Iran Journal of Nursing

Introduction
One of the most important mental disorders is bipolar disorder, which is characterized by episodes of mania and depression. This disorder can be associated with negative emotions and mental pain. Mental pain is caused by a person’s failure to meet and satisfy their needs, which can lead to tension and negative emotions such as feelings of shame, guilt, despair, humiliation, sadness, and anger. Mental pain is seen in patients with mental disorders such as anxiety, eating disorders, personality disorders, schizophrenia, and bipolar disorder, but is more common in patients with bipolar disorder. It can be associated with the symptoms of psychosis. This pain has a big role in the pathology of depression and is directly related to the severity of depression in patients with depressive disorder. Mental pain can cause self-harm and is one of the predictors of suicide attempt in patients with the depressive episode of bipolar disorder. When the mental pain becomes severe and annoying, a person commits suicide to get rid of it. With low mental pain, the patients with psychological disorders respond better to psychotherapy. This study aims to determine the mental pain of people with bipolar disorder in Tehran, Iran.
Materials & Methods 
This is a descriptive study. Participants were 153 people with bipolar disorder admitted to Iran Psychiatry Hospital in Tehran, Iran who were selected by a continuous sampling method. Inclusion criteria were: Having a diagnosed bipolar disorder based on medical records, age 18-60 years, being literate, and not having visual and hearing impairments. A demographic form and Orbach Mikulincer Mental Pain (OMMP) Scale were used to collect data. The demographic form was used to survey the age, gender, marital status, educational level, employment status, economic status, history of suicide, and history of previous hospitalization in the psychiatric ward. The OMMP scale was designed by Orbach et al. (2003) [24] and has 44 items rated on a 5-point Likert scale as 1=Strongly disagree, 2=Disagree, 3=Somewhat agree, 4=Agree, and 5=Strongly Agree. The total score ranges from 44 to 220.  Data analysis was performed in SPSS software version 16 using descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistics (Pearson correlation test, independent t-test, and analysis of variance). P<0.05 was statistically significant. 
Results 
The freezing dimension of mental pain had the lowest score, while the emotional flooding dimension had the highest score. Comparison of mental pain scores based on demographic characteristics showed that the statistically significant relationship of history of suicide attempt (P<0.001), economic status (P=0.002), and employment status (P=0.02) with mental pain. Those with a history of suicide attempt, those with poor financial status, and unemployed patients had higher mental pain.
Discussion
The results of the present study emphasize the need for psychological interventions to reduce mental pain in patients with bipolar disorder. It seems that having a history of suicide attempt increases their mental pain due to creating mental preoccupation. In addition, having a poor economic status, which can be due to unemployment, can increase the severity of mental pain in patients with bipolar disorder. More studies are needed to generalize the results to all patients with bipolar disorder in Iran.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethical committee of the Iran University of Medical Sciences (Code: IR.IUMS.REC.1399.602). All ethical principles are considered in this article.

Funding
This study is taken from the Master's thesis of Samira Alwandi, Department of Psychiatry, Faculty of Nursing and Midwifery, Iran University of Medical Sciences.

Authors' contributions
Conceptualization: Samira Elwandi and Marjan Mardani Hamouleh; Research: Marjan Mardani Hamouleh, Nazanin Esmaili and Fariba Ghasemi, Analysis: Shima Haqqani; Project management: Marjan Mardani Hamouleh; Compilation and finalization: Marjan Mardani Hamouleh.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The researchers are thankful to all of the participants.

References

1. Ranjbar M, Seyed Fatemi N, Mardani Hamooleh M, Esmaeeli N, Haghani S. [Correlation of stigma with self-compassion in patients with bipolar disorder (Persian]. Iran J Nurs. 2020; 32(122):1-13. [DOI:10.29252/ijn.32.122.1]
2. Ghanbari Jolfaei A, Ataei S, Ghayoomi R, Shabani A. High frequency of bipolar disorder comorbidity in medical inpatients. Iran J Psychiatry. 2019; 14(1):60-6. [DOI:10.18502/ijps.v14i1.424] [PMID] [PMCID]
3. Mee S, Bunney BG, Fujimoto K, Penner J, Seward G, Crowfoot K, et al. A study of psychological pain in substance use disorder and its relationship to treatment outcome. PLoS One. 2019; 14(11):e0216266. [DOI:10.1371/journal.pone.0216266] [PMID] [PMCID]
4. Khoshnevisan M, Seyedfatemi N, Mardani Hamooleh M, Ranjbar M, Haghani H. [The effect of anger management educational program on aggression in the individuals with the bipolar disorder: A quasi-experimental study (Persian)]. Iran J Nurs. 2020; 33 (123):62-72. [Link]
5. Fertuck EA, Karan E, Stanley B. The specificity of mental pain in borderline personality disorder compared to depressive disorders and healthy controls. Borderline Personal Disord Emot Dysregul. 2016; 3:2. [DOI:10.1186/s40479-016-0036-2] [PMID] [PMCID]
6. Verrocchio MC, Carrozzino D, Marchetti D, Andreasson K, Fulcheri M, Bech P. Mental pain and suicide: A systematic review of the literature. Front Psychiatry. 2016; 7:108. [DOI:10.3389/fpsyt.2016.00108] [PMID] [PMCID]
7. Tomko C, Schneider KE, Rouhani S, Urquhart GJ, Nyeong Park J, Morris M, et al. Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: How do psychological pain and unmet mental health need contribute to overdose risk? Addict Behav. 2022; 127:107215. [DOI:10.1016/j.addbeh.2021.107215] [PMID] [PMCID]
8. Li H, Xie W, Luo X, Fu R, Shi C, Ying X, et al. Clarifying the role of psychological pain in the risks of suicidal ideation and suicidal acts among patients with major depressive episodes. Suicide Life Threat Behav. 2014; 44(1):78-88. [DOI:10.1111/sltb.12056] [PMID]
9. Tossani E. The concept of mental pain. Psychother Psychosom. 2013; 82(2):67-73. [DOI:10.1159/000343003] [PMID]
10. Bagian M, Karami J, Momeni K, Elahi A. [The investigation of the role of childhood trauma experience, cognitive reactivity, and mental pain in suicide attempted and normal individuals (Pesian)]. Thoughts Behav Clin Psychol. 2019; 14(53):77-89. [Link]
11. Karami J, Bagian MJ, Momeni K, Elahi A. [Measurement of mental pain: Psychometric properties and confirmatory factor analysis of multidimensional mental pain questionnaire (Persian)]. Q J Health Psychol 2018; 7(25):146-72. [Link]
12. Fava GA, Tomba E, Brakemeier EL, Carrozzino D, Cosci F, Eöry A, et al. Mental pain as a transdiagnostic patient-reported outcome measure. Psychother Psychosom. 2019; 88(6):341-9.  [DOI:10.1159/000504024] [PMID]
13. Berardelli I, Sarubbi S, Spagnoli A, Fina C, Rogante E, Erbuto D, et al. Projective technique testing approach to the understanding of psychological pain in suicidal and non-suicidal psychiatric inpatients. Int J Environ Res Public Health. 2019; 17(1):284. [DOI:10.3390/ijerph17010284] [PMID] [PMCID]
14. Bohaterewicz B, Nowicka M, Sobczak AM, Plewka AA, Gaszczyk P, Marek T. Clinical and psychosocial characteristics of adolescent pediatric patients hospitalized after different types of suicidal behaviors-a preliminary study. Int J Environ Res Public Health. 2020; 17(15):5568. [DOI:10.3390/ijerph17155568] [PMID] [PMCID]
15. Landi G, Furlani A, Boccolini G, Mikulincer M, Grandi S, Tossani E. Tolerance for Mental Pain Scale (TMPS): Italian validation and evaluation of its protective role in depression and suicidal ideation. Psychiatry Res. 2020; 291:113263. [DOI:10.1016/j.psychres.2020.113263] [PMID]
16. Uğur K, Polat H. The relationship of suicidal ideation with psychological pain and anger rumination in patients with major depressive disorder. Arch Psychiatr Nurs. 2021; 35(5):479-85.  [DOI:10.1016/j.apnu.2021.06.012] [PMID]
17. Holden RR, Lambert CE, Rochelle ML, Billet MI, Fekken GC. Invalidating childhood environments and nonsuicidal self-injury in university students: Depression and mental pain as potential mediators. J Clin Psychol. 2021; 77(3):722-31. [DOI:10.1002/jclp.23052] [PMID]
18. Tomba E, Tecuta L, Gardini V, Lo Dato E. Mental pain in eating disorders: An Exploratory controlled study. J Clin Med. 2021; 10(16):3584. [DOI:10.3390/jcm10163584] [PMID] [PMCID]
19. Davis KC, Anderson JL. Psychological pain: A moderating factor between personality psychopathology and self-harm. J Am Coll Health. 2021; 1-9. [DOI:10.1080/07448481.2021.1928677]
20. Levi-Belz Y, Gvion Y, Apter A. The serious suicide attempts approach for understanding suicide: Review of the psychological evidence. Omega (Westport). 2022; 86(2):591-608. [DOI:10.1177/0030222820981235] [PMID]
21. Mento C, Silvestri MC, Muscatello MRA, Rizzo A, Celebre L, Bruno A, et al. Psychological pain and risk of suicide in adolescence. Int J Adolesc Med Health. 2020; 34(3). [DOI:10.1515/ijamh-2019-0270] [PMID]
22. Jollant F, Perreira F, Fiori LM, Richard-Devantoy S, Lutz PE, Belzeaux R, et al. Neural and molecular correlates of psychological pain during major depression, and its link with suicidal ideas. Prog Neuropsychopharmacol Biol Psychiatry. 2020; 100:109909. [DOI:10.1016/j.pnpbp.2020.109909] [PMID]
23. Reist C, Mee S, Fujimoto K, Rajani V, Bunney WE, Bunney BG. Assessment of psychological pain in suicidal veterans. PLoS One. 2017; 12(5):e0177974.  [DOI:10.1371/journal.pone.0177974] [PMID] [PMCID]
24. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: A multidimensional operationalization and definition. Suicide Life Threat Behav. 2003; 33(3):219-30. [DOI:10.1521/suli.33.3.219.23219] [PMID]
25. Khanjani S, Asmari Y, Mousavi Asl E, Ashouri A. [Relationship of non-suicidal self-injury behaviors with mental pain in soldiers: The mediating role of self-compassion (Persian)]. J Mil Med. 2020; 22(4):363-72. [Link]
26. Shamsaei F, Yaghmaei S, Haghighi M. Exploring the lived experiences of the suicide attempt survivors: A phenomenological approach. Int J Qual Stud Health Well-being. 2020; 15(1):1745478. [DOI:10.1080/17482631.2020.1745478] [PMID] [PMCID]
27. Kremer I, Orbach I, Rosenbloom T. Mental pain and suicidal tendencies in sexual and physical abuse victims. Arch Suicide Res. 2017; 21(2):307-21. [DOI:10.1080/13811118.2016.1175394] [PMID]
28. Grossman-Giron A, Becker G, Kivity Y, Shalev S, Bitan DT. Mental pain intensity and tolerance as predictors of psychotherapy process and outcome. J Clin Psychol. 2021; 77(6):1296-1306.  [DOI:10.1002/jclp.23085] [PMID]
29. Gvion Y, Levi-Belz Y. Serious suicide attempts: Systematic review of psychological risk factors. Front Psychiatry. 2018; 9:56. [DOI:10.3389/fpsyt.2018.00056] [PMID] [PMCID]
30. Courtet P, Olié E. [Social pain at the core of suicidal behavior (French)]. Encephale. 2019; 45 (Suppl 1):S7-12. [DOI:10.1016/j.encep.2018.09.005] [PMID]
31. Campos RC, Gomes M, Holden RR, Piteira M, Rainha A. Does psychache mediate the relationship between general distress and suicide ideation? Death Stud. 2017; 41(4):241-5. [DOI:10.1080/07481187.2016.1251510] [PMID]
32. May AM, Pachkowski MC, Klonsky ED. Motivations for suicide: Converging evidence from clinical and community samples. J Psychiatr Res. 2020; 123:171-7. [DOI:10.1016/j.jpsychires.2020.02.010] [PMID]