Journal of Affective Disorders 262 (2020) 43–48

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Journal of Affective Disorders

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Research paper An investigation of self-compassion and nonattachment to self in people T with ⁎ Yan Yanga, , Kathryn Fletchera, Erin E. Michalakb, Greg Murraya a Centre for Mental Health, Swinburne University of Technology, PO Box 218, Hawthorn Victoria, 3122 Hawthorn, Australia b Department of Psychiatry, University of British Columbia, Vancouver, Canada

ABSTRACT

Background: There have been longstanding theories and research evidence into the important role of the person's vulnerability at the level of self-concept in bipolar disorder (BD). The current study investigated two emerging self-related constructs, self-compassion and nonattachment to self in BD. Specifically, we examined the levels of the two constructs in people with BD compared with those from the general population, and the associations between the constructs and bipolar symp- tomologies within the BD group. Methods: The BD group consisted of 302 individuals with a diagnosis of BD participating in an international randomised controlled trial. A general population sample (n = 372) was recruited from an Australian university as a comparison group. All participants completed measures of self-compassion and nonattachment to self. The BD group completed additional measures of depression and symptoms of hypo/mania. Results: Participants with BD showed significantly lower self-compassion and nonattachment to self than those from the comparison group after controlling for demographic variables (e.g., gender, age, education, occupation). In the BD group, lower self-compassion and nonattachment to self were associated with greater severity of depression on both self- and clinician-rated scales. Nonattachment to self but not self-compassion was negatively associated with hypo/mania sympto- mology. Limitations: The cross-sectional design cannot determine the direction of the relationships between study variables. Nonattachment to self is a novel psychological construct and further research is needed to replicate study findings. Conclusions: The study findings suggest that self-compassion and nonattachment to self may be meaningful targets in psychological interventions for peoplewithBD.

1. Introduction their own adversity as an isolated or shared human experience (Neff, 2003a). Existing research suggests that low self-compassion is Bipolar disorder (BD) is a serious mental illness, associated with common in mental disorders and may represent a modifiable ther- high comorbidity, marked psychological impairment, and elevated risk apeutic target in clinical practice (Braun et al., 2016; Krieger et al., of suicide (Goodwin and Jamison, 2007). One of the increasingly re- 2013; Krieger et al., 2016). Despite growing interest in the role of self- cognised issues in BD relates to the person's vulnerability at the level of compassion in the broad psychopathology, relatively few studies have self-concept (Leitan, 2016; Power, 2005). Major theoretical frameworks investigated this construct in BD. Døssing et al. (2015) reported lower including the classic manic defence model (Winters and Neale, 1985) levels of self-compassion in participants with BD compared to healthy and a contemporary cognitive model (Mansell et al., 2007) suggest that controls but found that self-compassion was not associated with the extremely positive and negative self-concept may drive a complex illness course and symptoms of BD. However, Yang et al. (2018) showed psychological process of behavioural in/activation and problematic that lower self-compassion was related to greater manic and depressive interpersonal dynamics, potentially leading to mood episodes in BD. severity, and served as a unique mediator between bipolar tendencies The aim of this study was to advance understanding of the self-concept and psychological distress in a non-clinical sample. Given the scarcity of in BD by examining whether people with diagnosed BD differ from the research in this area, many foundational questions addressing the role general population in relation to two putatively protective self-related of self-compassion in BD remain largely inconclusive. constructs: self-compassion and nonattachment to self. The study also Nonattachment to self is conceptualised as releasing fixation on sought to explore whether the self-related constructs were related to rigid self- (Shonin et al., 2016). In Buddhism, nonattach- bipolar symptomologies. ment to self is thought to mitigate emotional distress and improve Self-compassion encapsulates the extent of warmth and kindness to psychosocial functioning through relinquishing clinginess to desirable which the individual relates to the self and the degree to which they see personal qualities and being content with those deemed undesirable

⁎ Corresponding author. E-mail address: [email protected] (Y. Yang). https://doi.org/10.1016/j.jad.2019.10.042 Received 27 May 2019; Received in revised form 4 September 2019; Accepted 28 October 2019 Available online 30 October 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved. Y. Yang, et al. Journal of Affective Disorders 262 (2020) 43–48

(Sahdra et al., 2010; Shonin et al., 2016). Indeed, growing research obtained from all participants. shows that a general mentality of nonattachment may buffer against psychological dysfunction (Arch et al., 2016; Bhambhani and 3. Measures Cabral, 2016; Wang et al., 2016). Yang et al. (2018) reported that lower levels of nonattachment to self were associated with greater manic and 3.1. Self-compassion depressive tendencies in a non-clinical sample. Yang et al. (2018) ad- ditionally found that nonattachment to self uniquely mediated the re- Self-compassion was assessed by the Self-Compassion Scale (SCS; lationship between BD tendencies and psychological distress over and Neff, 2003b). The SCS comprises 26 items rated on a five-point Likert above a well-established psychological construct (rumination). Non- scale (1 = almost never; 5 = almost always). Neff (2003b) established attachment to self has not been empirically investigated in people with sound psychometric properties including excellent internal reliability BD despite the potential utility of the construct in research and ther- (Cronbach's α = 0.92) and convergent validity. The SCS has been used apeutic settings. widely in psychological research, total SCS score as recently established The concepts of self-compassion and nonattachment to self both as a reliable measure of global self-compassion (Neff et al., 2017). In- emerge from Buddhism and hence overlap conceptually; nevertheless ternal consistency was adequate in the present samples (Cronbach's they are also meaningfully distinguishable (Yang et al., 2018). The α = 0.94 in both the BD and general population sample). former involves cultivating positive attitudes towards the self, whilst the latter aims to reduce preoccupation with self-concept regardless of 3.2. Nonattachment to self valence. The two are therefore psychologically distinguishable parti- cularly as potential therapeutic targets. The present study examined the Nonattachment to self was assessed by the recently developed levels of self-compassion and nonattachment to self in people with BD Nonattachment to Self Scale (NTS; Whitehead et al., 2018). The NTS relative to the general population. It was hypothesised that self-com- comprises 7 items rated on a seven-point Likert scale (1 = strongly passion and nonattachment to self would be significantly lower in disagree; 7 = strongly agree) measuring the degree to which the person people with BD compared with those from the general population after releases fixation on self-related thoughts and feelings. A standard pro- controlling for relevant demographic confounds and anxiety (con- tocol of scale development and validation was followed to generate the ducted as a subsidiary analysis controlling for state mood) (Hypothesis initial items (e.g., consultations with experts in the field) and validate 1). The study further investigated the associations between the two self- the scale (e.g., use of factor analysis) (Whitehead et al., 2018). Sound related constructs, and depression and hypo/mania symptomatology in psychometric properties were established including good reliability the BD group. It was hypothesised that self-compassion and non- (Cronbach's α = 0.84; test-retest reliability: r = 0.80), construct va- attachment to self would be negatively associated with depressive and lidity and criterion validity (Whitehead et al., 2018). Internal con- hypo/manic symptoms (Hypothesis 2). sistency was good in the present samples (Cronbach's α = 0.88 and 0.87 in the BD and general population sample respectively). 2. Methods 3.3. Anxiety 2.1. Participants Anxiety was assessed by the anxiety subscale of the Depression Participants in the BD group (n = 302) were recruited to participate Anxiety Stress Scale-21 items (DASS-21; Lovibond and in an international randomised controlled trial investigating an online Lovibond, 1995). The anxiety subscale, comprising seven items rated on self-management intervention for people with BD (the ORBIT project; a four-point Likert scale (0= did not apply to me at all; 3= applied to see Fletcher et al., 2018 for protocol details). The general population me very much, or most of the time), measures physiological arousal and sample (n = 372) was drawn from an Australian university in exchange fear-based emotions. The DASS-21 subscales were shown good internal of course credit. consistency (Cronbach's alphas ranging from 0.73 to 0.81; Lovibond and Lovibond, 1995). Internal consistency was adequate in 2.2. Design and procedures the current samples (Cronbach's α = 0.76 in the BD sample and 0.83 in the general population sample). For the BD group, the initial inclusion criteria consist of being aged between 18 and 65 years old, self-report of a BD diagnosis (I, II, or BD 3.4. Bipolar symptomatology not otherwise specified) and receiving care from a medical practitioner. Those who reported having a BD diagnosis were subsequently assessed 3.4.1. Depression by trained clinical research assistants to confirm their diagnosis by Depression was assessed by both self-reported and clinician-ad- using the MINI International Neuropsychiatric Interview (MINI; ministered measures. The Quick Inventory of Depressive Sheehan et al., 1998). Participants assessed as experiencing a current Symptomatology-Self-Report (QIDS-SR; Rush et al., 2003) was used as a mood episode, current psychotic features and/or active suicidality were self-reported measure of depression severity. A 16-item measure rated excluded. on a four-point Likert scale, the QIDS-SR measures severity of multiple For the comparison group, the inclusion criteria consist of being symptom domains including sleep, and changes in appetite and weight, aged over 18 years old and having proficient understanding of written and shows sound psychometric properties, including internal con- English. Participants were asked to report whether they have been di- sistency (Cronbach's α = 0.87) and concurrent validity (Rush et al., agnosed with BD; diagnosis of mental illnesses was not an exclusion 2003). Internal consistency was acceptable in the current BD sample criterion. (Cronbach's α = 0.76). All participants completed a battery of questionnaires, collecting Depression was additionally assessed by a clinician-administered demographic information (e.g., age, gender, marital status, highest measure, the Montgomery-Asberg Depression Rating Scale (MADRS; education level, main occupation), and quantifying levels of self-com- Montgomery and Asberg, 1979).The MADRS comprises 10-item rated passion, nonattachment to self and anxiety symptoms. The BD group on a seven-point Likert scale (0 = not present or normal; 6 = most completed additional questionnaires assessing symptomatology and severe symptoms) measuring the majority of depressive symptoms for a illness related information including age of illness onset. The study major depressive episode based on the Diagnostic Statistical Manual obtained ethical approval from Swinburne University Human Research criteria (American Psychiatric Association, 2013). Montgomery and Ethics Committee (2016/289), and written informed consent was Asberg (1979) reported good internal reliability (e.g., Cronbach's α

44 Y. Yang, et al. Journal of Affective Disorders 262 (2020) 43–48 range between 0.89 and 0.97). Internal consistency was adequate in the Table 1 present BD sample (Cronbach's α = 0.86). Participant Characteristics of the BD and comparison group. Participant characteristics BD group (n Comparison group Test statistics 3.4.2. Hypo/mania = 302) (n = 372) (X2/t) Hypo/mania was assessed by a clinician-administered measure, the Young Mania Rating Scale (YMRS) (Young et al., 1978). The YMRS Female % (n), 70.5 (213) 79.8 (297) 7.85** Age M (SD) 43.98 (11. 35.54 (10.70) 9.69*** comprises 11 items rated on an eight-point Likert scale for four 68) symptom domains (e.g., irritability, speech) and a four-point Likert Marital Status % (n) 9.21* scale for the remainder (e.g., sleep, sexual interest). The YMRS shows Single 37.1 (112) 32.5 (121) sound validity and reliability (Young et al., 1978). Internal consistency Partnership 46.7 (141) 57.3 (213) Other marital status 16.2 (49) 10.2 (38) was adequate in the present BD sample (Cronbach's α = 0.77). Main Occupation % (n) 127.26*** Full-time 29.8 (90) 41.4 (154) 3.4.3. Statistical analysis Other work type 28.1 (85) 24.7 (92) Statistical analyses were performed using IBM. SPSS. Statistics Not currently working 36.1 (109) 6.5 (24) Version 24.0. Independent samples t-tests comparing means of self- Student 6.0 (18) 27.4 (102) Highest Education Level 104.73*** compassion and nonattachment to self between the BD and general Below undergraduate 30.1 (91) 67.2 (250) population sample were first conducted. Chi-square tests and t-tests Undergraduate 30.8 (93) 15.9 (59) were used to assess homogeneity between the two groups based on the Postgraduate 31.8 (96) 9.4 (35) demographic variables. If significant differences were found between Other education 7.3 (22) 7.5 (28) BD Diagnosis % (n) groups, the demographic variable was subsequently included in the BD I 80.1 (242) multiple regression analyses as a control variable. Categorical variables BD II 17.9 (54) with more than two levels were re-coded and dummy variables were BD NOS 2.0 (6) subsequently created in preparation for multiple regression analyses. Separate multiple regressions were performed to assess whether levels Note: Other marital status= divorced, separated or widowed; Other work of self-compassion and nonattachment to self differ significantly be- type = part time, casual or volunteer, Not currently working = unemployed, retired, home duties, or pension, Student = main occupation of student full tween the two groups. Age, gender, marital status, highest education time or student part-time, Below undergraduate = year 11 or less/GCSE, year level, and main occupation were entered as control variables in the first 11/12 or A levels, or diploma, Undergraduate = associative degree or bachelor step; BD-status was entered in the second step. Subsidiary analyses of degree, Postgraduate = postgraduate diploma/graduate certificate, masters Hypothesis 1 controlling for state mood differences were also con- degree or doctoral degree; BD =bipolar disorder, BD NOS = bipolar disorder ducted. Pearson's correlation coefficients were used to assess there- not otherwise specified. Test statistics = X2 for categorical variables and t for lationships between self-compassion, nonattachment to self and bipolar continuous variables. *** P < .001, **P < .01, *P < .05. symptomology (depression and hypo/mania). An assumption check was performed suggesting absence of violation for homoscedasticity (by self-compassion. Introducing BD-status to the regression model ex- inspecting residual probability plots) and multicollinearity (VIF values plained a further 15% variation in self-compassion, and this change in were no greater than 3) in the multiple regression analyses. Univariate R2 was significant, F (1, 662) = 131.136, p < .001. 1 outlier analyses for the two self-related constructs were also conducted Nonattachment to self as the dependent variable (Table 3): Simi- by computing Z scores and no outliers were detected. larly, BD-status significantly predicted nonattachment to self after controlling for demographic variables. The demographic variables 4. Results contributed significantly to the regression model, F (10, 663) = 4.721, p < .001 and counted for 6.6% of the variance in nonattachment to self. 4.1. Descriptive data and sample characteristics Adding BD-status to the regression model explained a further 14% variation in nonattachment to self, and this change in R2 was sig- BD-status differed significantly in age and gender ratio, and dis- nificant, F (1, 662) = 115.015, p < .001.2 tribution of marital status, main occupation and highest education level Hypothesis 2: Correlates of self-compassion and nonattachment to (Table 1). Notably, the mean age for the BD group was around 44 years self in the BD group old and 71% identified as female, compared with the comparison As shown in Table 4, bivariate analyses showed that self-compassion group, which had a mean age about 36 years old and 80% of females. was negatively correlated with both clinician-rated (MADRS; Compared with those from the general population sample, partici- r = −0.20, p < .05) and self-rated (QIDS-SR; r = −0.31, p < .01) pants with BD reported significantly lower mean scores of self-com- depression, but not with hypo/mania (YMRS; r = −0.11). Similarly, passion (M = 66.25, SD = 19.63 in BD group; M = 83.48, SD =16.43 nonattachment to self was negatively correlated with clinician-rated in comparison group; t (587) = −12.178, p < .001) and nonattach- (MADRS; r = −0.23, p < .01) and self-rated (QIDS-SR; r = −0.30, ment to self (M = 24.52, SD = 9.24 in BD group; M = 32.25, p < .01) depression. Nonattachment to self was also negatively corre- SD = 7.70 in comparison group; t (585) = −11.640, p < .001). Within lated with hypo/mania (YMRS; r = −0.12, p < .05). Illness duration the BD group, participants displayed low severity of hypo/manic was also included in the bivariate correlational analyses and it was not symptoms (M = 2.92, SD = 3.72 in the YMRS) and mild depression correlated with either self-compassion or nonattachment to self. (M = 8.20, SD = 7.25 in the MADRS). As expected on clinical scales, the four mood variables were positively skewed in the BD group 1 (Table 2). Self-compassion and nonattachment to self were moderately A case-control matching analysis was also conducted and a gender and age positively correlated in the BD group (r = 0.694, p < .01) (Table 4). matched sample (n = 190 per group) was generated. The pattern of the findings did not change. BD-status remained as a significant predictor for self-compas- Hypothesis 1: Self-compassion and nonattachment to self in BD re- sion: β =. 452, p < .001, ΔR2 = .138; nonattachment to self: β =. lative to general population sample 501 p < .001, ΔR2 = .169. Self-compassion as the dependent variable (Table 3): Multiple re- 2 Subsidiary analyses were also conducted adding anxiety in step 2 as an gression analyses showed that BD-status significantly predicted self- additional covariate in the hierarchical regressions. The pattern of the findings compassion after controlling for demographic variables. The demo- did not change. BD-status in step 3 remained as a significant predictor for self- graphic variables contributed significantly to the regression model, F compassion: F (1, 661) = 106.285, p < .001, R2 =.110; nonattachment to self: (10, 663) = 5.670, p < .001 and counted for 7.9% of the variance in F (1, 661) = 91.920, p < .001, R2 = .100.

45 Y. Yang, et al. Journal of Affective Disorders 262 (2020) 43–48

Table 2 Means and standard deviations for study variables, and bivariate statistics between the BD and comparison group.

BD group Comparison group Bivariate results

M (SD) Range Skewness Kurtosis M (SD) Range t Cohen's d SCS 66.25(19.63) 26–126 .43 −0.12 83.48 (16.43) 32–128 -12.18*** .95 NTS 24.52 (9.24) 7–49 .16 −0.62 32.25 (7.70) 10–49 -11.64*** .909 DASS-Anx 8.31 (7.23) 0–34 1.04 0.81 5.67 (6.90) 0–30 4.841*** .374 YMRS 2.92 (3.72) 0–29 .40 −0.67 .77 MADRS 8.20 (7.25) 0–40 1.14 1.18 .86 QIDS-SR 8.31 (4.78) 0–21 2.63 11.78 .76

Note: n = 302 (participants with bipolar disorder), n = 372 (comparison group). BD = bipolar disorder. SCS = Self-Compassion Scale, NTS =Nonattachment to Self Scale, YMRS = Young Mania Rating Scale, MADRS = Montgomery-Asberg Depression Rating Scale, QIDS -SR= Quick Inventory of Depressive Symptomatology-Self Report. DASS-Anx = Depression Anxiety Stress Scale -21 items (anxiety subscale).

Table 3 symptomology. However, there was no association between self-com- Multiple regressions BD-status predicting self-compassion and nonattachment passion and hypo/mania symptomology. The findings pertaining to to self. both hypotheses will be reviewed in the broader context of psycholo- Predictors Self-compassion Nonattachment to self gical research in BD. Therapeutic implications and study limitations ΔR2 β ΔR2 β will also be discussed. Step 1: Demographic variables 0.079*** 0.066** In our study, participants with BD reported diminished self-com- Gender −0.014 0.006 passion and nonattachment to self compared with participants from the Age −0.034 −0.078 Single 0.009 0.003 general population. These results are consistent with that of Døssing Other marital status 0.093* −0.060 et al. (2015), whereby lower levels of self-compassion were observed in Full time 0.303*** 0.248*** those with BD. As this is the first investigation of nonattachment to self Other work type 0.221*** 0.148** in a clinical population of individuals with BD, study results indicate Student 0.150** 0.09 that BD may also be characterised by a low level of nonattachment to Undergraduate −0.142*** −0.143*** Postgraduate −0.069 −0.066 self. Of particular interest, the difference in the present self-related Other education level −0.013 −0.011 constructs between the BD and general population sample remained Step 2: BD-status 0.152*** .138*** after controlling for anxiety symptoms, lending preliminary evidence to BD-status 0.483*** 0.460*** suggest that maladaptive self-concept may not be merely correlates of mood symptoms but may serve as a vulnerability factor. These findings Note. N = 674. BD status = bipolar disorder group versus comparison group. ***p < .0001, ** p < .01, * p < .05. Analyses were run with and without the align with the broader research picture, whereby BD appears to be participants (n = 8) from the general population sample who self-reported a characterised by multiple vulnerabilities at the level of self-concept. For diagnosis of bipolar disorder. Removing them from the analyses did not impact instance, people with BD in prior research have been observed to show the directional significance of the findings. Findings were presented withthe low and/or unstable self-esteem (Knowles et al., 2007; Nilsson et al., whole samples. 2010; Pavlova et al., 2011), self- of incompetence and in- adequacy in multiple social roles (Prerost and Song, 2012), elevation of Table 4 problematic self-schemas such as undeveloped self and grandiosity Correlations between self-compassion and nonattachment and symptoms in BD (Ak et al., 2012), and greater self-compartmentalisation and self-com- participants. plexity representing disintegrated self-concept (Power et al., 2002; Measures 1 2 3 4 5 Taylor et al., 2007). The present study adds to this literature an in- dicator that the vulnerabilities of self-concept in BD might also be SCS 1 manifested in diminished self-compassion and nonattachment to self. NTS 2 0.694** The current study showed that diminished self-compassion was as- YMRS 3 −0.108 −0.120* MADRS 4 −0.201* −0.231** 0.361** sociated with higher severity of depression in the BD group, in contrast QIDS-SR 5 −0.308** −0.298** 0.327* 0.684* with the findings of prior work by Døssing et al. (2015). Døssing et al.’s Illness duration 6 0.042 0.008 −0.055 −0.039 0.018 (2015) finding might be attributable to the small sample size(n = 30), which is statistically susceptible to type II error (i.e., failure to reject a Note. N = 302. BD =bipolar disorder, SCS =Self-Compassion Scale, NTS false null hypothesis). The negative association between self-compas- =Nonattachment to Self Scale, YMRS = Young Mania Rating Scale, sion and bipolar depression in the current study is likely to be robust as MADRS = Montgomery-Asberg Depression Rating Scale, QIDS-SR = Quick Inventory of Depressive Symptomatology-Self Report. ** p < .01, * p < .05. this association was present for both the self and clinician-rated mea- sures. On the other hand, there was no association found between self- 5. Discussion compassion and hypo/manic severity in both our study and that of Døssing et al. (2015). Neff’s (2003b) conceputlisation of self-compas- The present study examined self-compassion and nonattachment to sion entails a kind attitude towards the self during the person's adver- self in BD relative to a general population sample, and associations of sity. Self-compassion might not be relevant to the hypo/manic states these variables with BD symptomatology. As hypothesised (Hypothesis that predominately charaterise ecstatic moods, inflated confidence and 1), the difference in self-compassion and nonattachment to self was high levels of energy. Alternately, the lack of association between self- significantly predicted by BD-status, with lower levels of both in theBD compassion and hypo/manic symptomology might be explained by the group after taking into account demographic characteristics. Group restrict range of hypo/manic severity that the eligible participants differences remained after controlling for state mood operationalised in presented (e.g., the mean score of the YMRS was 2.92 in our BD group), the anxiety subscale of the DASS. Study findings partially confirmed as those with more severe hypo/manic symptoms were excluded from Hypothesis 2. As expected, both self-related constructs were negatively the study. It is also worth noting that illness duration was not associated associated with self and clinician-rated depressive symptomology, and with either of the self-related constructs, possibly suggesting that ma- nonattachment to self was negatively associated with hypo/manic ladaptive self-concept measured in the current study is less likely to be a

46 Y. Yang, et al. Journal of Affective Disorders 262 (2020) 43–48 result of the experience of BD symptoms. Taken together, whilst the 6. Conclusions relationship between self-compassion and hypo/mania was not estab- lished and may benefit from further investigation, the present findings The current findings suggest that individuals with BD have lower suggest that low levels of self-compassion may contribute to more se- levels of self-compassion and nonattachment to self, compared with the vere depression in BD. general population. The study contributes meaningfully to the growing The study showed that lower levels of nonattachment to self were self-concept research in BD by investigating how two novel self-related associated with greater severity of depression and hypo/manic symp- constructs may be manifested in BD. The negative associations between tomology in participants with BD. The finding is consistent with Yang the two constructs and bipolar symptoms found in the current study et al. (2018) that reported negative associations between nonattach- shed light on potentially viable ways to ameliorate these symptoms ment to self and bipolar tendencies in a non-clinical sample. Whilst this particularly in BD depression through cultivation of self-compassion is the first study to empirically investigate nonattachment to self inBD, and nonattachment to self. the finding suggests that a tendency to rigid fixation on personal traits may contribute to escalation of depresson and hypo/mania in BD. Our Contributors speculation fits well with major psychological models of BD. Forin- stance, the cognitive model developed by Mansell et al. (2007) suggests Author Yan Yang managed the literature searches, designed the that people with BD are particularly sensitive to personally relevant study, collected and analysed the data, and wrote the first draft of the information and this heightened sensitivity may serve as an important manuscript. Authors Kathryn Fletcher and Greg Murray contributed to antecedent to the occurance of mood eposides. It is plausible that the all stages of the study, draft proofreading and editing. Author Erin E. associated vulnerabilities at the level of self-concept in BD may be Michalak contributed to editing and manuscript preparation. All au- rooted in an over-attachment to self-concept. If this is established, thors have approved the final manuscript. cultivation of nonattachment to self may be an important therapeutical goal in psychological interventions. Role of the funding source There is growing empirical evidence supporting the therapeutic benefits of both self-compassion (Krieger et al., 2016) and nonattach- The authors disclosed receipt of the Australian National Health and ment to self (Van Gordon et al., 2016) in treating mental disorders. The Medical Research Council (NHMRC) project grant (APP1102097) for present study yielded preliminary but promising findings to motivate the project. However, the funder did not influence the study design, and further research into the role of self-compassion and nonattachment to preparation and submission of the manuscript. self in BD. For instance, Døssing et al. (2015) posited that self-com- passion may represent a shared vulnerability across mood disorders, Declaration of Competing Interest however this hypothesis has not yet been investigated empirically. As such future research can examine self-compassion and nonattachment The Authors declare no conflicts of interest to self in BD and unipolar depression simultaneously. Clinically, it is a promising possibility that these two novel variables may be effectively Acknowledgements targeted in therapy to decrease illness severity and improve quality of life for individuals with BD. We thank our research participants, the research team Fiona Foley, Self-compassion and nonattachment to self can be seen as related Katrina Lindblom, Summer Guo and Kerrie Salsbury for recruitment but distinguishable constructs. As shown in the present study, they were assistance, and Lesley Berk, Michael Berk, Steve Bowe, Sue Cotton, moderately correlated and associated similarly with the majority of the Lidia Engel, Sheri L Johnson, Steven Jones, Michael Kyrios, Sara study variables except with hypo/manic symptoms (i.e., lowered non- Lapsley, Cathrine Mihalopoulos, Tania Perich and Neil Thomas for in- attachment to self was associated with hypo/manic severity whilst self- tellectual input regarding the larger international randomized con- compassion was not). One forum in which their difference may be ap- trolled trial (ORBIT). parent pertains to therapeutic strategies. Self-compassion involves cultivating an affective style of appraisal that entails positive valence of Supplementary materials self-concept including kindness and warmth. Nonattachment to self represents an ontological style, the therapeutic content of which focuses Supplementary material associated with this article can be found, in on deemphasising the importance of the self as an entity. Whilst the the online version, at doi:10.1016/j.jad.2019.10.042. latter contrasts drastically with the longstanding traditional approach of elevating the self (e.g., enhancing self-esteem, modifying self-pre- References sentation) in western , our results suggest that nonattach- ment to self may present an adaptive alternative target for BD psy- Ak, M., Lapsekili, N., Haciomeroglu, B., Sutcigil, L., Turkcapar, H., 2012. Early mala- chotherapy. daptive schemas in bipolar disorder. Psychol. Psychother. 85, 260–267. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental The study had a number of limitations, most notably its cross-sec- Disorders : DSM-5, fifth ed. American Psychiatric Association, Washington, DC. tional design precluding any inference as to causality (see aforemen- Arch, J.J., Landy, L.N., Brown, K.W., 2016. Predictors and moderators of biopsychological tioned). Longitudinal data is needed to further understand the role of social stress responses following brief self-compassion meditation training. Psychoneuroendocrinology 69, 35–40. self-compassion and nonattachment to self in BD. The exclusion of Bhambhani, Y., Cabral, G., 2016. Evaluating nonattachment and decentering as possible participants with severe hypo/manic symptoms might have contributed mediators of the link between mindfulness and psychological distress in a nonclinical to the null association between self-compassion and hypo/manic se- college sample. J. Evid. Based Complementary Altern. Med. 21, 295–305. verity. Additionally, considering nonattachment to self as a novel psy- Braun, T.D., Park, C.L., Gorin, A., 2016. 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