Factor structure of recalled DSM-IV hypomanic symptoms of bipolar II disorder

The DSM-IV-TR definition of hypomania in bipolar II disorder (BP-II) has yet to show its validity. The aim of the current study was to find the factor structure of hypomania by using DSM-IV-TR symptoms, and to assess the DSM-IV-TR definition of hypomania. One hundred ninety-seven consecutive BP-II remitted outpatients were interviewed by the Structured Clinical Interview for DSM-IV (SCID-CV) as modified by Benazzi and Akiskal (2003) and by Benazzi (2003), in a private practice, assessing the symptoms that were more common during past hypomanic episodes. The factor structure of hypomania was studied by principal component factor analysis. Almost all patients reported overactivity (increased goal-directed activity) during hypomania, and less commonly elevated mood. Overactivity plus three or more symptoms identified 89.3% of DSM-IV-TR BP-II. Factor analysis found three factors: factor 1, including racing thoughts ("mental activation"); factor 2, including elevated mood ("high mood"); and factor 3, including overactivity ("behavioral activation"). Elevated mood was correlated only with two of the nine DSM-IV-TR hypomanic symptoms. The three-domains structure of hypomania by Kraepelin (i.e., increased mood, thought, and activity) was found in the DSM-IV-TR definition of hypomania, partly supporting its list of symptoms. However, DSM-IV-TR priority given to mood change for the diagnosis of hypomania was not supported. An upgrading of overactivity to at least a priority level similar to mood change was supported by (1) its high frequency, (2) its utility to diagnose BP-II, and (3) by factor analysis showing that elevated mood (the "prototypical" symptom of hypomania in DSM-IV-TR) correlated with few symptoms, and that three factors (of which only one included elevated mood) were present.     

Comparison of the treatment with paroxetine and reboxetine in panic disorder: a randomized, single-blind study

INTRODUCTION: Serotonergic agents have greater effectiveness than noradrenergic ones in the treatment of Panic Disorder (PD). However preliminary studies suggested that reboxetine might be effective in the treatment of PD. We compared the effectiveness and tolerability of reboxetine and paroxetine in the treatment of PD. METHODS: Sixty-eight patients with PD were assigned to treatment groups in a single-blind, randomized design. Each patient was assessed at day 0 and 90 by the Panic Associated Symptoms Scale (PASS), the Sheehan Disability Scale (SDS) and the Fear Questionnaire (FQ). Side effects were also recorded. RESULTS: Reduction of PASS scores was significantly greater in the paroxetine group than in the reboxetine one. Vice versa we did not find any significant differences for other outcome measures. Sexual dysfunction and weight gain were significantly less frequent in the reboxetine group. CONCLUSIONS: The results showed a greater effect of paroxetine on panic attacks than reboxetine, while no differences for anticipatory anxiety and avoidance were found, suggesting a different role of noradrenaline and serotonin in the treatment of PD.     

The increasing use of anticonvulsants in prophylactic treatment of bipolar disorder

The medical records of patients with bipolar disorders who received prophylactic drug treatments during three time periods from January 1983 to December 1984, January 1988 to December 1989, and from January 1993 to December 1994, were reviewed retrospectively. The percentage of lithium monotherapy sharply decreased from 96% (51/53) in the first study period to 51.9% (83/160) in the third study period. Carbamazepine monotherapy and combination of lithium and carbamazepine increased from 3.8% in the first study period to 45.6% in the third study period. These results suggest that anticonvulsants may become one of the major drug treatment strategies for bipolar disorder in the future.     

Cognitive styles in hypomanic episodes of bipolar I disorder

Lex C, Hautzinger M, Meyer TD. Cognitive styles in hypomanic episodes of bipolar I disorder.
Bipolar Disord 2011: 13: 355–364. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Cognitive vulnerability‐stress theories have recently been extended to bipolar disorder by suggesting that an activation of negative cognition might lead to depressive mood episodes and an activation of positive cognition might lead to manic mood episodes. Alternatively, the manic defense hypothesis claims that hypomanic and manic states are not the opposite of depression but rather contain similar underlying negative cognitions. The objective of this study was to further evaluate these theories by examining the cognitive patterns in bipolar I hypomania. Methods: We compared 15 hypomanic bipolar I disorder patients, 26 remitted bipolar I disorder patients, and 21 healthy individuals in a cross‐sectional study. All participants completed the Dysfunctional Attitude Scale, the Attributional Style Questionnaire, the Emotional Stroop Task, and the Emotional Auditory Verbal Learning Test. Results: Hypomanic bipolar disorder individuals showed cognitions associated with depressive states as well as cognitions associated with manic states. The results for the remitted bipolar disorder patients paralleled those for the control group. Conclusion: Dysfunctional cognition in bipolar disorder seems to relate to state rather than to trait. Hypomania includes depression‐related as well as mania‐related cognitions and can therefore not be considered as the mere opposite of depression.     

双相情感障碍患者和家属对双相情感障碍前驱症状识别能力的比较研究

目的 比较双相情感障碍（BD）患者和家属对 BD 前驱症状的识别能力。方法 回顾性调 查 2015 年 3 月至 2018 年 9 月首都医科大学附属北京安定医院门诊和住院部收治的 80 例非急性期 BD 患 者以及与患者密切接触的 80 名家属（照料者 / 监护人）。采用 BD 前驱症状回顾性量表（BPSS-R）对研究对 象进行半结构式访谈,比较患者、家属对前驱症状的识别能力。结果 80 例患者中,BD-Ⅰ型占 73.8% （59/80）,BD-Ⅱ型占 26.2%（21/80）;女性占 35.0%（28/80）;首次发作症状为抑郁的患者占 38.8%（31/80）,前 驱期发作病程为（7.1±3.4）个月;首次发作症状为轻躁狂 / 躁狂的患者占 61.2%（49/80）,前驱期发作病程 为（6.1±3.6）个月。当首次发作为抑郁发作时,家属对社会孤立、学业和职业功能不良、焦虑 / 紧张、注 意力不集中、思维混乱或奇怪的想法的识别率高于患者,评估学校 / 工作问题的严重程度高于患者,差 异有统计学意义（P＜0.05）。当首次发作为轻躁狂/躁狂发作时,家属对社会孤立、焦虑/紧张、运动迟缓、 失眠、体重或食欲下降、事物的愉快感或兴趣丧失的识别率高于患者,差异有统计学意义（P＜ 0.05）。无 论首次发作是抑郁还是轻躁狂 / 躁狂发作,患者对抑郁心境的识别率高于家属,差异有统计学意义（P＜ 0.01）。结论 BD 患者和家属对于 BD 前驱症状的识别能力存在差异,家属对除抑郁心境外的其他多个 前驱症状的识别能力高于患者。     

A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder

BACKGROUND: Lamotrigine has been shown to be an effective treatment for bipolar depression and rapid cycling in placebo-controlled clinical trials. This double-blind, placebo-controlled study was conducted to assess the efficacy and tolerability of lamotrigine and lithium compared with placebo for the prevention of relapse or recurrence of mood episodes in recently manic or hypomanic patients with bipolar I disorder. METHODS: After an 8- to 16-week open-label phase during which treatment with lamotrigine was initiated and other psychotropic drug regimens were discontinued, patients were randomized to lamotrigine (100-400 mg daily), lithium (0.8-1.1 mEq/L), or placebo as double-blind maintenance treatment for as long as 18 months. RESULTS: Of 349 patients who met screening criteria and entered the open-label phase, 175 met stabilization criteria and were randomized to double-blind maintenance treatment (lamotrigine, 59 patients; lithium, 46 patients; and placebo, 70 patients). Both lamotrigine and lithium were superior to placebo at prolonging the time to intervention for any mood episode (lamotrigine vs placebo, P =.02; lithium vs placebo, P =.006). Lamotrigine was superior to placebo at prolonging the time to a depressive episode (P =.02). Lithium was superior to placebo at prolonging the time to a manic, hypomanic, or mixed episode (P =.006). The most common adverse event reported for lamotrigine was headache. CONCLUSIONS: Both lamotrigine and lithium were superior to placebo for the prevention of relapse or recurrence of mood episodes in patients with bipolar I disorder who had recently experienced a manic or hypomanic episode. The results indicate that lamotrigine is an effective, well-tolerated maintenance treatment for bipolar disorder, particularly for prophylaxis of depression.     

Subsyndromal symptoms assessed in longitudinal, prospective follow-up of a cohort of patients with bipolar disorder

Background: Many patients with bipolar disorder (BD) do not regain full function following an acute illness episode, but the extent to which this impairment is the result of persistent symptoms has not been well established. This study examined factors associated with persistent subsyndromal symptoms in a well characterized group of BD patients who were prospectively followed for an average of 3 years.
Methods: Detailed life charting data from 138 patients with BD were reviewed. Patients were categorized into euthymic, subsyndromal or syndromal groups according to the clinical state during their most recent year of follow-up. The three groups were then examined with respect to comorbidity, function and treatment received.
Results: Patients with subsyndromal symptoms had high rates of comorbid anxiety disorders, and were more likely to have increased rates of eating disorders as well. Patients with subsyndromal symptoms had lower global assessment of function (GAF) scores than euthymic patients, and had as many clinic contacts and medication trials as patients with full episodes of illness.
Conclusions: Persistent subsyndromal symptoms in BD patients are associated with high rates of comorbidity that is important to recognize and treat in order to optimize mood and functioning.     

家庭支持干预对分裂情感性精神障碍患者生活质量的影响：6个月单盲随机对照研究

目的探讨分裂情感性精神障碍患者经家庭支持干预后生活质量的改善。方法将48例门诊分裂情感性精神障碍患者随机分为观察组（24例）和对照组（24例）,两组患者均给予常规抗精神病药物治疗,研究组在此基础上给予家庭干预6个月,干预前后分别采用简明健康测量量表（SF-36）和临床总体评定量表的疾病严重程度（CGI-SI）评定患者的生活质量和疾病严重程度。结果实施家庭支持干预6个月后,研究组的生活质量指标明显优于对照组[SF-36躯体功能分量表的均分（标准差）分别为73.3（6.2）分与66.8（6.4）分,t=4.67,P〈0.001;社会功能分量表的均分（标准差）分别为53.4（12.8）分与42.1（7.9）分,t=4.13,P〈0.001],研究组CGI-SI量表总分[均分（标准差）]低于对照组[分别为2.4（0.5）与2.9（0.9）,t=2.52,P=0.015]。结论家庭支持干预有助于提高分裂情感性精神障碍患者的生活质量。     

Cognitive function across manic or hypomanic, depressed, and euthymic states in bipolar disorder

OBJECTIVE: The study aims were to address neuropsychological functioning across different states of bipolar illness and to determine relationships among clinical features, neuropsychological performance, and psychosocial functioning. METHOD: Several domains of cognitive function were examined in 30 depressed bipolar patients (DSM-IV criteria for major depression, Hamilton Depression Rating Scale score > or = 17), 34 manic or hypomanic bipolar patients (DSM-IV criteria for manic or hypomanic episode, Young Mania Rating Scale score > or = 12), and 44 euthymic bipolar patients (6 months of remission, Hamilton depression scale score < or = 8, and Young Mania Rating Scale score < or = 6). The comparison group consisted of 30 healthy subjects without history of neurological or psychiatric disorders. A neuropsychological battery assessed executive function, attention, and verbal and visual memory. RESULTS: The three groups showed cognitive dysfunction in verbal memory and frontal executive tasks in relation to the comparison group. Low neuropsychological performance was associated with poor functional outcome. Impairment of verbal memory was related to the duration of illness and the numbers of previous manic episodes, hospitalizations, and suicide attempts. CONCLUSIONS: A poorer performance was observed in all bipolar groups regarding executive function and verbal memory in relation to the healthy comparison subjects. These cognitive difficulties, especially related to verbal memory, may help explain the impairment regarding daily functioning, even during remission. Further studies should focus on testing, whether optimizing prophylactic pharmacological treatment and psychoeducation might reduce cognitive impairment, and whether bipolar patients would benefit from neuropsychological rehabilitation in order to reduce the impact of cognitive impairment in their overall functioning.     

Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine

Kwentus J, Riesenberg RA, Marandi M, Manning RA, Allen MH, Fishman RS, Spyker DA, Kehne JH, Cassella JV. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo‐controlled clinical trial with inhaled loxapine. Bipolar Disord 2012: 14: 31–40. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objective: The present study evaluated inhaled loxapine for the acute treatment of agitation in patients with bipolar I disorder. Methods: A Phase 3, randomized, double blind, placebo‐controlled, parallel group inpatient study was performed at 17 psychiatric research facilities. Agitated patients (N = 314) with bipolar I disorder (manic or mixed episodes) were randomized (1:1:1) to inhaled loxapine 5 mg or 10 mg, or inhaled placebo using the Staccato^® system. Following baseline assessments, patients received Dose 1 and were evaluated for 24 hours. If required, up to two additional doses of study drug and/or lorazepam rescue medication were given. The primary efficacy endpoint was change from baseline in the Positive and Negative Syndrome Scale‐Excited Component (PANSS‐EC) score two hours after Dose 1. The key secondary endpoint was the Clinical Global Impression‐Improvement score at two hours after Dose 1. Additional endpoints included the changes from baseline in the PANSS‐EC from 10 min through 24 hours after Dose 1. Safety was assessed by adverse events, vital signs, physical examinations, and laboratory tests. Results: For the primary and key secondary endpoints, both doses of inhaled loxapine significantly reduced agitation compared with placebo. Reduced agitation, as reflected in PANSS‐EC score, was evident 10 min after Dose 1 with both doses. Inhaled loxapine was well tolerated, and the most common adverse events were known effects of loxapine or minor oral effects common with inhaled medications (dysgeusia was reported in 17% of patients receiving active drug versus 6% receiving placebo). Conclusions: Inhaled loxapine provided a rapid, non‐injection, well‐tolerated acute treatment for agitation in patients with bipolar I disorder.     

双相障碍误诊及患者求医轨迹

目的了解双相障碍患者被误诊情况、临床特点和求医轨迹,为双相障碍的识别和诊疗提供参考。方法根据目前诊断和首次诊断是否相同,将2007年6月-2010年10月在广州市医科大学附属脑科医院就诊的处于抑郁发作期的247例双相障碍患者分为误诊组和确诊组,通过调查、访谈及问卷法收集患者资料,比较两组临床特点和求医轨迹。结果检出确诊病例72例,误诊患者175例,误诊率为70.85%。误诊病例中被误诊为单相抑郁障碍的最多(64.00%),其次为精神分裂症(22.29%)。与确诊组相比,误诊组有更高比例的病前生活事件(41.9%vs.23.6%,P0.01)、过去存在更高比例的轻躁狂症状(70.9%vs.55.6%,P0.01)、间歇性病程更少(55.2%vs.70.8%,P=0.02),而确诊组更多患者首次即去精神病专科医院就诊(83.3%vs.70.3%,P=0.03)。结论具有病前生活事件、轻躁狂症状以及间歇性病程更少的双相障碍患者应尽早到精神病专科医院就诊,以提高确诊率。     

Clinical significance of lifetime panic spectrum symptoms in the treatment of patients with bipolar I disorder

BACKGROUND: Given the observed association between panic disorder and bipolar disorder and the potential negative influence of panic symptoms on the course of bipolar illness, we were interested in the effects of what we have defined as "panic spectrum" conditions on the clinical course and treatment outcome in patients with bipolar I (BPI) disorder. We hypothesized that lifetime panic spectrum features would be associated with higher levels of suicidal ideation and a poorer response to acute treatment of the index mood episode in this patient population. METHODS: A sample of 66 patients with BPI disorder completed a self-report measure of lifetime panic-agoraphobic spectrum symptoms. Patients falling above and below a predefined clinical threshold for panic spectrum were compared for clinical characteristics, the presence of suicidal ideation during acute treatment, and acute treatment response. RESULTS: Half of this outpatient sample reported panic spectrum features above the predefined threshold. These lifetime features were associated with more prior depressive episodes, higher levels of depressive symptoms, and greater suicidal ideation during the acute-treatment phase. Patients with BPI disorder who reported high lifetime panic-agoraphobic spectrum symptom scores took 27 weeks longer than those who reported low scores to remit with acute treatment (44 vs 17 weeks, respectively). CONCLUSIONS: The presence of lifetime panic spectrum symptoms in this sample of patients with BPI disorder was associated with greater levels of depression, more suicidal ideation, and a marked (6-month) delay in time to remission with acute treatment. Alternate treatment strategies are needed for patients with BPI disorder who endorse lifetime panic spectrum features.     

Depressive symptoms in patients with unipolar and bipolar affective disorder.

The study of biologic differences in patients with affective illness is dependent in part on a clinical classification which separates depressed patients into subgroups of greater homogeneity. The unipolar-bipolar classification is one such system, and the use of this classification has been supported by clinical, biologic, genetic, and pharmacologic studies of affective disorder.¹ This paper is part of a series of studies to determine if patients with depression and hypomania (“bipolar II”) can be distinguished from patients with depression and severe mania (“bipolar I”) and patients with depression without hypomania (unipolar).^2–4 In this paper, symptoms of depression, as measured with the use of a modified Hamilton depression rating scale,⁵ a nurses' global rating scale, and self-administered adjective check list, will be examined in moderately to severely depressed patients who were admitted to a clinical metabolic research unit.     

Clinical features of antidepressant associated manic and hypomanic switches in bipolar disorder

The present study investigated possible clinical differences between bipolar patients with and without manic or hypomanic switch during antidepressant (AD) treatment. The authors undertook a retrospective assessment of 169 individuals affected by bipolar disorder type I (BP I: n=96) and II (BP II: n=73) who experienced at least one manic or hypomanic episode following depression without any interposed normothymic period ("manic switch") during AD therapy. They were compared with a sex, age (+/-5 years), and ethnicity-matched group of 247 subjects, randomly selected from our pool of bipolar subjects who have never had manic switches. Only 2 of the 169 patients had had spontaneous switches before the AD-related one. Switched subjects were marginally older (t=-2.65, df=414, P=.008) compared to not switched and less frequently delusional (chi2=13.86, P=.0002). Polarity of the onset episode was more frequently depressive in switched patients (chi2=21.93, P=.00002), which had also less previous manic episodes than not switched (t=3.44, df=332, P=.0006). Those differences were more pronounced in the BP I subsample. Switched patients were more frequently BP I (chi2=29.66; P<.00001). Maintenance with mood stabilizers appears to be a strong protective factor; in fact, of the 124 individuals undertaking a mood stabilizer therapy, 21 had a switch and 103 had no switches (chi2=41.10, P<.000001). In conclusion, some clinical variables, such as the number of manic episodes, the presence of delusions, the polarity of onset episode, and the mood-stabilizing treatment, may be involved in AD-related switches. Further studies are required to investigate the causal relationships between those factors.     

Behavioral treatment in two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder

The authors describe two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder. Behavior therapy consisting of in vivo exposure plus response prevention controlled the obsessive-compulsive symptoms only after the affective illness was well controlled pharmacologically.