Mindfulness trait and the potential mediating role of emotional regulation strategies in bipolar disorder

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Introduction
Bipolar disorder (BD) is a chronic condition characterized by recurrent episodes of depression, mania, and hypomania, with difficulties in emotional regulation and high comorbidity with, among others, anxiety disorders (Bojic & Becerra, 2017).Despite the widespread use of conventional pharmacological treatments, episodic relapse is common (Kishi et al., 2021).Risk factors for relapse include difficulties in emotional regulation due to the tendency to experience more intense emotional cycles than usual (Eisner et al., 2017).In this regard, the relationship between emotional regulation difficulties and the presence of psychopathology has been consistently shown to coexist with a significant increase in disorganized responses to emotional cycles that led to a significant increase in maladaptive responses to emotional stimuli and a decrease in adaptive responses to regulate intense emotional experiences (Miola et al., 2022).
Among the maladaptive Emotional Regulation Strategies (ERS), self-blame refers to thoughts of blaming oneself for what one has experienced (De Prisco et al., 2022); Rumination or thought concentration refers to the feelings and thoughts associated with the adverse event (Bojic & Becerra, 2017); Catastrophising refers to thoughts that explicitly emphasize the terror of the experience by emphasizing the seriousness of the event/emphasizing the severity of the situation (Ruiz, 2014).Positive reappraisal refers to thoughts of creating positive meaning for the event regarding personal growth.Refocusing on planning refers to thinking about what steps to take and how to handle the adverse event (Garfefski et al., 2016).Mindfulness has been defined as an intentional way of paying attention to what is happening and observing the phenomena that appear in the field of consciousness with pure attention, sustained, and equanimous (Segovia, 2018).However, the alternative framework Radford et al. (2014) proposed that emotion regulation also involves understanding, awareness, and acceptance of emotional distress rather than just control.Thus, the emphasis of mindfulness on observation and description of one's experience promotes emotional awareness and acceptance of all emotions, including unpleasant ones (Kabat-Zinn, 2021).
In this regard, one psychological factor that may act as a protective mechanism for BD patients and their emotional regulation deficit is dispositional mindfulness or trait mindfulness (Roemer et al., 2015).Trait mindfulness is the enduring dispositional tendency that facilitates disconnection from automatic thoughts and unhealthy habits or behavioral patterns (Brown & Ryan, 2003).There is a previous rich literature on mindfulness through which it has been observed that greater trait mindfulness can optimize self-regulatory processes that are important for psychological well-being, such as greater mental flexibility and resilience, reduced mental rumination and wandering, as well as lower levels of impulsivity, stress, and anxiety (Bojic & Becerra, 2017;Carpenter et al., 2019;Sala et al., 2020).Thus, this psychological disposition has been related to several benefits related to the emotional wellbeing of BD patients, such as a negative relationship between its effects on anxiety and depression (Burgos et al., 2022) and positive concerning psychological well-being (Desrosiers et al., 2013).
The mechanisms by which dispositional mindfulness might benefit people with BD have not yet been established.However, evidence suggests that individuals with higher dispositional mindfulness would do better in mindfulness training for better emotional regulation than those with lower trait mindfulness (Banfi & Randall, 2022).In this sense, ERS may link certain mindfulness levels and mood symptomatology, especially in BD patients, due to their higher use of maladaptive ERS compared to the general population (Desrosiers et al., 2013).Indeed, BD patients report less emotional clarity and difficulties accepting emotional responses to believe in their ability to regulate emotion effectively (Bojic & Becerra, 2017).These difficulties have been repeatedly associated with depressive tendencies (Van Rheenen, 2015).
Similarly, other studies have proposed theoretical models where certain ERS mediate the relationship between mindfulness and affective symptomatology.For example, Desrosiers et al. (2013) evaluated a mediational model, where less anxious and depressive symptomatology was related to a more significant presence of mindfulness.This relationship is mediated through specific regulatory mechanisms.These authors found that worry mediated the relationship between mindfulness and anxiety symptoms, while rumination and reappraisal mediated the relationship between mindfulness and depressive symptoms.
Specifically, several studies suggest that mindfulness practice is associated with healthy ERS, reducing the intensity of distress effects, increasing emotional recovery, reducing negative self-referential processing, and increasing the ability to engage in goal-directed behaviors (Roemer et al., 2015).Regarding mindfulness practice, previous literature has reported that emotion regulation mediates the dispositional effect mindfulness has on bipolar patients (Burgos et al., 2022).In this regard, some studies analyzing the efficacy of mindfulnessbased intervention (MBI) treatment protocols have shown improvement in maladaptive ERS such as worry, rumination, and reappraisal (Hanssen et al., 2019;Painter et al., 2019).
Given the above and given that the effect of dispositional mindfulness on BD may occur through its effects on emotion regulation, the present study aims to explore whether difficulties in emotional regulation in BD mediate the relationship between the effects of dispositional mindfulness and the characteristic symptomatology of BD (depression, mania, and anxiety).Specifically, the first objective seeks to explore the ERS that are related to BD.In contrast, the second specific objective focuses on determining the ERS that could mediate between mindfulness and BD symptomatology (see Figure 1).Based on preliminary evidence concerning BD-related ERS from the CERQ questionnaire (Garnefski & Kraaij, 2007), it is proposed: Hypothesis 1.a.Maladaptive ERS such as rumination, selfblame, and catastrophizing are positively related to symptoms of depression, mania, and trait anxiety.
Hypothesis 1. b. Adaptive ERS, such as positive reappraisal and putting into perspective, harbor a negative relationship with depressive symptoms, mania, and trait anxiety.
Hypothesis 2. ERS mediates mindfulness and symptoms of depression, mania, and trait anxiety.

Method Participants
Participants were selected among the members of the BAO.Inclusion criteria were being at least eighteen years old, following pharmacological treatment and psychiatric supervision, having a diagnosis of BD and being in a period of total remission, in which and during the last two months, no signs or symptoms characteristic of the disorder according to the DSM-5 (APA, 2013).Exclusion criteria were neurological/neurodegenerative disease, history of severe head injury with loss of consciousness, pregnancy, history of habitual drug use, significant change in medication two months prior to the study, or having a psychotic disorder or personality disorder.
The complete sample of participants consisted of a total of 24 people diagnosed with BD with an age range of 29 -60 years (M = 44.17,SD = 8.54), of which 14 (58%) were men and 10 (42%) women.The sample distribution concerning the type of BD is distributed in 18 (75%) people with BDtype I, three with BD-type II (12.50%), and three with cycloanales de psicología / annals of psychology, 2024, vol.40, nº 2 (may) thymia (12.50%).Regarding the pharmacological treatment followed, seven (29.16%) people followed a treatment based on mood stabilizers (FSS), either lithium and/or anticonvulsants, eight (33.33%)followed a treatment based on FSS together with antidepressants, three (12.50%)FSS plus antipsychotics, three FSS (12.50%) together with anxiolytics.In comparison, three (12.50%)people are treated with FSS together with antipsychotics and anxiolytics.

Design and procedure
The present study used a cross-sectional design with a single group of participants belonging to the BAO.Participants were selected following the data previously collected by psychologists, psychiatrists, and neurologists working in BAO.The final sample consisted of 24 people.

Instruments
The psychological variables analyzed in a standardized manner were as follows: For the application of the inclusion and exclusion criteria, results of the MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) were screen.This is a short, structured interview that explores the primary psychiatric disorders of Axis I of the DSM-5 and ICD-11.It is divided into 17 diagnostic sections, including bipolar disorders.For emotional episodes of BD, the test shows sensitivity indices between .94 and .86 and specificity indices between .79 and .92.Its adaptation to the Spanish population was performed by Ferrando et al. (2015) and has shown good psychometric properties (α = .85).
Dispositional mindfulness was assessed through the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), a unidimensional psychometric instrument that measures the frequency with which we are aware of our daily experiences.It focuses on the presence or absence of awareness of what is happening in the present moment.It is composed of 15 items scored on a Likert scale from 1 to 6 (1 = "almost always" and 6 = "almost never"), with a maximum score of 90 points.The higher the score, the greater the awareness of what is happening in the present moment.It can be applied to clinical and general populations and does not require subjects to be familiar with meditation techniques.Its adaptation to the Spanish population (Barajas & Garra, 2014) presents good psychometric properties (α = .88;current study α = .86).
The Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski & Kraaij, 2007) is a 36-item self-report questionnaire consisting of nine conceptually different ERS by which people respond to specific adverse events or situations.These ERS are measured on a five-point Likert-type scale, from 1 (almost never) to 5 (almost always).For the present study, five of the scales that make up this instrument are used.The self-blame dimension refers to those thoughts directed towards oneself and about what happened.Rumination refers to thinking about the feelings and thoughts associated with the adverse event.Catastrophizing refers to those thoughts that emphasize the worst of an experience.Positive reappraisal refers to those thoughts that adhere to a positive meaning of the events in terms of personal growth.Putting in perspective refers to thoughts that minimise the event's severity or emphasize its relativity compared to other events.It adaptation to the Spanish population (Chamizo et al., 2020) presents good psychometric properties, with levels a = .89and w = .96 The State-Trait Anxiety Inventory-R (STAI-RR; Spielberger et al., 1982) is a self-report instrument with a total of 20 items, measuring the frequency with which anxiety reactions are experienced, evaluated on a Likert scale with four alternative responses, from "almost never" (0) to "almost always" (3).Total scores range from 0 to 30.This questionnaire measures individual differences in trait anxiety and consists of 20 items.In Spanish population samples (Buela-Casal et al., 2017), high levels of internal consistency have been found (α = .93).
The Beck Depression Inventory-II (BDI-II; Beck et al., 1996) is a well-established self-report instrument comprising 21 items designed to assess the severity of depressive symptomatology in adults and adolescents.For each item, the person must choose, from a set of four alternatives ordered from least to most severe, the statement that best describes his or her state during the past two weeks.Each item is scored from 0 to 3 depending on the alternative chosen, being able to obtain a total score of between 0-63 points.The validity and reliability (α = .89) of the BDI-II are well established (Sanz et al., 2005).
The Altman Self-Rating Mania Scale (ASRM; Altman et al., 1997)is a self-administered scale that measures manic mood in the past week.It has a total of five statements, scored in increasing order of severity from 0 to 4, with a range of total scores from 0 to 20 points.The higher the score, the greater the severity.The Spanish adaptation was used (Alvarez et al., 2005), showing adequate reliability (α = .84).

Data analysis
First, an exploratory analysis was carried out to check the adequacy of the data to the multivariate normal distribution using the Royston test.In addition, a descriptive analysis of the data was performed, including the indices of central tendency, deviation and, finally, an analysis of bivariate correlations between the variables included in the study.Prior to the mediation analysis and for the testing of hypotheses 1.a and 1.b, a stepwise multiple regression analysis was performed for each of the dependent variables (depression, mania and trait anxiety).Those factors of emotional regulation that were significant in each regression model were subsequently included in the mediational analysis.
For the testing of hypothesis 2, a mediation analysis was conducted using the PROCESS macro (Hayes, 2013) for SPSS.The estimation of the models is based on the nonpar-ametric bootstrapping procedure.(Hayes & Rockwood, 2019).This way, an empirical confidence interval was estimated without assuming the normality assumption.In order to test for indirect effects, 95% confidence intervals were estimated based on 10,000 bootstrap samples.Indirect effects are considered significant if the estimated Bootstrap intervals do not include the value zero.Complementarily, the adjusted coefficient of determination was reported for the set of variables in each model.Following Fairchild and McDaniel (2017), as a measure of effect size for the indirect effects, we will use the mediated ratio (hereafter TE/PM).This ratio represents the proportion in which, out of the total effect, the relationship is mediated by the indirect effects.Through statistical power analysis we estimate the minimum sample size to achieve a power of .80,with a large effect size, and a twotailed contrast with a significance level of p = .05.

Results
The exploratory analysis indicates a misfit of the data to the multivariate normal distribution, contrasted by Royston's test (R = 14.93; p = .01),which justifies the application, in the estimation of the mediational models, of a nonparametric method by bootstrapping.Table 1 shows the descriptive statistics and the correlation between the variables included in the mediation models.The exploratory analysis indicates an inadequacy of the data to the multivariate normal distribution, contrasted by Royston's test (R = 14.93; p =.01), which justifies applying a nonparametric bootstrapping method in the estimation of the mediational models.Statistical power analysis indicates that a minimum sample size of 20 participants is needed to achieve a power of 0.80.These same results have been reported by Fritz and MacKinnon (2007).Regarding Hypothesis 1. a, the results of the multiple regression analysis show that the depression variable is significantly and positively related to selfblame.These results indicate that high levels of depression are associated with a greater presence of self-blame.As for the variable mania, no significant relationship was found in any of the variables included in the regression model.As for the trait anxiety variable, a significant and positive association was found with self-blame and catastrophism.In this sense, higher levels of self-blame and catastrophism are related to a greater presence of trait anxiety (see Table 2).The results of the multiple regression analysis for each excluded variable are shown in the supplementary material.No statistically significant results were found for Hypothesis 1.b (see supplementary Figure 1).Regarding Hypothesis 2, the results of the mediation analysis have shown a significant effect for the variable self-blame both in the relationship between mindfulness and depression (a*b = -.15;BCI 95% [-.36, -.03]), and in the relationship between mindfulness and trait anxiety (a*b = -.09;BCI 95% [-.27, -.01]).

Discussion
By virtue of the importance that ERS acquire in the etiology of BD, the present study aims to explore the mechanisms of emotional regulation that appear to be enhanced or mitigated as a function of different levels of trait mindfulness and their interaction with BD symptomatology.Although studies relate mindfulness and emotional regulation to BD symptomatology, the mechanism through which mindfulness and emotional regulation are related to BD symptomatology is unclear (Parmentier et al., 2019).The mechanism through which trait mindfulness could be acting to improve symptomatological well-being in BD remains poorly explored.This is why the feasibility of a mediational model has been analyzed based on the existing preliminary evidence (Carruthers et al., 2022;Desrosiers et al., 2013;Garland et al., 2015;Hayes & Rockwood, 2019).
Regarding the results obtained around maladaptive ERS (Hypothesis 1.a), some of them have turned out to be significantly related to BD symptomatology, as we expected.Specifically, the hypothesis is confirmed that self-blame is associated with depression and stable trait anxiety while catastrophising appears only associated with trait anxiety.We found no evidence of ER strategies associated with manic symptomatology, so the effects are only partially consistent with preliminary evidence.The results show an increased likelihood of engaging in these emotional regulation processes in response to adverse events, associated with increased depressive and anxious symptomatology.Overall, these results show how self-blame and catastrophizing could contribute to the increased effects of psychological distress in people with BD.In line with these results, different findings show how self-blame and catastrophizing emerge as risk factors for depressive and anxious psychopathology.These two strategies have allowed for more severe psychological distress in people with BD (Chan et al., 2015;Zahn et al., 2015) and how they have made it possible to discriminate between clinical and non-clinical populations (Garnefski et al., 2002).
Concerning adaptive ERS, such as reappraisal or putting into perspective and BD symptomatology, Hypothesis 1.b is not confirmed, so the results are inconsistent with preliminary evidence (Van Rheenen et al., 2015).However, recent review studies have questioned the differences in using these strategies between people with BD and control subjects (Dodd et al., 2019).
Hypothesis 2 proposes that both self-blame and catastrophizing, related to BD symptoms, could represent how mindfulness could mitigate the effects on affective symptomatology.The results are partially consistent with this hypothesis.On the one hand, depressive symptomatology is negatively related to mindfulness through its interaction with self-blame, so the impact of mindfulness on this strategy is related to an improvement in depressive symptoms.On the other hand, the effects of catastrophizing lose their significance when this variable is introduced into the multiple mediation model, together with self-blame, for trait anxiety.
Thus, in this way, self-blame becomes the only significant variable in the mediational model for both depression and anxiety.Mindfulness, therefore, could be associated with reducing symptoms of depression and anxiety by combating those repetitive thoughts that involve attributing blame for what happened to oneself.In this sense, self-blame has emerged in different studies associated with BD symptomatology.(Hassani & Kia, 2016;Wolkenstein et al., 2014).These results find partial support in previous studies.
Theoretically, cognitive vulnerability models (Alloy et al., 2018) assume that dysfunction to inhibit mood-congruent stimuli represents an essential component of emotional dysregulation in BD.Thus, in people with BD, attentional control of mood relevant stimuli requires more significant effort, evidencing the critical role it plays in emotional dysregulation in BD (Garcia-Blanco et al., 2013).Therefore, the role of mindfulness in the improvement of affective symptomatology in BD could be related to attentional control via executive functions through the effect that it could cause by producing a reprocessing of the outgoing emotional information at that moment (Teper & Inzlicht, 2013).
As shown in the scientific literature, self-blame and catastrophising feedback into a negative affective state (Green et al., 2011;Hassani & Kia, 2016;Wolkenstein et al., 2014) is present as an emotional regulation mechanism in BD.In this sense, studies with neuroimaging through the application of mindfulness-based interventions have shown preliminary evidence in the improvement of processing and ERS, via executive functions, through an increase of activation in cortical regions related to these functions (Howells et al., 2012(Howells et al., , 2014;;Ives-Deliperi et al., 2013).In this sense, mindfulness implies an attentional control strategy, and those people with a higher degree of dispositional mindfulness show a more flexible and efficient attentional orientation.(Sørensen et al., 2018).
In this line, we agree with previous literature recommending for maladaptive ERS the practice of sitting o formal mindfulness exercises from the Mindfulness-based for Stress Reduction program (MBSR, Kabatt-Zinn, 1990) or the Mindfulness-based Cognitive Therapy program (MBCT; Segal et al., 2018) that focus on emotions, as well as the self-compassion meditations of the protocol of Mindfulness and Self-Compassion program (Germer & Neff, 2019).
As certain ERS are related to worse affective symptomatology in people with BD previous literature has shown how mindfulness could lessen the impact of these strategies to improve the present affective tone (Hassen et al., 2019).In our study, however, the small sample size could delimit or bias specific characteristics in this model.Moreover, the exploratory and cross-sectional nature of the study does not allow us to determine potential causal mechanisms that account for the results obtained.These limitations support the caution that should be exercised regarding the conclusions of this study.
The results of this research point to the need to explore the deficits in ERS present in people with BD, even in periods of euthymia, so that an adequate assessment would allow predicting, as a prodrome, the existence of depressive episodes or anxious symptoms, with the intended effect on the course of the disease.On the other hand, mediating mechanisms between mindfulness and symptoms of depression and anxiety in BD would make it possible to adjust the different treatments.Finally, in future studies, it is necessary to replicate the results obtained with larger samples and specify whether different types of BD are related to specific ER strategies.

Complementary information
Acknowledgment: this work would not have been possible without the invaluable collaboration of Dr. Juan Manuel Manzaneque, Dra.Laura Ferrando and the members and volunteers of the Asociación de Bipolares de Andalucía Oriental (BAO; https://trastornobipolarbao.com)/ (in English, Bipolar Association of Oriental Andalusia).Funding: The authors declare that they have not received any funding for this research.Conflict of interest: the authors declare that they have no conflicts of interest related to this research.

Figure 1
Figure 1Conceptual diagram illustrating the mediational model between mindfulness and the characteristic symptomatology of bipolar disorder (depression, mania, and trait anxiety), mediated by the emotional regulation strategies.

Table 1
Means, standard deviations, and correlations with confidence intervals for the variables included in the mediation models.

Table 2
Multiple linear regression endpoint models results on maladaptive emotional regulation variables.

Table 3
Results of the mediation model for the dependent variables depression and trait anxiety.