ISSN: 2455-5460
Archives of Depression and Anxiety
Review Article       Open Access      Peer-Reviewed

How to help managing emotions felt by bipolar patients?

Michel Bourin*

Neurobiology of Anxiety and Depression, University of Nantes, 98, rue Joseph Blanchart, 44100 Nantes, France
*Corresponding author: Michel Bourin, Neurobiology of Anxiety and Depression, University of Nantes, 98, rue Joseph Blanchart, 44100 Nantes, France, E-mail: michel.bourin@univ-nantes.fr
Received: 26 June, 2023 | Accepted: 30 June, 2023 | Published: 01 July, 2023
Keywords: Bipolar disorder; Emotions; Euthymic state; Mood stabilizers

Cite this as

Bourin M (2023) How to help managing emotions felt by bipolar patients? Arch Depress Anxiety 9(2): 041-044. DOI: 10.17352/2455-5460.000079


© 2023 Bourin M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The regulation of the control of the emotional experience is one of the determining parameters of the adaptation of an individual to his environment. Bipolar disorder is a psychiatric pathology in which disturbances in the processing of emotions are particularly marked during acute episodes and persist during the interictal period. Treatment with mood stabilizers generally improves the perception of emotions, while antidepressants are brakes on this perception. Finally, simple psychological measures can be useful in controlling emotions.


The regulation of cognitive activities and the control of emotional experience are determining parameters of the adaptation of an individual to his environment [1]. Organic or functional disturbances of these processes are likely to induce pathologies clinically characterized by behavioral disorders, particularly in the field of social interactions, and an alteration in the level of functioning. Thus, psychiatric illnesses are frequently studied as pathological models of the interactions between cognitions and emotions. Given the limits of the diagnostic criteria defined by the nosographic classifications, new readings of the clinic are necessary to understand the complexity and heterogeneity of mental illnesses. Particularly relevant, the dimensional approach to symptomatology consists of a description of clinical or psychopathological dimensions, such as cognitive and emotional disorders.

The management of emotions is a lot of many aspects of mental health, in particular bipolar disorder [2]. Some of the emotions we face include anger, depression, despair, loneliness, indifference, fear, sadness, love, happiness, confidence, peace, strength, and relaxation [3]. We often feel several emotions at the same time. Then there are times when we feel empty and nothing seems to bother us.

Trying to understand how we feel is a lot harder than it looks because we often feel more than one emotion at a time and also have trouble explaining our emotions to others. We may know that we are depressed, hypomanic, or in a mixed state, but determining the emotional details of these states is extremely tricky [4]. When friends, family members, or even doctors ask the patient how he is feeling, he does not always know what to say or to answer. Writing often helps us understand our emotional state. We have also learned to ask ourselves a series of questions, such as: how and why do we feel what we feel? Often there are not always answers to these questions when treating bipolar disorder because the patient cannot figure out what they are feeling.

Current classifications of mental disorders do not take into account the euthymic phase of bipolar disorder. However, it has now been established that many patients have comorbid conditions and/or residual symptoms during these phases [5].

Studies on impulsivity in bipolar patients have demonstrated an interest in this type of approach for improving our understanding of the modifications occurring during episodes and for a better characterization of the euthymic period [6].

Surprisingly few studies have addressed the emotional reactivity of bipolar patients. The mood episodes characterizing bipolar disorder are most often defined on the basis of emotional tone (sadness/euphoria). Most bipolar patients spontaneously report having excessively strong emotional reactions, even between depressive or manic episodes [7]. They often say that they are more sensitive than others to events. Several elements suggest that emotional reactivity is disturbed in bipolar patients even during euthymic periods. Indeed, it is linked to stress management during these phases [8]. Stressful events have been shown to have deleterious effects, increasing the frequency of relapses in patients with bipolar disorder [9]. On the other hand, bipolar patients experience considerable daily variation in effect, even when they are euthymic. Similarly, having “highs and lows” during euthymic periods is predictive of recurrent depressive episodes.

Emotional processes in bipolar disorder

Mania and depression have long been considered two poles of a one-dimensional axis, which is reflected in the use of the term “bipolar” [9]. The thymic exaltation of the manic patient (playful joviality, morbid euphoria, extravagant presentation, hyper syntonic contact) is the counterpart of the sadness of the depressed mood (globally pessimistic experience with many feelings of dissatisfaction, devaluation, and moral pain characterized by the disagreeable tone of affect). However, the increasingly frequent description of mixed forms (mixed mania, dysphoric mania, agitated depression, mixed depression) suggests that the pathology of emotions should be understood from a non-qualitative, but quantitative side. Thus, emotional hyperreactivity would be at the very heart of bipolar disease; its persistence during periods of euthymia would reflect persistent emotional instability, likely to promote mood relapses when a stressful life event occurs [10].

In addition to the disorders of emotional experience, the quality and intensity of which are inappropriate to the context, abnormalities in the recognition of emotional stimuli have been reported in bipolar patients. Compared to healthy subjects, depressed patients show an overall deficit in the recognition of basic emotions, in particular, joy and sadness [11].

Studies suggest, in manic patients, a deficit of identification of facial emotions compared to healthy subjects [12]. Explorations of emotion identification in euthymic patients yield contradictory results [13]. It is therefore currently unclear whether disorders of emotion recognition constitute a marker of a trait or a state [14].

Emotional hyper-reactivity during euthymic periods

During euthymic periods, bipolar patients experience more intense emotions than patients with personality disorders or control subjects, resulting in a higher level of emotional variability [15].

These results were obtained in studies using self-administered questionnaires according to the classic technique of showing the subject positive, neutral, or negative images, ensuring that the patients have a good understanding of the images shown to them and assess subjective and objective factors related to the emotions triggered by images [16]. Thus, by this method of emotional induction, the emotional reactivity of the subjects can be studied objectively, by comparing it with that of control subjects who consider the same stimuli as neutral. Subjective ratings of arousal and startle reflex when viewing neutral images are greater in euthymic bipolar patients than in control subjects, demonstrating their higher level of emotional reactivity.

Bipolar patients present with episodes of hypomania or depression interspersed with sub syndromic features between episodes. These minimal thymic elements may result from underlying emotional hyper-reactivity, leading to emotional reactivity that becomes chronic and corresponds to sub-syndromic symptoms [17]. The tone of these symptoms in a sub-depressive or euphoric and irritable mode may depend on the environmental situation, but also on the character traits of the subjects or even on comorbidities, including, in particular, anxiety.

This emotional hyper-reactivity seems to increase considerably during manic states, associated with all types of stimuli (positive, neutral, and negative). In euthymic periods, this emotional hyper-reactivity seems to be limited to neutral situations [18]. This can be explained by the fact that the positive and negative images induce a stronger reactivity which does not make it possible to discriminate the differences by reaching a point of saturation.

Is emotional reactivity hereditary?

It would be useful to conduct similar studies to measure emotional reactivity in parents of bipolar subjects. The presence of the same characteristics in patients and their relatives would identify this emotional hyper-reactivity as an endophenotype associated with susceptibility to bipolar disorder [19]. Emotional hyper-reactivity may also be a risk factor for developing acute episodes in bipolar patients.

Emotional hyper-reactivity may explain the particularly acute sensitivity of bipolar patients to life events. Bipolar subjects not only have a high risk of recurrence when faced with major life events, but they also appear to be particularly susceptible to minor life events [20]. It was found that events that seemed minor and could be considered almost neutral were nevertheless likely to disrupt social routine and trigger bouts of mania.

Is emotional reactivity an endophenotype of bipolar disorder? If so, it could be used to identify subjects at risk of developing bipolar disorder.

What effect do treatments have on emotional reactivity?

A good response to mood stabilizer treatment is most often associated with a decrease in emotional reactivity [21]. In contrast, bipolar patients treated for long periods (several years) with antidepressants have been shown to tend to progress to a chronic state of emotional reactivity, mainly to dysphoric episodes (unstable mood) associated with insomnia [22]. This reflects their very often unexplained discomfort and paradoxically makes it difficult to stop antidepressants, which must be done by gradually reducing the doses or adding or increasing a mood stabilizer [23].

Studies of emotional reactivity can thus contribute to improving our understanding of the mechanisms underlying mood changes. Neurobiological disturbances involved in bipolar disorders; suggest that these are characterized by an increased sensitivity to emotionally salient environmental information and an inability to regulate their mood [24]. Additionally, bipolar patients appear to have an inability to differentiate between relevant and irrelevant emotional stimuli.

Neuroimaging studies in children and adults show the involvement of the prefrontal cerebral regions, and more particularly the dorsolateral prefrontal cortex and the anterior cingulate cortex in the genesis of emotions [25]. Thus, the definition of bipolar disorder could be refined in light of enduring dysfunction in emotional reactivity, rather than simply as recurrence of episodes. A mild emotional hyper-reactivity characterizes the inter-crisis periods and partly explains the high prevalence of sub-syndromic symptoms. It has also been shown that bipolar mood episodes can also be defined by emotional reactivity, not just affect tone (euphoria/depressed mood). Manic and mixed states are characterized by high emotional hyper-reactivity and this concept, extended to depressive episodes, makes it possible to distinguish two types of bipolar depression. Indeed, mixed bipolar patients can experience, at the same time or in a very short interval, emotions as different as euphoria, sadness, irritability, or anxiety. Thus, bipolar disorder must be considered as a global emotional dysregulation, fluctuating from inhibition to excitation [26,27].

Can we improve this “disease of emotions”?
  1. When it comes to emotions, certain actions can be taken to help manage emotionExercise increases the synthesis of brain neurotransmitters that serve to regulate emotions.
  2. Spend time with people and talk to them about how you feel.
  3. Various forms of talk therapy are beneficial for emotional situations (talk groups).
  4. Don't get carried away with negative thoughts, even if it's really easy. The patient will improve over time in positive thinking.
  5. Meditation is known to help keep people calm and feel at peace.
  6. Depending on the music, it can help relax people or bring them joy.
  7. Being grateful helps you achieve all the good things you have in life.
  8. Whether indoors or outdoors, playing and having fun with others can help you feel better.
  9. Sometimes a simple distraction like watching TV or reading a book can help lift your mood.
  10. Writing or keeping a diary of your emotions helps keep track of feelings over a period of time.

It is very important for bipolar people to keep track of their emotions and their evolution over time [28]. Other close people can also help determine the emotional state: in fact, to understand how we feel, they can observe what we say and how we act. Body language provides information about the emotional state; it says more about a person's emotions than verbal communication. Paying attention to your own body language is important, especially when you don't know how you feel, it can be the key to determining your emotional state.

Emotion monitoring and tracking are useful, especially for doctors. During consultations, psychiatrists and therapists often begin by saying: "So how are you?"

The patient usually does not know how to answer this question, but if one keeps track of his moods, this attention contributes to the treatment and general progress. If one can manage/monitor one's emotions then one can properly inform the doctor of the progress being felt and the treatment can be more accurate and helpful.


The exploration of emotional processes, in a dimensional approach, helps to question the clinical definition and etiopathogenic hypotheses of bipolar disorder. This condition constitutes a model of pathological interactions between cognitions and emotions whose neurofunctional and neuroanatomical mechanisms are still poorly understood. Another fundamental line of research will be the identification of cognitive and emotional markers of genetic vulnerability [29,30].

  1. Ochsner KN, Gross JJ. The cognitive control of emotion. Trends Cogn Sci. 2005 May;9(5):242-9. doi: 10.1016/j.tics.2005.03.010. PMID: 15866151.
  2. Bourin M. Psychoeducation of bipolar disorder patients and their relatives. Arch Depress Anxiety. 2018; 4(1): 001-002.
  3. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol. 2001 Mar;56(3):218-26. doi: 10.1037//0003-066x.56.3.218. PMID: 11315248; PMCID: PMC3122271.
  4. Emilien G, Septien L, Brisard C, Corruble E, Bourin M. Bipolar disorder: how far are we from a rigorous definition and effective management? Prog Neuropsychopharmacol Biol Psychiatry. 2007 Jun 30;31(5):975-96. doi: 10.1016/j.pnpbp.2007.03.005. Epub 2007 Mar 16. PMID: 17459551.
  5. McIntyre RS, Alda M, Baldessarini RJ, Bauer M, Berk M, Correll CU, Fagiolini A, Fountoulakis K, Frye MA, Grunze H, Kessing LV, Miklowitz DJ, Parker G, Post RM, Swann AC, Suppes T, Vieta E, Young A, Maj M. The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management. World Psychiatry. 2022 Oct;21(3):364-387. doi: 10.1002/wps.20997. PMID: 36073706; PMCID: PMC9453915.
  6. Santana RP, Kerr-Gaffney J, Ancane A, Young AH. Impulsivity in Bipolar Disorder: State or Trait? Brain Sci. 2022 Oct 5;12(10):1351. doi: 10.3390/brainsci12101351. PMID: 36291285; PMCID: PMC9599710.
  7. M'bailara K, Demotes-Mainard J, Swendsen J, Mathieu F, Leboyer M, Henry C. Emotional hyper-reactivity in normothymic bipolar patients. Bipolar Disord. 2009 Feb;11(1):63-9. doi: 10.1111/j.1399-5618.2008.00656.x. PMID: 19133967.
  8. Henry C, Phillips M, Leibenluft E, M'Bailara K, Houenou J, Leboyer M. Emotional dysfunction as a marker of bipolar disorders. Front Biosci (Elite Ed). 2012 Jun 1;4(7):2622-30. doi: 10.2741/e578. PMID: 22652673; PMCID: PMC3927326.
  9. Kim EY, Miklowitz DJ, Biuckians A, Mullen K. Life stress and the course of early-onset bipolar disorder. J Affect Disord. 2007 Apr;99(1-3):37-44. doi: 10.1016/j.jad.2006.08.022. Epub 2006 Nov 7. PMID: 17084905; PMCID: PMC1852465.
  10. Born C, Grunze H, Post RM, Altshuler LL, Kupka R, McElroy SL, Frye MA, Suppes T, Keck PE, Nolen WA, Schaerer L. Mania and bipolar depression: complementing not opposing poles-a post-hoc analysis of mixed features in manic and hypomanic episodes. Int J Bipolar Disord. 2021 Nov 16;9(1):36. doi: 10.1186/s40345-021-00241-5. PMID: 34782957; PMCID: PMC8593087.
  11. Koenders MA, Dodd AL, Karl A, Green MJ, Elzinga BM, Wright K. Understanding bipolar disorder within a biopsychosocial emotion dysregulation framework. Journal of Affective Disorders Reports. 15 December 2020; 2:100031.
  12. Monferrer M, García AS, Ricarte JJ, Montes MJ, Fernández-Caballero A, Fernández-Sotos P. Facial emotion recognition in patients with depression compared to healthy controls when using human avatars. Sci Rep. 2023 Apr 12;13(1):6007. doi: 10.1038/s41598-023-31277-5. PMID: 37045889; PMCID: PMC10097677.
  13. Işık Ulusoy S, Gülseren ŞA, Özkan N, Bilen C. Facial emotion recognition deficits in patients with bipolar disorder and their healthy parents. Gen Hosp Psychiatry. 2020 Jul-Aug;65:9-14. doi: 10.1016/j.genhosppsych.2020.04.008. Epub 2020 Apr 25. PMID: 32361661.
  14. Reddy PV, Anandan S, Rakesh G, Shivakumar V, Joseph B, Vasu SK, Agarwal SM, Muralidharan K, Venkatasubramanian G, Narayanaswamy JC. Emotion Processing Deficit in Euthymic Bipolar Disorder: A Potential Endophenotype. Indian J Psychol Med. 2022 Mar;44(2):145-151. doi: 10.1177/02537176211026795. Epub 2021 Aug 19. PMID: 35655991; PMCID: PMC9120978.
  15. Seo E, Park HY, Park K, Koo SJ, Lee SY, Min JE, Lee E, An SK. Impaired Facial Emotion Recognition in Individuals at Ultra-High Risk for Psychosis and Associations With Schizotypy and Paranoia Level. Front Psychiatry. 2020 Jun 26;11:577. doi: 10.3389/fpsyt.2020.00577. PMID: 32676040; PMCID: PMC7333645.
  16. Wenzel M, Althen H, Veeh J, Reif A. Euthymic patients with predominantly manic polarity avoid happy faces in a dot probe task. Int J Bipolar Disord. 2022 Jun 23;10(1):16. doi: 10.1186/s40345-022-00262-8. PMID: 35739323; PMCID: PMC9226225.
  17. Askim K, Knardahl S. The Influence of Affective State on Subjective-Report Measurements: Evidence From Experimental Manipulations of Mood. Front Psychol. 2021 Feb 18;12:601083. doi: 10.3389/fpsyg.2021.601083. PMID: 33679520; PMCID: PMC7930079.
  18. Grunze H, Born C. The Impact of Subsyndromal Bipolar Symptoms on Patient's Functionality and Quality of Life. Front Psychiatry. 2020 Jun 12;11:510. doi: 10.3389/fpsyt.2020.00510. PMID: 32595531; PMCID: PMC7304232.
  19. M'Bailara K, Atzeni T, Colom F, Swendsen J, Gard S, Desage A, Henry C. Emotional hyperreactivity as a core dimension of manic and mixed states. Psychiatry Res. 2012 May 30;197(3):227-30. doi: 10.1016/j.psychres.2011.12.003. Epub 2012 Mar 11. PMID: 22414662.
  20. Guglielmo R, Miskowiak KW, Hasler G. Evaluating endophenotypes for bipolar disorder. Int J Bipolar Disord. 2021 May 27;9(1):17. doi: 10.1186/s40345-021-00220-w. PMID: 34046710; PMCID: PMC8160068.
  21. Aldinger F, Schulze TG. Environmental factors, life events, and trauma in the course of bipolar disorder. Psychiatry Clin Neurosci. 2017 Jan;71(1):6-17. doi: 10.1111/pcn.12433. Epub 2016 Sep 21. PMID: 27500795; PMCID: PMC7167807.
  22. Ahn SW, Baek JH, Yang SY, Kim Y, Cho Y, Choi Y, Lee K, Park T, Hong KS. Long-term response to mood stabilizer treatment and its clinical correlates in patients with bipolar disorders: a retrospective observational study. Int J Bipolar Disord. 2017 Dec;5(1):24. doi: 10.1186/s40345-017-0093-5. Epub 2017 Jul 9. PMID: 28480482; PMCID: PMC5502006.
  23. McInerney SJ, Kennedy SH. Review of evidence for use of antidepressants in bipolar depression. Prim Care Companion CNS Disord. 2014 Oct 16;16(5):10.4088/PCC.14r01653. doi: 10.4088/PCC.14r01653. PMID: 25667812; PMCID: PMC4321017.
  24. Bourin M. Are antidepressants useful in bipolar disease? Arch Depress Anxiety. 2017; 3(2): 058-059.
  25. Koenders MA, Dodd AL, Karl A, Greene MJ, Elzinga BM, Wright K. Understanding bipolar disorder within a biopsychosocial emotion dysregulation framework Journal of Affective Disorders Reports. (020; 2:100031
  26. Marsh R, Gerber AJ, Peterson BS. Neuroimaging studies of normal brain development and their relevance for understanding childhood neuropsychiatric disorders. J Am Acad Child Adolesc Psychiatry. 2008 Nov;47(11):1233-51. doi: 10.1097/CHI.0b013e318185e703. PMID: 18833009; PMCID: PMC2759682.
  27. Stein DJ, Horn N, Ramesar R, Savitz J. Bipolar disorder: emotional dysregulation and neuronal vulnerability. CNS Spectr. 2009 Mar;14(3):122-6. doi: 10.1017/s1092852900020095. PMID: 19407708.
  28. Bourin M. Treating the cognitive impairment in bipolar patients. J Neurosci Neurosurg. 2018; 1(1):107.
  29. Fulford D, Peckham AD, Johnson K, Johnson SL. Emotion perception and quality of life in bipolar I disorder. J Affect Disord. 2014 Jan;152-154:491-7. doi: 10.1016/j.jad.2013.08.034. Epub 2013 Sep 7. PMID: 24070906; PMCID: PMC3851889.
  30. Bevilacqua L, Goldman D. Genetics of emotion. Trends Cogn Sci. 2011 Sep;15(9):401-8. doi: 10.1016/j.tics.2011.07.009. Epub 2011 Aug 10. PMID: 21835681; PMCID: PMC3408019.

Help ?