Research Article - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 0, Issue 0
Explanation of Subjective Experience in Patients with Bipolar I Disorder Facing Love Trauma Based on Grounded TheoryRoya Rezapur1, Shahram Vaziri2* and Farah Lotfi Kashani2
2Associate Professor, Department of Clinical Psychology, Faculty of Psychology and Social Sciences, Islamic Azad University of Roodehen Branch, Tehran, Iran
Shahram Vaziri, Associate Professor, Department of Clinical Psychology, Faculty of Psychology and Social Sciences, Islamic Azad University of Roodehen Branch, Tehran, Iran, Email: firstname.lastname@example.org
Received: 07-Feb-2022, Manuscript No. CSRP-22-53646; Editor assigned: 09-Feb-2022, Pre QC No. CSRP-22-53646(PQ); Reviewed: 23-Feb-2022, QC No. CSRP-22-53646; Revised: 28-Feb-2022, Manuscript No. CSRP-22-53646(R); Published: 07-Mar-2022, DOI: 10.3371/CSRP.RRSV.030722
Experiencing failure and rejection in emotional relationships is a traumatic experience in patients with bipolar I disorder due to their mood changes. This study aimed to explain subjective experience in confrontation with love trauma in patients with bipolar I disorder. To achieve this goal, a qualitative research method, grounded theory based on the Strauss-Corbin approach, and a semi-structured interview were used. The participants were 19 patients with bipolar I disorder in 2021 in Zanjan City who was selected based on theoretical sampling and theoretical saturation. Data analysis was performed based on three coding methods: open, axial, and selective coding. Analysis of participants' experiences led to the identification of 102 primary concepts, 13 subcategories, and 5 main categories, including "traumatic experiences within one’s family", "vulnerable/undeveloped-self", "ineffective coping strategies", "negative experience of separation" and “interfering factors associated with intimate partner". The category of "vulnerable/undeveloped-self" was at the heart of the present study. Misbehaviour, neglect, and stressful family environment, as well as common traumatic experiences within the family, could lead to a lack of proper development of "self" which in turn would lead it to get away from the positive growth process. The need to merge with the partner and the fear of loneliness and abandonment leads them to assume any distance and separation as rejection and therefore they attempt to employ ineffective coping strategies that challenge the structure of "self" and exacerbate the feeling of defect and shame.
Bipolar I disorder • Love trauma • Grounded theory
Bipolar disorder is a chronic debilitating mental disease characterized by clinical periods of depression and high mood (mania or mild mania) with normal mood intervals . Bipolar patients have longer illness periods with less improvement . Some other consequences of this disorder include mood instability , impulsiveness , functional destruction , and impaired interpersonal interactions as well as poor life quality . In a study, Whipple, et al. showed that these people face numerous conflicts and paradoxes in behavior, emotion, cognition, and interpersonal relationships and consequently have behaviors with problematic interpersonal results due to their extreme emotional reactions, explosive anger, and impaired perception of social signals (negatively biased interpretation of others’ feelings) [7,8]. They also have a problem making close friendships or expressing their feelings . Smyth, et al. found that bipolar patients are frequently challenged with the management of their symptoms, social performance, family, and romantic relationships . Love trauma is one of the most painful events in life  associated with some extreme symptoms that last long after the romantic failure  and influence one’s expectation of a safe relationship (and of the relationship itself). This traumatic experience causes psychological, emotional, and even physical distress .
The present study seeks to understand the experience of failure and abandonment as a common phenomenon amongst bipolar patients. The most important point in this study is the experience of failure in romantic relationships and its meaning to these patients that is symbolic interaction. In symbolic interactionism, it is supposed that the outer world is symbolic. Both the outer and the inner worlds are created/recreated through interaction; meanings are aspects of interactions that relate to other systems of meaning. Since the researcher was not able to measure the real inner feelings of bipolar patients when facing love failure by a quantitative approach, qualitative approach and grounded theory seem to be good methods that seek to explore and theoretically explain the statements and interpretations for a specific phenomenon . This method is also a good way of attaining an insight through exploring meanings that are not obtained just by finding a cause-effect relationship but by promoting our perception of the whole. From among all proposed qualitative approaches, the grounded theory, with its focus on symbolic interactionist presuppositions, may be useful in explaining a patient’s experience. Research of grounded theory has been designed to study social phenomena and incorporating a regular set of data collection methods may help plan a theory through an analogical method. During the research process, the author analyses the data and then redefines or formulates emerging analytical theories by a dynamic approach .
Despite the destructive effects of bipolar disorder, studies on this clinical debilitating disorder are limited. Moreover, instability in relationships along with mood instability and problems with emotion regulation are among the most important characteristics of this mood disorder. However, regarding love failure, with its strong relationship with mood instability and emotion regulation, limited quantitative research has been done. On the other hand, these studies have not done more qualitative analyses on this disorder, especially on romantic relationships with other people including their love partners (that affects mood instability); in other words, reviewing the studies indicated that we scarcely know much about the process of romantic failure in bipolar patients and there is no comprehensive study on this process. Feeling failure and rejection is considered a traumatic experience and one of the main problems in bipolar patients that lead to the recurrence of the disease. Since the perception and explanation of this mental experience can be effective in explaining the patient’s experience and selecting the best treatment, and because the insight resulting from the patient’s experience can help therapists to treat this disorder and other similar disorders besides developing the related theories, the present study sought to explain the mental experience of patients with bipolar disorder facing romantic failures (love trauma).
The present study was conducted with a qualitative approach based on the grounded theory of Corbin and Strauss . Because the study aimed to develop deep rich data, regarding love failure experiences of bipolar patients, the qualitative approach and the grounded theory were selected. The population of the study consisted of patients with bipolar disorder who were between 16 to 38 years old, able to understand and speak the Persian language, and had the desire to participate in the study. In grounded theory, the process of participant selection is started with objective-based methods and ended with theoretical sampling . To select the participants, the researchers referred to psychological clinics and the psychiatry wards of Zanjan hospitals. The psychologists and psychiatrists of these centers were informed and the bipolar patients were included with their consent and will. The selection of new participants depended on previous participants, their related data, the resulted categories, and the relationship between the categories .Therefore, in the present study, theoretical sampling as a part of the collection process, the analysis process to fill the categories, and theoretical development to saturate the concept categories continued. The saturation was when the interviews with the participants were repeated and no new concept was derived to form a new category. As a result, after interviewing four other participants, gaining no new findings to foster new categories, the sampling process ended. The guiding principle for sampling in qualitative researches is data saturation that is when:
1) No new data or data related to a category is obtained
2) The category is developed for its characteristics, dimensions, and variety
3) The interactions among the categories are determined and validated
The major method of data collection for the present study was deep unstructured interactional (face-to-face) studying the individuals to attain a clear, deep, and pure image of the bipolar patients’ mental experience. The data was collected and analyzed from February to July 2020 (5 months). First, primary questions related to the study objectives were formulated. After the first interview, flaws of questions and the whole process of the interview were identified and modified with the help of the research group. After obtaining the introduction letter from the concerned university, the interviews began. With participants’ consent, the interviews were recorded and transcribed word by word. At the same time, interviews were soon analyzed. The data collected from numerous sessions and their analyses were given to the research group. Then, data from previous interviews and the resulted concepts became the basis for future interviews and data collections. In the present study, sampling continued to the completion of the relationships among the categories and saturation, with no limitations. After analyzing the last four interviews, the researcher found that no new data was added and all the information was just repeated. Moreover, the characteristics of the categories were completed and their relationships were identified. Regarding the theoretical saturation, data collection was stopped. In total, 23 bipolar patients were interviewed and 19 were determined to provide rich data for the researcher, so they were selected as the participants/subjects. The formal duration for an interview depended on the situation and the environment, participants’ consent, time, and mood; it ranged from 35 minutes to 70 minutes with an average of 43 minutes. To assure the accuracy of recordings and prevent likely data loss, all the interviews were recorded by two cell phone devices. Data collection and analysis were done simultaneously. Corbin, et al. methodology was incorporated in data analysis. In such a methodology, the analysis involves the process of creation, development, and clearing the concepts being made during the time. The researcher analyzed to determine the concepts, ground, the current process of action, interaction, perception of events, and finally the fusion of the categories. At the beginning of the study, the analysis was usually partial or microscopic because, before getting any interpretation, the researcher tried to find all possibilities. The next analyzes were more general to attain full development and validation for the interpretations . Data analysis was done by Corbin, et al. methodology in four stages: data analysis for concepts, data analysis for the ground (background), the inclusion of the process in the analysis, integrity of categories. First of all, the researcher started to conceptualize, and then integrate the categories within one central combination to develop a theoretical line for the whole story and consequently identify the central category. This study was conducted by the code of conduct IR.IAU.TMU. REC.1399.580 with informed consent from the participants, assuring them about the confidentiality of the information, their right to leave the study, and their privacy of them.
The participants of the study were 19 patients with bipolar disorder. Their age ranged from 19 to 41 years old with a mean of 30. Their education ranged from high school to bachelors. 102 major concepts were derived at the coding stage. 13 primary categories were identified: misbehavior, need to merge with the partner, fear of loneliness and abandonment, self-harm behavior, other destructive behaviors, emotional experiences of separation, cognitive experiences of separation, symptoms of depression, symptoms of mania, internal interfering factors, external intervening factors. Finally, after axial coding and selective coding, 5 categories were extracted: vulnerable/undeveloped self, inefficient coping strategies, negative feelings of separation, and interfering factors related to the partner. After reviewing these 5 categories, and rereading the theoretical story and the concepts, the central concept of “vulnerable/undeveloped self” was formulated (Table 1).
|Type of concept||Concept||Subcategory 1||Subcategory 2||Subcategory 3|
|Background||Traumatic experiences within the family||Physical/ mental misbehavior||Misbehavior||Corporal punishment|
|Being teased by others|
|Family distrust in the individual|
|Ignorance||Being deprived of mother’s love|
|Being deprived of family empathy|
|Being deprived of family life|
|The emotional coldness with the family|
|Stressful family environment||Tension with parents|
|Family mental illness|
|abandonment||Need to merge with the intimate partner||Extreme need to attention|
|Need to partner’s permanent presentation|
|Fear of loneliness||Not tolerating loneliness|
|Begging to avoid abandonment|
|Fear of loss|
|Strategies||Inefficient coping strategies||Self-injured behaviors||Social isolation|
|Threat to suicide|
|Commit a suicide|
|Drug/ alcohol abuse|
|Perceived punishment/ atonement|
|Overuse of medicine|
|Making numerous relationships|
|Running away from home|
|Other destructive behaviors||Conflicts with the law|
|Harm to others|
|Consequences||Negative experiences of separation||Emotional experiences of separation||Boredom to the partner|
|feeling wicked and dirty|
|Perceived rejection/ abandonment|
|Anxiety and restlessness|
|Loss of perceived possession|
|Loss of self-confidence|
|Feeling that no one loves the individual|
|The feeling of being humiliated|
|Perceived weakness and disability from the illness|
|Feeling boredom to the opposite sex|
|Cognitive experiences of separation||Mental rumination about the partner and the reasons for separation|
|Blaming the partner|
|Negative attitude toward love|
|Negative feeling toward one’s self|
|Symptoms of depression||Low mood|
|Losing joy and interest|
|Lack of energy|
|Low ability to think|
|Symptoms of maniac||Needing less sleep|
|Being busy in activities with bad consequences|
|Feeling high energy|
|Interfering conditions||Interfering factor related to the partner||Internal interfering factors||Existence of another person|
|The emotional coldness with the partner|
|Lack of ability in meeting needs|
|Recurrence of the illness|
|External interfering factors||Sexual abuse|
|Lack of partner’s independence|
|Being deprived of family support|
|Lack of understanding from the partner|
|Numerous failures in the past|
|Partner’s parents’ addiction|
|Family disapproval of marriage|
|Drug abuse at lower ages|
|Drug abuse in company with the partner|
|Family distrust to one’s partner|
|Mental illness stigma|
The final stage of data analysis in grounded theory is fusion or integration of the categories that is done to create a theory, and by making a relationship between the categories around a central category, and then purification and modification of the resulting theoretical structure. The central category reflects the main theme of the research, covers the whole analyzed data, and shows the quality of the research. The researcher tried to provide an acceptable explanation of bipolar patients’ experience of romantic failures by searching the lost issues and linking all the disciplines involved in the research. To find the central category, answering the question: “what is happening?” based on data from the analysis process, the major line of the story was obtained and a research paradigm was designed (Figure 1).
The grounded event in the process of emotional romantic failure in bipolar patients is perceived as “vulnerable/ undeveloped self”. Due to the effect of traumatic experiences within one’s family, these traumas have irrecoverable emotional damages by physical/mental misbehavior. Irresponsible or abusing environment leads to futile relationships with family members. The physical/ mental harms felt within the family are more effective when they are from the beloved ones, like the parents. These behaviors impose traumas like feeling weak, low self-confidence, not bearing loneliness, feeling invaluable, feeling of being dirty or wicked, feeling guilty, and generally, ‘vulnerable’ self. The personality is questioned and the feeling of a developed self is not developed so it is associated with lower mental capacity and mental disorder. Such traumatic experiences may lead to inefficient attitudes towards one’s self and others which pave the way to higher irritability to the others’ attitude towards one, and the possibility of surrender to others. The undeveloped self in such individuals makes them need continuous admits by others and consider themselves as being dirty, invaluable, inadequate, and infernal at the time of separation. With these identity flaws and vulnerable selves, they need a significant other to continue their mental life. Emotional separation creates unbearable anxiety for them; extreme anxiety, perceived abuse, and anger eruption in the form of exploding feelings and impulsive behaviors felt after separation from the lover, result from the anxiety of destruction which in turn leads to suicide thoughts, committing suicide, and other destructive harmful behaviors. They then feel a sense of freedom for a long time. Their desire to merge with the partner leads to more rejection from the partner so that when the partner leaves the patients try to go near them and feel their presence much more than in the past. However, this is very annoying for the partner. The undeveloped self leads to patients’ denial of a distinctive identity for themselves and then getting much closer to the partner, which in turn intensifies the vulnerable self of the patient. The patient has no way but to get closer and closer to continue emotional relationships (where the boundaries between self and others are unclear). In such an emotional relationship, the significant other becomes a part of one’s self and two factors of constant presence and accessibility are covers for their perceived vulnerable self.
After the separation, they have constant rumination about their relationship and reasons for their separation which in turn leads them to self-blame and blaming of the partner or others. It also hurts their attitude towards love and makes a negative perspective about ‘self’ so that, instead of making the present time better for themselves, the individuals think about their past behaviors wishing to have a better behavior (regret). Besides creating cognitive errors, separation increases the possibility of recurrence of depression symptoms, like low mood, loss of joy and interest, lack of energy, sleeping problems, decreased thinking ability, suicide thoughts, as well as symptoms of mania like irritable mood, impulsiveness, feeling high energy, distractibility, needing less sleep, and being busy with activities with negative consequences which in turn lead to broader consequences for patients. Separation and romantic failures threaten ‘self’ by creating a sense of detachment. As a result, the patients always seek ways of reconnecting to their partners. If they do not find such ways, they use some coping strategies leading to more rejection from the partner. Acting out, impulsive uncontrollable behaviors, and extreme anxiety, with their frightening nature, reflect the belief in the patient that they need merging and if they do not attain it, they feel lonely and hopeless. Drug/ alcohol abuse are some of those inefficient coping strategies and when the patient’s efforts to ‘merge’ with the partner are in vein, some attractive symptoms like committing suicide, aggression, drug abuse, alcohol abuse, etc. emerge. Because emotional failure is associated with feeling hatred toward one’s self, as well as perceived atonement, such behaviors like social isolation and self-harm occur. In addition, it paves the way for running away from home and having conflicts with the law, as well as, damaging other people, or the desire to get revenge from the partner. Generally, inefficient coping strategies of these patients are a desperate effort to experience their failed merging and enthusiasm to the partner.
The tragic story of romantic adventures along with numerous failures experienced by bipolar patients is continuing nonstop. However, the thing that intensifies the pain from perceived abandonment during and after the separation are the interfering factors being imposed from the outside, including lack of understanding from others, being blamed, being judged, etc. one of the major issues for bipolar patients stems from the fact that, they have never been understood or even counted by others, nor have they been abused by sexual assault, abortions, unwanted pregnancies, and partner’s cheatings. This would have consequences related to emotional failure and abandonment as well as vulnerability. Other major interfering factors are interpersonal conflicts with the partner, lack of family supports, the stigma of mental disease, which is in turn likely to lower the quality of other relationships and more failures by affecting the patient’s emotional relationship with their partner.
The aim of the present study was to explain subjective experience in bipolar patients with bipolar I disorder facing love trauma, and the process was explained by background theory from qualitative approach. The process of love failure or trauma in these patients paves the way for some background factors like family traumatic experiences including various abuses, ignorance, and tension, the result of which is that the patient’s ‘self’ is not developed positively; moreover, negative experiences of separation and the resulted depression and mania result in a vulnerable sensitive ‘self’ governed by perceived ugliness of appearance, defect and unworthiness. As a result they give a negative response to intercourse with partner, fear of loneliness and perceived abandonment. They consider any kind of distance and separation from the partner as a rejection which triggers intense reactions in them. This continues until the real abandonment and separation occurs, and when these patients face the leaving of their partner (because they have no imagination of a life without the partner), they employ useless inefficient coping strategies which in turn intensifies defectiveness and questions their own ‘self’. In such a situation, lack of support from significant others aggravates the negative feelings from abandonment and then they develop a feeling of defectiveness and vulnerability. As the central variable with 5 primary layers and 102 concepts, ‘vulnerable/ undeveloped self’ explained the emotional failure and its quality in patients with bipolar I disorder. Misbehavior/abuse, ignorance and tension in the family is a sign of inefficient parenting styles, and childhood/adolescence traumas, as a background factor for the mentioned disorder, warn the need for training appropriate parenting styles and promoting awareness within the whole society in order to escalating the knowledge of good parenting. Likewise, therapist’s attention to bipolar disorder regarding the ‘vulnerable/undeveloped self’ helps such patients better understand their own (sometimes contradictory) needs and expectations. This way the therapist finds the best therapy to shaping the unorganized ‘self’ in order to correct the defected development process among these patients and consequently help them grow a better character. In addition, training efficient coping strategies and promoting behavior repertoire of bipolar patients have a significant role in preventing the return of their symptoms.
Regarding the core category of ‘vulnerable/undeveloped self’, understanding and explanation of the subjective experience has a remarkable part in explaining patient’s experience and choosing the best therapy. The insight resulted from the patient’s experience of the failure (trauma) expands the various theories on this subject which is helpful in treatment of bipolar disorder and other similar disorders. With the theoretical model of the process of experiencing love trauma in patients with bipolar I disorder, therapeutic, interventional and rehabilitating protocols can be provided for the patients. It is recommended that the present study be conducted on other patients like patients with Narcissistic Personality Disorder (NPD). It is also recommended that other studies be conducted considering questions regarding family patterns of bipolar patients and the factors influencing their coping with love trauma.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Washington, D.C.: American Psychiatric Association Publication, USA, (2013).
- Tundo, Antonio, Franco De Crescenzo, Davide Gori and Paola Cavalieri. "Long-term Treatment Response to Continuous Cycling Course in Bipolar Disorders: A Meta-Analysis." J Affect Disord 241 (2018): 367-70.
- Mason, Liam, Eran Eldar and Robb B. Rutledge. "Mood Instability and Reward Dysregulation-A Neurocomputational Model of Bipolar Disorder." JAMA Psychiatry 74 (2017): 1275-6.
- Feki, Ines, Mariem Moalla, Imen Baati and Dorsaf Trigui, et al. "Impulsivity in Bipolar Disorders in a Tunisian Sample." Asian J Psychiatr 22 (2016): 77-80.
- Bonnín, Caterina Mar, Esther Jiménez, Brisa Solé and Carla Torrent, et al. "Lifetime Psychotic Symptoms, Subthreshold Depression and Cognitive Impairment as Barriers to Functional Recovery in Patients with Bipolar Disorder." J Clin Med 8 (2019): 1046.
- Brissos, Sofia, Vasco Videira Dias and Flávio Kapczinski. "Cognitive Performance and Quality of Life in Bipolar Disorder." Can J Psychiatry 53 (2008): 517-24.
- Whipple, Rachel and J. Christopher Fowler. "Affect, Relationship Schemas, and Social Cognition: Self-Injuring Borderline Personality Disorder Inpatients." Psychoanalytic Psychology 28 (2011): 183-95.
- Sharp, Carla, Heather Pane, Carolyn Ha and Amanda Venta, et al. "Theory of Mind and Emotion Regulation Difficulties in Adolescents with Borderline Traits." J Am Acad Child Adolesc Psychiatry 50 (2011): 563-73.
- Paris, Joel. Handbook of Personality Disorders: Theory, Research, and Treatment. New York: Guilford Press, USA, (2018).
- Smyth, Kristin, Alison Salloum and Jaclyn Herring. "Interpersonal Functioning, Support, and Change in Early-onset Bipolar Disorder: A Transcendental Phenomenological Study of Emerging Adults." J Ment Health 30 (2021): 121-8.
- Sailor, Joanni L. "A Phenomenological Study of Falling Out of Romantic Love." Qualitative Report 18 (2013): 37.
- Rosse, R. B. The Love Trauma Syndrome: Free Yourself from the Pain of a Broken Heart. Massachusetts: Da Capo Press, USA, (2007).
- Dehghani, Mahmood, Mohammad-Kazem Atef-Vahid and Banafsheh Gharaee. "Efficacy of Short–Term Anxiety-Regulating Psychotherapy on Love Trauma Syndrome." Iran J Psychiatry Behav Sci 5 (2011): 18-25.
- Speziale, Helen Streubert, Helen J. Streubert and Dona Rinaldi Carpenter. Qualitative Research in Nursing: Advancing the Humanistic Imperative. Lippincott Williams & Wilkins: Pennsylvania, USA, (2011).
- Corbin, Juliet, and Anselm Strauss. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. New York: Sage Publications, USA (2014).
- Corbin, Juliet, and Anselm Strauss. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. New York: Sage Publications, USA (2008).
- Ranjbar, Hadi, Ali Akbar Haghdoost, Mahvash Salsali, and Alireza Khoshdel, et al. "Sampling in Qualitative Research: A Guide for Beginning." AMHSR 10 (2012): 238-50.
Citation: Rezapur, Roya, Shahram Vaziri and Farah Lotfi Kashani. “Explanation of Subjective Experience in Patients with Bipolar I Disorder Facing Love Trauma Based on Grounded Theory.” Clin Schizophr Relat Psychoses 16S (2022). Doi: 10.3371/CSRP.RRSV.030722.
Copyright: © 2022 Rezapur R, 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. 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 work is properly cited.