Psychiatr. Pol. 2014; 48(3): 489–502 PL ISSN 0033-2674 www.psychiatriapolska.pl Profile of moral reasoning in persons with bipolar affective disorder Roksana Epa 1, Natalia Czyżowska 1, Dominika Dudek 1, Marcin Siwek 1, Józef Krzysztof Gierowski 2 1 Institute of Affective Disorders, Department of Psychiatry, UJ CM Head: prof. dr hab. D. Dudek 2 Department of Psychiatry, UJ CM Head: prof. dr hab. J.K. Gierowski Summary Aim: The subject of the research presented in this paper was to analyze the relationships between bipolar disorder (BD) and the profile of moral reasoning according to the concept of James Rest. Material and methods: 86 persons took part in the research, including 43 bipolar patients and 43 healthy individuals. To measure the severity of depression and mania symptoms the following scales were used: Hamilton Rating Scale for Depression (HAM-D), Montgom- ery- Asberg Depression Rating Scale (MADRS) and Young Rating Scale for Mania (YMRS). Profile of moral reasoning was defined on the basis of the results obtained in the Defining Issue Test (DIT) by James Rest. Results: Statistical analysis showed that there is a relationship between bipolar disorder (and its phases) and the profile of moral reasoning: bipolar patients significantly less often than healthy individuals chose answers indicating the postconventional thinking (p=0,000) – and more often – answers indicating stage 3 and those belonging to the anti-institutional thinking index (p=0,000). There was also a relationship shown between the development of moral reasoning and the phase of bipolar disorder: patients in mania less often than per- sons in euthymia chose answers indicating the final stage of moral thinking (p=0,050). There were no significant differences between the results of patients with a depressive episode and the results of patients in mania and between the results of patients with a depressive episode and the results of patients in euthymia. Conclusions: The results suggest that the psychological state of the individual may have an impact on the process of moral reasoning – bipolar disorder may to some extent influ- ence the way of thinking about moral dilemmas. The collected data also seem to emphasize the specificity of the manic phase which is especially worth exploration when conducting further studies. Key words: morality, development of moral reasoning, bipolar affective disorder 490 Roksana Epa et al. Introduction The issue of morality in bipolar disorder still remains an area that needs in-depth examination. There have been reports outlining the moral image of emotionality in bipolar patients pointing to the existence of some deviations from the norm in this group on the ability of empathizing, tendency to feel shame and guilt [1-5]. There are fewer studies demonstrating such behavioral tendencies in people with a diagnosis of bipolar disorder that express themselves in the proceedings resulting in crossing standards widely regarded as some determinants of what is morally right and proper [6, 7]. It should be noted that emotions and behaviour are only two-thirds of what can be understood by the term ‘human morality’. An equally important part of it – untested so far on the basis of psychiatry – is the cognitive component, described in terms of moral reasoning: understanding of the values, resolving dilemmas and making choices in ethically ambiguous situations. The research aims to present the issues of the development of moral reasoning diagnosed with bipolar disorder from the perspective of the concept of James Rest – a leading representative of neo-Kohlbergian approach in psychology of morality [8-10]. Rest, like Kohlberg [11], presented a model of moral development composed of six stages, showing the successive levels of moral thinking development (Table 1.). A very important element of the concept of Rest is putting pressure on the cognitive construction of social reality [12] – each person constructs and understands catego- ries such as: right, fault, justice, social order and reciprocity in their own way. It is equally important that changes in moral thinking, which take place during the life of the individual, are developmental – successive stages are characterized by more mature forms of understanding the rules governing social intercourse. Reaching a new stage of development, the person can better recognize what is right and consistent with the principles of justice and due to that cope better in a complex social reality [9, 10]. Thus, starting from the level when private needs and desires of a person are most important to him/her (reasoning is dominated by the so-called personal interests schema: stages 2 and 3), he/she reaches the point where he/she begins to perceive the surrounding reality from the perspective of a member of a social group – then sees the greatest value in caring for the welfare of society (the maintaining norms schema: stage 4). Although the vast majority of people stop at this stage, some part of them manages to get to the next one, where abstract values (not the rules set by society and institutions) – for example human life and dignity – are reliable indicators of what is morally correct (postconventional schema: stages 5 and 6). According to Rest [10], the mentioned schemas are developmentally ordered ways to answer the question of how to function in society to live properly. Profile of moral reasoning in persons with bipolar affective disorder 491 Tab.1. Stages of moral reasoning by James Rest Stage 1. The morality of obedience (relates in particular to children) Individual is self-centered and cannot take someone else’s perspective. The basic rule is obeying the immutable laws derived from the caregivers (seniority rule). Failure to comply with the rules should be punished. Personal Interests Schema Stage 2. Instrumental Egoism and Simple Exchange Person begins to perceive the needs and interests of others. The beginnings of cooperation, which is a favor for a favor exchange, are established. Person believes that the law should be respected only when it is beneficial and associated with the achievement of a particular purpose. Stage 3. Interpersonal Concordance Moral behavior is driven by care for the approval of others. Important limitation of this stage is that the cooperation between the units takes place only if they establish a relationship of friendship. The Maintaining Norms Schema Stage 4. Law and Duty to the Social Order Everyone is obliged to comply with the law and at the same time is protected by it. There is a formal organization of the social roles performed by the regulations, which enable the determination of the applicable standards. Compliance with the law applies regardless of the individual circumstances. Postconventional Schema Stage 5 (5A and 5B). Societal Consensus What is important is the choice of an appropriate and fair system of cooperation (5A) and respect for the fundamental rights of every human (“intuitive humanism”, 5B). Stage 6. Nonarbitrary Social Cooperation Morality is more than the effect of social consensus. Resorting to abstract moral principles (for example: life, dignity) Man is considered to be an end in itself, not a means to achieve another good. Order of the stages of moral development is immutable – that means, firstly, that changes always lead ‘to the top’ and secondly, that the individual who has reached a certain stage, could not miss any of the intermediate steps. However, pace of de- velopment and its final point can be differentiated [12, 13]. It should be noted that when a person goes to higher levels of reasoning, he/she does not lose the ability to use the schemes characterizing the previous stages – but begins to show a preference for values appropriate to the new developmental stage. Each level of moral reasoning is associated with different ways of interpreting the moral dilemmas and different as- sessment of their essential aspects [8]. 492 Roksana Epa et al. The main aim of the research was to answer the question whether people with a di- agnosis of bipolar disorder differ in terms of moral reasoning from healthy controls. The next goal was to investigate whether moral thinking is associated with the phase of the disease, and if so – what is the nature of this relation. Material and methods The research was conducted with the approval of Commission on Research Eth- ics at the Institute of Psychology Jagiellonian University. 86 persons took part in the research, out of whom half were patients diagnosed with the bipolar disorder (ac- cording to the criteria of ICD-10) treated in a stationary or ambulatory mode (n=43), and half – healthy volunteers. The group of healthy subjects included 18 men and 25 women (average age was 38.3 years), of which 31 persons had higher education and 12 had secondary education. The group of people with bipolar disorder included 14 men and 29 women (average age was 43.3 years), of which 30 persons had higher education, 10 had secondary education and one had vocational education. These groups did not differ significantly in terms of the structure of sex, age and level of education. The group of patients was further divided into three subgroups: (a) persons with a de- pressive episode (n=13), (b) persons in mania (n = 13) and (c) persons in euthymia (symptomatic remission) (n=17). The criterion for the division was the stage of the disease during the study. Patients were included in the specific subgroups on the basis of a diagnosis by a psychiatrist and obtained the appropriate number of points in the scales of depression and mania. To measure the severity of depressive symptoms the following scales were used: Hamilton Rating Scale for Depression (HAM-D) [14, 15] and the Montgomery-Asberg Depression Rating Scale (MADRS) [15, 16]. The minimum amounts of points, which meant inclusion of a person to the subgroup of patients with a depressive episode, were: 7 points for HAM-D and 11 points for MADRS.