The Hidden Wound: Self-Stigma Strikes Nearly Six in Ten Working Bipolar Patients

Bipolar disorder has long been understood as a condition of extremes, marked by the dramatic swings between mania and depression that define its clinical profile. But a new study from Tunisia draws attention to a quieter, more insidious burden carried by people living with the illness: the stigma they turn against themselves. In a cross-sectional investigation of 106 working patients with bipolar disorder, researchers from the occupational health departments of Charles Nicole University Hospital in Tunis and Farhat Hached University Hospital in Sousse found that nearly 57 percent were self-stigmatised, a phenomenon in which individuals internalise the negative stereotypes society attaches to mental illness and apply them to their own identity. The findings, published in BMC Psychiatry on 13 October 2026, suggest that this internalised stigma is not merely a matter of wounded pride. It is tightly linked to measurable impairments in daily functioning, particularly in the workplace, where the consequences can cascade into lost productivity, precarious employment and worsening illness trajectories.

The research team, led by Fatma Ezzahra Boujmil and colleagues, recruited participants who were undergoing medical examinations to determine their fitness for work, a setting that placed the study squarely at the intersection of psychiatry and occupational medicine. All patients were in a state of clinical euthymia, meaning their mood symptoms were stabilised at the time of assessment. This detail matters scientifically: it demonstrates that even when the florid symptoms of bipolar disorder are controlled, a substantial residue of psychological and functional damage can persist. The average age of participants was 43.8 years, squarely within prime working life, and the gender ratio of 0.53 indicates that men outnumbered women in the sample by nearly two to one, reflecting the composition of the working population examined.

To quantify self-stigma, the researchers used the Internalised Stigma of Mental Illness scale, a validated instrument that probes experiences of alienation, stereotype endorsement, perceived discrimination, social withdrawal and stigma resistance. The average ISMI score in the sample was 2.58, with a standard deviation of 0.87, a level that placed the majority of patients above the threshold conventionally used to identify meaningful internalised stigma. Functioning, meanwhile, was assessed with the Functioning Assessment Short Test, a tool designed to capture the real-world capacities that matter most to patients: managing a job, maintaining relationships, handling finances, and sustaining the cognitive abilities needed for independent living. The results were sobering. Overall functional impairment was present in 89.6 percent of patients, with occupational functioning affected in 64.2 percent and cognitive functioning in 50 percent, making these two domains the most heavily damaged.

The demographic and clinical correlates of self-stigma painted a picture of vulnerability concentrated among specific groups. Average ISMI scores were significantly higher in patients under the age of 40, in women, in those who were single or divorced, and in patients with low incomes. Each of these factors plausibly amplifies the psychological weight of a psychiatric diagnosis. Younger patients may still be constructing their professional and personal identities when the illness strikes, making the internalised label more corrosive. Women in the Tunisian working context may face layered expectations that intensify the sense of falling short. Social isolation, whether through singleness or divorce, removes protective relationships that might otherwise buffer negative self-beliefs, and financial hardship compounds the sense of diminished worth and limited horizons.

Occupational characteristics also left their mark. Patients working atypical hours, such as night shifts or irregular schedules, carried significantly higher self-stigma scores than those with standard working patterns. This finding resonates with a growing body of occupational health research showing that disrupted circadian rhythms and unstable schedules are particularly punishing for people with mood disorders, since sleep regularity is a cornerstone of bipolar disorder management. An atypical schedule may also signal to patients themselves that they occupy a marginal position in the world of work, feeding the internal narrative of difference and deficiency. Early onset of bipolar disorder was another correlate of heightened self-stigma, consistent with the idea that the longer a person lives with the illness, and the earlier it interrupts the formation of adult identity, the deeper the internalised stereotypes can root.

One of the most clinically actionable findings concerned treatment. Patients who had not received cognitive behavioural therapy showed significantly higher self-stigma scores than those who had. CBT is specifically designed to identify and challenge distorted beliefs about the self, and its protective association here suggests that structured psychological therapy may do more than alleviate mood symptoms; it may actively dismantle the internalised prejudice that patients absorb from their social environment. In health systems where psychiatric care is often reduced to medication management and brief consultations, the study offers an argument for embedding psychotherapy into routine care for bipolar disorder, not as a luxury but as a targeted intervention against a measurable driver of disability.

The statistical heart of the paper lies in the correlation between self-stigma and functioning. Higher ISMI scores were significantly associated with greater overall functional impairment on the FAST, with the strongest links involving the perceived discrimination and social withdrawal subscales. This pattern is theoretically coherent: a patient who expects rejection and consequently withdraws from colleagues, friends and family loses the opportunities to test those expectations against reality, and the withdrawal itself erodes social skills, professional networks and confidence. Functioning deteriorates not because the illness has flared, but because the patient has pre-emptively shrunk their own world. The authors emphasise that this dynamic is widely underestimated, particularly in the workplace, where the quiet retreat of a capable employee may be misread as laziness or lack of ambition rather than recognised as the downstream effect of internalised stigma.

Methodologically, the study has the strengths and limits inherent to its cross-sectional design. Because all data were collected at a single point in time, the direction of causality between self-stigma and impaired functioning cannot be definitively established; it is plausible that each feeds the other in a vicious cycle, with functional difficulties confirming negative self-beliefs and those beliefs in turn undermining functional recovery. The sample of 106 patients recruited through fitness-for-work examinations is also a selected population, since severely disabled patients may no longer be employed at all, potentially leading the study to underestimate the true burden of self-stigma in the broader bipolar population. Nevertheless, the consistency of the associations, the use of validated instruments, and the ethical rigour of the protocol, which adhered to the Declaration of Helsinki and was approved by the ethics committee of Charles Nicole Hospital, lend the findings considerable weight.

The implications reach well beyond Tunisia. Bipolar disorder affects roughly one percent of the population worldwide and primarily strikes people of working age, meaning that its economic and social costs are concentrated in the very decades when individuals are building careers and families. If more than half of working patients carry internalised stigma and nearly nine in ten show functional impairment even in remission, then treating mood symptoms alone addresses only part of the problem. The authors conclude that the high prevalence of self-stigma and its association with impaired functioning highlight the need to address contributing factors, particularly in the workplace, in order to maintain employment and limit the adverse impact on the progression of the disorder. That agenda could include workplace mental health education to dismantle public stereotypes before they are internalised, schedule accommodations for patients with mood disorders, routine screening for internalised stigma in psychiatric follow-up, and wider access to cognitive behavioural therapy. What this study makes clear is that the battle against bipolar disorder is fought on two fronts, and the quieter one, inside the patient’s own mind, may be the one that decides whether recovery translates into a functioning life.

Subject of Research: Self-stigma and functional impairment in working patients with bipolar disorder

Article Title: Bipolar disorder, self-stigma and functioning: a cross-sectional study conducted among a working population in Tunis

Article References: Bipolar disorder, self-stigma and functioning: a cross-sectional study conducted among a working population in Tunis. (n.d.). https://doi.org/10.1186/s12888-026-08727-1

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08727-1

Keywords: bipolar disorder, self-stigma, internalised stigma, functioning, occupational health, workplace mental health, cognitive behavioural therapy, Tunisia, cross-sectional study, psychiatry, social withdrawal, perceived discrimination