Journal of Affective Disorders 184 (2015) 67–71
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research Report
Coping and personality in older patients with bipolar disorder Sigfried N.T.M. Schouws a,n, Nadine P.G. Paans a, Hannie C. Comijs a,b, Annemiek Dols a, Max L. Stek a a b
GGZ inGeest, Mental Health Institute, Amsterdam, The Netherlands Department of Psychiatry, EMGO Institute of Care and Health Research, VU University Medical Center, Amsterdam, The Netherlands
art ic l e i nf o
a b s t r a c t
Article history: Received 6 March 2015 Received in revised form 22 May 2015 Accepted 22 May 2015 Available online 2 June 2015
Background: Little is known about coping styles and personality traits in older bipolar patients. Adult bipolar patients show a passive coping style and higher neuroticism scores compared to the general population. Our aim is to investigate personality traits and coping in older bipolar patients and the relationship between coping and personality. Method: 75 Older patients (age460) with bipolar I or II disorder in a euthymic mood completed the Utrecht Coping List and the NEO Personality Inventory FFI and were compared to normative data. Results: Older bipolar patients show more passive coping styles compared to healthy elderly. Their personality traits are predominated by openness, in contrast conscientiousness and altruism are relatively sparse. Neuroticism was related to passive coping styles, whereas conscientiousness was related to an active coping style. Conclusions: Older bipolar patients have more passive coping styles. Their personality is characterized by openness and relatively low conscientiousness and altruism. Our sample represents a survival cohort; this may explain the differences in personality traits between older patients in this study and in adult bipolar patients in other studies. The association between coping styles and personality traits is comparable to reports of younger adult patients with bipolar disorder. Longitudinal studies are warranted to explore if coping and personality change with ageing in bipolar patients and to determine which coping style is most effective in preventing mood episodes. & 2015 Elsevier B.V. All rights reserved.
Keywords: Bipolar disorder Elderly Personality Coping
1. Introduction Coping style, defined as the behavioral or cognitive response of an individual to uncomfortable or difficult situations, has hardly been studied in older patients with a bipolar disorder (BD). Coping plays an important role in successful aging (Ouwehand et al., 2003), and active coping might prevent BD patients from becoming more impaired in functioning and having psychiatric symptoms in later stages of the illness. However, older individuals with BD may be less flexible in their use of coping styles because their cognitive functioning declines with age (Gildengers et al., 2009) as was shown in a group of schizophrenia patients (Wilder-Willis et al., 2002). Coping styles can be divided in functional or active coping styles and nonfunctional or passive coping styles. Compared to patients with unipolar depression, adult BD patients have more active coping skills (Coulston et al., 2013). However, compared with the general population, adult BD patients (age range n Correspondence to: GGZ inGeest, Amstelveenseweg 589, 1081 JC Amsterdam, The Netherlands. Tel.: þ 31 20 5736565; fax: þ31 20 3016926. E-mail address: [email protected] (S.N.T.M. Schouws).
http://dx.doi.org/10.1016/j.jad.2015.05.045 0165-0327/& 2015 Elsevier B.V. All rights reserved.
23–65) show a more passive coping style (Goossens et al., 2008). Kramer et al. (2009) also found a lower level of active coping in BD patients compared to healthy controls. The choice of coping styles depends highly on personality characteristics. Personality traits represent one of the most important factors in vulnerability to mood disorders (Scott et al., 2000). All personality disorders are common in mood disorders, yet cluster B and C personality disorders are most common in BD (Friborg et al., 2014). The Big Five personality traits are five broad dimensions representing a continuum in personality traits: neuroticism, extraversion, openness, altruism and conscientiousness. Most patients with a personality disorder score high on neuroticism, and high extraversion is often found in persons with cluster B personality disorder (Costa and McCrae, 1990). Previous studies show higher scores on neuroticism and lower scores on extraversion in older bipolar patients compared to the general population (Canuto et al., 2010; Jylhä et al., 2010). This is in-line with the results in adult bipolar patients (mean age of 29 years) (Smillie et al., 2009). Personality traits change with aging, as cross sectional studies that examined age effects on the Big five dimensions revealed that extraversion and openness are negatively related with age
68
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
whereas agreeableness is positively associated with age (Donellon and Lucas, 2008). Personality traits, coping styles and psychiatric symptoms interact with each other. Studies focusing on the adult population (age range 17–62) show that neuroticism is related to passive coping styles, whereas conscientiousness and to a lesser extent extraversion are more related to active coping styles (Karimzade and Besharat, 2011; Leandro and Castillo, 2010). The relation between coping styles and Big-Five personality traits in older bipolar patients is still unclear. Psychiatric symptoms are related to coping; passive reaction or lack of initiative is one of the core features of depression. Improvements in coping style can also have an important impact on functional outcome in older patients with BD and therefore interventions should include management of coping styles. The aims of the current study are (1) to assess coping styles and personality traits in older bipolar patients and (2) to evaluate the association between coping style and personality traits in older bipolar patients. We hypothesize that older bipolar patients show a passive coping style compared to healthy subjects. We further hypothesize that older bipolar patients score high on neuroticism and low on extraversion with respect to healthy subjects. We finally hypothesize that neuroticism is related to passive coping styles, whereas conscientiousness and extraversion are associated with active coping styles.
coping styles, while avoidance, passive reaction and expressing emotions are thought to reflect more passive coping styles. Palliative reaction and seeking social support are related to both active and passive coping styles (Schreurs et al., 1993). The scores on the subscales palliative reaction and avoidance range from 8 to 32, and scores on the subscales active problem solving and passive reaction range between 7 and 28. Scores on subscales emotion expression, comforting cognitions and social support could theoretically range from 3 to 12, 5 to 20 and from 6 to 24 respectively. 2.2.3. Personality The NEO Five-Factor Inventory (NEO-FFI) (Hoekstra et al., 1996) assessed the participants' personality traits. The Dutch version of the NEO-FFI consists of 60 questions, and assesses the following personality dimensions: neuroticism, extraversion, openness, conscientiousness and altruism. The scores for each of the five subscales could theoretically range from 12 to 60. 2.2.4. Mood The Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) and the Young Mania Rating Scale (YMRS) (Young et al., 1978) were used to assess current symptoms of depression and mania. The Dutch version of the CES-D consisted of 20 items that assess the frequency of emotional, cognitive, motoric and physiological symptoms of depression during the last week (Beekman et al., 1997). The Dutch version of the YMRS consisted of 11 items that rated several manic symptoms.
2. Method 2.1. Participants Euthymic bipolar patients were included with type I and II BD. Patients were recruited by searching the computerized record keeping system of the Mental Health Organization (GGZ inGeest, Amsterdam, the Netherlands) and were selected when they received treatment during the time between January 1, 2012 and December 31, 2013 (details described elsewhere, Dols et al., 2014). Additional patients were recruited from our study of cognitive functioning in older bipolar patients from outpatient clinics in other regions, as described elsewhere (Schouws et al., 2009). Patients were excluded if they were unable to communicate in Dutch or English or were suffering from mental retardation (IQ below 70). Patients with a clinical diagnosis of dementia or a MMSE score (The Mini Mental State Examination) below 18 were excluded from the study. Eligible subjects were reported to be euthymic for at least three weeks by their psychiatrist. The study was approved by the Medical Ethics Committee of the VU University Medical Center, Amsterdam, the Netherlands. Written informed consent was obtained from all subjects. 2.2. Measurements 2.2.1. Demographic Education was based on a Dutch scoring system, a 7-point scale ranging from unfinished primary education (level 1, i.e., less than 6 years of formal education) to university degree (level 7, 16 years or more of formal education) (Verhage, 1964).
2.2.5. Cognition The Mini Mental State Examination (MMSE) (Folstein et al., 1975) was used to get an overall impression of cognitive functioning. The total score could theoretically range between 0 and 30. 2.2.6. Statistical analysis Data were first examined to see whether they fulfilled the assumptions for parametric analysis. Control groups were created using normative data based on reliability and validity studies of the NEO (Hoekstra et al., 1996) and UCL (Schreurs et al., 1993). The following normative data were available: for the NEO healthy elderly above 60 years of age, and for the UCL healthy elderly above 65 years of age, males and females separately. Differences between bipolar patients and normative data with respect to the scores on the UCL and the NEO-FFI were tested with independent samples T-tests. To test the association between coping styles and personality traits in bipolar patients multiple regression analyses were used, with coping styles as dependent variable, and personality traits and demographic characteristics as independent variables. Prior to running the regression, correlations were examined and variables that were not significantly correlated with coping styles were dropped from consideration for the regression. Results at level p o0.05 were considered to be statistically significant. All analyses were performed with SPSS version 21.
3. Results 3.1. Demographic and clinical data
2.2.2. Coping The Utrechtse Copinglijst (Utrecht Coping List, UCL) (Schreurs et al., 1993) examined the participants' coping styles. The UCL consists of 47 items, measuring 7 independent subscales: active problem solving, palliative reaction, avoidance and passive expectancy, seeking social support, passive reaction pattern, expressing emotions, and comforting cognitions. Active problem solving and comforting cognitions are thought to represent active
The mean age of 75 patients with BD was 67.17 years (SD 5.47). The group consisted of 32 males (42.7%) and 43 females (57.3%). Mean level of education was 5.09 (1.6), which equals an above average education of 10 or more years. The mean MMSE score was 28.73 (SD 1.23), indicating no global cognitive impairment. Mean YMRS and CES-D scores were respectively 0.67 (SD 1.22) and 10.82 (SD 6.60); these scores indicate that all patients were euthymic
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
Table 1 Summary of the mean and standard deviation for personality traits and coping styles of BD patients (N ¼ 75).
UCL – malesa (N¼ 32) Active problem solving Palliative reaction Avoidance Social support Passive reaction Expressing emotions Comforting cognitions
BD patients
Normative data t(df)
18.88 (3.39)
18.10 (3.68)
17.59 16.16 13.13 12.34 6.13 12.09
15.70 14.90 11.40 11.00 6.20 11.80
UCL – femalesa (N ¼42) Active problem 17.35 solving Palliative reaction 18.88 Avoidance 16.12 Social support 14.35 Passive reaction 12.19 Expressing emotions 6.24 Comforting 12.23 cognitions NEO-FFIb (N ¼ 71) Neuroticism Extraversion Openness Altruism Conscientiousness
31.51 38.18 35.80 34.66 38.06
(2.15) (2.40) (3.10) (3.38) (1.26) (2.35)
(3.60) (3.20) (3.20) (3.00) (1.80) (2.50)
p-Value
1.30 (31) 4.98 3.03 3.15 2.25 0.34 0.71
(31) (31) (31) (31) (31) (31)
(3.85)
18.90 (7.20)
2.60 (41)
(3.40) (3.44) (3.63) (3.13) (1.60) (2.59)
17.80 16.00 13.10 11.60 6.80 13.20
2.06 0.22 2.24 1.22 2.27 2.40
(8.50) (8.60) (6.70) (8.00) (3.60) (5.20)
(4.25) 30.70 (7.80) (4.25) 38.00 (6.10) (3.60) 33.90 (5.70) (4.38) 43.80 (5.10) (3.26) 45.50 (5.60)
1.60 0.36 4.46 17.56 17.97
(41) (41) (41) (41) (41) (41)
(70) (70) (70) (70) (70)
0.21 o 0.01 o 0.01 o 0.01 0.03 0.74 0.48
0.01 0.04 0.82 0.03 0.23 0.03 o 0.01
0.11 0.71 o 0.01 o 0.01 o 0.01
Values are presented as mean (standard deviation); UCL: Utrechtse Coping Lijst; BD: Bipolar Disorder. a b
Norm group: healthy males/females 465 years of age; Norm group: healthy elderly 4 60 years of age (n ¼281).
and without clinically relevant manic or depressive mood symptoms.
Table 2 Summary of multivariate regression analysis studying the association between personality traits and coping styles (N ¼ 70). Model
Constant
Active problem solvinga Neuroticism Conscientiousness CES-D
18.23
Comforting cognitionsa Neuroticism Altruism Conscientiousness
7.12
Avoidanceb Neuroticism CES-D
8.51
Passive reactionb Neuroticism CES-D
2.12
Expressing emotionsb Extraversion Altruism Conscientiousness Age
0.30
Palliative reactionc Altruism Conscientiousness
16.03
Social supportc Neuroticism Altruism Conscientiousness
24.58
To verify if BD patients do have a passive coping style, the coping styles of males and females were compared separately because only norms for separate groups were available (Table 1). Male BD patients showed higher scores compared with normative data on coping skills that are palliative reaction, avoidance, social support and passive reaction. Female BD patients showed higher scores on palliative reaction and social support, and lower scores on active problem solving, expressing emotions and comforting cognition.
b
SE-b
Beta
p-Value
0.25 0.26 0.20
0.10 0.12 0.06
0.29 0.23 0.36
0.01 0.03 o 0.01
0.15 0.09 0.19
0.07 0.07 0.09
0.26 0.16 0.23
0.04 0.23 0.06
0.23 0.04
0.09 0.06
0.32 0.09
0.01 0.48
0.26 0.18
0.08 0.05
0.35 0.37
o 0.01 o 0.01
0.14 0.06 0.08 0.02
0.05 0.04 0.06 0.03
0.41 0.17 0.17 0.09
0.04 0.15 0.24 0.51
0.01 0.07
0.09 0.12
0.01 0.07
0.93 0.57
0.11 0.18 0.04
0.10 0.10 0.13
0.14 0.22 0.03
0.30 0.09 0.79
R2 0.32
0.11
0.13
0.34
0.16
0.01
0.10
The dependent variables were the UCL subscales. a b
3.2. Coping
69
c
Active coping style. Passive coping style. Both active and passive coping style.
respect to comforting cognitions, regression analysis showed an association with neuroticism only. Results also showed an association between avoidance and neuroticism. In addition, associations between passive reaction and neuroticism and depression scores were found; this model accounted for 34% of the variance in passive reaction. Finally, regression analysis showed an association between expressing emotions and extraversion. The raw and standardized regression coefficients of the predictors together with their correlations with the coping styles are shown in Table 2.
3.3. Personality 4. Discussion The results on personality traits showed significant differences between patients and normative data of healthy elderly (Table 1). Compared with the normative data, BD patients revealed higher scores on openness and lower scores on altruism and conscie ntiousness. 3.4. Relation between coping and personality Personality dimensions and demographic characteristics were used in multiple regression analyses to study possible associations with different coping styles. Active problem solving was statistically significantly associated with the personality traits neuroticism, conscientiousness, and with depressive symptoms, accounting for approximately 32% of the variance in active problem solving. With
In line with our hypothesis, older bipolar patients showed a more passive coping style compared to healthy elderly. Contrary to our hypothesis older bipolar patients did not score high on neuroticism and low on extraversion, but they did score lower on conscientiousness and altruism and higher on openness compared to healthy elderly. Neuroticism was related to passive coping styles as hypothesized, whereas conscientiousness was related to an active coping style. This is in line with findings in the adult population (Karimzade and Besharat, 2011; Leandro and Castillo, 2010). The more passive coping style that we found in elderly bipolar patients is in accordance with the results in studies on how elderly people cope with aging and failing health (Birkeland and Natvig,
70
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
2009). The main strategy of elderly who are sick or unhealthy is to accept the situation, this is often colored by a resigned and passive acceptance. The use of acceptance as main coping strategy however can also enable them to adapt and carry out different activities. Thus, in case of elderly bipolar patients a passive coping style can be useful especially when it is very difficult to change their situation. Our findings differ from Jylhä et al. (2010) who studied a group of older bipolar patients and found higher scores on neuroticism and lower scores on extraversion. Besides using a different instrument to measure personality traits, the patients in their study participated while being clinically depressed. Patients in our study were euthymic and without clinically relevant manic or depressive mood symptoms. This could explain why scores on neuroticism were higher and on extraversion lower than in our study, as high neuroticism and low extraversion are related to depressed mood (Jylh and Isomelsä, 2006). Differences in personality traits, notably a higher neuroticism and lower extraversion, that have been found between adult bipolar patients and normal population, were not present in our study. Is it possible that personality traits change over lifetime? Donellan and Lucas (2008) were the first to examine all of the Big Five in a nationally representative sample across the life span. They used a 15-item version of the Big Five and studied two large groups, one in Britain and one in Germany. Extraversion and openness were negatively associated with age whereas altruism was positively associated. Conscientiousness was highest for participants in middle age. The results on neuroticism were ambiguous, in Germany there was no difference in neuroticism across different age groups. The results are consistent with other findings (Costa and McCrae, 1986; Steunenberg et al., 2005), thus certain aspects of personality seem to change across the life span. The results of our study suggest that our bipolar patients, who are often stable for a long time, adapt to traits related to positive affect and sociability as they grow older, because they have lower scores on neuroticism and higher scores on extraversion then younger adult patients. Jeste's study on healthy aging shows that a higher sense of purpose in life, optimism and more positive attitude towards aging are associated with longer lifespans (Jeste et al., 2010). Thus the personality style as we found in elderly bipolar patients seems rather beneficial. However, by including euthymic outpatients we studied a convenience sample; there may also be a group of bipolar patients with a worse outcome. To our knowledge, this is the first study that examined coping styles, personality traits and their relationship in the older population of bipolar patients. A strong point of our study is the careful selection of patients who were in a euthymic state. Although we used reliable and well-validated instruments a limitation is that the normative data are based on different age groups for the different instruments. Differences between the sexes cannot be accounted for the measurement of personality. Another limitation is that we used a cross-sectional design. Clearly prospective studies on the course of personality traits are needed to identify changes in traits such as neuroticism and extraversion. Further research should also focus on the relation between cognition and coping; as neurocognitive dysfunction is considered the main predictor of overall outcome of BD (Vieta et al., 2013), it is still a debate if cognitive dysfunction progresses over time (Strejilevich and Martino, 2013). An important implication of our study is that a passive coping style is present in older bipolar patients; therapeutic interventions could focus on this aspect. Passive coping can mean acceptance and the start of a more active problem focused coping. People with more active coping are less depressed (Dysvik et al., 2005) so it is important to have a consecutive dialog with patients about their needs and to encourage them in practicing different activities.
Older patients also show personality traits related to positive affect and sociability, at least in a euthymic group of patients. Our sample represents a survival cohort; possibly they are exhibiting coping styles and personality traits that are most effective in preventing mood episodes and enabling in living independently. Longitudinal studies are warranted to explore if coping and personality change with ageing in bipolar patients and which coping and personality traits are effective in these patients to cope with a severe mental illness and to participate in the community.
Role of the funding source Nothing declared.
Conflict of interest The authors of this paper do not have any commercial associations that might pose a conflict of interest in connections with this manuscript.
Acknowledgments This research was not supported by other sources.
References Beekman, A.T., Deeg, D.J.H., Limbeek, J. van, Braam, A.W., Vries, M.Z. de, Tilburg, W. Van, 1997. Criterium validity of the Center for Epidemiologic Studies Depression Scale (CES-D): results from a community based sample in The Netherlands. Psychol. Med. 27, 231–235. Birkeland, A., Natvig, G.K., 2009. Coping with ageing and failing health: a quantitative study among elderly living alone. J. Nurs. Pract. 15, 257–264. Canuto, A., Giannakopoulos, P., Moy, G., Rubio, M.M., Ebbing, K., Meiler-Mititelu, C., Herrmann, F.R., et al., 2010. Neurocognitive deficits and personality traits among euthymic patients with mood disorders in late life. J. Neurol. Sci. 299 (1–2), 24–29. Costa, P.T., McCrae, T.T., 1986. Cross-sectional studies of personality in a national sample: 1. Development and validation of survey measures. Psychol. Aging 1, 140–143. Costa, P.T., McCrae, T.T., 1990. Personality disorder and the five-factor model of personality. J. Personal. Disord. 4, 362–371. Coulston, C.M., Bargh, D.M., Tanious, M., Cashman, E.L., Tufrey, K., Curran, G., Kuiper, S., et al., 2013. Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients. J. Affect. Disord. 145 (1), 54–61. Dols, A., Rhebergen, D., Beekman, A., Kupka, R., Sajatovic, M., Stek, M.L., 2014. Psychiatric and medical comorbidities: results from a bipolar elderly cohort study. Am. J. Geriatr. Psychiatry 22, 1066–1074. Donellon, M.B., Lucas, R.E., 2008. Age differences in the BigFive across the life span: evidence from two national samples. Psychol. Aging 23, 558–566. Dysvik, E., Natvig, G.K., Eikeland, O.J., Lindstrom, T.C., 2005. Coping with chronic pain. Int. J. Nurs. Stud. 42, 297–305. Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. “Mini-mental state” a practical method for grading the cognitive state of patient for the clinici. J. Psychiatric Res. 12, 189–198. Friborg, O., Martinsen, E.W., Martinussen, M., Kaiser, S., Overgard, T.K.T., Rosenvinge, J.H., 2014. Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010. J. Affect. Disord. 152–154, 1–11. Gildengers, A.G., Mulsant, B.H., Begley, A., et al., 2009. The longitudinal course of cognition in older adults with bipolar disorder. Bipolar Disord. 11, 744–752. Goossens, P.J.J., Knoppert-van Der Klein, E.A.M., Van Achterberg, T., 2008. Coping styles of outpatients with a bipolar disorder. Arch. Psychiatr. Nurs. 22 (5), 245–253. Hoekstra, H.A., Ormel, J., de Fruyt, F., 1996. Handleiding NEO PersoonlijkheidsVragenlijsten NEO-PI-R en NEO-FFI. Swets & Zeitlinger, Lisse, The Netherlands. Jeste, D.V., Depp, C.A., Vahia, I.V., 2010. Succesful cognitive and emotional aging. World Psychiatry 9, 78–84. Jylh, ä P., Isomelsä, E., 2006. The relationship of neuroticism and extraversion to symptoms of anxiety and depression in the general population. Depress. Anxiety 23, 281–289. Jylhä, P., Mantere, O., Melartin, T., Suominen, K., Vuorilehto, M., Arvilommi, P., Leppämäki, S., et al., 2010. Differences in neuroticism and extraversion between patients with bipolar I or II and general population subjects or major depressive disorder patients. J. Affect. Disord. 125 (1–3), 42–52. Karimzade, A., Besharat, M.A., 2011. An investigation of the relationship between personality dimensions and stress coping styles. Soc. Behav. Sci. 30, 797–802.
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
Kramer, U., Drapeau, M., Khazaal, Y., Bodenmann, G., 2009. Coping specificities in bipolar affective disorder: relation with symptoms and therapeutic alliance. Ger. J. Psychiatry 12, 19–27. Leandro, P.G., Castillo, M.D., 2010. Coping with stress and its relationship with personality dimensions, anxiety, and depression. Soc. Behav. Sci. 5, 1562–1573. Ouwehand, C., de Ridder, D.T., Bensing, J.M., 2003. A review of successful aging models: proposing proactive coping as an important additional strategy. Clin. Psychol. Rev. 27, 873–884. Radloff, C.S., 1977. The CES-D scale: a self report depression scale for research in the general population. Appl. Psychol. Meas. 1 (3), 385–401. Schouws, S.N.T.M., Comijs, H.C., Stek, M.L., Dekker, J., Oostervink, F., Naarding, P., Velde, I., van der, Beekman, A., 2009. Cognitive impairment in early and late bipolar disorder. Am. J. Geriatr. Psychiatry 17, 508–515. Schreurs, P.J.G., Van De Willige, G., Brosschot, J.F., Grau, G., 1993. De Utrechtse Copinglijst: UCL Handleiding. Swets en Zeitlinger, Lisse, The Netherlands. Scott, J., Stanton, B., Garland, A., 2000. Psychol. Med. 30, 467–472. Smillie, L.D., Bhairo, Y., Gray, J., Gunasinghe, C., Elkin, A., McGuffin, P., Farmer, A., 2009. Personality and the bipolar spectrum: normative and classification data for the Eysenck Personality Questionnaire – Revised. Compr. Psychiatry 50 (1), 48–53.
71
Steunenberg, B., Twisk, J.W., Beekman, A.T., Deeg, D.J., Kerkhof, A.J., 2005. Stability and change of neuroticism in aging. J. Gerontol. B Psychol. Sci. Soc. Sci. 60, 27–33. Strejilevich, S.A., Martino, D.J., 2013. Cognitive function in adulthood and elderly euthymic bipolar patients: a comparison to test models of cognitive evolution. J. Affect. Disord. 150, 1188–1191. Verhage, F., 1964. Intelligentie en Leeftijd: Onderzoek Bij Nederlanders Van Twaalf Tot Zevenenzeventig Jaar (Dissertation). Van Gorcum, Assen. Vieta, E., Popovic, D., Rosa, A.R., Solé, B., Grande, I., Frey, B.N., Martinez-Arian, A., Sanchez-Moreno, J., Balnza-Martinez, V., Tabarés-Seisdedos, R., Kaczinski, F., 2013. The clinical implications of cognitive impairment and allostatic load in bipolar disorder. Eur. Psychiatry 28, 21–29. Wilder-Willis, K.E., Shear, P.K., Steffen, J.J., Borkin, J., 2002. The relation between cognitive dysfunction and coping abilities in schizophrenia. Schizophr. Res. 43, 259–267. Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliabity, validity and sensitivity. Br. J. Psychiatry 133, 429–435.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research Report
Coping and personality in older patients with bipolar disorder Sigfried N.T.M. Schouws a,n, Nadine P.G. Paans a, Hannie C. Comijs a,b, Annemiek Dols a, Max L. Stek a a b
GGZ inGeest, Mental Health Institute, Amsterdam, The Netherlands Department of Psychiatry, EMGO Institute of Care and Health Research, VU University Medical Center, Amsterdam, The Netherlands
art ic l e i nf o
a b s t r a c t
Article history: Received 6 March 2015 Received in revised form 22 May 2015 Accepted 22 May 2015 Available online 2 June 2015
Background: Little is known about coping styles and personality traits in older bipolar patients. Adult bipolar patients show a passive coping style and higher neuroticism scores compared to the general population. Our aim is to investigate personality traits and coping in older bipolar patients and the relationship between coping and personality. Method: 75 Older patients (age460) with bipolar I or II disorder in a euthymic mood completed the Utrecht Coping List and the NEO Personality Inventory FFI and were compared to normative data. Results: Older bipolar patients show more passive coping styles compared to healthy elderly. Their personality traits are predominated by openness, in contrast conscientiousness and altruism are relatively sparse. Neuroticism was related to passive coping styles, whereas conscientiousness was related to an active coping style. Conclusions: Older bipolar patients have more passive coping styles. Their personality is characterized by openness and relatively low conscientiousness and altruism. Our sample represents a survival cohort; this may explain the differences in personality traits between older patients in this study and in adult bipolar patients in other studies. The association between coping styles and personality traits is comparable to reports of younger adult patients with bipolar disorder. Longitudinal studies are warranted to explore if coping and personality change with ageing in bipolar patients and to determine which coping style is most effective in preventing mood episodes. & 2015 Elsevier B.V. All rights reserved.
Keywords: Bipolar disorder Elderly Personality Coping
1. Introduction Coping style, defined as the behavioral or cognitive response of an individual to uncomfortable or difficult situations, has hardly been studied in older patients with a bipolar disorder (BD). Coping plays an important role in successful aging (Ouwehand et al., 2003), and active coping might prevent BD patients from becoming more impaired in functioning and having psychiatric symptoms in later stages of the illness. However, older individuals with BD may be less flexible in their use of coping styles because their cognitive functioning declines with age (Gildengers et al., 2009) as was shown in a group of schizophrenia patients (Wilder-Willis et al., 2002). Coping styles can be divided in functional or active coping styles and nonfunctional or passive coping styles. Compared to patients with unipolar depression, adult BD patients have more active coping skills (Coulston et al., 2013). However, compared with the general population, adult BD patients (age range n Correspondence to: GGZ inGeest, Amstelveenseweg 589, 1081 JC Amsterdam, The Netherlands. Tel.: þ 31 20 5736565; fax: þ31 20 3016926. E-mail address: [email protected] (S.N.T.M. Schouws).
http://dx.doi.org/10.1016/j.jad.2015.05.045 0165-0327/& 2015 Elsevier B.V. All rights reserved.
23–65) show a more passive coping style (Goossens et al., 2008). Kramer et al. (2009) also found a lower level of active coping in BD patients compared to healthy controls. The choice of coping styles depends highly on personality characteristics. Personality traits represent one of the most important factors in vulnerability to mood disorders (Scott et al., 2000). All personality disorders are common in mood disorders, yet cluster B and C personality disorders are most common in BD (Friborg et al., 2014). The Big Five personality traits are five broad dimensions representing a continuum in personality traits: neuroticism, extraversion, openness, altruism and conscientiousness. Most patients with a personality disorder score high on neuroticism, and high extraversion is often found in persons with cluster B personality disorder (Costa and McCrae, 1990). Previous studies show higher scores on neuroticism and lower scores on extraversion in older bipolar patients compared to the general population (Canuto et al., 2010; Jylhä et al., 2010). This is in-line with the results in adult bipolar patients (mean age of 29 years) (Smillie et al., 2009). Personality traits change with aging, as cross sectional studies that examined age effects on the Big five dimensions revealed that extraversion and openness are negatively related with age
68
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
whereas agreeableness is positively associated with age (Donellon and Lucas, 2008). Personality traits, coping styles and psychiatric symptoms interact with each other. Studies focusing on the adult population (age range 17–62) show that neuroticism is related to passive coping styles, whereas conscientiousness and to a lesser extent extraversion are more related to active coping styles (Karimzade and Besharat, 2011; Leandro and Castillo, 2010). The relation between coping styles and Big-Five personality traits in older bipolar patients is still unclear. Psychiatric symptoms are related to coping; passive reaction or lack of initiative is one of the core features of depression. Improvements in coping style can also have an important impact on functional outcome in older patients with BD and therefore interventions should include management of coping styles. The aims of the current study are (1) to assess coping styles and personality traits in older bipolar patients and (2) to evaluate the association between coping style and personality traits in older bipolar patients. We hypothesize that older bipolar patients show a passive coping style compared to healthy subjects. We further hypothesize that older bipolar patients score high on neuroticism and low on extraversion with respect to healthy subjects. We finally hypothesize that neuroticism is related to passive coping styles, whereas conscientiousness and extraversion are associated with active coping styles.
coping styles, while avoidance, passive reaction and expressing emotions are thought to reflect more passive coping styles. Palliative reaction and seeking social support are related to both active and passive coping styles (Schreurs et al., 1993). The scores on the subscales palliative reaction and avoidance range from 8 to 32, and scores on the subscales active problem solving and passive reaction range between 7 and 28. Scores on subscales emotion expression, comforting cognitions and social support could theoretically range from 3 to 12, 5 to 20 and from 6 to 24 respectively. 2.2.3. Personality The NEO Five-Factor Inventory (NEO-FFI) (Hoekstra et al., 1996) assessed the participants' personality traits. The Dutch version of the NEO-FFI consists of 60 questions, and assesses the following personality dimensions: neuroticism, extraversion, openness, conscientiousness and altruism. The scores for each of the five subscales could theoretically range from 12 to 60. 2.2.4. Mood The Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) and the Young Mania Rating Scale (YMRS) (Young et al., 1978) were used to assess current symptoms of depression and mania. The Dutch version of the CES-D consisted of 20 items that assess the frequency of emotional, cognitive, motoric and physiological symptoms of depression during the last week (Beekman et al., 1997). The Dutch version of the YMRS consisted of 11 items that rated several manic symptoms.
2. Method 2.1. Participants Euthymic bipolar patients were included with type I and II BD. Patients were recruited by searching the computerized record keeping system of the Mental Health Organization (GGZ inGeest, Amsterdam, the Netherlands) and were selected when they received treatment during the time between January 1, 2012 and December 31, 2013 (details described elsewhere, Dols et al., 2014). Additional patients were recruited from our study of cognitive functioning in older bipolar patients from outpatient clinics in other regions, as described elsewhere (Schouws et al., 2009). Patients were excluded if they were unable to communicate in Dutch or English or were suffering from mental retardation (IQ below 70). Patients with a clinical diagnosis of dementia or a MMSE score (The Mini Mental State Examination) below 18 were excluded from the study. Eligible subjects were reported to be euthymic for at least three weeks by their psychiatrist. The study was approved by the Medical Ethics Committee of the VU University Medical Center, Amsterdam, the Netherlands. Written informed consent was obtained from all subjects. 2.2. Measurements 2.2.1. Demographic Education was based on a Dutch scoring system, a 7-point scale ranging from unfinished primary education (level 1, i.e., less than 6 years of formal education) to university degree (level 7, 16 years or more of formal education) (Verhage, 1964).
2.2.5. Cognition The Mini Mental State Examination (MMSE) (Folstein et al., 1975) was used to get an overall impression of cognitive functioning. The total score could theoretically range between 0 and 30. 2.2.6. Statistical analysis Data were first examined to see whether they fulfilled the assumptions for parametric analysis. Control groups were created using normative data based on reliability and validity studies of the NEO (Hoekstra et al., 1996) and UCL (Schreurs et al., 1993). The following normative data were available: for the NEO healthy elderly above 60 years of age, and for the UCL healthy elderly above 65 years of age, males and females separately. Differences between bipolar patients and normative data with respect to the scores on the UCL and the NEO-FFI were tested with independent samples T-tests. To test the association between coping styles and personality traits in bipolar patients multiple regression analyses were used, with coping styles as dependent variable, and personality traits and demographic characteristics as independent variables. Prior to running the regression, correlations were examined and variables that were not significantly correlated with coping styles were dropped from consideration for the regression. Results at level p o0.05 were considered to be statistically significant. All analyses were performed with SPSS version 21.
3. Results 3.1. Demographic and clinical data
2.2.2. Coping The Utrechtse Copinglijst (Utrecht Coping List, UCL) (Schreurs et al., 1993) examined the participants' coping styles. The UCL consists of 47 items, measuring 7 independent subscales: active problem solving, palliative reaction, avoidance and passive expectancy, seeking social support, passive reaction pattern, expressing emotions, and comforting cognitions. Active problem solving and comforting cognitions are thought to represent active
The mean age of 75 patients with BD was 67.17 years (SD 5.47). The group consisted of 32 males (42.7%) and 43 females (57.3%). Mean level of education was 5.09 (1.6), which equals an above average education of 10 or more years. The mean MMSE score was 28.73 (SD 1.23), indicating no global cognitive impairment. Mean YMRS and CES-D scores were respectively 0.67 (SD 1.22) and 10.82 (SD 6.60); these scores indicate that all patients were euthymic
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
Table 1 Summary of the mean and standard deviation for personality traits and coping styles of BD patients (N ¼ 75).
UCL – malesa (N¼ 32) Active problem solving Palliative reaction Avoidance Social support Passive reaction Expressing emotions Comforting cognitions
BD patients
Normative data t(df)
18.88 (3.39)
18.10 (3.68)
17.59 16.16 13.13 12.34 6.13 12.09
15.70 14.90 11.40 11.00 6.20 11.80
UCL – femalesa (N ¼42) Active problem 17.35 solving Palliative reaction 18.88 Avoidance 16.12 Social support 14.35 Passive reaction 12.19 Expressing emotions 6.24 Comforting 12.23 cognitions NEO-FFIb (N ¼ 71) Neuroticism Extraversion Openness Altruism Conscientiousness
31.51 38.18 35.80 34.66 38.06
(2.15) (2.40) (3.10) (3.38) (1.26) (2.35)
(3.60) (3.20) (3.20) (3.00) (1.80) (2.50)
p-Value
1.30 (31) 4.98 3.03 3.15 2.25 0.34 0.71
(31) (31) (31) (31) (31) (31)
(3.85)
18.90 (7.20)
2.60 (41)
(3.40) (3.44) (3.63) (3.13) (1.60) (2.59)
17.80 16.00 13.10 11.60 6.80 13.20
2.06 0.22 2.24 1.22 2.27 2.40
(8.50) (8.60) (6.70) (8.00) (3.60) (5.20)
(4.25) 30.70 (7.80) (4.25) 38.00 (6.10) (3.60) 33.90 (5.70) (4.38) 43.80 (5.10) (3.26) 45.50 (5.60)
1.60 0.36 4.46 17.56 17.97
(41) (41) (41) (41) (41) (41)
(70) (70) (70) (70) (70)
0.21 o 0.01 o 0.01 o 0.01 0.03 0.74 0.48
0.01 0.04 0.82 0.03 0.23 0.03 o 0.01
0.11 0.71 o 0.01 o 0.01 o 0.01
Values are presented as mean (standard deviation); UCL: Utrechtse Coping Lijst; BD: Bipolar Disorder. a b
Norm group: healthy males/females 465 years of age; Norm group: healthy elderly 4 60 years of age (n ¼281).
and without clinically relevant manic or depressive mood symptoms.
Table 2 Summary of multivariate regression analysis studying the association between personality traits and coping styles (N ¼ 70). Model
Constant
Active problem solvinga Neuroticism Conscientiousness CES-D
18.23
Comforting cognitionsa Neuroticism Altruism Conscientiousness
7.12
Avoidanceb Neuroticism CES-D
8.51
Passive reactionb Neuroticism CES-D
2.12
Expressing emotionsb Extraversion Altruism Conscientiousness Age
0.30
Palliative reactionc Altruism Conscientiousness
16.03
Social supportc Neuroticism Altruism Conscientiousness
24.58
To verify if BD patients do have a passive coping style, the coping styles of males and females were compared separately because only norms for separate groups were available (Table 1). Male BD patients showed higher scores compared with normative data on coping skills that are palliative reaction, avoidance, social support and passive reaction. Female BD patients showed higher scores on palliative reaction and social support, and lower scores on active problem solving, expressing emotions and comforting cognition.
b
SE-b
Beta
p-Value
0.25 0.26 0.20
0.10 0.12 0.06
0.29 0.23 0.36
0.01 0.03 o 0.01
0.15 0.09 0.19
0.07 0.07 0.09
0.26 0.16 0.23
0.04 0.23 0.06
0.23 0.04
0.09 0.06
0.32 0.09
0.01 0.48
0.26 0.18
0.08 0.05
0.35 0.37
o 0.01 o 0.01
0.14 0.06 0.08 0.02
0.05 0.04 0.06 0.03
0.41 0.17 0.17 0.09
0.04 0.15 0.24 0.51
0.01 0.07
0.09 0.12
0.01 0.07
0.93 0.57
0.11 0.18 0.04
0.10 0.10 0.13
0.14 0.22 0.03
0.30 0.09 0.79
R2 0.32
0.11
0.13
0.34
0.16
0.01
0.10
The dependent variables were the UCL subscales. a b
3.2. Coping
69
c
Active coping style. Passive coping style. Both active and passive coping style.
respect to comforting cognitions, regression analysis showed an association with neuroticism only. Results also showed an association between avoidance and neuroticism. In addition, associations between passive reaction and neuroticism and depression scores were found; this model accounted for 34% of the variance in passive reaction. Finally, regression analysis showed an association between expressing emotions and extraversion. The raw and standardized regression coefficients of the predictors together with their correlations with the coping styles are shown in Table 2.
3.3. Personality 4. Discussion The results on personality traits showed significant differences between patients and normative data of healthy elderly (Table 1). Compared with the normative data, BD patients revealed higher scores on openness and lower scores on altruism and conscie ntiousness. 3.4. Relation between coping and personality Personality dimensions and demographic characteristics were used in multiple regression analyses to study possible associations with different coping styles. Active problem solving was statistically significantly associated with the personality traits neuroticism, conscientiousness, and with depressive symptoms, accounting for approximately 32% of the variance in active problem solving. With
In line with our hypothesis, older bipolar patients showed a more passive coping style compared to healthy elderly. Contrary to our hypothesis older bipolar patients did not score high on neuroticism and low on extraversion, but they did score lower on conscientiousness and altruism and higher on openness compared to healthy elderly. Neuroticism was related to passive coping styles as hypothesized, whereas conscientiousness was related to an active coping style. This is in line with findings in the adult population (Karimzade and Besharat, 2011; Leandro and Castillo, 2010). The more passive coping style that we found in elderly bipolar patients is in accordance with the results in studies on how elderly people cope with aging and failing health (Birkeland and Natvig,
70
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
2009). The main strategy of elderly who are sick or unhealthy is to accept the situation, this is often colored by a resigned and passive acceptance. The use of acceptance as main coping strategy however can also enable them to adapt and carry out different activities. Thus, in case of elderly bipolar patients a passive coping style can be useful especially when it is very difficult to change their situation. Our findings differ from Jylhä et al. (2010) who studied a group of older bipolar patients and found higher scores on neuroticism and lower scores on extraversion. Besides using a different instrument to measure personality traits, the patients in their study participated while being clinically depressed. Patients in our study were euthymic and without clinically relevant manic or depressive mood symptoms. This could explain why scores on neuroticism were higher and on extraversion lower than in our study, as high neuroticism and low extraversion are related to depressed mood (Jylh and Isomelsä, 2006). Differences in personality traits, notably a higher neuroticism and lower extraversion, that have been found between adult bipolar patients and normal population, were not present in our study. Is it possible that personality traits change over lifetime? Donellan and Lucas (2008) were the first to examine all of the Big Five in a nationally representative sample across the life span. They used a 15-item version of the Big Five and studied two large groups, one in Britain and one in Germany. Extraversion and openness were negatively associated with age whereas altruism was positively associated. Conscientiousness was highest for participants in middle age. The results on neuroticism were ambiguous, in Germany there was no difference in neuroticism across different age groups. The results are consistent with other findings (Costa and McCrae, 1986; Steunenberg et al., 2005), thus certain aspects of personality seem to change across the life span. The results of our study suggest that our bipolar patients, who are often stable for a long time, adapt to traits related to positive affect and sociability as they grow older, because they have lower scores on neuroticism and higher scores on extraversion then younger adult patients. Jeste's study on healthy aging shows that a higher sense of purpose in life, optimism and more positive attitude towards aging are associated with longer lifespans (Jeste et al., 2010). Thus the personality style as we found in elderly bipolar patients seems rather beneficial. However, by including euthymic outpatients we studied a convenience sample; there may also be a group of bipolar patients with a worse outcome. To our knowledge, this is the first study that examined coping styles, personality traits and their relationship in the older population of bipolar patients. A strong point of our study is the careful selection of patients who were in a euthymic state. Although we used reliable and well-validated instruments a limitation is that the normative data are based on different age groups for the different instruments. Differences between the sexes cannot be accounted for the measurement of personality. Another limitation is that we used a cross-sectional design. Clearly prospective studies on the course of personality traits are needed to identify changes in traits such as neuroticism and extraversion. Further research should also focus on the relation between cognition and coping; as neurocognitive dysfunction is considered the main predictor of overall outcome of BD (Vieta et al., 2013), it is still a debate if cognitive dysfunction progresses over time (Strejilevich and Martino, 2013). An important implication of our study is that a passive coping style is present in older bipolar patients; therapeutic interventions could focus on this aspect. Passive coping can mean acceptance and the start of a more active problem focused coping. People with more active coping are less depressed (Dysvik et al., 2005) so it is important to have a consecutive dialog with patients about their needs and to encourage them in practicing different activities.
Older patients also show personality traits related to positive affect and sociability, at least in a euthymic group of patients. Our sample represents a survival cohort; possibly they are exhibiting coping styles and personality traits that are most effective in preventing mood episodes and enabling in living independently. Longitudinal studies are warranted to explore if coping and personality change with ageing in bipolar patients and which coping and personality traits are effective in these patients to cope with a severe mental illness and to participate in the community.
Role of the funding source Nothing declared.
Conflict of interest The authors of this paper do not have any commercial associations that might pose a conflict of interest in connections with this manuscript.
Acknowledgments This research was not supported by other sources.
References Beekman, A.T., Deeg, D.J.H., Limbeek, J. van, Braam, A.W., Vries, M.Z. de, Tilburg, W. Van, 1997. Criterium validity of the Center for Epidemiologic Studies Depression Scale (CES-D): results from a community based sample in The Netherlands. Psychol. Med. 27, 231–235. Birkeland, A., Natvig, G.K., 2009. Coping with ageing and failing health: a quantitative study among elderly living alone. J. Nurs. Pract. 15, 257–264. Canuto, A., Giannakopoulos, P., Moy, G., Rubio, M.M., Ebbing, K., Meiler-Mititelu, C., Herrmann, F.R., et al., 2010. Neurocognitive deficits and personality traits among euthymic patients with mood disorders in late life. J. Neurol. Sci. 299 (1–2), 24–29. Costa, P.T., McCrae, T.T., 1986. Cross-sectional studies of personality in a national sample: 1. Development and validation of survey measures. Psychol. Aging 1, 140–143. Costa, P.T., McCrae, T.T., 1990. Personality disorder and the five-factor model of personality. J. Personal. Disord. 4, 362–371. Coulston, C.M., Bargh, D.M., Tanious, M., Cashman, E.L., Tufrey, K., Curran, G., Kuiper, S., et al., 2013. Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients. J. Affect. Disord. 145 (1), 54–61. Dols, A., Rhebergen, D., Beekman, A., Kupka, R., Sajatovic, M., Stek, M.L., 2014. Psychiatric and medical comorbidities: results from a bipolar elderly cohort study. Am. J. Geriatr. Psychiatry 22, 1066–1074. Donellon, M.B., Lucas, R.E., 2008. Age differences in the BigFive across the life span: evidence from two national samples. Psychol. Aging 23, 558–566. Dysvik, E., Natvig, G.K., Eikeland, O.J., Lindstrom, T.C., 2005. Coping with chronic pain. Int. J. Nurs. Stud. 42, 297–305. Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. “Mini-mental state” a practical method for grading the cognitive state of patient for the clinici. J. Psychiatric Res. 12, 189–198. Friborg, O., Martinsen, E.W., Martinussen, M., Kaiser, S., Overgard, T.K.T., Rosenvinge, J.H., 2014. Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010. J. Affect. Disord. 152–154, 1–11. Gildengers, A.G., Mulsant, B.H., Begley, A., et al., 2009. The longitudinal course of cognition in older adults with bipolar disorder. Bipolar Disord. 11, 744–752. Goossens, P.J.J., Knoppert-van Der Klein, E.A.M., Van Achterberg, T., 2008. Coping styles of outpatients with a bipolar disorder. Arch. Psychiatr. Nurs. 22 (5), 245–253. Hoekstra, H.A., Ormel, J., de Fruyt, F., 1996. Handleiding NEO PersoonlijkheidsVragenlijsten NEO-PI-R en NEO-FFI. Swets & Zeitlinger, Lisse, The Netherlands. Jeste, D.V., Depp, C.A., Vahia, I.V., 2010. Succesful cognitive and emotional aging. World Psychiatry 9, 78–84. Jylh, ä P., Isomelsä, E., 2006. The relationship of neuroticism and extraversion to symptoms of anxiety and depression in the general population. Depress. Anxiety 23, 281–289. Jylhä, P., Mantere, O., Melartin, T., Suominen, K., Vuorilehto, M., Arvilommi, P., Leppämäki, S., et al., 2010. Differences in neuroticism and extraversion between patients with bipolar I or II and general population subjects or major depressive disorder patients. J. Affect. Disord. 125 (1–3), 42–52. Karimzade, A., Besharat, M.A., 2011. An investigation of the relationship between personality dimensions and stress coping styles. Soc. Behav. Sci. 30, 797–802.
S.N.T.M. Schouws et al. / Journal of Affective Disorders 184 (2015) 67–71
Kramer, U., Drapeau, M., Khazaal, Y., Bodenmann, G., 2009. Coping specificities in bipolar affective disorder: relation with symptoms and therapeutic alliance. Ger. J. Psychiatry 12, 19–27. Leandro, P.G., Castillo, M.D., 2010. Coping with stress and its relationship with personality dimensions, anxiety, and depression. Soc. Behav. Sci. 5, 1562–1573. Ouwehand, C., de Ridder, D.T., Bensing, J.M., 2003. A review of successful aging models: proposing proactive coping as an important additional strategy. Clin. Psychol. Rev. 27, 873–884. Radloff, C.S., 1977. The CES-D scale: a self report depression scale for research in the general population. Appl. Psychol. Meas. 1 (3), 385–401. Schouws, S.N.T.M., Comijs, H.C., Stek, M.L., Dekker, J., Oostervink, F., Naarding, P., Velde, I., van der, Beekman, A., 2009. Cognitive impairment in early and late bipolar disorder. Am. J. Geriatr. Psychiatry 17, 508–515. Schreurs, P.J.G., Van De Willige, G., Brosschot, J.F., Grau, G., 1993. De Utrechtse Copinglijst: UCL Handleiding. Swets en Zeitlinger, Lisse, The Netherlands. Scott, J., Stanton, B., Garland, A., 2000. Psychol. Med. 30, 467–472. Smillie, L.D., Bhairo, Y., Gray, J., Gunasinghe, C., Elkin, A., McGuffin, P., Farmer, A., 2009. Personality and the bipolar spectrum: normative and classification data for the Eysenck Personality Questionnaire – Revised. Compr. Psychiatry 50 (1), 48–53.
71
Steunenberg, B., Twisk, J.W., Beekman, A.T., Deeg, D.J., Kerkhof, A.J., 2005. Stability and change of neuroticism in aging. J. Gerontol. B Psychol. Sci. Soc. Sci. 60, 27–33. Strejilevich, S.A., Martino, D.J., 2013. Cognitive function in adulthood and elderly euthymic bipolar patients: a comparison to test models of cognitive evolution. J. Affect. Disord. 150, 1188–1191. Verhage, F., 1964. Intelligentie en Leeftijd: Onderzoek Bij Nederlanders Van Twaalf Tot Zevenenzeventig Jaar (Dissertation). Van Gorcum, Assen. Vieta, E., Popovic, D., Rosa, A.R., Solé, B., Grande, I., Frey, B.N., Martinez-Arian, A., Sanchez-Moreno, J., Balnza-Martinez, V., Tabarés-Seisdedos, R., Kaczinski, F., 2013. The clinical implications of cognitive impairment and allostatic load in bipolar disorder. Eur. Psychiatry 28, 21–29. Wilder-Willis, K.E., Shear, P.K., Steffen, J.J., Borkin, J., 2002. The relation between cognitive dysfunction and coping abilities in schizophrenia. Schizophr. Res. 43, 259–267. Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliabity, validity and sensitivity. Br. J. Psychiatry 133, 429–435.
