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Manic patients exhibit more utilitarian moral judgments in comparison with euthymic bipolar and healthy persons Sung Hwa Kim a, b , Tae Young Kim a , Vin Ryu c , Ra Yeon Ha a , Su Jin Lee b , Kyooseob Ha c, d , Hyun-Sang Cho a, b,⁎ a
Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea c Department of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea d Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea b
Abstract Both emotional and cognitive processes are involved in moral judgments. Ventromedial prefrontal lesions are related to impaired prosocial emotions and emotional dysregulation, and patients with these lesions exhibit increased utilitarian judgments of emotionally salient personal moral dilemmas. Bipolar patients experiencing manic episode also have impaired emotional regulation and behavioral control. We investigated the characteristics of moral judgment in manic and euthymic patients with bipolar disorder using the 50 hypothetical moral dilemma task (17 non-moral, 20 personal, and 13 impersonal). Our study included 27 manic bipolar patients, 26 euthymic bipolar patients, and 42 healthy controls. Subjects were instructed to determine whether or not each dilemma was morally acceptable, and their reaction times were recorded. Manic patients showed significantly greater utilitarian judgment than euthymic patients and normal controls for personal moral dilemmas. However, there were no significant between-group differences for the non-moral and impersonal moral dilemmas. Our results suggest that increased utilitarian judgments of personal moral dilemmas may be a state-related finding observed only in manic patients. This difference in moral judgment assessments may reflect the decision-making characteristics and underlying neurobiological mechanisms of bipolar disorder, especially during the manic state. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Morality includes respecting the rights of others and having concern for their welfare [1]; thus, it determines the direction and form of human behaviors. In traditional moral psychology models, moral judgment has been regarded as a product of conscious reasoning [2]. However, the social intuitionist model recently proposed an important role of emotion in moral judgment and suggested that reasoning only offers post-hoc justifications for the judgment [3,4]. Greene et al. suggested a dual-process model in which moral judgment comprised both cognitive and emotional processing, and depending on the type of moral dilemma, one of two processes becomes a relatively larger contributor [5,6].
⁎ Corresponding author at: Department of Psychiatry, College of Medicine, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea. Tel.: +82 2 2228 1587; fax: +82 2 313 0891. E-mail address: [email protected] (H.-S. Cho). http://dx.doi.org/10.1016/j.comppsych.2014.12.010 0010-440X/© 2015 Elsevier Inc. All rights reserved.
There are well-known similar but different moral dilemmas, such as the “trolley” and “footbridge” dilemmas. In the “trolley” dilemma, a malfunctioning trolley is approaching five people. If it is switched to a side track, it will sacrifice only one person. In the “footbridge” dilemma, the only way to save the five people is by pushing one stranger off the footbridge and down onto the track. Most people say that to sacrifice one person to save the other persons is morally acceptable in the “trolley” but not the “footbridge” dilemma [7] because the latter is more emotionally salient [5]. This makes the “trolley” and “footbridge” dilemmas impersonal and personal moral dilemmas, respectively. Greene and colleagues showed that the ventromedial prefrontal cortex (VMPC) and superior temporal sulcus, which are associated with emotional processing, are relatively activated in personal moral decision making, whereas the dorsolateral prefrontal cortex and inferior parietal lobe, which are associated with cognitive control, are comparatively activated in impersonal dilemmas [5]. They suggested that these two separate psychological processes
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(i.e., cognition and emotion) influence moral judgment. From the view of utilitarian judgment, it is better that five people survive instead of one because this will promote the greater good. But most people feel strong emotional aversion or disgust when they choose utilitarian judgment [8,9] because they do not feel that the consequences justify the means. Despite intact moral reasoning, individuals with VMPC lesions, who exhibit markedly reduced social emotions (e.g., compassion or guilt) [10,11] and defects in emotional regulation [12], are more likely to endorse moral violations (e.g., pushing a person off a footbridge) when faced with emotionally salient moral dilemmas [13]. Subjects with Asperger's syndrome, which is characterized by impaired prosocial emotions, exhibit more utilitarian moral judgment, which has been associated with difficulties in social cognition [14]. Collectively, the evidence indicates that some psychiatric patients with impaired social emotion or emotional regulation may have different views about moral judgment compared with normal subjects. Bipolar disorder is a major psychiatric disorder characterized by alternating manic and depressive mood episodes with cognitive–perceptual and behavioral changes. During manic states, bipolar patients exhibit severe emotional dysregulation and loss of behavioral control [15,16], which manifest as increased goal-directed activities that might result in painful consequences or conflict with others. Treating manic patients can be difficult as they have judgmental and critical views of other people’s morality or conscience [17]. Manic patients also have difficulties in social cognition, including facial emotional recognition [18], theory of mind [19], and empathic abilities [20]. This impairment in social cognition has been associated with aggressive and maladaptive antisocial behaviors [21,22]. So impaired social cognition in mania frequently leads to disinhibition and the exploitation of others’ weaknesses [23]. Compared to euthymic patients, manic patients show reduced VMPC activity [24], which is an important region for human moral cognition [25]. Although remitted bipolar patients continue to exhibit some deficits in emotional processing and social cognition, the literature reports mixed outcomes or relatively small effects for facial emotional recognition [26,27], no difference for decision making [27], or less impairment of social compared with nonsocial cognitive ability [28]. In this study, we investigated moral judgment in manic and euthymic patients with bipolar disorder using the moral dilemma task. Because bipolar disorder is characterized by deficits in emotional regulation, social cognition and altered VMPC activity, especially in manic states, we hypothesized that manic patients would exhibit increased utilitarian moral judgment compared with euthymic patients and normal controls. We also investigated the prominence of group differences for “high-conflict” personal moral dilemmas and correlations between clinical symptoms/disgust scores and moral acceptability.
2. Methods 2.1. Participants The two patient groups included 27 manic and 26 euthymic patients with bipolar I disorder, which was diagnosed by two psychiatrists based on clinical interviews and the criteria for bipolar disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) [29]. Patients’ diagnoses were briefly confirmed using the MiniInternational Neuropsychiatric Interview (MINI) [30] by two qualified psychiatrists (S.H.K or R.Y.H and H.S.C). The subjects were recruited from the outpatient and inpatient units at Severance Mental Health Hospital in the Yonsei University Health System. Patients with schizoaffective disorder, severe personality disorder, recent substance abuse, a history of head trauma, or any other Axis I disorders were excluded. Euthymic patients were reported to be in remission for at least 2 months, and this was confirmed by scores b7 points on Young’s Mania Rating Scale (YMRS) [31] and b9 points on the Montgomery– Åsberg Depression Rating Scale (MADRS) [32] on the experimental day. Forty-two healthy control subjects were recruited from the local community via advertisement and were screened with the MINI administered by psychiatrists (S.H.K, R.Y.H, or H.S.C) to exclude neurological disease and other major psychiatric diseases. The subjects’ demographic and clinical characteristics are summarized in Table 1. The YMRS, MADRS, Beck Depression Inventory (BDI) [33], and Beck Anxiety Inventory (BAI) [34] were administered to all subjects to assess their objective and subjective mood and anxiety symptoms. The Disgust Scale-Revised (DS-R) is a 27-item measure of disgust sensitivity comprising three subscales of core disgust (i.e., rotting foods), animal-reminder disgust (i.e., death, body envelope violations), and contamination disgust (i.e., interpersonal transmission of bodily fluids) [35–37]. We administered the DS-R because disgust is experienced in response to a wide range of aversive stimuli, including moral violation [9]. This study was approved by the Institutional Review Board of Severance Mental Health Hospital and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent. 2.2. Dilemma task for moral judgment A battery of 60 moral dilemmas was adapted and translated from Green et al. [38]. These are available online (http://www.neuron.org/cgi/content/full/44/2/389/DC1/). Considering cultural differences, we evaluated the applicability of the battery with the Self-Assessment Manikin (SAM) [39] and response rate in eight normal control subjects. The SAM is a non-verbal, picture-oriented instrument that measures the affective dimensions (e.g., valence and arousal) associated in response to stimuli. We excluded 10 moral dilemmas with inappropriate response rates and affective reactions and ultimately used 50 hypothetical moral judgment dilemmas (17 non-moral, 20 personal moral, and 13 impersonal).
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Table 1 Sociodemographic and clinical characteristics of subjects. Mania
Euthymia
Control
F, t
P
Post-hoc
1N2=3 1=2N3
(n = 27)
(n = 26)
(N = 42)
or χ
Age (years) Gender (M/F) Education (years) IQ No. of admission Duration of illness (years) YMRS MADRS BDI BAI DS-R Total Core Animal reminder Contamination
34.6 ± 10.2 15/12 3.5 ± 0.5 106.3 ± 10.4 3.0 ± 2.2 7.4 ± 7.3 17.7 ± 9.1 5.1 ± 4.0 9.7 ± 10.4 9.2 ± 12.4 53.7 ± 16.8 27.0 ± 8.8 20.0 ± 6.1 6.7 ± 4.1
37.1 ± 9.8 13/13 3.6 ± 0.5 107.8 ± 10.2 3.8 ± 3.4 11.5 ± 8.6 1.3 ± 1.5 3.7 ± 3.1 8.2 ± 9.1 5.9 ± 6.2 65.4 ± 12.6 32.9 ± 6.6 23.5 ± 5.5 9.0 ± 3.1
33.7 ± 6.6 21/21 3.7 ± 0.5 111.5 ± 9.0 – – 0.7 ± 1.1 1.5 ± 2.2 6.3 ± 6.2 4.9 ± 4.8 54.7 ± 16.3 28.4 ± 8.0 20.4 ± 6.2 6.0 ± 3.5
1.301 0.239 0.748 2.585 −0.972 −1.889 109.796 12.013 1.343 2.363 4.854 4.172 2.865 5.728
0.277 0.887 0.476 0.081 0.336 0.065 b0.001 b0.001 0.266 0.100 0.010 0.018 0.062 0.005
Mood stabilizer Lithium (mg) Valproic acid (mg) Antipsychotics a
850.0 ± 209.6 (n = 15) 1041.7 ± 208.7 (n = 12) 528.2 ± 210.2 (n = 27)
890.0 ± 154.9 (n = 15) 796.2 ± 426.4 (n = 13) 171.2 ± 171.0 (n = 24)
– – –
−0.594 1.803 6.602
0.557 0.085 b0.001
2
2N1=3 2N1 2N3
IQ: Intelligent Quotient, YMRS: Young Mania Rating Scale, MADRS: Montgomery–Åsberg Depression Scale, BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory, DS-R: Disgust Scale-Revised, 1: Mania, 2: Euthymia, 3: Control. a Chlorpromazine equivalent dose (mg).
Personal moral dilemmas analogous to the “footbridge” dilemma require participants to consider the appropriateness of moral violence. These dilemmas have to meet three criteria: 1) harmful violation, 2) the victim must be a particular individual, and 3) authored, not deflecting an existent threat [38]. If these three criteria are not met, the dilemmas are classified as impersonal. Because the “trolley” dilemma involves deflecting an existent threat, it is considered impersonal. In this study, 20 personal moral dilemmas were further divided into “high” (n = 13) and “low” (n = 7) conflict dilemmas, as classified by Koenigs et al., which were based on reaction times and the general agreement of normal controls [13]. Impersonal moral dilemmas are less emotionally provoking than personal moral dilemmas (e.g., whether or not make a $200 donation to aid an organization). The non-moral dilemmas are neutral questions (e.g., whether to take the coastal route or highway when driving to your friend’s house). The moral dilemma task was presented on a computer using e-Prime software. Participants’ responses and their response times were recorded. They were instructed to read the dilemmas on the screen with no time limit and to answer “yes” or “no” in response to whether the proposed action was acceptable. One scenario consisted of three text screens, and response time recording started when the last text screen was shown. In the moral dilemma, a “yes” response meant advocating the proposed action to maximize the consequences despite strong emotional aversion.
χ 2 tests. Correlations between clinical characteristics and moral acceptability were explored with Pearson correlation tests. These statistical analyses were conducted with SPSS 19.0. To test for between-group differences in the probability of acceptance of the proposed action for each dilemma (non-moral, impersonal moral, and personal moral), we conducted a logistic regression fitted with the generalized estimating equations (GEE) method with SAS 9.2. GEE provides a framework to analyze correlated non-normally distributed dichotomous variables [40,41]. We applied this method because each type of dilemma consisted of several scenarios, and the probability of “yes” or “no” responses might have been correlated with the judgment of other scenarios. We also used the GEE method to test group differences in high- and low-conflict moral dilemmas. Mixed ANOVA with group as the between-subject factor and dilemma type as the within-subject factor was used to analyze reaction times. In post hoc analyses, Bonferroni corrections were performed to adjust the p-value for multiple comparisons. For further analysis of response times for low- and highconflict personal moral dilemmas across group, we used mixed-effects ANOVA (group × personal moral dilemma type). SAS version 9.2 was used for the statistical analysis of reaction times.
2.3. Statistical analyses
3. Results
The demographic and clinical characteristics of the manic and euthymic patient groups and the healthy control group were compared using analyses of variance (ANOVAs) and
The between-group differences in endorsement of the proposed action (i.e., a “yes” response) for non-moral, impersonal moral, and personal moral dilemmas are shown
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Fig. 1. Moral judgments of each dilemma type (non-moral, impersonal, and personal). On personal moral dilemmas, manic patients (n = 27) were more endorsement the proposed utilitarian action (“yes” judgments) than normal controls (n = 42) and euthymic patients (n = 26). But there were no significant differences between groups on the non-moral and impersonal moral dilemmas. Error bars indicate 95% confidence intervals.
in Fig. 1. In the analysis with the GEEs, manic patients were more likely to choose “yes” for the proposed action in personal moral dilemmas than euthymic patients (odds ratio [OR] = 1.871, p = 0.050) and normal controls (OR = 2.025, p = 0.009). However, no significant differences were found for non-moral (p = 0.942) and impersonal moral (p = 0.131) dilemmas. These findings indicate that manic patients’ responses only differed for personal moral dilemmas, which are more emotionally provocative than non-moral and impersonal moral dilemmas. In a more thorough analysis, personal moral dilemmas were subdivided into low- and high-conflict dilemmas. Manic patients made significantly more “yes” responses than euthymic patients and healthy controls in low-conflict dilemmas (mania vs. control, OR = 5.572, p b 0.001; mania vs. euthymia, OR = 3.739, p = 0.015) as well as high-conflict dilemmas (mania vs. control, OR = 2.058, p = 0.015; mania vs. euthymia, OR = 2.015, p = 0.049). There were no significant differences between the euthymic patients and healthy controls for low-conflict dilemmas (OR = 1.490, p = 0.325) or highconflict dilemmas (OR = 1.021, p = 0.947). A mixed ANOVA on reaction times with group (mania, euthymia, control) as the between-subject factor and dilemma type as the within-subject factor yielded statistically significant effects of both group (F = 4.06, p = 0.020) and dilemma type (F = 34.05, p b 0.001). There was no significant group × dilemma type interaction (F = 0.66, p = 0.622). Table 2 shows the between-group differences in reaction times for each dilemma type. There were no significant between-group differences for the impersonal (p = 0.113, corrected) or non-moral (p = 0.209, corrected) dilemmas. By contrast, for personal moral dilemmas, manic patients took significantly longer than normal controls (p b 0.05, corrected), with no differences between either manic and euthymic patients (p = 0.285) or euthymic and normal controls (p = 0.063).
Further analysis of reaction times for low-conflict and highconflict personal moral dilemmas revealed main effects of group (F = 4.73, p = 0.011) and dilemma type (F = 190.78, p b 0.001), but no statistically significant interaction was found (F = 0.81, p = 0.449). For low-conflict personal dilemmas, manic patients exhibited longer reaction times than normal controls (p = 0.007, corrected), whereas no difference was found between either manic and euthymic patients (p = 0.214) or euthymic and normal controls (p = 0.086). There was no significant between-group difference for high-conflict personal dilemmas (p = 0.119, corrected). We also investigated the correlations between endorsement of the proposed action and subjects’ clinical and emotional characteristics. In manic patients, there were no statistically significant correlations between personal moral acceptability and clinical symptoms or disgust emotion (YMRS, MADRS, BAI, disgust scale total, core disgust, animal-reminder disgust, and contamination-related disgust, all p values = 0.063–0.892). Euthymic patients exhibited a negative correlation between personal moral acceptability and contamination disgust (r = −0.415, p = 0.035), but there were no significant correlations between most clinical or other disgust emotion scores and personal moral dilemmas (all p values = 0.233–0.868).
4. Discussion We used moral dilemma tasks to compare moral judgments in manic and euthymic bipolar subjects and healthy controls. For emotionally salient personal moral dilemmas, manic patients were more acceptable of moral violations than normal controls and euthymic patients, both of whom had similar acceptability of personal dilemmas. However, the proportion of “yes” responses for impersonal or non-moral dilemmas was not significantly different among the three groups. Although a cross-sectional comparison was done with different subjects in different mood states, our finding suggests that altered moral judgment of personal dilemmas in the manic state may normalize once manic subjects become euthymic. To our knowledge, this is the first study to investigate moral judgments using the moral dilemma task in bipolar Ι disorder patients. More utilitarian judgment in manic patients in comparison to euthymic and healthy subjects may be due to the characteristic processing of emotional or cognitive information in the manic state. It has been reported that manic patients have impaired negative emotional processing. For example, manic subjects have impaired recognition of fear and disgust [18,42] and reduced P300 amplitudes elicited by negative facial stimuli (sad, fear, and disgust) [43]. Difficulties in ratings of negative facial emotions and affective labeling are also associated with manic states [42,44]. A recent study on moral judgment in subjects with alcohol dependence suggested that deficits in disgust and fear decoding contribute to utilitarian decision-making [45]. Manic patients’ reduced perception of negative emotional situations at the time of
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Table 2 Mean response times (ms) and standard errors across groups. Type of dilemma Non-moral Impersonal Personal Low-conflict High-conflict
Group Mania 6348.64 7409.29 6910.24 5617.31 7606.44
Euthymia ± ± ± ± ±
405.38 395.36 390.39 461.18 430.76
5653.41 6879.62 6312.09 4793.20 7129.96
± ± ± ± ±
pa
Post-hoc
0.209 0.113 0.023 0.024 0.119
– – 1N3 1N3 –
Control 413.10 402.90 397.82 469.97 438.97
5140.99 6127.24 5366.09 3756.71 6232.68
± ± ± ± ±
325.03 317.00 313.01 369.77 345.38
1: Mania, 2: Euthymia, 3: Control. a Corrected for multiple comparisons.
personal moral judgments could explain the increased utilitarian responses. This hypothesis is supported by a report stating that inducing positive affect increased utilitarian responses to the footbridge dilemma in healthy subjects [46]. With regard to cognitive functions, deficits in theory of mind ability and sustained attention are prominent or exacerbated in manic states [19,47,48]. Moreover, manic patients have impaired inhibition of behavioral responses to emotionallycharged stimuli in a go/no-go task [49], and they are more likely to make suboptimal and bad decisions for betting strategies in the Cambridge Gambling Task [50]. All these deficits observed in manic states may partially contribute to the differences in moral judgments between manic patients and euthymic or normal subjects. However, the fact that we only observed group differences for personal moral dilemmas cannot be fully explained by these deficits. According to Greene’s dual-process view [38,51], conflicts between utilitarian (a cognitive controlled response aimed at maximizing well-being) and deontological (an emotional aversion aimed at human duty) judgments happen when subjects consider personal moral dilemmas. In order to render utilitarian judgments when faced with personal moral dilemmas, cognitive processes should outweigh negative autonomic emotional responses. Recently, the understanding of moral judgments has focused on the integrated role of cognition and emotion rather than their mutually competing roles [52–54]. In particular, the VMPC is associated with integrative moral judgments involving utilitarian and emotional assessments [52]. Personal dilemmas strongly elicit increased amygdala responses in healthy subjects [38]. Also, amygdala activities are positively correlated with negative feelings or unacceptability associated with the utilitarian option, and amygdala-VMPC connectivity is higher when emotional components are more engaged [52]. Therefore, the interaction or reciprocity between the VMPC and amygdala is critical in making moral judgments. Likewise, altered functioning or connectivity between the prefrontal cortex, including ventrolateral and ventromedial regions, and the amygdala may be involved in emotional regulation and emotional processing in subjects with bipolar disorder [55–57]. Amygdala activity is increased during mania and is normal during euthymia when compared to healthy controls [57], and reduced activation of the ventral prefrontal cortex has been found across mood states in bipolar disorder [57]. It has been reported that the VMPC
(orbitofrontal) may be involved in modulating stimuli arising from internal feeling states (e.g., sadness elicited by a specific event) and automatic emotional regulation [58–60]. Therefore, the increased utilitarian judgment of personal dilemmas observed in manic patients might reflect disrupted synchronization between the prefrontal cortex and subcortical structures, including the amygdala. In other words, despite negative emotions produced by the amygdala in reaction to moral violations, VMPC dysfunction may result in failure to perform the integrative and balanced moral decision-making in the manic state. In this study, manic patients exhibited increased utilitarian responses even on low-conflict personal dilemmas as well as high-conflict ones. On the other hand, other reports found that VMPC-damaged or alcohol-dependent subjects showed no significant differences in “yes” responses to low-conflict dilemmas in comparison to healthy controls [13,61]. As described above, altered VMPC and amygdala activities in manic patients compared with euthymic or healthy subjects might lead to more utilitarian responses, even in low-conflict personal dilemmas. Impulsivity, a trait characteristic in bipolar disorder [62], is increased and related to impaired attention and behavioral inhibition or delayed reward gratification in the manic state [63,64]. This characteristic may be another potential reason for utilitarian responses even to low-conflict dilemmas in manic subjects. According to Kohlberg’s theory of moral development [2], there are three levels of morality. At the pre-conventional level, all focus is on the self, and behaviors are viewed according to the impact on the self. Individuals at the conventional level conform to rules of authority for mutual interpersonal expectations or society. Lastly, post-conventional individuals know that morality is more than social consensus and follow abstract moral principles (e.g., dignity). The endorsement of low-conflict personal dilemmas in manic patients (e.g., decide to get rid of your boss just because he makes everyone around him miserable, including you) could be explained by their possible focus on the self or interpersonal expectations. This interpretation is supported by a recent report that manic patients are less likely to choose post-conventional thinking than euthymic or healthy individuals ([65]). In the current study, manic patients had longer response times than healthy controls for personal moral dilemmas. This result was also observed for low-conflict personal moral
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dilemmas. As described above, our manic patients showed increased utilitarian judgments, even in low-conflict moral dilemmas. The deficits in verbal learning and sustained attention observed in patients with bipolar mania [47,48] could delay the comprehension of dilemmas. One study investigating a potential relationship between cognitive processes and utilitarian judgments found that cognitive load manipulation selectively increased the response times for utilitarian but not for non-utilitarian judgments [66]. Therefore, longer reaction times even for low-conflict dilemmas during a manic state may be due to cognitive interference associated with utilitarian judgments. Disgust is a basic emotion triggered by diverse stimuli from bad tastes to moral transgressions [67]. As one of three factors of the DS-R, contamination (interpersonal) disgust reflects the perceived threat of contagion by direct or indirect contact with other persons [68]. In the current study, euthymic patients exhibited a negative correlation between personal moral acceptability and the contamination disgust score, but this was not observed in manic patients. As shown in Table 1, euthymic patients showed greater disgust scores than manic patients and normal controls. Other studies have demonstrated selectively enhanced recognition of disgust facial expressions in euthymic patients [69] and reduced recognition of disgust faces in manic patients [18]. Enhanced disgust sensitivity in euthymia might affect the negative correlation between the personal dilemma response rate and the contamination disgust score. However, the total and other factor scores of disgust were not significantly correlated, therefore further study will be required to understand the relationship between disgust and moral judgments. In considering the clinical implications, our results suggest the need for discouraging or delaying important decision-making during the manic status. As impaired cognition or impulsivity may be related with this disinhibited behavior, behavioral intervention such as decreasing goal-directed activities is required for the treatment of manic patients. Moreover, unrealistically high goals and excessive confidence may be associated with increased utilitarian judgment; thus, cognitive behavioral approaches that promote better control over these judgment processes should be used. These approaches may be helpful for reducing manic symptoms and preventing mania. This study has several limitations. First, its cross-sectional design did not allow us to make inferences on longitudinal progress or causality in bipolar disorder. Such conclusions would require prospective studies and follow-up in different mood states. Second, we did not control for psychotropic medication use. Previous literature showed that enhancing serotonin or beta-adrenergic blockade might influence emotionally salient moral dilemmas toward deontological judgments [70,71]. We did not find any significant correlations between acceptability of each dilemma type (personal, impersonal or non-moral) and medications (chlorpromazine-equivalent doses or doses of lithium and valproic acid) in the patient groups. However, we cannot completely rule out the potential influence of psychotropic drugs on moral judgments. Third, our results should be carefully
interpreted because of the relatively small sample size and single-site recruitment. In conclusion, this study provides insight into characteristic moral judgments by subjects with bipolar disorder. Manic patients make more utilitarian moral judgments than either euthymic patients or normal controls with regard to emotionally salient personal moral dilemmas. These results suggest that increased utilitarian judgments on personal dilemmas may be a state-related phenomenon observed in only manic patients. This difference may be related to decision-making characteristics and the underlying neurobiological mechanisms of bipolar disorder, especially during manic states. Electrophysiological and imaging studies will be needed to identify the neural mechanisms related to unique moral judgments in bipolar disorder.
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ScienceDirect Comprehensive Psychiatry xx (2015) xxx – xxx www.elsevier.com/locate/comppsych
Manic patients exhibit more utilitarian moral judgments in comparison with euthymic bipolar and healthy persons Sung Hwa Kim a, b , Tae Young Kim a , Vin Ryu c , Ra Yeon Ha a , Su Jin Lee b , Kyooseob Ha c, d , Hyun-Sang Cho a, b,⁎ a
Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea c Department of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea d Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea b
Abstract Both emotional and cognitive processes are involved in moral judgments. Ventromedial prefrontal lesions are related to impaired prosocial emotions and emotional dysregulation, and patients with these lesions exhibit increased utilitarian judgments of emotionally salient personal moral dilemmas. Bipolar patients experiencing manic episode also have impaired emotional regulation and behavioral control. We investigated the characteristics of moral judgment in manic and euthymic patients with bipolar disorder using the 50 hypothetical moral dilemma task (17 non-moral, 20 personal, and 13 impersonal). Our study included 27 manic bipolar patients, 26 euthymic bipolar patients, and 42 healthy controls. Subjects were instructed to determine whether or not each dilemma was morally acceptable, and their reaction times were recorded. Manic patients showed significantly greater utilitarian judgment than euthymic patients and normal controls for personal moral dilemmas. However, there were no significant between-group differences for the non-moral and impersonal moral dilemmas. Our results suggest that increased utilitarian judgments of personal moral dilemmas may be a state-related finding observed only in manic patients. This difference in moral judgment assessments may reflect the decision-making characteristics and underlying neurobiological mechanisms of bipolar disorder, especially during the manic state. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Morality includes respecting the rights of others and having concern for their welfare [1]; thus, it determines the direction and form of human behaviors. In traditional moral psychology models, moral judgment has been regarded as a product of conscious reasoning [2]. However, the social intuitionist model recently proposed an important role of emotion in moral judgment and suggested that reasoning only offers post-hoc justifications for the judgment [3,4]. Greene et al. suggested a dual-process model in which moral judgment comprised both cognitive and emotional processing, and depending on the type of moral dilemma, one of two processes becomes a relatively larger contributor [5,6].
⁎ Corresponding author at: Department of Psychiatry, College of Medicine, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea. Tel.: +82 2 2228 1587; fax: +82 2 313 0891. E-mail address: [email protected] (H.-S. Cho). http://dx.doi.org/10.1016/j.comppsych.2014.12.010 0010-440X/© 2015 Elsevier Inc. All rights reserved.
There are well-known similar but different moral dilemmas, such as the “trolley” and “footbridge” dilemmas. In the “trolley” dilemma, a malfunctioning trolley is approaching five people. If it is switched to a side track, it will sacrifice only one person. In the “footbridge” dilemma, the only way to save the five people is by pushing one stranger off the footbridge and down onto the track. Most people say that to sacrifice one person to save the other persons is morally acceptable in the “trolley” but not the “footbridge” dilemma [7] because the latter is more emotionally salient [5]. This makes the “trolley” and “footbridge” dilemmas impersonal and personal moral dilemmas, respectively. Greene and colleagues showed that the ventromedial prefrontal cortex (VMPC) and superior temporal sulcus, which are associated with emotional processing, are relatively activated in personal moral decision making, whereas the dorsolateral prefrontal cortex and inferior parietal lobe, which are associated with cognitive control, are comparatively activated in impersonal dilemmas [5]. They suggested that these two separate psychological processes
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(i.e., cognition and emotion) influence moral judgment. From the view of utilitarian judgment, it is better that five people survive instead of one because this will promote the greater good. But most people feel strong emotional aversion or disgust when they choose utilitarian judgment [8,9] because they do not feel that the consequences justify the means. Despite intact moral reasoning, individuals with VMPC lesions, who exhibit markedly reduced social emotions (e.g., compassion or guilt) [10,11] and defects in emotional regulation [12], are more likely to endorse moral violations (e.g., pushing a person off a footbridge) when faced with emotionally salient moral dilemmas [13]. Subjects with Asperger's syndrome, which is characterized by impaired prosocial emotions, exhibit more utilitarian moral judgment, which has been associated with difficulties in social cognition [14]. Collectively, the evidence indicates that some psychiatric patients with impaired social emotion or emotional regulation may have different views about moral judgment compared with normal subjects. Bipolar disorder is a major psychiatric disorder characterized by alternating manic and depressive mood episodes with cognitive–perceptual and behavioral changes. During manic states, bipolar patients exhibit severe emotional dysregulation and loss of behavioral control [15,16], which manifest as increased goal-directed activities that might result in painful consequences or conflict with others. Treating manic patients can be difficult as they have judgmental and critical views of other people’s morality or conscience [17]. Manic patients also have difficulties in social cognition, including facial emotional recognition [18], theory of mind [19], and empathic abilities [20]. This impairment in social cognition has been associated with aggressive and maladaptive antisocial behaviors [21,22]. So impaired social cognition in mania frequently leads to disinhibition and the exploitation of others’ weaknesses [23]. Compared to euthymic patients, manic patients show reduced VMPC activity [24], which is an important region for human moral cognition [25]. Although remitted bipolar patients continue to exhibit some deficits in emotional processing and social cognition, the literature reports mixed outcomes or relatively small effects for facial emotional recognition [26,27], no difference for decision making [27], or less impairment of social compared with nonsocial cognitive ability [28]. In this study, we investigated moral judgment in manic and euthymic patients with bipolar disorder using the moral dilemma task. Because bipolar disorder is characterized by deficits in emotional regulation, social cognition and altered VMPC activity, especially in manic states, we hypothesized that manic patients would exhibit increased utilitarian moral judgment compared with euthymic patients and normal controls. We also investigated the prominence of group differences for “high-conflict” personal moral dilemmas and correlations between clinical symptoms/disgust scores and moral acceptability.
2. Methods 2.1. Participants The two patient groups included 27 manic and 26 euthymic patients with bipolar I disorder, which was diagnosed by two psychiatrists based on clinical interviews and the criteria for bipolar disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) [29]. Patients’ diagnoses were briefly confirmed using the MiniInternational Neuropsychiatric Interview (MINI) [30] by two qualified psychiatrists (S.H.K or R.Y.H and H.S.C). The subjects were recruited from the outpatient and inpatient units at Severance Mental Health Hospital in the Yonsei University Health System. Patients with schizoaffective disorder, severe personality disorder, recent substance abuse, a history of head trauma, or any other Axis I disorders were excluded. Euthymic patients were reported to be in remission for at least 2 months, and this was confirmed by scores b7 points on Young’s Mania Rating Scale (YMRS) [31] and b9 points on the Montgomery– Åsberg Depression Rating Scale (MADRS) [32] on the experimental day. Forty-two healthy control subjects were recruited from the local community via advertisement and were screened with the MINI administered by psychiatrists (S.H.K, R.Y.H, or H.S.C) to exclude neurological disease and other major psychiatric diseases. The subjects’ demographic and clinical characteristics are summarized in Table 1. The YMRS, MADRS, Beck Depression Inventory (BDI) [33], and Beck Anxiety Inventory (BAI) [34] were administered to all subjects to assess their objective and subjective mood and anxiety symptoms. The Disgust Scale-Revised (DS-R) is a 27-item measure of disgust sensitivity comprising three subscales of core disgust (i.e., rotting foods), animal-reminder disgust (i.e., death, body envelope violations), and contamination disgust (i.e., interpersonal transmission of bodily fluids) [35–37]. We administered the DS-R because disgust is experienced in response to a wide range of aversive stimuli, including moral violation [9]. This study was approved by the Institutional Review Board of Severance Mental Health Hospital and was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent. 2.2. Dilemma task for moral judgment A battery of 60 moral dilemmas was adapted and translated from Green et al. [38]. These are available online (http://www.neuron.org/cgi/content/full/44/2/389/DC1/). Considering cultural differences, we evaluated the applicability of the battery with the Self-Assessment Manikin (SAM) [39] and response rate in eight normal control subjects. The SAM is a non-verbal, picture-oriented instrument that measures the affective dimensions (e.g., valence and arousal) associated in response to stimuli. We excluded 10 moral dilemmas with inappropriate response rates and affective reactions and ultimately used 50 hypothetical moral judgment dilemmas (17 non-moral, 20 personal moral, and 13 impersonal).
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Table 1 Sociodemographic and clinical characteristics of subjects. Mania
Euthymia
Control
F, t
P
Post-hoc
1N2=3 1=2N3
(n = 27)
(n = 26)
(N = 42)
or χ
Age (years) Gender (M/F) Education (years) IQ No. of admission Duration of illness (years) YMRS MADRS BDI BAI DS-R Total Core Animal reminder Contamination
34.6 ± 10.2 15/12 3.5 ± 0.5 106.3 ± 10.4 3.0 ± 2.2 7.4 ± 7.3 17.7 ± 9.1 5.1 ± 4.0 9.7 ± 10.4 9.2 ± 12.4 53.7 ± 16.8 27.0 ± 8.8 20.0 ± 6.1 6.7 ± 4.1
37.1 ± 9.8 13/13 3.6 ± 0.5 107.8 ± 10.2 3.8 ± 3.4 11.5 ± 8.6 1.3 ± 1.5 3.7 ± 3.1 8.2 ± 9.1 5.9 ± 6.2 65.4 ± 12.6 32.9 ± 6.6 23.5 ± 5.5 9.0 ± 3.1
33.7 ± 6.6 21/21 3.7 ± 0.5 111.5 ± 9.0 – – 0.7 ± 1.1 1.5 ± 2.2 6.3 ± 6.2 4.9 ± 4.8 54.7 ± 16.3 28.4 ± 8.0 20.4 ± 6.2 6.0 ± 3.5
1.301 0.239 0.748 2.585 −0.972 −1.889 109.796 12.013 1.343 2.363 4.854 4.172 2.865 5.728
0.277 0.887 0.476 0.081 0.336 0.065 b0.001 b0.001 0.266 0.100 0.010 0.018 0.062 0.005
Mood stabilizer Lithium (mg) Valproic acid (mg) Antipsychotics a
850.0 ± 209.6 (n = 15) 1041.7 ± 208.7 (n = 12) 528.2 ± 210.2 (n = 27)
890.0 ± 154.9 (n = 15) 796.2 ± 426.4 (n = 13) 171.2 ± 171.0 (n = 24)
– – –
−0.594 1.803 6.602
0.557 0.085 b0.001
2
2N1=3 2N1 2N3
IQ: Intelligent Quotient, YMRS: Young Mania Rating Scale, MADRS: Montgomery–Åsberg Depression Scale, BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory, DS-R: Disgust Scale-Revised, 1: Mania, 2: Euthymia, 3: Control. a Chlorpromazine equivalent dose (mg).
Personal moral dilemmas analogous to the “footbridge” dilemma require participants to consider the appropriateness of moral violence. These dilemmas have to meet three criteria: 1) harmful violation, 2) the victim must be a particular individual, and 3) authored, not deflecting an existent threat [38]. If these three criteria are not met, the dilemmas are classified as impersonal. Because the “trolley” dilemma involves deflecting an existent threat, it is considered impersonal. In this study, 20 personal moral dilemmas were further divided into “high” (n = 13) and “low” (n = 7) conflict dilemmas, as classified by Koenigs et al., which were based on reaction times and the general agreement of normal controls [13]. Impersonal moral dilemmas are less emotionally provoking than personal moral dilemmas (e.g., whether or not make a $200 donation to aid an organization). The non-moral dilemmas are neutral questions (e.g., whether to take the coastal route or highway when driving to your friend’s house). The moral dilemma task was presented on a computer using e-Prime software. Participants’ responses and their response times were recorded. They were instructed to read the dilemmas on the screen with no time limit and to answer “yes” or “no” in response to whether the proposed action was acceptable. One scenario consisted of three text screens, and response time recording started when the last text screen was shown. In the moral dilemma, a “yes” response meant advocating the proposed action to maximize the consequences despite strong emotional aversion.
χ 2 tests. Correlations between clinical characteristics and moral acceptability were explored with Pearson correlation tests. These statistical analyses were conducted with SPSS 19.0. To test for between-group differences in the probability of acceptance of the proposed action for each dilemma (non-moral, impersonal moral, and personal moral), we conducted a logistic regression fitted with the generalized estimating equations (GEE) method with SAS 9.2. GEE provides a framework to analyze correlated non-normally distributed dichotomous variables [40,41]. We applied this method because each type of dilemma consisted of several scenarios, and the probability of “yes” or “no” responses might have been correlated with the judgment of other scenarios. We also used the GEE method to test group differences in high- and low-conflict moral dilemmas. Mixed ANOVA with group as the between-subject factor and dilemma type as the within-subject factor was used to analyze reaction times. In post hoc analyses, Bonferroni corrections were performed to adjust the p-value for multiple comparisons. For further analysis of response times for low- and highconflict personal moral dilemmas across group, we used mixed-effects ANOVA (group × personal moral dilemma type). SAS version 9.2 was used for the statistical analysis of reaction times.
2.3. Statistical analyses
3. Results
The demographic and clinical characteristics of the manic and euthymic patient groups and the healthy control group were compared using analyses of variance (ANOVAs) and
The between-group differences in endorsement of the proposed action (i.e., a “yes” response) for non-moral, impersonal moral, and personal moral dilemmas are shown
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Fig. 1. Moral judgments of each dilemma type (non-moral, impersonal, and personal). On personal moral dilemmas, manic patients (n = 27) were more endorsement the proposed utilitarian action (“yes” judgments) than normal controls (n = 42) and euthymic patients (n = 26). But there were no significant differences between groups on the non-moral and impersonal moral dilemmas. Error bars indicate 95% confidence intervals.
in Fig. 1. In the analysis with the GEEs, manic patients were more likely to choose “yes” for the proposed action in personal moral dilemmas than euthymic patients (odds ratio [OR] = 1.871, p = 0.050) and normal controls (OR = 2.025, p = 0.009). However, no significant differences were found for non-moral (p = 0.942) and impersonal moral (p = 0.131) dilemmas. These findings indicate that manic patients’ responses only differed for personal moral dilemmas, which are more emotionally provocative than non-moral and impersonal moral dilemmas. In a more thorough analysis, personal moral dilemmas were subdivided into low- and high-conflict dilemmas. Manic patients made significantly more “yes” responses than euthymic patients and healthy controls in low-conflict dilemmas (mania vs. control, OR = 5.572, p b 0.001; mania vs. euthymia, OR = 3.739, p = 0.015) as well as high-conflict dilemmas (mania vs. control, OR = 2.058, p = 0.015; mania vs. euthymia, OR = 2.015, p = 0.049). There were no significant differences between the euthymic patients and healthy controls for low-conflict dilemmas (OR = 1.490, p = 0.325) or highconflict dilemmas (OR = 1.021, p = 0.947). A mixed ANOVA on reaction times with group (mania, euthymia, control) as the between-subject factor and dilemma type as the within-subject factor yielded statistically significant effects of both group (F = 4.06, p = 0.020) and dilemma type (F = 34.05, p b 0.001). There was no significant group × dilemma type interaction (F = 0.66, p = 0.622). Table 2 shows the between-group differences in reaction times for each dilemma type. There were no significant between-group differences for the impersonal (p = 0.113, corrected) or non-moral (p = 0.209, corrected) dilemmas. By contrast, for personal moral dilemmas, manic patients took significantly longer than normal controls (p b 0.05, corrected), with no differences between either manic and euthymic patients (p = 0.285) or euthymic and normal controls (p = 0.063).
Further analysis of reaction times for low-conflict and highconflict personal moral dilemmas revealed main effects of group (F = 4.73, p = 0.011) and dilemma type (F = 190.78, p b 0.001), but no statistically significant interaction was found (F = 0.81, p = 0.449). For low-conflict personal dilemmas, manic patients exhibited longer reaction times than normal controls (p = 0.007, corrected), whereas no difference was found between either manic and euthymic patients (p = 0.214) or euthymic and normal controls (p = 0.086). There was no significant between-group difference for high-conflict personal dilemmas (p = 0.119, corrected). We also investigated the correlations between endorsement of the proposed action and subjects’ clinical and emotional characteristics. In manic patients, there were no statistically significant correlations between personal moral acceptability and clinical symptoms or disgust emotion (YMRS, MADRS, BAI, disgust scale total, core disgust, animal-reminder disgust, and contamination-related disgust, all p values = 0.063–0.892). Euthymic patients exhibited a negative correlation between personal moral acceptability and contamination disgust (r = −0.415, p = 0.035), but there were no significant correlations between most clinical or other disgust emotion scores and personal moral dilemmas (all p values = 0.233–0.868).
4. Discussion We used moral dilemma tasks to compare moral judgments in manic and euthymic bipolar subjects and healthy controls. For emotionally salient personal moral dilemmas, manic patients were more acceptable of moral violations than normal controls and euthymic patients, both of whom had similar acceptability of personal dilemmas. However, the proportion of “yes” responses for impersonal or non-moral dilemmas was not significantly different among the three groups. Although a cross-sectional comparison was done with different subjects in different mood states, our finding suggests that altered moral judgment of personal dilemmas in the manic state may normalize once manic subjects become euthymic. To our knowledge, this is the first study to investigate moral judgments using the moral dilemma task in bipolar Ι disorder patients. More utilitarian judgment in manic patients in comparison to euthymic and healthy subjects may be due to the characteristic processing of emotional or cognitive information in the manic state. It has been reported that manic patients have impaired negative emotional processing. For example, manic subjects have impaired recognition of fear and disgust [18,42] and reduced P300 amplitudes elicited by negative facial stimuli (sad, fear, and disgust) [43]. Difficulties in ratings of negative facial emotions and affective labeling are also associated with manic states [42,44]. A recent study on moral judgment in subjects with alcohol dependence suggested that deficits in disgust and fear decoding contribute to utilitarian decision-making [45]. Manic patients’ reduced perception of negative emotional situations at the time of
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Table 2 Mean response times (ms) and standard errors across groups. Type of dilemma Non-moral Impersonal Personal Low-conflict High-conflict
Group Mania 6348.64 7409.29 6910.24 5617.31 7606.44
Euthymia ± ± ± ± ±
405.38 395.36 390.39 461.18 430.76
5653.41 6879.62 6312.09 4793.20 7129.96
± ± ± ± ±
pa
Post-hoc
0.209 0.113 0.023 0.024 0.119
– – 1N3 1N3 –
Control 413.10 402.90 397.82 469.97 438.97
5140.99 6127.24 5366.09 3756.71 6232.68
± ± ± ± ±
325.03 317.00 313.01 369.77 345.38
1: Mania, 2: Euthymia, 3: Control. a Corrected for multiple comparisons.
personal moral judgments could explain the increased utilitarian responses. This hypothesis is supported by a report stating that inducing positive affect increased utilitarian responses to the footbridge dilemma in healthy subjects [46]. With regard to cognitive functions, deficits in theory of mind ability and sustained attention are prominent or exacerbated in manic states [19,47,48]. Moreover, manic patients have impaired inhibition of behavioral responses to emotionallycharged stimuli in a go/no-go task [49], and they are more likely to make suboptimal and bad decisions for betting strategies in the Cambridge Gambling Task [50]. All these deficits observed in manic states may partially contribute to the differences in moral judgments between manic patients and euthymic or normal subjects. However, the fact that we only observed group differences for personal moral dilemmas cannot be fully explained by these deficits. According to Greene’s dual-process view [38,51], conflicts between utilitarian (a cognitive controlled response aimed at maximizing well-being) and deontological (an emotional aversion aimed at human duty) judgments happen when subjects consider personal moral dilemmas. In order to render utilitarian judgments when faced with personal moral dilemmas, cognitive processes should outweigh negative autonomic emotional responses. Recently, the understanding of moral judgments has focused on the integrated role of cognition and emotion rather than their mutually competing roles [52–54]. In particular, the VMPC is associated with integrative moral judgments involving utilitarian and emotional assessments [52]. Personal dilemmas strongly elicit increased amygdala responses in healthy subjects [38]. Also, amygdala activities are positively correlated with negative feelings or unacceptability associated with the utilitarian option, and amygdala-VMPC connectivity is higher when emotional components are more engaged [52]. Therefore, the interaction or reciprocity between the VMPC and amygdala is critical in making moral judgments. Likewise, altered functioning or connectivity between the prefrontal cortex, including ventrolateral and ventromedial regions, and the amygdala may be involved in emotional regulation and emotional processing in subjects with bipolar disorder [55–57]. Amygdala activity is increased during mania and is normal during euthymia when compared to healthy controls [57], and reduced activation of the ventral prefrontal cortex has been found across mood states in bipolar disorder [57]. It has been reported that the VMPC
(orbitofrontal) may be involved in modulating stimuli arising from internal feeling states (e.g., sadness elicited by a specific event) and automatic emotional regulation [58–60]. Therefore, the increased utilitarian judgment of personal dilemmas observed in manic patients might reflect disrupted synchronization between the prefrontal cortex and subcortical structures, including the amygdala. In other words, despite negative emotions produced by the amygdala in reaction to moral violations, VMPC dysfunction may result in failure to perform the integrative and balanced moral decision-making in the manic state. In this study, manic patients exhibited increased utilitarian responses even on low-conflict personal dilemmas as well as high-conflict ones. On the other hand, other reports found that VMPC-damaged or alcohol-dependent subjects showed no significant differences in “yes” responses to low-conflict dilemmas in comparison to healthy controls [13,61]. As described above, altered VMPC and amygdala activities in manic patients compared with euthymic or healthy subjects might lead to more utilitarian responses, even in low-conflict personal dilemmas. Impulsivity, a trait characteristic in bipolar disorder [62], is increased and related to impaired attention and behavioral inhibition or delayed reward gratification in the manic state [63,64]. This characteristic may be another potential reason for utilitarian responses even to low-conflict dilemmas in manic subjects. According to Kohlberg’s theory of moral development [2], there are three levels of morality. At the pre-conventional level, all focus is on the self, and behaviors are viewed according to the impact on the self. Individuals at the conventional level conform to rules of authority for mutual interpersonal expectations or society. Lastly, post-conventional individuals know that morality is more than social consensus and follow abstract moral principles (e.g., dignity). The endorsement of low-conflict personal dilemmas in manic patients (e.g., decide to get rid of your boss just because he makes everyone around him miserable, including you) could be explained by their possible focus on the self or interpersonal expectations. This interpretation is supported by a recent report that manic patients are less likely to choose post-conventional thinking than euthymic or healthy individuals ([65]). In the current study, manic patients had longer response times than healthy controls for personal moral dilemmas. This result was also observed for low-conflict personal moral
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dilemmas. As described above, our manic patients showed increased utilitarian judgments, even in low-conflict moral dilemmas. The deficits in verbal learning and sustained attention observed in patients with bipolar mania [47,48] could delay the comprehension of dilemmas. One study investigating a potential relationship between cognitive processes and utilitarian judgments found that cognitive load manipulation selectively increased the response times for utilitarian but not for non-utilitarian judgments [66]. Therefore, longer reaction times even for low-conflict dilemmas during a manic state may be due to cognitive interference associated with utilitarian judgments. Disgust is a basic emotion triggered by diverse stimuli from bad tastes to moral transgressions [67]. As one of three factors of the DS-R, contamination (interpersonal) disgust reflects the perceived threat of contagion by direct or indirect contact with other persons [68]. In the current study, euthymic patients exhibited a negative correlation between personal moral acceptability and the contamination disgust score, but this was not observed in manic patients. As shown in Table 1, euthymic patients showed greater disgust scores than manic patients and normal controls. Other studies have demonstrated selectively enhanced recognition of disgust facial expressions in euthymic patients [69] and reduced recognition of disgust faces in manic patients [18]. Enhanced disgust sensitivity in euthymia might affect the negative correlation between the personal dilemma response rate and the contamination disgust score. However, the total and other factor scores of disgust were not significantly correlated, therefore further study will be required to understand the relationship between disgust and moral judgments. In considering the clinical implications, our results suggest the need for discouraging or delaying important decision-making during the manic status. As impaired cognition or impulsivity may be related with this disinhibited behavior, behavioral intervention such as decreasing goal-directed activities is required for the treatment of manic patients. Moreover, unrealistically high goals and excessive confidence may be associated with increased utilitarian judgment; thus, cognitive behavioral approaches that promote better control over these judgment processes should be used. These approaches may be helpful for reducing manic symptoms and preventing mania. This study has several limitations. First, its cross-sectional design did not allow us to make inferences on longitudinal progress or causality in bipolar disorder. Such conclusions would require prospective studies and follow-up in different mood states. Second, we did not control for psychotropic medication use. Previous literature showed that enhancing serotonin or beta-adrenergic blockade might influence emotionally salient moral dilemmas toward deontological judgments [70,71]. We did not find any significant correlations between acceptability of each dilemma type (personal, impersonal or non-moral) and medications (chlorpromazine-equivalent doses or doses of lithium and valproic acid) in the patient groups. However, we cannot completely rule out the potential influence of psychotropic drugs on moral judgments. Third, our results should be carefully
interpreted because of the relatively small sample size and single-site recruitment. In conclusion, this study provides insight into characteristic moral judgments by subjects with bipolar disorder. Manic patients make more utilitarian moral judgments than either euthymic patients or normal controls with regard to emotionally salient personal moral dilemmas. These results suggest that increased utilitarian judgments on personal dilemmas may be a state-related phenomenon observed in only manic patients. This difference may be related to decision-making characteristics and the underlying neurobiological mechanisms of bipolar disorder, especially during manic states. Electrophysiological and imaging studies will be needed to identify the neural mechanisms related to unique moral judgments in bipolar disorder.
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