Mania in neurologic disorders

Polymicrogyria: An Unusual Case of Secondary Mania

BACKGROUND

Secondary mania refers to a manic episode that arises during a medical illness other than bipolar disorder or in response to a drug or medication. As the psychopathological features of secondary mania resemble those of mania due to bipolar disorder, misdiagnosis is frequent.

PURPOSE AND BASIC PROCEDURES

We present the case of a 20-year-old woman who developed a manic episode with psychotic symptoms, in whom polymicrogyria, a malformation of the cortical development with abnormal electroencephalographic activity, was documented. After initiating antiepileptic management, the affective symptoms completely subsided.

MAIN FINDINGS

To date, no specific recommendations are available concerning when to perform advanced studies in patients with a manic episode; however, as our case shows, these are much needed.

PRINCIPAL CONCLUSION

Because the treatment of secondary conditions largely depends on finding the underlying cause, patients with a new-onset mania should undergo a thorough assessment for secondary causes.

Bipolar disorder and frontotemporal dementia: A systematic review

OBJECTIVES

To detail the biological, clinical and neurocognitive characteristics differentiating bipolar disorder (BD) from frontotemporal dementia (FTD) and to investigate whether BD is a risk factor for FTD.

METHODS

A total of 16 studies were included in this systematic review. Five studies described biological and/or neurocognitive characteristics between patients with BD and FTD, and 11 studies investigated whether BD was a risk factor for FTD.

RESULTS

Individuals with FTD presented higher levels of serum neurofilament light chain, greater grey matter reduction in frontal, parietal and temporal lobes, and increased slow wave oscillations in channels F3, F4, T3, T5, T4 and T6 within an electroencephalogram (EEG), relative to individuals with BD. Patients with FTD presented greater deficits in executive function and theory of mind compared to patients with BD in a euthymic state, and more deficits in verbal fluency compared to patients with BD in a current mood episode. Patients with BD in a current mood episode showed greater impairment in attention, working memory, verbal memory and executive function relative to individuals with FTD. In addition, retrospective studies showed that 10.2%-11.6% of patients with behavioural variant FTD (bvFTD) had a preceding history of BD.

CONCLUSION

Biological and neurocognitive characteristics help to distinguish between BD and FTD, and it may help to reach a more precise diagnosis. In addition, individuals with BD are at higher risk of developing FTD. More studies are needed to identify the predictors of the conversion between BD to FTD.

CHROME Criteria and Quality of Life: A Pilot Study from Maria Wolff-Albertia

BACKGROUND

Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia.

OBJECTIVE

Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL).

METHODS

Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME's diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115).

RESULTS

Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p < 0.0005). Substantive reduction in prescribing frequency was observed for antidepressants (76.9% pre-intervention, 33.8% post-intervention) and for atypical neuroleptics (38.8% pre-intervention, 15.1% post-intervention). There was improvement in patient's response to surroundings (p < 0.0005) and total NPS (p < 0.01), but small worsening occurred in social interaction (p < 0.02, completer subjects). Safety measurements remained stable.

CONCLUSION

CHROME criteria appear to optimize psychotropic prescriptions, avoid chemical restraints, and allow external verification of quality prescriptions. Extensive use seems feasible, related to substantial reduction of prescriptions, and of benefit for people with dementia as de-prescriptions are not associated to increased NPS or QoL loss.

Syndrome-Based Prescription to Optimize Psychotropics: Are CHROME Criteria a Game Changer?

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

Manic-like presentation with an organic aetiology

A 57-year-old man with chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea (OSA) and no prior psychiatric history presented repeatedly over 6 months with mental and behavioural changes. Laboratory tests, chest X-ray and sleep study diagnosed an infective exacerbation of COPD, type II respiratory failure and OSA. Differential diagnoses included delirium, primary mania in bipolar affective disorder or organic pathology causing secondary mania. Oxygen, steroids, bronchodilators, antibiotics and non-invasive ventilation were administered to treat his infection and respiratory failure. However, blood gas analysis showed persistent hypoxia and hypercarbia, aggravating his ongoing mental state disturbance that required security supervision and sedation with antipsychotics and benzodiazepines. Sudden onset of classic manic symptoms and multiple presentations suggested secondary mania, driven by chronic hypoxia in end-stage COPD and OSA. The challenge was establishing a balance between mental state control and treatment of physical illness.

Bipolar Disorder Among Patients Diagnosed With Frontotemporal Dementia

OBJECTIVE

Previous studies have documented manic and hypomanic symptoms in behavioral variant frontotemporal dementia (bvFTD), suggesting a relationship between bipolar disorder and bvFTD.

METHODS

The investigators conducted a literature review as well as a review of the psychiatric histories of 137 patients with bvFTD, and patients with a prior diagnosis of bipolar disorder were identified. The clinical characteristics of patients' bipolar disorder diagnosis, family history, features of bvFTD, and results from fluorodeoxyglucose positron emission tomography (FDG-PET), as well as autopsy findings, were evaluated.

RESULTS

Among the 137 patients, 14 (10.2%) had a psychiatric diagnosis of bipolar disorder, eight of whom met criteria for bipolar disorder (type I, N=6; type II, N=2) 6-12 years preceding onset of classic symptoms of progressive bvFTD. Seven of the eight patients with bipolar disorder had a family history of mood disorders, four had bitemporal predominant hypometabolism on FDG-PET, and two had a tauopathy involving temporal lobes on autopsy. Three additional patients with late-onset bipolar I disorder proved to have a nonprogressive disorder mimicking bvFTD. The remaining three patients with bvFTD had prior psychiatric symptoms that did not meet criteria for a diagnosis of bipolar disorder. The literature review and the findings for one patient further suggested a shared genetic mutation in some patients.

CONCLUSIONS

Manic or hypomanic episodes years before other symptoms of bvFTD may be a prodrome of this dementia, possibly indicating anterior temporal involvement in bvFTD. Other patients with late-onset bipolar disorder exhibit the nonprogressive frontotemporal dementia phenocopy syndrome. Finally, a few patients with bvFTD have a genetic predisposition for both disorders.

Mania induced by isoniazid preventive therapy during steroid treatment for rheumatoid arthritis and organising pneumonia

Isoniazid preventative therapy is widely used for latent tuberculosis infection. Isoniazid is highly effective but has many adverse effects, including neuropsychiatric. We describe the case of an 80-year-old woman with mania. She had received isoniazid preventative therapy during steroid treatment for rheumatoid arthritis and organising pneumonia for the previous 5 months. Her mania resolved after discontinuation of isoniazid. Adverse effects of isoniazid should be considered even if a long time has elapsed since the start of administration. Physicians other than infectious disease and respiratory specialists also must be aware of the adverse effects of isoniazid preventative therapy.

Manic Episodes Due to Medical Illnesses: A Literature Review

The body of evidence for mania as a secondary syndrome due to organic diseases is small. The clinical diagnosis and management of these patients are mainly based on clinical experience and on some case reports. Treatment should be focused on both the underlying medical illness and the control of acute symptoms. Mania due to a medical condition is relevant in the clinical setting, and thus more research is needed to add evidence-based recommendations to the currently available clinical knowledge. In this review, we summarize the latest information on the etiology, epidemiology, diagnostic aspects, and management of secondary mania.

Huntington's Disease in a Patient Misdiagnosed as Conversion Disorder

Huntington's disease (HD) is an inherited, progressive, and neurodegenerative neuropsychiatric disorder caused by the expansion of cytosine-adenine-guanine (CAG) trinucleotide in Interested Transcript (IT) 15 gene on chromosome 4. This pathology typically presents in individuals aged between 30 and 50 years and the age of onset is inversely correlated with the length of the CAG repeat expansion. It is characterized by chorea, cognitive deficits, and psychiatric symptoms. Usually the psychiatric disorders precede motor and cognitive impairment, Major Depressive Disorder and anxiety disorders being the most common presentations. We present a clinical case of a 65-year-old woman admitted to our Psychiatric Acute Unit. During the 6 years preceding the admission, the patient had clinical assessments made several times by different specialties that focused only on isolated symptoms, disregarding the syndrome as a whole. In the course of her last admission, the patient was referred to our Neuropsychiatric Team, which made the provisional diagnosis of late-onset Huntington's disease, later confirmed by genetic testing. This clinical vignette highlights the importance of a multidisciplinary approach to atypical clinical presentations and raises awareness for the relevance of investigating carefully motor symptoms in psychiatric patients.

Manic behavior and asymmetric right frontotemporal dementia from a novel progranulin mutation

Studies suggest a relationship of manic behavior and bipolar disorder (BD) with behavioral variant frontotemporal dementia (bvFTD). The nature of this relationship is unclear. This report presents a patient with initial manic behavior as the main manifestation of familial bvFTD from a novel progranulin (GRN) mutation. In contrast, there are other reports of a long background of BD preceding a diagnosis of bvFTD. A review of the literature and this patient suggest that manic symptoms result from damage to right frontotemporal neural structures from longstanding BD, as well as from bvFTD and other focal neurological disorders. In addition, there is a subgroup of patients with a probable genetic predisposition to both BD and bvFTD.

Update on the Epidemiology, Diagnosis, and Treatment of Mania in Older-Age Bipolar Disorder

PURPOSE OF REVIEW

The population over age 60 is growing more rapidly than the general population. Given the projected increase and need for data that can inform treatment, this review provides a brief description of newer publications focused on mania in older-age bipolar disorder (OABD), including epidemiology, diagnosis, and treatments.

RECENT FINDINGS

Age cutoffs to define OABD range from 50 to 65 years. OABD clinical presentation and course of illness is highly variable, often characterized by mood episode recurrence, medical comorbidity, cognitive deficits, and impaired functioning. There is little pharmacotherapy data on mania in OABD. Lithium and valproate have been tested in a single randomized controlled trial and there is data of more limited quality with other compounds. Treating OABD is challenging due to medical complexity, comorbidity, diminished tolerance to treatment, and a limited evidence base. More data is needed to keep pace with clinical demand.

Neurobehavioral Manifestations of Human Immunodeficiency Virus/AIDS: Diagnosis and Treatment

Behavioral disorders are common in persons infected with human immunodeficiency virus (HIV). The differential includes preexisting psychiatric diseases, substance abuse, direct effects of HIV infection, opportunistic infection, and the adverse effects of medical therapies. Many patients have more than one contributing or comorbid problem to explain these behavioral changes. The differential should always include consideration of psychosocial, genetic, and medical causes of disease. Treatment strategies must take into account the coadministration of antiretroviral therapy and the specific neurologic problems common in patients infected with HIV.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder

OBJECTIVES

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures.

METHODS

For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder.

RESULTS

The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed.

CONCLUSIONS

Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

Disadvantageous decision-making on a rodent gambling task is associated with increased motor impulsivity in a population of male rats

BACKGROUND

Impulsivity is understood as a range of behaviours, but the association between these behaviours is not well understood. Although high motor impulsivity is a key symptom of disorders like pathological gambling and addiction, in which decision-making on laboratory tasks is compromised, there have been no clear demonstrations that choice and motor impulsivity are associated in the general population. We examined this association in a large population of rodents.

METHODS

We performed a meta-analysis on behavioural data from 211 manipulation-naive male animals that performed a rodent gambling task in our laboratory between 2008 and 2012. The task measures an aspect of both impulsive decision-making and impulsive action, making it possible to evaluate whether these 2 forms of maladaptive behaviour are related.

RESULTS

Our meta-analysis revealed that motor impulsivity was positively correlated with poor decision-making under risk. Highly motor impulsive rats were slower to adopt an advantageous choice strategy and quicker to make a choice on individual trials.

LIMITATIONS

The data analyzed were limited to that produced by our laboratory and did not include data of other researchers who have used the task.

CONCLUSION

This work may represent the first demonstration of a clear association between choice and motor impulsivity in a nonclinical population. This lends support to the common practice of studying impulsivity in nonclinical populations to gain insight into impulse control disorders and suggests that differences in impulsive behaviours between clinical and nonclinical populations may be ones of magnitude rather than ones of quality.

Bipolar disorder and comorbidity: increased prevalence and increased relevance of comorbidity for hospital-based mortality during a 12.5-year observation period in general hospital admissions

BACKGROUND

Bipolar disorder (BD) is associated with an increase of psychiatric and physical comorbidities, but the effects of these disorders on general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on hospital-based mortality differed between individuals with and without BD during a 12.5-year observation period in general hospital admissions.

METHODS

During 1 January 2000 and 30 June 2012, 621 individuals with BD were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 6210 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses. Comorbidities that increased the risk for hospital-based mortality (but not mortality outside of the hospitals) were identified using multivariate logistic regression analyses.

RESULTS

Individuals with BD had a more severe course of disease than controls that was associated with a higher total number of in-hospital deaths. Individuals with BD compared to controls had a substantial higher burden of comorbidities, the most frequent comorbidities included asthma, type-2 diabetes mellitus (T2DM), and alcohol dependence. 18 other diseases with a surplus of diabetes related complications were also increased. Fourteen comorbidities contributed to the prediction of hospital-based mortality in univariate analyses. Risk factors for hospital-based mortality in multivariate analyses were ischemic stroke, pneumonia, bronchitis, chronic obstructive pulmonary disease, T2DM, and hypertension. The impact of T2DM on hospital-based mortality was higher in individuals with BD than in controls.

LIMITATIONS

The study design was not assigned to assess the type of BD, the current bipolar status, and if individuals with BD were treated with medication. It was neither possible to compare drug effects, nor to compare the adherence to treatment between samples.

CONCLUSION

In one of the largest samples of individuals with BD in general hospitals, the excess comorbity in individuals with BD compared to controls is in particular caused by asthma and T2DM. T2DM and its complications cause significant excess hospital-based mortality in individuals with BD.

Neurosyphilis presenting as mania

OBJECTIVE

General paresis of the insane is a late and severe form of neurosyphilis characterized by nonspecific neuropsychiatric symptoms. There are a limited number of case reports of mood disorders presenting in neurosyphilis, with depressive illness being the most common.

METHODS

We performed a literature review of case reports of secondary bipolar disorder induced by syphilitic infection.

RESULTS

Herein reported is a case of a 53-year-old woman who initially presented with symptoms of mania and depression, mimicking bipolar disorder, but was subsequently diagnosed with general paresis of the insane.

CONCLUSION

The present case report emphasizes that if a substantial delay occurs in syphilis diagnosis and management, the patient may have a very poor prognosis.

Urgent and emergent psychiatric disorders

In the emergency department, neurologists regularly evaluate patients exhibiting behavioral abnormalities that stem from underlying neurologic diseases. This behavior may be the initial presence of a neurologic illness or may indicate the deterioration and progress of the disease process. In addition, many neurologic patients present with acute and potentially dangerous psychiatric symptoms that demand rapid and accurate management. Assessment, diagnosis, and treatment of patients with psychiatric manifestations in the context of neurologic illness pose a significant challenge to treating neurologists. This article discusses a general approach to assessment and treatment of some of the more common psychiatric disorders.

Huntington's Disease and Striatal Signaling

Huntington’s Disease (HD) is the most frequent neurodegenerative disease caused by an expansion of polyglutamines (CAG). The main clinical manifestations of HD are chorea, cognitive impairment, and psychiatric disorders. The transmission of HD is autosomal dominant with a complete penetrance. HD has a single genetic cause, a well-defined neuropathology, and informative pre-manifest genetic testing of the disease is available. Striatal atrophy begins as early as 15 years before disease onset and continues throughout the period of manifest illness. Therefore, patients could theoretically benefit from therapy at early stages of the disease. One important characteristic of HD is the striatal vulnerability to neurodegeneration, despite similar expression of the protein in other brain areas. Aggregation of the mutated Huntingtin (HTT), impaired axonal transport, excitotoxicity, transcriptional dysregulation as well as mitochondrial dysfunction, and energy deficits, are all part of the cellular events that underlie neuronal dysfunction and striatal death. Among these non-exclusive mechanisms, an alteration of striatal signaling is thought to orchestrate the downstream events involved in the cascade of striatal dysfunction.

Mania and stroke: a systematic review

BACKGROUND

Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.

METHODS

We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.

RESULTS

From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).

CONCLUSIONS

Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

White matter: beyond focal disconnection

The complex phenomenology of white matter dementia and many neuropsychiatric disorders implies that they originate from involvement of distributed neural networks, and white matter neuropathology is increasingly implicated in the pathogenesis of these network disconnection syndromes. White matter disorders produce functional asynchrony of interdependent cerebral regions subserving normal cognitive and emotional functions. Accumulating evidence suggests that white matter dementia primarily reflects disturbed frontal systems connectivity, whereas disruption of frontal and temporal lobe systems is implicated in the pathogenesis of neuropsychiatric disorders. Continued study of normal and abnormal white matter promises to help resolve challenging problems in behavioral neurology and neuropsychiatry.

The diagnostic challenge of psychiatric symptoms in neurodegenerative disease: rates of and risk factors for prior psychiatric diagnosis in patients with early neurodegenerative disease

OBJECTIVE

To identify rates of and risk factors for psychiatric diagnosis preceding the diagnosis of neurodegenerative disease.

METHOD

Systematic, retrospective, blinded chart review was performed of 252 patients with a neurodegenerative disease diagnosis seen in our specialty clinic between 1999 and 2008. Neurodegenerative disease diagnoses included behavioral-variant frontotemporal dementia (n = 69), semantic dementia (n = 41), and progressive nonfluent aphasia (n = 17) (all meeting Neary research criteria); Alzheimer's disease (n = 65) (National Institute of Neurologic and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association research criteria); corticobasal degeneration (n = 25) (Boxer research criteria); progressive supranuclear palsy (n = 15) (Litvan research criteria); and amyotrophic lateral sclerosis (n = 20) (El Escorial research criteria). Reviewers remained blinded to each patient's final neurodegenerative disease diagnosis while reviewing charts. Extensive caregiver interviews were conducted to ensure accurate and reliable diagnostic histories. For each patient, we recorded history of psychiatric diagnosis, family psychiatric and neurologic history, age at symptom onset, and demographic information.

RESULTS

A total of 28.2% of patients with a neurodegenerative disease received a prior psychiatric diagnosis. Depression was the most common psychiatric diagnosis in all groups. Behavioral-variant frontotemporal dementia patients received a prior psychiatric diagnosis significantly more often (50.7%; P < .001) than patients with Alzheimer's disease (23.1%), semantic dementia (24.4%), or progressive nonfluent aphasia (11.8%) and were more likely to receive diagnoses of bipolar disorder or schizophrenia than were patients with other neurodegenerative diseases (P < .001). Younger age (P < .001), higher education (P < .05), and a family history of psychiatric illness (P < .05) increased the rate of prior psychiatric diagnosis in patients with behavioral-variant frontotemporal dementia. Cognitive, behavioral, and emotional characteristics did not distinguish patients who did or did not receive a prior psychiatric diagnosis.

CONCLUSIONS

Neurodegenerative disease is often misclassified as psychiatric disease, with behavioral-variant frontotemporal dementia patients at highest risk. While this study cannot rule out the possibility that psychiatric disease is an independent risk factor for neurodegenerative disease, when patients with neurodegenerative disease are initially classified with psychiatric disease, the patient may receive delayed, inappropriate treatment and be subject to increased distress. Physicians should consider referring mid- to late-life patients with new-onset neuropsychiatric symptoms for neurodegenerative disease evaluation.

Hyponatremia-induced change in mood mimicking late-onset bipolar disorder

OBJECTIVE

Hyponatremia and bipolar disorder are rarely considered to have common features. This report describes a case of hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) presenting as late-onset bipolar disorder and discusses the evidence linking hyponatremia to mood disorders.

METHOD

Case report and review of published literature.

RESULTS

This case provides evidence that mood changes identical to those seen in bipolar disorder may be caused by hyponatremia at a variety of concentrations.

CONCLUSIONS

Further research is required to determine causes of SIADH in psychiatric patients with symptomatic hyponatremia and to elucidate the mechanism by which hyponatremia causes changes in mood. In older patients presenting with new-onset bipolar disorder, a physical etiology must always be excluded.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

Mania in the medically ill

Manic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. Manic symptoms may be due to an independent psychiatric illness, may be induced or precipitated by a medical condition, or may result from medication or substance use. The presence of manic symptoms in medically ill patients can lead to misdiagnosis or complicate the management of comorbid medical illness. It is of paramount importance to identify the etiology of the mania and, in particular, differentiate primary from secondary mania. Management of mania in the medically ill should focus on treating the underlying medical condition, medication management (antipsychotic agents, mood stabilizers, and/or benzodiazepines), and psychotherapy (if needed). Selecting appropriate medication for treatment requires basic knowledge of the pharmacokinetics of the medications, their side effect profile, and drug-drug interaction. The majority of deficits accompanying secondary mania resolve with treatment of the underlying cause, and supportive psychopharmacology may be all that is needed, but if symptoms persist, patients may need medications for a longer duration.

Postictal Mania versus Postictal Psychosis: Differences in Clinical Features, Epileptogenic Zone, and Brain Functional Changes during Postictal Period

PURPOSE

To clarify the differences between postictal mania (PIM) and postictal psychosis (PIP).

METHODS

Five patients with PIM were compared to 17 patients with PIP, with respect to clinical, epileptological, electrophysiological, and neuroimaging features. PIM was distinguished from PIP by the symptoms observed in the postictal period based on the ICD-10 criteria.

RESULTS

Postictal manic episodes lasted for a longer period than postictal psychotic episodes. Patients with PIM had more recurrent postictal episodes than patients with PIP. The age at onset of epilepsy in patients with PIM was older than that in patients with PIP. PIM was associated with frontal lobe and temporal lobe epilepsies, whereas PIP was associated with temporal lobe epilepsy. The estimated epileptogenic zone was on the language dominant side in PIM, whereas there was no predominant hemispheric laterality in PIP. Electroencephalography (EEG) performed during the early period of postictal manic and psychotic episodes showed decreased frequency of interictal epileptiform discharges in both PIM and PIP. Single-photon emission computed tomography (SPECT) during postictal manic and psychotic episodes showed increased perfusion in the temporal and/or frontal lobes in both PIM and PIP. Three patients with PIM showed increased perfusion during postictal episodes on bilateral or the language nondominant side, which were contralateral to the estimated epileptogenic zone, whereas three patients with PIP showed increased perfusion on the areas, which were ipsilateral to the estimated epileptogenic zone.

CONCLUSIONS

PIM has a distinct position among the mental disorders observed in the postictal period.

Les anomalies structurales observées en imagerie cérébrale dans le trouble bipolaire

The number of structural neuroimaging studies of bipolar disorder have increased during recent years, expanding the literature on the nature of cerebral abnormalities underlying this disorder. The purpose of this paper is to provide a selective review on the main issues concerning this literature. Consistent findings are higher rate of periventricular and deep subcortical white matter hyperintensites seen on MRI. Although there is strong evidence for links between hyper-intense lesions and age or cardio-vascular risk factors, some authors have observed the presence of these abnormalities early in the course of the illness. There are also frequent reports on ventricular enlargement, which has been described as mild and predominant in the right lateral ventricle. Total cerebral volume appears to be preserved. Whereas changes in total grey matter volume are uncertain, evidence suggests that reduced white matter volume reflects genetic factors predisposing to the disorder. Recent studies have reported volume changes in several cortical areas including the subgenual cingular, frontal and temporal cortices. Additionally, a number of reports described morphometric abnormalities in various subcortical structures, such as amygdala, basal ganglia and thalamus. Part of the variability in the morphometric abnormalities might be attributable to differences in clinical status and demographic characteristics of patient groups. Despite some inconsistencies across the studies, it emerges that abnormalities are asymmetrically distributed throughout the two cerebral hemispheres. When increase in volume is reported, it is preferentially localised in the left cerebral hemi-sphere and more specifically in prefrontal and temporal cortices and in amygdala. By contrast, when structural abnormalities concern the right cerebral hemisphere, they are identified as deficits. These latter results are in direct line with those of studies of mania following brain injuries, which report that these secondary mania result mainly from right cerebral lesions. It is also important to notice that most of the abnormalities concern both the cortical and subcortical level, ie frontal, striatal, thalamic and limbic regions. These abnormalities highlight the role in the pathophysiology of bipolar disorder of the loops involved in emotional information processing. The particular role of fronto-limbic loops in the phenomenology of bipolar disorder have been emphasised by recent data from functional neuroimaging studies.

Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders

OBJECTIVE

To estimate the comparative prevalence of bipolar symptoms in respondents with epilepsy vs other chronic medical conditions.

METHODS

The Mood Disorder Questionnaire (MDQ), a validated screening instrument for bipolar I and II symptoms, in conjunction with questions about current health problems, was sent to a sample of 127,800 people selected to represent the US adult population on selected demographic variables. A total of 85,358 subjects (66.8%) aged 18 or older returned the survey and had usable data. Subjects who identified themselves as having epilepsy were compared to those with migraine, asthma, diabetes mellitus, or a healthy comparison group with regard to relative lifetime prevalence rates of bipolar symptoms and past clinical diagnoses of an affective disorder.

RESULTS

Bipolar symptoms, evident in 12.2% of epilepsy patients, were 1.6 to 2.2 times more common in subjects with epilepsy than with migraine, asthma, or diabetes mellitus, and 6.6 times more likely to occur than in the healthy comparison group. A total of 49.7% of patients with epilepsy who screened positive for bipolar symptoms were diagnosed with bipolar disorder by a physician, nearly twice the rate seen in other disorders. However, 26.3% of MDQ positive epilepsy subjects carried a diagnosis of unipolar depression, and 25.8% had neither a uni- nor bipolar depression diagnosis.

CONCLUSION

Bipolar symptoms occurred in 12% of community-based epilepsy patients, and at a rate higher than in other medical disorders. One quarter were unrecognized.

Psychiatric and medical comorbidities of bipolar disorder

OBJECTIVES

This review summarizes the literature on psychiatric and medical comorbidities in bipolar disorder. The coexistence of other Axis I disorders with bipolar disorder complicates psychiatric diagnosis and treatment. Conversely, symptom overlap in DSM-IV diagnoses hinders definition and recognition of true comorbidity. Psychiatric comorbidity is often associated with earlier onset of bipolar symptoms, more severe course, poorer treatment compliance, and worse outcomes related to suicide and other complications. Medical comorbidity may be exacerbated or caused by pharmacotherapy of bipolar symptoms.

METHODS

Articles were obtained by searching MEDLINE from 1970 to present with the following search words: bipolar disorder AND, comorbidity, anxiety disorders, eating disorder, alcohol abuse, substance abuse, ADHD, personality disorders, borderline personality disorder, medical disorders, hypothyroidism, obesity, diabetes mellitus, multiple sclerosis, lithium, valproate, lamotrigine, carbamazepine, atypical antipsychotics. Articles were prioritized for inclusion based on the following considerations: sample size, use of standardized diagnostic criteria and validated methods of assessment, sequencing of disorders, quality of presentation.

RESULTS

Although the literature establishes a strong association between bipolar disorder and substance abuse, the direction of causality is uncertain. An association is also seen with anxiety disorders, attention-deficit/hyperactivity disorder, and eating disorders, as well as cyclothymia and other axis II personality disorders. Medical disorders accompany bipolar disorder at rates greater than predicted by chance. However, it is often unclear whether a medical disorder is truly comorbid, a consequence of treatment, or a combination of both.

CONCLUSION

To ensure prompt, appropriate intervention while avoiding iatrogenic complications, the clinician must evaluate and monitor patients with bipolar disorder for the presence and the development of comorbid psychiatric and medical conditions. Conversely, physicians should have a high index of suspicion for underlying bipolar disorder when evaluating individuals with other psychiatric diagnoses (not just unipolar depression) that often coexist with bipolar disorder, such as alcohol and substance abuse or anxiety disorders. Anticonvulsants and other mood stabilizers may be especially helpful in treating bipolar disorder with significant comorbidity.

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Peri-Ictal Behavioral and Cognitive Changes

Peri-ictal behavioral and cognitive changes contribute substantially to disability and distress among people with epilepsy. Psychosis, depression, and suicide may all occur as complications of seizures. Greater appreciation and understanding of the peri-ictal period is clinically important and might open novel therapeutic windows. At the same time this period provides a model for understanding basic mechanisms underlying mood and thought disorders and the substrates of cognition, volition, emotion, and consciousness. This review will discuss behavioral and cognitive antecedents of seizures, including the preictal milieu, reflex seizures, and self-induced seizures. Behavioral and cognitive treatment approaches that have been undertaken are reviewed. Both acute and delayed postictal emotional, behavioral, and cognitive changes will be discussed. Finally, possible mechanisms by which epileptic brain activity and behavior may modify each other are considered.