Cannabis et trouble bipolaire : recherche d’une association à partir d’une revue de la littérature

Introduction

It has been established that cannabis use is involved in the emergence and evolution of psychotic disorders. Although cannabis use is very frequent in mood disorders, there has been a considerable debate about the association observed between these two disorders. This review aims to clarify the relation between cannabis use and bipolar disorder, in order to unveil a possible causality and find the effect of cannabis on the prognosis and expression of bipolarity.

Methods

The review used MedLine database using the keywords “cannabis” or “marijuana” and “bipolar” or “mania” or “depression”. This search found 36 articles who were clinically relevant to the subject and were included and discussed in this review.

Results

The first studies discussing the link between cannabis use and psychotic disorders reveal manic features in the substance abuse group, hence suggesting a possible association between cannabis use and bipolar disorder, in favor of triggering a manic episode. According to the studies, between 25 and 64% of bipolar patients are cannabis users, and the prevalence is higher in younger and male patients. The risk of developing a mood disorder is higher among cannabis users compared to the general population. This substance abuse in bipolar disorders would increase the frequency and duration of manic episodes without changing the total duration of mood episodes. In a first episode of bipolar disorder, the use of cannabis would increase the rate of relapses of manic episodes and worsen the prognosis of the disorder.

Discussion

The frequency of substance abuse in bipolar disorders is higher than the prevalence in the general population, and cannabis is one of the most used illegal substances in the worldwide. Hence, the association between cannabis use and bipolar disorders is frequent. Cannabis users may experience euphoria, relaxation and subjective feelings of well-being; this substance may also have antiepileptic effect, which may explain some of the effects of cannabis on bipolar disorders. In fact, the use of cannabis would increase the frequency and duration of manic episodes in bipolar patients without increasing the total duration of mood episodes, suggesting a possible antidepressing and mood stabilizing effects. This impact of cannabis on mood disorders and its possible pharmacological effect is still controversial and needs further experiencing to be proved.     

Syndrome démentiel dans les suites d’une bipolarité

Introduction

Converging evidence suggests that people with bipolar disorder (BPD) exhibit persistent cognitive impairment independently from the emotional state. In old age BPD, the cognitive decline is more severe and can fulfill the criteria of dementia. However, the characteristics of bipolar disorder dementia are still unknown.

Aim of the study

The aim of the study was to characterise the cognitive and imaging profile of the dementia following bipolar disorder.

Method

Patients fulfilling criteria of dementia and followed-up in the memory unit for at least two years were included. Patients with substance abuse were excluded. A battery of specific (assessing verbal memory, attention, frontal executive function, construction and visuospatial impairment), and global (MMSE and Mattis dementia rating scale) neuropsychological tests, behavioural assessment using the frontotemporal behavioural scale, MRI and HMPAO–SPECT imaging were performed in all patients during euthymic state.

Results

We included 13 patients with bipolar disorder (9W/4M). The mean age was 70.8 years (±7.7). Dementia began in average 29.2 years (±10.1) after the onset of the bipolar disorder. The mean score of MMSE was 24.0 (±4.3). The mean score of the Mattis dementia rating scale was 122.5 (±8.9). After an average of 6.1 years (±2.8) of follow-up, the mean score of MMSE was 23.5 (±3.2). The annual MMSE score decrease was of 0.5 (±4.4) per year. In more than 75% of the patients, Trail-Making Test-part B, Go-nogo test, Stroop test, delayed free recall in verbal explicit long-term memory test, category fluency tasks and code test were impaired. In more than 50% of patients, free recall, delayed cued recall, clock test, visuospatial battery and temporal orientation were impaired. On the other hand, spatial orientation and recognition were within the standards. The mean of the BREF score was 10.6 (±3.2). A moderate frontal behavioural syndrome was observed, but never persistent hallucinations. Seven patients had been treated with lithium and seven with antipsychotics, but none during the neurological assessment. Moderate extrapyramidal signs were reported in 10 patients, of which the seven patients treated in the past with antipsychotics. MRI showed no focal atrophy and no vascular lesions. Functional imaging conducted in 10 patients always showed uptake decrease in the frontotemporal regions and sometimes in the parietal region too. After six years of follow-up, no patient fulfilled the probable criteria for the main dementia, Alzheimer disease, vascular dementia, frontotemporal dementia and dementia with Lewy bodies.

Conclusion

The data of this study support a possible specific dementia postbipolar disorder and not only mild cognitive decline. This hypothesis could be tested in a prospective study. Such dementia could be a main differential diagnosis from long lasting frontotemporal dementia. The pathogenic process of this dementia could also be determined.     

Validation of the Mood Disorder Questionnaire in the general population in Hong Kong

Objective

The objective of the study was to determine the reliability and validity of a Chinese version of the Mood Disorder Questionnaire (MDQ) in the general population in Hong Kong.

Methods

One thousand five hundred eighteen adults aged at least 18 years were randomly drawn from the general population and interviewed using a lay-administered version of the MDQ. A subsample of 114 randomly selected participants received a telephone-based Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition. Six subjects were diagnosed to have bipolar disorder (bipolar I = 1, bipolar II = 4, and bipolar not otherwise specified = 1), 13 had substance/alcohol use disorder, and 95 had neither bipolar nor substance/alcohol use disorder. We determined the internal consistency, factor structure, and concurrent validity of the Chinese MDQ.

Results

The Cronbach α coefficient of the Chinese MDQ was 0.78. Principal component analysis with varimax rotation indicated a “euphoria-irritability-racing thoughts” factor, an “energized-activity” factor, and a “risky behavior” factor, which explained 46.6% of the rotated variance. There were significant differences in MDQ scores between the bipolar and non-bipolar non-substance/alcohol use disorder groups. The performance of the Chinese MDQ for detecting bipolar disorder was limited by a low sensitivity. Using the original cutoff criterion, defined as clustering of 7 or more symptoms that caused moderate or severe problems, the sensitivity was 0%, whereas the overall specificity was 95.4%. Lowering the cutoff criterion to a symptom score of at least 7 that caused minor or more problems yielded the best sensitivity (0.50) and specificity (0.92).

Conclusion

The Chinese MDQ is a reliable and valid measure of bipolar disorder in the community.     

Spouses and bipolar disorder

Objective

To assess the quality of life of a population of spouses of bipolar patients compared with a control population.

Patients and methods

We conducted a cross-sectional study which included two groups: a group of 30 spouses of patients followed for bipolar I disorder according to DSM IV criteria and a second group of 30 subjects from the general population. Both groups were matched by age, sex, marital status and socioeconomic level. This device was designed to limit the differences between the two groups solely those of the bipolar illness. Evaluating the quality of life was achieved using the quality of life scale: SF-36. This is a scale that has already been translated and validated in dialect Arabic.

Results

Regarding sociodemographic variables, the two study groups differed only for: recreation, friendly relations and the couple relationship that included more and better skills among the control group. In the categorical approach, the quality of life was impaired in 60% of spouses and 40% of controls with a statistically significant difference. The following standardized dimensions: mental health (D4), limitation due to mental health (D5), life and relationship with others (D6) and perceived health (D8) and mental component (CM) were significantly altered in patients’ spouses compared to controls. We found significant differences between the two groups for: overall average score (51.1 vs. 68.2), mental health (D4), limitation due to mental health (D5), life and relationship with others (D6), perceived health (D8) and perceived health (D8) standards.

Discussion

The impairment of quality of life of bipolar patients’ spouses is related to the extra responsibility, stress, financial problems and health problems, stigma, and loss of security of the person loved.

Conclusion

Considering the consequences that the appearance of bipolar disorder on the patient's spouse may have, certain measures must be proposed to improve their quality of life.     

Une approche de la phénoménologie de la dépression par l’Entretien Semi-structuré Multiregistres

Objective

Whereas instruments are available to diagnose depression and to rate its severity, there is a lack of instruments to assess the phenomenology of depression, i.e., a set of mental phenomena that compose subjective experience. The Algorithmically Structured Systematic Exploration of Subject's State of Mind (Assess_Mind) is based on open questions asked via a structured algorithm. The objective of the present study was to show how the Assess_Mind allows to investigate the depressive phenomenology in patients presenting a major depressive episode.

Patients and methods

Thirty-five patients presenting a major depressive episode were assessed with the Assess_Mind and with a battery of standardized instruments. After hospital admission, two Assess_Mind interviews separated by 24 hours were conducted, and a third interview took place 3 weeks later. Using vignettes drawn from the three interviews conducted in two patients, we illustrate the workings of the Assess_Mind and the clinical material that it reveals.

Results

The Assess_Mind provides a detailed and specific assessment of the patients’ phenomenology and of its course over time.

Conclusion

In major depressive episodes, the Assess_Mind should contribute to help clinicians to conduct the initial assessment and to follow the course of patients under treatment.     

La conscience des troubles (insight) dans la schizophrénie : une revue critique: Partie I : insight et schizophrénie, caractéristiques cliniques de l’insight

Introduction

Schizophrenia is the psychiatric disorder in which the awareness of pathology (or insight) is most frequently altered.

Literature findings

A review of the literature shows that between 50 and 80% of patients with schizophrenia do not believe they have a disorder. Studies published on this subject over the two last decades stressed the specificity of this phenomenon in schizophrenic patients, taking into account both its prevalence and its clinical consequences comparatively to other mental disorders. If in bipolar disorders a lack of insight is linked with the intensity and acuteness of symptomatology, there is only a limited relationship between these factors in schizophrenia, thus making lack of insight a trait rather than a state-related symptom.

Discussion

Though defined for a very long time as a dichotomic phenomenon, the recent interest on insight in psychosis and the development of assessment tools for its evaluation have made it possible to underline its multifactorial and dynamic characteristics. Although lack of insight related to pathologies may vary across time in bipolar disorders, the results of clinical studies suggest that this phenomenon remains stable in schizophrenia.

Conceptual proposals

In this review, we will reconsider the evolution of this concept in psychiatry and its definition. The clinical characteristics, which are specifically associated with the lack of insight in schizophrenia will be outlined. We will describe more specifically the model of Amador and Strauss and their assessment tool: the Scale to Assess Unawareness of Mental Disorder (SUMD). This model developed since the 1990s takes into account the time-related evolution of insight, and can be applied both to bipolar and psychotic disorders.

Assessment tools

The SUMD has six general items and four subscales. The general items estimate the three most widely used definitions of insight: awareness of having a mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder, and include assessment of both current and past-time periods. Four other subscales, each composed of 17 items, assess awareness and attribution of specific current and retrospective symptoms as well as deficits associated with severe mental disorders. Insight, thus, appears as a multidimensional and continuous phenomenon, since patients’ awareness may apply only to part of their symptoms and vary over time. In this article, we will review existing scales assessing insight in schizophrenia. The deficiency of available scales validated in French limits the number of scientific publications concerning this important aspect of the clinical evaluation of schizophrenic patients.

Therapeutical aspects

Finally, interventions to improve insight in patients with schizophrenia are presented. Recent studies have shown cognitive behavioural therapy (CBT) to be of benefit in the treatment of poor insight in schizophrenia.

Conclusion

Evidence suggests that early diagnosis and treatment of schizophrenia leads to better prognosis. An important suggestion from theses studies may be that psychosocial therapy needs to focus on explanations that are in tune with the culture, rather than focus on diagnostic labels.     

Traitement de l’information à contenu émotionnel et représentation de soi chez des patients bipolaires de type I après traitement combiné médicamenteux et comportemental-cognitif

Objectives

Bipolar disorder currently affects around 1 % of the general population. Despite mood stabilizers, 37 % of patients continue to present mood fluctuations. Moreover, psychotherapeutic approaches, together with prophylactic treatment, have been developed over the past 10 years, including the behavioural and cognitive approach. Lam's behavioural model has thus become a major reference. Bipolar patients who have undergone cognitive behavioural therapy (CBT) based on this program experience fewer manic and depressive recurrences as well as fewer hospitalizations, thus improving the quality of their relations with others, reducing their dysfunctional beliefs and attitudes, and enhancing their self-esteem. However, no study has evaluated the effects of CBT on cognitive functions in this disorder, such as memory, nor on its connection with cognitive patterns, among bipolar patients. Previous research has suggested the existence of many disturbances of cognitive functions. Several studies have demonstrated memory disturbances in a free recall task among type I bipolar patients, even during periods of remission. However, none of these studies focused on explicit-memory recall bias for words with affective valence during remission, nor did they investigate the connection between self schemata and bias in memory processes. The goal of this study was to explore the cognitive vulnerability of bipolar I patients in remission by linking self schemata with recall bias for words with affective valence, and to compare these variables among patients who underwent CBT, and patients who did not.

Materials and methods

The study included 24 bipolar I patients, 12 were in the control group (mood regulating treatment) and 12 were in the experimental group (CBT in conjunction with a mood stabilizer), according to the DSM-IV criteria. The free recall tasks for words with distinct affective valences (positive, neutral, negative) allowed us to assess the performance and recall bias for affective information. In addition, the lexical assessment enabled us to study the cognitive schemata with reference to self-representation.

Results

The results do not indicate any signs of depression, mania or anxiety among the two groups at the time of their inclusion in the study. The cognitive results show that not only is the experimental group significantly more likely to recall words with positive affective valence (F1, 22 = 5.770; P = 0.025) and significantly less likely to recall those with negative affective valence (F1, 22 = 6.629; P = 0.017) than the control group, but that it also presents a specific recall bias for words with a positive connotation as compared to neutral words (t11 = 4.722; P = 0.001) and negative words (t11 = 5.777; P < 0.0001). Furthermore, the experimental group uses a vocabulary which is less focused on the disorder mood and cognitive symptoms.

Conclusion

The results demonstrate the various recall biases between the two groups, with a specific bias for the positive words and a self-representation which is less focused on bipolar illness in the experimental group. Learning the cognitive and behavioural coping strategies based on the Lam et al. model may lead to a modification of bipolar patients’ cognitive schemata. This modification may itself contribute to a better recall of positive stimuli. Just as, according to Bower, the activation of a negative emotion may facilitate the recall of negative information, a better management of emotions seems to result in a better recall of positive information.     

Decision making: rational or hedonic?

Background

Antisocial behaviors are complex polygenic phenotypes that are due to a multifactorial arrangement of genetic polymorphisms. Little empirical research, however, has been undertaken that examines gene × gene interactions in the etiology of conduct disorder and antisocial behavior. This study examined whether adolescent conduct disorder and adult antisocial behavior were related to the dopamine D2 receptor polymorphism (DRD2) and the dopamine D4 receptor polymorphism (DRD4).

Methods

A sample of 872 male participants from the National Longitudinal Study of Adolescent Health (Add Health) completed self-report questionnaires that tapped adolescent conduct disorder and adult antisocial behavior. DNA was genotyped for DRD2 and DRD4.

Results

Multivariate regression analysis revealed that neither DRD2 nor DRD4 had significant independent effects on conduct disorder or antisocial behavior. However, DRD2 interacted with DRD4 to predict variation in adolescent conduct disorder and in adult antisocial behavior.

Conclusion

The results suggest that a gene × gene interaction between DRD2 and DRD4 is associated with the development of conduct disorder and adult antisocial behavior in males.     

The FAQ self-report is a valid instrument to characterize endophenotypes of the autistic spectrum in parents of children with autism

Background

We have previously developed the FAQ self-report, an adaptation of the Baron-Cohen's Autism Quotient self-report, in order to detect traits of the autistic spectrum in the parents and siblings of children with autism. We have previously shown that parents of children with autism show significant differences in their global scores and in their social functioning scores according to their answers to the FAQ self-report.

Objective

Our aim was to validate the FAQ self-report in a population of control parents, and to confirm our previous results concerning parents of children with autism.

Methodology

Hundred and twenty-seven adults (67 female, 60 male), parents of children with normal development were recruited in the general population. They were asked to fulfill the 40 questions of the FAQ self-report at two different times. Sixty-six parents of children with autism were asked to fulfill the FAQ self-report, for group comparisons. Statistical factor analysis and test-retest reliability analysis was performed with the Matlab toolbox^© software.

Results

Statistical factor analysis and test-retest reliability show that the FAQ is structured in two main factors, socialization and communication on one hand, rigidity and imagination on the other, with good test-retest reliability. Further comparison between parents of children with autism and control parents shows a significant difference between the two groups for the socialization and communication domain, and for the global score. We show for the first time that scores of the parents of children with autism remain unchanged from infancy to adulthood.

Conclusion

The FAQ is the first French validated self-report focused on the detection of traits of the autistic spectrum in parents and siblings of children with autism. It is structured in two main factors, corresponding to imagination/rigidity, which are negatively correlated, and communication and socialization, which are positively correlated. The FAQ is therefore a reliable instrument to measure endophenotypes associated with the autistic spectrum in parents of children with autism, and may be useful in genetic studies.     

Infarctus cérébral récidivant révélant une maladie de Biermer

Introduction

Biermer's disease is an autoimmune disorder characterized by vitamin B12 deficiency. Ischemic stroke is an uncommon complication of Biermer's disease, possibly though hyperhomocysteinemia.

Case report

A 58-year-old male presented with recurrent ischemic stroke. Extensive investigations were normal, except for a high plasma level of homocysteine in the context of pernicious anemia which was otherwise asymptomatic.

Discussion

Hyperhomocysteinemia is a known marker, and probably a risk factor, for stroke, fostering atherosclerosis and thrombosis. It can be found among individuals suffering from homocysteinuria, but also when there is deficiency of vitamin B12 or folic acid. Vitamin B12 supplementation would reduce homocysteine concentration which in turn would reduce the risk of ischemic stroke.