Research paperMindfulness, mood symptom tendencies and quality of life in bipolar disorder: An examination of the mediating influence of emotion regulation difficulties
Introduction
Despite widespread use of conventional pharmacological treatments, episodic relapse after mood stabilisation in bipolar disorder (BD) is common (Gitlin et al., 1995). Key risk factors for relapse and poor clinical course in BD include trait depressive tendencies, comorbid anxiety, and the presence of residual mood symptoms during inter-episode periods (Altman et al., 2006; Brietzke et al., 2012; Judd et al., 2008; Lozano and Johnson, 2001; Samalin et al., 2016; Treuer and Tohen, 2010). At the same time, these emotion-relevant symptoms contribute to the persistent psychosocial dysfunction that is characteristic of a large proportion of individuals with the disorder (Van Rheenen and Rossell, 2014a, 2014b).
One psychological factor implicated as a protective mechanism against maladaptive mood symptoms is mindfulness (Radford et al., 2014). Mindfulness refers to both an enduring dispositional tendency as well as a meditative practice that facilitates a disengagement from automatic thoughts, habits, and unhealthy behavioural patterns (Brown and Ryan, 2003). Being mindful, therefore, involves paying purposeful attention to present moment experiences with a curious, non-judgemental and accepting attitude (Hölzel et al., 2011; Kabat-Zinn, 2009; Ludwig and Kabat-Zinn, 2008). Since greater dispositional mindfulness optimises self-regulatory processes important for psychological well-being, it has been linked to a range of emotional health-related benefits. These include, but are not limited to, increased mental flexibility and resilience, reduced maladaptive ruminations and mind-wandering, as well as lower levels of impulsivity, stress and anxiety (Becerra et al., 2017; Chambers et al., 2009; Chiesa and Serretti, 2009; Davis and Hayes, 2011; Grossman et al., 2004; Keng et al., 2011).
Mindfulness practices have been incorporated into formal psychological therapies since the 1980s, with mindfulness-based interventions grounded on the premise that distress is a result of an individual's response to an experience or symptom rather than the event itself (Abba et al., 2008; Hayes, 2004; Kabat-Zinn, 1982; Kabat-Zinn, 2009; Louise et al., 2018; Phang and Oei, 2012). Thus, mindfulness training in its essence, teaches observation and acceptance of all experiences, as opposed to directly reacting to, challenging, or ruminating on these experiences (Murray et al., 2017). There is evidence that suggests individuals with higher dispositional mindfulness have better outcomes from mindfulness training compared to individuals with lower dispositional mindfulness (Shapiro et al., 2011). To our knowledge, dispositional mindfulness has not been explicitly assessed in BD, although mindfulness-based interventions are being increasingly trialled in the disorder. Whilst these interventions appear to have minimal effect on manic symptoms, significant improvements in sub-clinical depression and anxiety, psychological well-being and psychosocial functioning have been reported amongst euthymic BD individuals (Bojic and Becerra, 2017; Chu et al., 2018; Lovas and Schuman-Olivier, 2018; Murray et al., 2017). However, the mechanisms by which mindfulness benefits people with BD are yet to be established.
One process put forward as a potential mediating factor in the relationship between mindfulness and psychopathology is that of emotion regulation (Chambers et al., 2009; Coffey et al., 2010; Gratz and Tull, 2010; Guendelman et al., 2017). Traditionally, emotion regulation has been defined as a set of automatic and control processes that initiate, maintain, and modify the intensity and duration of emotions (Gross, 1998, 2014). This purportedly occurs through selecting, modifying, or attending to specific components of the emotion-inducing situation/stimulus, altering how the situation/stimulus is perceived mentally, or directly modifying the behavioural response to the emotion. An alternate framework put forward by Gratz and Roemer (2004) posits that emotion regulation also involves the understanding, awareness, and acceptance of emotional distress, rather than only the control or dampening of emotions or emotional arousal. This framework highlights emotion regulation as involving the flexible and goal-directed use of situationally appropriate strategies to modulate the responses to emotions, rather than attempts to control emotions for the purpose of avoiding or eliminating them entirely. Within this, the dimensions of emotion regulation that recognise that all emotions serve a purpose, appear to be most relevant to the study of mindfulness, and are likely mediators of mindfulness-based psychological change (Gratz and Tull, 2010). Specifically, the emphasis of mindfulness on the observation and description of one's experiences is theorised to promote emotional awareness, clarity, objectivity, and acceptance of all emotions, even those that are unpleasant. It has been argued that this may lead to a decoupling of emotion from behaviour, and thus eventually, less automatic reactions to emotional experiences (Gratz and Tull, 2010). In contrast, control-based conceptualisations of emotion regulation are likely to reinforce a non-accepting and judgemental stance towards unwanted emotions, a process which goes against the principles of mindfulness and mindfulness-based therapies.
Central to the present study is the fact that emotion regulation difficulties are characteristic and enduring features of BD (Dodd et al., 2019; Townsend and Altshuler, 2012). Indeed, patients with the disorder report increased maladaptive coping strategy use compared to controls (Bridi et al., 2018; Fletcher et al., 2013; Green et al., 2011), as well as poorer emotional clarity and difficulties accepting emotional responses or believing in one's own capacity to regulate emotion effectively (Becerra et al., 2013; Van Rheenen et al., 2020, 2015). Such difficulties have been repeatedly associated with depressive tendencies (Van Rheenen et al., 2020, 2015).
Several lines of empirical inquiry indicate that emotion regulation mediates the effect that dispositional mindfulness has on various psychopathologies (Coffey and Hartman, 2008; Coffey et al., 2010), and that enhancements to emotion regulation in non-clinical populations arise from formal mindfulness training (Schirda et al., 2020; Wimmer et al., 2019; Zhang et al., 2019). It is thus possible that the effect of mindfulness on indicators of psychopathology in BD occur via its effects on emotion regulation. As such, the aim of the current study was to explore whether emotion regulation difficulties mediated the relationship between dispositional mindfulness and depressive and manic tendencies in individuals with the disorder, as well as their subjective quality of life. It was hypothesised that individuals with BD would report lower dispositional mindfulness compared to controls. It was also hypothesised that lower levels of dispositional mindfulness in the BD group would be associated with increased depressive tendencies and poorer quality of life; with these associations mediated by the magnitude of emotion regulation difficulties. Finally, given the negligible findings of the mindfulness trial-based literature in relation to mania, a secondary exploratory aim of the current study was to examine whether these associations extended to mania tendencies.
Section snippets
Method
This works complies with the ethical standards of the Local Human Ethics Review Board and with the Declaration of Helsinki.
Descriptive analysis
The results of the descriptive comparisons of BD and HCs are display in Table 1. There were no significant between group differences in age or sex. The BD group had significantly higher 7 Up, 7 Down, DERS subscale, MADRS and YMRS scores, and significantly lower MAAS scores compared to the HC group. Effect sizes for all comparisons were large.
Primary meditation analysis
Mindfulness-emotion regulation difficulty (i.e., a path): Lower MAAS scores significantly predicted higher scores on all five DERS subscales (Clarity [B
Discussion
In this study, we sought to contribute to the understanding of dispositional mindfulness and its influence on BD. To this end, we examined i) BD-HC differences in dispositional mindfulness, ii) determined relationships between mindfulness, and depressive and manic tendencies as well as and subjective quality of life in BD, and iii) identified whether these relationships were mediated by difficulties in emotion regulation.
As expected, lower dispositional mindfulness was reported by BD patients
Funding source
The authors would like to acknowledge project specific financial support of the Jack Brockhoff Foundation, University of Melbourne, Barbara Dicker Brain Sciences Foundation, Rebecca L Cooper Foundation and the Society of Mental Health Research. TVR was supported by an NHMRC Early Career Fellowship (GNT1088785), SLR was supported by an NHMRC Senior Fellowship (GNT1154651). JK was supported by Swinburne University/ postgraduate scholarship and LF was supported by an Australian Rotary Health/Ian
CRediT authorship contribution statement
Sean P. Carruthers: Visualization, Formal analysis, Writing – original draft. Susan L. Rossell: Conceptualization. Greg Murray: Conceptualization. James Karantonis: Data curation. Lisa S. Furlong: Data curation. Tamsyn E. Van Rheenen: Visualization, Formal analysis, Writing – original draft, Data curation.
Declaration of Competing Interest
None.
Acknowledgments
The authors would like to thank all the participants who took the time and effort to take part in this study.
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