Copyright ª Blackwell Munksgaard 2005 Bipolar Disorders 2005: 7: 431–440
BIPOLAR DISORDERS
Original Article
Burden and marital and sexual satisfaction in the partners of bipolar patients Lam D, Donaldson C, Brown Y, Malliaris Y. Burden and marital and sexual satisfaction in the partners of bipolar patients. Bipolar Disord 2005: 7: 431–440. ª Blackwell Munksgaard, 2005
Dominic Lama, Catherine Donaldsona, Yael Brownb and Yanni Malliarisa a
Objectives: Bipolar disorder can be traumatic for both patients and patientsÕ partners. Hence, partnersÕ stress, burden, marital and sexual satisfactions are important areas to investigate. However, there have been problems with past attempts to identify the determinants of marital satisfaction in bipolar patients and their partners. The present study aimed to address these issues and provide an accurate description of relationship functioning in these couples.
Department of Clinical Psychology, Institute of Psychiatry, London, b Eating Disorders Unit, Maudsley Hospital, London, UK
Methods: The sample involved 37 partners of bipolar patients. A semistructured interview assessed the impact of bipolar disorder on aspects of everyday functioning and partnersÕ attributions for patientsÕ disturbing behaviour. Standardized instruments assessed partnersÕ sexual and marital satisfaction across the different affective states. Results: Despite couples staying together, significant numbers of partners reported strain as a result of socioeconomic and household changes. More male partners reported premature ejaculation and female partners reported sexual infrequency when patients were depressed. Overall, partners were less sexually satisfied when the patient was ill. Marital disharmony was greater when patients were ill and worse during manic than depressed phases. Marital disharmony was also more likely when partners believed the patient could control their illness; they had increased domestic responsibilities; or were sexually dissatisfied. Conclusion: Reductions in sexual satisfaction during affective episodes may be the result of illness-related changes in sexual interest, responsiveness and affection. Partners who attribute control for the illness to the patient may use strategies to influence behaviour that disrupt marital harmony. Interventions involving education, problemsolving strategies and sex therapy components may help to reduce marital dissatisfaction.
Bipolar disorder runs a course of frequent relapses. Even when compliance with mood-stabilizers is high, recurrences are experienced by up to 60% of patients within 2 years of an acute episode (1–5). The limitations of pharmacotherapy were acknowledged in the 1996 report by the National Institute of Mental Health who emphasized the need for
The authors of this paper do not have any commercial associations that might pose a conflict of interest in connection with this manuscript.
Key words: bipolar disorder – burden – marital satisfaction – partners – sexual satisfaction Received 7 October 2004, revised and accepted for publication 6 June 2005 Corresponding author: Dominic Lam, PhD, Psychology Department, Henry Wellcome Building, Institute of Psychiatry, DeCrespigny Park, London SE5 8AF, UK. Fax: 0207 7848 5006; e-mail: spjtdhl@iop.kcl.ac.uk
psychosocial interventions as an adjunct to medication (6). One important psychosocial area to investigate is the patientsÕ interpersonal environment. Previous research has shown that the risk of bipolar relapse is doubled in couples and families with high levels of expressed emotion (EE; 7, 8) and that patient outcome is adversely affected by high levels of caregiver burden (9). Furthermore, the impact of EE on bipolar symptoms in patients can be mitigated by family focused interventions (10) and significant improvements in patient functioning
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can be obtained from marital interventions aimed at reducing strain (11, 12). One set of determinants of marital strain in bipolar disorder is illness symptoms. It was found that insensitivity, shifting responsibility for their own actions to others and overstepping cultural and relationship norms were related to interpersonal difficulties (13). Other researchers have pointed to violent behaviours and some features of the depressed state such as withdrawal and dependence (14, 15). More recent work in this area has suggested that how partners attribute control for the patientsÕ symptoms and illness is also important in understanding the quality of these relationships. For example, Hooley and Licht’s (16) study on unipolar depression and the study of Weisman et al. (17) on schizophrenia found an association between spouses believing that patients can exert control over their difficulties and the expression of high levels of criticism towards the depressed partner. Furthermore, in normal couples research has implicated both the attributions spouses make for their partner’s and their own behaviour in determining levels of marital dissatisfaction (18). Changes to socioeconomic factors are also known to present challenges to bipolar partnerships with restrictions in social activities and a fall in family income being noted across several studies (15, 19, 20). However changes in other domains, for example those associated with domestic responsibilities, may also leave partners feeling burdened with responsibilities they would prefer to share and this too may lead to problems in the marital relationship (21). Problem behaviours, perceived controllability for the illness and changes in socioeconomic domains can be assessed with the RelativesÕ Burden Schedule (RBS; 19). This schedule has been used in the research of Fadden et al. (19) and Dore and Romans (20). However, in Fadden et al. (19) only eight patients in their sample had bipolar disorder and in Dore and Romans (20) a variety of relatives and friends were interviewed, only 13 of who were spouses or partners. These issues compromise the utility of this research as each psychiatric disorder is associated with a distinct set of problems and the burdens faced by partners may be different from those faced by parents or other relatives (20, 22). As a consequence, a detailed and reliable account is still required of the experiences of the partners of bipolar patients. Since the 1970s, information has been accruing about the more interpersonal aspects of couple relationships. Several studies have noted high levels of disharmony (e.g. 23) with some authors even suggesting that marital conflict is so ubiquitous as
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to act as an indicator of the presence of bipolar disorder in one of the partners (24). However there is conflicting evidence on these points with some studies noting little additional marital conflict in the partnerships of bipolar patients compared to well couples (25). One explanation for the inconsistent findings is the use of unstandardized instruments in a significant portion of this literature and the failure to collect information on changes in relationship factors over the course of the different illness states. For example, during the manic phase spouses may tend to interact less with the patient who may be preoccupied with goaldirected or pleasure-seeking behaviours, while during the depressed phase partners may be more involved in an attempt to alleviate the person’s sadness. An additional criticism of this research is that some aspects of spousal relationships have been explored less frequently. One such area is sexual functioning, which is associated with marital dissatisfaction (26) and may vary across the different affective states. For example, during the manic phase, partners may feel more tense and anxious and have difficulties coping with increases in the person’s sexual drive. Partners may avoid intimate contact or have more sexual problems such as vaginismus or impotence because of patients not being able to display sensitivity or affection. By contrast, during the depressed phase, partners may find the patient’s loss of libido difficult to manage or feel less inclined towards sexual activity themselves as the patient is irritable and unhappy. The present study seeks to address some of the limitations of previous research. We aim to provide a thorough description of the burdens faced by the partners of bipolar patients. This task is partly exploratory as this is the first occasion where the RBS scale has been used with a sample that comprises only partners of bipolar patients. We also aim to contribute to the understanding of relationship dynamics by using standardized measurements of sexual satisfaction and marital quality and examining changes in these variables during the euthymic, manic and depressed phases of the disorder. Hypotheses
1 Both sexual and marital satisfaction would be worse when patients are ill compared to when they are well and worse during manic compared to depressed episodes. 2 Partners would report different sets of sexual problems when patients were manic, depressed and well.
Marital and sexual satisfaction in bipolar disorder 3 Marital satisfaction is predicted by objective difficulties (i.e. symptoms, psychosocial changes), perceptions of controllability and sexual satisfaction.
Method
Participants
Participants were the partners of 37 bipolar patients who fulfilled DSM-IV (27) criteria of bipolar affective disorder type 1 and who had been recruited from the outpatients population of the South London and Maudsley Trust. This group formed part of the cohort involved in two studies of cognitive therapy for bipolar disorders (28, 29). All patients were judged not to be in an acute episode of illness. Mania Rating Scale (30) scores up to 9 and Beck Depression Inventory (31) scores up to 30 were permissible providing the criteria for a DSM-IV bipolar episode were not met. Couples were heterosexual and either married or cohabiting for the last 3 years during which at least one manic and one depressed episode had occurred. Well partners provided information on their own contact with mental health services and the nature of the problems that had prompted them to seek help. They also reported on the number of episodes of mania and depression the patient had experienced during their relationship. Materials
The following materials were administered to the well partners. RelativesÕ Burden Schedule. This structured interview schedule was adapted for use by spouses (19). It comprises nine sections: (i) Relationship with the Patient; (ii) Household Roles; (iii) Social Life; (iv) Effects on Children and Parenting Difficulties; (v) Occupation and (vi) Finances. There were also detailed sections on (vii) Patient Behaviour; (viii) Knowledge about Illness; and (ix) Relative’s Psychological Adjustment. All sections were administered to the bipolar partners with the exception of (i) Relationship with the Patient as this dimension is covered by the Golombok–Rust Inventory of Marital State (GRIMS) scale (see below). In the Patient Behaviour section relatives were asked three questions about 29 specific illness behaviours: (i) whether or not the behaviour had occurred, (ii) how problematic it was, and (iii) their causal attributions for the behaviour. Respondents were given the choice of two external explanations: bipolar disorder and medication; and two internal
explanations: the patient’s temperament and the patient’s personal control over these specific behaviours. In the Knowledge about Illness section there were several items about relativesÕ causal attributions for the illness as a whole. In one item, relatives were asked to rate the amount of control they viewed the patient as having over their illness on a 7-point Likert scale with 1 indicating no control and 7 strong control. They were also asked a similar question about the amount of control they viewed themselves as having over the patient’s illness. In the Psychological Adjustment section relatives provided information on their coping strategies and how their views and outlook concerning their relationship had changed over the course of the patient’s illness. Overall, the RBS has been shown to provide meaningful information about the problems faced by those living with patients who have bipolar and unipolar depression (19). General Health Questionnaire (GHQ). The 28item version of this self-report scale was used to measure levels of psychological morbidity in partners. Individual items were rated using a bimodal scale (0-0-1-1) and psychiatric caseness was indicated by scores of 5 or above (32). Golombok–Rust Inventory of Sexual Satisfaction (GRISS). This questionnaire measures the presence and extent of problems in a couple’s sexual relationship. There are separate versions for males and females. The versions share five subscales: non-communication, infrequency, avoidance, nonsensuality, and dissatisfaction and each has two unique subscales: impotence and premature ejaculation for males and anorgasmia and vaginismus for females. Both versions consist of 28 items. Raw scores for the scale overall and for individual subscales can be converted to transformed scores ranging from 1 to 9 with scores of 5 and above indicating sexual problems. Both the male and female versions show high internal consistency (coefficients range from 0.87 to 0.94), moderate test–re-test reliability (0.65–0.76) and significant concurrent validities with therapistsÕ ratings of problem severity (33). Golombok–Rust Inventory of Marital State. This questionnaire assesses the quality of the relationship in cohabiting couples using 28 items that cover satisfaction, communication, shared interest, trust and respect. Items have a 4-point response format (0–3) and are summed to give the total raw score. The scale shows high levels of internal consistency (coefficients range from 0.81 to 0.94)
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and concurrent validity with significant agreement being found between GRIMS scores and therapistsÕ ratings of marital quality (34). Partners completed both the GRISS and GRIMS three times, that is, for periods when the patient was well, manic and depressed. Partners were given a lay description of an episode of mania and depression that was based on DSM-IV criteria. A description of euthymia was also included. Main analyses procedures
In order to examine differences in sexual satisfaction across illness states, a repeated-measures analysis of variance (ANOVA) was conducted with the raw GRISS scores for well, manic and depressed phases being the within-subjects variables. Additional pairwise comparisons with Bonferroni adjustment were used to identify the location of any significant differences. Gender differences in sexual satisfaction across all three phases were examined using independent samples t-tests. All these analyses were performed using version 10.0.7 of SPSS (35). Raw data from GRIMS were subjected to linear regression with robust standard errors performed using Stata version 8.1 (36). Robust standard errors enabled the analysis to take account of missing data, deviations from normality and the repeated-measures subject design. That is, the analysis procedure controlled for the fact that each subject had given three measurements of marital satisfaction one for the manic phase, one for the depressed phase and one for the well phase [total cases ¼ 111 (3 · 37)]. Variables were considered for entry into the model in blocks starting with background variables (both clinical and demographic), then objective burdens, then attributions and sexual functioning and finally one set of interaction variable: 1 Background variables included gender (male ¼ 0, female ¼ 1) and two dummy variables generated to represent the three phases of bipolar disorder. 2 Indicators of objective burden were the changes to partner’s domestic, social and financial situations as a result of the patient’s illness and a count of the number of patient behaviours, both from the RBS. 3 Attributional measurements were partner’s view of (i) the patient’s level of control over their illness and (ii) their own level of control over the patient’s illness (both measured on a 1–7 scale) from the ÔKnowledge of IllnessÕ section from the RBS. Sexual satisfaction was represented by raw GRISS scores.
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4 A set of interaction terms representing the relationship between phase of illness and sexual satisfaction. For each block, a stepwise selection procedure. Initially the dummy variables representing illness phases were coded as state 1 being mania, state 2 being depression and wellness being the reference. This enabled a test to be made of the difference between the two types of illness episode and periods of euthymia. In order to test the hypothesis that GRIMS scores would be different in manic and depressed phases the regression analysis was repeated with the dummy variables recoded as state 1 being depression, state 2 being wellness and mania being the reference.
Results
Sample
The sample of 37 partners was composed of 17 females and 20 males who were married to or co-habiting with the patient. All partners were aged between 18 and 65 with the mean age being 47.5 years (SD 8.5). Two partners living separately from the patient were also included as these separations were of short duration (<4 weeks), viewed as temporary and partners considered their relationships to be intact. The mean duration of cohabitation was 21.5 years (SD 2.6) and on average patients were reported to have had experienced 4.8 episodes of mania (SD 3.2) and 5.4 episodes of depression (SD 3.0) during this time. Only 21.6% (8/37) partners had no children. Of those that did have children, 18 had offspring under 18 and 11 had adult children only. In terms of employment, 65% (24/ 37) partners were in full-time employment or education, 10.8% (4/37) worked part-time, 13.5% (5/37) were homemakers, 8.1% (3/37) were unemployed and 2.7% (1/37) was retired. A total of 32.4% (12/37) partners had experienced mental health problems of their own for which they had contacted a psychologist or a psychiatrist (nine reported affective problems, two alcohol problems and one received bereavement counselling). RBS changes to household, social, parenting, occupational and financial situations
Table 1 gives details of the proportion and numbers of partners who endorsed items on the household, social, parenting, occupational and financial sections of the RBS. Slightly more than two-thirds of partners reported disruptions to their
Marital and sexual satisfaction in bipolar disorder Table 1. RelativesÕ Burden Schedule % partners endorsing item Household roles More household responsibilities since illness began Disruption to household routine since illness began Strain in managing household since illness began
54 (20/37) 70 (26/37) 35 (13/37)
Social life Never go out with the patient to socialize due to his/her illness Never go out alone to socialize due to patient’s illness Have cut down on going out & socializing since s/he became ill Fewer friends visit because of the patient’s illness Embarrassed to tell friends/relatives about patient’s illness Have experienced stigma since patient became unwell Problems with neighbours due to illness/patient’s behaviour Strain due to change in social life
46 38 57 54 38 32 19 40
(17/37) (14/37) (21/37) (20/37) (14/37) (12/37) (7/37) (15/37)
Occupation Work outside the home Have had to reduce hours worked due to patient’s illness Have had to increase hours worked due to patient’s illness Have had to take time off work because of patient’s illness Strain/difficulty functioning at work due to patient’s illness Decline in work standard due to patient’s illness
76 25 32 57 36 14
(28/37) (7/28) (9/28) (16/28) (10/28) (4/28)
Finances Fall in household income due to patient’s illness Increased money management responsibilities due to patient’s illness Strain caused by money worries that are due to patient’s illness
38 (14/37) 65 (24/37) 59 (22/37)
household routine since the illness began and a half said that they had more domestic responsibilities. Over half of the partners reported disruption of social life, either in terms of cutting down on going out and socializing or having fewer visitors. Over half of partners who worked outside the home had either reduced or increased their working hours since the patient became ill. More than half of the sample experienced financial worries and strain caused by the illness. Thus, more partners were burdened by financial alterations than by changes to household, social, parenting or occupational roles as a result of the patient’s illness. Only 49% (18/37) of the sample had children under the age of 18 in their households. Of these, 61% (11/18) felt they had more childcare responsibilities; 50% (9/18) reported that children had emotional problems related to their partnersÕ illness and 44% (8/18) reported more difficulties functioning as a parent since their partners became ill. RBS patient behaviours
Table 2 gives details of the frequency, difficulty and causal attributions for several bipolar symptoms. Disruptions to sleep, activity, mood and sociability were amongst the most commonly occurring features. The 10 most problematic behaviours included some depressive features such
Table 2. Difficult patient behavioursa and their attributionsa Behaviours
Present
Problematic
Internal
Sleeping too much/little Withdrawal Misery Underactivity Worrying Overdependence Increased sociability Unpredictability Appetite Irritability Odd ideas Unwise spending Nagging/grumbling Attention seeking Verbal aggression Offensive behaviour Heavy drinking Gambling
89 84 84 81 78 76 73 73 70 70 70 68 65 51 49 41 19 5
91 81 94 90 76 82 63 89 58 85 88 100 92 89 100 93 86 0
24 35 29 34 55 36 34 26 54 35 19 40 33 31 28 13 86 50
(33/37) (31/37) (31/37) (30/37) (29/37) (28/37) (27/37) (27/37) (26/37) (26/37) (26/37) (25/37) (24/37) (19/37) (18/37) (15/37) (7/37) (2/37)
(30/33) (25/31) (29/31) (27/30) (22/29) (23/28) (17/27) (24/27) (15/26) (22/26) (23/26) (25/25) (22/24) (17/19) (18/18) (14/15) (6/7) (0/2)
(8/33) (11/31) (9/31) (10/30) (16/29) (10/28) (9/27) (7/27) (14/26) (9/26) (5/26) (10/25) (8/24) (6/19) (5/18) (2/15) (6/7) (1/2)
Values are expressed as % (n). a The top 10 most frequent problematic behaviours and internal attributions are in bold.
as misery and underactivity and, some manic features such as unwise spending, verbal aggression and offensive behaviour. The majority of partners considered behaviours to be due to external factors (i.e. illness or medication). Behaviours that were attributed to internal causes (i.e. temperament or choice) by at least a third of partners included
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withdrawal, poor appetite, underactivity, unwise spending, increased sociability, heavy drinking, overdependence and worrying. RBS knowledge about the illness
Eighty-nine per cent (33/37) said that the patient had a psychiatric condition. The majority (76%, 28/37) also believed that their difficulties had a biological/genetic cause and 14% (5/37) believed that Ôthings got too much for themÕ. Relatedly, 70% (26/37) of partners worried that their partner’s illness may be genetically passed on to their children and 46% (17/37) said that they sometimes became concerned by mood changes in relatives. Almost half of partners could distinguish normal mood variation in the patient from bipolar symptoms (49%, 18/37), although a pattern of overidentification was reported by 38% (14/37) with these partners becoming concerned about any alteration to mood. In terms of partnersÕ ratings of the amount of control they thought the patient had over their illness, 30% (11/37) of the sample thought patients had little or no control (scores 1–2), 57% (21/37) saw patients as having some control (scores 3–4) and 13% (5/37) thought patients had a moderate to strong amount of influence over their illness (scores 5–7). As regards partnersÕ ratings of their own level of control, 51% (19/37) rated themselves as having little or no control (scores 1–2), 30% (11/37) saw themselves as having some control (scores 3–4) and 19% (7/37) thought they had a moderate to strong influence over the patient’s illness (scores 5–7). RBS psychological adjustment
In terms of psychological adjustment, 59% (22/37) of partners reported that they believed their lives had been irrevocably altered by the patient’s illness and 54% (20/37) of partners thought that at times they felt overwhelmed by their situation. Furthermore, 65% (24/37) felt conflicted about their
situation at least sometimes believing that life was a misery but at the same time not wanting to leave the patient. Forty per cent (15/37) of partners reported feeling aggrieved and bitter about their situation at least occasionally, and 38% (14/37) said that they had experienced feelings of loss because of changes in the patient. In terms of how partners coped with the patient’s illness, acceptance was a common strategy with 84% (31/37) reporting that they had been able to reconcile themselves to the situation and were attempting to make the best of it. Overall 92% (34/37) of partners said they felt happy to continue living with the patient and 78% (29/37) wanted to continue looking after the patients despite the difficulties and the problems that arose, reflecting the solid couple relationship in this sample. About 16% (6/37) felt that having the hope of a cure helped them to Ôkeep goingÕ and cope with their situation. GHQ-28: mental health status of partners of bipolar patients
Despite the partnersÕ commitment in the couple relationship, 46% (17/38) scored above the threshold for caseness on the GHQ-28, which is indicative of them being psychologically unwell. Sexual satisfaction in the partners of bipolar patients
Table 3 summarizes the raw GRISS scores for partners (data from seven partners were missing from this set of analyses). There were significant differences in sexual satisfaction during manic, depressed and euthymic episodes (F ¼ 6.7, 2 df, p ¼ 0.002). While levels of satisfaction were significantly lower when the patient was manic compared to well (mean difference ¼ 6.3, SE ¼ 1.8, p ¼ 0.005) and depressed compared to well (mean difference ¼ 6.1, SE ¼ 1.8, p ¼ 0.008), they were not significantly different during manic and depressed phases. There were no gender differences in any state.
Table 3. Mean (SD) of sexual and marital satisfaction in the partners of bipolar patients Sexual satisfaction in partners (GRISS)
Marital satisfaction in partners (GRIMS)
Clinical status of patient
Overall
Males
Females
Overall
Males
Females
Manic Depressed Well
34.1 (13.0) 33.9 (10.7) 27.8 (8.3)
33.7 (10.2) 34.4 (9.5) 26.3 (7.5)
34.5 (15.1) 33.5 (11.8) 28.9 (8.9)
43.5 (10.9) 38.2 (10.8) 28.7 (8.1)
40.0 (12.5) 38.1 (11.0) 30.5 (7.1)
46.2 (8.8) 38.9 (10.9) 27.2 (8.7)
GRISS ¼ Golombok–Rust Inventory of Sexual Satisfaction; GRIMS ¼ Golombok–Rust Inventory of Marital State.
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Marital and sexual satisfaction in bipolar disorder Specific sexual problems
Table 5. Parameter estimates for the final model for marital satisfaction
Table 4 provides details on the specific sexual problems reported by male and female partners respectively. In terms of frequencies, male partners reported several sexual behaviours as problematic during the depressed and manic phases compared to when the patient was well. During episodes of illness, male partners were also more likely to report that they avoided sexual contact, were dissatisfied with the sexual side of their relationships, and had difficulty communicating their sexual needs For female partners, levels of problems such as vaginismus were equally high during manic and depressed phases and sexual dissatisfaction was also relatively prevalent during illness episodes. More female partners cited sexual infrequency as a problem during the patient’s depressed rather than manic phases. Marital satisfaction in the partners of bipolar patients
Table 3 shows partnersÕ raw marital satisfaction (GRIMS) scores across manic, depressed and well states. These scores were subjected to a linear regression analysis with robust standard errors. This showed that marital dissatisfaction was more likely when the patient was manic or depressed, domestic responsibilities had increased, partners believed the patient could control their illness or partners were sexually dissatisfied. The multiple correlation coefficient was 0.27 and explanatory variables together explained 51% of the variance in raw satisfaction scores. When the analysis was
GRIMS scores
Variables State 1 State 2 Changes to domestic responsibilities Patient control GRISS
Regression coefficient
95% CI
14.38 9.43 6.92
10.32–18.44 6.19–12.48 1.54–12.03
<0.0005 <0.0005 0.008
0.76–3.71 0.003–0.01
0.004 0.004
2.30 0.007
p-value
GRISS ¼ Golombok–Rust Inventory of Sexual Satisfaction; GRIMS ¼ Golombok–Rust Inventory of Marital State.
repeated with the state variables recoded, the unstandardized regression coefficient for state 1 was )5.1 (CI ¼ )9.13 to )1.01) and statistically significant (p ¼ 0.02). These results indicated that partners were more dissatisfied with their marriages when patients were manic compared to depressed. Details of the analyses are shown in Table 5. Discussion
Before considering the results of the specific hypotheses, it is worth noting the limitations of the present study. First, all of the couples included in the study represent relationships that have survived the impact of bipolar disorder. The ability of these couples to remain intact suggests that they may have some traits that distinguish them from couples who separate as a result of the illness. Therefore, the findings in this study may not be
Table 4. Specific sexual problems reported by the partners of bipolar patients Sexual domain
When patient was manic
The percentage of male partners who reported a problem Non-communication 41 (7/17) Infrequency 59 (10/17) Dissatisfaction 29 (5/17) Avoidance 65 (11/17) Non-sensuality 47 (8/17) Male impotence 65 (11/17) Male premature ejaculation 24 (4/17) The percentage of female partners who reported a problem Non-communication 45 (9/20) Infrequency 50 (10/20) Dissatisfaction 25 (5/20) Avoidance 55 (11/20) Non-sensuality 55 (11/20) Female vaginismus 45 (9/20) Female anorgasmia 20 (4/20)
When patient was depressed
When patient was well
53 53 41 53 53 65 41
(9/17) (9/17) (7/17) (9/17) (9/17) (11/17) (7/17)
29 65 12 18 41 24 24
(5/17) (11/17) (2/17) (3/17) (7/17) (4/17) (4/17)
50 75 30 45 45 45 10
(10/20) (15/20) (6/20) (9/20) (9/20) (9/20) (2/20)
35 55 5 40 60 30 5
(7/20) (11/20) (1/20) (8/20) (12/20) (6/20) (1/20)
Values are expressed as % (n).
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generalizable to couples whose relationships are disrupted. Secondly, this is a cross-sectional study, partners were answering questions about manic and depressive episodes retrospectively and consequently these responses may have been subject to recall biases. Furthermore, the finding of high GHQ score could be due to assertive mating. Thirdly, our study did not involve a control group of couples to enable comparisons of levels of sexual and marital satisfaction. Investigating couple relationships in a particular clinical group in the absence of controls can lead to the erroneous conclusion that these relationships are more unsatisfactory than non-clinical couples whose relationships may also be subject to arguments and financial, social, domestic and sexual difficulties (25). The initial part of the present study described the impact of bipolar disorder on partners. A significant number of partners reported feeling strain as a result of restrictions to their social life, increased domestic responsibilities and financial worries. Indeed, 46% were cases on the GHQ which is considerably higher than the 17% rate of GHQ cases reported by a previous study (20). However, there are sample differences in that the previous study involved relatives, spouses and friends only half of whom lived with the bipolar patient. Our findings raise the possibility that higher levels of distress are experienced by partners who live with bipolar patients. Our study also identified a range of both depressive, manic and hostile behaviours as being problematic thereby confirming the findings from several earlier studies (e.g. 13, 15). Most of the symptoms that were seen as internal, that is nonillness related and due to temperament or choice, were either behavioural deficits (e.g. withdrawal) or impulse control problems (e.g. heavy drinking). This is in keeping with the symptom-controllability model of marital satisfaction (16), which states that symptoms such as these are more likely to be misinterpreted because behavioural deficits represent an extreme version of normal behaviours and impulse control problems can appear pleasurable. Worrying was appraised as being under the patient’s control by more than half of partners and again this may be because it occurs as part of normal behaviour and may only be seen as a sign of illness when severity increases markedly. Interestingly, more than two-thirds of partners thought the patient had at least some control over their illness and almost half saw themselves as having influence. This is in contrast to the results of an earlier study (19) where only a third of partners believed the patient could exercise control and
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almost none thought that they themselves made a contribution. The results may be due to the high levels of GHQ caseness in partners as individuals are known to engage in more causal search when distressed (37) and perhaps may be more likely to alight on explanations that implicate either the patient or themselves. In comparison with males from the clinic sample patients at a Marital and Sexual Difficulties Clinic (38), whose mean GRISS and GRIMS scores were 26.3 and 28.8, respectively, male partners in this study reported equivalent levels of satisfaction to these when patients were well, but were more dissatisfied when patients were depressed or manic. As regards female partners, GRISS scores indicated that they were less sexually dissatisfied across all illness states than female out patients (mean ¼ 39.4). Comparisons of GRIMS scores were more complex with female partners in this study reporting less marital dissatisfaction than clinic females (mean ¼ 34.2) when patients were well but more dissatisfaction when patients were depressed or manic. These data indicate that during illness episodes our sample of partners of bipolar patients were more maritally dissatisfied and the male partners within this group were also more sexually dissatisfied than normal couples whose relationships are in difficulty and have sought therapeutic intervention. Levels of sexual satisfaction were worse during periods of illness compared to when the patient was well, but equivalent during manic and depressed phases. As regards specific sexual problems, rates varied depending on whether the patient was manic or depressed. For male partners premature ejaculation occurred more often when the patient was depressed than manic and for female partners, sexual infrequency was more of a problem when the patient was depressed compared to manic. These findings may be explained by considering that depression-related reductions in sexual responsiveness in patients may have a detrimental influence on sexual performance in male partners while depression-related reductions in libido may lead to dissatisfaction with the rate of sexual contact in female partners. The results of the regression analysis confirmed our prediction that marital dissatisfaction would be greater during periods of illness and worse during manic compared to depressed episodes. These findings may be partly explained by the results of a small-scale study (39), which found deterioration in specific relationship characteristics when patients were in episodes (both manic and depressed episodes were considered together). This study found that spouses reported a reduction in
Marital and sexual satisfaction in bipolar disorder the levels of affection, support and consideration that patients expressed to them during manic and depressed episodes. The regression analysis also helped to clarify the roles played by sexual satisfaction, attributions of partner and patient controllability and the different types of objective difficulty (e.g. patient symptoms; domestic, social and financial changes). The finding of a link between unhappiness with the sexual side of the relationship and marital discord replicated the results of a previous study (34), which showed a relationship between sexual and marital dissatisfaction in male and female attenders at a general sexual and marital clinic. However, neither the present study nor the previous study (34) was able to identify a causal association between these two variables or a direction of causality. Therefore, it is possible that sexual problems give rise to relationship problems or relationship problems give rise to sexual problems or that some other unmeasured factors cause both. Again longitudinal studies are recommended as these would enable an investigation of how these variables relate over time and help to clarify this issue. The present analyses also revealed that partnersÕ beliefs about the amount of control the patient could exert over their illness was a strong determinant of marital difficulties. This may be because partners who do not attribute sufficient influence to an illness process may think patients are often unwilling to behave ÔnormallyÕ and may use strategies to encourage appropriate behaviour that disrupt marital harmony (e.g. reprimands, lecturing, criticism). Such an explanation is consistent with the findings in unipolar depression that spouses, who believed patients could exert control over their difficulties, expressed high levels of criticism towards the depressed partner (40). Finally, partners who had to shoulder more domestic responsibilities as a result of the illness were more likely to report marital strain but there were no associations between social or financial changes and marital functioning. An attributional explanation may also be behind this pattern of results as reductions in going out or having visitors (social changes) usually involves some contribution from other people and financial changes may be seen as Ôa fact of lifeÕ as the person’s illness may mean they simply cannot work in a formal employment. However, partners may view patients as still being able to carry out tasks within the flexibility of the home environment and may feel that it is unfair if these tasks are distributed unevenly. In terms of clinical implications, the present findings emphasize the need to assess for the possibility of psychological morbidity among the
partners of bipolar patients as high levels were noted in the present sample. PartnersÕ tendency to attribute both specific symptoms and the illness as a whole to the patient’s volition rather than to a clinical disorder also needs to be addressed. Psychoeducational materials are often a valuable resource for partners and in this instance should provide general information about bipolar illness and its symptoms but perhaps give particular attention to behavioural deficits, impulse control problems and worry. Even though cognitive behavioural therapy (CBT) interventions can help patients to manage their illness better and prevent prodromes from escalating into full episodes (29), educational materials should describe the limitations that remain to the amount of personal control the patient can exert over their symptoms and condition. The comparable levels of marital and sexual dissatisfaction reported by our sample and those by attenders at a sexual and marital clinic suggest a possible need to interview partners when assessing bipolar patients and enquire about the marital and sexual harmony during illness episodes. The relationship between sexual satisfaction and marital quality underscores the potential utility of including training in methods such as sensate focus (41) in interventions with these couples as soon as patients are well enough to take part in such training. Such methods may help to address the problems of sexual infrequency reported by female partners and performance difficulties reported by male partners. Marital interventions may also need to involve a problem-solving component as a means of dealing with issues such as the division of labour within the household. A psychosocial couplebased intervention that would incorporate these components may be a useful supplement to medication and CBT for bipolar patients whose functioning and well-being is affected by relationship difficulties. In severe cases of relationship or sexual difficulties, specialist referrals to marital or sex clinics should be made. Acknowledgement We would like to acknowledge Dr Isobel Horn’s help in data collection.
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