¼2.23, p¼.028. We did not find any significant differences between BD participants and MDD participants (all pZ.264). 3.2. Association between cognitive emotion regulation strategies and residual symptoms We further examined whether the habitual use of cognitive ER strategies is associated with self-reported residual symptoms separately for the BD and the MDD subsamples. Within the BD subsample we found a positive correlation between depressive residual symptoms as assessed by the QIDS and the use of blaming others (r ¼.541, p o.001). In contrast, acceptance was negatively correlated with depressive residual symptoms (r ¼ .354, p ¼.021). Manic residual symptoms as assessed by the SRMI were positively correlated with self-blame (r ¼ .359, p ¼ .020). Within the MDD subsample the QIDS sum score was negatively correlated with putting into perspective (r ¼ .378, p ¼.012). 3.3. Within-group differences in the BD group with respect to cognitive emotion regulation strategies As the BD group comprised n ¼ 26 BD-I participants and n ¼16 BD-II participants, we decided to explore whether BD-I and BD-II
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patients differed in their habitual use of cognitive emotion regulation strategies. First, we examined whether BD-I and BD-II patients differed in symptom levels. We did not find any withingroup differences on the QIDS-SR (t(40) ¼ 1.50, p ¼.149), HAM-D (t(40) ¼ 0,87, p ¼.389), SRMI (t(40) ¼0.56, p ¼.580), and YMRS (t(40) ¼ 1.47, p¼ .150). Second, we conducted a MANOVA on the total scores of the nine CERQ subscales. The main effect of ‘subgroup’ was not significant, F(9, 32) ¼0.22, p¼ .989, indicating that BD-I and BD-II patients do not differ with respect to their habitual use of cognitive emotion regulation strategies.
4. Discussion With the knowledge that dysregulated emotion is a defining characteristic of BD, this study examined whether euthymic BD individuals differ from HC with respect to their habitual use of ER strategies. To clarify whether deficits in ER are specific to the bipolar spectrum or generalize to affective disorders, we included a sample of unipolar depressed patients in remission in the study design. We hypothesized that compared to HC both, euthymic BD patients and remitted MDD patients, would display an increased use of rumination and catastrophizing as well as a decreased use of positive reappraisal and putting into perspective. Furthermore, we proposed that only remitted BD patients would display an increased use of self-blaming compared to HC. In line with our hypothesis, we found that BD as well as MDD, compared to HC, are associated with increased use of rumination and catastrophizing alongside decreased use of positive reappraisal and putting into perspective. In contrast to our hypotheses, we additionally found that both, remitted BD patients as well as remitted MDD patients, show an increased use of self-blame compared to HC. Indeed, our study yielded no differences between BD and MDD participants in self-reported habitual use of ER strategies. Furthermore, no group differences were found with respect to the use of blaming others, acceptance, positive refocusing, or refocus on planning. A heightened tendency to ruminate in response to negative events has repeatedly been reported in BD populations (Green et al., 2011; Thomas et al., 2007; Van Der Gucht et al., 2009). Studies have also shown that BD participants seem to ruminate to the same extent as participants suffering from MDD (Kim et al., 2012; Johnson et al., 2008). However, studies addressing the latter issue did not assess the current mood state of their participants. Thus, it remained unclear whether the increased use of rumination is also present in inter-episode BD or whether this finding is merely due to a subsample of acutely depressed BD participants. Our results show that euthymic BD participants ruminate to the same extent as participants with a history of MDD. Moreover, and in line with previous studies, we found that increased use of catastrophizing and decreased use of putting into perspective are associated with a history of both, MDD (Ehring et al., 2008) and BD (Green et al., 2011; Rowland et al., 2013). Notably, this is the first study to demonstrate that neither increased use of rumination and catastrophizing nor decreased use of putting into perspective are specific to BD or MDD, but rather seem to reflect a general marker of vulnerability to affective disorders. In addition, our results indicate that increased use of self-blame and decreased use of positive reappraisal are also markers of affective disorders, rather than being specific to either BD or MDD. However, this finding is in contrast to the results reported in a study by Ehring et al. (2008), in which neither increased selfblame nor decreased reappraisal was found in remitted MDD participants, as well as to the two studies including BD individuals, which did not find decreased use of positive reappraisal in BD (Green et al., 2011; Rowland et al., 2013).
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Differences in the samples may be responsible for differences in findings across the studies. Whereas the current study only included remitted bipolar patients, neither Green et al. (2011) nor Rowland et al. (2013) controlled for current mood state. Thus, while a decreased use of positive reappraisal may be characteristic of euthymic BD, the inclusion of symptomatic BD participants may have blurred this finding in previous studies. As outlined previously, it is possible that particularly (hypo-)manic BD participants make use of positive reappraisal, which might have led to non-significant findings in the studies of Green et al. (2011) and Rowland et al. (2013). This finding illustrates the importance of clearly defining the mood state of BD participants in studies looking at the habitual use of ER strategies. Whereas a decreased use of adaptive cognitive reframing techniques in remitted BD patients may reflect impaired capacities to set aside the significance of a negative event and to re-appraise, an increased use of these strategies in (hypo-)manic BD individuals may be indicative of their current symptoms. Whereas Ehring et al. (2008) did not find differences between recovered depressed participants and HC with respect to selfblame and positive reappraisal, we found increased use of selfblame and decreased use of reappraisal not only in euthymic BD but also in remitted MDD participants. Here, the difference in findings could be due to differences in depressive residual symptoms of the remitted MDD groups in the two studies, but it is unlikely. Whereas in the current study MDD differed from HC participants with respect to depressive symptoms, no such difference was reported in the study by Ehring et al. (2008). However, with a mean QIDS-SR score of 4.40 within the MDD group, the MDD participants in the current study were clearly remitted, as were the participants in the Ehring sample. Furthermore, we did not find any correlations between depressive residual symptoms and self-blame or positive reappraisal within our MDD subsample. Thus, it remains unclear what causes the differences between our findings and the findings of Ehring et al. (2008). However, studies in non-clinical samples consistently indicate significant relations between increased use of self-blame, rumination, and catastrophizing and decreased use of positive reappraisal and emotional problems (e.g., current and future depressive symptoms) (Garnefski and Kraaij, 2007, 2009). Thus, one would expect not only euthymic BD patients but also remitted MDD patients to display increased use of self-blame and decreased use of positive reappraisal, which is in line with our results. Future studies are necessary to replicate these findings. In addition to the group differences, correlational analyses revealed associations between depressive residual symptoms within the BD group and two strategies that did not differ between groups: Blaming others was positively correlated with depressive residual symptoms whereas acceptance was negatively correlated with depressive symptoms. It is possible that compared to HC, BD patients show a significantly increased extent of blaming others as well as a significantly decreased extent of acceptance only during acute depressive episodes. Future studies are required to directly investigate these hypotheses. Furthermore, an explorative within-group analysis yielded no significant difference between BD-I and BD-II patients with respect to their habitual use of cognitive emotion regulation strategies. As this analysis was based on a comparatively small sample size, replication studies using larger samples will be necessary to provide further support for this result. Our results demonstrate that it is vital to examine which ER strategies BD patients use while in a stable euthymic mood state as compared to their strategy selection in view of first affective symptoms of either polarity. It is possible, for example, that the strategy of positive refocusing is useful inter-episode as well as in the face of first depressive symptoms, whereas it might not be
useful when experiencing first (hypo-)manic symptoms. Gaining more insight into these selection processes will be useful for the development of appropriate intervention strategies. In this context it is worth mentioning that recent studies have demonstrated that euthymic BD individuals compared to HC report to expend increased effort to regulate their emotions independent of whether they watch an emotional or a non-emotional film-clip— suggesting that inter-episode BD individuals demonstrate a lessnuanced strategy selection with respect to the circumstances (Gruber et al., 2012). 4.1. Limitations While the findings of our study contribute significantly to our understanding of the habitual use of ER strategies within the context of euthymic BD and remitted MDD, there are a number of limitations of this study that should be kept in mind. The focus of this study was on the regulation of negative affect. Previous research, however, has pointed out that individual differences in responding to positive affect may play a critical role in BD (Johnson et al., 2008; Gruber et al., 2011; Alloy et al., 2009). Dampening or positive rumination, for example, have not only been shown to be associated with depressive symptoms but also with symptoms that might be of special relevance for elevated mood-states such as mania (Feldman et al., 2008). In contrast to depression, BD is not only associated with an increased tendency to ruminate in response to negative affect but also with an increased selfreported tendency to ruminate in response to positive affect (Johnson et al., 2008; Gruber et al., 2011). Whereas traitrumination in response to both negative and positive affect has been associated with higher life-time frequency of depression (Alloy et al., 2009; Gruber et al., 2011), only trait-rumination in response to positive affect has also been linked to higher lifetimefrequency of mania (Gruber et al., 2011). Furthermore, positive rumination has been found to be associated with symptoms of hypomania in a college student sample (Raes et al., 2009). Future studies should address this issue and broaden our knowledge about ER strategy use in euthymic BD patients by examining responding to negative as well as positive affect. Furthermore, even though the CERQ is frequently used to assess the habitual use of cognitive emotion regulation strategies (Ehring et al., 2008; Green et al., 2011), it has to be kept in mind that it is a self-report measure. Thus, it presumes a certain amount of introspective abilities to answer the questions of the CERQ. It is debatable whether subjects do have comprehensive access to their own cognitive processes and are able to give valid answers to such questions. There may be memory biases, for example, that distort participants0 response patterns. Thus, it will be interesting to extent the measures used to assess cognitive emotion regulation strategies in euthymic bipolar patients by integrating more objective measures in future studies. Of note, even though there are first studies demonstrating which brain networks are involved in particular emotion regulation strategies (McRae et al., 2008), our knowledge with respect to this question is limited. 4.2. Conclusions To summarize, euthymic BD as well as remitted MDD, is associated with an increased use of (primarily) maladaptive ER strategies and a decreased use of (primarily) adaptive ER strategies. Given that this pattern of ER strategy use is present during remission, i.e., it is not associated with the presence of acute affective symptoms, it may likely be a risk factor for the development of further affective episodes. Studies are needed that go beyond the examination of self-reported habitual use of ER strategies and assess whether the use of certain ER strategies predicts the
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recurrence of affective episodes and whether BD and MDD participants can be trained to effectively use adaptive ER strategies. In a recent study Gruber et al. (2012) found that bipolar patients report greater effort but less success in spontaneously regulating their emotions which suggests that besides the habitual use of certain ER strategies there may be other deficits influencing ER ability in patients suffering from affective disorders. Future studies are needed to clarify which processes underlie these deficits to successfully regulate emotions and to develop appropriate interventions. Furthermore, we need to examine whether ER deficits are specifically characteristic for remitted affective disorders or whether they characterize individuals with any lifetime psychiatric diagnosis. The latter would indicate that deficient ER constitutes a risk factor for the recurrence of either psychopathology. Role of funding source We had no funding for this study.
Conflict of interest All authors declare that they have no conflicts of interest.
Acknowledgements We thank Marjorie Kinney, who kindly assisted with the proof-reading of the manuscript.
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