Low self-compassion in patients with bipolar disorder
Introduction
Bipolar disorder (BD) is a debilitating and often chronic affective disorder characterized by affective episodes such as mania and depression interceded by intervals with remission [1]. BD often entails functional impairments [2] and reduced quality of life [3].
A central characteristic of BD is the marked variations in self-perception during affective episodes, with low self-esteem during depression and high or inflated self-esteem during mania. Abnormalities in self-conception are, however, not confined to mood episodes in BD. Previous studies suggest that during periods of remission BD is associated with self-criticism [4], [5], low self-esteem [6], maladaptive self-schemas [7], [8] and a dichotomized self-organization [9]. As a result of the cognitive focus within this research, less attention has been devoted to emotional aspects of self-conception. Acknowledging that BD is an affective disorder with major shifts in mood and emotion, emotional aspects of self-conception indeed appears relevant.
Self-compassion, which entails certain emotional inclinations towards the self, is a relatively new psychological concept that has been conceptualized in different but overlapping theories by Neff [10], [11] and Gilbert [12], [13]. High self-compassion involves being kind and understanding toward oneself in difficult times and perceiving difficulties as part of a larger human experience [10]. More broadly, it involves an accepting and nonjudgmental attitude toward one’s experiences. Low self-compassion, on the other hand, involves being self-judgmental and inclined to over-identify with negative experiences as well as feeling isolated by suffering.
Self-compassion has to our knowledge not previously been examined in BD patients. There are, nevertheless, a number of reasons for assuming a relevance of self-compassion in BD.
One of these is empirical as previous studies indicate that self-compassion is related to psychopathology. A meta-analysis by Macbeth and Gumley [14] found that low self-compassion was associated with symptoms of depression and anxiety in both clinical and non-clinical populations. Also, in a study by Krieger et al. [15] patients with Major Depressive Disorder (MDD) exhibited lower self-compassion compared to a non-clinical control group, even when controlling for depressive symptoms. Thus, based on prior research it appears that low self-compassion may be linked to depression and depressive symptoms. However, it remains to be examined whether this association also applies to BD with its different affective symptomatology.
The other reason for assuming a relevance of the concept in BD is the theorized connection between low self-compassion and affective dysregulation. According to Gilbert [12], [13], self-compassion is a critical component in the human capacity to regulate emotions. In his theoretical model, three neurobiological systems influence affect regulation; the threat system related to fear and avoidance, the drive system related to motivation and rewards and the soothing system related to feelings of calmness and affiliation. It is particularly the soothing system that is involved in compassion towards self and others. The soothing system contributes to handling both ups and downs and resisting psychological stress.
Drawing upon Gilbert’s theory and the Behavioral Activation System theory of BD [16], Lowens [17] proposes that affect dysregulation in BD involves an over- and underactivation of the drive system, an unstable threat system and a limited soothing system. From this perspective, BD could involve a restricted capacity for a self-compassionate attitude due to a limited soothing system. The abnormal oxytocin levels [18], [19] and increased amygdala activity [20] found in BD patients support the idea of a limited soothing system at a neurobiological level. However, it remains to be examined whether such presents as low self-compassion at the phenomenological level.
Based on the outlined empirical and theoretical reasons, self-compassion was investigated in a sample of BD patients. The purpose of the study was two-fold. Firstly, in order to examine the overall level of self-compassion, BD patients were compared to age- and sex matched controls. Secondly, to explore the potential impact of self-compassion in BD patients, associations between self-compassion and indicators of illness severity and psychological well-being were examined. In agreement with prior research, age of onset and frequency of past affective episodes were used as proxies for illness severity [21], [22]. As indicators of psychological well-being measures of functional impairment, internalized stigma and quality of life were employed. In order to control for the confounding effects of mood symptoms, a remission design was employed with absence of affective episodes as an inclusion criteria for study participation.
Section snippets
Sample and procedure
The present study was a naturalistic case-control study comparing remitted BD patients and age- and sex matched controls. Recruitment of participants was confined to a period of four months, from February to May 2014. All of the participants provided informed consent after receiving verbal and written descriptions of the study. Participation was entirely voluntary and independent of ongoing treatment. The study was approved by The National Committee of Health Research Ethics in Denmark.
Thirty
Baseline characteristics and self-compassion
Descriptive characteristics of the 30 BD patients who participated in the study are provided in Table 1. The SCS total was not significantly correlated with affective symptoms, as measured by MDI (r = −.18, p = .351), ASRM (r = −.08, p = .672), length of remission (r = .29, p = .131), or polarity of most recent affective episode (r = −.25, p = .180). In the BD group (r = .40, p = .028), but not in the control group (r = .24, p = .194) the SCS total correlated significantly with age. Moreover,
Discussion
The present study revealed that in comparison to age- and sex matched controls, remitted BD patients had substantially lower self-compassion. Since self-compassion was not related to the subsyndromal symptoms or proximity and polarity of most recent affective episode, this finding cannot be interpreted as reflecting an epiphenomenon of mood symptoms. Thus, the salient question is what may explain the low self-compassion in BD? One possibility is that low self-compassion is an aspect of the
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2020, Journal of Affective DisordersCitation Excerpt :In our study, participants with BD reported diminished self-compassion and nonattachment to self compared with participants from the general population. These results are consistent with that of Døssing et al. (2015), whereby lower levels of self-compassion were observed in those with BD. As this is the first investigation of nonattachment to self in a clinical population of individuals with BD, study results indicate that BD may also be characterised by a low level of nonattachment to self.