Premenstrual changes: a comparison of five populations

Several studies have suggested that a special relationship exists between premenstrual and major affective disorders. The present report describes the incidence of reported premenstrual symptoms in women with and without prospectively confirmed premenstrual syndrome, women with bipolar or seasonal affective disorder, and controls. The inability of reported symptoms to differentiate women with and without confirmed premenstrual syndrome, as well as the reduced prevalence of reported premenstrual changes in our affective populations relative to previous reports, is discussed.     

Premenstrual depression in women with a history of affective disorder: mood and attentional processes

Survey studies have pinpointed high concordance rates between affective disorder and premenstrual depression. This relationship was investigated in women with a history of both disorders. Sixteen subjects rated symptoms daily during one menstrual cycle, and were assessed on measures of mood and selective attention pre- and postmenstrually. Prospective ratings confirmed premenstrual depression in only eight of the subjects. These subjects demonstrated a significant premenstrual elevation in dysphoric affect, yet exhibited a dysphoric attentional bias both pre- and postmenstrually. These data do not suggest an interactive relationship between affective disorder and premenstrual depression along the particular cognitive dimension of study.     

The clinical nature and formal diagnosis of premenstrual,postpartum, and perimenopausal affective disorders

Various mood and anxiety disorders are more prevalent in reproductive-aged women, and appear to be linked to hormonal and reproductive events. Premenstrual affective disorders consist of premenstrual syndrome, premenstrual dysphoric disorder, and premenstrual exacerbation of mood or anxiety disorders. Postpartum affective disorders can range from postpartum “blues” to postpartum depression with or without psychosis, and also include anxiety disorders, such as panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. In perimenopausal women, the vulnerability to mood and anxiety disorders is increased. All of these disorders share risk factors, and have etiologic features in common, such as exposure to the rise and fall of ovarian sex steroids. The following is a review of these syndromes and their etiology, diagnosis, and treatment.     

Dysphorie prémenstruelle et trouble bipolaire atténué chez l’adolescente. À propos d’un cas clinique

Premenstrual Dysphoric Disorder (PMDD) and bipolarity expanded to a broad spectrum are both two new fashionable clinical entities. First, PMDD has been recently recognized and extracted from the global premenstrual disorder. Second, new research is challenging conservative rates for bipolar disorder in light of a broader concept involving at the one extreme psychotic states, and at the other cyclic mood disorders with minor sub-syndromal affective dysregulations. From a clinical case report and the review of current research studies in this domain, new preliminary hypotheses will be discussed, especially about the comorbidity between bipolar disorders and PMDD. We suggest that a soft bipolar disorder could be hidden behind a PMDD (or the reverse) and raises important therapeutic questions: Are selective serotoninergic inhibitors likely to worsen this disorder? Should these patients be treated with mood stabilizers at first line?     

Premenstrual mood disorder and psychiatric illness

The results of several studies suggest that a special relationship exists between premenstrual syndromes and major psychiatric disorders, particularly affective illness. These studies in general have not employed prospective criteria to diagnose premenstrual syndrome. In this paper the authors report a significant difference in the lifetime history of psychiatric illness between women with prospectively confirmed menstrually related mood disorder and those without it.     

Mood disorder history and personality assessment in premenstrual dysphoric disorder.

BACKGROUND: Menstrually related dysphoria is known to be associated with other affective disorders, notably major depressive disorder and puerperal depression. The relationship between premenstrual dysphoric disorder (PMDD) and maladaptive personality disorders and traits, however, is less established, at least in part because of the methodological and nosologic difficulties in the diagnosis of both PMDD and personality disorders. This study seeks to address this problem to elucidate the relationship between PMDD, other affective disturbances commonly experienced by women, and maladaptive personality. METHOD: Axis I and II disorders were examined using standardized instruments and stringent diagnostic criteria (DSM-IV and the International Personality Disorders Examination) in 34 women with DSM-IV PMDD and 22 healthy women without severe premenstrual mood changes. RESULTS: Seventy-seven percent of the PMDD group had suffered from a past Axis I disorder in comparison with 17% of the control group. Two thirds of the parous women with PMDD had suffered from major depressive disorder in the puerperium. Personality disorder diagnoses were not highly represented in either group of women. The women with PMDD had significantly more obsessional personality traits (p < .001 ) but not absolute personality disorder diagnoses. CONCLUSION: Obsessional symptoms are known to cluster with the affective disorders and may reflect underlying temperamental and biological vulnerability. This study provides further evidence of the link between serotonergic dysregulation, personality vulnerability, and mood changes related to the female reproductive cycle.     

Insight and outcome in bipolar, unipolar, and anxiety disorders

We performed a study to assess the relationship between impairment of insight and the long-term outcome in affective and anxiety disorders. Standardized insight assessments were made using the Scale to Assess Unawareness of Mental Disorder (SUMD) in 101 outpatients with psychiatric disorders, mostly affective and anxiety disorders, treated over 1 year in a university-based clinic. Outcome was prospectively assessed with the Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) rating scales. The mean follow-up period was 3.9 months. Initial impairment of insight did not correlate with poor outcome. However, improvement in insight correlated with good outcome, particularly in bipolar disorder type I (r = .56 to .67, P = .0005). Insight was similarly impaired in bipolar and unipolar major depressive disorders, and more so than in anxiety disorders (P = .002). An association between a lack of improvement in insight and a poor outcome, most significantly in bipolar disorder type I, was observed in this sample. We found a greater relative impairment of insight in mood versus anxiety disorders.     

Individual and familial risk factors for bipolar affective disorders in Denmark

BACKGROUND: Few population-based studies have addressed risk factors for bipolar affective disorder. OBJECTIVE: To study the possible association between bipolar affective disorder and history of mental illness in a parent or sibling; urbanicity of birth place; season of birth; sibship characteristics, including birth order; influenza epidemics during pregnancy; and early parental loss. DESIGN: We used a population-based cohort of 2.1 million individuals based on data from the Danish Civil Registration System linked with the Danish Psychiatric Central Register. SETTING: Nationwide population-based sample of all individuals hospitalized or in outpatient clinic contact for the first time with bipolar affective disorder.Patients Overall, 2299 individuals were first diagnosed with bipolar affective disorder during the 31.8 million person-years of follow-up. RESULTS: Risk of bipolar affective disorder was associated with a history of bipolar affective disorder as well as other psychiatric disorders, including schizophrenia and schizoaffective disorder, in parents or siblings. People with a first-degree relative with bipolar affective disorder had a 13.63-fold (95% confidence interval, 11.81-15.71) increased risk of bipolar affective disorder. No other consistent associations were found with the exception of an association between early parental loss, in particular maternal, and bipolar affective disorder. Children who experienced maternal loss before their fifth birthday had a 4.05 (95% confidence interval, 1.68-9.77) increased risk of bipolar affective disorder. CONCLUSIONS: Early parental loss may represent both environmental and genetic risk factors for bipolar affective disorder. Most of the risk factors included in our study that previously have been associated with schizophrenia were not associated with bipolar affective disorder, supporting that the 2 disorders may be at least partially separate etiological entities.     

Premenstrual symptoms and depression in a university population.

The correlation between a premenstrual syndrome based on emotional symptoms and primary affective disorder was prospectively studied in 105 college freshmen. Students with premenstrual symptoms were twice as likely as controls to have a history of a serious depressive episodes and twice as likely to have a close family member with depression. Seven percent of women with premenstrual emotional symptoms and none of the controls had an affective episode during the ensuing year. The premenstrual syndrome did not interfere with academic performance and was not associated with any lowering of professional aspirations. The inconsistent results of past research on the relationship between depressive disorder and premenstrual symptoms may have been the consequence of differing definitions in different studies. The final answer on this possible association may result from using a clear definition of premenstrual symptoms based on emotional difficulties and a well defined research oriented criteria for the diagnoses of affective disorder.     

Mood-related obsessive-compulsive symptoms in a patient with bipolar affective disorder

The authors present a case of coexisting obsessive-compulsive disorder (OCD) and bipolar affective disorder in which the obsessive-compulsive symptoms disappeared during episodes of mania and reappeared during periods of depression. Although patients with coexisting bipolar disorder and OCD are relatively rare, careful study of those patients may increase our understanding of the complex relationship between obsessive-compulsive symptoms and mood. Abnormalities in serotonergic neurotransmission have been postulated in both affective disorders and OCD and may provide important clues to the pathophysiology of OCD.     

Preadolescent alcohol abuse and dependence

The authors document 10 cases of children who met the criteria for a DSM-III axis I diagnosis of alcohol abuse or dependence by the age of 13. They present one case report to demonstrate the family history of affective disorder, especially bipolar disorder, and alcoholism that characterized these 10 patients. Most of the children with bipolar disorder responded well to psychotropics. The authors suggest that there may be a relationship between early-onset alcohol abuse and the development of major affective disorders in adolescence.     

The genetics of affective disorder: data, theory, and clinical applications

A genetic factor in the etiology of the affective disorders has been a subject of considerable interest and investigation during the last five decades. Data from twin studies, family studies, and adoption studies strongly support three major findings: genetic factors are significant in the etiology of both bipolar and unipolar affective disorder; bipolar and unipolar affective disorder tend to breed true and are genetically distinct diseases; and both bipolar and unipolar affective disorder are genetically distinct from schizophrenia. While the mode of transmission for the affective disorders remains unclear, the genetic data already afford clinical applications pertinent to diagnosis, prognosis, treatment response, and both immediate and longitudinal clinical course. Pharmacogenetic factors unrelated to the illness are also relevant to the management of antidepressant pharmacotherapy.     

Comorbid bipolar disorder and panic disorder in families with a high prevalence of bipolar disorder.

OBJECTIVE: Panic attacks are a common complication of affective disorder, although the etiologic relationship of panic and affective symptoms has not been determined. Evidence from a family study suggests that panic attacks and panic disorder may be related genetically to bipolar disorder. This study used diagnostic data from the NIMH Bipolar Disorder Genetics Initiative to assess in a separate, larger family set the familiality of panic combined with bipolar disorder. METHOD: First-degree relatives (N=966) of probands with bipolar I disorder (N=192) and schizoaffective disorder, bipolar type, (N=11) were included in the study. All subjects were interviewed directly and were assigned best-estimate diagnoses for major affective and other psychiatric disorders. The risk of a family member being diagnosed with panic disorder if the proband with bipolar disorder had panic attacks or panic disorder was calculated with logistic regression analysis with generalized estimating equations that controlled for sex and affective disorder subdiagnosis. RESULTS: More than 90% of the probands and first-degree relatives with panic disorder also had an affective disorder diagnosis. Panic disorder was present in 17% of the relatives with recurrent major affective disorder and in 3% of the relatives without recurrent major affective disorder. Risk of panic disorder in relatives with bipolar disorder was increased significantly if the proband had panic attacks or panic disorder. CONCLUSIONS: Risk for panic disorder with familial bipolar disorder appears to be inherited. Inherited risk for panic disorder with bipolar disorder may indicate a shared genetic etiology for both disorders in some families. The patterns of bipolar disorder and panic disorder comorbidity observed in families imply a complex genetic etiology, which may be elucidated by using endophenotypes.     

Genetic models of schizophrenia and bipolar disorder

Abstract Schizophrenia and affective disorder have been considered to be nosologically and etiologically distinct disorders. This postulate is challenged by progress in new biological research. Both disorders are strongly influenced by genetic factors; thus genetic research is a main contributor to this discussion. We review current evidence of the genetic relationship between schizophrenia and affective disorders, mainly bipolar disorder (the various genetic research methods have been particularly applied to bipolar disorder). Recent family and twin studies reveal a growing consistency in demonstrating cosegregation between both disorders which is difficult to detect with certainty given the low base rates. Systematic molecular genetic search for specific genes impacting on either disorder has now identified one gene which is apparently involved in both disorders (G72/G30); other candidate genes reveal some evidence to present as susceptibility genes with very modest effects for each of both disorders, although not consistently so (e. g., COMT, BDNF). There is room for speculation about other common susceptibility genes, given the overlap between candidate regions for schizophrenia and those for bipolar disorder emerging from linkage studies.     

Frequency of comorbid personality disorders in bipolar and unipolar affective disorders

One expression of the complex relationship between personality and affective disorder is the comorbidity of personality disorders (PDs) with affective disorders. In a sample of 117 patients with unipolar and 60 with bipolar affective disorders, we assessed DSM-III-R PDs with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and compared them with personality factors as obtained by the five-factor model (FFM-NEO Five-Factor Inventory). Fifty-one percent of the unipolar and 38% of the bipolar disorders fulfilled criteria for a comorbid PD. The three most frequent PDs were obsessive-compulsive PD, borderline PD, and narcissistic (bipolar) or avoidant (unipolar) PD. Cluster C PDs and especially avoidant PD occurred significantly more frequently in unipolar than in bipolar patients, while narcissistic PD occurred significantly more often in bipolar than in unipolar patients. The FFM results supported the validity of our PD diagnoses. In a logistic regression analysis, higher depression score at the time of the SCID-II interview and shorter duration of the illness were weakly related to a higher frequency of PDs. Our results indicate that PDs are frequent in affective disorders and that there are subtle differences between unipolar and bipolar patients concerning such comorbid disorders.     

Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences

Objectives: many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar disorders, and borderline personality disorder and some studies have suggested that these disorders are co-transmitted in families. However, few studies have compared personality traits between these disorders to determine whether there is a dimensional overlap between the two diagnoses. The aim of this study was to compare impulsivity, affective lability and intensity in patients with borderline personality and bipolar II disorder and in subjects with neither of these diagnoses. Methods: patients with borderline personality but without bipolar disorder (n=29), patients with bipolar II disorder without borderline personality but with other personality disorders (n=14), patients with both borderline personality and bipolar II disorder (n=12), and patients with neither borderline personality nor bipolar disorder but other personality disorders (OPD; n=93) were assessed using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), the Buss–Durkee Hostility Inventory (BDHI) and the Barratt Impulsiveness Scale (BIS-7B). Results: borderline personality patients had significantly higher ALS total scores (P<0.05) and bipolar II patients tended to have higher ALS scores than patients with OPD (P<0.06). On one of the ALS subscales, the borderline patients displayed significant higher affective lability between euthymia and anger (P<0.002), whereas patients with bipolar II disorder displayed affective lability between euthymia and depression (P<0.04), or elation (P<0.01) or between depression and elation (P<0.01). A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxiety and depression (P<0.01) with the ALS. High scores for impulsiveness (BISTOT, P<0.001) and hostility (BDHI, P<0.05) were obtained for borderline personality patients only and no significant interactions between diagnoses were observed. Only borderline personality patients tended to have higher affective intensity (AIM, P<0.07). Conclusions: borderline personality disorder and bipolar II disorder appear to involve affective lability, which may account for the efficacy of mood stabilizers treatments in both disorders. However, our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affective disorders.     

Boundaries of schizophrenia.

The frontiers of schizophrenia are being increasingly challenged from several directions. In addition to ongoing debate as to divisions between schizophrenia and disorders of the schizophrenic spectrum, including schizotypal personality disorder and schizophreniform disorder, it has been suggested that obsessive-compulsive disorder might overlap phenomenologically with schizophrenia. There has been a long debate around the relationship of schizophrenia to affective disorders, particularly bipolar and schizoaffective disorder. The evidence suggests that although schizotypal personality and schizophreniform disorders are not homogeneous syndromes, they are related to or represent milder forms of schizophrenia. Obsessive-compulsive disorder seems to involve pathology in many of the same regions as observed in some patients with schizophrenia, which may account for the significant incidence of obsessive-compulsive symptoms in a subset of patients with schizophrenia. Despite similarities between schizophrenia and bipolar disorder, significant differences extend across suggested causes, phenomenology, and pathophysiology. These findings support the current conceptualization that the two disorders represent distinct disorders, probably with heterogeneous causes, rather than the ends of a spectrum of symptoms comprising a single syndrome. Schizoaffective disorder likely is made up of patients from the schizophrenic and bipolar cluster of illnesses. The long-standing debate as to the boundaries of schizophrenia is ultimately must await the eventual further elaboration of the underlying causes of schizophrenia and other psychotic disorders.     

Affective disorders and ABO blood types.

Results of the present study provide evidence of: 1) a positive association between bipolar affective disorder and blood type O and a corresponding negative association between the former and blood type A, 2) a positive association between unipolar affective disorder and blood type O, and 3) a positive association between involutional depression and blood type A and a corresponding negative association between the former and blood types B and O. Sex does not appear to modify the ABO blood types' distribution in patients with bipolar, unipolar affective disorder, or involutional depression, and the same holds for early- or late-onset of the illness in patients with bipolar or unipolar affective disorders. Findings in the present study do not support the validity of the bipolar-unipolar distinction of affective disorders, and provide evidence in favour of the view that involutional depression is a genetically distinct nosological entity.     

Premenstrual tension syndrome in rapid-cycling bipolar affective disorder

Premenstrual tension syndrome (PMS) and rapid-cycling bipolar affective disorder have similarities of symptoms, cyclical mood swings, and putative neurotransmitter dysfunction. The possible relationship between these disorders was assessed by evaluating 25 patients with rapid-cycling disorders and 25 normal controls for PMS symptoms. Patients with rapid-cycling affective disorder had an increased tendency to have more severe forms of PMS. In addition, patients with rapid-cycling disorders and more severe forms of PMS tended to cycle more frequently. The significance of this finding and its clinical implications are discussed.     

Affective disorders in the first-degree relatives of bipolar probands: results from the South Island Bipolar Study

The current study was performed to document observed rates of affective disorders in the first degree relatives of probands with bipolar I or II disorder; to determine whether bipolar II probands have an excess of bipolar II relatives; and to determine whether bipolar probands with a history of one or more suicide attempts have more relatives who have also made suicide attempts. Bipolar probands with positive family histories of affective disorder were recruited from a variety of sources for a study on the molecular genetics of bipolar disorder. Probands and relatives were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and blood was obtained for DNA extraction and genetic analyses. Among 423 first-degree adult relatives of 153 bipolar probands, 7% (29) had bipolar I disorder, 7% had bipolar II disorder, and 7% had bipolar not otherwise specified (NOS) disorder, making 21% of relatives with any bipolar disorder. A further 42% of relatives had a depressive disorder and only 38% had no affective disorder. A suicide attempt by a proband was not associated with any increase in suicide attempts by relatives. We conclude that while unipolar depressive disorders are the most common affective disorders in the first-degree relatives of bipolar probands, extension of the bipolar phenotype to include bipolar spectrum disorders results in 21% of relatives having any bipolar disorder.