Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatry. Jul 19, 2022; 12(7): 929-943
Published online Jul 19, 2022. doi: 10.5498/wjp.v12.i7.929
Believing processes during the COVID-19 pandemic in individuals with bipolar disorder: An exploratory study
Sophie Tietz, Jolana Wagner-Skacel, Hans-Ferdinand Angel, Michaela Ratzenhofer, Frederike T Fellendorf, Eva Fleischmann, Christof Körner, Eva Z Reininghaus, Rüdiger J Seitz, Nina Dalkner
Sophie Tietz, Christof Körner, Institute of Psychology, University of Graz, Graz 8010, Austria
Sophie Tietz, Michaela Ratzenhofer, Frederike T Fellendorf, Eva Fleischmann, Eva Z Reininghaus, Nina Dalkner, Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz 8036, Austria
Jolana Wagner-Skacel, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz 8036, Austria
Hans-Ferdinand Angel, Department of Catechetics and Religious Education, University of Graz, Graz 8010, Austria
Rüdiger J Seitz, Department of Neurology, Centre of Neurology and Neuropsychiatry Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf D-40629, Germany
Author contributions: Tietz S and Fleischmann E wrote the first draft of the manuscript; Dalkner N supervised the study procedure; Wagner-Skacel J, Angel H-F, Ratzenhofer M, Fellendorf FT, Körner C, Reininghaus EZ, Seitz RJ and Dalkner N edited the manuscript and gave important intellectual input.
Institutional review board statement: The study was reviewed and approved by the local ethics committee in accordance with the current revision of the Declaration of Helsinki, ICH guideline for Good Clinical Practice and current regulations (Medical University of Graz, Austria; individuals with BD were from the BIPLONG study, EK-number: 25-335 ex 12/13; data was collected in the course of a new study, EK number: 32-363 ex 19/20).
Informed consent statement: All study participants provided informed consent prior to study enrollment.
Conflict-of-interest statement: All the authors declare no conflict of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE guidelines and the manuscript was prepared and revised according to the STROBE guidelines.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nina Dalkner, MSc, PhD, Senior Scientist, Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Auenbruggerplatz 31, Graz 8036, Austria. nina.dalkner@medunigraz.at
Received: December 20, 2021
Peer-review started: December 20, 2021
First decision: March 13, 2022
Revised: March 27, 2022
Accepted: June 23, 2022
Article in press: June 23, 2022
Published online: July 19, 2022
Processing time: 210 Days and 15.2 Hours

Believing or “credition” refers to psychological processes that integrate the cognitions and emotions that influence our behavior. In the credition model by Angel and Seitz, four parameters are postulated: proposition, certainty, emotion and mightiness. It is assumed that believing processes are influenced by both the individual as well as socio-cultural factors and external circumstances. External or environmental circumstances can include threatening situations such as the ongoing pandemic. It has been hypothesized that believing processes related to the pandemic differ between individuals with bipolar disorder (BD) and healthy controls (HC).


To investigate credition in individuals with BD during the coronavirus disease 2019 (COVID-19) pandemic.


Psychiatrically stable individuals with BD (n = 52) and age- and sex matched HC (n = 52) participated in an online survey during the first lockdown of the COVID-19 pandemic. The survey took place between April 9th and June 4th, 2020, in Austria. Participants completed the Brief Symptom Inventory-18, the Beck Depression Inventory-II, the Altman Self-Rating Mania Scale, the Pittsburgh Sleep Quality Index and a dedicated Believing Questionnaire assessing four parameters of credition (proposition, certainty, emotion and mightiness). The MAXQDA software was used to analyze the qualitative data. Statistical analyses included analyses of variance, a multivariate analysis of variance and a multivariate analysis of co-variance.


Individuals with BD reported significantly more negative propositions [F (1,102) = 8.89, P = 0.004, η2p = 0.08] and negative emotions [Welch´s F (1,82.46) = 18.23, P < 0.001, η2p = 0.18], while HC showed significantly more positive propositions [F (1,102) = 7.78, P = 0.006, η2p = 0.07] and emotions [F (1,102) = 14.31, P < 0.001, η2p = 0.12]. In addition, individuals with BD showed a higher incongruence between their propositions and their emotions [F (1,102) = 9.42, P = 0.003, η2p = 0.08] and showed strong correlations between the parameters of the Believing Questionnaire and their psychiatric symptoms (r = 0.51-0.77, all P < 0.001). Positive as well as negative emotions and propositions were associated with scores measuring symptoms of depression, anxiety and sleep quality.


Believing parameters were associated with psychiatric symptoms in BD during the pandemic. Findings broaden knowledge about the susceptibility of believing processes for ambient challenges in individuals with BD.

Keywords: COVID-19, Bipolar disorder, Cognition, Emotions, Judgement, Evaluation study

Core Tip: Research concerning believing processes (“creditions”) in individuals with bipolar disorder (BD) during the coronavirus disease 2019 pandemic showed that patients reported more negative emotions and propositions than healthy controls who reported more positive emotions and propositions. Individuals with BD had a higher incongruence between their propositions and their emotions and strong correlations between the parameters of the Believing Questionnaire and psychiatric symptoms. These findings provide insight into the attitudes and beliefs of people with BD during a crisis.