Emotion dysregulation in bipolar disorder compared to other mental illnesses: a systematic review and meta-analysis

Abstract

People with bipolar disorder (BD) often present emotion dysregulation (ED), a pattern of emotional expression interfering with goal-directed behavior. ED is a transdiagnostic construct, and it is unclear whether it manifests itself similarly in other conditions, such as major depressive disorder (MDD) or borderline personality disorder (BPD), or has specific features in BD. The present systematic review and meta-analysis explored ED and adopted emotion regulation (ER) strategies in BD compared with other psychiatric conditions. PubMed/MEDLINE, EMBASE, Scopus, and PsycINFO databases were systematically searched from inception to April 28th, 2022. Studies implementing validated instruments assessing ED or ER strategies in BD and other psychiatric disorders were reviewed, and meta-analyses were conducted. Twenty-nine studies yielding multiple comparisons were included. BD was compared to MDD in 20 studies (n = 2451), to BPD in six studies (n = 1001), to attention deficit hyperactivity disorder in three studies (n = 232), to anxiety disorders in two studies (n = 320), to schizophrenia in one study (n = 223), and to post-traumatic stress disorder in one study (n = 31). BD patients did not differ from MDD patients in adopting most adaptive and maladaptive ER strategies. However, small-to-moderate differences in positive rumination and risk-taking behaviors were observed. In contrast, patients with BPD presented an overall higher degree of ED and more maladaptive ER strategies. There were insufficient data for a meta-analytic comparison with other psychiatric disorders. The present report further supports the idea that ED is a transdiagnostic construct spanning a continuum across different psychiatric disorders, outlining specific clinical features that could represent potential therapeutic targets.

Keywords: Bipolar disorder; borderline personality disorder; emotion dysregulation; emotion regulation; major depressive disorder.

Figure 1.

PRISMA flowchart, 2020 edition, adapted.

Figure 2.

Differences in adopted emotion regulation strategies between people with bipolar disorder and people with major depressive disorder (left) and borderline personality disorder (right). Overall results of the comparisons included in the meta-analysis. Note: BD, ‘bipolar disorder’; BPD, ‘borderline personality disorder’; CERQ, ‘cognitive emotion regulation scale’; CERQ-1, ‘self-blame’; CERQ-2, ‘blaming others’; CERQ-3, ‘rumination’; CERQ-4, ‘catastrophizing’; CERQ-5, ‘putting into perspective’; CERQ-6, ‘positive refocusing’; CERQ-7, ‘positive reappraisal’; CERQ-8, ‘acceptance’; CERQ-9, ‘focus on replanning’; DERS, ‘difficulties in emotion regulation scale’; DERS-1, ‘nonacceptance’; DERS-2, ‘goals’; DERS-3, ‘impulse’; DERS-4, ‘awareness’; DERS-5, ‘strategies’; DERS-6, ‘clarity’; DERS-TOT, ‘total score’; ERQ, ‘emotion regulation questionnaire’; ERQ-1, ‘reappraisal’; ERQ-2, ‘suppression’; MDD, ‘major depressive disorder’; RPA, ‘response to positive affect’; RPA-1, ‘emotion focus’; RPA-2, ‘dampening’; RPA-3, ‘self-focus’; RRS, ‘ruminative response scale’; RRS-1, ‘reflective pondering’; RRS-2, ‘brooming’; RSQ-, ‘response style questionnaire’; RSQ-1, ‘rumination’; RSQ-2, ‘adaptive’; RSQ-3, ‘risk-taking’. *These items' effect sizes (ES) have been inverted to present graphically coherent results since the scale initially measures the individual's difficulties in adopting that emotion regulation strategy. The point size is proportional to the total sample size for that particular comparison. The number in parentheses indicates the number of studies considered for that particular comparison.