Daring to feel: Emotion-focused psychotherapy increases amygdala activation and connectivity in euthymic bipolar disorder

Objectives: In bipolar disorder (BD), the alternation of extreme and sustained positive and negative mood states indicates deficits in emotion processing. These alterations in emotion processing are accompanied by aberrant neural function of the emotion network. Focusing on the amygdala as the central node of this network, the present study aimed to investigate the effects of an emotion-centered psychotherapeutic intervention on amygdala responsivity and connectivity during emotional face processing in BD.Methods: In a randomized controlled trial within the multicentric BipoLife project, euthymic BD patients received one of two interventions over six months: an emotion-focused intervention where patients were guided to adequately perceive and label their emotions (FEST, n = 28) or a specific, cognitive-behavioral intervention (SEKT, n = 31). Before and after interventions, patients completed an established emotional face-matching paradigm contrasting emotional faces versus shapes during functional magnetic resonance imaging (fMRI). Healthy controls (n = 32) were scanned twice after the same interval without receiving any intervention. Given the focus of FEST on emotion processing, we expected the FEST intervention to strengthen amygdala activation and connectivity. Results: Clinically, both interventions effectively stabilized patients’ euthymic states in terms of affective symptoms. At the neural level, FEST versus SEKT showed increased amygdala activation and connectivity with the insula at post relative to prae-intervention timepoint. In FEST, the increase in amygdala activation was further associated with fewer depressive symptoms (r = .72) six months post-intervention. Conclusion: Enhanced activation and functional connectivity of the amygdala during emotional face-matching for FEST versus SEKT may represent a neural marker of improved emotion processing and remediated depressive symptoms thus promoting the FEST intervention as effective tool in the relapse prevention treatment of BD.