Attachment, reflective functioning and emotion regulation as predictors of proneness to develop bipolar disorder

Abstract

Background Within the context of developmental psychopathology and the psychological factors associated with the onset of severe mood instability, this thesis proposes that early attachment related interactions underlie the development of reflective functioning and effective emotional regulation necessary for optimal functioning. Both insecure attachment and poor reflective functioning have been linked to various mental disorders in which emotion dysregulation surfaces as a core feature. However, the underlying mechanisms by which these constructs interact to predict increased risk to develop bipolar disorder have yet to be considered. Objectives This project’s objectives were to investigate, through a quantitative cross sectional design, the following questions: 1) In what way are attachment, reflective function and emotion regulation associated with proneness to bipolar disorder? 2) Do reflective functioning, emotion regulation, depression and specific metacognitive patterns mediate the influence of attachment on increased likelihood of developing bipolar disorder? Method An online survey was used to ask 2325 participants to complete questionnaires measuring the variables of hypomanic traits, attachment relationship style, mood, emotion regulation, metacognitive patterns and reflective functioning. The survey was designed to give participants feedback immediately after entry completion, which proved to be a very successful recruitment strategy. For the analysis of the data, structural equation modeling (SEM), multivariate and univariate statistics were used. Results SEM analysis demonstrated that internal dysfunctional emotion regulation is the strongest predictor of bipolar disorder proneness, whilst anxious insecure attachment holds a strong direct relationship with internal dysfunctional emotion regulation not mediated by reflective functioning. Thus, anxious insecure attachment and reflective functioning emerged as indirect predictors to bipolar proneness, being fully mediated by internal dysfunctional emotion regulation strategies, depressive symptoms, perceived well being and negative metacognitive patterns. The use of dysfunctional emotion regulation strategies directly predicted low mood and indirectly predicted decreased well being and increased risk to develop bipolar disorder. Furthermore, in this sample the presence of hypomanic traits alone did not imply proneness to bipolar disorder, but it was the combination of hypomanic traits and depressive symptoms that best predicted increased likelihood of experiencing bipolar disorder. Discussion The results highlight the importance of investigating the underlying mechanisms of severe mood instability. The findings support the manic defense hypothesis, which suggests that manic symptoms emerge to offset underlying depressive mood. It was concluded that severe mood instability emerges and is maintained because of the influence of developmental interpersonal risk factors such as anxious insecure attachment. The latter fosters dysfunctional cognitive features that promote the use of maladaptive emotion regulation strategies, which in turn give rise to depressive mood, diminished well being and ultimately increased risk to develop bipolar disorder. Thus, to better understand and treat bipolar disorder it is important to focus on tackling these psychological aspects of the disorder.