Subcortical and ventral prefrontal cortical neural responses to facial expressions distinguish patients with bipolar disorder and major depression

Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder

Reflecting a paradigm shift in clinical neuroscience, many chronic psychiatric illnesses are now hypothesized to result from perturbed neural development. However, most work in this area focuses on schizophrenia. Here, we extend this paradigm to pediatric bipolar disorder (BD), thus demonstrating traction in the developmental psychobiology perspective. To study amygdala dysfunction, we examined neural mechanisms mediating face processing in 22 youths (mean age 14.21 +/- 3.11 yr) with BD and 21 controls of comparable age, gender, and IQ. Event-related functional MRI compared neural activation when attention was directed to emotional aspects of faces (hostility, subjects' fearfulness) vs. nonemotional aspects (nose width). Compared with controls, patients perceived greater hostility in neutral faces and reported more fear when viewing them. Also, compared with controls, patients had greater activation in the left amygdala, accumbens, putamen, and ventral prefrontal cortex when rating face hostility, and greater activation in the left amygdala and bilateral accumbens when rating their fear of the face. There were no between-group behavioral or neural differences in the nonemotional conditions. Results implicate deficient emotion-attention interactions in the pathophysiology of BD in youth and suggest that developmental psychobiology approaches to chronic mental illness have broad applicability.

The neural basis of mood dysregulation in bipolar disorder

Bipolar disorder is characterised by affective instability and mood dysregulation. Understanding of the neural mechanism underlying this remains limited, however. Here, findings will be described from studies that have employed neuroimaging techniques to measure neural responses to emotionally salient stimuli in individuals with the disorder. These findings will be discussed in relation to a theoretical framework previously proposed for understanding the separate cognitive processes underlying emotion perception to allow the formulation of a postulated neural mechanism for the mood dysregulation in bipolar disorder.

Functional neuroimaging studies in mood disorders

BACKGROUND

Our understanding of the neural circuitry involved in mood disorders is rapidly expanding through the ever-increasing application of functional brain imaging techniques.

OBJECTIVES

A selective review of functional neuroimaging studies in patients with primary mood disorders was undertaken in order to identify points of commonality and controversy in the existing literature.

METHODS

Articles published between 1980 and July 2005 were identified using a range of keywords from relevant on-line databases and key journals.

RESULTS

Increased activity within limbic regions has been consistently associated with depressive states and may also be present in manic states too. Dorsal and ventral prefrontal regions appear compromised as suggested by emerging evidence of cortical inefficiency within prefrontal regions or reductions in their connectivity with limbic areas. Most of the functional changes observed are at least partly reversible following clinical remission although deficits in prefrontal regions may be state-related.

CONCLUSIONS

Despite the use of disparate functional imaging modalities, there is a convergence of findings, and the results described do not appear to differ between unipolar and bipolar depression. However, further data are required in order to fully determine the functional changes occurring during manic states. Future work will also need to elucidate the effects of medication, the utility of specific cognitive tasks, and blood oxygenation level-dependent interactions within these affective states.

Functional magnetic resonance imaging studies in bipolar disorder

Abnormalities in brain activation using functional magnetic resonance imaging (fMRI) during cognitive and emotional tasks have been identified in bipolar disorder patients, in frontal, subcortical and limbic regions. Several studies also indicate that mood state may be differentiated by lateralization of brain activation in fronto-limbic regions. The interpretation of fMRI studies in bipolar disorder is limited by the choice of regions of interest, medication effects, comorbidity, and task performance. These studies suggest that there is a complex alteration in regions important for neural networks underlying cognition and emotional processing in bipolar disorder. However, measuring changes in specific brain regions does not identify how these neural networks are affected. New analytical techniques of fMRI data are needed in order to resolve some of these issues and identify how changes in neural networks relate to cognitive and emotional processing in bipolar disorder.

Stroop performance in bipolar disorder: further evidence for abnormalities in the ventral prefrontal cortex

OBJECTIVES

Bipolar patients are impaired in Stroop task performance, a measure of selective attention. Structural and functional abnormalities in task-associated regions, in particular the prefrontal cortex (PFC), have been reported in this population. We aimed to examine the relationship between functional abnormalities, impaired task performance and the severity of depressive symptoms in bipolar patients.

METHODS

Remitted bipolar patients (n = 10; all medicated), either euthymic or with subsyndromal depression, and age-matched control subjects (n = 11) viewed 10 alternating blocks of incongruent Stroop and control stimuli, naming the colour of the ink. Neural response was measured using functional magnetic resonance imaging. We computed between-group differences in neural response and within-group correlations with mood and anxiety.

RESULTS

There were no significant between-group differences in task performance. During the Stroop condition, controls demonstrated greater activation of visual and dorsolateral and ventrolateral prefrontal cortical areas; bipolar patients demonstrated relative deactivation within orbital and medial prefrontal cortices. Depression scores showed a trend towards a negative correlation with the magnitude of orbitofrontal cortex deactivation in bipolar patients, whereas state anxiety correlated positively with activation of dorsolateral PFC and precuneus in controls.

CONCLUSIONS

Our findings confirm previous reports of decreased ventral prefrontal activity during Stroop task performance in bipolar patients, and suggest a possible negative correlation between this and depression severity in bipolar patients. These findings further highlight the ventromedial PFC as a potential candidate for illness related dysfunction in bipolar disorder.

Frontal lobe function in bipolar disorder: A multichannel near-infrared spectroscopy study

Frontal lobe dysfunction has been implicated as one of the pathophysiological bases of bipolar disorder. Detailed time courses of brain activation in the bipolar disorder group were investigated using multichannel near-infrared spectroscopy (NIRS), a recently developed functional neuroimaging technology with a high time resolution, and were compared with those in the major depression and healthy control groups. Seventeen patients with bipolar disorder, 11 equally depressed patients with major depression, and 17 healthy controls participated in the study. Changes in oxy hemoglobin concentration ([oxy-Hb]) during cognitive and motor tasks were monitored using frontal and temporal probes of two sets of 24-channel NIRS machines. [oxy-Hb] increases in the bipolar disorder group were smaller than those in the healthy control group during the early period of a verbal fluency task, larger than those in the major depression and healthy control groups during the late period of this task, and were smaller than those in the major depression group during a finger-tapping task. Depressive symptoms and antidepressant dosages did not correlate with [oxy-Hb] changes in the two patient groups. Bipolar disorder and major depression were characterized by preserved but delayed and reduced frontal lobe activations, respectively, in the present high-time-resolution study by multichannel NIRS.

The psychopathology and treatment of bipolar disorder

In this chapter we review research on the diagnosis, course, etiology, and pharmacological and psychosocial treatment of bipolar disorder (BD). BD is a highly recurrent and severe illness, with high rates of suicidality and functional impairment. The disorder is heritable and appears to share susceptibility genes with schizophrenia. It is characterized by dysregulation in the dopamine and serotonin systems and by pathology in the brain systems involved in regulating emotion. Psychosocial stressors, notably life events and familial expressed emotion, significantly influence the course of the illness in the context of these vulnerabilities. Findings of randomized clinical trials indicate that psychosocial interventions enhance long-term outcomes when added to pharmacotherapy. Much remains to be clarified about the interactive contributions of genetic, neurobiological, and psychosocial factors to the course of the disorder, and the moderators and mediators of treatment effects.

Emotional information processing in mood disorders: a review of behavioral and neuroimaging findings

PURPOSE OF REVIEW

A relatively long history of research has shown that mood disorders are associated with abnormalities in the processing of emotional stimuli. Only the most recent studies, however, have begun to elucidate the specificity and neural basis of these abnormalities. This article reviews and discusses the results of these studies.

RECENT FINDINGS

Individuals diagnosed with major depressive disorder exhibit an attentional bias toward negative emotional cues (e.g. sad faces), an attentional bias away from positive emotional cues (e.g. happy faces), and an enhanced memory for negative emotional material. Compared with healthy controls, individuals with major depressive disorder show increased neural activity in response to sad faces and diminished neural activity in response to happy faces in emotion-related brain circuits (e.g. amygdala and ventral striatum). Some of these abnormalities in the processing of emotional information persist after symptom remission and they have also been found in healthy individuals who are at heightened risk for the development of mood disorders.

SUMMARY

The reviewed data show that major depressive disorder involves specific abnormalities in the cognitive and neural processing of emotional information and that these abnormalities may potentially contribute to the vulnerability for negative emotion and onset of depressive episodes.

Neural circuitry and neuroplasticity in mood disorders: insights for novel therapeutic targets

SUMMARY

Major depressive disorder and bipolar disorder are severe mood disorders that affect the lives and functioning of millions each year. The majority of previous neurobiological research and standard pharmacotherapy regimens have approached these illnesses as purely neurochemical disorders, with particular focus on the monoaminergic neurotransmitter systems. Not altogether surprisingly, these treatments are inadequate for many individuals afflicted with these devastating illnesses. Recent advances in functional brain imaging have identified critical neural circuits involving the amygdala and other limbic structures, prefrontal cortical regions, thalamus, and basal ganglia that modulate emotional behavior and are disturbed in primary and secondary mood disorders. Growing evidence suggests that mechanisms of neural plasticity and cellular resilience, including impairments of neurotrophic signaling cascades as well as altered glutamatergic and glucocorticoid signaling, underlie the dysregulation in these circuits. The increasing ability to monitor and modulate activity in these circuits is beginning to yield greater insight into the neurobiological basis of mood disorders. Modulation of dysregulated activity in these affective circuits via pharmacological agents that enhance neuronal resilience and plasticity, and possibly via emerging nonpharmacologic, circuitry-based modalities (for example, deep brain stimulation, magnetic stimulation, or vagus nerve stimulation) offers promising targets for novel experimental therapeutics in the treatment of mood disorders.

Explicit and implicit facial affect recognition in manic and depressed States of bipolar disorder: a functional magnetic resonance imaging study

BACKGROUND

The pathophysiology of abnormal mood states-mania and depression-in patients with bipolar disorder remains unclear. Facial affect processing paradigms are an effective way of studying behavioral and functional magnetic resonance imaging (fMRI) correlates of affective disorders.

METHODS

We used a factorial design to measure the neural correlates of tasks, tapping explicit and implicit recognition of sad, fearful, and happy facial expressions using event-related fMRI paradigms in three groups of participants: eight bipolar depressed patients, eight bipolar manic patients, and eight control subjects.

RESULTS

Depressed and manic patients exhibited overactivated responses to fearful faces, as well as to mood-incongruent facial expressions, with the depressed group exhibiting overactivity in fronto-striato-thalamic systems in response to happy faces and the manic group exhibiting overactivity in the fusiform gyrus in response to sad faces. For manic patients, task type also affected the neural response to sad faces, with the corticolimbic regions showing overactivation for implicit processing and underactivation for explicit processing.

CONCLUSIONS

Depressed and manic patients exhibited abnormal neural responses to sad, fearful, and happy facial expressions. Additionally, the attentional level of sad facial affect processing has important consequences for abnormalities of amygdala and cingulate activation in manic patients.

Beyond threat: amygdala reactivity across multiple expressions of facial affect

The amygdala has been consistently isolated as a key neural substrate for processing facial displays of affect. Recent evidence from human lesion and functional neuroimaging studies have begun to challenge the notion that the amygdala is reserved for signals of threat (fear/anger). We performed a 4 T fMRI study in which 20 subjects viewed a contemporary set of photographs displaying 6 different facial expressions (fearful, disgusted, angry, sad, neutral, happy) while performing a task with minimal cognitive demand. Across subjects, the left amygdala was activated by each face condition separately, and its response was not selective for any particular emotion category. These results challenge the notion that the amygdala has a specialized role in processing certain emotions and suggest that the amygdala may have a more general-purpose function in processing salient information from faces.

Preliminary evidence for persistent abnormalities in amygdala volumes in adolescents and young adults with bipolar disorder

OBJECTIVES

Abnormalities in volumes of the amygdala have been reported previously in adolescents and adults with bipolar disorder (BD). Several studies have reported reduced volumes in adolescents with BD; however, both decreases and increases in volumes have been reported in adults with BD. Understanding of potential developmental contributions to these disturbances in morphology of the amygdala has been limited by the absence of longitudinal data in persons with BD. Here we use a within-subject longitudinal design to investigate whether amygdala volume abnormalities persist in adolescents and young adults with BD over a time interval of approximately 2 years.

METHODS

Participants included 18 adolescents and young adults: 10 participants with BD I and 8 healthy comparison participants. Amygdala volumes were measured on high-resolution magnetic resonance imaging scans acquired twice for each subject over intervals of approximately 2 years. Amygdala volumes were the dependent measures in a mixed-model statistical analysis to compare amygdala volumes between groups over time while covarying for total brain volume.

RESULTS

Amygdala volumes were significantly smaller in adolescents and young adults with BD compared with healthy participants (p = 0.018). The effect of time was not significant.

CONCLUSIONS

Although the sample size is modest, this study provides preliminary evidence to support the presence of decreased amygdala volumes in adolescents and young adults with BD that persist during this developmental epoch.

Preliminary evidence for medication effects on functional abnormalities in the amygdala and anterior cingulate in bipolar disorder

RATIONALE

Abnormal amygdala and frontocortical responses to emotional stimuli are implicated in bipolar disorder (BD) and have been proposed as potential treatment targets.

OBJECTIVES

The aim of this study was to investigate amygdala and frontocortical responses to emotional face stimuli in BD and the influences of mood-stabilizing medications on these responses.

METHODS

Functional magnetic resonance imaging was performed while 17 BD participants (5 unmedicated) and 17 healthy comparison (HC) participants viewed faces with happy, sad, fearful, or neutral expressions.

RESULTS

The group by stimulus-condition interaction was significant (p<0.01) for amygdala activation, with the greatest effects in the happy face condition. Relative to HC, amygdala increases were greater in unmedicated BD, but lower in medicated BD. Rostral anterior cingulate (rAC) activation was decreased in unmedicated BD compared to HC; however, BD participants taking medication demonstrated rAC activation similar to HC participants.

CONCLUSIONS

Although the sample sizes were small, these preliminary results suggest that BD is associated with increased amygdala and decreased rAC response to emotional faces. The findings also provide preliminary evidence that mood-stabilizing medications may reverse abnormalities in BD in the response of an amygdala-frontal neural system to emotional stimuli.

Subgenual anterior cingulate activation to valenced emotional stimuli in major depression

Major depression has been associated with anomalous activation in the subgenual anterior cingulate cortex, but its response to emotional stimuli is poorly understood. The primary goal of this study was to compare levels of activation in the subgenual anterior cingulate cortex of diagnosed depressed and nondepressed participants in response to happy and sad facial expressions of affect. Whereas cognitive theories of depression predict increased activation to negative stimuli, depressed participants were found to exhibit increased activation to both types of stimuli in the subgenual anterior cingulate cortex. Importantly, the loci were in different regions of the subgenual anterior cingulate cortex, suggesting that there is functional specialization in the processing of negatively and positively valenced stimuli.

Preliminary evidence for medication effects on functional abnormalities in the amygdala and anterior cingulate in bipolar disorder

RATIONALE

Abnormal amygdala and frontocortical responses to emotional stimuli are implicated in bipolar disorder (BD) and have been proposed as potential treatment targets.

OBJECTIVES

The aim of this study was to investigate amygdala and frontocortical responses to emotional face stimuli in BD and the influences of mood-stabilizing medications on these responses.

METHODS

Functional magnetic resonance imaging was performed while 17 BD participants (5 unmedicated) and 17 healthy comparison (HC) participants viewed faces with happy, sad, fearful, or neutral expressions.

RESULTS

The group by stimulus-condition interaction was significant (p<0.01) for amygdala activation, with the greatest effects in the happy face condition. Relative to HC, amygdala increases were greater in unmedicated BD, but lower in medicated BD. Rostral anterior cingulate (rAC) activation was decreased in unmedicated BD compared to HC; however, BD participants taking medication demonstrated rAC activation similar to HC participants.

CONCLUSIONS

Although the sample sizes were small, these preliminary results suggest that BD is associated with increased amygdala and decreased rAC response to emotional faces. The findings also provide preliminary evidence that mood-stabilizing medications may reverse abnormalities in BD in the response of an amygdala-frontal neural system to emotional stimuli.

The effect of citalopram pretreatment on neuronal responses to neuropsychological tasks in normal volunteers: an FMRI study

Changes in serotonin neurotransmission have also been implicated in the etiology and treatment of impulse control disorders, depression, and anxiety. We have investigated the effect of enhancing serotonin function on fundamental brain processes that we have proposed are abnormal in these disorders. In all, 12 male volunteers received citalopram (7.5 mg intravenously) and placebo pretreatment in a single-blind crossover design before undertaking Go/No-go, Loss/No-loss, and covert (aversive) face emotion recognition tasks during functional magnetic resonance imaging (fMRI). Blood oxygenation level dependent responses were analyzed using Statistical Parametric Mapping (SPM2). The tasks activated prefrontal and subcortical regions generally consistent with literature with lateral orbitofrontal cortex (BA47) common to the three tasks. Citalopram pretreatment enhanced the right BA47 responses to the No-go condition, but attenuated this response to aversive faces. Attenuations were seen following citalopram in the medial orbitofrontal (BA11) responses to the No-go and No-loss (ie relative reward compared with Loss) conditions. The right amygdala response to aversive faces was attenuated by citalopram. These results support the involvement of serotonin in modulating basic processes involved in psychiatric disorders but argue for a process-specific, rather than general effect. The technique of combining drug challenge with fMRI (pharmacoMRI) has promise for investigating human psychiatric disorders.

Differential effects of chronic lithium and valproate on brain activation in healthy volunteers

RATIONALE

Previous functional imaging studies have shown altered brain activity during cognitive task performance in bipolar patients. However, the fact that these patients are often on medication makes it unclear to what extent these changes reflect treatment effects.

OBJECTIVES

This study aims to identify regional brain activity changes occurring following lithium and valproate treatment in healthy volunteers.

METHODS

This was a double-blind, placebo-controlled, study in which volunteers received either 1000 mg sodium valproate (n = 12), 900 mg lithium (n = 9), or placebo (n = 12). Functional images were acquired using functional magnetic resonance imaging (fMRI) while subjects performed three cognitive tasks, a word generation paradigm, a spatial attention task and a working memory task. fMRI was carried out both before and after 14 days of treatment with valproate, lithium or placebo. The changes in the magnitude of the blood-oxygen-level-dependent (BOLD) signal after treatment were compared between the groups using a one-way ANOVA for each task followed by a post-hoc multiple comparisons correction.

RESULTS

A significant group effect was noted in the change in BOLD signal magnitude from baseline to post-treatment, in all three tasks (working memory p< 0.000; spatial attention task p = 0.003; word generation paradigm p = 0.030). In the working memory task, the lithium group had a significant decrease in BOLD signal change, compared with the control group (p< 0.000). A decrease in BOLD signal change was also noted in the valproate group, in the spatial attention task (p = 0.004). Both lithium and valproate groups had a decreased BOLD signal in the verbal task, following treatment, compared with the placebo group (p = 0.061 (lithium approached significance); p = 0.050 (valproate)).

CONCLUSIONS

These findings suggest that lithium and valproate have independent effects on brain activation that vary in a task and region-dependent manner.

Magnetic resonance findings in bipolar disorder

The MR findings reviewed in this article suggest structural, chemical, and functional abnormalities in specific brain regions participating in mood and cognitive regulation, such as the DLPFC, anterior cingulate, amygdala,STG, and corpus callosum in subjects with bipolar disorder. These abnormalities would represent an altered anterior-limbic network disrupting inter- and intrahemispheric communication and underlying the expression of bipolar disorder. Available studies are limited by several confounding variables, such as small and heterogeneous patient samples, differences in clinical and medication status, and cross-sectional design. It is still unclear whether abnormalities in neurodevelopment or neurodegeneration play a major role in the pathophysiology of bipolar disorder. These processes could act together in a unitary model of the disease, with excessive neuronal pruning/apoptosis during childhood and adolescence being responsible for the onset of the disorder and subsequent neurotoxic mechanisms and impaired neuroplasticity and cellular resilience being responsible for further disease progression. Future MR studies should investigate larger samples of first-episode drug-free patients, pediatric patients, subjects at high risk for bipolar disorder, and unaffected family members longitudinally. Such a study population is crucial to examine systematically whether brain changes are present before the appearance of symptoms (eg, maldevelopment) or whether they develop afterwards, as a result of illness course (eg, neurodegeneration). These studies will also be instrumental in minimizing potentially confounding factors commonly found in adult samples, such as the effects of long-term medication, chronicity, and hospitalizations. Juvenile bipolar patients often have a strong family history of bipolar disorder. Future studies could help elucidate the relevance of brain abnormalities as reflections of genetic susceptibility to the disorder. MR studies associated with genetic, post-mortem, and neuropsychologic studies will be valuable in separating state from trait brain abnormalities and in further characterizing the genetic determinants, the neuropathologic underpinnings, and the cognitive disturbances of bipolar disorder.

Affect-modulated startle in adults with childhood-onset depression: relations to bipolar course and number of lifetime depressive episodes

To study affect regulation in adults with unipolar (n=38) and bipolar (n=38) forms of childhood-onset depression (COD), as compared with adults with no history of psychiatric illness (n=60), we examined affective modulation of the startle eyeblink reflex. Participants were subjected to binaural bursts of white noise while viewing pictures designed to elicit pleasant, neutral, or unpleasant affective states. The blink response was recorded from surface electrodes over the orbicularis oculi muscle during and following pictures. Participants rated the valence and arousal of their responses. Unlike control or bipolar groups, the unipolar group displayed a greater startle during the neutral condition than during the pleasant condition, and failed to display an increase in startle during the unpleasant condition. The bipolar group, unlike the unipolar and control groups, displayed a similar startle response after pleasant and unpleasant pictures. Participants with a high number of lifetime depressive episodes displayed a blunted startle response across affective conditions. Groups reported similar subjective responses to affective stimuli. Current affective symptoms and comorbid diagnoses did not influence startle modulation. In unipolar and bipolar forms of COD, unusual affective modulation or maintenance of the startle response, respectively, may reflect underlying deficits in affect regulation.

Neural substrates for voluntary suppression of negative affect: a functional magnetic resonance imaging study

BACKGROUND

Successful control of affect partly depends on the capacity to modulate negative emotional responses through the use of cognitive strategies. Although the capacity to regulate emotions is critical to mental well-being, its neural substrates remain unclear.

METHODS

We used functional magnetic resonance imaging to ascertain brain regions involved in the voluntary regulation of emotion and whether dynamic changes in negative emotional experience can modulate their activation. Fourteen healthy subjects were scanned while they either maintained the negative affect evoked by highly arousing and aversive pictures (e.g., experience naturally) or suppressed their affect using cognitive reappraisal. In addition to a condition-based analysis, online subjective ratings of intensity of negative affect were used as covariates of brain activity.

RESULTS

Inhibition of negative affect was associated with activation of dorsal anterior cingulate, dorsal medial prefrontal, and lateral prefrontal cortices, and attenuation of brain activity within limbic regions (e.g., nucleus accumbens/extended amygdala). Furthermore, activity within dorsal anterior cingulate was inversely related to intensity of negative affect, whereas activation of the amygdala was positively covaried with increasing negative affect.

CONCLUSIONS

These findings highlight a functional dissociation of corticolimbic brain responses, involving enhanced activation of prefrontal cortex and attenuation of limbic areas, during volitional suppression of negative emotion.

Neural systems of positive affect: relevance to understanding child and adolescent depression?

From an affective neuroscience perspective, the goal of achieving a deeper, more mechanistic understanding of the development of depression will require rigorous models that address the core underlying affective changes. Such an understanding will necessitate developing and testing hypotheses focusing on specific components of the complex neural systems involved in the regulation of emotion and motivation. In this paper, we illustrate these principles by describing one example of this type of approach: examining the role of disruptions in neural systems of positive affect in major depressive disorder in school-age children and adolescents. We begin by defining positive affect, proposing that positive affect can be distinguished from negative affect by its neurobehavioral features. We provide an overview of neural systems related to reward and positive affect, with a discussion of their potential involvement in depression. We describe a developmental psychopathology framework, addressing developmental issues that could play a role in the etiology and maintenance of early-onset depression. We review the literature on altered positive affect in depression, suggesting directions for future research. Finally, we discuss the treatment implications of this framework.

Neurobiological findings in bipolar II disorder compared with findings in bipolar I disorder

OBJECTIVE

To determine whether there are consistent neurobiological differences between patients with bipolar I disorder (BD I) and those with bipolar II disorder (BD II).

METHOD

We reviewed the literature in areas where the most consistent neurobiological findings have been reported for bipolar disorder, specifically, neuroimaging and brain metabolism. The imaging studies reviewed examined structure, using magnetic resonance imaging (MRI), and function, using functional MRI, positron emission tomography, and single photon emission computed tomography. We used magnetic resonance spectroscopy to examine brain chemistry. We reviewed those metabolic studies that examined cell calcium, 3-methoxy-4-hydroxyphenylglycol, and protein kinase C.

RESULTS

Some genetic studies suggest that there may be differences between BD II and BD I patients. However, our review of the imaging and metabolic studies identified few studies directly comparing these 2 groups. In those studies, there were few differences, if any, and these were not consistent.

CONCLUSIONS

While genetic data suggest there may be differences between BD II patients and BD I patients, the neurobiological findings to date do not provide support. However, this may be owing to the small number of studies directly comparing the 2 groups and also to the fact that those carried out have not been adequately powered to detect possible small true differences. This is an important issue because, if there are no neurobiological differences, it would be anticipated that similar treatments would be similarly effective in both groups. Given the importance of understanding whether there are neurochemical differences between these groups, further research in this area is clearly needed.

A developmental model for similarities and dissimilarities between schizophrenia and bipolar disorder

Schizophrenia and mania have a number of symptoms and epidemiological characteristics in common, and both respond to dopamine blockade. Family, twin and molecular genetic studies suggest that the reason for these similarities may be that the two conditions share certain susceptibility genes. On the other hand, individuals with schizophrenia have more obvious brain structural and neuropsychological abnormalities than those with bipolar disorder; and pre-schizophrenic children are characterised by cognitive and neuromotor impairments, which are not shared by children who later develop bipolar disorder. Furthermore, the risk-increasing effect of obstetric complications has been demonstrated for schizophrenia but not for bipolar disorder. Perinatal complications such as hypoxia are known to result in smaller volume of the amygdala and hippocampus, which have been frequently reported to be reduced in schizophrenia; familial predisposition to schizophrenia is also associated with decreased volume of these structures. We suggest a model to explain the similarities and differences between the disorders and propose that, on a background of shared genetic predisposition to psychosis, schizophrenia, but not bipolar disorder, is subject to additional genes or early insults, which impair neurodevelopment, especially of the medial temporal lobe.

Bipolaroids: functional imaging in bipolar disorder

OBJECTIVE

To evaluate the literature pertaining to the use of functional magnetic resonance imaging (fMRI) in bipolar disorder research.

METHOD

A search for papers published in English in journals from 1984 onwards was conducted using MedLine and EMBASE with the following terms: functional neuroimaging or fMRI and depression or bipolar disorder. In addition, retrieved papers and literature known to the authors was also scrutinized for further relevant reports.

RESULTS

The research findings from 26 articles are tabulated and the results from 10 articles dealing specifically with bipolar disorder are discussed in detail.

CONCLUSION

fMRI is a useful tool for investigating bipolar disorder. Preliminary studies point to trait and state abnormalities involving structures known to be associated with the generation and modulation of emotion. The patterns of fMRI activation are different to those found in healthy subjects and patients with major depression. FMRI studies are likely to provide valuable insights into the pathophysiology of bipolar disorder.