The relationship of bulimia and anorexia nervosa with bipolar disorder and its temperamental foundations

The optimal cut-off score of the Eating Attitude Test-26 for screening eating disorders in Japan

PURPOSE

The Eating Attitude Test-26 (EAT-26) is a screening tool for eating disorders (EDs) in clinical and non-clinical samples. The cut-off score was suggested to be varied according to target population. However, no studies have examined the appropriateness of the originally proposed score of 20 for screening DSM-5 eating disorders in Japan. This study aimed to identify an appropriate cut-off score to better differentiate clinical and non-clinical samples in Japan for EDs.

METHODS

The participants consisted of 54 patients with anorexia nervosa restricting type, 58 patients with anorexia nervosa binge-eating/purging type, 37 patients with bulimia nervosa diagnosed according to DSM-5 criteria, and 190 healthy controls (HCs). Welch's t test was used to assess differences in age, body mass index (BMI), and total EAT-26 scores between HCs and patients with EDs. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal cut-off score.

RESULTS

The HCs had significantly higher BMI and lower total EAT-26 mean scores than patients with EDs. The area under the ROC curve was 0.925, indicating that EAT-26 had excellent performance in discriminating patients with EDs from HCs. An optimal cut-off score of 17 was identified, with sensitivity and specificity values of 0.866 and 0.868, respectively.

CONCLUSIONS

The result supports the suggestions that optimal cut-off score should be different according to target populations. The newly identified cut-off score of 17 would enable the identification of patients with EDs who have been previously classified as non-clinical samples in the EAT-26 test.

LEVEL OF EVIDENCE

III: evidence obtained from case-control analytic study.

Prevalence of eating disorders in patients with bipolar disorder: a scoping review of the literature

BACKGROUND

Eating disorder (ED) and bipolar disorder (BD) exhibit certain phenomenological similarities rooted in eating behavior and emotional regulation. However, despite the growing body of research on the comorbidity of ED and BD, scientific data on the concurrent course of these disorders has remained poorly systematized.

AIM

To conduct a scoping review of published data on the prevalence of various types of ED among patients with BD types I and II in the context of the sex and clinical features of the concurrent course of these disorders.

METHODS

The analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search was conducted in the MEDLINE electronic database. Studies were included if they were focused samples of patients diagnosed with BD and ED, and the Diagnostic and Statistical Manual of Mental Disorders, fourth and fifth editions (DSM-IV, DSM-5), or International Statistical Classification of Diseases and Related Health Problems, tenth Revision (ICD-10), were used for the verification of the ED and BD diagnoses. The descriptive analysis method was used to summarize the review findings.

RESULTS

A total of 41 studies were selected for the review. Lifetime ED in patients with BD ranged from 2.2% to 31.1%, and the prevalence rates of BD among patients with ED varied from 11.3% to 68.1%. ED nominally had a higher prevalence among individuals with BD type II and females. Additionally, the presence of ED in patients with BD was associated with earlier onset of mood disorder, a higher number of depressive episodes, higher levels of atypical depressive symptoms, suicide attempts, as well as a higher frequency of comorbid obsessive-compulsive and anxiety disorders, addictions, and various metabolic disorders.

CONCLUSION

Despite the high degree of volatility in the results, the prevalence rates of a concurrent course of ED and BD are rather high. For this reason, screening for ED in patients with BD and vice versa holds significant value in the accurate diagnosis and selection of the most effective therapy. The patterns of comorbidity among different types of ED and BD, depending on gender, need further exploration in future research.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Phonological working memory is adversely affected in adults with anorexia nervosa: a systematic literature review

PURPOSE

Cognitive restraint has potentiating and deleterious effects on working memory (WM) in anorexia nervosa (AN). Conflicting evidence may be due to heterogeneity of tasks examining different WM components (e.g., verbal/auditory versus visuospatial), and differences in adolescent versus adult AN. Additionally, differential cognitive profiles of restricting versus binge/purging subtypes, comorbid psychiatric disorders and psychotropic medication use may confound findings.

METHODS

To address these conflicts, 25 studies, published between 2016 and 2021, investigating WM in children, adolescents and adults with AN were systematically reviewed using PRISMA guidelines.

RESULTS

In 71% of WM tasks, no difference in performance between AN patients and age-matched controls was reported, while 29% of WM tasks showed worse performance. Adults with AN displayed deficits in 44% of the verbal/auditory tasks, while performance remained unaffected in 86% of visuospatial tasks.

CONCLUSION

Examining age groups and WM subsystems separately revealed novel findings of differentially affected WM components in AN. Comorbidities and psychotropic medications were common among AN participants and should be regarded as critical confounding factors for WM measures. Future studies examining different components of WM, acknowledging these confounding factors, may reveal specific deficits in AN to aid treatment improvement strategies.

LEVEL OF EVIDENCE

I, systematic review.

The prevalence, odds and predictors of lifespan comorbid eating disorder among people with a primary diagnosis of bipolar disorders, and vice-versa: Systematic review and meta-analysis

BACKGROUND

There are scarce and discrepant data about the prevalence and correlates of co-occurring eating disorders (EDs) among people with a primary diagnosis of bipolar disorder (BD), and vice-versa, compelling a systematic review and meta-analysis on the matter.

METHODS

MEDLINE/PsycINFO databases were systematically searched for original studies documenting BD⇌ED comorbidity across the lifespan, from inception up until April 20^th, 2020. Random-effects meta-analysis and meta-regression analyses were conducted, accounting for multiple moderators.

RESULTS

Thirty-six studies involved 15,084 primary BD patients. Eleven studies encompassed 15,146 people with primary EDs. Binge eating disorder (BED) occurred in 12.5% (95%C.I.=9.4-16.6%, I²=93.48%) of BDs, while 9.1% (95%C.I.=3.3-22.6%) of BEDs endorsed BD. Bulimia Nervosa (BN) occurred in 7.4% (95%C.I.=6-10%) of people with BD, whereas 6.7% (95%C.I.=12-29.2%) of subjects with BN had a diagnosis of BD. Anorexia Nervosa (AN) occurred in 3.8% (95%C.I.=2-6%) of people with BDs; 2% (95%C.I.=1-2%) of BD patients had a diagnosis of AN. Overall, BD patients with EDs had higher odds of being female vs. non-ED controls. Several moderators yielded statistically significant differences both within- and between different types of BDs and EDs.

LIMITATIONS

Scant longitudinal studies, especially across different EDs and pediatric samples. High heterogeneity despite subgroup comparisons. Limited discrimination of the quality of the evidence.

CONCLUSIONS

The rates of BD⇌ED comorbidity vary across different diagnostic groups, more than they do according to the "direction" of BD⇌ED. Further primary studies should focus on the risks, chronology, clinical impact, and management of the onset of intertwined BD⇌ED across different ages, promoting a continuum approach.

Challenges in diagnosis and treatment of comorbid eating disorders and mood disorders

PURPOSE

This paper explores complex challenges in diagnosis and treatment of patients with comorbid eating disorders and mood disorders. An integrative review of the literature examines overlapping symptoms, phenotypes, neural circuits, and genetic factors for these disorders. A case study illustrates how the integration of knowledge from research and practice can inform a diagnostic formulation and multifaceted treatment plan.

CONCLUSIONS

Patients with complex clinical presentations inspire a search for research and clinical literature that helps build the neuroscience foundations of advanced practice.

PRACTICE IMPLICATIONS

Sharing clinical challenges and processes of discovery is a form of scholarship that promotes the evolution of advanced psychiatric nursing practice.

[Bipolar disorders and anorexia nervosa: A clinical study]

PURPOSE

Anorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed.

METHOD

Overall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria.

RESULTS

A high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities.

CONCLUSION

The occurrence of anorexia nervosa-bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits

BACKGROUND

Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder.

METHODS

Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety.

RESULTS

AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors.

LIMITATIONS

Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments.

CONCLUSIONS

An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

Lifetime eating disorder comorbidity associated with delayed depressive recovery in bipolar disorder

Background

Although eating disorders (EDs) are common in bipolar disorder (BD), little is known regarding their longitudinal consequences. We assessed prevalence, clinical correlates, and longitudinal depressive severity in BD patients with vs. without EDs.

Methods

Outpatients referred to Stanford University BD Clinic during 2000–2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) affective disorders evaluation, and while receiving naturalistic treatment for up to 2 years, were monitored with the STEP-BD clinical monitoring form. Patients with vs. without lifetime EDs were compared with respect to prevalence, demographic and unfavorable illness characteristics/current mood symptoms and psychotropic use, and longitudinal depressive severity.

Results

Among 503 BD outpatients, 76 (15.1%) had lifetime EDs, which were associated with female gender, and higher rates of lifetime comorbid anxiety, alcohol/substance use, and personality disorders, childhood BD onset, episode accumulation (≥10 prior mood episodes), prior suicide attempt, current syndromal/subsyndromal depression, sadness, anxiety, and antidepressant use, and earlier BD onset age, and greater current overall BD severity. Among currently depressed patients, 29 with compared to 124 without lifetime EDs had significantly delayed depressive recovery. In contrast, among currently recovered (euthymic ≥8 weeks) patients, 10 with compared to 95 without lifetime EDs had only non-significantly hastened depressive recurrence.

Limitations

Primarily Caucasian, insured, suburban, American specialty clinic-referred sample limits generalizability. Small number of recovered patients with EDs limited statistical power to detect relationships between EDs and depressive recurrence.

Conclusions

Further studies are warranted to explore the degree to which EDs impact longitudinal depressive illness burden in BD.

Cognitive Psychophysiological Substrates of Affective Temperaments

Affective temperaments are the subclinical manifestations or phenotypes of mood states and hypothetically represent one healthy end of the mood disorder spectrum. However, there is a scarcity of studies investigating the neurobiological basis of affective temperaments. One fundamental aspect of temperament is the behavioral reactivity to environmental stimuli, which can be effectively evaluated by use of cognitive event-related potentials (ERPs) reflecting the diversity of information processing. The aim of the present study is to explore the associations between P300 and the affective temperamental traits in healthy individuals. We recorded the P300 ERP waves using an auditory oddball paradigm in 50 medical student volunteers (23 females, 27 males). Participants' affective temperaments were evaluated using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-auto questionnaire version (TEMPS-A). In bivariate analyses, depressive temperament score was significantly correlated with P300 latency ( r_s = 0.37, P < .01). In a multiple linear regression analysis, P300 latency showed a significant positive correlation with scores of depressive temperament (β = 0.40, P < .01) and a significant negative one with scores of cyclothymic temperament (β = -0.29, P = .03). Affective temperament scores were not associated with P300 amplitude and reaction times. These results indicate that affective temperaments are related to information processing in the brain. Depressive temperament may be characterized by decreased physiological arousal and slower information processing, while the opposite was observed for cyclothymic temperament.

Comparison of associated features and drug treatment between co-occurring unipolar and bipolar disorders in depressed eating disorder patients

BACKGROUND

To examine the differences of associated characteristics and prescription drug use between co-occurring unipolar and bipolar disorders in patients with eating disorders (EDs).

METHODS

Patients with EDs and major depressive episode (MDE) were recruited from psychiatric outpatient clinics. They were interviewed and completed self-administered measures assessing eating and general psychopathology. The prescribed drugs at the index outpatient visit were recorded. Clinical characteristics and prescription drugs of groups with major depressive disorder (ED-MDD), MDE with lifetime mania (ED-BP I), and MDE with lifetime hypomania (ED-BP II) were compared. Continuous variables between groups were compared using generalized linear regression with adjustments of age, gender, and ED subtype for pair-wise comparisons. Multivariate logistic regression with adjustments of age, gender, and ED subtype was employed to estimate adjusted odds ratios with 95% confidence intervals between groups.

RESULTS

Two hundred and twenty-seven patients with EDs had a current MDE. Among them, 17.2% and 24.2% experienced associated manic and hypomanic episodes, respectively. Bipolar I and II patients displayed significantly poorer weight regulation, more severe impulsivity and emotional lability, and higher rates of co-occurring alcohol use disorders than ED-MDD patients. ED-BP I patients were found to have the lowest IQ, poorest working memory, and the most severe depression, suicidality and functional impairment among all patients. Patients with ED-BP II shared affect and behavioral dysregulations with ED-BP I, but had less severe degrees of cognitive and functional impairments than ED-BP I. Patients with ED-BP I were significantly less likely than those in the ED-MDD and ED-BP II groups to be on antidepressant monotherapy, but a great rate (27%) of ED-BP I individuals taking antidepressant monotherapy had potential risk of mood switch during the course of treatment.

CONCLUSIONS

Our study identified discriminative features of bipolar I and II disorders from MDD among a group of depressed ED patients. We suggest that the associated mania, hypomania, and mood lability are predictors of clinical severity and should be identified from ED patients presented with depressive features. Accurate diagnosis of bipolar disorders may have implications for pharmacotherapy in patients with EDs.

Characteristics of depressive patients according to family history of affective illness: Findings from a French national cohort

BACKGROUND

Literature is scarce about the characteristics of mood disorder patients with a family history (FH) of affective illness. The aim of the current study was to compare the prominent features of depressive patients with a FH of mania (FHM), those of depressive patients with a FH of depression (FHD), and those of depressive patients with no FH of affective illness (FHO).

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 45 (9.1%) were classified as FHM, 210 (42.6%) as FHD, and 238 (48.3%) as FHO.

RESULTS

The main characteristics of FHM patients were a cyclothymic temperament, the presence of mixed features and diurnal variations of mood during depression, early sexual behaviour, a high number of mood episodes and hypomanic switches, high rates of suicide attempts and rapid cycling; diagnosis of bipolar disorder was more frequent in this group as well as comorbid obsessive compulsive disorder, posttraumatic stress disorder, bulimia, attention deficit/hyperactivity disorder and impulse control disorders. The FHD patients had more depressive temperament, generalized anxiety disorder, and anorexia nervosa. Compared to FHO, FHM and FHD showed an earlier age at onset, more comorbid anxiety disorders, as well as more psychotic features.

LIMITATIONS

The following are the limitations of this study: retrospective design, recall bias, and preferential enrolment of bipolar patients with a depressive predominant polarity.

CONCLUSIONS

In light of genetic studies conducted in affective disorder patients, our findings may support the hypothesis of genetic risks factors common to affective disorders and dimensions of temperament, that may extend to comorbid conditions specifically associated with bipolar or unipolar illness.

A genome-wide association study of bipolar disorder with comorbid eating disorder replicates the SOX2-OT region

BACKGROUND

Bipolar disorder is a heterogeneous mood disorder associated with several important clinical comorbidities, such as eating disorders. This clinical heterogeneity complicates the identification of genetic variants contributing to bipolar susceptibility. Here we investigate comorbidity of eating disorders as a subphenotype of bipolar disorder to identify genetic variation that is common and unique to both disorders.

METHODS

We performed a genome-wide association analysis contrasting 184 bipolar subjects with eating disorder comorbidity against both 1370 controls and 2006 subjects with bipolar disorder only from the Bipolar Genome Study (BiGS).

RESULTS

The most significant genome-wide finding was observed bipolar with comorbid eating disorder vs. controls within SOX2-OT (p=8.9×10(-8) for rs4854912) with a secondary peak in the adjacent FXR1 gene (p=1.2×10(-6) for rs1805576) on chromosome 3q26.33. This region was also the most prominent finding in the case-only analysis (p=3.5×10(-7) and 4.3×10(-6), respectively). Several regions of interest containing genes involved in neurodevelopment and neuroprotection processes were also identified.

LIMITATIONS

While our primary finding did not quite reach genome-wide significance, likely due to the relatively limited sample size, these results can be viewed as a replication of a recent study of eating disorders in a large cohort.

CONCLUSIONS

These findings replicate the prior association of SOX2-OT with eating disorders and broadly support the involvement of neurodevelopmental/neuroprotective mechanisms in the pathophysiology of both disorders. They further suggest that different clinical manifestations of bipolar disorder may reflect differential genetic contributions and argue for the utility of clinical subphenotypes in identifying additional molecular pathways leading to illness.

Emotional reactivity to social stimuli in patients with eating disorders

Patients with eating disorders often display a wide range of difficulties in psychosocial functioning. Most of the studies on this subject have focused on theory of mind; however, little is known about the subjective emotional reactivity of patients to social situations. The aim of this study was to evaluate the patients' perceptions of their own emotions when viewing pictures with social content. Emotional reactivity was assessed in 85 women (29 with anorexia nervosa, 28 with bulimia nervosa, and 28 healthy controls) by using 30 images from the International Affective Picture System. Images were divided into categories based on its social content and its emotional valence. The emotional response was evaluated through the Self-Assessment Manikin. Patients with bulimia nervosa presented higher arousal and lower control when viewing images with social content of pleasant, unpleasant, and neutral valence. Patients with anorexia nervosa reported higher arousal and lower control only for social images with neutral valence. There were no differences between groups for the control images. The finding of specific differences in emotional reactivity to pictures with social content contributes to a more accurate understanding of the difficulties of patients in social situations.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

Data emerging from both academic centers and from public and private outpatient facilities indicate that from 20% to 50% of all subjects that seek help for mood, anxiety, impulsive and addictive disorders turn out, after careful screening, to be affected by cyclothymia. The proportion of patients who can be classified as cyclothymic rises significantly if the diagnostic rules proposed by the DSM-5 are reconsidered and a broader approach is adopted. Unlike the DSM-5 definition based on the recurrence of low-grade hypomanic and depressive symptoms, cyclothymia is best identified as an exaggeration of cyclothymic temperament (basic mood and emotional instability) with early onset and extreme mood reactivity linked with interpersonal and separation sensitivity, frequent mixed features during depressive states, the dark side of hypomanic symptoms, multiple comorbidities, and a high risk of impulsive and suicidal behavior. Epidemiological and clinical research have shown the high prevalence of cyclothymia and the validity of the concept that it should be seen as a distinct form of bipolarity, not simply as a softer form. Misdiagnosis and consequent mistreatment are associated with a high risk of transforming cyclothymia into severe complex borderline-like bipolarity, especially with chronic and repetitive exposure to antidepressants and sedatives. The early detection and treatment of cyclothymia can guarantee a significant change in the long-term prognosis, when appropriate mood-stabilizing pharmacotherapy and specific psychological approaches and psychoeducation are adopted. The authors present and discuss clinical research in the field and their own expertise in the understanding and medical management of cyclothymia and its complex comorbidities.

Affective temperaments in subjects with female-to-male gender dysphoria

BACKGROUND

Males and females have different temperaments. In individuals with gender dysphoria (GD) there is marked incongruence between a person׳s expressed/experienced gender and their biological sex. The present study aimed to investigate the most common affective temperaments in individuals with female-to-male (FtM) GD.

METHODS

We performed a prospective and comparative study investigating affective temperaments in subjects with FtM GD. Eighty subjects with FtM GD and 68 female controls were enrolled. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) was completed by all participants.

RESULTS

TEMPS-A scores were significantly higher in subjects with FtM GD for hyperthymic temperament (p≤0.001), whereas depressive (p≤0.001), anxious (p≤0.001), and cyclothymic (p=0.028) temperament scores were significantly higher in female controls.

LIMITATIONS

The study was limited by the lack of male-to-female subjects and male controls.

CONCLUSIONS

The results of our study indicate that individuals with FtM GD have significantly higher scores of hyperthymic temperament, measured by TEMPS-A. Biological basis underlying the development of gender identity independent from the biological sex might be related with affective temperaments.

Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits

OBJECTIVE

To investigate distinguishing features between bipolar I, II and unipolar depression, and impulsivity/aggression traits in particular.

METHODS

Six hundred and eighty-five (n=685) patients in a major depressive episode with lifetime Unipolar (UP) depression (n=455), Bipolar I (BP-I) disorder (n=151), and Bipolar II (BP-II) (n=79) disorder were compared in terms of their socio-demographic and clinical characteristics.

RESULTS

Compared to unipolar patients, BP-I and BP-II depressed patients were significantly younger at onset of their first depressive episode, and were more likely to experience their first depressive episode before/at age of 15. They also had more previous affective episodes, more first- and second-degree relatives with history of mania, more current psychotic and subsyndromal manic symptoms, and received psychopharmacological and psychotherapy treatment at an earlier age. Furthermore, BP-I and BP-II depressed patients had higher lifetime impulsivity, aggression, and hostility scores. With regard to bipolar subtypes, BP-I patients had more trait-impulsivity and lifetime aggression than BP-II patients whereas the latter had more hostility than BP-I patients. As for co-morbid disorders, Cluster A and B Personality Disorders, alcohol and substance abuse/dependence and anxiety disorders were more prevalent in BP-I and BP-II than in unipolar patients. Whereas the three groups did not differ on other socio-demographic variables, BP-I patients were significantly more often unemployed that UP patients.

CONCLUSION

Our findings comport with major previous findings on differences between bipolar and unipolar depression. As for trait characteristics, bipolar I and II depressed patients had more life-time impulsivity and aggression/hostility than unipolar patients. In addition, bipolar I and II patients also differed on these trait characteristics.

Suicidal behavior in adolescents and adults with bulimia nervosa

BACKGROUND

Recent evidence suggests increased risk for mortality in bulimia nervosa (BN). However, little is yet known about suicidal behavior in BN.

AIMS

To examine frequency and correlates of suicidal ideation and attempts in adolescents and adults with BN in two population-based samples.

METHOD

A total of 10,123 adolescents and 2980 adults in two nationally representative surveys of mental disorder were queried regarding eating disorder symptoms and suicidal ideation and attempts.

RESULTS

Less than 1 percent (0.9%) of adolescents and 1.0% of adults met the criteria for BN. Suicidal ideation was more common among adolescents with BN (53.0%) compared with those with binge eating disorder (BED) (34.4%), other psychopathology (21.3%) or no psychopathology (3.8%). Similar trends emerged for the association between BN and self-reported suicidal plans or attempts. Among adults, suicidality was more common in BN than in the no psychopathology group, but not significantly different from the anorexia nervosa (AN), BED, or other psychopathology subgroups.

CONCLUSION

There is a high risk of suicidal ideation and behavior among those with BN. These results underscore the importance of addressing suicide risk in adolescents and adults with eating disorder symptoms.

The effects of ethnic, social and cultural factors on axis I comorbidity of bipolar disorder: results from the clinical setting in Korea

OBJECTIVE

Ethnic, social and cultural factors contribute to axis I comorbid conditions in bipolar disorder (BPD). Korea has strict laws against illicit drugs and a relatively permissive prevailing attitude toward alcohol. The present study aimed to explore the lifetime axis I comorbidity rate in patients with BPD in Korea.

METHODS

Clinically stable patients with bipolar I (n=222) and bipolar II (n=194) disorders were recruited from four tertiary medical centers in Korea. The subjects׳ diagnoses and axis I comorbid conditions were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Korean version of the Diagnostic Interview for Genetic Studies (K-DIGS). The lifetime prevalence of anxiety disorders, substance use disorders and eating disorders was explored. The prevalence of these axis I comorbid conditions was compared with data from prior studies in other countries and to data concerning the general Korean population.

RESULTS

A total of 45.1% of all subjects had at least one axis I comorbid condition. Anxiety disorders (30.2%) were the most common comorbidity, followed by alcohol use disorders (16.8%). Males with BPD showed a higher rate of alcohol dependence compared to the general male population and females with BPD showed a greater risk of having alcohol use disorder compared to the general female population. The rate of drug use disorder was extremely low (1.7%), and only one subject had an illicit-drug-related problem.

LIMITATION

Cross-sectional studies.

CONCLUSION

Comorbid conditions of Korean patients with BPD showed a distinct pattern, which is associated with the ethnic, social and cultural characteristics in Korea.

Temperamental dimensions of the TEMPS-A in females with co-morbid bipolar disorder and bulimia

OBJECTIVES

We investigated the effect of co-morbid bipolar disorder and bulimia on temperamental dimensions measured by TEMPS-A, relative to "pure" bulimia and "pure" bipolar disorder, in female patients.

METHODS

The study was performed on 47 patients with bipolar disorder (BD) with a mean age of 36±10 years, 96 patients with bulimia or bulimic type of anorexia, mean age 26±9 years and 50 control healthy females (HC), mean age 29±6 years. Among bulimic patients, a group of 68 subjects with co-morbid bulimia with bipolarity (BD+B) was identified, based on positive score of the Mood Disorder Questionnaire (MDQ). The TEMPS-A questionnaire, 110 questions version, has been used, evaluating five temperament domains: depressive, cyclothymic, hyperthymic, irritable and anxious. Parametric analysis was performed for 4 groups (BD, "pure" bulimia (PB), BD+B and HC), with 28 subjects randomly chosen from each group, using analysis of variance and cluster analysis.

RESULTS

All clinical groups significantly differed from control group by having higher scores of depressive, cyclothymic, irritable and anxious temperaments and lower of hyperthymic one. Among patients, significantly higher scores of cyclothymic and irritable temperaments were found in BD+B compared to both PB and BD. These differences were also reflected in cluster analysis, where two clusters were identified.

LIMITATIONS

Bipolarity in bulimic patients assessed only by the MDQ.

CONCLUSIONS

These results show that co-morbid bulimia and bipolar disorder is characterized by extreme dimensions of both cyclothymic and irritable temperaments, significantly higher than each single diagnosis. Possible clinical implications of such fact are discussed.

Bipolar disorder with seasonal pattern: clinical characteristics and gender influences

Bipolar disorder (BD) has a multifactorial etiology with heterogeneous clinical presentations. Around 25% of BD patients may present with a depressive seasonal pattern (SP). However, there are limited scientific data on the prevalence of SP, its clinical manifestations, and any gender influence. Four hundred and fifty-two BD I and II cases (62% female), recruited from three French university-affiliated psychiatric departments, were assessed for SP. Clinical, treatment, and sociodemographic variables were obtained from structured interviews. One hundred and two (23%) cases met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for SP, with similar frequency according to gender. Multivariate analysis showed a significant association between SP and BD II (odds ratio [OR] = 1.99, p = 0.01), lifetime history of rapid cycling (OR = 2.05, p = 0.02), eating disorders (OR = 2.94, p = 0.003), and total number of depressive episodes (OR = 1.13, p = 0.002). Seventy-one percent of cases were correctly classified by this analysis. However, when stratifying the analyses by gender, SP was associated with BD II subtype (OR = 2.89, p = 0.017) and total number of depressive episodes (OR = 1.21, p = 0.0018) in males but with rapid cycling (OR = 3.02, p = 0.0027) and eating disorders (OR = 2.60, p = 0.016) in females. This is the first study to identify different associations between SP and clinical characteristics of BD according to gender. The authors suggest that SP represents a potentially important specifier of BD. These findings indicate that seasonality may reflect increased severity or complexity of disorder.

Lifetime and recent DSM and ICD psychiatric comorbidity of inpatients engaging in different eating disorder behaviours

OBJECTIVE

Previous studies investigating psychiatric comorbidity in eating disorder (ED) patients compared groups according to ED diagnoses. The current paper compared groups according to ED behaviours: self-induced vomiting, objective binge eating, excessive exercising, and to body mass index (BMI, kg/m(2)) for selected psychiatric comorbidity using two systems: Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) and International Classification of Diseases - Tenth Revision (ICD-10) diagnoses.

METHOD

Two hundred and twenty-six patients admitted for treatment in a specialised Eating Disorders Unit completed the Composite International Diagnostic Interview (CIDI). Lifetime and recent (12 months) psychiatric diagnoses were produced according to DSM-IV and ICD-10. Associations between presence of ED behaviours or BMI and psychiatric comorbidity were investigated.

RESULTS

Eighty-eight percent of patients had a lifetime history (72% recent history) of at least one comorbid diagnosis (regardless of diagnostic system). Agreement between the systems was high for mood (affective) disorders and moderate for anxiety/somatoform disorders. Significantly more patients who vomit had lifetime and recent mood (affective) disorders (DSM-IV and ICD-10). Significantly more 'vomiters' had recent anxiety disorders (DSM-IV) and neurotic, stress-related and somatoform disorders (ICD-10) including post-traumatic stress disorder (PTSD; DSM-IV and ICD-10). More patients with BMI >17.5 kg/m(2) had lifetime and recent mood (affective) disorders and lifetime PTSD (DSM-IV and ICD-10). The results for 'excessive exercisers' varied and appeared inconsistent. There were no differences in any disorders for objective binge eaters.

DISCUSSION

Patients who induce vomiting have more psychiatric comorbidity than 'non-vomiters', both lifetime and recent, and may benefit from diagnostic recognition as a separate group, for example 'vomiting' or 'purging' ED, who can then receive specialist treatment for their comorbidity and associated problems.

Differences between bipolar I and bipolar II disorders in clinical features, comorbidity, and family history

BACKGROUND

The present study was designed to investigate whether bipolar II disorder (BP-II) has different characteristics from bipolar I disorder (BP-I), not only in manic severity but also in clinical features, prior course, comorbidity, and family history, sufficiently enough to provide its nosological separation from BP-I.

METHODS

Comprehensive clinical evaluation was performed based on information available from ordinary clinical settings. Seventy-one BP-I and 34 BP-II patients were assessed using the Diagnostic Interview for Genetic Studies, Korean version. Psychiatric assessment for first-degree relatives (n=374) of the probands was performed using the modified version of the Family History-Research Diagnostic Criteria.

RESULTS

The frequency of depressive episodes was higher in BP-II (p=0.009) compared to BP-I. Further, seasonality (p=0.035) and rapid-cycling course (p=0.062) were more common in BP-II. Regarding manic expression, 'elated mood' was predominant in BP-II whereas 'elated mood' and 'irritable mood' were equally prevalent in BP-I. With regard to depressive symptoms, psychomotor agitation, guilty feeling, and suicidal ideation were more frequently observed in BP-II. BP-II patients exhibited a higher trend of lifetime co-occurrence of an axis I diagnosis (p=0.09), and a significantly higher incidence of phobia and eating disorder. The overall occurrence rate of psychiatric illness in first-degree relatives was 15.4% in BP-I and 26.5% in BP-II (p=0.01). Major depression (p=0.005) and substance-related disorder (p=0.051) were more prevalent in relatives of BP-II probands.

CONCLUSION

Distinctive characteristics of BP-II were identified in the current study and could be adopted to facilitate the differential diagnosis of BP-I and BP-II in ordinary clinical settings.

Current research on affective temperaments

PURPOSE OF REVIEW

The aim of this review is to highlight the relationship between affective temperaments and clinical mood disorders and to summarize the earlier and most recent studies on affective temperaments in both clinical and nonclinical populations.

RECENT FINDINGS

Current research findings show that specific affective temperament types (depressive, cyclothymic, hyperthymic, irritable and anxious) are the subsyndromal (trait-related) manifestations and commonly the antecedents of minor and major mood disorders. Up to 20% of the population has some kind of marked affective temperaments; depressive, cyclothymic and anxious temperament is more frequent in women, whereas hyperthymic and irritable temperaments predominate among men. Molecular genetic studies show a strong involvement of the central serotonergic (depressive, cyclothymic, irritable and anxious temperaments) and dopaminergic (hyperthymic temperament) regulation, suggesting that the genetic potential of major mood episodes lies in these temperaments.

SUMMARY

Premorbid affective temperament types have an important role in the clinical evolution of minor and major mood episodes including the direction of the polarity and the symptom formation of acute mood episodes. They can also significantly affect the long-term course and outcome including suicidality and other forms of self-destructive behaviours such as substance use and eating disorders.