• biological rhythms
• Bipolar Disorder
• early trauma
• impulsivity
• sleep
• suicidality

Despite extant research has identified a wide range of clinical predictors of core aspects of Bipolar Disorder (BD), the potential clinical pathways from early life traumatic events to BD symptoms have not been well defined, in adults.
Although, both biological rhythms and emotion regulation are increasingly considered as independent catalysts for the BD course and further, both insomnia and suicidality are representing typical conditions of the disorder, until today, no studies have examined the synergistic role of both emotional regulation and biological rhythms as mediating factors in the complex interplay between early life traumatic events and the clinical expression of BD.
The study aimed to investigate the potential pathways that mediated early exposure to traumatic events that occurred before the age of 18 and the clinical manifestations of 162 individuals with BD in adulthood, such as severity of depressive symptoms, sleep complaints and suicidality, focusing on the mediating role of both emotional dysregulation and alterations of the biological rhythms. Moreover, it felt within the aim of the study to evaluate the correlations between every kind of early life trauma event and both the relevant biological systems alterations and emotional dysregulation, to better describes this interplay, in adults with BD. In order to explore this hypothesis, it has been decided to adopt the structural equation model-path analysis. Participants were assessed by the Structural Clinical Interview for DSM-5 (SCID-5), the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS), the the Early Trauma Inventory Self Report-Short Form (ETISR-SF), the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), the Difficulties in Emotion Regulation Scale (DERS), the Insomnia Severity Index (ISI) and the Scale for Suicide Ideation (SSI). Of the 162 individuals with BD, 45.7% satisfied a diagnosis of BD-I and 54.3% a diagnosis of BD-II. 88 subjects satisfied the diagnosis of a major depressive episode and 74 the diagnosis of a major depressive episode with mixed features. Participants reported significant high scores in all the psychometric tools. Significant correlations between early life traumatic events, depressive symptoms, emotional dysregulation, insomnia symptoms, biological rhythms desynchronization and suicidality have been found. Participants with early traumatic events experienced emotional dysregulation such as impulsivity, difficulties in engaging goals, non-acceptance of emotions and limited access to affective regulatory strategies. Moreover, both physical, emotional and sexual abuses, as well as general traumatic experiences were correlated with biological rhythms disturbances such as misalignment of the sleep-wake cycle, difficulties to keep a regular timing for meals, to end up the daily activities as well as to adapt the daily rhythm to that of the others. The path analysis lead to conclude that those who experience more early life traumatic events and, in particular sexual and emotional abuse, shows an increase in impulsiveness and therefore in emotional instability and a greater desynchronization of biological rhythms that, thus, play roles of mediation in determining a greater severity of both depressive and insomnia symptoms and an increased risk of suicide, characterizing a severe phenotype of the BD.
Assessing the evolution of these dimensions over time could offer an interesting complementary approach to characterize BD and to target treatment strategies. The management of early life traumatic events should be based on a comprehensive dimensional assessment over time including emotional regulation and biological rhythms that can contribute to the clinical expression of BD. These factors should be considered in the clinical evaluation of individuals with BD, in order to achieve the best functional outcome possible.