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Assessment of implicit self-esteem in bipolar manic and euthymic patients using the implicit association test Jin Young Park a, b , Vin Ryu c , Ra Yeon Ha b, d , Su Jin Lee b , Won-Jung Choi b, e , Kyooseob Ha f , Hyun-Sang Cho b, g,⁎ a
Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, South Korea b Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea c Department of Psychiatry, Konyang University College of Medicine, Daejon, South Korea d Department of Psychiatry, Seoul Bukbu Hospital, Seoul, South Korea e Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, South Korea f Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea g Department of Psychiatry, Yonsei University College of Medicine, Severance Mental Health Hospital, Gwangju, South Korea
Abstract Objective: Although self-esteem is thought to be an important psychological factor in bipolar disorder, little is known about implicit and explicit self-esteem in manic patients. In this study, we investigated differences in implicit and explicit self-esteem among bipolar manic patients, bipolar euthymic patients, and healthy controls using the Implicit Association Test (IAT). Methods: Participants included 19 manic patients, 27 euthymic patients, and 27 healthy controls. Participants completed a self-esteem scale to evaluate explicit self-esteem and performed the self-esteem IAT to evaluate implicit self-esteem. Results: There were no differences among groups in explicit self-esteem. However, there were significant differences among groups in implicit self-esteem. Manic patients had higher IAT scores than euthymic patients and a trend toward higher IAT scores than healthy controls. Conclusions: Our findings suggest that, on the latent level, a manic state is not simply the opposite of a depressed state. Furthermore, there may be a discontinuity of implicit self-esteem between manic and euthymic states. These unexpected results may be due to characteristics of the study participants or the methods used to assess implicit self-esteem. Nevertheless, they provide greater insights on the psychological status of manic patients. © 2014 Elsevier Inc. All rights reserved.
1. Introduction In psychoanalysis, mania is regarded as an unconscious defensive reaction to depression [1]. According to Neale’s cognitive explanation, grandiose ideas, which arise from the avoidance of low self-esteem, result in mood elation and excited behaviors [2]. For bipolar patients, a state of low selfesteem may be a predisposing factor, and a precipitating event can threaten the vulnerable sense of self-esteem. Then bipolar patients who experience underlying negative cognition might activate positively-biased explicit cognition to avoid painful cognition for awareness and to keep out of ⁎ Corresponding author. Yonsei University College of Medicine, 696-6 Tanbeol-Dong, Gwangju-Si, Gyeonggi-Do, South Korea 464-100. Tel.: +82 31 761 0000. E-mail address: [email protected] (H.-S. Cho). 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.09.012
distressing depressed mood. These grandiose ideas might lead to mood elevation to mania although the implicit cognition is still related to depressive cognition [3]. The core of this cognitive reformulation of the psychoanalytic hypothesis lies in the ‘implicit’ psychological status of manic patients that manifests in ‘explicit’ elative mood, inflated self-esteem, and grandiose self-representation. Explicit (direct) and implicit (indirect) attitudes may not be the same, as patients may resist self-presentational forces that mask personally or socially undesirable evaluative associations or that prevent accurate reporting of attitudes [4]. Bipolar patients may express self-esteem indirectly [3], with a discrepancy between explicit and implicit self-esteem in both remitted [3] and manic states [5]. Several tools for assessing implicit emotional processing have been used for manic patients. In empirical studies using the emotional Stroop test, manic or hypomanic patients
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exhibit negative information processing biases that are implicated in depressed states [5,6]. Lyon and his colleagues, however, found that manic patients possess both implicit negative views and explicit positive views of themselves [5]. In recent studies using implicit tasks, including an emotional auditory verbal learning test, bipolar hypomania was found to be associated with both depression-related and maniarelated cognitive processing [7], with no differences observed between hypomanic and euthymic states [7,8]. Likewise, some researchers propose that hypomania is associated with both negative and positive cognitive biases [9]. Thus, attempts to understand the psychology of manic patients using implicit approaches are still limited and produce inconsistent results. Explicit self-esteem can be assessed by deliberate, conscious self-reports, whereas implicit self-esteem can be assessed by automatic, non-conscious responses [10]. Recent studies suggest that explicit self-esteem is revealed through controlled, reflective responses, whereas implicit self-esteem is revealed through spontaneous, affective responses [11,12]. The Implicit Association Test (IAT) is a useful tool for measuring implicit self-esteem [4,13] in healthy subjects and patients with psychiatric illnesses including paranoia [14], social anxiety disorder [15], body dysmorphic disorder [16], borderline personality disorder [17], and narcissistic personality disorder [18]. Recent studies using the self-esteem IAT equivocally report either lower implicit self-esteem in current depressive patients compared with healthy controls [19] or no differences in implicit self-esteem between subjectively high depressive volunteer students whose BDI score was over 21 and low depressive ones [20]. Unipolar depressive patients in remission, however, show either higher implicit self-esteem or no differences compared with healthy controls [19,21,22]. Furthermore, a greater number of previous depressive episodes are associated with lower implicit self-esteem [19], emphasizing the necessity of evaluating self-esteem for relapse prevention treatment. These inconsistent findings of implicit self-esteem among manic patients might partly result from differences among assessment tools or heterogeneity among samples [7]. To our knowledge, the IAT has not previously been used to evaluate implicit self-esteem among patients with bipolar I mania or euthymia. We expect that this approach will not only increase our understanding of the cognitive patterns of mania but also suggest cognitive strategies for preventing mania recurrence. Self-efficacy has been assessed (simultaneously) along with self-esteem in a large number of psychological studies on ‘self’. The concept of self-efficacy and self-esteem seems to measure the same factors [23]. However, self-efficacy is defined as the perception of one's own ability to complete and reach goals and hence, by definition, differs subtly from selfesteem which is defined as a person's sense of own worth. Manic patients show behavioral abnormalities that are related to psychological state of inflated self-esteem — they exhibit increased goal-directed activities and frequently
show behavioral problems such as getting excessively involved in pleasurable activities that have a high potential for painful consequence. So self-efficacy, by its definition, possibly is psychological status that well represents such behavioral characteristics observed in manic episode. The purpose of this study was to assess implicit and explicit self-esteem in patients with bipolar disorder, particularly those in manic states. We hypothesized that manic patients would have higher explicit self-esteem and lower implicit self-esteem compared to euthymic patient or normal controls. Explicit self-esteem was measured using the Rosenberg self-esteem scale, and implicit self-esteem was measured using the self-esteem IAT. Remitted bipolar euthymic patients and healthy controls were included to address the specificity of self-esteem characteristics associated with manic states. Also, we analyzed relationships among explicit/implicit self-esteem, self-efficacy, and recent affective status. 2. Methods 2.1. Participants Nineteen manic patients and 27 euthymic patients were recruited from the Severance Mental Health Hospital of Yonsei University Health System. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-IV [24]. Diagnoses were briefly confirmed using the Mini-International Neuropsychiatric Interview (MINI) [25] which was performed by two experienced psychiatrists (J.Y.P. or H.S.C.). We excluded patients with mixed manic states due to possible confounding effects of depressed mood. Patients with recent substance abuse, severe personality disorder, neurological diseases, or any other current axis I disorders were also excluded. For healthy controls, we selected 27 individuals who responded to a recruitment notice. All the patients participated in this study were diagnosed with bipolar I disorder and there was no bipolar II disorder patient. 7 manic patients and 12 euthymic patients experienced manic episode only and did not experience depressive episode. These individuals had no history of psychiatric disorders and did not show any notable psychiatric symptoms during the MINI interview. Mood status and psychopathology were also assessed using the Young Mania Rating Scale (YMRS) [26] and the Montgomery and Åsberg Depression Rating Scale (MADRS) [27]. Montgomery–Åsberg Depression Rating Scale is a tool for evaluating depressive symptoms by raters, and it has total 10 items such as sadness, tension, reduced sleep, reduced appetite, concentration difficulty, and so on. Scores from each item are added up [28]. Young Mania Rating Scale is a clinical rating scale for evaluation of maniac symptoms and consists of 11 items such as mood, sexual interest, speech, disruptive–offensive behavior, and so on. 7 items are rated from 0 to 4 and 4 items are rated from 0 to8. Higher score indicates severe maniac symptom [29]. Mini International
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a task or reach a goal [34,35]. The Self-Efficacy Scale (SES) is comprised of 23 items subdivided into two subscales: a general self-efficacy subscale (17 items) and a social selfefficacy subscale (6 items). Participants were asked to indicate their agreement with statements on a scale ranging from 0 (strongly disagree) to 4 (strongly agree) [36,37].
Neuropsychiatric Interview was developed by Sheehan et al. in 1998 and is a simple and effective method of interview. It considered international diagnosis standard such as ICD-10 or DSM-IV and considered changes within major symptoms to increase utilization in research or clinical practice [30] As shown in Table 1, there was no significant difference among the three groups regarding age, gender, education, occupation, and religion. YMRS scores and MADRS scores showed significant differences among the three groups. Tukey’s HSD post-test revealed that YMRS scores of manic patients were higher than those of euthymic patients (p b 0.001) or normal controls (p b 0.001). The MADRS scores of normal controls were lower than those of manic patients (p b 0.001) or euthymic patients (p = 0.001). Furthermore, no differences in clinical characteristics were observed between manic group and euthymic group.
2.2.3. Implicit association test In the IAT, individuals categorize stimuli according to automatic associations between concept discrimination (self vs. non-self) and an attribute dimension (positive vs. negative) [4]. Reaction times are used to measure the relative strength of these implicit associations [38]. As in previous studies [19,39], we used pronouns for the self vs. non-self dimension to avoid semantic associations that may be elicited by nouns [40,41]. For the positive vs. negative dimension, we used a set of adjectives describing 10 positive and 10 negative personal attributes. Adjectives were selected from those used in a previous IAT study conducted in the Korean language [42]. Adjectives in the ‘positive’ category were freedom, health, happiness, praise, stability, satisfaction, love, peace, kindness, and smile. Adjectives in the ‘negative’ category were abuse, grief, insult, hatred, tragedy, violation, poverty, crash, death, and decomposition. All Korean adjectives were composed of two syllables. Pronouns in the ‘self’ category were I, me, my, mine, and self, and pronouns in the ‘other’ category were they, them, their, it, and other [13]. Target words in black letters were presented in the center of a computer screen against a gray background. Participants were directed to assign target words as quickly as possible to their corresponding dimension by pressing a computer key. In the self-positive task, participants were instructed to press the ‘E’ key when presented with a stimulus from the ‘self’ or ‘positive’ categories and the ‘I’ key when presented with a stimulus
2.2. Measures 2.2.1. Rosenberg Self-Esteem Scale Explicit self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES) [31], which is a widely used selfreport measure of global attitudes about one’s overall worthiness as a human being [32]. This 10-item scale consists of five positively worded and five negatively worded items. Ratings are based on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s α reliability coefficient was calculated to identify internal consistency reliability for verifying the reliability of Korean version of Rosenberg Self-esteem. The reliability coefficient ranged between 0.75 and 0.87[33]. Higher RSES scores were considered to reflect higher levels of explicit self-esteem. 2.2.2. Self-Efficacy Scale Self-efficacy refers to expectations of personal mastery, which are major determinants of initial decisions to complete Table 1 Participant demographic and clinical characteristics. Measure
Group Bipolar Manic (n = 19) Mean/n
Demographics Age (years) Gender (male) Education (years) Employed or student status Religion (devotee) Clinical Symptoms YMRS MADRS Clinical Characteristics Illness duration (weeks) Number of manic episodes Number of depressive episodes Total number of mood episodes
SD/%
Statistical Results
Bipolar Euthymic (n = 27) Mean/n
SD/%
Healthy Control (n = 27) Mean
SD/%
F/χ 2/t
p
32.79 12 13.79 9 14
9.00 63.15 2.07 47.37 57.89
36.30 14 13.74 13 12
8.30 51.85 2.21 48.15 44.44
33.52 18 14.63 15 17
9.87 66.67 2.50 55.56 62.96
1.01 1.33 1.23 0.41 0.42
0.369 0.515 0.299 0.815 0.121
21.05 5.32
9.79 3.22
1.33 3.78
1.24 2.17
0.59 1.41
1.62 1.89
108.31 15.71
b0.001 b0.001
179.79 2.47 1.63 4.11
149.84 1.31 1.92 2.69
202.00 3.44 1.44 4.44
157.85 2.58 1.83 3.32
0.48 1.68 -0.34 0.37
0.634 0.102 0.739 0.715
YMRS, Young Mania Rating Scale; MADRS, Montgomery and Åsberg Depression Rating Scale.
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from the ‘other’ or ‘negative’ categories. In the self-negative task, participants were instructed to press the ‘E’ key for ‘self’ or ‘negative’ stimuli and the ‘I’ key for ‘other’ and ‘positive’ stimuli. The logic behind the IAT is that response latency will be shorter when two associated categories are assigned to the same key than when two less associated (or non-associated) categories are assigned to the same key. Thus, shorter reaction times in the self-positive compared with the self-negative task can be regarded as greater implicit positive self-esteem [13,43,44]. 2.2.4. Procedure This study was approved by the institutional review board of Severance Mental Health Hospital. Written consent was obtained from participants after complete explanation of the study. After signing the consent form and filling in sociodemographic questions, participants performed the IAT. After that, they performed evaluation of the self-esteem scores and self-efficacy scores. Before the self-positive and self-negative tasks, subjects were informed about computer key assignments. Subjects were required to categorize the target words presented on the center of the computer screen by pressing the specified key mapped to the corresponding category as quickly as possible. The interval of response stimulus was 250 ms. Categorization errors resulted in the display of a red ‘x’ on the screen. Subjects were given three brief practice blocks (20 trials each; blocks 1, 2, and 4) and two test blocks consisting of self-positive or self-negative task trials (60 trials each; blocks 3 and 5). Task order was counterbalanced to prevent order-specific effects [4]. The IAT was conducted using visual STIM software (Millisecond Software, US). After the IAT, subjects completed the RSES and SES. 2.2.5. Statistical analysis IAT score was computed according to the improved scoring algorithm of Greenwald et al. [38]. All trials from the test blocks were analyzed to provide a measure representing the difference in reaction time between blocks 3 and 5 divided by the standard deviation of all reaction times for blocks 3 and 5. Higher positive scores reflect higher implicit self-esteem. Statistical analyses were performed using SPSS software (version 13.0, Chicago, IL, USA). Group differences were tested using analysis of variance (ANOVA), and post-hoc Tukey HSD tests were used to correct for multiple comparisons. χ 2 was used to compare the demographic data among three groups, and Independent t-tests were used to do the number of mood episodes between manic and euthymic groups. Statistical significance was set at p b 0.05. 3. Results 3.1. Participant demographics Participant demographic characteristics are shown in Table 1. There were no differences between groups in age,
gender, education level, religion, or employment/student status. Medication status and doses are presented in Table 2. One-way ANOVA revealed significant differences among groups in YMRS (F(2,70) = 108.31, p b 0.001) and MADRS scores (F(2,70) = 15.71, p b 0.001). Post-hoc tests showed that manic patients had higher YMRS scores than euthymic patients (Tukey HSD p b 0.001) and healthy controls (Tukey HSD p b 0.001), and that manic patients had higher MADRS scores than healthy controls (Tukey HSD p b 0.001). Independent t-tests showed that there were no significant differences between manic and euthymic patients in total duration of mood episodes (t = 0.48, n.s.), number of manic episodes (t = 0.17, n.s.), number of depressive episodes (t = -0.34, n.s.), or total number of mood episodes (t = 0.37, n.s.). 3.2. Implicit and explicit self-esteem scores Manic patients had higher implicit self-esteem than euthymic patients. One-way ANOVA revealed significant differences among groups in self-esteem IAT scores (F(2,70) = 3.58, p = 0.033, η 2 = 0.16). Post-hoc tests showed that manic patients had significantly higher IAT scores than euthymic patients (p = 0.037) (Table 3). Manic patients also had higher IAT scores than healthy controls, but this difference did not reach statistical significance (p = 0.076). Euthymic patients and control subjects showed no differences in IAT scores. After controlling for depressive symptoms by including MARDS score as a covariate, the significant difference among groups in self-esteem IAT score remained (F(3,69) = 2.83, p = 0.045). There were no significant differences among groups in explicit self-esteem scores or self-efficacy scores (Table 3). 3.3. Correlations between implicit and explicit self-esteem and clinical variables Among manic patients, implicit self-esteem score was correlated with explicit self-esteem score (r = 0.58, p = 0.010) and social self-efficacy score (r = 0.77, p b 0.001).
Table 2 Number of patients in bipolar manic and euthymic groups taking psychotrophic medications and their daily doses (mean ± SD) in mg. Medication
Group Bipolar Manic (n = 19) Bipolar Euthymic (n = 27)
Lithium Divalproate Sodium Carbamazepine Quetiapine Risperidone Olanzapine Aripiprazole Haloperidol Perphenazine
9 (933.3 ± 268.1) 13 (980.8 ± 296.9) 15 (576.7 ± 247.8) 7 (3.86 ± 1.68) 1 (20) 1 (5)
14 (889.3 ± 124.3) 13 (692.3 ± 208.0) 1 (400) 5 (95.0 ± 90.8) 8 (1.25 ± 0.46) 2 (10.00 ± 7.07) 1 (30) 1 (5) 1 (4)
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Table 3 IAT and questionnaire scores for bipolar manic patients, bipolar euthymic patients, and healthy control subjects. Measure
Group 1: Bipolar Manic (n = 19)
Implicit self-esteem score Explicit self-esteem score Self-efficacy, general Self-efficacy, social
2. Bipolar Euthymic (n = 27)
3. Healthy Control (n = 27)
Post-hoc Tests (p, Tukey HSD)
Mean
SD
Mean
SD
Mean
SD
F
p
1 vs. 2
1 vs. 3
2 vs. 3
0.77 20.37 45.90 15.37
0.43 5.43 11.87 5.17
0.47 19.37 44.22 14.22
0.40 4.46 10.59 3.85
0.51 21.85 47.74 15.63
0.35 3.53 9.16 3.70
3.58 2.14 0.77 0.85
0.03 0.13 0.47 0.43
0.04 0.73 0.85 0.63
0.08 0.51 0.83 0.98
0.94 0.11 0.44 0.44
Among euthymic patients and control subjects, however, there were no significant correlations between self-esteem and self-efficacy scores (Table 4). We also analyzed correlations between self-esteem scores and mood disorderrelated variables, including severity of manic and depressive symptoms, total duration of illness, and the numbers of previous manic, depressive, and total mood episodes in bipolar patients. Implicit self-esteem score was correlated with YMRS score (r = 0.35, p = 0.019) but not with MADRS score. Explicit self-esteem score was not correlated with YMRS or MADRS score. No significant correlations were found between implicit or explicit self-esteem scores and total duration of illness (r = −0.06, n.s.) or numbers of previous manic, depressive, or total mood episodes (r = −0.01 to −0.29, n.s.). 4. Discussion The goal of this study was to investigate implicit and explicit self-esteem in bipolar I disorder patients using the self-esteem IAT and self-report questionnaires. As far as we are aware, this is the first study to assess self-esteem in manic patients using the IAT. Implicit self-esteem of manic patients was significantly higher than that of remitted patients and numerically, but not significantly, higher than that of healthy subjects. Implicit self-esteem score was positively correlated with severity of manic symptoms but not with depressive symptoms or previous mood episodes in bipolar patients. By contrast, there were no differences in explicit self-esteem scores among groups. In the implicit self-esteem task, manic patients demonstrated higher levels of self-esteem than euthymic patients or Table 4 Correlation coefficients between implicit and explicit self-esteem scores.
Explicit self-esteem score Self-efficacy, general Self-efficacy, social
Statistical Results
Bipolar Manic
Bipolar Euthymic
Healthy Controls
0.58⁎ 0.34 0.77⁎
0.16 -0.12 -0.08
-0.19 -0.13 0.13
⁎ Correlation is significant at the 0.01 level (2-tailed).
healthy subjects. This finding suggests that levels of implicit self-esteem are high in manic states but may decline to normal levels in euthymic states. This may result from either a discrepancy between high standards and negative reality or self-esteem instability. As previously mentioned, low selfesteem or negative information processing bias may underlie manic states [2,5]. Identification of the exact cause for the ‘unexpected’ result of higher implicit self-esteem in manic patients than in euthymic patients is not feasible with the current results. The reason of this result could be inferred as follows. Firstly, it is possible that implicit self-esteem reflects high standard in manic status and reality in euthymic status. Secondly, it was reported that bipolar patients show changes in the self-perception [45] or instability regarding self-esteem [46] between specific mood episodes. The corresponding result would be reflecting differences in implicit self-esteem between the two groups with different mood status. It also suggests that implicit self-esteem is a state rather than a trait However it is considered that there are much evidence which imply the possibility that implicit selfesteem is a trait: hypomanic traits in undergraduate subjects were associated with interference of color naming for depressive but not euphoria-related words during the emotional Stroop test [6]; manic patients as well as depressive patients attributed negative events more than positive events to self on an implicit attributional style [5]; and remitted bipolar patients like remitted unipolar patients attributed significantly more negative events to internal cause than did normal controls by pragmatic inference task, which reflects a cognitive schema of low self-esteem in implicit way [3]. Such studies are evidence which support the manic defense theory. By contrast to such previous studies, implicit self-esteem appeared ‘unexpectedly’ higher in manic status than in euthymic status in the present study. This result suggests that self-esteem measured using IAT is not a trait marker that appears in bipolar disorder patients regardless of their mood status, but a state marker which appears with relevance to mood status. We can consider two possible explanations for the contrasting findings. Firstly, based on the prevalence of mixed manic states, some researchers have suggested a model explaining mixed
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positive and negative self-esteem in hypomanic states [47,48]. Our findings might result from the exclusion of cases of mixed manic episodes due to potential effects of depressive symptoms on IAT performance, as some studies report that depressed patients have lower self-esteem than non-depressed patients [19,49]. Secondly, differences among studies may be due to differences in tasks used to assess self-esteem. Lyon et al. [5] found low self-esteem at the implicit level among manic patients using the emotional Stroop task. Although there have been no IAT studies of patients with bipolar disorder, several studies using the IAT show unexpected results such as positive self-esteem in depressed patients [21,22,50], and in practice the IAT scores may measure a combination of trait and state [51]. One recent review suggests that studies using the IAT among subjects with psychiatric disorders may produce biased results because IAT scores may only reflect that selfevaluation is more positive than evaluation of others [44]. In contrast with implicit levels of self-esteem, we found no significant differences among groups in explicit levels of self-esteem. Similarly, Lyon et al. [5] found no differences in RSES scores between normal and manic groups, but bipolar depressed subjects had lower scores than the two other groups. Moreover, hypomanic patients reported the highest scores for positive as well as negative self-esteem [47]. Therefore, our explicit self-esteem results are generally consistent with those of previous reports. Our findings may be due to the course of treatment for the subjects. All manic subjects received inpatient treatment, and the majority of patients were still recovering from their symptoms. Therefore, their explicit self-esteem may have been lower at the time of investigation compared with that during their full manic episodes and may have declined as a result of insights into their illness. More focused and detailed studies will be needed in the future to illuminate how self-esteem changes throughout the course of illness and recovery. One of our main findings was that manic patients exhibited inconsistent performance between the two assessments, with higher implicit self-esteem on the IAT and normal explicit self-esteem on the questionnaires compared with euthymic patients and healthy subjects. Lyon et al. [5] suggested that similar levels of implicit self-esteem between manic and depressive states may reflect psychological continuity between the opposite types of mood episodes. The current study, however, suggests that mania cannot simply be regarded as the opposite of depression at the latent level and shows a potential discontinuity or different kinds of latent self-esteem and cognitive processing between manic and euthymic states. We found significant positive correlations between implicit and explicit self-esteem in manic patients but not in euthymic patients or healthy controls. Speculatively, this finding suggests that explicit and implicit self-esteem may be temporarily related during manic states but unrelated during recovered euthymic states. However, because we cannot be certain whether the explicit and implicit assessments measure the same psychological
attributes [52], more elaborate and structured research is needed to test this possibility. As mentioned in introduction, the Implicit Association Test (IAT) is a useful tool for measuring implicit self-esteem [4,13] in healthy subjects and patients with psychiatric illnesses including paranoia [14], social anxiety disorder [15], body dysmorphic disorder [16], borderline personality disorder [17], narcissistic personality disorder [18], and depressive disorder [19]. In addition to these studies, we found that the self-esteem IAT might be a good tool for understanding the cognitive patterns of mania. The selfesteem IAT might also be a useful tool for explaining the newer theories for bipolar disorder or cognitive strategies for treating affective disorders. For example, the integrative cognitive model of mood swings presents how attempts in the area of affect regulation are disrupted by conflicting personal meanings which are given to internal status [48]. The self-esteem IAT would more elaborate the internal states. On the other hand, according to beck’s cognitive triad, negative view of self is the key feature of depression, and correction of these cognitive distortions is the main issue of cognitive therapy. However, it is not to estimate objectively the implicit cognitive bias. Estimation of internal self-esteem using IAT would help to evaluate the current status of depression and to judge the effect of therapies. This study has several limitations. First, the manic patients who participated in this study were inpatients. As the inpatient environment can influence self-esteem, this may limit the generalization of our findings. However, considering that “to necessitate hospitalization” is critical to the diagnosis of manic episodes according to DSM criteria, this may be an inevitable choice. Second, a cross-sectional design was used, which does not allow for inferences about longitudinal change or causality of self-esteem in bipolar disorder. Third, the sample size was relatively small, therefore it is anticipated that greater insights will be gained from studies utilizing larger samples. Finally, further validation of implicit measures and more information on relationships between implicit cognitive processing and psychopathology are needed. Because our results were somewhat unexpected, any conclusions based on this study may be limited. For example, in a previous study using a large sample of healthy individuals, explicit self-esteem and implicit self-esteem were weakly but positively correlated [13]. In this study, however, a significant positive correlation was observed only among manic patients. Greenwald et al. [13] found correlation between implicit self-esteem and explicit self-esteem in 150 participants, but we did not find any correlations in the control group or in the euthymic group. Relatively small sample in this study may have been insufficient to gain significant results. Thus, a positive correlation between implicit and explicit self-esteem may also have existed for other groups if our sample sizes had been larger. In conclusion, using the IAT to measure implicit selfesteem among bipolar patients, we found that manic patients
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had higher implicit self-esteem than euthymic patients or healthy controls. Although there is a growing emphasis on genetic and neurobiological evidence for bipolar disorder, in clinical practice the understanding of bipolar disorder on a psychological level is still important for enhancing the effectiveness of psychosocial interventions such as cognitive behavior therapy [53–56]. Self-esteem is also an important factor contributing to clinical outcomes. Type of treatment, number of prior hospitalizations, and level of self-esteem are the most influential factors for a favorable progression of refractory bipolar disorder [57]. Negative self-esteem is the most robust predictor of treatment outcome [47], and selfesteem support appears to be the most important predictor of changes in depression among bipolar patients across a 6-month follow-up [58]. However, research on self-esteem among bipolar patients has taken place mainly with euthymic patients, with a severe lack of studies considering manic patients. Also, controversy still exists regarding whether mania is the opposite of depression or a manic defense. Therefore, studies of self-esteem among manic patients will provide a deeper comprehension of core pathophysiology and will assist in clinical trials and prognosis. Acknowledgment This study was supported by a grant (A101915) from the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. References [1] Abraham K. Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. Selected papers on psychoanalysis; 1911. p. 137-56. [2] Neale JM. In: Oltmann TD, & Mahler BA, editors. Defensive functions of manic episodes. New York: Wiley; 1988. [3] Winters KC, Neale JM. Mania and low self-esteem. J Abnorm Psychol 1985;94:282-90. [4] Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998;74:1464-80. [5] Lyon HM, Startup M, Bentall RP. Social cognition and the manic defense: attributions, selective attention, and self-schema in bipolar affective disorder. J Abnorm Psychol 1999;108:273-82. [6] Bentall RP, Thompson M. Emotional Stroop performance and the manic defence. Br J Clin Psychol 1990;29(Pt 2):235-7. [7] Lex C, Hautzinger M, Meyer TD. Cognitive styles in hypomanic episodes of bipolar I disorder. Bipolar Disord 2011;13:355-64. [8] Kerr N, Scott J, Phillips ML. Patterns of attentional deficits and emotional bias in bipolar and major depressive disorder. Br J Clin Psychol 2005;44:343-56. [9] Mansell W. An integrative formulation-based cognitive treatment of bipolar disorders: application and illustration. J Clin Psychol 2007;63:447-61. [10] Kernis MH. Toward a conceptualization of optimal self-esteem. Psychol Inq 2003;14:1-26. [11] Conner T, Barrett LF. Implicit self-attitudes predict spontaneous affect in daily life. Emotion 2005;5:476-88. [12] Rudolph KD. Implicit theories of peer relationships. Soc Dev 2010;19:113-29.
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[35] Bandura A, Adams NE, Beyer J. Cognitive processes mediating behavioral change. J Pers Soc Psychol 1977;35:125-39. [36] Shu B, Choi Y. Impulsivity and self-efficacy according to internet addiction. J Korean Acad Comm Health Nurs 2005;19:310-6. [37] Han K. Self efficacy, health promoting behaviors, and symptoms of stress among university students. J Korean Acad Nurs 2005;35:585-92. [38] Greenwald AG, Nosek BA, Banaji MR. Understanding and using the implicit association test: I. An improved scoring algorithm. J Pers Soc Psychol 2003;85:197-216. [39] Hofmann W, Gawronski B, Gschwendner T, Le H, Schmitt M. A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull 2005;31: 1369-85. [40] Steffens MC, Kirschbaum M, Glados P. Avoiding stimulus confounds in Implicit Association Tests by using the concepts as stimuli. Br J Soc Psychol 2008;47:217-43. [41] Steffens MC. Is the implicit association test immune to faking? Exp Psychol 2004;51:165-79. [42] Hong Y, Lee H. Measurements of resional prejudice by implicit association test. Korean J Soc Pers Psychol 2001;15:185-204. [43] Banaji MR. Implicit attitudes can be measured. In: H. L. Roediger III, Nairne JS, Neath I, editors. Surprenant A The nature of remembering: Essays in honor of Robert G. Crowder. Washington, DC: American Psychological Association 2001. p. 117. [44] Roefs A, Huijding J, Smulders FT, MacLeod CM, de Jong PJ, Wiers RW, et al. Implicit measures of association in psychopathology research. Psychol Bull 2011;137:149-93. [45] Ashworth CM, Blackburn IM, McPherson FM. The performance of depressed and manic patients on some repertory grid measures: a crosssectional study. Br J Med Psychol 1982;55(Pt 3):247-55. [46] Knowles R, Tai S, Jones SH, Highfield J, Morriss R, Bentall RP. Stability of self-esteem in bipolar disorder: comparisons among remitted bipolar patients, remitted unipolar patients and healthy controls. Bipolar Disord 2007;9:490-5. [47] Scott J, Pope M. Cognitive styles in individuals with bipolar disorders. Psychol Med 2003;33:1081-8.
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Assessment of implicit self-esteem in bipolar manic and euthymic patients using the implicit association test Jin Young Park a, b , Vin Ryu c , Ra Yeon Ha b, d , Su Jin Lee b , Won-Jung Choi b, e , Kyooseob Ha f , Hyun-Sang Cho b, g,⁎ a
Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, South Korea b Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea c Department of Psychiatry, Konyang University College of Medicine, Daejon, South Korea d Department of Psychiatry, Seoul Bukbu Hospital, Seoul, South Korea e Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, South Korea f Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea g Department of Psychiatry, Yonsei University College of Medicine, Severance Mental Health Hospital, Gwangju, South Korea
Abstract Objective: Although self-esteem is thought to be an important psychological factor in bipolar disorder, little is known about implicit and explicit self-esteem in manic patients. In this study, we investigated differences in implicit and explicit self-esteem among bipolar manic patients, bipolar euthymic patients, and healthy controls using the Implicit Association Test (IAT). Methods: Participants included 19 manic patients, 27 euthymic patients, and 27 healthy controls. Participants completed a self-esteem scale to evaluate explicit self-esteem and performed the self-esteem IAT to evaluate implicit self-esteem. Results: There were no differences among groups in explicit self-esteem. However, there were significant differences among groups in implicit self-esteem. Manic patients had higher IAT scores than euthymic patients and a trend toward higher IAT scores than healthy controls. Conclusions: Our findings suggest that, on the latent level, a manic state is not simply the opposite of a depressed state. Furthermore, there may be a discontinuity of implicit self-esteem between manic and euthymic states. These unexpected results may be due to characteristics of the study participants or the methods used to assess implicit self-esteem. Nevertheless, they provide greater insights on the psychological status of manic patients. © 2014 Elsevier Inc. All rights reserved.
1. Introduction In psychoanalysis, mania is regarded as an unconscious defensive reaction to depression [1]. According to Neale’s cognitive explanation, grandiose ideas, which arise from the avoidance of low self-esteem, result in mood elation and excited behaviors [2]. For bipolar patients, a state of low selfesteem may be a predisposing factor, and a precipitating event can threaten the vulnerable sense of self-esteem. Then bipolar patients who experience underlying negative cognition might activate positively-biased explicit cognition to avoid painful cognition for awareness and to keep out of ⁎ Corresponding author. Yonsei University College of Medicine, 696-6 Tanbeol-Dong, Gwangju-Si, Gyeonggi-Do, South Korea 464-100. Tel.: +82 31 761 0000. E-mail address: [email protected] (H.-S. Cho). 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.09.012
distressing depressed mood. These grandiose ideas might lead to mood elevation to mania although the implicit cognition is still related to depressive cognition [3]. The core of this cognitive reformulation of the psychoanalytic hypothesis lies in the ‘implicit’ psychological status of manic patients that manifests in ‘explicit’ elative mood, inflated self-esteem, and grandiose self-representation. Explicit (direct) and implicit (indirect) attitudes may not be the same, as patients may resist self-presentational forces that mask personally or socially undesirable evaluative associations or that prevent accurate reporting of attitudes [4]. Bipolar patients may express self-esteem indirectly [3], with a discrepancy between explicit and implicit self-esteem in both remitted [3] and manic states [5]. Several tools for assessing implicit emotional processing have been used for manic patients. In empirical studies using the emotional Stroop test, manic or hypomanic patients
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exhibit negative information processing biases that are implicated in depressed states [5,6]. Lyon and his colleagues, however, found that manic patients possess both implicit negative views and explicit positive views of themselves [5]. In recent studies using implicit tasks, including an emotional auditory verbal learning test, bipolar hypomania was found to be associated with both depression-related and maniarelated cognitive processing [7], with no differences observed between hypomanic and euthymic states [7,8]. Likewise, some researchers propose that hypomania is associated with both negative and positive cognitive biases [9]. Thus, attempts to understand the psychology of manic patients using implicit approaches are still limited and produce inconsistent results. Explicit self-esteem can be assessed by deliberate, conscious self-reports, whereas implicit self-esteem can be assessed by automatic, non-conscious responses [10]. Recent studies suggest that explicit self-esteem is revealed through controlled, reflective responses, whereas implicit self-esteem is revealed through spontaneous, affective responses [11,12]. The Implicit Association Test (IAT) is a useful tool for measuring implicit self-esteem [4,13] in healthy subjects and patients with psychiatric illnesses including paranoia [14], social anxiety disorder [15], body dysmorphic disorder [16], borderline personality disorder [17], and narcissistic personality disorder [18]. Recent studies using the self-esteem IAT equivocally report either lower implicit self-esteem in current depressive patients compared with healthy controls [19] or no differences in implicit self-esteem between subjectively high depressive volunteer students whose BDI score was over 21 and low depressive ones [20]. Unipolar depressive patients in remission, however, show either higher implicit self-esteem or no differences compared with healthy controls [19,21,22]. Furthermore, a greater number of previous depressive episodes are associated with lower implicit self-esteem [19], emphasizing the necessity of evaluating self-esteem for relapse prevention treatment. These inconsistent findings of implicit self-esteem among manic patients might partly result from differences among assessment tools or heterogeneity among samples [7]. To our knowledge, the IAT has not previously been used to evaluate implicit self-esteem among patients with bipolar I mania or euthymia. We expect that this approach will not only increase our understanding of the cognitive patterns of mania but also suggest cognitive strategies for preventing mania recurrence. Self-efficacy has been assessed (simultaneously) along with self-esteem in a large number of psychological studies on ‘self’. The concept of self-efficacy and self-esteem seems to measure the same factors [23]. However, self-efficacy is defined as the perception of one's own ability to complete and reach goals and hence, by definition, differs subtly from selfesteem which is defined as a person's sense of own worth. Manic patients show behavioral abnormalities that are related to psychological state of inflated self-esteem — they exhibit increased goal-directed activities and frequently
show behavioral problems such as getting excessively involved in pleasurable activities that have a high potential for painful consequence. So self-efficacy, by its definition, possibly is psychological status that well represents such behavioral characteristics observed in manic episode. The purpose of this study was to assess implicit and explicit self-esteem in patients with bipolar disorder, particularly those in manic states. We hypothesized that manic patients would have higher explicit self-esteem and lower implicit self-esteem compared to euthymic patient or normal controls. Explicit self-esteem was measured using the Rosenberg self-esteem scale, and implicit self-esteem was measured using the self-esteem IAT. Remitted bipolar euthymic patients and healthy controls were included to address the specificity of self-esteem characteristics associated with manic states. Also, we analyzed relationships among explicit/implicit self-esteem, self-efficacy, and recent affective status. 2. Methods 2.1. Participants Nineteen manic patients and 27 euthymic patients were recruited from the Severance Mental Health Hospital of Yonsei University Health System. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-IV [24]. Diagnoses were briefly confirmed using the Mini-International Neuropsychiatric Interview (MINI) [25] which was performed by two experienced psychiatrists (J.Y.P. or H.S.C.). We excluded patients with mixed manic states due to possible confounding effects of depressed mood. Patients with recent substance abuse, severe personality disorder, neurological diseases, or any other current axis I disorders were also excluded. For healthy controls, we selected 27 individuals who responded to a recruitment notice. All the patients participated in this study were diagnosed with bipolar I disorder and there was no bipolar II disorder patient. 7 manic patients and 12 euthymic patients experienced manic episode only and did not experience depressive episode. These individuals had no history of psychiatric disorders and did not show any notable psychiatric symptoms during the MINI interview. Mood status and psychopathology were also assessed using the Young Mania Rating Scale (YMRS) [26] and the Montgomery and Åsberg Depression Rating Scale (MADRS) [27]. Montgomery–Åsberg Depression Rating Scale is a tool for evaluating depressive symptoms by raters, and it has total 10 items such as sadness, tension, reduced sleep, reduced appetite, concentration difficulty, and so on. Scores from each item are added up [28]. Young Mania Rating Scale is a clinical rating scale for evaluation of maniac symptoms and consists of 11 items such as mood, sexual interest, speech, disruptive–offensive behavior, and so on. 7 items are rated from 0 to 4 and 4 items are rated from 0 to8. Higher score indicates severe maniac symptom [29]. Mini International
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a task or reach a goal [34,35]. The Self-Efficacy Scale (SES) is comprised of 23 items subdivided into two subscales: a general self-efficacy subscale (17 items) and a social selfefficacy subscale (6 items). Participants were asked to indicate their agreement with statements on a scale ranging from 0 (strongly disagree) to 4 (strongly agree) [36,37].
Neuropsychiatric Interview was developed by Sheehan et al. in 1998 and is a simple and effective method of interview. It considered international diagnosis standard such as ICD-10 or DSM-IV and considered changes within major symptoms to increase utilization in research or clinical practice [30] As shown in Table 1, there was no significant difference among the three groups regarding age, gender, education, occupation, and religion. YMRS scores and MADRS scores showed significant differences among the three groups. Tukey’s HSD post-test revealed that YMRS scores of manic patients were higher than those of euthymic patients (p b 0.001) or normal controls (p b 0.001). The MADRS scores of normal controls were lower than those of manic patients (p b 0.001) or euthymic patients (p = 0.001). Furthermore, no differences in clinical characteristics were observed between manic group and euthymic group.
2.2.3. Implicit association test In the IAT, individuals categorize stimuli according to automatic associations between concept discrimination (self vs. non-self) and an attribute dimension (positive vs. negative) [4]. Reaction times are used to measure the relative strength of these implicit associations [38]. As in previous studies [19,39], we used pronouns for the self vs. non-self dimension to avoid semantic associations that may be elicited by nouns [40,41]. For the positive vs. negative dimension, we used a set of adjectives describing 10 positive and 10 negative personal attributes. Adjectives were selected from those used in a previous IAT study conducted in the Korean language [42]. Adjectives in the ‘positive’ category were freedom, health, happiness, praise, stability, satisfaction, love, peace, kindness, and smile. Adjectives in the ‘negative’ category were abuse, grief, insult, hatred, tragedy, violation, poverty, crash, death, and decomposition. All Korean adjectives were composed of two syllables. Pronouns in the ‘self’ category were I, me, my, mine, and self, and pronouns in the ‘other’ category were they, them, their, it, and other [13]. Target words in black letters were presented in the center of a computer screen against a gray background. Participants were directed to assign target words as quickly as possible to their corresponding dimension by pressing a computer key. In the self-positive task, participants were instructed to press the ‘E’ key when presented with a stimulus from the ‘self’ or ‘positive’ categories and the ‘I’ key when presented with a stimulus
2.2. Measures 2.2.1. Rosenberg Self-Esteem Scale Explicit self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES) [31], which is a widely used selfreport measure of global attitudes about one’s overall worthiness as a human being [32]. This 10-item scale consists of five positively worded and five negatively worded items. Ratings are based on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s α reliability coefficient was calculated to identify internal consistency reliability for verifying the reliability of Korean version of Rosenberg Self-esteem. The reliability coefficient ranged between 0.75 and 0.87[33]. Higher RSES scores were considered to reflect higher levels of explicit self-esteem. 2.2.2. Self-Efficacy Scale Self-efficacy refers to expectations of personal mastery, which are major determinants of initial decisions to complete Table 1 Participant demographic and clinical characteristics. Measure
Group Bipolar Manic (n = 19) Mean/n
Demographics Age (years) Gender (male) Education (years) Employed or student status Religion (devotee) Clinical Symptoms YMRS MADRS Clinical Characteristics Illness duration (weeks) Number of manic episodes Number of depressive episodes Total number of mood episodes
SD/%
Statistical Results
Bipolar Euthymic (n = 27) Mean/n
SD/%
Healthy Control (n = 27) Mean
SD/%
F/χ 2/t
p
32.79 12 13.79 9 14
9.00 63.15 2.07 47.37 57.89
36.30 14 13.74 13 12
8.30 51.85 2.21 48.15 44.44
33.52 18 14.63 15 17
9.87 66.67 2.50 55.56 62.96
1.01 1.33 1.23 0.41 0.42
0.369 0.515 0.299 0.815 0.121
21.05 5.32
9.79 3.22
1.33 3.78
1.24 2.17
0.59 1.41
1.62 1.89
108.31 15.71
b0.001 b0.001
179.79 2.47 1.63 4.11
149.84 1.31 1.92 2.69
202.00 3.44 1.44 4.44
157.85 2.58 1.83 3.32
0.48 1.68 -0.34 0.37
0.634 0.102 0.739 0.715
YMRS, Young Mania Rating Scale; MADRS, Montgomery and Åsberg Depression Rating Scale.
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from the ‘other’ or ‘negative’ categories. In the self-negative task, participants were instructed to press the ‘E’ key for ‘self’ or ‘negative’ stimuli and the ‘I’ key for ‘other’ and ‘positive’ stimuli. The logic behind the IAT is that response latency will be shorter when two associated categories are assigned to the same key than when two less associated (or non-associated) categories are assigned to the same key. Thus, shorter reaction times in the self-positive compared with the self-negative task can be regarded as greater implicit positive self-esteem [13,43,44]. 2.2.4. Procedure This study was approved by the institutional review board of Severance Mental Health Hospital. Written consent was obtained from participants after complete explanation of the study. After signing the consent form and filling in sociodemographic questions, participants performed the IAT. After that, they performed evaluation of the self-esteem scores and self-efficacy scores. Before the self-positive and self-negative tasks, subjects were informed about computer key assignments. Subjects were required to categorize the target words presented on the center of the computer screen by pressing the specified key mapped to the corresponding category as quickly as possible. The interval of response stimulus was 250 ms. Categorization errors resulted in the display of a red ‘x’ on the screen. Subjects were given three brief practice blocks (20 trials each; blocks 1, 2, and 4) and two test blocks consisting of self-positive or self-negative task trials (60 trials each; blocks 3 and 5). Task order was counterbalanced to prevent order-specific effects [4]. The IAT was conducted using visual STIM software (Millisecond Software, US). After the IAT, subjects completed the RSES and SES. 2.2.5. Statistical analysis IAT score was computed according to the improved scoring algorithm of Greenwald et al. [38]. All trials from the test blocks were analyzed to provide a measure representing the difference in reaction time between blocks 3 and 5 divided by the standard deviation of all reaction times for blocks 3 and 5. Higher positive scores reflect higher implicit self-esteem. Statistical analyses were performed using SPSS software (version 13.0, Chicago, IL, USA). Group differences were tested using analysis of variance (ANOVA), and post-hoc Tukey HSD tests were used to correct for multiple comparisons. χ 2 was used to compare the demographic data among three groups, and Independent t-tests were used to do the number of mood episodes between manic and euthymic groups. Statistical significance was set at p b 0.05. 3. Results 3.1. Participant demographics Participant demographic characteristics are shown in Table 1. There were no differences between groups in age,
gender, education level, religion, or employment/student status. Medication status and doses are presented in Table 2. One-way ANOVA revealed significant differences among groups in YMRS (F(2,70) = 108.31, p b 0.001) and MADRS scores (F(2,70) = 15.71, p b 0.001). Post-hoc tests showed that manic patients had higher YMRS scores than euthymic patients (Tukey HSD p b 0.001) and healthy controls (Tukey HSD p b 0.001), and that manic patients had higher MADRS scores than healthy controls (Tukey HSD p b 0.001). Independent t-tests showed that there were no significant differences between manic and euthymic patients in total duration of mood episodes (t = 0.48, n.s.), number of manic episodes (t = 0.17, n.s.), number of depressive episodes (t = -0.34, n.s.), or total number of mood episodes (t = 0.37, n.s.). 3.2. Implicit and explicit self-esteem scores Manic patients had higher implicit self-esteem than euthymic patients. One-way ANOVA revealed significant differences among groups in self-esteem IAT scores (F(2,70) = 3.58, p = 0.033, η 2 = 0.16). Post-hoc tests showed that manic patients had significantly higher IAT scores than euthymic patients (p = 0.037) (Table 3). Manic patients also had higher IAT scores than healthy controls, but this difference did not reach statistical significance (p = 0.076). Euthymic patients and control subjects showed no differences in IAT scores. After controlling for depressive symptoms by including MARDS score as a covariate, the significant difference among groups in self-esteem IAT score remained (F(3,69) = 2.83, p = 0.045). There were no significant differences among groups in explicit self-esteem scores or self-efficacy scores (Table 3). 3.3. Correlations between implicit and explicit self-esteem and clinical variables Among manic patients, implicit self-esteem score was correlated with explicit self-esteem score (r = 0.58, p = 0.010) and social self-efficacy score (r = 0.77, p b 0.001).
Table 2 Number of patients in bipolar manic and euthymic groups taking psychotrophic medications and their daily doses (mean ± SD) in mg. Medication
Group Bipolar Manic (n = 19) Bipolar Euthymic (n = 27)
Lithium Divalproate Sodium Carbamazepine Quetiapine Risperidone Olanzapine Aripiprazole Haloperidol Perphenazine
9 (933.3 ± 268.1) 13 (980.8 ± 296.9) 15 (576.7 ± 247.8) 7 (3.86 ± 1.68) 1 (20) 1 (5)
14 (889.3 ± 124.3) 13 (692.3 ± 208.0) 1 (400) 5 (95.0 ± 90.8) 8 (1.25 ± 0.46) 2 (10.00 ± 7.07) 1 (30) 1 (5) 1 (4)
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Table 3 IAT and questionnaire scores for bipolar manic patients, bipolar euthymic patients, and healthy control subjects. Measure
Group 1: Bipolar Manic (n = 19)
Implicit self-esteem score Explicit self-esteem score Self-efficacy, general Self-efficacy, social
2. Bipolar Euthymic (n = 27)
3. Healthy Control (n = 27)
Post-hoc Tests (p, Tukey HSD)
Mean
SD
Mean
SD
Mean
SD
F
p
1 vs. 2
1 vs. 3
2 vs. 3
0.77 20.37 45.90 15.37
0.43 5.43 11.87 5.17
0.47 19.37 44.22 14.22
0.40 4.46 10.59 3.85
0.51 21.85 47.74 15.63
0.35 3.53 9.16 3.70
3.58 2.14 0.77 0.85
0.03 0.13 0.47 0.43
0.04 0.73 0.85 0.63
0.08 0.51 0.83 0.98
0.94 0.11 0.44 0.44
Among euthymic patients and control subjects, however, there were no significant correlations between self-esteem and self-efficacy scores (Table 4). We also analyzed correlations between self-esteem scores and mood disorderrelated variables, including severity of manic and depressive symptoms, total duration of illness, and the numbers of previous manic, depressive, and total mood episodes in bipolar patients. Implicit self-esteem score was correlated with YMRS score (r = 0.35, p = 0.019) but not with MADRS score. Explicit self-esteem score was not correlated with YMRS or MADRS score. No significant correlations were found between implicit or explicit self-esteem scores and total duration of illness (r = −0.06, n.s.) or numbers of previous manic, depressive, or total mood episodes (r = −0.01 to −0.29, n.s.). 4. Discussion The goal of this study was to investigate implicit and explicit self-esteem in bipolar I disorder patients using the self-esteem IAT and self-report questionnaires. As far as we are aware, this is the first study to assess self-esteem in manic patients using the IAT. Implicit self-esteem of manic patients was significantly higher than that of remitted patients and numerically, but not significantly, higher than that of healthy subjects. Implicit self-esteem score was positively correlated with severity of manic symptoms but not with depressive symptoms or previous mood episodes in bipolar patients. By contrast, there were no differences in explicit self-esteem scores among groups. In the implicit self-esteem task, manic patients demonstrated higher levels of self-esteem than euthymic patients or Table 4 Correlation coefficients between implicit and explicit self-esteem scores.
Explicit self-esteem score Self-efficacy, general Self-efficacy, social
Statistical Results
Bipolar Manic
Bipolar Euthymic
Healthy Controls
0.58⁎ 0.34 0.77⁎
0.16 -0.12 -0.08
-0.19 -0.13 0.13
⁎ Correlation is significant at the 0.01 level (2-tailed).
healthy subjects. This finding suggests that levels of implicit self-esteem are high in manic states but may decline to normal levels in euthymic states. This may result from either a discrepancy between high standards and negative reality or self-esteem instability. As previously mentioned, low selfesteem or negative information processing bias may underlie manic states [2,5]. Identification of the exact cause for the ‘unexpected’ result of higher implicit self-esteem in manic patients than in euthymic patients is not feasible with the current results. The reason of this result could be inferred as follows. Firstly, it is possible that implicit self-esteem reflects high standard in manic status and reality in euthymic status. Secondly, it was reported that bipolar patients show changes in the self-perception [45] or instability regarding self-esteem [46] between specific mood episodes. The corresponding result would be reflecting differences in implicit self-esteem between the two groups with different mood status. It also suggests that implicit self-esteem is a state rather than a trait However it is considered that there are much evidence which imply the possibility that implicit selfesteem is a trait: hypomanic traits in undergraduate subjects were associated with interference of color naming for depressive but not euphoria-related words during the emotional Stroop test [6]; manic patients as well as depressive patients attributed negative events more than positive events to self on an implicit attributional style [5]; and remitted bipolar patients like remitted unipolar patients attributed significantly more negative events to internal cause than did normal controls by pragmatic inference task, which reflects a cognitive schema of low self-esteem in implicit way [3]. Such studies are evidence which support the manic defense theory. By contrast to such previous studies, implicit self-esteem appeared ‘unexpectedly’ higher in manic status than in euthymic status in the present study. This result suggests that self-esteem measured using IAT is not a trait marker that appears in bipolar disorder patients regardless of their mood status, but a state marker which appears with relevance to mood status. We can consider two possible explanations for the contrasting findings. Firstly, based on the prevalence of mixed manic states, some researchers have suggested a model explaining mixed
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positive and negative self-esteem in hypomanic states [47,48]. Our findings might result from the exclusion of cases of mixed manic episodes due to potential effects of depressive symptoms on IAT performance, as some studies report that depressed patients have lower self-esteem than non-depressed patients [19,49]. Secondly, differences among studies may be due to differences in tasks used to assess self-esteem. Lyon et al. [5] found low self-esteem at the implicit level among manic patients using the emotional Stroop task. Although there have been no IAT studies of patients with bipolar disorder, several studies using the IAT show unexpected results such as positive self-esteem in depressed patients [21,22,50], and in practice the IAT scores may measure a combination of trait and state [51]. One recent review suggests that studies using the IAT among subjects with psychiatric disorders may produce biased results because IAT scores may only reflect that selfevaluation is more positive than evaluation of others [44]. In contrast with implicit levels of self-esteem, we found no significant differences among groups in explicit levels of self-esteem. Similarly, Lyon et al. [5] found no differences in RSES scores between normal and manic groups, but bipolar depressed subjects had lower scores than the two other groups. Moreover, hypomanic patients reported the highest scores for positive as well as negative self-esteem [47]. Therefore, our explicit self-esteem results are generally consistent with those of previous reports. Our findings may be due to the course of treatment for the subjects. All manic subjects received inpatient treatment, and the majority of patients were still recovering from their symptoms. Therefore, their explicit self-esteem may have been lower at the time of investigation compared with that during their full manic episodes and may have declined as a result of insights into their illness. More focused and detailed studies will be needed in the future to illuminate how self-esteem changes throughout the course of illness and recovery. One of our main findings was that manic patients exhibited inconsistent performance between the two assessments, with higher implicit self-esteem on the IAT and normal explicit self-esteem on the questionnaires compared with euthymic patients and healthy subjects. Lyon et al. [5] suggested that similar levels of implicit self-esteem between manic and depressive states may reflect psychological continuity between the opposite types of mood episodes. The current study, however, suggests that mania cannot simply be regarded as the opposite of depression at the latent level and shows a potential discontinuity or different kinds of latent self-esteem and cognitive processing between manic and euthymic states. We found significant positive correlations between implicit and explicit self-esteem in manic patients but not in euthymic patients or healthy controls. Speculatively, this finding suggests that explicit and implicit self-esteem may be temporarily related during manic states but unrelated during recovered euthymic states. However, because we cannot be certain whether the explicit and implicit assessments measure the same psychological
attributes [52], more elaborate and structured research is needed to test this possibility. As mentioned in introduction, the Implicit Association Test (IAT) is a useful tool for measuring implicit self-esteem [4,13] in healthy subjects and patients with psychiatric illnesses including paranoia [14], social anxiety disorder [15], body dysmorphic disorder [16], borderline personality disorder [17], narcissistic personality disorder [18], and depressive disorder [19]. In addition to these studies, we found that the self-esteem IAT might be a good tool for understanding the cognitive patterns of mania. The selfesteem IAT might also be a useful tool for explaining the newer theories for bipolar disorder or cognitive strategies for treating affective disorders. For example, the integrative cognitive model of mood swings presents how attempts in the area of affect regulation are disrupted by conflicting personal meanings which are given to internal status [48]. The self-esteem IAT would more elaborate the internal states. On the other hand, according to beck’s cognitive triad, negative view of self is the key feature of depression, and correction of these cognitive distortions is the main issue of cognitive therapy. However, it is not to estimate objectively the implicit cognitive bias. Estimation of internal self-esteem using IAT would help to evaluate the current status of depression and to judge the effect of therapies. This study has several limitations. First, the manic patients who participated in this study were inpatients. As the inpatient environment can influence self-esteem, this may limit the generalization of our findings. However, considering that “to necessitate hospitalization” is critical to the diagnosis of manic episodes according to DSM criteria, this may be an inevitable choice. Second, a cross-sectional design was used, which does not allow for inferences about longitudinal change or causality of self-esteem in bipolar disorder. Third, the sample size was relatively small, therefore it is anticipated that greater insights will be gained from studies utilizing larger samples. Finally, further validation of implicit measures and more information on relationships between implicit cognitive processing and psychopathology are needed. Because our results were somewhat unexpected, any conclusions based on this study may be limited. For example, in a previous study using a large sample of healthy individuals, explicit self-esteem and implicit self-esteem were weakly but positively correlated [13]. In this study, however, a significant positive correlation was observed only among manic patients. Greenwald et al. [13] found correlation between implicit self-esteem and explicit self-esteem in 150 participants, but we did not find any correlations in the control group or in the euthymic group. Relatively small sample in this study may have been insufficient to gain significant results. Thus, a positive correlation between implicit and explicit self-esteem may also have existed for other groups if our sample sizes had been larger. In conclusion, using the IAT to measure implicit selfesteem among bipolar patients, we found that manic patients
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had higher implicit self-esteem than euthymic patients or healthy controls. Although there is a growing emphasis on genetic and neurobiological evidence for bipolar disorder, in clinical practice the understanding of bipolar disorder on a psychological level is still important for enhancing the effectiveness of psychosocial interventions such as cognitive behavior therapy [53–56]. Self-esteem is also an important factor contributing to clinical outcomes. Type of treatment, number of prior hospitalizations, and level of self-esteem are the most influential factors for a favorable progression of refractory bipolar disorder [57]. Negative self-esteem is the most robust predictor of treatment outcome [47], and selfesteem support appears to be the most important predictor of changes in depression among bipolar patients across a 6-month follow-up [58]. However, research on self-esteem among bipolar patients has taken place mainly with euthymic patients, with a severe lack of studies considering manic patients. Also, controversy still exists regarding whether mania is the opposite of depression or a manic defense. Therefore, studies of self-esteem among manic patients will provide a deeper comprehension of core pathophysiology and will assist in clinical trials and prognosis. Acknowledgment This study was supported by a grant (A101915) from the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. References [1] Abraham K. Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. Selected papers on psychoanalysis; 1911. p. 137-56. [2] Neale JM. In: Oltmann TD, & Mahler BA, editors. Defensive functions of manic episodes. New York: Wiley; 1988. [3] Winters KC, Neale JM. Mania and low self-esteem. J Abnorm Psychol 1985;94:282-90. [4] Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998;74:1464-80. [5] Lyon HM, Startup M, Bentall RP. Social cognition and the manic defense: attributions, selective attention, and self-schema in bipolar affective disorder. J Abnorm Psychol 1999;108:273-82. [6] Bentall RP, Thompson M. Emotional Stroop performance and the manic defence. Br J Clin Psychol 1990;29(Pt 2):235-7. [7] Lex C, Hautzinger M, Meyer TD. Cognitive styles in hypomanic episodes of bipolar I disorder. Bipolar Disord 2011;13:355-64. [8] Kerr N, Scott J, Phillips ML. Patterns of attentional deficits and emotional bias in bipolar and major depressive disorder. Br J Clin Psychol 2005;44:343-56. [9] Mansell W. An integrative formulation-based cognitive treatment of bipolar disorders: application and illustration. J Clin Psychol 2007;63:447-61. [10] Kernis MH. Toward a conceptualization of optimal self-esteem. Psychol Inq 2003;14:1-26. [11] Conner T, Barrett LF. Implicit self-attitudes predict spontaneous affect in daily life. Emotion 2005;5:476-88. [12] Rudolph KD. Implicit theories of peer relationships. Soc Dev 2010;19:113-29.
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