Altered self-report of empathic responding in patients with bipolar disorder
Introduction
People with bipolar disorder (BD) experience significant disruptions in social functioning, which may negatively impact the quality of life of patients, family members and other supports (e.g., Begley et al., 2001, Lepine, 2001, Kessler et al., 2006). Poor social functioning may result in part from deficits in social cognition, involving the ability to understand and respond to the thoughts and feelings of others. Recent investigations have demonstrated impairments in facial affect processing (e.g., George et al., 1998, Lembke and Ketter, 2002, Getz et al., 2003) and in theory of mind (e.g., Kerr et al., 2003, Inoue et al., 2004, Inoue et al., 2006, Bora et al., 2005) in patients with BD. Less attention has been paid, however, to other aspects of social cognition, including empathy. In the present study, we examine the performance of patients with BD on a well-validated measure of empathic responding, the Interpersonal Reactivity Index (Davis, 1983), and the association of empathic responding with the clinical characteristics and psychosocial functioning of this sample.
Empathy refers broadly to the ability to infer and share the feeling states of another (Gallese, 2003). Empathic skills are thought to be essential for successful social communication and interactions (Baron-Cohen and Wheelwright, 2004) and important for promoting unselfish, prosocial behaviour (Eisenberg and Miller, 1987). Recent theoretical models have proposed that empathy is multidimensional in nature, involving both cognitive (e.g., understanding another's perspective) and affective (e.g., emotional response to the feeling states of others) components (Davis, 1980, Davis, 1983, Rankin et al., 2005). Neuroimaging and patient studies of empathy confirm this view, implicating a core network of neural regions that serve diverse functions and include cognitive (e.g., dorsolateral prefrontal cortex), affective (e.g., orbitofrontal and medial frontal; amygdala) and memory systems (e.g., hippocampus; anterior and posterior cingulate, temporal poles; Eslinger, 1998, Farrow et al., 2001, Völlm et al., 2006; see McKinnon et al., 2007 for a review).
Many of the regions included in these neural network models are affected in patients with BD, showing altered metabolic functioning (e.g., Blumberg et al., 2003a, Altshuler et al., 2005, Krüger et al., 2006, Foland et al., 2008) and volumetric abnormalities (e.g., Blumberg et al., 2003b, Adler et al., 2005, Bearden et al., 2008, McKinnon et al., 2009). Combined with well-established evidence of impairments on cognitive tasks in this population (Altshuler et al., 2004, Bearden et al., 2006, Malhi et al., 2007, Mur et al., 2007; see also MacQueen et al., 2005), which worsen with disease progression (MacQueen et al., 2002), there is substantial reason to suspect that patients with BD will have altered performance on social tasks that rely on the processing resources (e.g., executive functioning, emotion comprehension) subserved by these regions and thought to contribute to social cognitive performance, including empathy (McKinnon and Moscovitch, 2007).
To date, little work has been conducted concerning empathic responding in patients with mood disorders. Donges et al. (2005) found that depressed patients had reduced awareness of others' emotional states compared with healthy controls. They used the Levels of Emotional Awareness Scale, however, which is not a direct measure of empathy, although this finding is in keeping with the preoccupation with the self and negative self cognitions that form the core symptoms of this illness (Raes et al., 2006). Another study reported that patients with major depression score higher than controls on measures of altruism (O'Connor et al., 2002), a process linked closely to empathy, although not directly analogous to it. Hence, empathic responding has not been assessed directly in patients with BD, despite knowledge of impairments in social functioning in this population (Blairy et al., 2004). Moreover, the relation between performance on social reasoning tasks and measures of real-world social functioning has not been adequately examined.
This preliminary study was designed to investigate empathic responding in a sample of patients with established BD and matched healthy comparison subjects. We administered a standardized self-report measure of empathic responding: the Interpersonal Reactivity Index (IRI; Davis, 1983). This measure has demonstrated efficacy across multiple subject populations, including substance dependence (Alterman et al., 2003) and schizophrenia (Montag et al., 2007) and has been administered successfully in patients with frontal dysfunction (e.g., Eslinger, 1998). The IRI assesses four dimensions of dispositional empathy: Perspective Taking and Fantasy as well as Empathic Concern and Personal Distress. Each pair was designed to measure cognitive and affective elements of empathy, respectively. Given well-documented deficits in emotion regulation (Phillips et al., 2008) among patients with BD, we predicted that our sample would report difficulties in emotional self-control as measured by the Personal Distress Scale (e.g., “In emergency situations I feel apprehensive and ill at ease”). By contrast, recent evidence points towards impaired perspective taking ability in patients with active (Kerr et al., 2003) and sub-syndromal BD (McKinnon et al., submitted). Hence, we expected patients in our sample to report lower levels of perspective taking (e.g., “I sometimes find it difficult to see things from the ‘other guy's’ point of view”) than matched controls. The Fantasy subscale of the IRI has been described as best assessing imagination (e.g., “I daydream and fantasize with some regularity about things that might happen to me”; Baron-Cohen and Wheelwright, 2004); we did not expect patients with BD to show deficits on this scale as impairments in imagination have not been reported in this population. Finally, given the dearth of study regarding empathic concern in patients with BD (e.g., “I would describe myself as a pretty soft-hearted person.”), we were unable to make predictions for this subscale.
Because alterations in cognitive functioning have been shown to worsen with disease progression in patients with mood disorders (e.g., van Gorp et al., 1998, Lebowitz et al., 2001, MacQueen et al., 2002; but see Nehra et al., 2006, Pavuluri et al., 2006 for conflicting findings), we also examined the relation between illness burden and empathic responding. Finally, we explored relations between psychosocial functioning and performance on the IRI by administering a reliable and well-validated measure of psychosocial functioning, the Social Adjustment Scale Self-Report (SAS-SR; Weissman and Bothwell, 1976).
Section snippets
Participants
Twenty patients with bipolar disorder (mean age = 43.0, S.D. = 8.9; 14 women) were recruited from the outpatient Mood Disorders Clinic at St. Joseph's Healthcare in Hamilton. A primary diagnosis of BD was confirmed by the Structured Clinical Interview for DSM-IV (SCID; First et al., 2001). Fourteen bipolar type I and six bipolar type II patients were recruited in total. The healthy comparison (HC) group consisted of 20 subjects with no history of psychiatric illness matched to the patients in terms
Performance on the IRI
Patients with BD scored lower on the Perspective Taking subscale [F (1, 38) = 4.53, P < 0.05, ηp2 = 0.11] and higher on the Personal Distress subscale [F (1, 38) = 5.98, P < 0.05, ηp2 = 0.14] than the healthy controls (see Table 2). No other significant effects emerged.
Psychosocial functioning
As expected, the Work/Academic functioning [F (1, 14) = 10.93, P < 0.01, ηp2 = 0.44], Social/Leisure activities [F (1, 14) = 8.51, P < 0.05, ηp2 = 0.38], Relationship with Outside Family [F (1, 14) = 4.75, P < 0.05, ηp2 = 0.25], Parental Role [F (1, 14) = 5.51,
Discussion
To our knowledge, this is the first study to examine directly empathic responding in patients with BD. The main findings in this preliminary study were the reduced perspective taking and elevated levels of personal discomfort reported by BD patients in response to others' distress. Altered empathic responding, as assessed by these scales, was associated with decreased family, social and occupational functioning. Very preliminary evidence emerged that personal distress increased with higher
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