Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Characteristics of stress-coping behaviors in patients with bipolar disorders$ Eunsoo Moon a,b, Jae Seung Chang c, Sungwon Choi d, Tae Hyon Ha c, Boseok Cha e, Hyun Sang Cho f, Je Min Park a,b, Byung Dae Lee a,b, Young Min Lee a,b, Yoonmi Choi a, Kyooseob Ha c,g,h,n a

Department of Psychiatry, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea Department of Psychiatry, Pusan National University School of Medicine, Yangsan, Republic of Korea c Mood Disorder Clinic and Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea d Department of Psychology, Duksung Women's University, Seoul, Republic of Korea e Department of Psychiatry, Gyeongsang National University College of Medicine, Jinju, Republic of Korea f Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea g Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Institute of Human Behavioral Medicine, Medical Research Center, Seoul, Republic of Korea h Department of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea b

art ic l e i nf o

a b s t r a c t

Article history: Received 30 May 2013 Received in revised form 29 January 2014 Accepted 30 March 2014

Appropriate stress-coping strategies are needed to improve the outcome in the treatment of bipolar disorders, as stressful life events may aggravate the course of the illness. The aim of this study was to compare stress-coping behaviors between bipolar patients and healthy controls. A total of 206 participants comprising 103 bipolar patients fulfilling the Diagnostic and Statistical Manual for Axis I disorder fourth edition (DSM-IV) diagnostic criteria for bipolar I and II disorders and controls matched by age and sex were included in this study. Stress-coping behaviors were assessed using a 53-item survey on a newly-designed behavioral checklist. The characteristics of stress-coping behaviors between the two groups were compared by using t-test and factor analysis. Social stress-coping behaviors such as ‘journey’, ‘socializing with friends’, and ‘talking something over’ were significantly less frequent in bipolar patients than controls. On the other hand, pleasurable-seeking behaviors such as ‘smoking’, ‘masturbation’, and ‘stealing’ were significantly more frequent in bipolar patients than controls. These results suggest that bipolar patients may have more maladaptive stress-coping strategies than normal controls. It is recommended to develop and apply psychosocial programs to reduce maladaptive stresscoping behaviors of bipolar patients. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Stress Coping strategy Coping behavior Bipolar disorder

1. Introduction Stress can be closely related to bipolar disorder, as well as major depression. Stressful life events can have negative influences on onset and course of bipolar disorder. Stressful life events by social rhythm disruption were associated with manic episode in bipolar disorder (Malkoff-Schwartz et al., 2000). Goal attainment

☆ The results of this study were presented at the 2nd Meeting of East Asian Bipolar Forum, 7–8 September 2012, Fukuoka, Japan. n Corresponding author at: Mood Disorders Clinic and Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, 82 Gumi-Ro 173-Gil, Bundang-Gu, Seongnam, Gyeonggi 463-707, Republic of Korea. Tel.: þ 82 31 787 7431; fax: þ 82 31 787 4058. E-mail address: [email protected] (K. Ha).

life events were associated with subsequent manic symptoms, not with depressive symptoms (Johnson et al., 2000). Negative life events predicted increase in depressive symptoms (Johnson et al., 2008). Furthermore, patients with severe negative life events recovered later than those without severe life events (Johnson and Miller, 1997). There were significant relationships between the stressful life events and the risk of relapse in bipolar disorder (Ellicott et al., 1990; Hunt et al., 1992). Therefore, stressful life events can trigger the onset of bipolar disorders and increase the risk of relapse or recurrence of mood episodes. Given previous studies, it might be important to cope with stress in order to improve the outcome in the treatment of bipolar disorder. Coping for stress means the ability to use cognitive and behavioral strategies for reducing psychological distress and physiological reactions induced by stressful life events (Taylor

http://dx.doi.org/10.1016/j.psychres.2014.03.047 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Moon, E., et al., Characteristics of stress-coping behaviors in patients with bipolar disorders. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.047i

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and Stanton, 2007). Maladaptive coping with stress can trigger physical and mental illness and have a negative influence on the course of illness. In general population, avoidant strategy for coping with stress was positively correlated with depression (Nagase et al., 2009). In contrast, problem-solving strategy was negatively correlated with depression (Nagase et al., 2009). Additionally, in depressive patients, several studies have similarly shown that problem-solving coping strategy can decrease the risk of depression, in contrast, emotion-focused or approach coping strategy can increase the risk of depression (Uehara et al., 1999; Taylor and Stanton, 2007). Furthermore, bipolar patients take more emotional strategy than normal control (Jung et al., 2011). Specially, bipolar patients with high anxiety level tend to take emotional strategy. As well as cognitive strategies for coping with stress, behavioral ones can be important. Stress-coping behaviors may be not only reactions by stressful life events, but also can serve to buffer the effects of stress (Rao, 2009). An epidemiological survey on stresscoping strategies was conducted among a total of 24,551 general population of Japan (Nagase et al., 2009). In this study, behaviors such as eating, shopping, watching TV, listening to the radio, gambling, smoking, and drinking were positively associated with depression. Leisure activities and sports were negatively associated with depression. In a comparison study with 38 remitted bipolar patients and 38 healthy controls, patients spent less time working and with colleagues, and more time on passive leisure activities and alone than controls (Havermans et al., 2007). A French study with individuals having a lifetime history of mania or hypomania reported that untreated bipolar patients were less likely to have daily life routines such as being at work, in class, having social contact with work colleagues or students, and performing personal hygiene activities. In contrast, these people were more likely to be with a romantic partner (Gindre and Swendsen, 2010). Even though behavioral strategies for coping with stress, as well as cognitive ones, might have a clinical importance, there were few systematic studies on stress-coping behaviors in bipolar disorder. Most studies reported behavioral characteristics in part. In this study, we aimed to examine stress-coping behaviors in bipolar patients, and compare these behaviors between bipolar patients and healthy controls in order to explore the characteristics of stress-coping behaviors in bipolar patients.

2.2. Design and assessment We compared stress-coping behaviors between bipolar patients and healthy controls cross-sectionally at the stabilized state after treatment of acute symptoms. Sociodemographic variables such as age, sex, education levels, marital status and job were examined. Clinical variables such as onset age, numbers of previous mood episodes were also examined. In order to compare the characteristics of stresscoping behaviors between bipolar patients and healthy controls, we newly developed a survey questionnaire containing a broad range of candidate behaviors. Each stress-coping behavior was determined based on various factors such as psychological state, temperament, and personality (Ferguson, 2001; Nagase et al., 2009; Rueda and Rothbart, 2009). Each individual tend to show some stress-coping behaviors according to his/her own characteristics. These specific patterns of stresscoping behaviors may be influenced by psychopathologies associated with bipolar disorders. Therefore, we not only compared each behavior between the two groups, but also conducted between-group comparisons on the similarity-based domains of stress-coping behaviors. 2.2.1. Assessment of stress-coping behaviors Survey questionnaire consists of 53 behavioral items for coping stress. Each item has to be answered on the following question: “How often do you use following behaviors for coping stress?” In order to choose behavioral items, one psychiatrist intensively interviewed 20 bipolar patients and 20 healthy controls about behavioral strategies for coping stress. Behaviors examined by interviews were primarily summarized into 56 items. These items were condensed into 50 items after the discussion of clinical appropriateness by four psychiatrists and one psychologist. Three items such as stealing, gambling, use of drug and illegal substance that were not examined in the interviews, but can be important in the clinical aspects, were added into behavioral checklist. The questions were answered by 5 point Likert's scale as following: ‘No’ (0), ‘Rarely’ (1), ‘Often’ (2), ‘Frequent’ (3), and ‘Very frequent’ (4). Cronbach's alpha of all items in this survey questionnaire was 0.888 (Cronbach's alpha range: 0.883–0.891). This survey questionnaire exhibited an internal consistency with acceptable level. 2.3. Statistics Frequencies and percentages were calculated for categorical variables, and means and standard deviations were calculated for continuous variables. In order to compare these variables between bipolar patients and healthy controls, chisquare test or Fisher's exact test was used for categorical variables, and independent t-test was used for continuous variables. An exploratory factor analysis was performed to determine the underlying factors of stress-coping behaviors. Principal component analysis was used to extract factors. The number of factors was determined by the examination of screen plots, the size of eigenvalues, and comprehensibility. An oblimin rotation was then made to achieve a more readily interpretable factor structure. We chose 0.35 as a cutoff for size of loading to be interpreted. We used analysis of covariance (ANCOVA) with a covariate of total scores to compare stress-coping behaviors grouped by factor analysis between bipolar patients and healthy controls. Statistical analyses were performed using the Statistical Package for Social Sciences version 18.0 (SPSS Inc., Chicago, IL, USA). In all analyses, the level of significance was set at p o 0.05, 2-tailed probability.

3. Results 2. Methods 2.1. Subjects Subjects in this study were the patients that visited the outpatient clinics in the Department of Psychiatry at Seoul National University Bundang Hospital and at Pusan National University Hospital. Bipolar patients were required to fulfill the following criteria: (1) patients who were diagnosed as bipolar I and II disorders with Diagnostic and Statistical Manual for Axis I disorder fourth edition (DSM-IV) by psychiatrist (American Psychiatric Association, 2000), (2) euthymic patients who were continuously stable in less than three Clinical Global Impression-Bipolar Version (CGI-BP) scores for at least 2 months after the improvement of acute mood episode (Spearing et al., 1997). Exclusion criteria were the following: (1) patients having mental retardation or organic mental disorder, (2) patients having serious medical illness, and (3) patients who were illiterate or visually impaired. Healthy controls matched by age and sex were selected among hospital workers, their families and friends. Healthy controls were required to fulfill the following criteria: (1) no experience of psychiatric treatment and counseling, (2) no psychiatric problems having functional impairment and distress. Finally, total 206 subjects with 103 bipolar patients who consisted of 64 bipolar I (62.1%) and 39 bipolar II (34.0%) patients, and 103 healthy controls participated in this study. All subjects gave written informed consent for participation after the aims and procedures of this study had been fully explained, as approved by the respective Institutional Review Boards at the sites.

3.1. Sociodemographic and clinical variables Sociodemogrphic and clinical characteristics of participants in this study are shown in Table 1. Mean onset age of bipolar disorder was 33.2( 710.3) years, and mean age at participating in this study was 33.2( 7 10.2) years. Mean education levels were 13.8( 7 2.3) years in bipolar patients, and 15.8( 7 2.3) years in healthy controls. There was significant difference of education level between bipolar patients and healthy controls (po .001). Also, there was significant difference of job between two groups (p o.001). Other variables had not shown the significant differences between the two groups. 3.2. Comparison of stress-coping behaviors Bipolar patients had significantly less activities in ‘journey’ (p o0.001), ‘socializing with friends’ (p ¼0.001), ‘talking something over’ (p¼ 0.006), ‘dating’ (p ¼0.008), ‘social club’ (p¼ 0.021), ‘going to a movie/play/concert’ (p ¼0.023), ‘shopping at mall’

Please cite this article as: Moon, E., et al., Characteristics of stress-coping behaviors in patients with bipolar disorders. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.047i

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Table 1 Sociodemographic and clinical characteristics of the bipolar patients and healthy controls. Bipolar patients (n¼ 103)

Healthy controls (n¼ 103)

P value

Female, n (%) Age, mean( 7 S.D.) Education, mean(7 S.D.)

68(66.0) 33.2(7 10.3) 13.8(7 2.3)

68(66.0) 33.2(7 10.2) 15.8( 7 2.3)

– – o 0.001

Job, n (%) No Part-time Full-time

75(72.8) 21(20.4) 7(6.8)

35(34.0) 64(62.1) 4(3.9)

Marriage, n (%)a Unmarried Married Divorced or bereaved

51(49.5) 46(44.7) 6(5.8)

56(54.4) 46(44.7) 1(1.0)

Diagnosis, n (%) Bipolar I disorder Bipolar II disorder

64(62.1) 39(37.9)

– –

CGI-BP, mean(7 S.D.) Illness onset, mean(7 S.D.) Number of past admission, mean( 7S.D.)

2.0( 70.7) 23.8( 77.3) 1.7( 7 2.2)

1.7(7 0.5) – 0

Past mood episode Manic/mixed/hypomanic Depressive

2.7( 72.3) 2.6( 72.4)

0 0

a

o 0.001

0.170



o 0.001 – – –

Fisher's exact test.

Table 2 Comparison of stress-coping behaviors between the euthymic bipolar patients and healthy controls. Behavioral checklist

BP (n¼ 103)

HC (n ¼103)

P value

Behavioral checklist

BP (n ¼103)

HC (n¼103)

P value

1. Listening to music 2. Overeating 3. Dating 4. Home shopping 5. Use of internet 6. Having sex 7. Journey 8. Chatting 9. Taking a walk 10. Saying nasty things 11. Dancing 12. Social club 13. Singing 14. Drinking tea 15. Driving a car 16. Stealing 17. Reading a book 18. Going to a movie/play/concert 19. Throwing things 20. Smoking 21. Massage 22. Gambling 23. Meditation 24. Doing housework 25. Crying 26. Socializing with friends 27. Fast driving

2.5( 7 1.2) 1.9(7 1.2) 1.1( 7 1.3) 0.6( 7 0.9) 2.1( 71.4) 0.8( 7 0.9) 1.0(7 1.0) 2.0( 7 1.2) 1.9(7 1.2) 0.8( 7 1.1) 0.8( 7 1.0) 0.6( 7 0.9) 1.6(7 1.3) 1.8(7 1.4) 1.3(7 1.3) 0.19( 7 0.7) 1.7(7 1.2) 1.7(7 1.2) 0.6( 7 1.0) 1.0(7 1.5) 0.8( 7 1.1) 0.2( 7 0.5) 0.9( 7 1.1) 1.8(7 1.2) 1.4(7 1.2) 1.8(7 1.1) 0.4( 7 1.0)

2.6( 7 1.1) 1.8(7 1.1) 1.5(7 1.2) 0.9( 7 1.1) 2.4( 7 1.3) 0.9( 7 1.1) 1.8(7 1.1) 2.3( 7 1.3) 2.1( 71.1) 1.0(7 1.0) 0.7( 7 1.0) 0.9( 7 1.1) 1.5(7 1.3) 2.2( 7 1.3) 1.6(7 1.3) 0.03( 7 0.3) 1.7(7 1.2) 2.1( 71.1) 0.3( 7 0.8) 0.4( 7 1.0) 0.9( 7 1.1) 0.1( 70.6) 1.1( 7 1.2) 1.7(7 1.3) 1.1( 7 1.2) 2.3( 7 1.2) 0.4( 7 0.8)

0.719 0.799 0.008 0.044 0.107 0.296 o0.001 0.062 0.151 0.333 0.301 0.021 0.829 0.063 0.049 0.024 0.910 0.023 0.079 0.001 0.408 0.546 0.249 0.657 0.099 0.001 0.581

28. Shopping at mall 29 Watching TV 30. Sleeping 31. Making phone calls 32. Binge eating 33. Sauna 34. Internet shopping 35. Wandering about 36. Masturbation 37. Exercise 38. Shouting 39. Playing an instrument 40. Bathing/shower 41. Being alone 42. Using drug/illegal substance 43. Hitting 44. Extramarital affair 45. Computer game 46. Drinking alcohol 47. Yoga 48. Talking something over 49. Praying 50. Reckless driving 51. Drinking coffee 52. Writing 53. Internet chatting Total summation

1.3( 7 1.2) 2.2( 7 1.1) 2.5( 7 1.1) 2.0( 7 1.2) 1.5( 7 1.3) 1.1(7 1.2) 1.2( 7 1.3) 1.7( 7 1.2) 0.6( 7 1.0) 1.7( 7 1.3) 0.9( 7 1.2) 0.6( 7 1.0) 2.4( 7 1.1) 2.2( 7 1.3) 0.16( 7 0.7) 0.4( 7 1.0) 0.20( 7 0.6) 0.8( 7 1.2) 0.8( 7 1.2) 0.6( 7 1.1) 1.5( 7 1.2) 1.7( 7 1.5) 0.3( 7 0.8) 1.7( 7 1.3) 0.9( 7 1.2) 0.6( 7 1.1) 64.2( 7 24.8)

1.7( 71.4) 2.4(7 1.2) 2.6(7 1.0) 2.1( 7 1.3) 1.3( 71.3) 1.4( 71.2) 1.5( 71.2) 2.0(7 1.2) 0.3(7 0.7) 1.7( 71.2) 0.6(7 1.0) 0.6(7 1.0) 2.1( 7 1.2) 2.3(7 1.1) 0.02(7 0.2) 0.2(7 0.5) 0.06( 70.3) 0.9(7 1.2) 1.1( 7 1.3) 0.4(7 0.9) 2.0(7 1.3) 2.0(7 1.3) 0.2(7 0.6) 1.9( 71.4) 1.1( 7 1.2) 0.4(7 0.9) 68.3( 720.1)

0.029 0.181 0.329 0.653 0.169 0.190 0.030 0.104 0.004 0.743 0.405 0.685 0.098 0.908 0.044 0.039 0.030 0.564 0.127 0.156 0.006 0.233 0.198 0.168 0.350 0.163 0.197

BP, bipolar patients; HC, healthy controls.

(p ¼0.029), ‘internet shopping’ (p ¼0.030), ‘home shopping’ (p ¼0.044), and ‘driving a car’ (p ¼0.049) for coping with stress than healthy controls. In contrast, bipolar patients had significantly more activities in ‘smoking’ (p ¼0.001), ‘masturbation’ (p ¼0.004), ‘stealing’ (p ¼0.024), ‘extramarital affair’ (p ¼0.030), ‘beating’ (p ¼0.039), ‘using drug/illegal substance’ (p¼ 0.044) than healthy control (Table 2).

3.3. Factor analysis of stress-coping behaviors Based on scree plots, the size of eigenvalues, and comprehensibility, a four factor solution seemed most appropriate. Factor loadings are presented in Table 3. Four factors explained 16.70%, 7.94%, 5.55%, and 5.09% of the variance in total scores, and accounted for 35.28%. Eigenvalues of these factors were 8.85,

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Table 3 Factor analysis of stress-coping behaviors of the euthymic bipolar patients and healthy controls Behavioral checklist

14. Drinking tea 17. Reading a book 33. Sauna 40. Bathing/shower 9. Taking a walk 52. Writing 23. Meditation 24. Doing housework 37. Exercise 21. Massage 47. Yoga 51. Drinking coffee 49. Praying 44. Extramarital affair 22. Gambling 42. Using drug/illegal substance 43. Hitting 16. Stealing 19. Throwing things 27. Fast driving 36. Masturbation 50. Reckless driving 6. Having sex 20. Smoking 38. Shouting 45. Computer game 39. Playing an instrument 4. Home shopping 34. Internet shopping 8. Chatting 26. Socializing with friends 31. Making phone calls 48. Talking something over 28. Shopping at mall 10. Saying nasty things 7. Journey 18. Going to a movie/ play/concert 12. Social club 35. Wandering about 11. Dancing 46. Drinking alcohol 3. Dating 15. Driving a car 29 Watching TV 30. Sleeping 32. Binge eating 25. Crying 2. Overeating 41. Being alone 1. Listening to music 53. Internet chatting 5. Use of internet 13. Singing Eigenvalue Explained proportion (%) Cronbach's alpha

Factor 1

Factor 2

Factor 3

Factor 4

Personal activities

Pleasure-seeking activities

Social activities

Compulsive activities

0.687 0.648 0.612 0.599 0.578 0.559 0.525 0.525 0.481 0.430 0.408 0.400 0.367 0.064

0.106 0.185 0.359 0.206  0.002 0.045  0.023 0.080 0.254 0.380 0.119  0.005  0.071 0.657

0.245 0.095 0.306 0.340 0.290 0.169  0.059 0.347 0.283 0.254 0.127 0.003  0.055 0.058

 0.009 0.075  0.171  0.011  0.001 0.182  0.047 0.066  0.192  0.016  0.191 0.062 0.318  0.047

0.121 0.143

0.614 0.611

0.134  0.011

 0.077  0.035

 0.127 0.114  0.097 0.221  0.041 0.201 0.266  0.016 0.025  0.188 0.413

0.602 0.585 0.558 0.552 0.537 0.532 0.478 0.469 0.445 0.435 0.419

0.200  0.018 0.347 0.104 0.120 0.105 0.085  0.037 0.425 0.037 0.211

0.317 0.045 0.407  0.007 0.088  0.048  0.315  0.267 0.190  0.084 0.023

0.197 0.212 0.176 0.221

0.393 0.377  0.077 0.180

0.243 0.355 0.732 0.708

0.094 0.249  0.024  0.024

0.240

0.103

0.661

0.031

 0.020

 0.046

0.637

0.129

0.463  0.072

0.039 0.347

0.613 0.517

0.030 0.193

0.384 0.443

0.213 0.339

0.503 0.500

 0.283  0.139

0.297 0.369 0.267  0.084 0.279 0.355 0.068 0.201 0.074 0.077 0.056 0.152 0.336 0.114 0.088 0.295

0.340 0.116 0.355 0.367 0.280 0.331 0.048 0.059 0.367  0.067 0.238 0.068 0.246 0.333 0.332 0.307

0.476 0.467 0.415 0.408 0.391 0.388 0.380 0.369 0.166 0.236 0.066 0.074 0.233 0.215 0.295 0.329

 0.252 0.184  0.045  0.367  0.334  0.332 0.076 0.206 0.591 0.546 0.492 0.459 0.155 0.108 0.091  0.174

8.85 16.70

4.23 7.94

2.94 5.55

2.70 5.09

0.794

0.842

0.606

0.804

Bold figures indicate items greater than 0.35 of factor loading. Italic figures indicate items less than 0.35 of factor loading.

4.21, 2.94, and 2.70 correspondingly. First factor, which we labeled personal activity, reflected personal and common activity for coping with stress. This factor consisted of 13 behaviors such as

‘drinking tea’, ‘reading a book’, ‘sauna’, ‘bathing/shower’, ‘taking a walk’, ‘writing’, ‘meditation’, ‘doing housework’, etc. Second factor, which we labeled pleasure-seeking activity, reflected pleasureseeking and impulsive activity for coping with stress. This was made up of 16 behaviors such as ‘extramarital affair’, ‘gambling’, ‘using drug/illegal substance’, ‘beating’, ‘stealing’, ‘throwing things’, ‘fast driving’, ‘masturbation’, ‘reckless driving’, etc. Third factor, which we labeled social activity, included social and outgoing activity for coping with stress. This was composed of 16 behaviors such as ‘chatting’, ‘socializing with friends’, ‘making phone calls’, ‘talking something over’, ‘shopping at mall’, ‘saying nasty things’, ‘journey’, ‘going for a movie/play/concert’, etc. Fourth factor, which we labeled compulsive activity, was four behaviors such as ‘binge eating’, ‘crying’, etc. This factor reflected compulsive and overwhelmed behaviors for stressful situation. Cronbach's alpha among each factor ranged from 0.606 to 0.842 (Table 3). 3.4. Characteristics of stress-coping behaviors We compared behaviors classified by factor analysis between bipolar patients and healthy controls, in order to analyze the characteristics of stress-coping behaviors in bipolar disorder. After being adjusted by total scores, bipolar patients had significantly less social and greater pleasurable-seeking behaviors for coping with stress than controls (factor 2: pleasure-seeking, p¼ 0.003; factor 3: social, p o0.001) (Table 4).

4. Discussion It is important to assess stress-coping behaviors for establishing therapeutic planning to improve strategies for coping with stress, because stress can have negative influences on the course of bipolar disorder. In this study, we compared stress-coping behaviors between bipolar patients and healthy controls to examine the characteristics of stress-coping behaviors. There were some differences of stress-coping behaviors between bipolar patients and healthy control. Compared to healthy controls, bipolar patients showed less social activities such as ‘journey’, ‘socializing with friends’, ‘talking something over’, ‘dating’, ‘social savings club’, ‘going to a movie/play/concert’, and ‘driving a car’. Social dysfunction was often reported in bipolar patients (Goswami et al., 2006; de Almeida Rocca et al., 2008). Social phobia is one of common comorbidities in bipolar disorder (McElroy et al., 2001). Additionally, bipolar patients with atypical depression can have interpersonal sensitivity in euthymic state as well as in depressive phase (Benazzi, 2000; Parker, 2007). Social dysfunction might make bipolar patients not use social activities for reducing stress. In contrast, healthy controls can actively use social activities for solving stressful situation. That is, some bipolar patients with social dysfunction may not only recognize social situation as more perceived stress, but also have few resources for coping stress and negative influence on course of illness. To improve outcomes in the treatment of bipolar disorder, it is important to establish therapeutic planning for increasing social activities. In this study, meanwhile, bipolar patients had lower consuming activities for coping with stress. Decreased consuming activities may be caused by economic problem or anhedonia in depressive phase. Bipolar patients can experience financial hardship by increased consuming activities in the manic phase (Bhugra and Flick, 2005). Concerns from patient's families in aspects of economics can shrink consuming activities of bipolar patients. In addition, bipolar patients suffer from depressive symptoms for many periods of illness (Judd and Akiskal, 2003). Anhedonia, that

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Table 4 Comparison of stress-coping behaviors between bipolar patients and healthy controls. Unadjusted

Factor 1 Personal Factor 2 Pleasure-seeking Factor 3 Social Factor 4 Compulsive

Adjusted

Bipolar patients (n¼ 103)

Healthy controls (n¼ 103)

t

P value

Bipolar patients (n¼ 103)

Healthy controls (n¼ 103)

16.9(7 7.9)

17.5( 7 8.3)

 0.514

0.608

17.4( 7 0.6)

16.9( 7 0.6)

0.367

0.545

8.8(7 8.8)

7.5( 7 5.3)

1.245

0.215

9.2( 7 0.5)

7.0( 7 0.5)

8.995

0.003

22.9(7 10.1)

27.9( 7 9.9)

 3.600

23.6( 7 0.6)

27.1( 7 0.6)

19.957

7.0(7 3.4)

6.5( 7 3.2)

1.233

7.1( 7 0.3)

6.4( 7 0.3)

3.282

o0.001 0.219

F

P value

o 0.001 0.072

Statistics was tested by independent t-test and ANCOVA. Adjusted with total summation score in analysis of covariance (ANCOVA). Unadjusted values: mean( 7S.D.); adjusted values: mean(7 S.E).

is one of the common depressive symptoms, may decrease consuming activities. On the other hand, bipolar patients had higher pleasureseeking and impulsive activities such as ‘smoking’, ‘masturbation’, ‘stealing’, ‘extramarital affair’, ‘beating’, and ‘using drug/illegal substance’ than healthy controls. Impulsivities in bipolar patients were shown not only in acute manic phase, but also in remission state (Swann et al., 2003). Several researches on temperaments and character have observed that bipolar patients have higher novelty seeking behaviors than normal controls (Liraud and Verdoux, 2000; Henry et al., 2001; Nowakowska et al., 2005). In this study, the results that bipolar patients had higher pleasureseeking and impulsive behaviors for coping with stress might be caused by patient's temperaments and character. Furthermore, high comorbidities of alcohol and substance use disorders, and risk taking behaviors in bipolar patients may be related to the tendency to use pleasure-seeking and impulsive activities for coping with stress (Regier et al., 1990; Crum et al., 1995; Bizzarri et al., 2007; Kathleen Holmes et al., 2009). We can choose various behavioral strategies to cope with stress. However, some behaviors such as ‘smoking’, ‘using drug/ illegal substance’, and ‘drinking alcohol’ can threat physical health and induce addiction. And, other behaviors such as ‘stealing’, ‘extramarital affair’, and ‘beating’ can also provoke legal or social problems. Therefore, adaptive behavioral strategies for coping with stress can be desirable. In this study, bipolar patients showed less social and more pleasure-seeking and impulsive activities than healthy controls. Social dysfunction, pleasure-seeking and impulsive activities may have poor outcome on course, overall functional, and quality of life (Cohen et al., 2004; Bizzarri et al., 2007; Schwannauer et al., 2011; Victor et al., 2011; Jimenez et al., 2012). Considering potential risks of these activities, our results suggest that bipolar patients might have maladaptive behaviors for coping with stress. In order to improve the course of bipolar disorder, it will be important to decrease maladaptive coping behaviors. Several limitations of the present study should be taken into consideration. Firstly, we used the newly designed survey questionnaire without the confirmation of reliability and validity. Because there was no appropriate assessment scale for measuring behavioral strategies for coping with stress until now, we newly designed behavioral checklist. We included various behavioral strategies for coping stress into this checklist, as well as behavioral responses in stressful situation such as stealing, beating, and extramarital affair, in order to explore the characteristics of stress-coping behaviors. Further study is needed to develop assessment scale with appropriate reliability and validity for

measuring stress-coping behaviors. Secondarily, we did not control confounding factors affecting on stress-coping behaviors except age, sex, and mood state. Clinical variables such as bipolar subtype, first mood episode, and residual mood symptoms are needed in future study. Specially, residual depressive symptoms can influence on stress-coping behaviors. In general, residual depressive symptoms can reduce social activities and increase interpersonal sensitivity (Brown et al., 2011). In this study, we did not measure residual depressive symptoms. We cannot rule out the impact of residual depressive symptoms on our results. However, patients included in this study were euthymic in less than three CGI scores after recovery of acute symptoms, and mean CGI scores were about 2. Therefore, the impact of residual symptoms on stress-coping behaviors might be minimal. Thirdly, we did not measure types and amounts of stressors. Because stressors can influence on stress-coping behaviors, these factors are required to be measured in the future study. Fourthly, subjects in this study were small. In the future, large scale study is needed to confirm the results of this study. Despite these limitations, the study had several strengths. To our knowledge, this is the first systematic study to examine the characteristics of stress-coping behaviors in bipolar disorder. When considering that stress can aggravate the course of bipolar disorder, it is important to assess stress-coping behaviors of bipolar patients. Stress-coping behaviors should be evaluated in order to establish the therapeutic planning for improving behavioral strategies for coping stress in patients with bipolar disorder.

Conflicts of interest All authors declare that they have no conflicts of interest.

Acknowledgments This study was supported by a grant A101915 from the Korea Healthcare Technology R & D Project, Ministry of Health & Welfare, Republic of Korea. Reference American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th ed. American Psychiatric Association, Washington, DC. Benazzi, F., 2000. Characteristics of bipolar II patients with interpersonal rejection sensitivity. Psychiatry Clinical Neuroscience 54, 499–501.

Please cite this article as: Moon, E., et al., Characteristics of stress-coping behaviors in patients with bipolar disorders. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.047i

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Please cite this article as: Moon, E., et al., Characteristics of stress-coping behaviors in patients with bipolar disorders. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.047i

Characteristics of stress-coping behaviors in patients with bipolar disorders.

Appropriate stress-coping strategies are needed to improve the outcome in the treatment of bipolar disorders, as stressful life events may aggravate t...
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