Is overactivity the core feature of hypomania in bipolar II disorder?

BACKGROUND: Recent studies found that overactivity (increased goal-directed activities) may be as important as mood change (elevated and/or irritable mood) for the diagnosis of mania/hypomania (on family history and psychometric grounds), questioning DSM-IV-TR criteria always requiring mood change and listing overactivity among the other symptoms. The aim of the study was to find out if overactivity was at least as important as mood change for the diagnosis of hypomania. SAMPLING AND METHODS: A consecutive sample of 137 bipolar II disorder (BP-II) and 76 major depressive disorder remitted outpatients were interviewed with the Structured Clinical Interview for DSM-IV by a senior clinical and research psychiatrist in a private practice. Patients were asked if they had had hypomanic symptoms and episodes, and which were the most common hypomanic symptoms during the various episodes. The study aim had not been planned when variables were collected for different study goals. RESULTS: Overactivity was the most common hypomanic symptom in BP-II, more common than elevated mood, and had the strongest association with BP-II among all the hypomanic symptoms (overactivity odds ratio = 15.4, elevated mood odds ratio = 12.6). Three factors were found: an 'elevated mood' factor including elevated mood and increased self-esteem; a 'mental activation' factor including racing/crowded thoughts, and a 'behavioral activation' factor including overactivity. There was no relationship between overactivity and mood change. Irritable mood was not associated with overactivity and elevated mood. BP-II was present in 21.6%of patients without a history of overactivity, and in 81.0% of patients with a history of overactivity. BP-II was present in 25.0% of patients without elevated mood, and in 63.3% of patients with elevated mood. As a predictor of BP-II, overactivity had a sensitivity of 90.5%, a specificity of 61.8%, and a positive predictive value of 81.0% (elevated mood: 72.2, 82.8, and 88.3%, respectively). Five or more hypomanic symptoms had the most balanced combination of sensitivity (82.4%) and specificity (85.5%) for BP-II, and a positive predictive value of 91.1%. Overactivity was present in 89.5% of patients with a history of > or = 5 hypomanic symptoms, while elevated mood was present in 76.6%. CONCLUSIONS: Theresults seem to support the view that overactivity may be a core feature of hypomania, suggesting the upgrading of overactivity to a stem criterion for hypomania.     

Is impulsivity in remitted bipolar disorder a stable trait? A meta-analytic review

Objective

To review scores on measures of impulsivity in remitted bipolar disorder.

Data source

We used keywords “impulsivity and bipolar” and “impulsivity and mania” to narrow down our search on Medline, EMBASE and Psychinfo to include those studies that had reported impulsivity scores using validated and reliable assessment measures in remitted bipolar disorder (both I and II). We searched all English language studies from 1990 to October 2012.

Study Selection

Nineteen reports met the inclusion criteria and were reviewed by two abstractors independently.

Data abstraction

We generated weighted mean differences (WMDs) from pooled data using RevManager 5.0 from Cochrane analysis.

Results

The Barratt Impulsivity Scale (BIS) 11 was the instrument most commonly used. Nineteen studies met the inclusion criteria, of which 2 were excluded due to incomplete data. A WMD of 12.8 was observed for BIS 11 total scores, 4.3 on the motor component, 4.1 on the cognitive and 7.6 on the non-planning components of the BIS 11 respectively.

Conclusion

Impulsivity is significantly higher in remitted bipolar patients than normal controls. Non-planning impulsivity is a key domain affected in bipolar disorder, which may represent a stable trait.     

Thought disorder in euthymic bipolar patients: a possible endophenotype of bipolar affective disorder?

The search for psychological markers or for psychological endophenotypes for bipolar affective disorder has been frustrating, and the study of neuropsychological and neurocognitive functioning may be useful in this search. This article presents the results of a study comparing Rorschach protocols from a sample of adult euthymic bipolar patients (N = 18) and matched healthy controls (N = 8). Bipolar patients showed a higher proportion of immature responses and more instances of thought disorder; patients also showed significantly more severe thought disorder. These findings are discussed in the context of 2 related previous studies. We suggest that our modest series of studies using the Rorschach Inkblot Test provides preliminary evidence that certain variables-especially the measures of thought disorder but possibly also the lack of emotional responses under cognitive "control" and the excessive proportion of immature content responses-may represent a possible endophenotype of bipolar disorder.     

Klotho dysfunction: A pathway linking the aging process to bipolar disorder?

AimAlthough accelerated aging profile has been described in bipolar disorder (BD), the biology linking BD and aging is still largely unknown. Reduced levels and/or activity of a protein named Klotho is associated with decreased life span, premature aging and occurrence of age-related diseases. Therefore, this study was designed to evaluate plasma levels of Klotho in BD patients and controls.MethodsForty patients with type 1 BD and 30 controls were enrolled in this study. After clinical evaluation, peripheral blood samples were drawn and plasma levels of Klotho were measured using enzyme-linked immunosorbent assay.ResultsPatients with BD and controls presented similar age and sex distribution. The mean ± SD length of illness was 24.00 ± 12.75 years. BD patients presented increased frequency of clinical comorbidities in comparison with controls, mainly arterial hypertension, diabetes mellitus, and hypothyroidism. Both patients with BD in remission and in mania exhibited increased plasma levels of Klotho in comparison with controls. There was no significant difference between patients in mania and patients in remission regarding the levels of Klotho.ConclusionKlotho-related pathway is altered in BD. Contrary to our original hypothesis, our sample of patients with BD presented increased plasma levels of Klotho in comparison with controls. Elevated levels of Klotho in long-term BD patients may be associated with the disorder progression. Further studies are needed to better understand the role of Klotho in BD and other mood disorders.     

Comment on published article “A chat about bipolar disorder”

To the Editor, we follow the topic “A chat about bipolar disorder¹”. According to the study's findings, ChatGPT proved its ability to deliver basic and informative information on bipolar disorders.     

What clinical features precede the onset of bipolar disorder?

Despite a growing number of reports, there is still limited knowledge of the clinical features that precede the onset of bipolar disorder (BD). To explore this, we investigated baseline data from a prospectively evaluated longitudinal cohort of subjects aged 12–30 years to compare: first, lifetime rates of clinical features between a) subjects at increased genetic risk for developing BD (‘AR’), b) participants from families without mental illness (‘controls’), and c) those with established BD; and, second, prior clinical features that predict the later onset of affective disorders in these same three groups. This is the first study to report such comparisons between these three groups (though certainly not the first to compare AR and control samples). 118 AR participants with a parent or sibling with BD (including 102 with a BD parent), 110 controls, and 44 BD subjects were assessed using semi-structured interviews. AR subjects had significantly increased lifetime risks for depressive, anxiety and behavioural disorders compared to controls. Unlike prior reports, preceding anxiety and behavioural disorders were not found to increase risk for later onset of affective disorders in the AR sample, perhaps due to limited sample size. However, preceding behavioural disorders did predict later onset of affective disorders in the BD sample. The findings that i) AR subjects had higher rates of depressive, anxiety and behavioural disorders compared to controls, and ii) prior behavioural disorders increased the risk to later development of affective disorders in the BD group, suggest the possibility of therapeutic targeting for these disorders in those at high genetic risk for BD.     

When do antidepressants worsen the course of bipolar disorder?

Bipolar disorder may be more prevalent than previously believed. Because a substantial number of patients with bipolar disorder present with an index depressive episode, it is likely that many are misdiagnosed with unipolar major depression. Even if a correct diagnosis is made, depressive symptoms in bipolar disorder are notoriously difficult to treat. Patients are often treated with antidepressants, which, if used improperly, are known to induce mania and provoke rapid cycling. This article explores diagnostic conundrums in bipolar depression and their possible solutions, based on current research evidence. It also elucidates current evidence regarding the risks and benefits associated with antidepressant use and evaluates alternative treatment regimens for the depressed bipolar population, including the use of traditional mood stabilizers such as lithium, novel anticonvulsants such as lamotrigine, and atypical antipsychotics.     

Is borderline personality disorder part of the bipolar spectrum?

In recent years, advances in the areas of both bipolar and borderline personality disorders have generated considerable interest in the clinical interface between these two conditions. Developments in the study of the neurobiology of borderline personality disorder suggest that many patients with this diagnosis have etiological features in common with those diagnosed with bipolar disorders. This claim is supported by new insights into the phenomenology of both disorders and by evidence that mood stabilizers are efficacious in the pharmacological management of borderline patients. This area of research is an important one because of the considerable morbidity and public health costs associated with borderline personality disorder. Since borderline patients can be so challenging to care for, it may be that a reframing of the disorder as belonging to the broad clinical spectrum of bipolar disorders holds benefits for patients and clinicians alike.     

Deficits of entropy modulation of the EEG: A biomarker for altered function in schizophrenia and bipolar disorder?

BackgroundThe synchronized activity of distributed neural assemblies — reflected in the electroencephalogram (EEG) — underpins mental function. In schizophrenia, modulation deficits of EEG spectral content during a P300 task have been replicated. The effects of treatment, chronicity and specificity in these deficits and their possible relationship with anatomic connectivity remain to be explored.MethodsWe assessed spectral entropy modulation of the EEG during a P300 task in 79 patients with schizophrenia (of those, 31 were in their first episode), 29 patients with bipolar disorder and 48 healthy controls. Spectral entropy values summarize EEG characteristics by quantifying the irregularity of spectral content. In a subsample, we calculated the network architecture of structural connectivity using diffusion tensor imaging and graph-theory parameters.ResultsWe found significant spectral entropy modulation deficits with task performance in patients with chronic or first-episode schizophrenia and in patients with bipolar disorder, without significant pre-stimulus spectral entropy differences. The deficits were unrelated to treatment doses, and spectral entropy modulation did not differ between patients taking or not taking antipsychotics, lithium, benzodiazepines or antidepressants. Structural connectivity values were unrelated to spectral entropy modulation. In patients with schizophrenia, spectral entropy modulation was inversely related to negative symptoms and directly related to verbal memory.LimitationsAll patients were taking medication. Patients with bipolar disorder were euthymic and chronic. The cross-sectional nature of this study prevented a more thorough analysis of state versus trait criteria for spectral entropy changes.ConclusionSpectral entropy modulation with task performance is decreased in patients with schizophrenia and bipolar disorder. This deficit was not an effect of psychopharmacological treatment or structural connectivity and might reflect a deficit in the synchronization of the neural assemblies that underlie cognitive activity.     

Obsessive compulsive symptoms in bipolar disorder patients: a comorbid disorder or a subtype of bipolar disorder?

概述

在过去十年中，人们越来越关注同时符合两种或两种以上精神障碍诊断标准的患者。上述共病情况之一就是双相障碍合并强迫症，这在以双相障碍为主要诊断的患者中比较常见。但是，关于这种共病的诊断和治疗的研究很少，在中国尤为如此。现有的研究主要集中在小样本的横断面研究，因此它们在对理解这种共病情况的病因和病程作用有限。对有限的文献进行回顾发现这是双相障碍中一种相对严重的、难治性的亚型，只有少数情况可以被认为是一种共病障碍。要阐明这种共病的病因、预后以及合适的治疗方法，则需要大样本的前瞻性研究。

中文全文

本文全文中文版从2015年10月26日起在http://dx.doi.org/10.11919/j.issn.1002-0829.215091可供免费阅览下载 The Forum by Peng and Jiang[1] highlights the lack of literature about comorbid bipolar disorder and obsessive compulsive (OCD) disorder. To provide a preliminary summary of the available English-language literature, a search of PubMed using three relevant keywords (‘bipolar disorder’, ‘obsessive compulsive disorder’, and ‘comorbidity’) was conducted in July 2015. Only a few of the 176 papers retrieved by this search were directly related to the topic of interest: most of the relevant papers described the incidence and clinical features of comorbid bipolar disorder and OCD in relatively small samples of patients; some discussed the etiology and treatment of the comorbid condition; and a few reported on prospective, multi-center studies with relatively large samples. Bipolar-OCD comorbidity was first reported in a 1995 study from Germany[2] which found that more than half of all patients with bipolar disorder had experienced other mental disorders, including OCD, during the course of the bipolar disorder. The study reported that the prevalence of comorbid OCD was higher in patients with unipolar depression than among patients with bipolar disorder. A subsequent systematic review[3] of 64 relevant articles in 2014 reported that from 11 to 21% of persons with bipolar disorder experience comorbid OCD at some time during the course of their bipolar disorder. Most reports indicate that comorbid OCD exacerbates the symptoms of bipolar disorder and makes the diagnosis and treatment of bipolar disorder more difficult. Compared to OCD patients and bipolar disorder patients without other comorbid conditions, bipolar patients with comorbid OCD have: a) higher rates of obsessive ideas about sex and religion and lower rates of ritual checking;[4] b) higher rates of substance abuse (including use of alcohol, sedatives, caffeine, etc.);[5,6] more episodes of depression, higher rates of suicide, and more frequent admissions to hospitals;[7] and d) more chronic episodes and residual symptoms.[8,9] There were no differences between bipolar patients with and without comorbid OCD in age, gender, education, marital status, age of onset of bipolar disorder, personality, prevalence of psychotic symptoms or rapid cycling, history of suicide attempts, the type of initial bipolar episode (i.e., depressed or manic), and the type of episode that was most prevalent throughout the course of bipolar disorder.[9] The systematic review by Amerio and colleagues[3] found that compared to bipolar patients without comorbid OCD, patients with bipolar disorder with comorbid OCD were more likely to experience OCD symptoms during an affective disorder episode (75% v. 3%), had a higher mean (sd) number of depressive episodes (8.9 [4.2] v. 4.1 [2.7] episodes), and were more likely to experience an antidepressant-induced manic episode (39% v. 9%). They also found that among patients with comorbid bipolar disorder and OCD, OCD symptoms were more like to occur during depressive episodes than manic episodes (78% v. 64%). Based on their findings, these authors argue that the obsessive-compulsive symptoms observed in these patients were secondary to bipolar disorder, not a co-occurring independent disorder.[3] Following this logic, I recommend that the occurrence of obsessivecompulsive symptoms during the depressive (or manic) episodes of a bipolar disorder should not be sufficient to merit a diagnosis of comorbid bipolar disorder and OCD; this comorbid diagnosis should be restricted to situations in which a patient with bipolar disorder also meets the full OCD symptomatic and duration criteria when the patient is not experiencing a depressive or manic episode. There are only a few articles about the possible etiology of bipolar-OCD comorbidity. A long-term family study based on a multi-generational dataset[10] (cases registered from January 1969 to 2009 included 19, 814 with OCD, 58, 336 with schizophrenia, 48, 180 with bipolar disorders, and 14, 904 with schizoaffective disorder) found familial associations among individuals with bipolar disorder, OCD, and schizophrenia spectrum disorders. There are also few reports about the long-term prognosis of comorbid bipolar disorder and OCD. One study[11] that followed 20 patients with bipolar disorder without comorbid disorders and 20 patients with comorbid bipolar disorder and OCD for 4 years found no significant differences in the long-term outcomes between the two groups. The treatment of bipolar-OCD comorbidity is difficult because the use of antidepressants to treat obsessive compulsive disorder may induce manic episodes. The existing literature about the treatment is primarily composed of case reports, retrospective cross-sectional studies, and a few treatment studies with small samples. A recent systematic review that combined the results of four treatment studies[12] found that 42% of patients with comorbid bipolar disorder and OCD were simultaneously treated with multiple mood stabilizers and another 10% needed combined treatment with mood stabilizers and anti-psychotic medications. One of the four studies reported that the combined use of antidepressants and mood stabilizers was effective and another study reported that some patients benefitted from the combined use of mood stabilizers and psychological therapy.[11] Based on currently available information, I recommend that patients with comorbid bipolar disorder and OCD be initially treated with mood stabilizers; if mono-therapy with mood stabilizers is ineffective, adjunctive treatment with selective serotonin reuptake inhibitor antidepressants (which are less likely to induce mania) should be considered. In my opinion, the basic treatment for bipolar-OCD is mood stabilizers and could be combined with antidepressants if the patients do not respond to the single treatment (ineffective). Despite ongoing debates about the etiology, diagnosis, and treatment of comorbid bipolar disorder and OCD, the clinicians who regularly treat bipolar patients need more high-quality, evidence-based information to improve their identification and management of this relatively severe and refractory subgroup of bipolar patients. Well-designed prospective studies with relatively large samples that are specifically focused on this important subgroup of bipolar disorder patients are needed.     

Validating Angst’s “ups &; downs” personality trait as a new marker of bipolar II disorder

Abstract.Background: Angst has recently found an association between the bipolar spectrum and a personality trait called ups & downs, defined by the question would you say you were one of those people who have frequent ups and downs?. Study aimwas to find the frequency of ups & downs in a large sample of bipolar II (BPII) and major depressive disorder (MDD),and to test its association with BPII.Methods: Consecutive 89 MDD and 89 BPII outpatients were interviewed, during a major depressive episode (MDE),with the Structured Clinical Interview for DSM-IV, as modified by Benazzi and Akiskal (2003). Hypomanic symptoms during MDE were systematically assessed. The association between ups & downs (defined by Angsts question) and BPII was tested versus bipolar validators (young onset, many recurrences, atypical depression, depressive mixed state [MDE plus 3 or more concurrent hypomanic symptoms, following Akiskal and Benazzis definition (2003)], and bipolar family history. Associations were tested by univariate and multivariate logistic regression (STATA 7).Results: ups & downs was present in 62.9% of BPII and in 33.7% of MDD (ratio = 1.86, p = 0.0001). All bipolar validators were significantly more common in BPII versus MDD. Sensitivity and specificity of bipolar validators for predicting BPII, including ups & downs, showed that ups & downs had a balanced combination of sensitivity (62.9 %) and specificity (66.2 %) (i. e., sensitivity not too low compared to specificity and vice versa) for predicting BPII, and that it was strongly associated with BPII (odds ratio = 3.3, 95% CI 1.8–6.1). Multivariate analyses found that ups & downs independently and significantly predicted BPII among the other bipolar validators. Patients did not confuse ups & downs with many past MDEs, as the association with BPII did not change when controlled for recurrences.Conclusions: Findings suggest that Angsts ups and downs might be a new marker of BPII. Its simple question might be useful to clinicians to better detect the highly underdiagnosed BPII during assessment of depression.     

Pediatric mania: a developmental subtype of bipolar disorder?

Despite ongoing controversy, the view that pediatric mania is rare or nonexistent has been increasingly challenged not only by case reports, but also by systematic research. This research strongly suggests that pediatric mania may not be rare but that it may be difficult to diagnose. Since children with mania are likely to become adults with bipolar disorder, the recognition and characterization of childhood-onset mania may help identify a meaningful developmental subtype of bipolar disorder worthy of further investigation. The major difficulties that complicate the diagnosis of pediatric mania include: 1) its pattern of comorbidity may be unique by adult standards, especially its overlap with attention-deficit/hyperactivity disorder, aggression, and conduct disorder; 2) its overlap with substance use disorders; 3) its association with trauma and adversity; and 4) its response to treatment is atypical by adult standards.