Trait impulsivity in patients with mood disorders

[Psychotherapeutic and psychosocial interventions and endophenotypes in bipolar disorders]

Diseases with complex determinism, bipolar disorders, involve at the same time environmental and genetic factors of vulnerability. The characterization of these vulnerabilities would allow a better knowledge of their etiology and envisage the development of therapeutics, more specialized, even preventive. The research in genetic psychiatry allowed to highlight endophenotype candidates associated to bipolar disorders. They are endogenous clinical or biological features, biologically more elementary than phenotypes and more directly bound to the physiological consequences of genes and their polymorphisms. Targeting some of them with specific psychotherapy and psychosocial interventions could reduce the consequences of their expression and so have an action on the course of the disease and also preventive.

Trait impulsivity is increased in bipolar disorder patients with comorbid alcohol use disorders

BACKGROUND

Up to 60% of bipolar disorder (BD) patients develop alcohol use disorders (AUD) at some point in their lives. The causes of this highly prevalent comorbidity are unknown. High trait impulsivity characterizes both isolated BD and AUD and may be a link to explain the association between BD and AUD. In this study, our aims were to investigate whether BD patients with comorbid AUD would present higher trait impulsivity levels compared to BD patients without comorbid AUD, and whether trait impulsivity levels differ within subgroups of BD according to the subcategory of AUD (abuse vs. dependence, alcoholism alone vs. alcoholism plus drug use disorders).

SAMPLING AND METHODS

Forty-seven outpatients with BD with comorbid AUD (alcoholic BD group) were compared to 66 outpatients with BD alone (nonalcoholic BD group) and to 90 healthy controls (HC). BD and AUD diagnoses were obtained using the Structured Clinical Interview for DSM-IV diagnoses. Impulsivity was assessed using the Barratt Impulsiveness Scale (BIS-11), a self-report instrument that measures trait impulsivity in three domains: nonplanning, attentional and motor.

RESULTS

Alcoholic BD patients scored significantly higher than nonalcoholic BD and HC on the total and on each subscale BIS scores. Within the alcoholic BD patients, alcohol abusers and alcohol dependents did not statistically differ from each other on the BIS-11 scores. BD patients with AUD plus drug use disorders presented statistically higher nonplanning impulsivity than BD patients with AUD alone.

CONCLUSIONS

This was a cross-sectional study and causal inferences about the relationship between impulsivity and the comorbidity phenomenon cannot be made. Increased impulsivity may be a trait marker for the co-occurrence between BD and AUD, and mediate some severe manifestations of this comorbidity.

Reduced posterior corpus callosum area in suicidal and non-suicidal patients with bipolar disorder

BACKGROUND

Impulsivity is a characteristic of bipolar disorder (BD) that can contribute to the risk for suicidal behavior. Evidence suggests that gray and white matter abnormalities are linked with impulsivity, but little is known about the association between corpus callosum (CC) and impulsivity in BD. We examined the CC area and impulsivity in euthymic bipolar I patients, with and without lifetime history of suicide attempts, and in healthy controls.

METHODS

Nineteen bipolar patients with a suicide attempt history (BP-S), 21 bipolar patients without suicide attempt history (BP-NS), and 22 healthy controls (HC) underwent clinical assessment by the Structured Clinical Interview with the DSM-IV axis I (SCID-I), the Barratt Impulsiveness Scale (BIS-11), and MRI scan.

RESULTS

No differences were observed for any CC subregion between BP-S and BP-NS groups. There was a significant reduction in the genu (p=0.04) and isthmus areas (p=0.01), in bipolar patients compared with HC. In the BP-S group, the BIS-11 total (p=0.01), attention (p=0.001) and non-planning (p=0.02) impulsivity scores were significantly higher than in the BP-NS and HC groups.

LIMITATIONS

These results cannot establish causality because of the cross-sectional nature of the study.

CONCLUSION

This report potentially provides evidence that a reduction in the CC area is present even in non-symptomatic bipolar patients, which may be evidence of a biological trait marker for BD. Furthermore, the study demonstrated that BP-S group had higher impulsivity even during euthymia, which points to a sustained association between lifetime history of suicide attempts and impulsivity in BD.

Genetic variants in the catechol-o-methyltransferase gene are associated with impulsivity and executive function: relevance for major depression

The catechol-o-methyltransferase (COMT) gene has been extensively investigated in depression with somewhat contradictory results but the role of impulsivity, as a possible intermediate phenotype in this disorder, has not been considered yet. In our study, four tagging SNPs in the COMT gene (rs933271, rs740603, rs4680, rs4646316) were genotyped in two independent population cohorts: Manchester (n = 1267) and Budapest (n = 942). First, we investigated the association between COMT genotypes, impulsivity, neuroticism and depression using haplotype trend regression, and constructed a model using structural equation modeling to investigate the interaction between these factors. Secondly, we tested the effect of executive function on this model in a smaller interviewed sample (n = 207). Our results demonstrated that COMT haplotypes were significantly associated with impulsivity in the combined cohort, showing the same direction of effects in both populations. The COMT effect on depressive symptoms (in subjects without history of depression) and on executive function (interviewed sample) showed the opposite pattern to impulsivity. Structural equation models demonstrated that COMT and impulsivity acted, both together (through neuroticism) and independently, to increase the risk of depression. In addition, better executive function also operated as a risk factor for depression, possibly though reduced ability to flexibly disengage negative emotions. In conclusion, variations in the COMT gene exert complex effects on susceptibility to depression involving various intermediate phenotypes, such as impulsivity and executive function. These findings emphasise that modeling of disease pathways at phenotypic level are valuable for identifying genetic risk factors.

Bipolar disorder is associated with HIV transmission risk behavior among patients in treatment for HIV

This study examined HIV transmission risk behavior among 63 patients with bipolar disorder (BD), major depressive disorder, and no mood disorder; half had substance use disorders (SUDs). Patients with BD were more likely than others to report unprotected intercourse with HIV-negative partners and <95 % adherence to antiretroviral medications. In multivariate models, BD and SUD were independent predictors of both risk behaviors. Participants with poorer medication adherence were more likely to have detectable HIV viral loads and unprotected intercourse with HIV-negative partners. Patients with BD deserve careful evaluation and HIV prevention services to reduce HIV transmission risk behaviors.

Striatal dysfunction during failed motor inhibition in children at risk for bipolar disorder

BACKGROUND

A better understanding of the neural underpinnings of bipolar disorder (BD) can be obtained by examining brain activity in symptom-free individuals at risk for BD. This study examined the neural correlates of motor inhibition in a sample of symptom-free youths at familial risk for BD.

METHODS

19 euthymic youths with BD, 13 asymptomatic youths with a first-degree relative with BD, and 21 healthy comparison children completed the stop signal task in a 3 T scanner.

RESULTS

Children at familial risk for BD exhibited increased putamen activation during unsuccessful inhibition that distinguished them from both healthy and BD children. Youths with BD exhibited reduced activation of the right nucleus accumbens during unsuccessful inhibition as compared to the other participant groups.

CONCLUSIONS

Striatal activation patterns differ between youths at risk for BD and healthy comparison children during a motor inhibition task.

Impulsivity in the general population: a national study

OBJECTIVE

The construct of impulsivity is an important determinant of personality differences, psychiatric disorders, and associated risk-taking behaviors. Most existing knowledge about impulsivity comes from clinical samples. To date, no study has estimated the prevalence of impulsivity and examined its correlates in the general population.

METHOD

We analyzed data from a large national sample of the United States population. Face-to-face surveys of 34 653 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of mood, anxiety, and drug disorders as well as personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

RESULTS

Impulsivity was common (17% of the sample), particularly among males and younger individuals, and associated with a broad range of axis I and II disorders, particularly drug dependence, cluster B, dependent and schizotypal personality disorders, bipolar disorder and ADHD. It was associated with behavioral disinhibition, attention deficits, and lack of planning. Individuals with impulsivity were more likely to engage in behaviors that could be dangerous to themselves or others, including driving recklessly, starting fights, shoplifting, perpetrating domestic violence and trying to hurt or kill themselves. They were exposed to higher risk of lifetime trauma and to substantial physical and psychosocial impairment.

CONCLUSION

Given the association of impulsivity with psychiatric disorders and multiple adverse events, there is a need to target impulsivity in prevention and treatment efforts.

Trait impulsivity as an endophenotype for bipolar I disorder

OBJECTIVE

Impulsivity, conceptualized as impairment in planning and poor attentional and inhibitory control, is a key feature of bipolar disorder. Familial risk for bipolar disorder is known to affect inhibitory control but its impact on the attentional and planning dimensions of impulsivity is still unclear.

METHODS

We administered the Barratt Impulsiveness Scale, version 11 (BIS-11) to 54 euthymic individuals with DSM-IV bipolar I disorder, 57 of their clinically unaffected siblings, and 49 healthy comparison subjects. Groups were compared on the attentional (rapid shifts in attention/impatience with complexity), motor (acting impetuously), and non-planning (absence of weighing upon long-term consequences of actions) subscales of the BIS-11, and on total BIS-11 score. To investigate functional implications of trait impulsivity, total BIS-11 score was examined in relation to current psychosocial functioning and criminal history.

RESULTS

Individuals with bipolar I disorder had elevated scores compared to healthy comparison subjects on BIS-11 total score and all three subscales (p < 0.0001). Unaffected siblings had elevated BIS-11 total score (p = 0.0037), motor (p = 0.0027), and non-planning (p = 0.0379) subscales in comparison to unrelated healthy controls. Total BIS-11 score was negatively associated with global assessment of functioning (GAF) score (β = -0.32, p < 0.0001).

CONCLUSIONS

 Our results suggest that impulsivity is sensitive to familial liability for the illness, making it a potential endophenotype for bipolar disorder.

Bordering on bipolar: the overlap between borderline personality and bipolarity

OBJECTIVE

There is much debate over whether borderline personality disorder (BPD) belongs to the bipolar spectrum. The diagnosis of bipolar disorder (BD) in BPD patients, and conversely, BPD in BD patients is common, indicating prevalent co-morbidity, as well as potential misdiagnosis in either group. BD and BPD are often indistinguishable given the core characteristics of emotional dysregulation and impulsivity that feature in both. However, it may be argued that the manifestation of these characteristics in the two groups is different, and that the symptoms are driven by distinct aetiological factors. The primary objective of this paper was to examine where potential areas of discrimination lie between BD and BPD.

METHODS

A literature search was conducted using MEDLINE and PubMed databases to identify studies that have researched BD and BPD across the recognised domains of emotional dysregulation, impulsivity, childhood trauma, and their putative neurobiological substrates.

RESULTS

Research comparing BD and BPD patients on self-report measures is limited, and no studies have examined their neurobiological underpinnings in the same design. One possible differentiating variable is childhood trauma which shapes the circumstances in which emotional dysregulation and impulsivity are triggered, the types of behaviours exhibited, and the frequency and duration of mood states. There is growing evidence that childhood trauma not only predisposes individuals to both disorders, but also modulates the clinical expression and course of bipolar illness, particularly rapid cycling BD, a form of bipolarity that resembles the clinical profile of BPD, yet presents quite distinctly from other BD subtypes.

CONCLUSIONS

This paper provides an overview of BD and BPD with respect to emotional dysregulation, impulsivity, childhood factors, and neurobiological substrates. Based on findings predominantly within the independent areas of BD and BPD, it tentatively provides an integrated behavioural, aetiological and neurobiological approach for investigating the question of whether BPD belongs to the bipolar spectrum.

Does anxiety increase impulsivity in patients with bipolar disorder or major depressive disorder?

The objective of this study was to examine whether anxiety increases impulsivity among patients with bipolar disorder (BPD) and major depressive disorder (MDD). Subjects comprised 205 BPD (mean age ± SD 36.6 ± 11.5 y; 29.3% males) and 105 with MDD (mean age ± SD 38 ± 13.1 y; 29.5% males) diagnosed using the DSM-IV-SCID. Impulsivity was assessed with the Barratt Impulsivity Scale and anxiety with the Hamilton Anxiety Rating Scale. Comorbid anxiety disorders were present in 58.9% of the BPD and 29.1% of MDD. BPD were significantly more impulsive than MDD (p < 0.001), and both BPD and MDD subjects showed significantly higher impulsivity when anxiety was present either as a comorbidity (p = 0.010) or as a symptom (p = 0.011). Impulsivity rose more rapidly with increasing anxiety symptoms in MDD than in BPD. The presence of anxiety, either as a comorbid disorder or as current anxiety symptoms, is associated with higher impulsivity in subjects with either BPD or MDD.

Relationships of impulsiveness and depressive symptoms in alcohol dependence

BACKGROUND

Depressive symptoms as well as high levels of impulsivity are subjects of special interest in alcohol dependence, as these factors are considered to influence the course of this disorder. However, until now mutual relationships between impulsivity and depression have not been investigated thoroughly in alcohol-dependent patients.

METHODS

By means of the Barratt Impulsiveness Scale (BIS-11) and stop-signal task, levels of impulsivity among 304 alcohol-dependent patients were measured. The stop-signal task was used as a manipulation-free method of estimating the level of behavioral impulsiveness, and the BIS-11 is a self report measure of global as well as cognitive impulsivity. Patients were also asked to complete the Beck Depression Inventory (BDI) and Hopelessness Scale (BHS). The results were analyzed in order to examine relationships between impulsiveness and depressive symptoms.

RESULTS

Statistical analyses revealed significant associations between impulsiveness and severity of depressive symptoms. Individuals with higher scores on the BDI were more impulsive on the BIS-11, whereas patients with higher scores on the BHS were more impulsive on both the stop-signal task and BIS-11. The strongest correlations were found with the attention impulsivity subscale of BIS-11. Adjusting for other variables, a linear regression analysis revealed that cognitive impulsivity was the strongest predictor of depression severity.

LIMITATIONS

The main limitation of the study is a not fully representative sample, with exclusion of patients with active mood disorders

CONCLUSIONS

The results indicate a strong association between depressive symptoms and impulsivity in alcohol-dependent patients, and suggest an important distinction between hopelessness and other depressive symptoms.

Impulsivity and functional impairment in bipolar disorder

BACKGROUND

Impulsivity is substantially higher in bipolar patients (BP) and may be associated with a more severe course of illness, but no studies have so far examined the relationship between impulsivity and functional outcome in BP. Our goal was to investigate the functional impact of trait-impulsivity in BP.

METHODS

138 euthymic BP were recruited. All patients were assessed using an interview based on the Structured Clinical Interview for DSM Disorders (SCID). The Functioning Assessment Short Test (FAST) and the Barratt Impulsiveness Scale (BIS-11) were used to assess functional outcome and impulsivity, respectively. Seven multiple linear regressions, with each individual FAST subscale scores and overall FAST score as dependant variables, were conducted in order to evaluate the predictive role of trait-impulsivity on functional outcome.

RESULTS

After a multiple linear regression model, with the FAST total score as dependent variable, we found that depressive symptoms (β=1.580; p<0.001), number of hospitalizations (β=0.837; p=0.019) and impulsivity (β=0.319; p=0.004) were independently associated with overall functional impairment (F=6.854, df=9, p<0.001, adjusted R2=0.311).

LIMITATIONS

The cross-sectional design of the study.

CONCLUSIONS

Our results indicate that impulsivity, as well as depressive symptoms and the number of hospitalizations, is associated with overall functional impairment in BP. The assessment and treatment of impulsivity may be useful in improving functional outcome in BP.

Compulsive buying in bipolar disorder: is it a comorbidity or a complication?

BACKGROUND

The objective of this study was to investigate the frequency of compulsive buying in bipolar disorder (BD), to compare it with healthy controls, and to search if there is a difference between bipolar cases with and without compulsive buying in terms of sociodemographic qualities, temperament, clinical characteristics and comorbid diagnoses.

METHODS

One-hundred outpatient cases diagnosed as BD according to DSM-IV were evaluated consecutively. Following the diagnosis interview (SCID-I and II) the subjects completed the mood disorders registry form, Compulsive Buying Scale and TEMPS-A.

RESULTS

Compulsive buying scores were higher in bipolar patients than healthy controls (p<0.001). Cases with compulsive buying revealed higher cyclothymic and irritable temperament scores than other bipolar patients (p=0.029 vs 0.045). Premenstrual syndrome and postpartum onset were more frequent, while psychotic symptoms were less in compulsive buyer bipolar patients (p=0.002, 0.009 vs 0.034). Severity of episode was lower (p=0.01), number of episodes was higher (p=0.009). Acute onset and remission before and after maintenance treatment were more frequent in patients with compulsive buying (p=0.011 and p=0.011). Full remission between episodes was 100%. Cases with axis-1 and axis-2 comorbidities demonstrated higher compulsive buying scores (p=0.025 and 0.005).

LIMITATIONS

Treatment regimen differences between patients are a limitation of the study.

CONCLUSIONS

This is the first study to relate compulsive buying with the clinical characteristics of BD. Our results reveal that compulsive buying in BD occurs together with mood episodes which are not very severe, but frequent and with abrupt onset.

Neural recruitment during failed motor inhibition differentiates youths with bipolar disorder and severe mood dysregulation

Controversy exists about whether non-episodic irritability (operationalized as severe mood dysregulation, SMD) should be considered a developmental presentation of pediatric bipolar disorder (BD). While assessments of brain function may address this controversy, only one fMRI study has compared BD versus SMD. We compared neural activation in BD, SMD, and controls during a motor inhibition task, since motor disinhibition is an important clinical feature in both BD and SMD. During failed inhibition, BD youths exhibited less activation in the right anterior cingulate cortex (ACC) and right nucleus accumbens relative to both SMD and healthy youths. Exploratory analyses indicate that, in BD youths, reduced activation in the right ACC may be independent of comorbid ADHD. These findings highlight neural distinctions between the phenotypically related BD and SMD populations.

Neurogenetics and Epigenetics in Impulsive Behaviour: Impact on Reward Circuitry

Adverse, unfavourable life conditions, particularly during early life stages and infancy, can lead to epigenetic regulation of genes involved in stress-response, behavioral disinhibition, and cognitive-emotional systems. Over time, the ultimate final outcome can be expressed through behaviors bedeviled by problems with impulse control, such as eating disorders, alcoholism, and indiscriminate social behavior. While many reward gene polymorphisms are involved in impulsive behaviors, a polymorphism by itself may not translate to the development of a particular behavioral disorder unless it is impacted by epigenetic effects. Brain-derived neurotrophic factor (BDNF) affects the development and integrity of the noradrenergic, dopaminergic, serotonergic, glutamatergic, and cholinergic neurotransmitter systems, and plasma levels of the neurotrophin are associated with both cognitive and aggressive impulsiveness. Epigenetic mechanisms associated with a multitude of environmental factors, including premature birth, low birth weight, prenatal tobacco exposure, non-intact family, young maternal age at birth of the target child, paternal history of antisocial behavior, and maternal depression, alter the developmental trajectories for several neuropsychiatric disorders. These mechanisms affect brain development and integrity at several levels that determine structure and function in resolving the final behavioral expressions.

Relationship of trait impulsivity with clinical presentation in euthymic bipolar disorder patients

The purpose of this study was to examine trait impulsivity in patients with bipolar disorder and explore the possible connections between impulsivity and clinical presentation of the illness. Diagnoses were based on the Structured Clinical Interview for DSM-IV. The sociodemographic and clinical properties of 71 patients with bipolar disorder, who were euthymic according to Young Mania Rating Scale and Hamilton Depression Scale scores, were recorded. Their trait impulsivity was evaluated by using the Barratt Impulsiveness Scale (BIS) and impulsivity subscale of the Temperament and Character Inventory, and the results were compared with 50 age- and sex-matched healthy controls and among patients with different clinical properties. All BIS-11 subscale scores were higher in bipolar than in comparison subjects. There were no effects of education and age. Elevated BIS-11 scores were associated with predominant depressive polarity, longer duration of illness and a history of psychotic mood episodes and suicide attempts. These relationships persisted when age, gender, and education were taken into account. These results show that after accounting for common confounding factors, trait-like impulsivity was substantially higher in subjects with bipolar disorder than in nonbipolar comparison subjects and may vary according to different clinical presentations.

Antisocial personality and bipolar disorder: interactions in impulsivity and course of illness

Antisocial personality disorder (ASPD) and bipolar disorder are both characterized by impulsive behavior, increased incarceration or arrest, addictive disorders and suicidal behavior. These characteristics appear more severe in the combined disorders. Individuals with ASPD who also have bipolar disorder have higher rates of addictive disorders and suicidal behavior and are more impulsive, as measured by questionnaires or behavioral laboratory tests. Those with bipolar disorder who have ASPD have higher rates of addictive, criminal and suicidal behavior, earlier onset of bipolar disorder with a more recurrent and predominately manic course and increased laboratory-measured, but not questionnaire-rated, impulsivity. These characteristics may result in part from differential impulsivity mechanisms in the two disorders, with bipolar disorder driven more by excessive catecholamine sensitivity and ASPD by deficient serotonergic function.

Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders

BACKGROUND

Predictors of suicidal behaviors (SB) in bipolar (BD) and major depressive disorder (MDD) patients are poorly understood. It has been recognized that behavioral dysregulation characterizes SB with traits of impulsivity and aggression being particularly salient. However, little is known about how these traits are segregated among mood disorder patients with and without a history of suicide attempt (SA).

METHODS

This article aims to compare impulsivity and aggression between 143 controls, 138 BD and 186 MDD subjects with or without a history of SA.

RESULTS

BD and MDD patients showed higher impulsivity scores (BIS-10 = 57.9 vs. 44.7, p < 0.0001) and more severe lifetime aggression than controls (Lifetime History of Aggression = 7.3 vs. 3.9, p < 0.0001). Whereas impulsivity helped to distinguish MDD subjects without a history of SA from those with such a history, this was not the case in BD subjects where no difference in impulsive traits was observed between BD without and with history of SA (57.2 vs. 63.2 for BIS-10; p = 0.259). Impulsive and aggressive traits were strongly correlated in suicide attempters (independently of the diagnosis) but not in non-suicide attempters.

LIMITATIONS

Dimensional traits were not characterized at different stages of illness.

CONCLUSIONS

Impulsivity, as a single trait, may be a reliable suicide risk marker in MDD but not in BD patients, and its strong correlation with aggressive traits seems specifically related to SB. Our study therefore suggests that the specific dimension of impulsive aggression should be systematically assessed in mood disorder patients to address properly their suicidal risk.

Creativity and bipolar disorder: touched by fire or burning with questions?

Substantial literature has linked bipolar disorder with creative accomplishment. Much of the thinking in this area has been inspired by biographical accounts of poets, musicians, and other highly accomplished groups, which frequently document signs of bipolar disorder in these samples. A smaller literature has examined quantitative measures of creativity among people with bipolar disorder or at risk for the disorder. In this paper, we provide a critical review of such evidence. We then consider putative mechanisms related to the link of bipolar disorder with creativity, by drawing on literature outside of bipolar disorder on personality, motivational, and affective predictors of creativity. Because so little research has directly evaluated whether these factors could help explain the elevations of creativity in bipolar disorder, we conclude with an agenda for future research on the theoretically and clinically compelling topic of creativity in bipolar disorder.

Impulsivity in adolescents with bipolar disorder and/or attention-deficit/hyperactivity disorder and healthy controls as measured by the Barratt Impulsiveness Scale

OBJECTIVE

To compare the type and degree of impulsivity among adolescents with bipolar disorder (BD), adolescents with attention-deficit/hyperactivity disorder (ADHD), and healthy comparison subjects using the Barratt Impulsiveness Scale, Version 11 (BIS-11).

METHODS

Manic adolescents with BD (n=31), adolescents with ADHD (n=30), and healthy subjects (n=25) completed the BIS-11, a 30-item, self-report scale with three subscales (cognitive, motor, and nonplanning). The BIS-11 total and subscale scores were compared among groups. We also examined associations among the BIS-11, Young Mania Rating Scale and co-occurring disruptive behavioral disorders (DBDs) within the BD group.

RESULTS

Total and each subscale scores were significantly higher for the BD group than for the healthy controls (p<0.05). The total scores and the cognitive and motor subscale scores were significantly higher for the ADHD group than for the healthy control group (p<0.05). However, there was no statistically significant difference between the nonplanning subscale scores of the ADHD group and the healthy control group (p>0.05). There were no significant differences between the BD and ADHD groups or between the BD groups with and without ADHD. The BD patients with DBDs (i.e., oppositional defiant disorder or conduct disorder) scored significantly higher on the motor subscale than did BD patients without DBDs. There were no statistically significant associations between the Young Mania Rating Scale and BIS-11 scores within the BD group.

CONCLUSION

Our findings suggest that impulsivity is elevated in adolescents with BD as well as adolescents with ADHD, except for nonplanning impulsivity, which was not significantly different between adolescents with ADHD and the healthy comparison group. This may suggest that nonplanning impulsivity is relatively specific to adolescents with BD. Additionally, our data indicate that elevations in impulsivity, as measured by the BIS-11, may be independent of symptoms severity and, therefore, may be a stable, trait-related component of BD.

Temporal discounting of rewards in patients with bipolar disorder and schizophrenia

Patients with bipolar disorder (BD) and schizophrenia (SZ) often show decision-making deficits in everyday circumstances. A failure to appropriately weigh immediate versus future consequences of choices may contribute to these deficits. We used the delay discounting task in individuals with BD or SZ to investigate their temporal decision making. Twenty-two individuals with BD, 21 individuals with SZ, and 30 healthy individuals completed the delay discounting task along with neuropsychological measures of working memory and cognitive function. Both BD and SZ groups discounted delayed rewards more steeply than did the healthy group even after controlling for current substance use, age, gender, and employment. Hierarchical multiple regression analyses showed that discounting rate was associated with both diagnostic group and working memory or intelligence scores. In each group, working memory or intelligence scores negatively correlated with discounting rate. The results suggest that (a) both BD and SZ groups value smaller, immediate rewards more than larger, delayed rewards compared with the healthy group and (b) working memory or intelligence is related to temporal decision making in individuals with BD or SZ as well as in healthy individuals.

Impulsivity in euthymic patients with major depressive disorder: the relation to sociodemographic and clinical properties

The purpose of this study was to examine the trait impulsivity of patients with a major depressive disorder and to explore the possible connections between impulsivity and clinical and sociodemographic variables. The sociodemographic and clinical properties of 60 patients with major depression, who were euthymic according to Hamilton Depression Scale scores, were recorded. Their trait impulsivity was evaluated using the Barratt Impulsiveness Scale (BIS-11) and the impulsivity subscale of the Temperament and Character Inventory, and the results were compared with those of 50 age- and sex-matched healthy controls. We used general linear model analysis to evaluate the manner in which the variables contributed to BIS-11 scores. Some impulsivity scores were higher in those with a major depressive disorder than in comparison subjects. There were significant effects of education and sex in these differences. Elevated BIS-11 scores were associated with a history of psychotic mood episode and suicide attempts. These relationships persisted when age, sex, and education were taken into account. These results show that, after accounting for common confounding factors, trait-like impulsivity was substantially higher in subjects with major depressive disorder than in comparison subjects and may be associated with sociodemographic and clinical properties.

Impulse control disorder comorbidity among patients with bipolar I disorder

OBJECTIVE

Impulsivity is associated with mood instability, behavioral problems, and action without planning in patients with bipolar disorder. Increased impulsivity levels are reported at all types of mood episodes. This association suggests a high comorbidity between impulse control disorders (ICDs) and bipolar disorder. The aim of this study is to compare the prevalence of ICDs and associated clinical and sociodemographic variables in euthymic bipolar I patients.

METHOD

A total of 124 consecutive bipolar I patients who were recruited from regular attendees from the outpatient clinic of our Bipolar Disorder Unit were included in the study. All patients were symptomatically in remission. Diagnosis of bipolar disorder was confirmed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Impulse control disorders were investigated using the modified version of the Minnesota Impulsive Disorders Interview. Impulsivity was measured with the Barratt Impulsiveness Scale Version 11. Furthermore, all patients completed the Zuckerman Sensation-Seeking Scale Form V.

RESULTS

The prevalence rate of all comorbid ICDs in our sample was 27.4% (n = 34). The most common ICD subtype was pathologic skin picking, followed by compulsive buying, intermittent explosive disorder, and trichotillomania. There were no instances of pyromania or compulsive sexual behavior. There was no statistically significant difference between the sociodemographic characteristics of bipolar patients with and without ICDs with regard to age, sex, education level, or marital status. Comorbidity of alcohol/substance abuse and number of suicide attempts were higher in the ICD(+) group than the ICD(-) group. Length of time between mood episodes was higher in the ICD(-) group than the ICD(+) group. There was a statistically significant difference between the total number of mood episodes between the 2 groups, but the number of depressive episodes was higher in the ICD(+) patients as compared with the ICD(-) patients. There was no statistically significant difference between the age of first episode, seasonality, presence of psychotic features, and chronicity of illness. A statistically significant difference was observed between the ICD(+) and ICD(-) groups in terms of total impulsivity, attention, nonplanning, and motor impulsivity scores as determined by the Barratt Impulsiveness Scale Version 11.

CONCLUSION

The present study revealed that there is a high comorbidity rate between bipolar disorder and ICDs based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria. Alcohol/substance use disorders, a high number of previous suicide attempts, and depressive episodes should alert the physician to the presence of comorbid ICDs among bipolar patients that could affect the course and treatment of the disorder.

Quality of life and impulsivity in bipolar disorder

OBJECTIVES

Bipolar disorder (BD) is a chronic psychiatric illness that impairs quality of life (QoL) in numerous life domains even when mood symptoms are not present and is characterized by elevated impulsivity. Many of the comorbid conditions that are associated with diminished QoL in BD also involve impulsivity. The objective of this project was to investigate whether impulsivity might mediate the effects of these comorbid conditions on poor QoL.

METHODS

A total of 76 participants diagnosed with bipolar I disorder by the Structured Clinical Interview for DSM-IV Axis I disorders completed the Quality of Life in Bipolar Disorder (QoL-BD) scale, the Barratt Impulsivity Scale (BIS-11), and the Positive Urgency Measure (PUM). Participants were also assessed for comorbid DSM-IV diagnoses of anxiety, substance use, and impulse control disorders.

RESULTS

Several subscales of the BIS-11 as well as the PUM total score were significantly negatively correlated with overall QoL. PUM total score remained a significant predictor of QoL after controlling for comorbid anxiety, substance use, and impulse control disorders. After controlling for impulsivity, comorbid disorders were no longer significantly related to overall QoL.

CONCLUSIONS

The data support the hypothesis that impulsivity, specifically positive urgency, is highly correlated with QoL in BD. Impulsivity was found to mediate the relation between QoL and several comorbidities in BD. Interventions targeting impulsivity might help to improve QoL in BD.

Neuropsychological functioning in adult bipolar disorder and ADHD patients: a comparative study

Bipolar disorder (BD) and adult attention deficit hyperactivity disorder (ADHD) usually manifest with shared clinical symptoms, proving quite challenging to thoroughly differentiate one from another. Previous research has characterized these two disorders independently, but no study compared both pathologies from a neuropsychological perspective. The aim of this study was to compare the neuropsychological profile of adult ADHD and BD with each other and against a control group, in order to understand the way in which comprehensive cognitive assessment can contribute to their discrimination as distinct clinical entities as well as their differential diagnosis. All groups were successfully matched for age, sex, years of education, and premorbid IQ. Participants were assessed with an extensive neuropsychological battery evaluating multiple domains. Compared to controls, BD patients had a poorer performance on immediate verbal memory tasks. Both clinical groups exhibited significantly lower scores than controls on the recognition phase of verbal and non-verbal memory tasks, as well as on a task of executive functioning with high working memory demand. Noticeably, however, ADHD had significantly better performance than BD on the recognition phase of both the Rey list memory task and the Rey Figure. The better performance of ADHD patients over BD may reflect the crucial role of the executive component on their memory deficits and gives empirical support to further differentiate the neuropsychological profile of BD and adult ADHD patients in clinical practice.

Mechanisms of impulsivity in bipolar disorder and related illness

Aims – Impulsivity is a multifaceted aspect of behavior that is prominent in psychiatric disorders and has serious behavioral consequences. This paper reviews studies integrating behavioral and physiological mechanisms in impulsivity and their role in severity and course of bipolar and related disorders. Methods – This is a review of work that used questionnaire, human behavioral laboratory, and neurophysiological measurements of impulsivity or related aspects of behavior. Subjects included individuals with bipolar disorder, substance-use disorders, antisocial personality disorder, and healthy controls. Results – Models of impulsivity include rapid-response impulsivity, with inability to reflect or to evaluate a stimulus adequately before responding, and reward-based impulsivity, with inability to delay response for a reward. In normal subjects, rapid-response impulsivity is increased by yohimbine, which increases norepinephrine release. Impulsivity is increased in bipolar disorder, whether measured by questionnaire, by measures of rapid-response impulsivity, or by measures of ability to delay reward. While affective state has differential effects on impulsivity, impulsivity is increased in bipolar disorder regardless of affective state or treatment. Impulsivity, especially rapid-response, is more severe with a highly recurrent course of illness or with comorbid substance-use disorder, and with history of medically severe suicide attempt. In antisocial personality disorder, rapid-response impulsivity is increased, but rewardbased impulsivity is not. In general, impulsivity is increased more in bipolar disorder than in antisocial personality disorder. In combined bipolar disorder and antisocial personality disorder, increased impulsivity is associated with substance-use disorders and suicide attempts. Conclusions – Impulsivity is associated with severe behavioral complications of bipolar disorder, antisocial personality disorder, and substance-use disorders.

Impulsivity in Adolescent Bipolar Disorder

OBJECTIVE

Increased impulsivity has been demonstrated to be a trait feature of adults with bipolar disorder (BD), yet impulsivity has received little study in adolescents with BD. Thus, it is unknown whether it is a trait feature that is present early in the course of the disorder. We tested the hypotheses that self-reported impulsiveness is increased in adolescents with BD, and that it is present during euthymia, supporting impulsiveness as an early trait feature of the disorder.

METHODS

Impulsiveness was assessed in 23 adolescents with BD and 23 healthy comparison (HC) adolescents using the self-report measure of impulsivity, the Barratt Impulsiveness Scale (BIS), comprised by attentional, motor and nonplanning subscale scores. Effects of subscale scores and associations of scores with mood state and course features were explored.

RESULTS

Total and subscale BIS scores were significantly higher in adolescents with BD than HC adolescents. Total, attentional and motor subscale BIS scores were also significantly higher in the subset of adolescents with BD who were euthymic, compared to HC adolescents. Adolescents with BD with rapid-cycling and chronic mood symptoms had significantly higher total and motor subscale BIS scores than adolescents with BD without these course features.

CONCLUSION

These results suggest increased self-reported impulsiveness is a trait feature of adolescents with BD. Elevated impulsivity may be especially prominent in adolescents with rapid-cycling and chronic symptoms.

Correlates of incorrect condom use among depressed young women: an event-level analysis

STUDY OBJECTIVE

Depressed young women are at particularly high risk of sexually transmitted infections (STIs), yet little is known about their condom use practices. This study sought (1) to describe condom use errors among depressed adolescent and young adult women and (2) to identify event- and individual-level correlates of incorrect use.

DESIGN

Depressed, sexually active outpatients ages 15-22 responded to a computer-based questionnaire, then reported on penile-vaginal sex events on a handheld computer several times a day for two weeks. For each sex event with a condom, incorrect condom use was defined as a response indicating incorrect use on at least one of five questions. Event- and individual-level correlates of incorrect use were analyzed using logistic regression adjusted for age and within-individual clustering.

SETTING

Participants were recruited from two adolescent clinics, a psychiatric clinic, and a young parents' program of an urban children's hospital and collected data in the settings of their everyday lives.

PARTICIPANTS

Thirty-one young women contributed 143 condom use events to these analyses.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Incorrect condom use.

RESULTS

Incorrect condom use was reported for 51% of condom use events. The most common error was not holding the condom on withdrawal (31%). Having sex to change mood, to relax, or for physical pleasure increased the odds of incorrect condom use, but was no longer significant when individual-level variables were included in the model. In the multiple logistic regression model, impulsiveness increased and stronger belief that mood affects sexual behaviors decreased the odds of incorrect condom use (adjusted OR 1.3 and 0.81, respectively).

CONCLUSIONS

Even if they use condoms, depressed adolescent and young adult women are at increased risk of STIs because they frequently use condoms incorrectly. Psychological factors may help identify depressed young women who are at particularly high risk of incorrect condom use.

Personality correlates of impulsivity in subjects with generalized anxiety disorders

BACKGROUND

As yet, the relation between personality traits and impulsiveness has not been investigated in subjects affected by generalized anxiety disorder (GAD).

METHOD

A sample of 79 subjects with a diagnosis of GAD has been assessed at intake with Clinical Global Impression (CGI), Barratt Impulsiveness Scale (BIS-11), and with Temperament and Character Inventory. Comorbidity with cluster A or B personality disorders was excluded.

RESULTS

A multiple linear regression has identified 3 variables as independent predictors of impulsiveness: novelty seeking (NS) and reward dependence (RD) as for temperament and self-directedness (SD) as for character. Predictor analysis of the 3 subscales of BIS-11 showed that a higher NS is a predictor of all 3 subscales of BIS-11, whereas a higher RD is a protective factor for the attentive impulsiveness, and a low SD is predictive of a greater nonplanned impulsiveness. The CGI severity index is directly related to motor impulsiveness.

DISCUSSION

Preliminary results showed that in subjects with GAD only the motor component of impulsivity seems directly related to clinical severity, whereas impulsiveness is predicted by higher levels of 2 temperamental dimensions that are influenced by dopamine and norepinephrine systems and by weakness of character.

CONCLUSION

Subjects with GAD showed an interesting variability in NS. Differences in levels of NS and of other temperament (RD) and character (SD) dimensions seem related to different degrees of behavioral inhibition and to a different impact of the cognitive components of impulsiveness. Clinical implications are discussed.

Interactions between bipolar disorder and antisocial personality disorder in trait impulsivity and severity of illness

OBJECTIVE

We investigated trait impulsivity in bipolar disorder and antisocial personality disorder (ASPD) with respect to severity and course of illness.

METHOD

Subjects included 78 controls, 34 ASPD, 61 bipolar disorder without Axis II disorder, and 24 bipolar disorder with ASPD, by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (SCID-I and -II). Data were analyzed using general linear model and probit analysis.

RESULTS

Barratt Impulsiveness Scale (BIS-11) scores were higher in ASPD (effect sizes 0.5-0.8) or bipolar disorder (effect size 1.45) than in controls. Subjects with both had more suicide attempts and previous episodes than bipolar disorder alone, and more substance-use disorders and suicide attempts than ASPD alone. BIS-11 scores were not related to severity of crimes.

CONCLUSION

Impulsivity was higher in bipolar disorder with or without ASPD than in ASPD alone, and higher in ASPD than in controls. Adverse effects of bipolar disorder in ASPD, but not of ASPD in bipolar disorder, were accounted for by increased impulsivity.

Impulsivity across the course of bipolar disorder

OBJECTIVE

To determine whether abnormalities of impulse control persist across the course of bipolar disorder, thereby representing potential state markers and endophenotypes.

METHODS

Impulse control of 108 bipolar I manic or mixed patients was measured on three tasks designed to study response inhibition, ability to delay gratification, and attention; namely, a stop signal task, a delayed reward task, and a continuous performance task, respectively. Barrett Impulsivity Scale (BIS-11) scores were also obtained. Patients were then followed for up to one year and reassessed with the same measures if they developed depression or euthymia. Healthy comparison subjects were also assessed with the same instruments on two occasions to assess measurement stability.

RESULTS

At baseline, bipolar subjects demonstrated significant deficits on all three tasks as compared to healthy subjects, consistent with more impulsive responding in the bipolar manic/mixed group. In general, performance on the three behavioral tasks normalized upon switching to depression or developing euthymia. In contrast, BIS-11 scores were elevated during mania and remained elevated as bipolar subjects developed depression or achieved euthymia.

CONCLUSIONS

Bipolar I disorder patients demonstrate deficits on laboratory tests of various aspects of impulsivity when manic, as compared to healthy subjects, that largely normalize with recovery and switching into depression. However, elevated BIS-11 scores persist across phases of illness. These findings suggest that impulsivity has both affective-state dependent and trait components in bipolar disorder.

Corpus callosum abnormalities in pediatric bipolar disorder

The corpus callosum (CC) is a midline white matter brain region that is important in interhemispheric communication and coordination. CC abnormalities are associated with a variety of psychiatric conditions, including increased vulnerability for psychotic illness, stressful early-life experiences, marijuana use, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, borderline personality disorder, dementia, schizophrenia and bipolar disorder. CC abnormalities in bipolar disorder have been identified in both pediatric and adult populations. In adults, a consistent finding has been a reduction in CC size, as well as abnormal axonal orientation or structure. Axonal abnormalities have also been noted in pediatric populations, but overall CC size reductions have not thus far been demonstrated. Furthermore, there are unique gender differences in the expression of CC abnormalities in pediatric populations, possibly related to androgen changes during puberty. The protean number of conditions in which the CC is involved is reflective of its central role in normal brain function and its potential as an early marker of neuropathology in psychiatric illness. Specifically, in bipolar disorder it has the potential to be useful as an early preclinical marker of disease or disease risk.

Anterior cingulate volumes associated with trait impulsivity in individuals with bipolar disorder

OBJECTIVE

Impulsivity is associated with the clinical outcome and likelihood of risky behaviors among bipolar disorder (BD) patients. Our previous study showed an inverse relationship between impulsivity and orbitofrontal cortex (OFC) volume in healthy subjects. We hypothesized that BD patients would show an inverse relationship between impulsivity and volumes of the OFC, anterior cingulate cortex (ACC), medial prefrontal cortex, and amygdala, which have been implicated in the pathophysiology of BD.

METHODS

Sixty-three BD patients were studied (mean +/- SD age = 38.2 +/- 11.5 years; 79% female). The Barratt Impulsiveness Scale (BIS), version 11A, was used to assess trait impulsivity. Images were processed using SPM2 and an optimized voxel-based morphometry protocol. We examined the correlations between BIS scores and the gray matter (GM) and white matter (WM) volumes of the prespecified regions.

RESULTS

Left rostral ACC GM volume was inversely correlated with the BIS total score (t = 3.95, p(corrected) = 0.003) and the BIS motor score (t = 5.22, p(corrected) < 0.001). In contrast to our hypothesis, OFC volumes were not significantly associated with impulsivity in BD. No WM volume of any structure was significantly correlated with impulsivity. No statistical association between any clinical variable and the rostral ACC GM volumes reached significance.

CONCLUSIONS

Based on our previous findings and the current results, impulsivity may have a different neural representation in BD and healthy subjects, and the ACC may be involved in the pathophysiology of abnormal impulsivity regulation in BD patients.

Reduced brain activation in euthymic bipolar patients during response inhibition: an event-related fMRI study

Deficits in inhibitory control have been reported in euthymic bipolar disorder patients. To date, data on the neuroanatomical correlates of these deficits are exclusively related to cognitive inhibition. This study aimed to examine the neural substrates of motor inhibitory control in euthymic bipolar patients. Groups of 20 patients with euthymic bipolar disorder and 20 demographically matched healthy subjects underwent event-related functional magnetic resonance imaging while performing a Go-NoGo task. Between-group differences in brain activation associated with motor response inhibition were assessed by using random-effects analyses. Although euthymic bipolar patients and healthy subjects performed similarly on the Go-NoGo task, they showed different patterns of brain activation associated with response inhibition. Specifically, patients exhibited significantly decreased activation in the left frontopolar cortex and bilateral dorsal amygdala compared with healthy subjects. There were no brain regions that were significantly more activated in patients than in healthy subjects. The findings suggest that euthymic bipolar patients have deficits in their ability to engage the left frontopolar cortex and bilateral dorsal amygdala during response inhibition. Further research should ascertain the role that such deficits may play in the emergence of impulsive behaviors that characterize bipolar disorder.

Depressive symptoms and sexual risk behavior in young, chlamydia-infected, heterosexual dyads

PURPOSE

To examine associations between depressive symptoms and dyad-level sexual risk behavior in young heterosexual dyads with sexually transmitted infection (STI).

METHODS

Chlamydia-positive 14-24-year-old, heterosexually active outpatients and their opposite-sex partners completed an assessment that included demographics, past and recent STI risk behaviors, and the Beck Depression Inventory (BDI). Participants in the top 25% of BDI scores within gender were categorized as depressed. Variables were created to identify dyads in which the female or male partner was depressed, as well as a measure of concordance of depression between partners. Dyad-level STI risk variables were created from the STI risk characteristics reported by each dyad member, and associations between these and the depression variables were analyzed.

RESULTS

The 130 dyads were comprised of young men and women at high STI risk. One-third of dyads had at least one depressed partner. Dyads in which the female partner was depressed had greater partner age difference, greater total number of lifetime partners, and one or more partners reporting substance use within 2 hours before sex, compared with dyads in which the female partner was not depressed. Dyads in which the male partner was depressed were more likely than the nondepressed-male dyads to report substance use before sex. All dyads in which both partners were depressed reported substance use before sex.

CONCLUSIONS

In young, chlamydia-infected, heterosexual dyads, depressive symptoms, especially in women, is related to increased dyad-level STI risk, including greater partner age difference, more partners, and substance use before sex.

Increased trait-like impulsivity and course of illness in bipolar disorder

BACKGROUND

Impulsivity as a trait characteristic is increased in bipolar disorder and may be a core factor of the illness. We have investigated relationships between trait-like impulsivity, measured by the Barratt Impulsiveness Scale (BIS-11), and demographic and illness-course characteristics of bipolar disorder.

METHODS

We studied 114 subjects with bipolar disorder and 71 healthy comparison subjects. Diagnoses were based on the Structured Clinical Interview for DSM-IV. In addition to impulsivity, we examined age, education, gender, psychiatric symptoms, and characteristics related to course of illness. We used general linear mixed model analysis to evaluate the manner in which the variables contributed to BIS-11 scores.

RESULTS

All BIS-11 subscale scores were higher in bipolar disorder than in comparison subjects. There were less consistent independent effects of education and age. Elevated BIS-11 scores were associated with early onset, more frequent episodes of illness, and a history of suicide attempts. These relationships persisted when age, gender, and education were taken into account.

DISCUSSION

These results show that, after accounting for common confounding factors, trait-like impulsivity was substantially higher in subjects with bipolar disorder than in nonbipolar comparison subjects, regardless of symptoms. Within subjects with bipolar disorder, high trait impulsivity was associated with a more severe course of illness.

Characterizing impulsivity in mania

OBJECTIVE

To determine whether specific aspects of impulsivity (response disinhibition, inability to delay gratification, inattention) differ between healthy and bipolar manic subjects, and whether these aspects of impulsivity were associated with each other and severity of affective symptoms.

METHODS

Performance of 70 bipolar I manic or mixed patients was compared to that of 34 healthy subjects on three tasks specifically designed to study response inhibition, ability to delay gratification, and attention; namely, a stop signal task, a delayed reward task, and a continuous performance task, respectively. Correlations among tasks and with symptom ratings were also performed.

RESULTS

Bipolar subjects demonstrated significant deficits on all three tasks as compared to healthy subjects. Performance on the three tasks was largely independent. Task performance was not significantly associated with the severity of affective symptom ratings. However, measures of response inhibition and attention were sensitive to medication effects. Differences in the delayed reward task were independent of medication effects or symptom ratings. During the delayed reward task, although bipolar patients made their choices more slowly than healthy subjects, they were significantly more likely to choose a smaller, but more quickly obtained reward. Moreover, performance on this task was not associated with performance on the other impulsivity measures. Manic patients showed more impulsive responding than mixed patients.

CONCLUSIONS

Bipolar I manic patients demonstrate deficits on tests of various aspects of impulsivity as compared to healthy subjects. Some of these differences between groups may be mediated by medication effects. Findings suggested that inability to delay gratification (i.e., delayed reward task) was not simply a result of the speed of decision making or inattention, but rather that it reflected differences between bipolar and healthy subjects in the valuation of reward relative to delay.

Conceptualizing impulsivity and risk taking in bipolar disorder: importance of history of alcohol abuse

BACKGROUND

Elevated levels of impulsivity and increased risk taking are thought to be core features of both bipolar disorder (BD) and addictive disorders. Given the high rates of comorbid alcohol abuse in BD, alcohol addiction may exacerbate impulsive behavior and risk-taking propensity in BD. Here we examine multiple dimensions of impulsivity and risk taking, using cognitive tasks and self-report measures, in BD patients with and without a history of alcohol abuse.

METHODS

Thirty-one BD subjects with a prior history of alcohol abuse or dependence (BD-A), 24 BD subjects with no history of alcohol abuse/dependence (BD-N), and 25 healthy control subjects (HC) were assessed with the Barratt Impulsiveness Scale (BIS) and the computerized Balloon Analogue Risk Task (BART).

RESULTS

Both BD groups scored significantly higher than controls on the BIS. In contrast, only the BD-A group showed impaired performance on the BART. BD-A subjects popped significantly more balloons than the BD-N and HC groups. In addition, subjects in the BD-A group failed to adjust their performance after popping balloons. Severity of mood symptomatology was not associated with performance on either task.

DISCUSSION

The current study supports a primary role of prior alcohol abuse in risk-taking propensity among patients with bipolar disorder. In addition, findings suggest that impulsivity and risky behavior, as operationalized by self-report and experimental cognitive probes, respectively, are separable constructs that tap distinct aspects of the bipolar phenotype.

Personality and the bipolar spectrum: normative and classification data for the Eysenck Personality Questionnaire-Revised

BACKGROUND

Personality traits dispose individuals toward particular affective states and may therefore have an important role in the etiology of affective disorders in particular. Despite being one of the most widely used and well-researched personality instruments, few studies have studied bipolar spectrum disorders using the revised Eysenck Personality Questionnaire (EPQ-R) (Eysenck HJ, Eysenck SBG. The Eysenck Personality Questionnaire-Revised. Sevenoaks: UK; Hodder & Stoughton, 1992).

METHODS

The EPQ-R was administered to 50 bipolar patients, 50 unipolar patients, and 50 controls matched on age and sex. Participants in clinical groups were euthymic, and participants in the control groups were screened for symptoms of depression.

RESULTS

The EPQ-R scores were most effective at discriminating unipolar patients from controls, such that unipolar patients were higher on neuroticism and lower on extraversion. Bipolar patients showed a similar personality profile to, but were not clearly distinguished from, unipolar patients.

CONCLUSIONS

This research provides preliminary normative data for the EPQ-R that complement previous theoretical and empirical work in this area and suggests the usefulness of this tool in a clinical setting.

The phenomenology of bipolar disorder: what drives the high rate of medical burden and determines long-term prognosis?

Bipolar disorder (BD) has been classically described as one of episodic mood disturbances. New evidence suggests that a chronic course and multisystem involvement is the rule, rather than the exception, and that together with disturbances of circadian rhythms, mood instability, cognitive impairment, a high rate of medical burden is often observed. The current diagnostic approach for BD neither describes the multisystem involvement that the recent literature has highlighted nor points toward potential predictors of long- term outcome. In light of the new evidence that the long-term course of BD is associated with a high prevalence of psychiatric comorbidity and an increased mortality from medical disease, we propose a multidimensional approach that includes several symptom domains, namely affective instability, circadian rhythm dysregulation, and cognitive and executive dysfunction, presenting in various combinations that give shape to each individual presentation, and offers potential indicators of overall long-term prognosis.

Serotonergic function, two-mode models of self-regulation, and vulnerability to depression: what depression has in common with impulsive aggression

Evidence from diverse literatures supports the viewpoint that two modes of self-regulation exist, a lower-order system that responds quickly to associative cues of the moment and a higher-order system that responds more reflectively and planfully; that low serotonergic function is linked to relative dominance of the lower-order system; that how dominance of the lower-order system is manifested depends on additional variables; and that low serotonergic function therefore can promote behavioral patterns as divergent as impulsive aggression and lethargic depression. Literatures reviewed include work on two-mode models; studies of brain function supporting the biological plausibility of the two-mode view and the involvement of serotonergic pathways in functions pertaining to it; and studies relating low serotonergic function to impulsiveness, aggression (including extreme violence), aspects of personality, and depression vulnerability. Substantial differences between depression and other phenomena reviewed are interpreted by proposing that depression reflects both low serotonergic function and low reward sensitivity. The article closes with brief consideration of the idea that low serotonergic function relates to even more diverse phenomena, whose natures depend in part on sensitivities of other systems.

Commonalities and differences in characteristics of persons at risk for narcissism and mania

Clinicians have long noted overlap in some of the key features of narcissism and bipolar disorder, including excessively high goals and impulsivity. In addition, empirical findings consistently document high levels of comorbidity between the two conditions. To better understand the similarities and differences in psychological qualities associated with mania- and narcissism-related vulnerabilities, we administered to 233 undergraduates a broad range of measures pertaining to goals and affects (both their experience and their dysregulation) and impulsivity. As hypothesized, tendencies toward both narcissism and hypomania related to elevations on measures of affective and goal dysregulation. In addition, hypomania tendencies were related to higher impulsivity, but that association did not appear for narcissistic tendencies. Results highlight key commonalities and differences between those at risk for mania versus narcissism. Future research should examine these relationships in clinically diagnosed samples.

Bipolar pathophysiology and development of improved treatments

The purpose of this review is to provide strategies and their rationale which can facilitate scientifically productive investigations into genetic, neuronal, brain functional and clinical aspects of bipolar disorder. The presentation addresses both factors that have impeded and those that have facilitated landmark advances on the pathophysiology and treatment of bipolar disorders. Application of the strategies can provide a scientific platform that may be useful to basic and clinical scientists for the purposes of achieving seminal advances in understanding pathophysiology, including inherited and experience based contributors to disease expression. Current diagnostic criteria omit certain key symptoms, do not include illness course or family history and lack specification of the importance of fundamental symptomatology. Consideration of such factors in inclusion and exclusion criteria, and in assessment instruments in basic and clinical studies, serves to strengthen the capability of a research plan to test key hypotheses regarding moderating and mediating factors of this complex illness. For example, most studies of brain structure and function and of new interventions have selected subjects on the basis of traditional full syndromal criteria. Evidence indicates that additional consideration of principal behavioral domains of bipolar symptomatology, e.g., anxiety, psychosis, impulsivity, elevated psychomotor and cognitive processing speed, rather than strictly depressive or manic syndromes can provide more homogeneous samples for study, and increase the focus of experimental hypotheses.

A relationship between bipolar II disorder and borderline personality disorder?

BACKGROUND

The relationship between DSM-IV-TR borderline personality disorder (BPD) and bipolar disorders, especially bipolar II disorder (BP-II), is still unclear. Many recent reviews on this topic have come to opposite or different conclusions.

STUDY AIM

The aim was to test the association between hypomania symptoms and BPD traits, as hypomania is the defining feature of BP-II in DSM-IV-TR.

METHODS

During follow-up visits in a private practice, consecutive 138 remitted BP-II outpatients were re-diagnosed by a mood disorder specialist psychiatrist, using the Structured Clinical Interview for DSM-IV (as modified by Benazzi and Akiskal for better probing hypomania). Soon after, patients self-assessed (blind to interviewer) the SCID-II Personality Questionnaire for BPD. Associations and confounding were tested by logistic regression, between each criteria symptom of hypomania (apart from "racing thoughts" and "distractibility", not assessed as probing focused mainly on behavioral, observable signs), and the entire set of BPD traits. Multivariate regression was also used to jointly regress the entire set of hypomanic symptoms on the entire set of BPD traits.

RESULTS

Mean (SD) age was 39.0 (9.8) years, females were 76.3%. Frequency of BPD traits ranged between 17% and 66% (e.g. impulsivity trait 41%, affective instability trait 63%), mean (SD) number of traits was 4.2 (2.3). The most common episodic hypomanic symptoms were elevated mood (91%) and overactivity (93%); frequency of excessive risky, impulsive activities (impulsivity) was 62%. By logistic regression the only significant association was between the episodic impulsivity of hypomania and the trait impulsivity of BPD. Multivariate regression of the entire set of hypomanic symptoms jointly regressed on the entire set of BPD traits was not statistically significant.

DISCUSSION

The core feature of BP-II, i.e. hypomania, does not seem to have a close relationship with BDP traits in the study setting, partly running against a strong association between BPD and BP-II and a bipolar spectrum nature of BPD.

Impulsive-compulsive buying disorder: clinical overview

Impulsive-compulsive buying disorder (ICBD) is an impulse control disorder not otherwise specified (ICD-NOS) characterized by impulsive drives and compulsive behaviours (buying unneeded things), personal distress, impaired social and vocational functioning and financial problems. Despite being described in the 19th century, serious attention to ICBD began only in the last decade with the first epidemiological and pharmacological investigation. Biological, social and psychological factors contribute to the aetiology of ICBD. Cognitive-behavioural therapy and selective serotonin re-uptake inhibitors are currently considered the more effective interventions in the treatment of ICBD. The present review aims to provide a broad overview of the epidemiology, aetiology, phenomenology and treatment options of ICBD.

Trait impulsivity in a forensic inpatient sample: an evaluation of the Barratt impulsiveness scale

Impulsivity is a fundamental component of psychopathology and an essential trait to consider when working with forensic populations. Nevertheless, impulsivity has not been widely studied in psychiatric forensic patients. The current study evaluated the use of a self-report measure of impulsivity, the Barratt Impulsiveness Scale (BIS-11), in a sample of 425 male forensic psychiatric inpatients with varying degrees of psychopathology and criminality. Patients also completed a measure of psychopathology, the Personality Assessment Inventory (PAI). Descriptive information and psychometric properties of the BIS-11 are presented. The primary findings were elevated Nonplanning versus Motor and Attentional Impulsiveness, and strong associations between impulsiveness and various psychopathologies. Using principal component analysis, the factor structure of the BIS-11 was also evaluated. Results failed to support the previously identified factor structure of impulsivity. The meaning of the revised scales and utility of the BIS-11 in this population is discussed.