ÖZGÜN ARAŞTIRMA ORIGINAL RESEARCH

Med J SDU / SDÜ Tıp Fak Derg u 2022:29(3):356-366 doi: 10.17343/sdutfd.1095287

INVESTIGATION OF THE RELATIONSHIP

BETWEEN ILLNESS PERCEPTION AND CLINICAL
CHARACTERISTICS, COPING, SELF-EFFICACY IN
CASES DIAGNOSED WITH BIPOLAR DISORDER
BİPOLAR BOZUKLUK TANILI OLGULARDA HASTALIK ALGISININ KLİNİK
ÖZELLİKLER, BAŞ ETME VE ÖZYETERLİLİK İLE İLİŞKİSİNİN İNCELENMESİ

Gülin ÖZDAMAR ÜNAL1, Gizem Çağla AKTAŞ1, Gökçe İŞCAN2, İnci Meltem ATAY1
1 Süleyman Demirel Üniversitesi, Tıp Fakültesi, Psikiyatri Ana Bilim Dalı, Isparta, TÜRKİYE
2 Süleyman Demirel Üniversitesi, Tıp Fakültesi, Aile Hekimliği Ana Bilim Dalı, Isparta, TÜRKİYE

Cite this article as: Özdamar Ünal G, Aktaş GÇ, İşcan G, Atay İM. Investigation of the Relationship between Illness Perception and
Clinical Characteristics, Coping, Self-Efficacy in Cases Diagnosed with Bipolar Disorder. Med J SDU 2022; 29(3): 356-366.

Öz ti. Kısa Hastalık Algısı Ölçeği ile Genel Öz-yeterlilik

Ölçeği arasında negatif korelasyon vardı (r=-0.376;
Amaç p<0.001). Stresle Başa Çıkma Tarzları Ölçeğinin plan-
Birçok fiziksel hastalığın ve bazı ruhsal bozuklukların lı problem çözme (r=-0.286; p<0.001); olumlu yeniden
klinik seyrinde hastalık algısının rolü iyi tanımlanmış değerlendirme (r=-0.337; p<0.001); kaçma-kaçınma
olmasına rağmen, şu ana kadar bipolar bozukluk ile (r=0.216; p=0.020) alt boyutları arasında bir ilişki var-
ilişkili hastalık algısı hakkında çok az şey bilinmekte- dı. Kısa Hastalık Algı Anketini tahmin etmek için lineer
dir. Bu çalışmada bipolar bozukluk tanısı olan olgu- regresyon analizi yapıldı, anlamlı bir regresyon mode-
larda hastalık algısı, baş etme tarzları ve öz-yeterlilik li olduğu bulundu [F (5,151) =13.769; p<0.001] ve ba-
arasındaki ilişkiyi inceleyerek bu değişkenlerin klinik ğımlı değişkenlerdeki varyansın %29’unun bağımsız
seyir üzerindeki etkilerini araştırmak amaçlanmıştır. değişkenler tarafından açıklandığı gözlendi.

Gereç ve Yöntem Sonuç

Bu kesitsel çalışmada, Mart 2021- Eylül 2021 tarihleri Bu çalışma, BB tanılı hastalarda hastalık algılarının
arasında bipolar bozukluğu olan 157 katılımcıdan olu- özyeterlilik, başa çıkma tarzı ve klinik özellikler ile
şan bir kohortu değerlendirdik. Veri toplama araçları bağlantılı olduğunu göstermektedir. Olumlu hastalık
olarak Sosyodemografik Bilgi Formu, Kısa Hastalık algılarını artıran ve olumsuz hastalık algılarını azaltan
Algısı Ölçeği, Özyeterlilik Ölçeği ve Stresle Başa Çık- müdahaleler, hastalık sonuçları üzerinde iyileştirici bir
ma Tarzları Ölçeği kullanılmıştır. etkiye sahip olabilir.

Bulgular Anahtar Kelimeler: Başa çıkma, Bipolar bozukluk,

Olguların yaş ortalaması 42.08±12.92 yıl idi. Bu ka- Duygu odaklı başa çıkma; Hastalık algısı, Öz-yeterli-
tılımcıların 84'ü (%53.5) kadın, 73'ü (%46.5) erkek- lik, Problem odaklı başa çıkma

Sorumlu yazar ve iletişim adresi /Corresponding author and contact address: G.Ö.Ü. / gulin_ozdamar@hotmail.com
Müracaat tarihi/Application Date: 29.03.2022 • Kabul tarihi/Accepted Date: 23.04.2022
ORCID IDs of the authors: G.Ö.Ü: 0000-0002-6750-468X; G.Ç.A: 0000-0002-4640-6044;
G.İ: 0000-0003-0848-5201; İ.M.A: 0000-0002-5124-5556

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Abstract Illness Perception Questionnaire had a negative

correlation between General Self-Efficacy Scale
Objective (p<0.001; r=-0.376); and had a negative correlation
Even though the importance of illness perception in between The Ways of Coping Questionnaire’s
the clinical course of many physical diseases and subscales planful problem-solving (r=-0.286;
certain mental disorders has been well documented, p<0.001); positive reappraisal (r=-0.337; p<0.001);
little is known about illness perception in bipolar escape-avoidance (r=0.216; p=0.020). Linear
disorder. This study reveals the relationship between regression analysis was performed to predict the Brief
illness perception, coping styles, and self-efficacy in Illness Perception Questionnaire, it was found that
patients with bipolar disorder. Secondly, to investigate a significant regression model [F (5,151) =13.769;
the effects of these variables on the clinical course. p<0.001], and 29%, of the variance in the dependent
variable, were explained by the independent variables.
Material and Method
In this cross-sectional study, we evaluated a cohort Conclusion
of 157 subjects with bipolar disorder recruited from This study demonstrates that illness perceptions are
March 2021 to September 2021. Illness perception linked with self-efficacy, coping style, and clinical
was measured using the Turkish version of the Brief characteristics in patients with BD. Interventions that
Illness Perception Questionnaire. Self-efficacy was increase favorable illness perceptions and decrease
assessed using the Self-Efficacy Scale. Coping was negative illness perceptions may improve disease
evaluated using the Ways of Coping Questionnaire. outcomes.

Results Keywords: Bipolar disorder, illness perception,

Of 157 patients who had bipolar disorder ages’ mean coping, self-efficacy, problem-focused coping,
was 42.08±12.92. 84 (53.5%) of these participants emotion-focused coping
were female, 73 (46.5%) of them were male. Brief

Introduction emotional management of the illness and control

of its physical and psychosocial consequences (7-
Bipolar Disorder (BD) is a mood disorder in which 9). A positive perception of illness is that the illness
dramatic changes in mood, energy, activity levels, and can be controlled with individual effort or treatments.
behavioral and functional impairments are observed One factor that significantly affects patients' self-
(1, 2). Although there are different results regarding management, symptom control, and disease
the age of onset of the disease, it is thought that the outcomes is their perception of their disease based
first symptoms appear at the beginning of the twenties on coping mechanisms. Illness perception is patients'
(3, 4). It is defined as one of the chronic, serious mental beliefs about their illness, which vary according to
disorders that progress with periods of exacerbation their subjective experiences (10). Leventhal et al.
and remission. It has been reported that the lifetime developed the 'Self-Regulation Model' to describe
prevalence is 0.6% for Bipolar 1 Disorder, 0.4% for patients' coping methods with their diseases (11).
Bipolar 2 Disorder, 1.4% for sub-threshold BD, and According to this model, there are representations
2.4% for Bipolar Spectrum (5). Due to the disease's evaluated in five dimensions regarding the identity,
early onset, chronic nature, and high prevalence, it is cause, duration, treatment-controllability, and disease
one of the primary causes of intellectual disability. It outcomes in patients (12).
contributes significantly to the global patient burden
(6). In contrast, the negative perception of illness is the
belief that the illness cannot be controlled and will
In the treatment management of BD, it is essential to lead to wrong results (10). It has been reported that
focus on the subjective experiences of the patients these differences in perspective affect the patients'
in order to reduce the symptoms of the disease and treatment compliance, clinical course, and coping
prevent relapses. In recent years, an increasing mechanisms. Negative labeling causes significant
emphasis has been placed on developing self- difficulties in the fight against the disease (11). It is
management strategies for patients with chronic emphasized that these effects are linked to complex
illnesses such as BD, which include behavioral and processes, and further research is needed.

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Illness perception is mainly used to evaluate emotional and clinical variables among patients with BD,
and behavioral responses to somatic diseases and to identify the associated risk factors. Patients'
(12-16). There are fewer studies investigating the negative perceptions of illness may lead to treatment
perception of illness in mental illnesses. Most of the nonadherence, decrease in quality of life, decrease in
existing studies have focused on the relationship self-esteem, and poor clinical outcomes. Therefore,
between the perception of illness and treatment it is very important to know how patients with bipolar
compliance in BD. Studies have emphasized that disorder perceive their illness. Identifying risk factors
determining the disease perceptions of patients with for negative perceptions of illness will contribute to the
BD and positively changing the perceptions can development of appropriate interventions.
mediate the improvement of clinical outcomes by
increasing the coping with the stress of the disease, Material and Method
compliance with drug treatments, and increasing the
continuity of treatment (17-19). Study Design
This cross-sectional study was conducted between
Illness perception may be related to patients' coping March 2021 and September 2021. Patients with
mechanisms with life events and may affect the BD, who were followed up by the Süleyman Demirel
clinical course of patients. Coping mechanisms University Faculty of Medicine, Psychiatry outpatient
are cognitive and behavioral efforts to tolerate and clinic for at least one year, were included in the study.
minimize stressful situations (20). Lazarus and The participants were informed verbally and in writing
Folkman defined two types of coping mechanisms: about the procedure and purpose of the research.
problem-focused and emotion-focused. Problem- Those who gave consent to participate in the study
focused coping includes generating options for the were included. Data about the diagnosis and clinical
problem, evaluating the positive and negative aspects course of the patients were obtained from the
of different options, and determining steps to solve the patient follow-up files. A psychiatric examination and
problem. On the other hand, emotion-focused coping evaluation were performed. Disease diagnoses were
is generally a strategy for managing problem-related confirmed according to DSM-5 diagnostic criteria. The
distress (21). study was approved by the Clinical Research Ethics
Committee of Süleyman Demirel University Faculty
Self-efficacy is the belief that is effective in determining of Medicine (Date: 03.02.2021; No:55). This study
personal goals and evaluating their abilities, which was conducted in a framework that conforms to the
function as a determinant in people's motivation, Helsinki Declaration.
emotions, and actions (22). People with a solid sense
of self-efficacy are aware of their skills. It is observed Participants
that they persist in their actions without giving up when Inclusion criteria for the study were: Being older
they encounter difficulties and experience failure (23). than 18 years, being followed up in the psychiatry
Previous studies have shown that self-efficacy in outpatient clinic for at least one year with the diagnosis
BD can significantly affect the clinical course of the of BD, being in remission (Hamilton Depression
disease, functionality, quality of life, coping skills, Rating Scale (HAM-D) score below 7, Young Mania
and treatment management of the disease (24, 25). Rating Scale (YMDS) score below 5) and being
Identifying the factors associated with self-efficacy in literate. Exclusion criteria included being in a manic,
patients with BD may provide critical information for depressive, or mixed episode, receiving a score of
developing appropriate interventions to manage the greater than five on the YMRS or more significant
disease. than seven on the HAM-D, having any mental illness
other than BD, and failing to respond to more than 5%
Studies have been conducted on the perception of the questionnaire's questions. Four patients were
of illness covering different physical and mental excluded from the study because they did not answer
illnesses. However, as far as we know, there has been more than 5% of the research questions. Two of the
no study examining the relationship between illness patients were excluded from the study because they
perception, self-esteem, and coping mechanisms scored above five on the YMRS, three with a score
in patients with BD. We hypothesized that low self- above seven on the HAM-D, and one with a comorbid
esteem, unhealthy coping mechanisms and poor obsessive-compulsive disorder. Thus, the study was
outcomes of the illness may contribute to the negative carried out on 157 patients.
perception of their illness in patients with BD. This
study aims to reveal the perception of illness and its Main Outcome Measure
relationship with self-esteem, coping mechanisms The sociodemographic form, Young Mania Rating

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Scale, Hamilton Depression Rating Scale, Brief coping subscales, whereas emotional-focused coping
İllness Perception Questionnaire, The Ways of Coping consists of distancing, self-controlling, seeking social
Questionnaire, And Self-Efficacy Scale were used to support, accepting responsibility, escape-avoidance,
collect data. and positive reappraisal subscales. High scores from
the subscales indicate which coping style is used
The Sociodemographic Form more frequently in stressful situations.
The researcher completed the sociodemographic
form, including age, gender, education level, marital The General Self-Efficacy Scale (GSES)
status, monthly income, place of residence, duration After Sherer et al. developed the first 23-item form, the
of disease, hospitalization, and suicide history. scale was revised by Magaletta and Oliver, and a 17-
item form was started to be used (34, 35). The scale,
for which Yıldırım and İlhan conducted turkish validity
Young Mania Rating Scale (YMRS) and reliability studies, is used to evaluate self-efficacy
The 11-item-YMRS, created by Young et al., was (36). The scores obtained from the five-point Likert-
used to assess manic symptoms (26). Karadağ et al. type scale vary between 17-85. An increase in the
conducted a Turkish validity and reliability assessment scores obtained from the scale indicates increased
of the measure (27). The internal consistency coefficient self-efficacy beliefs.
of the Turkish version (Cronbach's alpha) was 0.79.
Statistical Analysis
Hamilton Depression Rating Scale (HAM-D) The SPSS Program for Windows, version 26.0, was
HAM-D developed by Hamilton was used to evaluate used for statistical analysis (SPSS Inc, Chicago, IL).
depressive symptoms (28). The Turkish validity and The mean, standard deviation (SD), median, and
reliability study of the scale was performed by Akdemir percent were used to express statistical data (percent).
et al. (29). The patient characteristics (e.g., age, number of
children, total number of episodes, mania, depression)
Brief Illness Perception Questionnaire (B-IPQ) and overall questionnaire scores were determined
The scale developed by Broadbent et al. consists of 8 using these indices (mean±SD). It will be compared
sub-dimensions: Consequences, Timeline, Personal with sociodemographic Chi-square and Student's
control, Treatment control, Identity, Concern, t-test. The outcome measurements were compared
Comprehensibility, Emotional response (30). Items using Spearman (GSES/WCQ/B-IPQ) Correlation. A
1, 2, 3, 4, 5 assess the cognitive representations correlation of 0.10 to 0.29 was regarded minor, 0.30
of the disease; item 6,8 assess the emotional to 0.49 was considered moderate, and 0.50 to 1.0
representations of the illness; item 7 assesses the was considered good for interpreting the results. The
intelligibility of the illness. High scores from the sub- better the fit and hence the correlation, the closer the
dimensions of the scale indicate a negative perception correlation coefficients. Linear regression analysis
of illness. The Turkish validity and reliability study of was performed to predict the Brief Illness Perception
the scale was performed by Karataş et al. (31). In Questionnaire. The median was used for data that did
the analyses, we used the total score (0 to 80), with not have a normal distribution (minimum-maximum).
a greater value suggesting more negative illness p<0.05 was used as the level of significance. With an
perceptions (together with decreased adaptive coping alpha = 0.05 and power = 0.95, the projected sample
and/or reduced illness awareness). size needed with this effect size (G Power 3.1 or other
software) is approximately N = 134 for this comparison
The Ways of Coping Questionnaire and 157 participants were included to the study.
(Revised) (WCQ)
The scale developed by Folkman and Lazarus to Results
evaluate coping mechanisms that emerge when
faced with a stressor is a four-point Likert-type scale The mean age of 157 BP patients was 42.08±12.92.
consisting of 66 items and eight subscales (32). The Also 53.5% (n=84) of these participants were
Turkish validity and reliability study of the scale was female. 63.1% of participants (n=99) graduated
performed by Durak et al. (33). These subgroups from high school and higher graduation. 52.9%
are confrontive coping, distancing, self-controlling, (n=83) of participants were married. 52.9% (n=83)
seeking social support, accepting responsibility, of participants had bipolar disease for more than 10
escape-avoidance, planful problem-solving, and years. The results of the analyzes, percentages, and
positive reappraisal. Problem-focused coping is numbers of sociodemographic data according to the
one of the planful problem-solving and confrontive B-IPQ are also shown in Table 1.

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Table 1 Sociodemographic characteristics of all patients and analysis results with B-IPQ scores.

mean SD p
Age 42.08 12.92 0.545***
Gender n (%) mean±SD
Women 84 (53.5) 37.64±16.02
0.117*
Men 73 (46.5) 41.77±16.69
Education
<High school 58 (36.9) 39.09±16.44
0.568*
≥High school 99 (63.1) 40.30±16.54
Marital Status
Single 74 (33.1) 38.67±14.38
Married 83 (52,9) 42.88±16.58 0.046**
Widow 22 (14) 34.95±16.37
Working Status
Working 98 (62,4) 37.40±18,92
0.265*
Not working 59 (37,6) 41,33±14.69
Having child/children
Yes 88 (56,1) 41.58±16.80
0.146*
No 69 (43.9) 37.65±15.87
Living together with
Alone 17 (10.8) 38.81±18.41
Parent 53 (33.8) 35.13±14.08
Spouse 13 (8.3) 57.85±8.99 0.001**
Spouse and Children 69 (43.9) 40.65±16.50
Extended family 5 (3.2) 33.20±19.99
Monthly income
≤Minimum wage 70 (44.6) 38.34±12.91
0.103*
>Minimum wage 87 (55.4) 41.07±18.83
Place of residence
Rural 67 (42.7) 41.27±16.08
0.374*
Urban 90 (57.3) 38.80±16.75
Disease duration (years)
≤4 38 (24.2) 39.39±19.71
5-10 36 (22.9) 35.83±18.90 0.373**
≥ 10 83 (52.9) 41.80±13.29
Hospitalization (lifetime)
No 37 (23.6) 41.35±17.99
0.681*
Yes 120 (76.4) 39.39±16.01
Suicide History(lifetime)
No 107 (68.2) 39.51±16.28
0.520*
Yes 50 (31.8) 40.58±16.99
Smoking
Yes 62 (39.5) 38.98±18.05
0.953*
No 95 (60.5) 40.42±15.41
Using Alcohol
Yes 17 (10.8) 46.76±17.16
0.021*
No 140 (89.2) 39.01±16.24

*Mann-Whitney U **Kruskal Wallis Analyses

*** Spearman Correlation (Correlation between B-IPQ). The bold type denotes statistical significance.

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Table 2 Median number of episodes, Scale and subscale scores of all participants

Questionnaires’ Scores [Median (minimum-maximum)]

YMRS 2 (1-5)
HAM-D 2 (1-5)
WCQ 63 (15-124)
Planful Problem Solving 7 (1-17)
Positive Reappraisal 9 (1-21)
Self-Controlling 9 (2-19)
Escape-Avoidance 10 (2-23)
Distancing 8 (0-18)
Seeking social support 8 (0-18)
Confrontive coping 7 (1-15)
Accepting responsibility 6 (0-12)
GSES 57 (32-79)
B-IPQ 41 (0-80)
Consequences 6 (0-10)
Timeline 8 (0-10)
Personal control 4 (0-10)
Treatment control 2 (0-10)
Identity 6 (0-10)
Concern 6 (0-10)
Comprehensibility 2 (0-10)
Emotional response 7 (0-10)
The number of total episodes 5 (0-25)
The number of depressive episodes 2 (0-15)
The number of manic episodes 2 (0-13)
The number of hypomanic episodes 0 (0-5)
The number of mixed episodes 0 (0-2)

YMRS: Young Mania Rating Scale, HAM-D: Hamilton Depression Rating Scale, B-IPQ: Brief Illness Perception Questionnaire,
WCQ: The Ways of Coping Questionnaire, GSES: The General Self-Efficacy Scale

As a result, there were significant differences between The mean scores of YMRS and HAM-D scores were
marriage status and B-IPQ scores (p=0.046). In 2.19±0.95; 2.37±0.89, respectively, so all patients
the post-hoc analysis, married participants with the were in remission. In two questionnaires, 5 was the
bipolar disease had statistically significantly higher maximum score. GSES mean score was 56.62±8.63,
B-IPQ scores (p=0.023). The patients who lived with and B-IPQ means the score was 39.85±16.46. Median
only a spouse had statistically significantly higher scores of all scales and subscales are in Table 2.
B-IPQ scores than all living types. The participants
using alcohol had higher B-IPQ scores than non- B-IPQ had a low and statistically significant positive
using participants (p=0.021). correlation with the number of total episodes (r=0.235;

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Table 3 Median number of episodes, Scale and subscale scores of all participants

r p
WCQ subscales
Self-controlling -0.146 0.069
Escape-avoidance 0.216 0.020
Planful problem-solving -0.286 <0.001
Positive reappraisal -0.337 <0.001
Distancing -0.101 0.210
Seeking social support -0.101 0.209
Confrontive coping -0.095 0.237
Accepting responsibility -0.093 0.245
GSES -0.376 <0.001
The number of total episodes 0.235 0.003
The number of depressive episodes 0.276 <0.001
The number of manic episodes -0.017 0.828
The number of hypomanic episodes 0.251 0.002
The number of mixed episodes 0.154 0.055
Disease duration 0.105 0.221
Hospitalization history -0.020 0.820
Suicide history 0.055 0.527
Age -0.049 0.545

YMRS: Young Mania Rating Scale, HAM-D: Hamilton Depression Rating Scale, B-IPQ: Brief Illness Perception Questionnaire,
WCQ: The Ways of Coping Questionnaire, GSES: The General Self-Efficacy Scale

p=0.003); the number of depressive episodes (r=0.276, with B-IPQ and other correlated variables [F (5,151)
p<0.001) and the number of hypomanic episodes =13.769; p<0.001], and 29% of the variance in the
episodes (r=0.251, p=0.002). There was a moderate dependent variable were explained by the independent
and statistically significant negative correlation variables by backward type of regression. This
between B-IPQ and GSES (r=-0.376, p<0.001); regression showed us to predict illness perception
also, low/moderate negative statistically significant with escape-avoidance, GSES score, and the number
correlation between B-IPQ and WCQ’s subscales as of hypomania episodes.
planful problem solving (r=-0.286, p<0.001); positive
reappraisal (r=-0.337, p<0.001). There was positively Discussion
and statistically significant correlation between B-IPQ
and escape-avoidance subscale (r=0.216, p=0.020). This study aimed to understand better how patients
All details were shown in table 3. with BD perceive their disease. We examined the links
between illness perception and clinical course and the
A multiple linear regression model was used to relationships between coping styles and self-efficacy.
identify independent predictors of illness perception Our findings correlated a negative illness perception to
in patients with BD. The model fit was assessed using lower self-esteem, more disease episodes, and more
appropriate residual and goodness of fit statistics manic and depressive episodes. While increases in
(table 4). There was a significant regression model the planful problem solving and positive reappraisal

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Multiple linear regression analysis of 4 models of WCQ subscales, GSES scales,

Table 4
episode types, by B-IPQ.

Model B S.E β p
(Constant) 68.398 7.908 <0.001
Escape-Avoidance 0.911 0.284 0.243 0.002
Planful problem solving -0.663 0.390 -0.156 0.091
Positive Reappraisal -0.649 0.365 -0.165 0.077
1 GSES -0.546 0.134 -0.294 <0.001
The number of total episodes 0.511 0.399 0.125 0.202
The number of depressive episodes -0.107 0.713 -0.015 0.881
The number of hypomanic episodes 3.917 1.855 0.156 0.328
Using Alcohol 2.136 2.178 0.070 0.036
(Constant) 68.383 7.881 <0.001
Escape-Avoidance 0.905 0.280 0.241 0.002
Planful problem solving -0.666 0.388 -0.157 0.088
Positive Reappraisal -0.644 0.362 -0.164 0.077
2
GSES -0.545 0.133 -0.294 <0.001
The number of total episodes 0.470 0.287 0.115 0.104
The number of hypomanic episodes 3.862 1.811 0.154 0.035
Using Alcohol 2.149 2.169 0.070 0.323
(Constant) 68.778 7.871 <0.001
Escape-Avoidance 0.988 0.268 0.263 <0.001
Planful problem solving -0.673 0.388 -0.158 <0.001
3 Positive Reappraisal -0.678 0.361 -0.173 0.085
GSES -0.552 0.133 -0.298 0.062
The number of total episodes 0.446 0.286 0.109 <0.001
The number of hypomanic episodes 3.736 1.807 0.149 0.121
(Constant) 71.003 7.777 <0.001
Escape-Avoidance 1.023 0.268 0.273 <0.001
Planful problem solving -0.711 0.389 -0.167 0.070
4
Positive Reappraisal -0.677 0.362 -0.172 0.064
GSES -0.552 0.133 -0.298 <0.001
The number of hypomanic episodes 4.400 1.764 0.176 0.014

GSES: The General Self-Efficacy Scale. The bold type denotes statistical significance.

subscale scores were associated with a decrease in The self-regulation model has been used to
negative illness perception, increases in the escape- understand the emotional and behavioral responses
avoidance subscale score were associated with an of individuals with somatic diseases to their illness.
increase in negative illness perception. This approach has recently been used to explore

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how people with mental illnesses such as psychosis, prognosis, treatment, and how they view their
eating disorders, depression, and BD perceive their illness. Experiencing more than ten episodes was a
illness. There are limited studies examining the significant predictor of disability and dysfunction in the
perception of illness in patients with BD. For example, Systematic Treatment Development Program (STEP-
Oflaz et al. examined the relationship between illness BD) population (43). Due to BD's symptoms, their
perception and dropout (19). They reported that the relapsing and remitting course, residual symptoms
perceptions of the disease in the domains of disease between episodes, related unemployment, loss of
outcomes, treatment control, identity, and emotional productivity, impaired social functioning, low quality
representation differ between dropout patients with BD of life, and disability, a negative perception of the
and those who adhere to treatment. Hou et al., on the disease may develop in patients. Patients who
other hand, reported that patients who did not adhere have unfavorable attitudes toward coping with and
to medication believed that their disease harmed their managing their disease and consider it dangerous
lives and would have a long-term effect more than may exhibit treatment noncompliance, a dropout from
those who adhered to medication (37). Lobban et al. follow-up clinics, and poor clinical results. (44).
demonstrated that patients with BD lacked personal
control over their mood swings and felt themselves Self-efficacy, defined as a person's perception of
making fewer attempts to improve, reporting higher their skill level and what they can do with it, can
levels of depression (38). Averous et al. revealed that influence an individual's general perspective of the
patients with BD who had a positive impression of the disease, affecting self-care activity regulation and
treatment control, had less negative feelings about treatment management. According to the current
their disease, had a lower sense of consequences, study, negative illness perceptions were associated
and had a better understanding of the diagnosis were with lower self-efficacy. In the qualitative study of
more committed to treatment (17). As far as we know, Lim et al., it was observed that as a result of low self-
no previous research has investigated the relationship efficacy, BD patients perceived their illness negatively
between BD patients' perceptions of illness and self- and distrusted their ability to manage their illness
efficacy and coping mechanisms. (45). Similar to our findings, it was suggested by
Lau-Walker (2006) that the perception of illness can
Our study observed that married participants had predict self-efficacy (46).
higher illness perception scores; single participants
also had higher personal control and treatment Our study highlights the primary role of coping
control scores. Contrary to our findings, many strategies as determinants of negative illness
previous studies have shown that marriage has perceptions. Individuals' coping styles affect how
beneficial effects on health, that married individuals they appraise and cognitively perceive health threats
have longer survival times and a lower prevalence of (47). Escape-avoidance, GSES scores and a total
health problems than unmarried individuals (39). In number of episodes were found as predictors of
managing chronic diseases, the family is the critical the results of the perception of illness. Although the
source of influence. According to research findings, positive reappraisal subscale was not a predictor
the structure and quality of the couple's relationship in the regression, it should be known that positive
are among the elements that influence how chronic reappraisal to the disease decreases the illness
disease patients perceive their illness (40). In BD, perception.
one of the chronic mental diseases, lifestyle and role
changes might occur, which can be difficult for the This study has several limitations that may affect
couple's relationship (41). Patients' emotional states its findings. We did not assess variations in illness
may swing, causing them to occasionally fail to fulfill perceptions, self-efficacy, or coping mechanisms
the tasks demanded by the couple's relationship across several effective phases of BD, including
and to meet their partners' expectations (42). The depression, mania, mixed episodes, and remission.
difficulties and conflicts experienced by the patients A cross-sectional design was used to collect data.
in their marital relationships may contribute to their Additional study with larger, more representative
difficulties in coping with their illness and negatively samples of patients with BD is necessary to replicate
perceive their illness. and validate these findings. Despite these limitations,
the present study has several strengths. One of the
Another remarkable finding in our study was that strengths of this study is to consider self-esteem,
negative perceptions of the disease increased as the coping mechanisms, and clinical variables in the
number of disease episodes increased. Accumulated illness perceptions of BD patients. Our findings
mood episodes may significantly impact patients' provide a more nuanced understanding of this issue,

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 Süleyman Demirel Üniversitesi Tıp Fakültesi Dergisi Bipolar Disorder and Illness Perception

as there are limited studies examining the perception

of illness in patients with BD, one of the serious mental Availability of Data and Materials
disorders. The datasets generated and/or analyzed during the
current study are available from the corresponding
We recommend that such studies be conducted with author on reasonable request.
different BD patient groups and with a larger sample
to increase the data's reliability and make the findings Authors Contributions
more generalizable. Qualitative research is necessary GÖÜ: Conceptualization; Formal analysis;
to have a comprehensive understanding of BD Investigation; Methodology; Validation; Visualization;
patients' illness views. Further research concentrating Writing-original draft.
on patients at various stages of the disease can be
conducted to determine how patients view BD. GÇA: Data curation; Visualization; Writing-original
draft.
This research adds to the literature on illness models in
severe mental illness by investigating the relationship Gİ: Investigation; Validation; Writing-original draft.
between illness perception and clinical features, self-
efficacy, and coping mechanisms in patients with İMA: Conceptualization; Formal analysis; Investigation;
BD. Physicians should consider that their patients' Methodology; Project administration; Resources;
perceptions of the disease may affect the outcome of Supervision; Validation; Writing-review & editing.
the disease. Perceiving the disease as a frightening
and threatening situation may negatively affect the Editorial
course and prognosis of the disease. In order to Although IMA, one of the authors of the article, is
make the perception of illness more positive and less editorial board member of the journal, she has not
threatening, patient-centered approaches including taken part in any stage of the publication processes
strategies to improve and increase self-efficacy and of this article.
coping skills should be developed.
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