ORIGINAL RESEARCH

published: 21 May 2021

doi: 10.3389/fpsyt.2021.678807

Resilience Predicts Self-Stigma and

Stigma Resistance in Stabilized
Patients With Bipolar I Disorder
Fabienne Post*, Melanie Buchta, Georg Kemmler, Silvia Pardeller, Beatrice Frajo-Apor
and Alex Hofer

Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck,
Innsbruck, Austria

The identification of factors that prevent self-stigma and on the other hand promote
stigma resistance are of importance in the long-term management of bipolar disorder.
Accordingly, the aim of the current study was to investigate the association of factors
deemed relevant in this context, i.e., resilience, premorbid functioning, and residual mood
symptoms, with self-stigma/stigma resistance. Sixty patients diagnosed with bipolar
I disorder were recruited from a specialized outpatient clinic. Self-stigma and stigma
resistance were measured by the Internalized Stigma of Mental Illness (ISMI) Scale.
The presence and severity of symptoms were assessed by the Montgomery-Asberg
Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS). Resilience
Edited by: and premorbid functioning were measured by the Resilience Scale (RS-25) and
Yuan-Pang Wang,
University of São Paulo, Brazil
the Premorbid Adjustment Scale (PAS), respectively. Resilience correlated negatively
Reviewed by:
with self-stigma and positively with stigma resistance and was a predictor for
Nian-Sheng Tzeng, self-stigma/stigma resistance in multiple linear regression analysis. Residual depressive
Tri-service General Hospital, Taiwan symptoms correlated positively with self-stigma and negatively with stigma resistance.
Elisabetta Filomena Buonaguro,
Università di Medicina e Chirurgia There were no significant correlations between sociodemographic variables, premorbid
Federico II Napoli, Italy functioning as well as residual manic symptoms and self-stigma/stigma resistance.
*Correspondence: The findings of this study implicate that resilience may be considered as an important
Fabienne Post
fabienne.post@i-med.ac.at
component of self-stigma reduction interventions.
Keywords: bipolar disorder, resilience, stigma, premorbid functioning, psychopathology
Specialty section:
This article was submitted to
Mood and Anxiety Disorders,
INTRODUCTION
a section of the journal
Frontiers in Psychiatry
Patients suffering from bipolar disorder (BD) may encounter many difficulties during the course of
Received: 10 March 2021 the illness that can have a negative impact on the outcome. Not only do they face challenges that
Accepted: 23 April 2021 are associated with the symptoms of the illness itself and side effects of treatment, but stigmatizing
Published: 21 May 2021
attitudes can play a negative role on the course of the illness. All these factors can lead to deprivation
Citation: of factors which define quality of life such as pursuing a good job, living in a safe environment,
Post F, Buchta M, Kemmler G,
having satisfactory health care, and having a wide spectrum of social contacts (1).
Pardeller S, Frajo-Apor B and Hofer A
(2021) Resilience Predicts Self-Stigma
Although there are efforts to reduce stigma, stigmatizing attitudes toward the mentally ill is
and Stigma Resistance in Stabilized still an issue across all levels of society (2). Consequently, it can lead to patients applying those
Patients With Bipolar I Disorder. negative stereotypes and stigmatizing attitudes toward themselves, which is known as self-stigma
Front. Psychiatry 12:678807. (3). Self-stigma may delay health seeking behavior and may also prevent effective treatment (4).
doi: 10.3389/fpsyt.2021.678807 However, it is important to note that not all patients experiencing public stigma automatically

Frontiers in Psychiatry | www.frontiersin.org 1 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

also suffer from self-stigma (5). Hence, self-stigma can be seen MATERIALS AND METHODS
as a modifiable risk factor (6) and in this context, identifying
factors that help prevent its development or identifying factors Sixty patients diagnosed with bipolar I disorder were recruited
that promote stigma resistance can be of great importance in the from a specialized outpatient clinic. Diagnosis was confirmed
long-term management of bipolar disorder. On the one hand, by the Mini International Neuropsychiatric Interview (M.I.N.I)
it may help us identify vulnerable patients, and on the other (29). Study participants had to be native German speakers
hand, it may facilitate the implementation of protective and aged between 18 and 65 years and had to be clinically stable,
therapeutic interventions. In this context, a study by Cuhadar and i.e., they had not been admitted and had no alteration in
Cam (7) showed a positive effect of a psychoeducation program psychopharmacological treatment in the last 6 months prior to
on levels of self-stigma in bipolar patients. In turn, previous study inclusion. Patients with a history of neurological and severe
research has shown that self-stigma has negative effects on self- somatic illness, cerebrovascular dysfunction as well as patients
esteem (8–11), quality of life (8, 11–14), treatment adherence with dementia were excluded from the study. The study was
(12) as well as socio-occupational participation and functioning approved by the local ethics committee and patients had to
(8, 15). However, to the best of our knowledge, the association provide written informed consent. All scales used in the study
between resilience and premorbid functioning on one hand are validated German translations of the original scales.
and self-stigma on the other have not yet been investigated in
bipolar disorder. Psychopathology
In the past years, the role of resilience in serious mental In patients, the presence and severity of depression and mania
illnesses has become a topic of growing interest. In schizophrenia, were measured by the Montgomery-Åsberg Depression Rating
it has been shown to have a positive impact on the long-term Scale (MADRS) (30) and the Young Mania Rating Scale (YMRS)
outcome (16) and high levels of resilience have been shown (31), respectively. The MADRS consists of 10 items (apparent
to reduce the risk of suicide in both schizophrenia (17) and sadness, reported sadness, inner tension, reduced sleep, reduced
depression (18). However, research on the role of resilience in appetite, concentration difficulties, lassitude, inability to feel,
patients suffering from bipolar disorder specifically, is rather pessimistic thoughts, and suicidal thoughts) and each item yields
scarce and its effects on the long-term outcome are yet to a score of 0 to 6. The overall score ranges from 0 to 60 with higher
be investigated. In our recent studies in patients with bipolar scores reflecting more severe depression. The YMRS consists of
disorder, we have shown resilience to be associated with quality 11 items with scores ranging from 0 to 4 or 8 according to the
of life (14, 19, 20), self-esteem, spirituality, and hopelessness (19). item: elevated mood (score 0 = absent to 4 = euphoric), increased
Lee et al. (21) have also shown a positive correlation between motor activity (score 0 = absent to 4 = motor excitement),
resilience and quality of life. A further study has shown that low sexual interest (score 0 = normal to 4 = overt sexual acts), sleep
levels of resilience were associated with high levels of impulsivity (score 0 = no decrease in sleep to 4 = denies need for sleep),
and an increased number of depressive episodes (22). These irritability (score 0 = absent to 8 = hostile, uncooperative),
findings show that resilience can act as a protective factor and speech (score 0 = no increase to 8 = pressured, uninterruptible),
may have a positive impact on the long-term outcome. Resilience thought disorder/language (score 0 = absent to 4 = incoherent),
may also play a positive role in the degree of self-stigma a patient content (score 0 = normal to 8 = delusions, hallucinations),
perceives and it may hence play a positive role in building stigma disruptive-aggressive behavior (score 0 = absent, cooperative to
resistance, as we have recently shown in one of our recent studies 8 = assaultive, destructive), appearance (score 0 = appropriate to
investigating self-stigma in patients with schizophrenia (23). 4 = completely unkempt, decorated, bizarre garb), and insight
In general, the role of premorbid functioning in bipolar (score 0 = present to 4 = denies any behavior changes). The
disorder remains unclear. So far, there are only few studies to overall score ranges from 0 to 60.
support the existence of premorbid disturbance in those affected There is currently no explicit definition for residual symptoms
and findings are inconsistent. Cannon et al. (24), for example, or symptomatic remission in bipolar disorder and past studies
reported on significantly lower overall premorbid functioning have used different cut-offs in this patient group. The
levels in participants with adult-onset BD compared to healthy International Society for Bipolar Disorder (ISBD) Task Force
control subjects, and Gade et al. (25) showed that premorbid (32) for example, suggested a YMRS score of <8 or >5 to
functioning is a notable predictor of overall functioning among define residual manic symptoms and a MADRS score of 8–14
adolescents and adults with BD. Still other investigations, in to define residual depressive symptoms. MADRS-Scores of ≤5
turn, have shown stable premorbid features in patients with BD or ≤7, and YMRS Scores of <8 or <5 have been recommended
(26, 27) and one cross-sectional study even identified higher to define symptomatic remission (32, 33). Based on our previous
premorbid functioning among patients with BD compared to studies [e.g., (34)], in the current study we used a score of
healthy controls (28). ≤8 on both the MADRS and the YMRS to define residual
Due to the lack of studies regarding this topic in bipolar mood symptoms.
disorder we decided to investigate the associations of the above
mentioned factors in stabilized outpatients and hypothesized Social Functioning
that low resilience, poor premorbid functioning as well as more Social functioning was measured by the Personal and Social
severe residual symptoms would be associated with low stigma Performance (PSP) Scale (35). It is a 100 point single item rating
resistance and high self-stigma. scale which is subdivided into 10 equal intervals, and ratings are

Frontiers in Psychiatry | www.frontiersin.org 2 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

based on the assessment of the patients’ functioning measured This instrument is divided into a general section and measures
in four domains: (i) socially useful activities, (ii) personal two discrete areas of premorbid functioning, academic and social
and social relationships, (iii) self-care, and (iv) disturbing and functioning, at each of four developmental stages: childhood
aggressive behavior. (up to age 11), early adolescence (age 12–15), late adolescence
(age 16–18), and adulthood (age 19 and older). Since there are
Self-Stigma/Stigma Resistance concerns regarding the validity of the general section (43), this
Self-stigma/stigma resistance was assessed by the Internalized was section was left out.
Stigma of Mental Illness (ISMI) scale (36), consisting of 29 items Items are scored on a scale from 0 (normal adjustment)
with a Likert-scale from 1 = strongly disagree to 4 = strongly to 6 (severe impairment). The range of scoring for each
agree. The scale itself is composed of five subscales: alienation developmental period is the same, allowing for comparison of
(6 items), stereotype endorsement (7 items), discrimination scores across developmental periods. As a matter of course,
experience (5 items), social withdrawal (6 items), and stigma adulthood was not assessed in patients with illness onset prior
resistance (5 items). The five “stigma resistance” items are to or at 19 years of age.
reverse-coded and serve as a validity check.
Stigma resistance is theoretically (36) and psychometrically Statistical Methods
(37) distinct from self-stigma and the current study therefore All statistical analyses were performed using SPSS, version
measured stigma resistance using the Stigma Resistance subscale 26. Statistical testing was done at a 0.05 level of significance.
and measured self-stigma by summing the averages of the Associations of premorbid functioning, psychopathology, and
remaining four subscales of the ISMI. The extent of self- resilience with self-stigma/stigma resistance were evaluated by
stigma/stigma resistance has previously been defined using a cut- means of Spearman rank correlation coefficients, as the majority
off point of 2.5 on the mean item scores (23, 37, 38). Accordingly, of the variables involved showed considerable departures from a
a value of 2.5 and above can be applied to define moderate to normal distribution.
high self-stigma/stigma resistance and lower than 2.5 for low The combined effect of patient characteristics (age, sex,
self-stigma/stigma resistance (38). education, duration of illness, and a history of psychotic
symptoms), premorbid functioning, psychopathology, and
Resilience resilience on self-stigma/stigma resistance was examined
Resilience was measured using the Resilience Scale (RS-25) by multiple linear regression analysis. We used backward
(39), which was the only resilience scale validated in German stepwise variable elimination for the identification of significant
language at the time of study conduction. The authors of predictors. To reduce the number of variables tested, only those
the RS-25 conceptualized resilience as “a positive personality variables were entered into the model that had yielded a p < 0.1
characteristic that enhances individual adaption” (39). It consists in the correlation analysis. For control purposes, we ran each
of 25 items and is divided into two categories: “acceptance of regression analysis a second time with forward variable selection,
self and life” (8 items) and “personal competence” (17 items). giving rise to the same final model in all cases. As a measure of
The subscale “acceptance of self and life” highlights features such determination of the regression model, R² is reported.
as adaptability, tolerance, flexibility, and balance, whereas the
subscale “personal competence” summarizes features such as self-
reliance, independence, determination, mastery, perseverance, Power Analysis
invincibility, and resourcefulness. Since the 2-factor structure The subsequent power analysis was conducted using G∗ Power,
could not be identified in the German version (40), we considered version 3.1.7. The sample size of 60 bipolar patients is sufficient
only the total score for our study. All items are scored on to detect, under standard conditions regarding type-one error
a 7-score item scale, ranging from 1 = strongly disagree (two-tailed α = 0.05) and power (1-β = 0.8), Pearson correlations
to 7 = strongly agree with possible scores ranging from 25 of r = 0.35 or greater. The same applies for Spearman rank
to 175. Higher scores indicate higher resilience, population- correlations. Moreover, under the same conditions regarding α
representative norm values are available (133.8 ± 22.5) (40). and β, the sample size of 60 allows detection of an effect size of f²
Schumacher and coworkers reported that age and sex differences = 0.136 in a linear regression analysis with up to 10 independent
are small and therefore hardly of practical importance (40). variables, when testing for the effect of one additional predictor.
The developers of the original scale categorized the overall RS- Both (r = 0.35, and f² = 0.136) are medium effects according to
25 score into 3 levels: scores below 125 reflect low resilience, Cohen’s classification (44).
scores between 126 and 145 indicate moderately low to moderate
levels of resilience, and scores of 146 and higher indicate high RESULTS
resilience (41).
Patient Characteristics
Premorbid Functioning Demographic and clinical characteristics of the 60 patients
Premorbid functioning was assessed retrospectively using the we recruited are summarized in Table 1. According to the
Cannon-Spoor Premorbid Adjustment Scale (PAS) (42). The PAS categorization by Wagnild and Young (39), the sample showed
was designed to measure “the degree of success in attainment of a moderately low to moderate RS-25 mean score (129.8 ± 23.1).
certain developmental goals at each phase of a subject’s life” (42). In turn, they had a relatively high stigma resistance mean score

Frontiers in Psychiatry | www.frontiersin.org 3 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

TABLE 1 | Patient characteristics (N = 60 bipolar patients). TABLE 2 | Premorbid functioning as measured by the PAS.

Variable Mean ± SD or N (%) Mean SD

Age 43.2 ± 11.0 Premorbid functioning (PAS scales, range 0–6)a

Sex PAS Childhood academic functioning 0.92 0.86
Male 25 (41.7%) PAS Childhood social functioning 1.32 1.52
Female 35 (58.3%) PAS Early adolescence academic functioningb 1.53 1.22
Education (years) 13.8 ± 3.2 PAS Early adolescence social functioning 1.21 1.19
Marital status PAS Late adolescence academic functioningc 1.68 1.26
Single 20 (33.3%) PAS Late adolescence social functioning 0.99 1.10
Married/stable partnership 28 (46.7%) PAS total score academic functioning 1.37 0.83
Divorced 12 (20.0%) PAS total score social functioning 1.18 1.12
Living situation
PAS, Premorbid Adjustment Scale.
With original family 5 (8.3%) a 0, normal functioning; 6, poorest category.
b Significantly poorer academic functioning compared to childhood (Z = 3.64, p < 0.001).
With own family 33 (55.0%)
c Significantly poorer academic functioning compared to childhood (Z = 3.49, p < 0.001).
Alone 17 (28.3%)
Others 5 (8.3%)
Employment
Full-time employment 11 (18.3%) Correlation Between Psychopathology and
Part-time employment 19 (31.7%) Self-Stigma/Stigma Resistance
Supported employment 1 (1.7%) Residual depressive symptoms correlated positively with self-
Training 2 (3.3%) stigma (r = 0.497, p = <0.001) and negatively with stigma
Retired 14 (23.3%) resistance (r = −0.373, p = 0.003). No significant correlations
Unemployed/Sick-leave 13 (21.7%) could be found between residual manic symptoms and self-
Duration of illness (years) 11.1 ± 10.3 stigma/stigma resistance. A history of psychotic symptoms did
MADRS total score 7.41 ± 8.23 not correlate significantly with self-stigma or stigma resistance.
YMRS total score 1.44 ± 2.84
History of psychotic symptoms 9 (15%) Correlation Between Resilience and
PSP 70 ± 21.5 Self-Stigma/Stigma Resistance
Psychotropic medication Resilience correlated negatively with self-stigma (r = −0.626, p <
Antipsychotic 39 (65.0%) 0.001) and positively with stigma resistance (r = 0.613, p < 0.001)
Mood stabilizer 41 (68.3%) showing that high resilience is associated with low self-stigma and
Antidepressant 25 (42.7%) higher stigma resistance.
Benzodiazepine 9 (15.0%)
Prediction of Self-Stigma/Stigma
SD, Standard deviation; MADRS, Montgomery-Asberg Depression Rating Scale; YMRS,
Young Mania Rating Scale; PSP, Personal and Social Performance Scale. Resistance by Resilience, Premorbid
Functioning, and Sociodemographic and
Clinical Data: Results of Multiple
of 2.87 ± 0.55, whereas the self-stigma mean score (1.86 ± 0.61) Regression Analysis
was relatively low. The combined effect of resilience, premorbid functioning,
sociodemographic data and clinical variables (duration of illness,
Premorbid Functioning MADRS, YMRS, history of psychotic symptoms) on self-
Premorbid academic functioning, as measured by the PAS and stigma/stigma resistance was investigated by multiple regression
shown in Table 2, deteriorated significantly from childhood (0.92 analysis (see Table 3). Only resilience emerged as a significant
± 0.86) to early adolescence (1.53 ± 1.22, p < 0.001) and late predictor for self-stigma and stigma resistance. Low resilience
adolescence (1.68 ± 1.26, p < 0.001). No significant changes in was a predictor for higher self-stigma and high resilience for
premorbid social functioning could be found. higher stigma resistance.

Correlation Between Premorbid DISCUSSION

Functioning and Self-Stigma/Stigma In general, factors protecting from self-stigma and promoting
Resistance stigma resistance in patients suffering from mental illnesses
There were no significant correlations between premorbid may be integrated in preventive and therapeutic interventions.
functioning and stigma for any PAS or ISMI subscales (|r|<0.15 Previous studies have investigated factors related to self-stigma
and p > 0.2 for all subscales). in patients with bipolar disorder (8, 9, 12, 13, 45), however,

Frontiers in Psychiatry | www.frontiersin.org 4 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

TABLE 3 | Results of multiple linear regression analysis.

Dependent variable Model information Independent variablesa Standardized Beta F d.f. (df1,df2) p-value R² adjusted

Self-stigma Final model 46.30 1,57 <0.001 0.439

RS-25 total score −0.669 46.30 1,57 <0.001
Stigma resistance Final model 48.85 1,57 <0.001 0.452
RS-25 total score 0.506 48.85 1,57 <0.001

RS-25, Resilience Scale.

a Only those independent variables are shown which were retained in the final model, i.e., statistically significant (p < 0.05) or nearly significant (p < 0.10) predictors.

The following independent variables were tested: PAS academic and social functioning, age, sex, education, and clinical variables (duration of illness, MADRS, YMRS, history of
psychotic symptoms).

this is the first study to examine the relevance of premorbid promote stigma resistance and could be an important component
functioning and resilience in this regard. As sociodemographic of anti-stigma interventions. This should be investigated in
data and MADRS and YMRS scores show, we recruited a future studies. Previously developed anti-stigma interventions
group of chronically ill patients with only mild symptoms and with focus on self-stigma, analyzed in a review by Yanos et al.
mild difficulties in social functioning. This approach targets a (53), have already used psychoeducation and most of them have
group of patients one is interested in when evaluating long- integrated cognitive techniques with promising results. However,
term management. the authors argued that implementation and outcome are still in
About half of the patients were married or living in a stable their early stages. Accordingly, the long-term role of resilience in
partnership, which is in line with earlier studies from other bipolar disorder on outcome and the effect of resiliency training
countries (46, 47). On the other hand, around 30–50% of patients programs remain unclear and should also be investigated in
considered as clinically remitted have previously been shown future longitudinal studies.
to fail to regain premorbid psychosocial functioning, which With regards to symptoms, similar to past studies, we found a
decreases their capability to take part in normal working life positive association between depressed mood and self-stigma (54,
(48). Accordingly, only around half of participants had a full- 55), whereas no association was found between residual manic
time or part-time job at the time of study inclusion, whereas symptoms and self-stigma (45, 55). However, due to the very
approximately one quarter was unemployed or on sick-leave. low YMRS mean, the latter needs to be interpreted with caution.
This points to the chronicity and severity of BD and corroborates Nevertheless, past studies have shown that although patients are
the findings of past studies, which have even shown much higher considered as remitted or euthymic, they still experience low
unemployment rates (46, 49, 50). Accordingly, bipolar patients grades of mood symptoms of either depression or mania which
are in need for continuous social support, even after remission might have a negative impact on outcome (34).
is achieved. Considering that we still found an association between self-
Compared to previous studies, as shown in a systematic review stigma/stigma resistance and very mild depressive symptoms
by Ellison et al. (51) where patients reported a moderate to high (whereby other factors not considered in the current study
degree of self-stigma, our patients showed relatively low self- may also have played a role here), our findings indicate that
stigma and high stigma resistance mean scores. This may be pharmaco-, psycho-, and sociotherapeutical measures should be
explained by our sample of chronically ill patients which may exhausted to promote stigma resistance.
have developed coping strategies over the years. Considering the The findings of previous studies regarding premorbid
above mentioned fact that around half of the study participants functioning of patients developing BD in the course of life
were either married or in stable relationships, were living with are conflicting and its relevance therefore remains unclear. In
their own families and were employed, one can hypothesize our sample, patients generally had low PAS scores (indicating
that these factors also play a substantial role in building stigma high premorbid functioning), similarly as found in past studies
resistance. However, this issue cannot be addressed by our data. (26, 56). We found a deterioration of premorbid academic
With regards to resilience, a below-average RS-25 mean functioning from childhood to adolescence, whereby premorbid
score compared to a norming sample from Germany (40) was social functioning was stable at all developmental epochs, which
recorded, which corroborates our findings in patients suffering corroborates the findings of Paya et al. (57). By contrast,
from schizophrenia (23) or major depressive disorder (52). We Cannon et al. (24) reported poorer social functioning during
previously found resilience to be associated with bipolar patients’ adolescence, whereas academic functioning remained stable.
self-esteem (19) and QoL (14). Accordingly, our finding of These inconsistent findings may be linked to the heterogeneity
higher resilience being associated with lower self-stigma and of samples and different methods used to measure premorbid
higher stigma resistance was not unexpected. Moreover, multiple functioning such as using the PAS-Scale [e.g., (28, 57)], a
linear regression analysis showed resilience to be a positive modified version of the PAS [e.g., (24, 27)], or using school
predictor for stigma resistance and a negative predictor for reports and parental interviews [e.g., (56)]. When interpreting
self-stigma. This suggests that resilience may potentially play the PAS, the presence of symptoms at the time of the interview
a preventive role in the development of self-stigma and may may also be considered. However, also in this regard there

Frontiers in Psychiatry | www.frontiersin.org 5 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

are no consistent findings: Goldberg and Ernst (58) found on both resilience and self-stigma/stigma resistance, e.g., social
depressed mood to be related to the PAS score in the adolescence support, are of relevance in this context.
period, whereas Uzelac et al. (27) found it to be related to the Altogether, our findings suggest that resilience might play an
childhood period. It has also been discussed that the PAS may important role in preventing self-stigma and building stigma
not capture important features of BD as it was originally designed resistance and hence should be considered as a component
for patients with schizophrenia (28). In the current study, we of self-stigma reduction interventions. Irrespective of these
could not find any significant correlations between premorbid considerations, further efforts are necessary to reduce public
functioning and self-stigma or stigma resistance. The generally stigma toward the mentally ill.
low PAS scores in our sample may explain this finding and the
above discussed points must also be taken into consideration. DATA AVAILABILITY STATEMENT
Therefore, it remains unclear whether premorbid functioning has
an impact on self-stigma/stigma resistance in BD. This calls for The original contributions presented in the study are included
further studies. in the article/supplementary material, further inquiries can be
Despite the implications of our findings, the cross-sectional directed to the corresponding author/s.
design and the relatively low sample size limit the generalizability
of our results. Patients having acute or more severe symptoms ETHICS STATEMENT
or those at an earlier stage of illness may have different levels of
self-stigma/stigma resistance and resilience and these may change The studies involving human participants were reviewed and
over the course of time. Clearly, to investigate both the process approved by Ethics Committee of the Medical University of
character of these factors and a potential causal interrelationship, Innsbruck, Austria. The patients/participants provided their
longitudinal studies are necessary. With regards to premorbid written informed consent to participate in this study.
functioning, recall bias may have played a role as we did not
gather information from family members to support patients’ AUTHOR CONTRIBUTIONS
claim. Furthermore, the RS-25 scale only captures personal traits,
while resilience is seen as a dynamic process. Again, this may limit FP and AH: drafting the article. GK, AH, and FP: data analysis.
the generalizability of our findings. FP, MB, SP, and BF-A: data collection. All authors study
Lastly, it will be critical to investigate whether other issues not design, approval of the final version, and critical revision of
considered in the current study and likely to have an influence the article.

REFERENCES 11. Picco L, Pang S, Lau YW, Jeyagurunathan A, Satghare P, Abdin E, et al.
Internalized stigma among psychiatric outpatients: associations with quality
1. Corrigan PW, Watson AC. Understanding the impact of stigma on people of life, functioning, hope and self-esteem. Psychiatry Res. (2016) 246:500–6.
with mental illness. World Psychiatry. (2002) 1:16–20. doi: 10.1016/j.psychres.2016.10.041
2. Babic D, Babic R, Vasilj I, Avdibegovic E. Stigmatization of mentally ill patients 12. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma
through media. Psychiatr Danub. (2017) 29(Suppl. 5):885–9. for people living with mental illness: a systematic review and meta-
3. Corrigan PW, Rao D. On the self-stigma of mental illness: stages, analysis. Soc Sci Med. (2010) 71:2150–61. doi: 10.1016/j.socscimed.2010.
disclosure, and strategies for change. Can J Psychiatry. (2012) 57:464–9. 09.030
doi: 10.1177/070674371205700804 13. Michalak EE, Yatham LN, Kolesar S, Lam RW. Bipolar disorder and quality
4. Latalova K, Ociskova M, Prasko J, Kamaradova D, Jelenova D, Sedlackova Z. of life: a patient-centered perspective. Qual Life Res. (2006) 15:25–37.
Self-stigmatization in patients with bipolar disorder. Neuro Endocrinol Lett. doi: 10.1007/s11136-005-0376-7
(2013) 34:265–72. 14. Post F, Pardeller S, Frajo-Apor B, Kemmler G, Sondermann C, Hausmann
5. Rusch N, Lieb K, Bohus M, Corrigan PW. Self-stigma, empowerment, and A, et al. Quality of life in stabilized outpatients with bipolar I disorder:
perceived legitimacy of discrimination among women with mental illness. associations with resilience, internalized stigma, and residual symptoms. J
Psychiatr Serv. (2006) 57:399–402. doi: 10.1176/appi.ps.57.3.399 Affect Disord. (2018) 238:399–404. doi: 10.1016/j.jad.2018.05.055
6. Oliveira SE, Esteves F, Carvalho H. Clinical profiles of stigma experiences, 15. Karidi MV, Vassilopoulou D, Savvidou E, Vitoratou S, Maillis A, Rabavilas
self-esteem and social relationships among people with schizophrenia, A, et al. Bipolar disorder and self-stigma: a comparison with schizophrenia.
depressive, and bipolar disorders. Psychiatry Res. (2015) 229:167–73. J Affect Disord. (2015) 184:209–15. doi: 10.1016/j.jad.2015.05.038
doi: 10.1016/j.psychres.2015.07.047 16. Torgalsboen AK. Sustaining full recovery in schizophrenia after 15 years:
7. Cuhadar D, Cam MO. Effectiveness of psychoeducation in reducing does resilience matter? Clin Schizophr Relat Psychoses. (2012) 5:193–200.
internalized stigmatization in patients with bipolar disorder. Arch Psychiatr doi: 10.3371/CSRP.5.4.3
Nurs. (2014) 28:62–6. doi: 10.1016/j.apnu.2013.10.008 17. Harris K, Haddock G, Peters S, Gooding P. Psychological resilience to
8. Pal A, Sharan P, Chadda RK. Internalized stigma and its impact in suicidal thoughts and behaviours in people with schizophrenia diagnoses
Indian outpatients with bipolar disorder. Psychiatry Res. (2017) 258:158–65. : a systematic literature review. Psychol Psychother. (2020) 93:777–809.
doi: 10.1016/j.psychres.2017.09.087 doi: 10.1111/papt.12255
9. Aydemir O, Akkaya C. Association of social anxiety with stigmatisation and 18. Nrugham L, Holen A, Sund AM. Associations between attempted
low self-esteem in remitted bipolar patients. Acta Neuropsychiatr. (2011) suicide, violent life events, depressive symptoms, and resilience in
23:224–8. doi: 10.1111/j.1601-5215.2011.00565.x adolescents and young adults. J Nerv Ment Dis. (2010) 198:131–6.
10. Hayward P, Wong G, Bright JA, Lam D. Stigma and self-esteem in doi: 10.1097/NMD.0b013e3181cc43a2
manic depression: an exploratory study. J Affect Disord. (2002) 69:61–7. 19. Mizuno Y, Hofer A, Suzuki T, Frajo-Apor B, Wartelsteiner F, Kemmler G, et al.
doi: 10.1016/S0165-0327(00)00380-3 Clinical and biological correlates of resilience in patients with schizophrenia

Frontiers in Psychiatry | www.frontiersin.org 6 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

and bipolar disorder: a cross-sectional study. Schizophr Res. (2016) 175:148– 38. Lau YW, Picco L, Pang S, Jeyagurunathan A, Satghare P, Chong SA, et al.
53. doi: 10.1016/j.schres.2016.04.047 Stigma resistance and its association with internalised stigma and psychosocial
20. Hofer A, Mizuno Y, Wartelsteiner F, Wolfgang Fleischhacker W, Frajo-Apor outcomes among psychiatric outpatients. Psychiatry Res. (2017) 257:72–8.
B, Kemmler G, et al. Quality of life in schizophrenia and bipolar disorder: doi: 10.1016/j.psychres.2017.07.027
the impact of symptomatic remission and resilience. Eur Psychiatry. (2017) 39. Wagnild GM, Young HM. Development and psychometric evaluation of the
46:42–7. doi: 10.1016/j.eurpsy.2017.08.005 Resilience Scale. J Nurs Meas. (1993) 1:165–78.
21. Lee D, Cha B, Park CS, Kim BJ, Lee CS, Lee SJ, et al. Effects of resilience 40. Schumacher J, Leppert K, Gunzelmann T, Strauß B, Brähler E.
on quality of life in patients with bipolar disorder. J Affect Disord. (2017) Die resilienzskala-ein fragebogen zur erfassung der psychischen
207:434–41. doi: 10.1016/j.jad.2016.08.075 widerstandsfähigkeit als personenmerkmal. ZKPPP. (2005) 53:16–39.
22. Choi JW, Cha B, Jang J, Park CS, Kim BJ, Lee CS, et al. Resilience and 41. Wagnild GM. The Resilience Scale User’s Guide for the U.S. English Version of
impulsivity in euthymic patients with bipolar disorder. J Affect Disord. (2015) the Resilience Scale and the 14-item Resilience Scale (RS-14). The Resilience
170:172–7. doi: 10.1016/j.jad.2014.08.056 Center, Worden, MT (2009).
23. Hofer A, Post F, Pardeller S, Frajo-Apor B, Hoertnagl CM, Kemmler G, 42. Cannon-Spoor HE, Potkin SG, Wyatt RJ. Measurement of premorbid
et al. Self-stigma versus stigma resistance in schizophrenia: associations with adjustment in chronic schizophrenia. Schizophr Bull. (1982) 8:470–84.
resilience, premorbid adjustment, and clinical symptoms. Psychiatry Res. doi: 10.1093/schbul/8.3.470
(2019) 271:396–401. doi: 10.1016/j.psychres.2018.12.029 43. van Mastrigt S, Addington J. Assessment of premorbid function in first-
24. Cannon M, Jones P, Gilvarry C, Rifkin L, McKenzie K, Foerster episode schizophrenia: modifications to the Premorbid Adjustment Scale. J
A, et al. Premorbid social functioning in schizophrenia and bipolar Psychiatry Neurosci. (2002) 27:92–101.
disorder: similarities and differences. Am J Psychiatry. (1997) 154:1544–50. 44. Cohen J. A power primer. Psychol Bull. (1992) 112:155–9.
doi: 10.1016/0924-9338(96)88868-7 doi: 10.1037/0033-2909.112.1.155
25. Gade K, Malzahn D, Anderson-Schmidt H, Strohmaier J, Meier S, Frank 45. Cerit C, Filizer A, Tural U, Tufan AE. Stigma: a core factor on predicting
J, et al. Functional outcome in major psychiatric disorders and associated functionality in bipolar disorder. Compr Psychiatry. (2012) 53:484–9.
clinical and psychosocial variables: a potential cross-diagnostic phenotype doi: 10.1016/j.comppsych.2011.08.010
for further genetic investigations? World J Biol Psychiatry. (2015) 16:237–48. 46. Kupfer DJ, Frank E, Grochocinski VJ, Cluss PA, Houck PR, Stapf DA.
doi: 10.3109/15622975.2014.995221 Demographic and clinical characteristics of individuals in a bipolar disorder
26. Schoeyen HK, Melle I, Sundet K, Aminoff SR, Hellvin T, Auestad BH, case registry. J Clin Psychiatry. (2002) 63:120–5. doi: 10.4088/JCP.v63n0206
et al. Occupational outcome in bipolar disorder is not predicted by 47. Schaffer A, Cairney J, Cheung A, Veldhuizen S, Levitt A. Community
premorbid functioning and intelligence. Bipolar Disord. (2013) 15:294–305. survey of bipolar disorder in Canada: lifetime prevalence and illness
doi: 10.1111/bdi.12056 characteristics. Can J Psychiatry. (2006) 51:9–16. doi: 10.1177/0706743706051
27. Uzelac S, Jaeger J, Berns S, Gonzales C. Premorbid adjustment in bipolar 00104
disorder: comparison with schizophrenia. J Nerv Ment Dis. (2006) 194:654–8. 48. Tohen M, Zarate CA Jr, Hennen J, Khalsa HM, Strakowski SM,
doi: 10.1097/01.nmd.0000235767.00901.e2 et al. The McLean-Harvard First-Episode Mania Study: prediction of
28. Rietschel M, Georgi A, Schmael C, Schirmbeck F, Strohmaier J, Boesshenz KV, recovery and first recurrence. Am J Psychiatry. (2003) 160:2099–107.
et al. Premorbid adjustment: a phenotype highlighting a distinction rather doi: 10.1176/appi.ajp.160.12.2099
than an overlap between schizophrenia and bipolar disorder. Schizophr Res. 49. Morselli PL, Elgie R, Cesana BM. GAMIAN-Europe/BEAM survey II: cross-
(2009) 110:33–9. doi: 10.1016/j.schres.2009.03.007 national analysis of unemployment, family history, treatment satisfaction and
29. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, impact of the bipolar disorder on life style. Bipolar Disord. (2004) 6:487–97.
et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the doi: 10.1111/j.1399-5618.2004.00160.x
development and validation of a structured diagnostic psychiatric interview 50. Carlborg A, Ferntoft L, Thuresson M, Bodegard J. Population study of
for DSM-IV and ICD-10. J Clin Psychiatry. (1998) 59(Suppl. 20):22–33. disease burden, management, and treatment of bipolar disorder in Sweden:
30. Montgomery SA, Asberg M. A new depression scale designed to be sensitive a retrospective observational registry study. Bipolar Disord. (2015) 17:76–85.
to change. Br J Psychiatry. (1979) 134:382–9. doi: 10.1192/bjp.134.4.382 doi: 10.1111/bdi.12234
31. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: 51. Ellison N, Mason O, Scior K. Bipolar disorder and stigma: a
reliability, validity and sensitivity. Br J Psychiatry. (1978) 133:429–35. systematic review of the literature. J Affect Disord. (2013) 151:805–20.
doi: 10.1192/bjp.133.5.429 doi: 10.1016/j.jad.2013.08.014
32. Tohen M, Frank E, Bowden CL, Colom F, Ghaemi SN, Yatham LN, et al. The 52. Pardeller S, Kemmler G, Hoertnagl CM, Hofer A. Associations between
International Society for Bipolar Disorders (ISBD) Task Force report on the resilience and quality of life in patients experiencing a depressive
nomenclature of course and outcome in bipolar disorders. Bipolar Disord. episode. Psychiatry Res. (2020) 292:113353. doi: 10.1016/j.psychres.2020.
(2009) 11:453–73. doi: 10.1111/j.1399-5618.2009.00726.x 113353
33. Zimmerman M, Chelminski I, Posternak M. A review of studies of the 53. Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting
Montgomery-Asberg Depression Rating Scale in controls: implications for mental health self-stigma: a review and comparison. Psychiatr Rehabil J. (2015)
the definition of remission in treatment studies of depression. Int Clin 38:171–8. doi: 10.1037/prj0000100
Psychopharmacol. (2004) 19:1–7. doi: 10.1097/00004850-200401000-00001 54. Boyd JE, Adler EP, Otilingam PG, Peters T. Internalized Stigma of Mental
34. Hoertnagl CM, Muehlbacher M, Biedermann F, Yalcin N, Baumgartner S, Illness (ISMI) scale: a multinational review. Compr Psychiatry. (2014) 55:221–
Schwitzer G, et al. Facial emotion recognition and its relationship to subjective 31. doi: 10.1016/j.comppsych.2013.06.005
and functional outcomes in remitted patients with bipolar I disorder. Bipolar 55. Howland M, Levin J, Blixen C, Tatsuoka C, Sajatovic M. Mixed-
Disord. (2011) 13:537–44. doi: 10.1111/j.1399-5618.2011.00947.x methods analysis of internalized stigma correlates in poorly adherent
35. Morosini PL, Magliano L, Brambilla L, Ugolini S, Pioli R. Development, individuals with bipolar disorder. Compr Psychiatry. (2016) 70:174–80.
reliability and acceptability of a new version of the DSM-IV Social doi: 10.1016/j.comppsych.2016.07.012
and Occupational Functioning Assessment Scale (SOFAS) to assess 56. Kutcher S, Robertson HA, Bird D. Premorbid functioning in adolescent
routine social functioning. Acta Psychiatr Scand. (2000) 101:323–9. onset bipolar I disorder: a preliminary report from an ongoing
doi: 10.1111/j.1600-0447.2000.tb10933.x study. J Affect Disord. (1998) 51:137–44. doi: 10.1016/S0165-0327(98)
36. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: 00212-2
psychometric properties of a new measure. Psychiatry Res. (2003) 121:31–49. 57. Paya B, Rodriguez-Sanchez JM, Otero S, Munoz P, Castro-Fornieles
doi: 10.1016/j.psychres.2003.08.008 J, Parellada M, et al. Premorbid impairments in early-onset
37. Sibitz I, Unger A, Woppmann A, Zidek T, Amering M. Stigma resistance psychosis: differences between patients with schizophrenia and bipolar
in patients with schizophrenia. Schizophr Bull. (2011) 37:316–23. disorder. Schizophr Res. (2013) 146:103–10. doi: 10.1016/j.schres.2013.
doi: 10.1093/schbul/sbp048 01.029

Frontiers in Psychiatry | www.frontiersin.org 7 May 2021 | Volume 12 | Article 678807

Post et al. Self-Stigma in Bipolar I Disorder

58. Goldberg JF, Ernst CL. Clinical correlates of childhood and adolescent Copyright © 2021 Post, Buchta, Kemmler, Pardeller, Frajo-Apor and Hofer. This is an
adjustment in adult patients with bipolar disorder. J Nerv Ment Dis. (2004) open-access article distributed under the terms of the Creative Commons Attribution
192:187–92. doi: 10.1097/01.nmd.0000116461.53411.ab License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
Conflict of Interest: The authors declare that the research was conducted in the original publication in this journal is cited, in accordance with accepted academic
absence of any commercial or financial relationships that could be construed as a practice. No use, distribution or reproduction is permitted which does not comply
potential conflict of interest. with these terms.

Frontiers in Psychiatry | www.frontiersin.org 8 May 2021 | Volume 12 | Article 678807