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Associations between mood instability and emotional processing in a large cohort of bipolar patients

  • A. C. Bilderbeck (a1), Z. E. Reed (a1) (a2), H. C. McMahon (a1), L. Z. Atkinson (a1), J. Price (a1), J. R. Geddes (a1), G. M. Goodwin (a1) and C. J. Harmer (a1)...



Aberrant emotional biases have been reported in bipolar disorder (BD), but results are inconsistent. Despite the clinical relevance of chronic mood variability in BD, there is no previous research investigating how the extent of symptom fluctuations in bipolar disorder might relate to emotional biases. This exploratory study investigated, in a large cohort of bipolar patients, whether instability in weekly mood episode symptoms and other clinical and demographic factors were related to emotional bias as measured in a simple laboratory task.


Participants (N = 271, BDI = 206, BDII = 121) completed an ‘emotional categorization and memory’ task. Weekly self-reported symptoms of depression and mania were collected prospectively. In linear regression analyses, associations between cognitive bias and mood variability were explored together with the influence of demographic and clinical factors, including current medication.


Greater accuracy in the classification of negative words relative to positive words was associated with greater instability in depressive symptoms. Furthermore, greater negative bias in free recall was associated with higher instability in manic symptoms. Participants diagnosed with BDII, compared with BDI, showed overall better word recognition and recall. Current antipsychotic use was associated with reduced instability in manic symptoms but this did not impact on emotional processing performance.


Emotional processing biases in bipolar disorder are related to instability in mood. These findings prompt further investigation into the underpinnings as well as clinical significance of mood instability.


Corresponding author

*Address for correspondence: Dr A. C. Bilderbeck, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK. (Email:


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Altman, EG, Hedeker, D, Peterson, JL, Davis, JM (1997). The Altman self-rating mania scale. Biological Psychiatry 42, 948955.
Anderson, NH (1968). Likableness ratings of 555 personality-trait words. Journal of Personality and Social Psychology 9, 272279.
Bellino, S, Bozzatello, P, Brignolo, E, Bogetto, F (2012). New antipsychotics in treatment of mood instability and cognitive perceptual symptoms in borderline personality disorder. Current Psychopharmacology 1, 8696.
Born, C, Amann, BL, Grunze, H, Post, RM, Scharer, L (2014). Saving time and money: a validation of the self ratings on the prospective NIMH Life-Chart Method (NIMH-LCM). BMC Psychiatry 14, 130.
Bourne, C, Bilderbeck, A, Drennan, R, Atkinson, L, Price, J, Geddes, JR, Goodwin, GM (2015). Verbal learning impairment in euthymic bipolar disorder: BDI v BDII. Journal of Affective Disorders 182, 95100.
Derntl, B, Seidel, EM, Kryspin-Exner, I, Hasmann, A, Dobmeier, M (2009). Facial emotion recognition in patients with bipolar I and bipolar II disorder. British Journal of Clinical Psychology 48, 363375.
Faurholt-Jepsen, M, Vinberg, M, Christensen, EM, Frost, M, Bardram, J, Kessing, LV (2013). Daily electronic self-monitoring of subjective and objective symptoms in bipolar disorder-the MONARCA trial protocol (MONitoring, treAtment and pRediCtion of bipolAr disorder episodes): a randomised controlled single-blind trial. BMJ Open 3.
Garcia-Blanco, AC, Perea, M, Livianos, L (2013). Mood-congruent bias and attention shifts in the different episodes of bipolar disorder. Cognition & Emotion 27, 11141121.
Garrett, DD, Samanez-Larkin, GR, MacDonald, SWS, Lindenberger, U, McIntosh, AR, Grady, CL (2013). Moment-to-moment brain signal variability: a next frontier in human brain mapping? Neuroscience and Biobehavioral Reviews 37, 610624.
Gershon, A, Eidelman, P (2015). Inter-episode affective intensity and instability: predictors of depression and functional impairment in bipolar disorder. Journal of Behavior Therapy and Experimental Psychiatry 46, 1418.
Gopin, CB, Burdick, KE, DeRosse, P, Goldberg, TE, Malhotra, AK (2011). Emotional modulation of response inhibition in stable patients with bipolar I disorder: a comparison with healthy and schizophrenia subjects. Bipolar Disorders 13, 164172.
Gotlib, IH, Krasnoperova, E (1998). Biased information processing as a vulnerability factor for depression. Behavior Therapy 29, 603617.
Harmer, CJ, Goodwin, GM, Cowen, PJ (2009). Why do antidepressants take so long to work? A cognitive neuropsychological model of antidepressant drug action. British Journal of Psychiatry 195, 102108.
Harmer, CJ, Heinzen, J, O'Sullivan, U, Ayres, RA, Cowen, PJ (2008). Dissociable effects of acute antidepressant drug administration on subjective and emotional processing measures in healthy volunteers. Psychopharmacology 199, 495502.
Henry, C, Van den Bulke, D, Bellivier, F, Roy, I, Swendsen, J, M'Bailara, K, Siever, LJ, Leboyer, M (2008). Affective lability and affect intensity as core dimensions of bipolar disorders during euthymic period. Psychiatry Research 159, 16.
Holmes, MK, Erickson, K, Luckenbaugh, DA, Drevets, WC, Bain, EE, Cannon, DM, Snow, J, Sahakian, BJ, Manji, HK, Zarate, CA (2008). A comparison of cognitive functioning in medicated and unmedicated subjects with bipolar depression. Bipolar Disorders 10, 806815.
Hsiao, YL, Wu, YS, Wu, JYW, Hsu, MH, Chen, HC, Lee, SY, Lee, IH, Yeh, TL, Yang, YK, Ko, HC, Lu, RB (2009). Neuropsychological functions in patients with bipolar I and bipolar II disorder. Bipolar Disorders 11, 547554.
Jahng, S, Wood, PK, Trull, TJ (2008). Analysis of affective instability in ecological momentary assessment: indices using successive difference and group comparison via multilevel modeling. Psychological Methods 13, 354375.
Koenigsberg, HW (2010). Affective instability: toward an integration of neuroscience and psychological perspectives. Journal of Personality Disorders 24, 6082.
Lau, MA, Segal, ZV, Williams, JM (2004). Teasdale's differential activation hypothesis: implications for mechanisms of depressive relapse and suicidal behaviour. Behaviour Research and Therapy 42, 1001–17.
Lemaire, M, Aguillon-Hernandez, N, Bonnet-Brilhault, F, Martineau, J, El-Hage, W (2014). Subjective and physiological emotional response in euthymic bipolar patients: a pilot study. Psychiatry Research 220, 294301.
Lembke, A, Ketter, TA (2002). Impaired recognition of facial emotion in mania. American Journal of Psychiatry 159, 302–4.
Lex, C, Meyer, TD, Marquart, B, Thau, K (2008). No strong evidence for abnormal levels of dysfunctional attitudes, automatic thoughts, and emotional information-processing biases in remitted bipolar I affective disorder. Psychology and Psychotherapy – Theory Research and Practice 81, 113.
Magill, CA (2004). The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges. Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie 49, 551556.
Malhi, GS, McAulay, C, Das, P, Fritz, K (2015). Maintaining mood stability in bipolar disorder: a clinical perspective on pharmacotherapy. Evidence Based Mental Health 18, 16.
Mercer, L, Becerra, R (2013). A unique emotional processing profile of euthymic bipolar disorder? A critical review. Journal of Affective Disorders 146, 295309.
Miklowitz, DJ, Price, J, Holmes, EA, Rendell, J, Bell, S, Budge, K, Christensen, J, Wallace, J, Simon, J, Armstrong, NM, McPeake, L, Goodwin, GM, Geddes, JR (2012). Facilitated Integrated Mood Management for adults with bipolar disorder. Bipolar Disorders 14, 185197.
Mocking, RJT, Pflanz, CP, Pringle, A, Parsons, E, McTavish, SF, Cowen, PJ, Harmer, CJ (2013). Effects of short-term varenicline administration on emotional and cognitive processing in healthy, non-smoking adults: a randomized, double-blind, study. Neuropsychopharmacology 38, 476484.
Murphy, FC, Sahakian, BJ, Rubinsztein, JS, Michael, A, Rogers, RD, Robbins, TW, Paykel, ES (1999). Emotional bias and inhibitory control processes in mania and depression. Psychological Medicine 29, 13071321.
Rock, PL, Goodwin, GM, Harmer, CJ (2010). The common adolescent bipolar phenotype shows positive biases in emotional processing. Bipolar Disorders 12, 606615.
Rush, J, Trivedi, M, Ibrahim, H, Carmody, T, Arnow, B, Klein, D, Markowitz, J, Ninan, P, Kornstein, S, Manber, R, Thase, M, Kocsis, J, Keller, M (2003). The 16-item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biological Psychiatry 54, 573583.
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC (1998). The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59, 2233.
Simonsen, C, Sundet, K, Vaskinn, A, Birkenaes, AB, Engh, JA, Hansen, CF, Jónsdóttir, H, Ringen, PA, Opjordsmoen, S, Friis, S, Andreassen, OA (2008). Neurocognitive profiles in bipolar I and bipolar II disorder: differences in pattern and magnitude of dysfunction. Bipolar Disorders 10, 245255.
Strejilevich, SA, Martino, DJ, Murru, A, Teitelbaum, J, Fassi, G, Marengo, E, Igoa, A, Colom, F (2013). Mood instability and functional recovery in bipolar disorders. Acta Psychiatrica Scandinavica 128, 194202.
Venn, HR, Gray, JM, Montagne, B, Murray, LK, Burt, DM, Frigerio, E, Perrett, DI, Young, AH (2004). Perception of facial expressions of emotion in bipolar disorder. Bipolar Disorders 6, 286293.
Vieta, E, Goikolea, JM (2005). Atypical antipsychotics: newer options for mania and maintenance therapy. Bipolar Disorders 7, 2133.
Wells, TT, Clerkin, EM, Ellis, AJ, Beevers, CG (2014). Effect of antidepressant medication use on emotional information processing in major depression. American Journal of Psychiatry 171, 195200.


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Associations between mood instability and emotional processing in a large cohort of bipolar patients

  • A. C. Bilderbeck (a1), Z. E. Reed (a1) (a2), H. C. McMahon (a1), L. Z. Atkinson (a1), J. Price (a1), J. R. Geddes (a1), G. M. Goodwin (a1) and C. J. Harmer (a1)...


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