Bipolar disorder (BD) is a severe and persistant illness with high impact, even outside of manic or depressive episodes, ranked second in days out of role per year (Alonso et al., 2011). A key issue in clinical practice is to identify personal factors associated with disability level (Rosa et al., 2007; Grande et al., 2013). Firstly, individuals with BD report a large number of residual symptoms, such as emotional dysregulation, disruption of circadian rhythms, cognitive complaints, guilt, low self-esteem and physical pain (Samalin et al., 2014). Secondly, even in the euthymic phase, people also report a high level of functional impairment (Samalin et al., 2014). There is not a single profile of functioning in individuals with BD (Roux et al., 2017), highlighting heterogeneity in functioning during the euthymic period. It now appears crucial to understand what might explain such differences. Impaired functioning is closely related to residual depressive symptoms (Fagiolini et al., 2005) and to deficits in neuropsychological performance (Roux et al., 2017; Léda-Rêgo et al., 2020).

Moreover, cognitive impairments are recurrent claims of people during euthymic phases. Subjective cognitive problems are reported by 2/3 of people with BD, particularly memory problems, attentional problems, and executive function problems (Martínez-Arán et al., 2005). Objective neuropsychological impairments affect key cognitive dimensions, such as verbal memory, attention, processing speed, executive functions (Bourne et al., 2013), social cognition with small to moderate deficits in theory of mind, small deficits in emotional recognition (Samamé et al., 2015), and risky decision making (Gorlyn et al., 2013). However, there is wide variation in the estimated prevalence of these deficits, ranging from 12.4% (Roux et al., 2019) to 34% (Tsapekos et al., 2021), or even 57.7% (Eric et al., 2013). Some bipolar patients have global impairment, some having selective moderate impairment, and others have good cognitive performance (Roux et al., 2017; Green et al., 2020). Several determinants of these neuropsychological deficits have been explored to understand this heterogeneity but data remain insufficient. There is no consensus on the relationship between cognitive functioning and residual thymic symptoms. Residual depressive symptoms have been reported to have a negative effect on cognitive functioning in some studies (Bourne et al., 2013), but not in others (Cullen et al., 2016; Roux et al., 2017).

It becomes important to better understand the basis of such a range of cognitive and functional impairments. Previous work has shown that personality is an important determinant of functioning in BD during euthymic phases (Kizilkurt et al., 2018). Comorbid personality disorders are associated with a greater severity of residual thymic symptoms, even in remission (George et al., 2003), as well as with a more negative course of the illness (Fan and Hassell, 2008). Moreover, personality is modestly associated with neuropsychological performance in the general population (Bartels et al., 2012; Berggren and Derakshan, 2013; Schaie et al., 2004). However, current research does not allow us to understand the link between personality and the heterogeneity of cognitive impairment associated with BD.

The personality approach proposed by Young’s schema theory appears relevant by considering personality in relation to the person’s developmental history. People exposed to adverse experiences in early childhood can develop “Early Maladaptive Schemas” (EMS) related to these experiences (Young et al., 2003). These EMS emerge when the person’s basic affective needs are not met. The five core emotional needs are:

The lack of satisfaction of needs is facilitated by the interaction between contextual (childhood adversity) and biological (temperament) factors. The different patterns are built during childhood and adolescence and are enhanced throughout life. An EMS is a recurring theme or dysfunctional pattern of information processing including beliefs, emotions, and memories about oneself, others and the world (Young et al., 2003). To adapt to their EMS, individuals engage in dysfunctional behaviors. EMS impact various aspects of psychosocial functioning (Scott and Crino, 2014).

The study of EMS is limited in individuals with BD. Young’s model of Early Maladaptive Schemas (EMS) appears highly relevant in describing the experiences of individuals with bipolar disorder. According to studies, the prevalence of cumulative trauma ranges from 29% (Etain et al., 2013) to 82% (Li et al., 2014). Emotional trauma is reported in 77% of individuals with bipolar disorder (Dualibe and Osório, 2017). Furthermore, the presence of cumulative childhood trauma is a factor associated with greater severity of bipolar disorder, including an earlier age of onset, longer episode duration, a higher number of mood episodes over a lifetime, an increased likelihood of psychotic features, and a higher probability of past suicide attempts (Li et al., 2014; Rowe et al., 2024). These findings strongly support the use of Young’s schema theory, as confirmed by Dadomo et al. (2016). Theoretical frameworks suggest that early adverse experiences shape core cognitive patterns by fostering negative self-beliefs and distorted perceptions of others, which can lead to maladaptive coping mechanisms in adulthood. Such patterns may manifest as pervasive feelings of abandonment, mistrust, or worthlessness, influencing emotional regulation and behavior (Young et al., 2003).This is further validated by a recent study that demonstrated connections between specific types of trauma and the activation of particular schemas (Özdin et al., 2018). A recent literature review found that, compared to people without BD, those with BD have greater general activation of EMS, even if a specific pattern of schemas cannot be identified (Munuera et al., 2020a). A study with Danish women with bipolar 1 disorder showed a high activation of the insufficient self-control EMS (Nilsson et al., 2010). In different culture (Iran, Turkey), people with BD have higher activation for many EMS in comparison with a control group (Ak et al., 2012; Khosravi et al., 2017; Özdin et al., 2018; Korkmaz et al., 2024). But, differences are not observed on the same EMS. Such different results might be related to culture but also with study methodology. Most studies compared a group of people with BD to a control group, or to a group of people with unipolar disorder. Previous studies do not consider clinical heterogeneity by examining people with BD as a homogeneous group. It seems relevant to define homogeneous subgroups of individuals according to EMS types and explore if they differ on clinical or functional criteria. This is consistent with a personalized clinical approach (Snyderman and Yoediono, 2006). A previous study showed that the activation of specific EMS clarifies the singularity of each remission profile in individuals with BD (Munuera et al., 2020b). However to date, no study has proposed such a centered approach of EMS profiles related to a global description of clinical state during euthymic phase, including symptomatology, psychosocial functioning, and neuropsychological functioning. To the best of our knowledge, only one study has reported that the level of cognitive complaints in older adults with subjective cognitive decline was significantly associated with EMS in the “Impaired autonomy, competence, and sense of identity” domain, with a lack of significant correlation between EMS activation and objective performance in episodic memory (Tandetnik et al., 2017). Relationships between EMS and neuropsychological performances remain to be explored in BD.

Several theoretical arguments suggest a link between EMS and cognitive and social functioning, for example because the impact of compensatory behaviors on social functioning, or because issues with cognitive and social functioning make people more prone to activation of EMS. The main objective of this study was to identify homogeneous profiles of people with BD in euthymic phase with respect to EMS activation, and to compare the different subgroups (clusters) with residual symptoms, psychosocial functioning, and neuropsychological performance. We hypothesize that more residual depressive symptoms and more psychosocial and cognitive functioning impairment would be found in subtypes with the highest activation of EMS. This study has several implications for clinical practice. In particular, if the results support the hypotheses, they could improve therapeutic recommendations. For example, one perspective is to highlight the relevance of referring patients to functional remediation for cognitive impairment (Bonnin et al., 2016) and/or schema therapy (Dadomo et al., 2016; Ociskova et al., 2022). These different interventions have shown relevant results, and the aim now is to establish them as tools to enhance personalized psychiatry.

Using cluster analysis, this study examined the link between Early Maladaptive Schema (EMS) profiles, clinical characteristics, residual symptoms of bipolar disorders (BD), psychosocial functioning, and neuropsychological performance. As a main result, we found three different cluster profiles based on EMS activation. This result is in line with previous studies and sheds light on the clinical heterogeneity in BD. People with BD are not homogeneous during euthymic phases which supports the relevance of proposing personalized medicine and care. Futhermore, these different profiles were associated with clinical variables and functioning outcomes, but not with neuropsychological performance.

Firstly, a significant proportion of participants in our sample displayed functioning measures within the norm during the euthymic phase of their BD, both in terms of EMS activation and psychosocial functioning. Indeed, the Hypoactivation cluster, comprising 40% of the sample, was particularly characterized by hypoactivation of dependence/incompetence, failure, defectiveness/shame, mistrust/abuse, negativity/pessimism, and vulnerability to harm/illness EMS, which was associated with good levels of psychosocial functioning. Regarding the hypoactivation of EMS, people in this cluster would be less likely to be pessimistic and have negative self-perceptions than the others in our sample. Thus, they might be less prone to social stigma and self-stigma. It might explain the better functioning found in this cluster because social stigma and self-stigma have a major weight which impact the functioning of people (Latalova et al., 2013; Au et al., 2019). Lastly, the activation of the self-sacrifice, entitlement/grandiosity, enmeshment/undeveloped self, emotional deprivation, punitiveness, approval/recognition-seeking EMS remains very close to the norm and lower than the other participants in our sample.

A second cluster, Light activation, composed 44.1% of the sample. Overall, people in this cluster were more activated on the different EMS than the norm, especially for entitlement/grandiosity, social isolation, and emotional deprivation. The latter two EMS belonging to the Separation and Rejection domain, people with activated EMS in this domain are more likely to have difficulty forming secure and satisfying relationships with others (Young et al., 2003). They feel that their needs for stability, security, attention, love and belonging will never be met. They highly tend to have difficulties in relationships with others, even in therapeutic relationships. Assessing and working on these EMS could help for increase therapeutic alliance.

The last identified cluster, Major hyperactivation composed a minority of participants (15.3%). Except for the self-sacrifice EMS, all the other EMS were markedly hyperactivated in this cluster, especially subjugation, defectiveness/shame, and social isolation. The activation of the defectiveness/shame (Özdin et al., 2018; Khosravi et al., 2017; Richa and Richa, 2013; Hawke and Provencher, 2012) and emotional deprivation (Khosravi et al., 2017; Richa and Richa, 2013; Hawke and Provencher, 2012) EMS is inconsistent across studies, but the social isolation EMS is one of the most frequently hyperactivated in people with BD (Ak et al., 2012; Özdin et al., 2018; Khosravi et al., 2017; Richa and Richa, 2013; Hawke and Provencher, 2012). The activation of this EMS suggests that people may experience difficulties in establishing or maintaining satisfactory social relationships. The subjugation EMS corresponds to excessive submission to the control of others, because the subject feels forced to do so, usually to avoid anger, retaliation, or abandonment. There is repressed anger causing symptoms such as passive/aggressive behavior or uncontrolled outbursts of anger. Indeed, it is well known that BD are associated with emotion regulation disturbances (De Prisco et al., 2022; Dodd et al., 2019; Kurtz et al., 2021; Miola et al., 2022). The lifetime history of substance use disorders was higher in the Major hyperactivation cluster, highlighting the critical issue of dual diagnosis in BD. This result is supported by a recent study reporting EMS to be overactivated in individuals with alcohol use disorders (Rubio-Escobar et al., 2024).

People with hypoactivated EMS seem to have less difficulties in their daily life than people with hyperactivated EMS. Indeed, we found that psychosocial functioning, quality of life, and marital life were generally better in the Hypoactivation cluster than in the other clusters. These results are consistent with a recent review suggesting that schema therapy was effective in improving the quality of life for personal disorders (Zhang et al., 2023). Moreover, clinical characteristics were less severe in this cluster than the others clusters (e.g., less anxious, less severe bipolar illness, last thymic episode further away).

However, only marital status remained significantly associated with cluster memberships in the multiple regression analysis: people with hyperactivated EMS seem to have more difficulty being and remaining in a marital relationship than people with hypoactivated EMS. The hyperactivation of EMS in the Separation and Rejection domain in the Light activation and Major hyperactivation clusters could explain the difficulty in establishing and maintaining a marital relationship, in line with the meta-analysis conducted by Janovsky et al. (2020) and the study by Dupouy et al. (2023) that highlights the contribution of the Separation and Rejection domain in relationship dysfunction. We know that a significant proportion of people with BD do not regain full functioning, particularly in the social domain, after an affective episode (MacQueen et al., 2001). This study emphasizes that marital life is a relevant functioning domain to target in clinical practice and to understand in relation to patients’ EMS. Based on these results, it therefore seems legitimate to recommend an EMS assessment for individuals with BD disorder in the euthymic phase who report difficulties in establishing a stable marital relationship, and subsequently, recommend schema therapy (Young et al., 2003).

Overall, this study showed that half of people with BD have activated EMS. According to Young’s schema theory (Young et al., 2003), EMS emerge from childhood trauma. Thus, the high prevalence of trauma in this population (Etain et al., 2010; Garno et al., 2005; Janiri et al., 2015) may be a cause of fragility in their construction throughout their lives, and thus favor the development of EMS. This hypothesis is supported by the results of this study showing that the clusters differed on the presence of childhood trauma in bivariable analysis. Particularly, the Hypoactivation cluster showed a lower childhood trauma score than the two other clusters. This result is consistent with scientific literature showing an association between childhood maltreatment and EMS (Carr and Francis, 2010). Furthermore, because there is an association between adverse childhood experiences and adult psychopathology (Etain et al., 2010), an interesting hypothesis is that EMS may mediate this relationship, and thus develop and maintain BD (Ball et al., 2003). More generally, there is a kind of correspondance between BD severity and EMS activation; people with the least activated EMS are the ones who are doing the best in terms of BD severity, anxiety symptom intensity, remission duration, and psychosocial functioning.

Although previous studies have demonstrated associations between intelligence and personality traits (Bartels et al., 2012; Schaie et al., 2004; Berggren and Derakshan, 2013), our findings did not reveal a significant relationship between neuropsychological performance and EMS. This absence of association may reflect the specific neuropsychological dimensions assessed in this study, which could be complemented by measures of social cognition. Given the established link between EMS and interpersonal functioning (DeTore et al., 2018), social cognition might provide a more relevant framework for exploring this relationship. Furthermore, while cognitive functioning is a critical determinant of psychosocial functioning in BD (Roux et al., 2024; Roux et al., 2017; Ehrminger et al., 2021), its role appears distinct from that of EMS. Furthermore, cognitive complaints should be assessed because they are frequently reported by people with BD such as memory or attentional difficulties (Rosa et al., 2013) and reported as having an impact on their daily life. Our findings suggest that cognitive deficits do not necessarily hinder the implementation of schema therapy, as the presence of early maladaptive schemas (EMS) and cognitive abilities do not appear to be related. This study underscores the importance of distinguishing between cognitive functioning (e.g., memory, attention, executive function) and the content of cognitions (in this case, cognitive schemas). From a personalized care perspective, it is therefore essential to specifically evaluate the factors that hinder the patient. Combining functional remediation and schema therapy may prove effective for individuals with difficulties in both areas, as one approach cannot substitute for the other.

This study has several limitations. One limitation concerns the heterogeneity caused by the three subtypes of bipolar disorders investigated in this study. Understanding whether Bipolar I and Bipolar II disorders are the same or distinct conditions is a significant area of research. It would be interesting to replicate this study, specifically highlighting the results found for EMS in Bipolar I and Bipolar II separately. Moreover, the study did not control for the socioeconomic status and comorbid psychiatric disorders, which may influence EMS in BD. For example, several psychiatric disorders, which are common in BD, are associated with EMS, like attention deficit hyperactivity (Kiraz and Sertçelik, 2021), borderline personality (Frías et al., 2018), anxiety disorders (Koerner et al., 2015) and obsessive-compulsive disorders (Dostal and Pilkington, 2023). In this study, the role of socioeconomic status was not measured, yet it could be an influential factor in early maladaptive schemas (EMS) and psychosocial functioning. Especially since there is a link between social disadvantage (household income, education status, employment status) and functional impairment in people with bipolar disorder (Sylvia et al., 2017). Furthermore, this study was conducted with a French population. It would be interesting to replicate this study in other populations, both to test the effect of culture on the one hand, and the effect of certain demographic variables on the other hand. Additionally, the cross-sectional design of the study should be acknowledged as a limitation. Developing longitudinal designs could provide further valuable insights. Growth-mixture models could track EMS activation and functional outcomes over time. Then, if schema therapy interventions are tested, measuring changes in EMS factors or class membership can help confirm whether “Major Hyperactivation” patients particularly benefit.

In spite of its limitations, this study contributes to a more accurate understanding of the clinical heterogeneity of people in euthymic phases of BD. Clinicians should have an eco-systemic approach, taking into account environment, in particular childhood environment, and current environment. Initially developed to treat borderline personality disorders, other specific models of schema therapy have been developed to treat almost all other personality disorders (Csukly et al., 2011) and other disorders such as eating disorders, anxiety disorders and post-traumatic stress disorders (Taylor et al., 2017). Indeed, previous papers have argued the relevance of schema therapy as a treatment option for people with BD in the euthymic phase (Hawke et al., 2013; Ociskova et al., 2022).