Theory of mind in remitted bipolar disorder: Interpersonal accuracy in recognition of dynamic nonverbal signals

RESEARCH ARTICLE Theory of mind in remitted bipolar disorder: Interpersonal accuracy in recognition of dynamic nonverbal signals Usue Espinós ID1*, Enrique G. Fernández-Abascal1, Mercedes Ovejero ID2 1 Facultad de Psicologı́a, Universidad Nacional de Educación a Distancia, Madrid, Spain, 2 Facultad de Psicologı́a, Universidad Complutense de Madrid, Madrid, Spain * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Espinós U, Fernández-Abascal EG, Ovejero M (2019) Theory of mind in remitted bipolar disorder: Interpersonal accuracy in recognition of dynamic nonverbal signals. PLoS ONE 14(9): e0222112. https://doi.org/10.1371/ journal.pone.0222112 Editor: Zezhi Li, National Institutes of Health, UNITED STATES Received: March 22, 2019 Accepted: August 21, 2019 Published: September 11, 2019 Copyright: © 2019 Espinós et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The authors provide an anonymized dataset that does not contain potentially identifying information. All relevant data are within the manuscript and its Supporting Information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abstract A relatively unexplored aspect in bipolar disorder (BD) is the ability to accurately judge other ´s nonverbal behavior. To explore this aspect of social cognition in this population is particularly meaningful, as it may have an influence in their social and interpersonal functioning. The aim of this research was to study interpersonal accuracy (IPA) in remitted BDs, that is, the specific skills that fall under the general term Theory of Mind (ToM). Study participants included 119 remitted individuals with BD (70 BD I and 49 BD II), and they were compared with a group of 39 persons diagnosed with unipolar depression (UD) and 119 control participants. The MiniPONS was used to test the whole spectrum of nonverbal cues as facial expressions, body language and voice. Results indicated a superiority of the control group with statistically significant differences both in the performance in the MiniPONS (number of right answers) and in each of the areas evaluated by this test. BD groups, in recognition of the meaning of gestures in face, body and voice intonation, performed significantly worse than controls. ANCOVA analysis controlling the effect of age shows that control group performed significantly better compared to clinical groups, and there were no differences between UD and BD groups. The results indicate a deficit in IPA and suggest that better comprehension of deficiencies in interpersonal accuracy in BD may help to develop new training programs to improve in these patients the understanding of others, which might have a positive impact in their psychosocial functionality, and thus lead to the objective of functional rehabilitation. Introduction Bipolar disorder (BD) is a psychiatric disorder characterized by periods of mania and depression [1]. Bipolar I (BD I) and II (BD II) are defined by a history of phases of elevated mood and a history of major depressive episodes, but BD II is distinguished from BD I by the presence of episodes of hypomania [1]. Despite treatment, many individuals with BD experience impaired functioning [2]. BD is associated with high rates of disability, with significant impairment in work, family and social life, beyond the acute phases of the illness [3]. These PLOS ONE | https://doi.org/10.1371/journal.pone.0222112 September 11, 2019 1 / 15 Theory of mind in bipolar disorder and interpersonal accuracy impairments in BD (I and II) persist even after significant mood symptoms have remitted. It is estimated that up to 60% of individuals do not recover completely after episodes [4] and only 38% of them achieve functional recovery after a manic phase [5]. This means that work productivity and employment may be negatively influenced [6]. Recovery includes not only symptomatic but also functional or premorbid levels of previous psychosocial functionality, and adaptive social relations. The quality of interpersonal relationships is often mentioned as one of the most important outcomes for patients with BD [7], as social impairment is observed in many patients with this disorder [8, 9]. Almost half of BD I patients and approximately three quarters of those with BD II will first have an episode of depression [10] and they can be misdiagnosed with unipolar depression (UD). This issue may lead to inadequate treatment [11], and this may have clinically relevant consequences. In many cases, it is difficult to distinguish BD from UD, approximately 69% of patients with BD are initially misdiagnosed with UD [12]. BD and UD have similarities and differences; both are chronic and recurrent disorders and both diseases may lead to cognitive and functional impairment [13, 14]. Individuals with UD present depressive episodes only, and those with BD II or I disorder show increasingly pronounced episodes of mood elevation. Another difference refers to the age of onset: patients with BD are younger at onset of first mood episode [15]. Clinical severity is greater among BD patients, as they have a higher prevalence of suicidal ideation [10]. The factors that may play a role in functional recovery of BD have been seldom studied, and understanding facts that might contribute to such inabilities is of essential importance. There is a need to understand mechanisms that may contribute to poor outcome in their psychological functioning. Thus, exploring social cognition in this population is particularly meaningful. Social cognition is an aspect of cognition that relates to the processing of social information for adaptive functioning [16]. Research on social cognition in BD is scarce and investigations have focused mostly on theory of mind (ToM), as deficits in ToM may contribute to deficiencies in social behavior [17, 18]. ToM is the ability to attribute mental states to others’, including beliefs, desires, emotions, and intentions [19], and refers to a competence, that is critical. ToM allows to choose adequate responses for successful interpersonal functioning [20, 21]. ToM enables individuals to decode others’ mental states based on observable information such as facial expressions and bodily gestures [22] and dysfunctions in ToM may be detrimental to social cognitive functioning [23]. There is research related to poor ability in the processing of social information in BD. In comparison to controls, psychosocial impairment is common across the three phases of BD (depression, mania and euthymia) although it has been verified that social functioning in BD patients is poorer in depression and hypomania [24]. For examp (...truncated)