The correlation between mentalization, internalized stigma and functioning in bipolar disorder patients

Authors

Abstract

AimThis study aims to investigate the effects of mentalizing disorder and internalized stigma on patients’ functioning in patients with bipolar disorder (BD).
MethodsOur study was conducted on a total of 75 patients in remission diagnosed with BD Type 1 according to DSM-5 diagnostic criteria who applied to Ankara Oncology Hospital Bipolar Disorders outpatient clinic in 2023. Sociodemographic data form, Hamilton Depression Rating Scale (HDRS), The Young Mania Rating Scale (YMRS), The Reading the Mind in the Eyes Test (RMET), Functional Assessment Short Test (FAST), and Internalized Stigma of Mental Illness Scale (ISMI) were administered to the participants.
ResultsIn the study, no correlation was found between ISMI and RMET scores and functioning. A significant correlation was found between the HDRS scores and the total scores of the FAST (r=0.266 p<0.05). In addition, those who used alcohol or drugs were significantly higher than those who did not, those who did not have a regular job were significantly higher than those who did, and those who had a lifetime history of suicide attempts were significantly higher than those who did not (p<0.05).
ConclusionInternalized stigma and mentalization levels do not affect functionality in patients with BD during remission. However, subthreshold depression symptoms, alcohol and substance abuse, and suicide attempts in the past may negatively affect the functioning of these patients even in the remission period, so it is important to evaluate these conditions carefully.

Keywords

Introduction

Bipolar disorder is recognised as a psychiatric disorder characterised by emotional fluctuations and mood swings.^1,2 Patients diagnosed with bipolar disorder alternate between episodes of mania and depression, which requires them to cope with a wide range of psychosocial challenges at different periods of their lives. However, they struggle not only with these challenges but also with bipolar disorder itself.³
In recent years, it has been observed that bipolar disorder patients’ mentalizing deficits further complicate this situation. Mentalizing involves the ability to understand other people’s thoughts, feelings, and intentions and is important in social interactions. It has been reported that bipolar disorder patients may also have mentalizing deficits, especially during mood episodes, and even during remission periods this situation causes impairment in functionality.⁴ Bodnar and Rybakowski⁵ reported that deficits in mentalizing among Bipolar I patients were significantly associated with cognitive impairments, predominantly during depressive episodes. Inanc et al.⁶ revealed the existence of a relationship between mentalization and stigma perception. Pal et al.⁷ reported that high levels of internalized stigma have negative effects such as social withdrawal, poor functioning, and poor quality of life. Cerit et al.⁸ stated that internalized stigma has a fundamental role in predicting functionality. Different studies conducted in patients with bipolar disorder consistently confirm the effects of mentalizing deficits and internalized stigma on functioning. These studies indicate the existence of a complex relationship between these three entities in bipolar disorder patients.
This study investigates the effects of mentalizing deficits and internalized stigma in patients with bipolar disorder on patients’ functioning. Internalized stigma means judging one’s own condition or symptoms in a negative way and identifying these negative judgements with one’s own identity,⁹ while functioning includes the ability to perform tasks and activities related to different life domains.¹⁰ Due to mentalization disorders, bipolar disorder may cause patients to stigmatise themselves and may cause problems in the areas of work, education, social relationships, and personal life. As a result, patients’ compliance and response to treatment may be prolonged. Our research aims to provide new perspectives on clinical practice and treatment strategies in this field and to help patients with bipolar disorder achieve a better quality of life.

Materials and Methods

Participants
In our study, a total of 75 patients who applied to the Bipolar Disorders Branch outpatient clinic of Ankara Oncology Hospital in 2023 and were diagnosed with Bipolar Disorder Type 1 in accordance with the Diagnostic and Statistical Manual (DSM-5) diagnostic criteria were included. These patients were selected from those with Young Mania Rating Scale (YMRS) scores below 7 and Hamilton Depression Rating Scale (HDRS) scores below 7. Participants were given detailed information about the study and written informed consent was obtained. Inclusion criteria were: age between 18-65, diagnosis of Bipolar Disorder Type 1 according to DSM-5, ability to adapt to the research protocol, written consent, and at least 8 years of basic education. Exclusion criteria included mental retardation or severe cognitive impairment, pervasive developmental disorder, social phobia or personality disorder, history of neurological or medical disease causing significant sequelae, inability to perform tests due to hearing or visual problems, and less than 8 years of basic education.
Data Collection
Socio-demographic Data FormA questionnaire developed by the researcher was used to determine disease characteristics and demographic information.
The Functioning Assessment Short Test (FAST)The FAST, developed by Rosa et al.¹¹ assesses functioning difficulties with 24 items on a four-point Likert scale. Adapted into Turkish by Aydemir and Uykur.¹² it showed high internal consistency (Cronbach’s alpha = 0.960) and test-retest reliability (0.945). Validity analyses revealed five factors: social activities, occupational functioning, autonomy, cognitive functioning, and financial issues. Confirmatory factor analysis indicated good fit (CFI = 0.912, RMSEA = 0.085). The FAST differentiated between symptomatic patients, recovered patients, and healthy controls (AUC = 0.824).
The Internalised Stigma of Mental Illness Scale (ISIS)Developed by Ritsher et al.¹³ in 2003, ISIS consists of 29 items. Adapted into Turkish by Ersoy and Varan.¹⁴ reliability analyses showed Cronbach’s alpha coefficients ranging from 0.63-0.87 for subscales and 0.93 for the whole scale. Convergent validity was confirmed through correlations with multiple psychological measures.
Reading the Mind in the Eyes Test (RMET)Adapted into Turkish by Yildirim et al.¹⁵ the 34-question test was applied to 117 healthy volunteers, with 70 retested two weeks later. After excluding items 19 and 21, mean correct responses were 23.64 (SD = 3.38) and 23.40 (SD = 4.32). The 32-question version was deemed reliable for assessing theory of mind and emotion recognition.
The Hamilton Depression Rating Scale (HDRS)The HDRS is a widely used tool for assessing depression, consisting of 17 items (HDRS17) focused on symptoms from the past week. A 21-item version (HDRS21) adds items for subtyping depression. While widely employed, HDRS has limitations, excluding atypical symptoms such as hypersomnia and hyperphagia.¹⁶
The Young Mania Rating Scale (YMRS)The YMRS is a brief tool for evaluating manic symptoms, comprising 11 items rated on severity. Four items are scored 0-8, seven items 0-4. It incorporates clinical observations and is widely used in clinical settings.¹⁷
Ethical Approval
This study was approved by SBÜ Dr. Abdurrahman Yurtaslan Ankara Oncology SUAM Non-Interventional Clinical Research Ethics Committee (Date: 10.02.2022, Decision No: 2022/-01/39).
Statistics
Descriptive statistics (mean, SD, median, min, max) were used for continuous data; percentages for discrete data. Shapiro-Wilk test evaluated normality. Mann Whitney U test was used for two-group comparisons, Kruskal-Wallis for more than two groups. Spearman correlation coefficient determined relationships between scale scores. Multivariate linear regression identified variables explaining FAST scores. Analyses were performed using IBM SPSS for Windows 20.0 (SPSS Inc., Chicago, IL). Statistical significance was set at p<0.05.

Results

There was no correlation discovered between age, disease characteristics, and FAST Total scores (p>0.05). However, a positive correlation was noted between HDRS scores and FAST Total scores (r=0.266, p<0.05). The investigation found no connection between ISIS Total and ISIS sub-dimension scores, and FAST Total scores (p>0.05). Similarly, no correlation was detected between RMET scores and FAST Total scores (p>0.05) (Table 1).
FAST scores did not differ significantly according to gender, educational level, marital status, or living area groups (p>0.05). However, a significant difference in FAST scores was observed between employment status groups; patients who worked regularly had significantly lower scores than those who did not work (p=0.013). In addition, FAST scores differed significantly between patients who used alcohol or drugs and those who did not, with the former having higher scores (p<0.05). There was no significant difference in FAST scores between patients with and without comorbidities (p>0.05).
A significant difference was found between patients with and without a history of lifetime suicide attempts (p<0.05). The mean FAST score of patients with a history of lifetime suicide attempt was 19.11 ± 9.88, while this score was 13.42 ± 9.41 in patients without a history of lifetime suicide attempts. This suggests that patients with a history of lifetime suicide attempts have lower functioning and higher FAST scores (Table 2).
The variables included in the model for the total score of the FAST were not found to be significant (R²=0.100, F=1.919, p=0.117) (Table 3).

Discussion

In our study, we examined the effect of mentalizing and internalized stigma levels on the functioning of patients with bipolar disorder in remission. Our findings show that these two factors do not significantly affect functioning. A striking point is that the majority of our sample consisted of individuals with at least 8 years of education. As it is known, increasing education level contributes to the development of mentalizing skills, which may explain why functionality in this sample was high. In addition, regular follow-up in the outpatient clinic, psycho-education, and family support may have positively affected functionality. Therefore, we think that their level of internalized stigma may be low.
Another important finding indicates that subthreshold depression symptoms and even suicide attempts may negatively affect functioning even in remission. This is an important result not only for patients with bipolar disorder but also for the design and orientation of mental health services in general.
Can and Tanrıverdi¹⁸ found a significant negative relationship between patients’ internalized stigma levels and social functioning. Yanos et al.¹⁹ reported that change in self-stigmatization was significantly negatively associated with change in social functioning and control of negative symptoms. Picco et al.²⁰ reported that there was no significant socio-demographic or clinical correlation with internalized stigma. These independent studies indicate that internalized stigma may be an effective factor in social functioning, but its impact may vary depending on different variables. Gustemps et al.²¹ revealed that adults with OCD exhibit different functional impairment profiles depending on age: younger patients experience more impairment in autonomy, while older patients face more difficulties in interpersonal relationships. Rosa et al.²² reported that bipolar patients exhibited worse functioning in all domains of the FAST, with advancing age, depressive symptoms, number of previous mixed episodes, and number of hospitalisations associated with poorer functioning. Icick et al.²³ found that patients with BD and comorbid AUD exhibited a more severe clinical profile than those without AUD. In our study, we observed a similar relationship in participants with subthreshold depressive symptoms. Although there was no diagnosis of AUD in our sample, functioning was significantly lower in individuals with alcohol use. These results, together with other factors mentioned in the literature, highlight the complexity of variables affecting functioning in bipolar disorder.
Another important finding was the FAST scores between patients with and without suicide attempts. FAST scores were higher in patients who attempted suicide. Literature has reported that suicide is an important source of illness burden in bipolar disorder.^24,25 Suicide attempts often negatively affect functionality. Physical and emotional health may be severely damaged after such attempts, leading to increased FAST scores. Furthermore, suicide attempts are often associated with challenging life events or intense emotional stress, which may reduce functioning.

Conclusion

This study analyzed factors influencing the functionality of bipolar disorder patients. Sociodemographic factors like age, disease characteristics, education, marital status, living areas, psychiatric diagnoses, psychotic features, movement disorders, and side effects showed no direct impact. However, employment status, alcohol/substance use, and suicide attempts significantly affected functioning, underlining the disorder’s complexity. Suicide risk and substance use emerged as crucial determinants. These findings underscore the necessity for more research, tailored treatment strategies, and individualized approaches for bipolar disorder patients.

Declarations

References

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About This Article

Received:

February 18, 2023

Accepted:

April 2, 2024

Published Online:

May 9, 2024

Printed:

July 1, 2024