Bipolar Disorder Is Not a Mood Disorder

Stephen M. Strakowski, MD: Hello, and thank you so much for turning into our conversation today. I’m excited to have Dr Sheri Johnson here to talk about bipolar disorder in a different way than we typically do. Dr Johnson is a distinguished professor at the University of California Berkeley and is truly the world’s expert in reward processing in bipolar disorder and mania, which is the conversation today.

Dr Johnson, welcome.

Sheri L. Johnson, PhD: Thanks so much for having me. Looking forward to our conversation.

What Does “Reward Processing” Mean in Bipolar Disorder?

Strakowski: Today we want to talk about reframing of bipolar disorder from a mood disorder to a reward processing disorder. To kick it off, I want to share one slide that I’ll have Dr Johnson walk us through here in a second.

It reflects a lot of the work that she’s done and is from a review article by Nusslock, Mittal, and Alloy from 2025 that’s talking about reward processing in bipolar disorder and depression, and I think schizophrenia in this one too.

So, Dr Johnson, what are we talking about when we’re saying we need to rethink bipolar disorder as a reward processing disorder?

Johnson: Sure. This is a beautiful article by Robin Nusslock and his colleagues going over decades of theory and research. Let’s start by taking on what we mean by reward processing.

All of us have systems in our brain to help motivate us. We have a threat and punishment motivation system that helps us get away from bad things. We also have a motivational system that helps us move towards great opportunities and good things that could happen. And so, this system helps us move towards anything from a great piece of chocolate, love, job accomplishment, ways to find ourselves being admired, liked, and all the goodies in life.

The great thing is that we all have one of these. We all have a brain system that helps us move towards the good things. The idea here for people with bipolar disorder is that the system is somehow hypersensitive and once it comes online, it tends to stay online a little bit too long, a little bit too high.

What does that do for us? One is it taps into a large body of the brain science of reward systems in the brain, but it also tells us a lot about ways in which we think mania unfolds over time and the early signals of risk for mania and bipolar disorder.

Is Reward Hypersensitivity Specific to Bipolar Disorder?

Strakowski: Is this hypersensitivity to reward unique in bipolar disorder, or does it happen in other conditions?

Johnson: There are many different conditions that seem to involve some differences in reward sensitivity, and that’s part of what I’ve been interested in now for a couple decades. Is there something more specific about what it looks like in bipolar disorder?

I think there really are two strands that are unique and specific in bipolar disorder. One is a tendency to set high goals and to go after goals even when the rewards might be pretty minor. People with bipolar disorder will describe themselves as being sensitive to rewards on self-report, if you ask them self-report questions, they’ll say, “Yeah, I am like that. When there’s a small opportunity for reward, I get more excited, more motivated than other people.” That can predict the onset and course of mania over time. But we think another thing it does is it leads them to set pretty high life goals and to be more ambitious and more willing to spend effort on going after and chasing those goals.

So that’s one whole piece of this puzzle that’s fascinating to me. Sometimes it has good sides. Sometimes it can predict more mania over time, but sometimes it actually helps people and their family members do a little bit more.

High Goal Setting and the Drive Toward Mania

Johnson: There’s another piece here in bipolar disorder that I’m really interested in though. Once people click into the process of going after a goal (what we call “goal pursuit”) and they get immersed in that I’m going after the goal, I’m going after the dream, they can get a little dysregulated, overly confident, and start to take some risks that they wouldn’t otherwise do. Often, when they come back out of that period, they feel really a sense of remorse, a sense of loss of like Hey, how did I end up doing that? That’s not something I would’ve normally done. It’s as though the whole thermometer went up a little bit and they were just acting with the only thing in view was I’m going for it. I’m going for the gold.

Strakowski: We have a tendency, particularly in the Western culture, but certainly in the United States, that we set that moods are goals. So, “life, liberty and the pursuit of happiness,” is a goal. But when I think about moods and emotions, the brain is firing off signals to try to motivate us to do things. If we think about it that way, does that somehow link the mood states of mania with this? How would you think about it?

Johnson: For all of us, when we feel like we’re going after a dream or a goal, something that we would really value, when we’re making progress towards that, it’s exciting. That excitement helps us mobilize our energy, our movement, our thinking, that sense of, Okay, I’m on fire. All of us have the capacity for some part of that. We just think the volume has turned a little higher for the person with bipolar disorder.

Does Euphoria Create a Self-Reinforcing Cycle?

Strakowski: Yeah, that’s what I’ve wondered. The euphoria would be your brain saying, “Keep doing what you’re doing,” and that would drive you to continue reward processing, which would drive more euphoria. It just feels like a vicious cycle that might land people in a manic state. Is that reasonable?

Johnson: That is a lot of how I think about it. I also think that part of what happens for most of us is that we can be really excited about our dream, but we have a really nice, strong signal from our body that it’s time to go to sleep, pipe down, and pick it up in the morning.

But if you have weekday and weeknight rhythms to begin with, which often happens for somebody with bipolar disorder, and you don’t have that strong body signal of, come on, you’re tired, go to sleep, pick it up in the morning. You can end up working on that dream and the goal through a large part of the night and get more dysregulated and have less of a break on the whole system.

Creativity, Success, and Genetic Risk

Strakowski: Very interesting thought. The other thing you kind of alluded to - if this personality trait or feature is present genetically, which is implied and as we know, things like creativity, charisma, success, run in bipolar families at higher rates than general population are you posing that perhaps it’s being expressed at different levels to the point of illness in some of the members but to great success in others?

Johnson: I’m fascinated by that question and I’m really glad you asked it. We do know that reward sensitivity is fairly heritable - it runs in families. We’ve looked at how this then relates to the creative accomplishments in people with bipolar disorder.

Simon Kyaga, MD, PhD, MBA, has done beautiful analyses of the entire population of Sweden to show that people with bipolar disorder, but more so their family members who’ve never had a mania, tend to be very creatively accomplished. They’re more likely to be paid as artists, more likely to be university professors, more likely to become entrepreneurs, and the family members who are entrepreneurs tend to make more money in business startups. So, all these signals of creativity running in the family.

We’ve done a set of studies to say, “What is that? What’s the magic juice there?” and one of the things we see is that willingness to work hard for a small reward is correlated with the creative accomplishment.

People who are being paid as artists or creative people tend to have higher levels of that, Yeah. I’ll work really hard for a small reward. Sadly, the life of an artist right now is that you work really hard for tiny signals of recognition for most of the career. So, we think that that kind of willingness to work really hard for a small reward is probably a great thing for creativity.

Now, the good news that I want to highlight is that you don’t need mania for that creativity to come through. The creativity is there in family members who have never had an episode of mania. I think something about that high level of reward pursuit, high levels of willingness to work hard that’s coming through, being carried in these families, is a huge advantage and that advantage is particularly there if we can protect people from all the difficulties that come along with mania.

Trait vs State: Is Reward Sensitivity Always Present?

Strakowski: The other thing that you had mentioned as you were talking about this constant high goal setting is that maybe this isn’t just occurring during mania, but is a trait present all the time, which is a genetic condition one would imagine is true. Do you believe that’s true?

Johnson: Yeah, but I think the form changes so we can ask people when they’re fully well between episodes, “Do you tend to set higher goals in your life than other people?” People will endorse very high goals, really wanting to make a huge difference in life, like make millions of dollars, be the subject of books or TV shows, be a leader. People will often have ideas of like, I’d like to be one of the people that engineers world peace or climate change. Big meaningful goals. They also hold themselves to really high standards. We’ll sometimes see a kind of strand of perfectionism of, I don’t want to do a bad job on this goal.

But that is often quietly in the background. So many of the people we work with will say, “Yeah, that’s there, but I don’t talk about it much. It’s just a hope. It’s just a dream.” But then when the mania kicks in, they tend to get very immersed in going after those goals and dreams and that’s when they stop sleeping as much, they may be spending more money than they wanted to, and they’re taking on that goal in a way that sometimes is painful because it’s too big, it’s too ambitious, it’s too much.

I always think, Okay, having a big dream is great. Steve, you and I want to make a difference in the world of bipolar disorder. That’s a really hard and difficult dream. Nobody is going to criticize us for having a big dream and hope. The key is that as people get manic, it becomes very hard to modulate how intensely and how calibrated the work of goal engagement is.

Clinical Implications of a Reward-Based Model

Strakowski: We might think about as the reward pursuit events occur, it drives a euphoric mood state, which are elevated, and the transition keeps cycling until it’s euphoric and then we have mania on something that’s always present. That’s the idea that this is a reward processing condition rather than a primary mood disorder.

How would that be applied to thinking about treatment? Does it change anything we commonly do, or would there be new models we might think about in our practices?

Johnson: Yeah, it does change things. We’ve done a little bit of treatment development - very exploratory work. At the biological front, my hope is that we’ll develop precision medicine approaches that help with that process. I don’t think we’re quite there yet, but that’s the hope.

But for now, since we don’t have that in hand, the hope is that we can help psychologically. One piece that we’ve had good luck with is just helping people with bipolar disorder understand this process. Helping them understand that they might be somebody who harbors higher goals than other people. I’ve often been surprised during that conversation that people with bipolar disorder won’t see their goals as particularly high. They don’t see themselves as hard driving. They just think like, Well, of course, doesn’t everybody hold to that kind of life ambition? They’re sometimes surprised to hear, “Yeah, no. Other people are not wandering around thinking about making a difference in world peace or changing bipolar disorder or doing other kinds of things like that.” I’m never going to criticize those goals, but I want them to be very self-compassionate when you can’t change something that big.

The other part that we work very hard on is recognizing the early signs of getting too goal engaged, too overly confident, starting to do the risk taking, and thinking about ways to retreat and give a break to the goal pursuit in that moment. Goal pursuit is an elixir. It makes everybody excited. Pull back, make sure you can take some breaths, make sure you can sleep through the night. If this is really a game changing, beautiful goal idea, it’ll still be there. It’s almost never in life where you have to seize the day immediately for this to work in the big picture. So, giving people ways to test the breaks and recognize the signals that they’re moving into one of those periods.

Helping Patients Regulate Goal Pursuit

Strakowski: It feels like cognitive behavioral therapy, where we start learning how to ratchet back a little bit when we get too high. Is that sort of how you all frame it when you work on it?

Johnson: I always talk about the idea of testing the brakes. It’s very hard to stop a car when it’s going full tilt, but if you start to feel the car having momentum, that’s the time to tap the brakes and make sure they’re working.

Strakowski: You and I have been talking about this and working on it, and I think it’s an interesting way to reconceptualize the illness and also to think about some alternative treatment development pathways, and so we’re excited and hope that other people will think about this. I’ve talked to a number of the people I treat and work with bipolar disorder, and it really seems to resonate with them. I don’t know if you’ve had that experience too, but they say, “That really feels like me in a way that mood changes didn’t.” Does that make sense?

Johnson: When we’ve written about this, I’m always struck by how many people will then contact me to say, “I think you’re on track.” That’s the heart and soul of why we want to do this. We want something that fits for people with the disorder.

Strakowski: Well, thank you. Like we said, we’re very excited about this as a new model that might help advance certainly the psychotherapeutic side of bipolar disorder, and as Dr Johnson mentioned, thinking about how we personalize things. Hopefully, all who are tuned in and listening to this find it also invigorating. Ask some of your patients and see what they think about it. We appreciate very much you are taking the time to sign into Medscape. I’m Steve Strakowski and thank you very much.

Stephen M. Strakowski, MD, is the professor and vice chair, Research of Psychiatry at Indiana University School of Medicine, and a professor at the Department of Community and Global Health at the Richard M. Fairbanks School of Public Health at Indiana University in Indianapolis, Indiana. He also serves as professor of psychiatry and associate vice president, Regional Mental Health at the Dell Medical School, University of Texas in Austin. In addition, Strakowski is editor-in-chief of the Journal of Mood and Anxiety Disorders.

Sheri L. Johnson, PhD, is a professor of psychology at the University of California Berkeley and renowned for her expertise on bipolar disorder. She is also the Cal Mania (CALM) program director, where she leads research surrounding emotion and impulsivity.

Note: This article originally appeared on Medscape.