Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders

Brain Structural and Functional Damage Network Localization of Suicide

BACKGROUND

Extensive neuroimaging research on brain structural and functional correlates of suicide has produced inconsistent results. Despite increasing recognition that damage in multiple different brain locations that causes the same symptom can map to a common brain network, there is still a paucity of research investigating network localization of suicide.

METHODS

To clarify this issue, we initially identified brain structural and functional damage locations in relation to suicide from 63 published studies with 2135 suicidal and 2606 nonsuicidal individuals. By applying novel functional connectivity network mapping to large-scale discovery and validation resting-state functional magnetic resonance imaging datasets, we mapped these affected brain locations to 3 suicide brain damage networks corresponding to different imaging modalities.

RESULTS

The suicide gray matter volume damage network comprised widely distributed brain areas primarily involving the dorsal default mode, basal ganglia, and anterior salience networks. The suicide task-induced activation damage network was similar to but less extensive than the gray matter volume damage network, predominantly implicating the same canonical networks. The suicide resting-state activity damage network manifested as a localized set of brain regions encompassing the orbitofrontal cortex and middle cingulate cortex.

CONCLUSIONS

Our findings not only may help reconcile prior heterogeneous neuroimaging results, but also may provide insights into the neurobiological mechanisms of suicide from a network perspective, which may ultimately inform more targeted and effective strategies to prevent suicide.

The mediation effects of nightmares and depression between insomnia and suicidal ideation in young adults

Suicide is prevalent among young adults, and epidemiological studies indicate that insomnia, nightmares, and depression are significantly associated with a high incidence of suicidal ideation (SI). However, the causal relationship between these factors and SI remains unclear. Therefore, the purpose of this study was to examine the association between nightmares and depression and insomnia and SI in young adults, as well as to develop a mediation model to investigate the causal relationship between insomnia, nightmare, depression, and SI. We assessed insomnia, nightmares, depression, and SI in 546 young adults using the Insomnia Severity Scale (ISI), Disturbing Dream and Nightmare Severity Scale (DDNSI), Depression Study Scale (CESD-20), and Columbia-Suicide Severity Rating Scale (C-SSRS). Using the Bootstrap method, the mediation effects of nightmares and depression between insomnia and SI were calculated. The results demonstrated that nightmares and depression fully mediated the relationship between insomnia and SI, including the chain-mediation of insomnia and SI between nightmare and depression with an effect value of 0.02, 95% CI 0.01-0.04, and depression as a mediator between insomnia and SI with an effect value of 0.22, 95% CI 0.15-0.29. This study found that depression and nightmares may be risk and predictive factors between insomnia and SI, which implies that the assessment and treatment of depression and the simple or linked effect of nightmares play crucial roles in preventing SI in young adults.

The Types of Psychosocial Factors Associated with Suicidality Outcomes for People Living with Bipolar Disorder: A Scoping Review

Bipolar Disorder is associated with high rates of suicidal thoughts, behaviors, and outcomes, yet the lived experience of suicidality and Bipolar Disorder is not particularly well understood. Understanding the role of psychosocial aetiologies in suicidality outcomes for those living with Bipolar Disorder is key for developing appropriately targeted interventions focusing on factors that are amenable to change. In line with PRISMA guidance, we conducted a scoping review to identify the types of psychosocial factors studied in relation to the experience of suicidality for people living with Bipolar Disorder diagnoses. Systematic literature searches identified a sample of 166 articles from which key study data were extracted and charted. A narrative synthesis of the reviewed literature is presented ordered by the factors investigated across studies, a frequency count of the types of psychological/social aetiologies studied, and a brief overview of the key findings for each aetiology. Most of the identified literature took the form of quantitative cross-sectional studies, with only one qualitative study and 18 quantitative prospective studies. The most studied aetiologies were trauma (specifically early adverse experiences and childhood traumas) and stressful life events, impulsivity (primarily subjective self-reported trait impulsivity), social support and functioning, and personality/temperament factors. Only six studies in the final sample reported basing their research questions and/or hypotheses on an explicit theoretical model of suicide. The literature was primarily focused on using self-report measurements of key aetiologies and on factors which lead to worsened suicidality rather than focusing on potentially protective or buffering factors. Future research needs to better justify the aetiologies investigated in relation to suicidality outcomes for people living with Bipolar Disorder, including a firmer basis in theory and hypothesis testing, more prospective designs, and the use of alternative assessments of psychosocial aetiologies in addition to self-report questionnaires.

Indirect effect of impulsivity on suicide risk through self-esteem and depressive symptoms in a population with treatment-resistant depression: A FACE-DR study

INTRODUCTION

Suicide is a major health issue. Its prevalence is particularly high in subjects presenting major depression disorder (MDD), making this a key suicide-related risk factor. Suicide attempts in severe forms of MDD were assumed to be linked to impulsivity and loss of control. Nevertheless, we failed to find data specifically investigating the link between impulsivity and suicide risk in treatment-resistant depression (TRD). This study seeks to review this relationship.

METHOD

Patients were recruited for a prospective cohort. Suicide risk and impulsivity were assessed using the International Neuropsychiatric Interview and Barratt Impulsiveness Scale, Version 10, respectively, while the severity of depressive symptoms was assessed using the Montgomery-Asberg Depression Rating Scale, anxiety with the State-Trait Anxiety Inventory and childhood maltreatment using the Childhood Trauma Questionnaire.

RESULTS

220 TRD patients were enrolled in the study. The impulsivity score was correlated with self-esteem, marital status, professional status and anxiety. There was no direct link to suicide risk. However, impulsivity was associated with self-esteem (coefficient: -0.24; p value 0.043) and depressive symptom severity (coefficient: 0.; p value 0.045). The suicide risk was significantly correlated with depressive symptom severity (coefficient = 0.38, p < 0.001) and self-esteem (coefficient = -0.34, p = 0.01). Considering these correlations, we postulated that the effect of impulsivity on suicide risk could be mediated by self-esteem in terms of depressive symptom severity and we finally found a relevant mediation model within impulsivity having an indirect effect on suicide risk by impacting self-esteem and depressive symptoms with anxiety also playing a significant role as a covariable.

CONCLUSION

We found that impulsivity could play an indirect role with the involvement of self-esteem and depressive symptoms and the contributing role of anxiety.

Neuroanatomical and functional substrates of the hypomanic personality trait and its prediction on aggression

Hypomanic personality manifests a close link with several psychiatric disorders and its abnormality is a risk indicator for developing bipolar disorders. We systematically investigated the potential neuroanatomical and functional substrates underlying hypomanic personality trait (HPT) and its sub-dimensions (i.e., Social Vitality, Mood Volatility, and Excitement) combined with structural and functional imaging data as well as their corresponding brain networks in a large non-clinical sample across two studies (n = 464). Behaviorally, HPT, specifically Mood Volatility and Excitement, was positively associated with aggressive behaviors in both studies. Structurally, sex-specific morphological characteristics were further observed in the motor and top-down control networks especially for Mood Volatility, although HPT was generally positively associated with grey matter volumes (GMVs) in the prefrontal, temporal, visual, and limbic systems. Functionally, brain activations related to immediate or delayed losses were found to predict individual variability in HPT, specifically Social Vitality and Excitement, on the motor and prefrontal-parietal cortices. Topologically, connectome-based prediction model analysis further revealed the predictive role of individual-level morphological and resting-state functional connectivity on HPT and its sub-dimensions, although it did not reveal any links with general brain topological properties. GMVs in the temporal, limbic (e.g., amygdala), and visual cortices mediated the effects of HPT on behavioral aggression. These findings suggest that the imbalance between motor and control circuits may be critical for HPT and provide novel insights into the neuroanatomical, functional, and topological mechanisms underlying the specific temperament and its impacts on aggression.

Clinical assessment of impulsiveness and defence mechanisms in young patients with mood disorders in a two-year prospective study

AIM

There have been limited prospective investigations of early clinical markers involved in mood regulation and diagnosis change in young patients. This study aimed to evaluate the changes in impulsivity and defence mechanisms in patients with major depressive disorder (MDD) and bipolar disorder (BD) with acute symptoms and remission compared to healthy controls (HC), and possible psychological predictors of diagnosis conversion.

METHODS

Seventy-nine young MDD or BD patients and 40 HC were enrolled in a two-year prospective study. A comprehensive clinical interview focused on clinical and psychological evaluation during follow-up visits. The severity of depressive symptoms was evaluated using the Hamilton Depression Rating Scale (HDRS-17), whilst the Young Mania Rating Scale (YMRS) was used for hypo/manic symptoms during each control visit. All patients completed the Defence Style Questionnaire (DSQ-40) and Barratt Impulsiveness Scale (BIS-11).

RESULTS

Patients used more immature defences, and had significantly higher total impulsivity scores than controls. BD patients had elevated motor and non-planning impulsivity compared with HC and MDD subjects. Total and non-planning impulsiveness remained elevated in euthymia in BD and MDD compared to HC. There were no statistically significant differences in total defence styles and impulsiveness scores at baseline vs. euthymia in MDD or BD patients groups. Significantly higher dissociation scores at baseline discriminated depressive patients who convert to BD in their diagnosis.

CONCLUSIONS

Patients with acute mood symptoms used more frequent immature defences and had significantly higher total impulsivity scores than healthy persons. A lack of differences in total defence styles and impulsiveness between patients with acute symptoms and after reaching euthymia in both MDD and BD groups indicates that they are independent of disease status. Dissociation defence mechanisms may be an early diagnostic indicator of BD.

Serial mediation of the relationship between impulsivity and suicidal ideation by depression and hopelessness in depressed patients

BACKGROUND

Close relationships have been observed among impulsivity, depression, hopelessness, and suicidal ideation in depressed patients. However, the precise mechanism that connects these psychological symptoms remains unclear. This study aims to explore the mediation effect of depression and hopelessness on the relationship between impulsivity and suicidal ideation in depressed patients.

METHODS

A total of 258 depressed patients were evaluated using the Hamilton Depression Scale, the Beck Hopelessness Scale, the Scale for Suicide Ideation, and the Barratt Impulsiveness Scale. A path analysis was afterwards performed to determine the specified relationships in the proposed model.

RESULTS

The relationship between impulsivity and suicidal ideation was found to be serially mediated by depression and hopelessness. The mediating effect of depression and hopelessness accounted for 26.59% of the total effect. Specifically, in the pathway from impulsivity to hopelessness, the mediating effect of depression accounted for 40.26%. Moreover, the relationship between impulsivity and suicidal ideation was mediated by hopelessness, with the mediating effect accounting for 12.41%. It is important to note that these relationships were observed to be independent of age and marital status. Furthermore, the proposed model demonstrated a good fit with the data.

CONCLUSIONS

This study identified a serial mediation pathway between impulsivity and suicidal ideation, mediated by depression and hopelessness. Our findings indicate that impulsivity indirectly influences suicidal ideation through its association with depression, which subsequently contributes to feelings of hopelessness. These results emphasize the importance of addressing symptoms of depression and hopelessness in the prevention and intervention efforts targeting individuals with depression. Additionally, monitoring and addressing impulsivity levels may also be crucial in reducing the risk of suicidal ideation among this population. These findings provide valuable insights for future preventive programs and interventions aimed at mitigating suicidal ideation in individuals with depression.

Fight the Fire: Association of Cytokine Genomic Markers and Suicidal Behavior May Pave the Way for Future Therapies

The fight against suicide is highly challenging as it may be one of the most complex and, at the same time, most threatening among all psychiatric phenomena. In spite of its huge impact, and despite advances in neurobiology research, understanding and predicting suicide remains a major challenge for both researchers and clinicians. To be able to identify those patients who are likely to engage in suicidal behaviors and identify suicide risk in a reliable and timely manner, we need more specific, novel biological and genetic markers/indicators to develop better screening and diagnostic methods, and in the next step to utilize these molecules as intervention targets. One such potential novel approach is offered by our increasing understanding of the involvement of neuroinflammation based on multiple observations of increased proinflammatory states underlying various psychiatric disorders, including suicidal behavior. The present paper overviews our existing understanding of the association between suicide and inflammation, including peripheral and central biomarkers, genetic and genomic markers, and our current knowledge of intervention in suicide risk using treatments influencing inflammation; also overviewing the next steps to be taken and obstacles to be overcome before we can utilize cytokines in the treatment of suicidal behavior.

Affective temperaments mediate aggressive dimensions in bipolar disorders: A cluster analysis from a large, cross-sectional, international study

BACKGROUND

Affective temperaments show potential for aggressive behavior (AB) preventive strategies in bipolar disorder (BD). We aim to define intra-diagnostic subgroups of patients with BD based on homogeneous behaviors related to AB. Subsequently, to assess whether affective temperament dimensions may contribute to the presence and severity of AB.

METHODS

Patients with BD were recruited. AB was evaluated through the modified overt aggression scale (MOAS); affective temperaments were assessed with the TEMPS-A. A cluster analysis was conducted based on TEMPS-A and MOAS scores. Stepwise backward logistic regression models were used to identify the predictive factors of cluster membership.

RESULTS

799 patients with BD were enrolled. Three clusters were determined: non-aggressive (55.5 %), self-aggressive (18 %), and hetero-aggressive (26.5 %). Depressive, irritable, and anxious temperament scores significantly increased from the non-aggressive (lower) to the self-aggressive (intermediate) and the hetero-aggressive group (highest). A positive history of a suicide attempt (B = 5.131; OR = 169.2, 95 % CI 75.9; 377) and rapid cycling (B = -0.97; OR = 0.40, 95 % CI 0.17; 0.95) predicted self-aggressive cluster membership. Atypical antipsychotics (B = 1.19; OR = 3.28, 95 % CI 2.13; 5.06) or SNRI treatment (B = 1.09; OR = 3, 95 % CI 1.57; 5.71), psychotic symptoms (B = 0.73; OR = 2.09, 95 % CI 1.34; 3.26), and history of a suicide attempt (B = -1.56; OR = 0.20, 95 % CI 0.11; 0.38) predicted hetero-aggressive cluster membership.

LIMITATIONS

Recall bias might have affected the recollection of AB.

CONCLUSIONS

Clinical factors orientate the prevention of different ABs in BD. Affective temperaments might play a role in preventing AB since patients with more pronounced affective temperaments might have an increased risk of showing AB, in particular hetero-AB.

Impulsivity and aggression in suicide ideators and suicide attempters of high and low lethality

BACKGROUND

Impulsivity and aggression have been associated with all forms of suicidal behaviour and linked to theories of suicide capability. There is a need to clarify the role of impulsivity and aggression in the progression from suicidal thoughts to suicide attempts and suicide.

METHOD

In this naturalistic cross-sectional study, suicide ideators (35), low lethal suicide attempters (37), and high lethal suicide attempters (26) were compared with the Columbia-suicide severity rating scale (C-SSRS), Barratt impulsiveness scale (BIS-11), and the Buss & Perry aggression questionnaire (AQ).

RESULTS

Physical aggression score (p = 0.032) contributed to the difference between predicted low lethal suicide attempt and predicted high lethal suicide attempt. This model predicting physical aggression showed a fairly weak positive relationship (OR = 1.1) to high lethal attempt and explained 13% of the variance so there is a need for further replications to verify these results. Impulsive behaviour scores in females were significantly higher in the low lethal suicide attempt group compared to suicide ideators (F(2.51) = 3.47, p = 0.039, η²= 0.12). Hostility aggression in females was significantly higher in the high lethal suicide attempters compared to suicide ideators (F(2.52) = 3.53, p = 0.037, η² = 0.12). Physical aggression scores in females were significantly higher in the high lethal attempters compared to suicide ideators (F(2.52) = 6.79, p = 0.002, η²= 0.21). When these analyses were conducted without the participants who died in suicide, men in the high lethal attempt group scored significantly higher than men in the low lethal attempt group (F(2.37) = 3.8, p = 0.031, η² = 0.17), but men did not differ in aggression and impulsivity scores in other comparisons.

CONCLUSION

Suicide prevention should address physical aggression, as high levels can be associated with high lethal attempts. Assessment of suicidal patients should address impulsive behaviour with the insight that it can be more prominent in female low lethal suicide attempters. It could be that assessment and treatment of suicidal patients should be tailored differently for men and women. Aggression as a feature of suicide capability could be the link that makes suicide possible.

Common and differential risk factors behind suicidal behavior in patients with impulsivity-related disorders: The case of bulimic spectrum eating disorders and gambling disorder

BACKGROUND AND AIMS

Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD.

METHODS

A total of 6,077 adults who sought treatment and met criteria either for BSED (n = 2,391) or GD (n = 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated.

RESULTS

The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD.

DISCUSSION

Patients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder.

CONCLUSIONS

Interventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders.

Prevalence and determinants of aggressive behavior among adults with problematic substance use in Northwest Ethiopia: a cross-sectional survey

BACKGROUND

The recent WHO data reported that a high treatment gap for behavioral illnesses (70%) in low- and- middle-income countries and the mortality rate of aggressive behavior reaches up to 32.1 per 100,000 populations in the region. However, the magnitude of aggressive behavior is not well stated in resource-limited settings. Therefore, the aim of this study was to assess the prevalence and determinant factors of aggressive behavior among adults with problematic substance use in northwest Ethiopia.

METHODS

A community-based cross-sectional study was employed from January to March 2019. A multi-stage cluster sampling method was used to screen a total of 4028 adults for problematic substance use by using the Cutdown, Annoyed, Guilty, and Eye-opener questionnaire (CAGE AID). Finally, 838 participants were positive for problematic substance use and interviewed for aggressive behavior using a modified overt aggression scale. Multiple logistic regression analysis was used to show the adjusted odds ratios (AOR) and p-value < 0.05 considered statistically significant. A multilevel binary logistic regressions model was employed for the hierarchical structure of two-level data for the individual and woreda/district levels.

RESULTS

The prevalence of aggressive behavior was found to be 37.9% (301/795, 95% CI: 34.5, 41.3). Stressful life events (AOR = 2.209, 95 CI; 1.423, 3.429), family history of mental illness (AOR = 4.038, 95 CI; 2.046, 7.971), comorbid physical illness (AOR = 2.01, 95 CI; 1.332, 3.032) and depressive symptoms (AOR = 2.342, 95 CI; 1.686, 3.253) were associated with aggressive behavior among individual with problem substance use.

CONCLUSION

Aggressive behavior was found to be high among problematic substance uses. An individual with problematic substance use is recommended to be screened by health extension workers for aggressive behavior at the community level.

Suicidal Ideation in Bipolar Disorder: The Relation with Clinical and Sociodemographic Variables

INTRODUCTION

Bipolar disorder (BD) has the highest risk of suicide among all mental disorders. Thus, identifying factors related to suicidal ideation is essential for a better assessment of the risk of suicide in BD.

OBJECTIVE

To analyze the relationship between suicidal ideation and clinical and sociodemographic characteristics in BD patients.

METHOD

This is a cross-sectional study that included eighty individuals with BD. Information regarding sociodemographic data and history of attempted suicide were collected, and the Hamilton Depression Scale, Young Mania Rating Scale, Positive And Negative Syndrome Scale/positive symptom subscale, Clinical Global Impressions Scale for use in bipolar illness, Insight Scale for Affective Disorders, and Barratt Impulsiveness Scale were administered. The presence and severity of suicidal ideation were assessed using the Beck Scale for Suicidal Ideation.

RESULTS

All regression models significantly predicted suicidal ideation. In the model that had the lowest AIC score and the highest cross-validity, the severity of depressive and of manic symptoms (standardized β = 0.49, p < 0.001; standardized β = 0.42, p = 0.007), the insight level (standardized β = - 0.38, p = 0.012) and previous suicide attempt (standardized β = 0.20, p = 0.036) acted as predictors of suicidal ideation, while degree of impulsivity (β standardized = 0.13, p = 0.229) and educational level (standardized β = - 0.16, p = 0.108) did not give a significant contribution.

CONCLUSION

According to our results, more severe depression and mania symptoms, higher level of insight and a history of suicide attempt indicate the occurrence of suicidal ideation in BD.

Rethinking "aggression" and impulsivity in bipolar disorder: Risk, clinical and brain circuitry features

BACKGROUND

Elevated aggression and impulsivity are implicated in Bipolar Disorder (BD); however, relationships between these behavioral constructs have not been clarified, which can lead to misconceptions with negative consequences including stigma and adverse outcomes including suicide. The study aimed to clarify brain-based distinctions between the two constructs and their associations to risk factors, symptoms and suicide thoughts and behaviors.

METHODS

Self-rated Brown-Goodwin Aggression (BGA) and Barratt Impulsiveness Scale (BIS) scores were compared between adults with BD (n = 38, 74% female) and healthy controls (HC, n = 29, 64% female). Relationships were examined between BGA and BIS with childhood trauma questionnaire (CTQ), mood, comorbidities, and magnetic resonance imaging gray matter volume (GMV) assessments.

RESULTS

In BD, BGA and BIS total scores were both elevated and associated with childhood maltreatment (CM), particularly emotional CM, depression, substance use disorders (SUDs) and suicide attempts (SAs). BGA scores were increased by items corresponding to dysregulation of emotional and social behavior and associated with elevated mood states and suicide ideation and GMV decreases in bilateral orbitofrontal cortex and left posterior insula brain regions, previously associated with these behaviors and clinical features. BIS motor impulsiveness scores were associated with GMV decreases in anterior cingulate cortex implicated in mood and behavioral dyscontrol.

LIMITATIONS

modest sample size, self-reports CONCLUSIONS: The findings suggest separable brain-based domains of dysfunction in BD of motor impulsiveness versus emotionally dysregulated feelings that are primarily self-directed. Both domains are associated with suicide behavior and modifiable risk factors of CM, depression and SUDs that could be targeted for prevention.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Sleep and circadian rhythm actigraphy measures, mood instability and impulsivity: A systematic review

The normal spectrum trait measures of mood instability and impulsivity are implicated in and comprise core symptoms of several psychiatric disorders. A bidirectional relationship between these traits and sleep disturbance and circadian rhythm dysfunction has been hypothesised, although has not been systematically assessed using objective measures in naturalistic settings. We systematically reviewed the literature following PRISMA guidelines, according to a pre-registered protocol (PROSPERO: CRD 42018108213). Peer-reviewed quantitative studies assessing an association between actigraphic variables and any measure of mood instability or impulsivity in participants aged 12-65 years old were included. Studies were critically appraised using the AXIS tool. Twenty-three articles were retained for inclusion. There was significant heterogeneity in the selection and reporting of actigraphic variables and metrics of mood instability and impulsivity. We identified emerging evidence of a positive association between circadian rest-activity pattern disturbance and delayed sleep timing with both mood instability and impulsivity. Evidence for an association with sleep duration, sleep efficiency or sleep quality was inconsistent. Future research should focus on longitudinal intra-individual associations to establish the directionality between these measures and may lead to the development of chronotherapeutic interventions for a number of psychiatric disorders.

Behaviors of Concern after Acquired Brain Injury: The Role of Negative Emotion Recognition and Anger Misattribution

OBJECTIVE

Behavioral changes are common after acquired brain injury (ABI) and may be caused by social cognition impairments. We investigated whether impaired emotion recognition, specifically Negative Emotion Recognition (NER) and Anger Misattribution (AM), after ABI was related to behavioral problems, so-called Behaviors of Concern (BoC).

METHOD

The study included 139 participants with ABI and 129 healthy controls. BoC was measured using four scales of the Brock Adaptive Functioning Questionnaire (BAFQ): Impulsivity, Aggression, Social Monitoring, and Empathy. Both self-ratings and informant ratings of BoC were obtained. Emotion recognition was measured with the Ekman 60 Faces Test (FEEST). A NER score was composed of the summed scores on Anger, Disgust, Fear, and Sadness. An AM score was composed of the number of facial expressions wrongly recognized as Anger.

RESULTS

Total FEEST scores in ABI participants were significantly worse than in healthy controls. The effect size is moderate. Informants rated significantly more problems in Social Monitoring and Empathy than participants. Effect sizes were small. Scores on FEEST total, NER, and AM were significantly correlated to informant ratings of Social Monitoring. Correlations were weak to moderate.

CONCLUSIONS

Worse NER and more profound AM were related to more informant-rated problems in social monitoring. In addition, informants rated more problems in social monitoring and empathy than participants. This strongly suggests problems in self-awareness in ABI participants. Consequently, social cognition tests and informant ratings should be used in clinical practice to improve the detection and treatment of BoC after ABI.

[Suicidal behaviors in bipolar disorder type 1]

OBJECTIVES

Bipolar disorder is one of the most common and severe psychiatric conditions. It is frequently complicated by suicidal behaviors, and patients with BD are among those at higher risk of suicide. The aims of our study were to evaluate the predictive factors of suicidal behaviors in patients with BD type 1, through the assessment of their socio-demographic, clinical and evolutionary characteristics as well as to study the implications of the childhood traumas and impulsivity as predictive factors for suicidal behaviors in these patients with bipolar disorder.

METHODS

One hundred patients with bipolar disorder type 1were recruited in order to conduct a cross-sectional, analytical and comparative study. The recruitment involved a first group made up of 40 patients suffering from type 1 bipolar disorder with a history of suicidal acts. This group was compared with a second group made up of 60 patients with no history of attempted suicide. We used a pre-established collection sheet for collecting socio-demographic, clinical and therapeutic data. We also used the Childhood Trauma Questionnaire for the assessment of childhood adversities, the Barratt Impulsivity Scale in its eleventh version for the assessment of impulsivity levels and the Global Assessment of Functioning Scale for the evaluation of overall functioning.

RESULTS

The suicidal behaviors in patients with bipolar disorder were significantly associated with: female gender (P<0.001), professional instability (P=0.002), family history of BD (P=0.02), family history of other psychiatric disorders (P=0.003), frequency of depressive episodes (P=0.002), shorter remission (P=0.025), more subsyndromal symptoms (P=0.029), sexual abuse dimension (P=0.009), and a high level of impulsivity (P<0.001). The predictive factors for suicidal behaviors in multivariate analysis, after adjusting for the confounding variables were: childhood sexual abuse (P=0.01; adjusted OR 4.5; 95% CI 1.44-14.2), a high level of impulsivity (P=0.002; adjusted OR 6.6; 95% CI 2-20), a higher rate of depressive episodes (P=0.003; adjusted OR 5; 95% CI 1.69-14.2) and more subyndromal symptoms (P=0.007; adjusted OR 5.8; 95% CI 1.63-20).

CONCLUSIONS

Suicide prevention is an important mental health subject. It would be imperative to include systematic screening for childhood adversities and adequate management of bipolar disorder and impulsivity.

Closing the gap: unmet needs of individuals with impulsive aggressive behavior observed in children and adolescents

Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.

Neurobiological Basis of Increased Risk for Suicidal Behaviour

According to the World Health Organization (WHO), more than 700,000 people die per year due to suicide. Suicide risk factors include a previous suicide attempt and psychiatric disorders. The highest mortality rate in suicide worldwide is due to depression. Current evidence suggests that suicide etiopathogenesis is associated with neuroinflammation that activates the kynurenine pathway and causes subsequent serotonin depletion and stimulation of glutamate neurotransmission. These changes are accompanied by decreased BDNF (brain-derived neurotrophic factor) levels in the brain, which is often linked to impaired neuroplasticity and cognitive deficits. Most suicidal patients have a hyperactive hypothalamus–pituitary–adrenal (HPA) axis. Epigenetic mechanisms control the above-mentioned neurobiological changes associated with suicidal behaviour. Suicide risk could be attenuated by appropriate psychological treatment, electroconvulsive treatment, and drugs: lithium, ketamine, esketamine, clozapine. In this review, we present the etiopathogenesis of suicide behaviour and explore the mechanisms of action of anti-suicidal treatments, pinpointing similarities among them.

Large-scale network abnormality in bipolar disorder: A multimodal meta-analysis of resting-state functional and structural magnetic resonance imaging studies

BACKGROUND

Bipolar disorder (BD) has been linked to abnormalities in the communication and gray matter volume (GMV) of large-scale brain networks, as reflected by impaired resting-state functional connectivity (rs-FC) and aberrant voxel-based morphometry (VBM). However, identifying patterns of large-scale network abnormality in BD has been elusive.

METHODS

Whole-brain seed-based rs-FC and VBM studies comparing individuals with BD and healthy controls (HCs) were retrieved from multiple databases. Multilevel kernel density analysis was used to identify brain networks in which BD was linked to hyper-connectivity or hypo-connectivity with each prior network and the overlap between dysconnectivity and GMV changes.

RESULTS

Thirty-six seed-based rs-FC publications (1526 individuals with BD and 1578 HCs) and 70 VBM publications (2715 BD and 3044 HCs) were included in the meta-analysis. Our results showed that BD was characterized by hypo-connectivity within the default network (DN), hyper-connectivity within the affective network (AN), and ventral attention network (VAN) and hypo- and hyper-connectivity within the frontoparietal network (FN). Hyper-connectivity between-network of AN-DN, AN-FN, AN-VAN, AN-thalamus network (TN), VAN-TN, VAN-DN, VAN-FN, and TN-sensorimotor network were found. Hypo-connectivity between-network of FN and DN was observed. Decreased GMV was found in the insula, inferior frontal gyrus, and anterior cingulate cortex.

LIMITATIONS

Differential weights in the number of included studies and sample size of FC and VBM might have a disproportionate influence on the meta-analytic results.

CONCLUSIONS

These results suggest that BD is characterized by both structural and functional abnormalities of large-scale neurocognitive networks, especially in the DN, AN, VAN, FN, and TN.

Aggression, Impulsivity and Suicidal Behavior in Depressive Disorders: A Comparison Study between New York City (US), Madrid (Spain) and Florence (Italy)

The association of aggression and impulsivity with suicidal behavior (SB) in depression may vary across countries. This study aimed (i) to compare aggression and impulsivity levels, measured with the Brown-Goodwin Scale (BGS) and the Barratt Impulsivity Scale (BIS), respectively, between New York City (NYC) (US), Madrid (Spain) and Florence (Italy) (ANOVA); and (ii) to investigate between-site differences in the association of aggression and impulsivity with previous SB (binary logistic regression). Aggression scores were higher in NYC, followed by Florence and Madrid. Impulsivity levels were higher in Florence than in Madrid or NYC. Aggression and impulsivity scores were higher in suicide attempters than in non-attempters in NYC and in Madrid. SB was associated with aggression in NYC (OR 1.12, 95% CI 1.07–1.16; p < 0.001) and in Florence (OR 1.11, 95% CI 1.01–1.22; p = 0.032). Impulsivity was linked with SB in NYC (OR 1.01, 95% CI 1.00–1.02; p < 0.001) and in Madrid (OR 1.03, 95% CI 1.02–1.05; p < 0.001). The higher suicide rates in NYC, compared to Madrid or Florence, may be, in part, explained by these cross-cultural differences in the contribution of aggression-impulsivity to SB, which should be considered by future research on SB prevention.

Comparison of religiosity and spirituality in patients of depression with and without suicidal attempts

AIM

This study is aimed to compare the religiosity and spirituality of patients with first-episode depression with suicidal ideation and those with recent suicidal attempts. Additional aim was compare the religiosity and spirituality of patients with first-episode depression with healthy controls.

METHODS

Patients of first episode depression with suicidal ideation and healthy controls were assessed by Centrality of Religiosity Scale (CRS), Duke University Religion Index (DUREL), Brief Religious coping scale (R-COPE), and Spiritual Attitude Inventory (SAI).

RESULTS

Patients with depression were divided into two groups based on the presence (n = 53) or absence (n = 62) of suicidal attempts in the previous 14 days. Both the patients with and without suicide attempts were matched for depression severity. Both the patient groups did not differ in terms of religiosity and spirituality as assessed using CRS and SAI. Both depression groups had lower scores on religiosity as compared to healthy controls as assessed on CRS. The two groups also had a lower score on the "sense of hope" which is a part of SAI, when compared to healthy controls. Compared to patients without suicide attempts (i.e., ideators group) and healthy controls, subjects with suicide attempts more often used negative religious coping. Total numbers of lifetime suicide attempts in the attempt group were associated with the ideology domain of the CRS.

CONCLUSION

Compared with healthy controls, patients with depression have lower levels of religiosity and spirituality. In the presence of comparable severity of depression, higher use of negative religious coping is associated with suicide attempts.

Symptom continuum reported by affective disorder patients through a structure-validated questionnaire

BACKGROUND

Affective disorders, such as major depressive (MDD), bipolar I (BD I) and II (BD II) disorders, are overlapped at a continuum, but their exact loci are not clear. The self-reports from patients with affective disorders might help to clarify this issue.

METHODS

We invited 738 healthy volunteers, 207 individuals with BD I, 265 BD II, and 192 MDD to answer a 79 item-MATRIX about on-going affective states.

RESULTS

In study 1, all 1402 participants were divided random-evenly and gender-balanced into two subsamples; one subsample was used for exploratory factor analysis, and another for confirmatory factor analysis. A structure-validated inventory with six domains of Overactivation, Psychomotor Acceleration, Distraction/ Impulsivity, Hopelessness, Retardation, and Suicide Tendency, was developed. In study 2, among the four groups, MDD scored the highest on Retardation, Hopelessness and Suicide Tendency, whereas BD I on Distraction/ Impulsivity and Overactivation.

CONCLUSION

Our patients confirmed the affective continuum from Suicide Tendency to Overactivation, and described the different loci of MDD, BD I and BD II on this continuum.

Study of Risk Factors Associated with Suicide Attempt in Patients with Bipolar Disorder Type I

Background  Suicide is the leading contributor to mortality in bipolar disorder (BD). A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries is rarer.

Objectives  The present study aimed to identify the risk factors associated with suicidal attempts in BD type I (BD-I).

Materials and Methods  Patients with BD-I currently in clinical remission ( N = 102) were recruited. Sociodemographic details and the clinical data were collected using a semistructured pro forma. The psychiatric diagnoses were confirmed using the Mini-International Neuropsychiatric Interview 5.0. The National Institute of Mental Health–Life Chart Methodology Clinician Retrospective Chart was used to chart the illness course. Presumptive Stressful Life Events Scale, Coping Strategies Inventory Short Form, Buss–Perry aggression questionnaire, Past Feelings and Acts of Violence, and Barratt Impulsivity scale were used to assess the patient’s stress scores, coping skills, aggression, violence, and impulsivity, respectively.

Statistical Analysis  Descriptive statistics were used for demographic details and characteristics of the illness course. Binary logistic regression analyses were performed to identify the predictors for lifetime suicide attempt in BD-I.

Results  A total of 102 patients (males = 49 and females = 53) with BD-I were included. Thirty-seven subjects (36.3%) had a history of suicide attempt. The illness course in suicide attempters more frequently had an index episode of depression, was encumbered with frequent mood episodes, especially in depression, and had a higher propensity for psychiatric comorbidities. On binary logistic regression analysis, the odds ratios (ORs) for predicting a suicide attempt were highest for positive family history of suicide (OR: 13.65, 95% confidence interval [CI]: 1.28–145.38, p = 0.030), followed by the presence of an index depressive episode (OR: 6.88, 95% CI: 1.70–27.91, p = 0.007), and lower scores on problem-focused disengagement (OR: 0.72, 95% CI: 0.56–0.92, p = 0.009).

Conclusion  BD-I patients with lifetime suicide attempt differ from non-attempters on various course-related and temperamental factors. However, an index episode depression, family history of suicide, and lower problem-focused engagement can predict lifetime suicide attempt in patients with BD-I.

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls

OBJECTIVES

To differentiate the relation between the structure and timing of rest-activity patterns and symptoms of impulsivity and mood instability in bipolar disorder (BD), borderline personality disorder (BPD) and healthy controls (HC).

METHODS

Eighty-seven participants (31 BD, 21 BPD and 35 HC) underwent actigraph monitoring for 28 days as part of the Automated Monitoring of Symptom Severity (AMoSS) study. Impulsivity was assessed at study entry using the BIS-11. Mood instability was subsequently longitudinally monitored using the digital Mood Zoom questionnaire.

RESULTS

BPD participants show several robust and significant correlations between non-parametric circadian rest-activity variables and worsened symptoms. Impulsivity was associated with low interdaily stability (r = -0.663) and weak amplitude (r = -0.616). Mood instability was associated with low interdaily stability (r = -0.773), greater rhythm fragmentation (r = 0.662), weak amplitude (r = -0.694) and later onset of daily activity (r = 0.553). These associations were not present for BD or HCs. Classification analysis using actigraphic measures determined that later L5 onset reliably distinguished BPD from BD and HC but did not sufficiently discriminate between BD and HC.

CONCLUSIONS

Rest-activity pattern disturbance indicative of perturbed sleep and circadian function is an important predictor of symptom severity in BPD. This appears to validate the greater subjective complaints of BPD individuals that are sometimes regarded as exaggerated by clinicians. We suggest that treatment strategies directed towards improving sleep and circadian entrainment may in the future be investigated in BPD.

Resilience and insight in euthymic patients with bipolar disorder

BACKGROUND

The relationship between resilience and insight may be of potential importance for coping with stress in bipolar disorder (BD). The aim of this study was to investigate if there was a relation between insight and resilience in euthymic patients with BD and also to analyze the associations between resilience, impulsivity, aggression, alcohol use and affective temperament.

METHODS

142 patients with BD type I in remission period were involved. Resilience Scale for Adults-Turkish version, Schedule for Assessment of Insight, Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire, Barratt Impulsiveness Scale, Buss-Perry Aggression Questionnaire, Michigan Alcoholism Screening Test were used.

RESULTS

Total insight scores were negatively correlated with the scores of perception of future. As distinct from other subscales of resilience, family cohesion had independent significant associations with insight in relabelling of psychotic experiences and attention impulsivity. There was no relationship between total insight and total resilience scores. Resilience scores were negatively correlated with number of depressive episodes and number of suicide attempts. Degree of aggression, degree of impulsivity, scores of depressive and hyperthymic temperament significantly predicted resilience.

LIMITATIONS

Recruitment of patients from a tertiary centre limits the generalizability of the findings.

CONCLUSIONS

Better insight was related to negative perception of the future and did not have significant associations with total resilience. Number of depressive episodes, number of past suicide attempts correlated with resilience, emphasizing the importance of interventions to increase resilience in BD.

A brief online intervention to address aggression in the context of emotion-related impulsivity for those treated for bipolar disorder: Feasibility, acceptability and pilot outcome data

Although aggression is related to manic symptoms among those with bipolar disorder, new work suggests that some continue to experience elevations of aggression after remission. This aggression post-remission appears related to a more general tendency to respond impulsively to states of emotion, labelled emotion-related impulsivity. We recently developed the first intervention designed to address aggression in the context of emotion-related impulsivity. Here, we describe feasibility, acceptability, and pilot data on outcomes for 21 persons who received treatment for bipolar disorder and endorsed high levels of aggression and emotion-related impulsivity. As with other interventions for aggression or bipolar disorder, attrition levels were high. Those who completed the intervention showed large changes in aggression using the interview-based Modified Overt Aggression Scale that were sustained through three months and not observed during wait list control. Although they also showed declines in the self-rated Buss-Perry Aggression Questionnaire and in self-rated emotion-related impulsivity as assessed with the Feelings Trigger Action Scale, these self-ratings also declined during the waitlist control. t Despite the limitations, the findings provide the first evidence that a brief, easily disseminated intervention could have promise for reducing aggression among those with bipolar disorder.

Impulsive and premeditated aggression in male offenders with antisocial personality disorder

INTRODUCTION

Aggression is a clinical symptom of various psychiatric disorders that can be conceptualised as a physical act towards another person with the intent to cause harm. In antisocial personality disorder (ASPD), aggression is a frequent manifestation that differently compromise therapeutic and prognostic goals according to its impulsive or premeditated categorisation. ASPD is characterised by high levels of impulsivity, psychopathic traits, and a high prevalence of co-morbid substance use disorders (SUDs). Aggression in ASPD patients may determine long and recurrent imprisonment thus representing a challenge clinicians and legal experts face.

OBJECTIVES

Our aims were to characterise impulsive and premeditated aggression in male ASPD offenders as well as to determine the potential role of SUDs, impulsivity, and psychopathic traits as predictors.

MATERIALS AND METHODS

In this cross-sectional study we evaluated a sample of ASPD offenders with a battery of clinical and psychometric, standardised instruments: the Psychopathy Checklist-Revised (PCL-R), the European Version of the Addiction Severity Index (EuropASI), the Barratt Impulsivity Scale Version 11 (BIS-11), and the Impulsive/Premeditated Aggression Scale (IPAS).

RESULTS

We used a total sample of 134 offenders, all of whom were male. ASPD patients (n = 96) had a 71.9% prevalence of impulsive aggression and a 28.1% prevalence of premeditated aggression. ASPD patients with impulsive aggression had significantly lower scores of total PCL-R (p<0.01) factor 1 and interpersonal facet 1 (p<0.05), compared with ASPD patients with premeditated aggression. ASPD patients with impulsive aggression and ASPD patients with premeditated aggression had comparable BIS-11 mean scores, and exhibited an equal prevalence of SUDs. The interpersonal facet 1of the PCL-R predicted the aggression type (p<0.05) in ASPD patients, and the exponential beta value for facet 1 was 1.42 (CI = 1.03; 1.95).

CONCLUSIONS

The aggression type that is associated with ASPD is mainly impulsive in nature. ASPD patients who have higher scores of psychopathic traits have a lower probability of exhibiting impulsive aggression and a higher probability of exhibiting premeditated aggression. Although ASPD patients have high levels of impulsivity and a high frequency of SUDs, these two variables were not predictors of the aggression type.

Boredom Proneness and Aggression Among People With Substance Use Disorder: The Mediating Role of Trait Anger and Impulsivity

Boredom proneness has been linked to aggressive behaviors; however, the relationship between them is not well understood. To better understand the mechanism underlying the relationship between boredom proneness and aggression, a serial multiple mediator model was built, where boredom proneness impacted aggression simultaneously through (a) impulsivity, (b) trait anger, and (c) impulsivity to trait anger. Using data collected among Chinese substance users, a battery of interview questionnaires was completed. Results from this study indicate a positive relationship between boredom proneness, impulsivity, trait anger, and aggression. Moreover, the mediating role of impulsivity, trait anger, and both impulsivity and trait anger in serial were found. This study reflects that the link from boredom proneness to aggression among substances users could be partially explained via impulsivity and anger.

Tobacco smoking and other substance use disorders associated with recurrent suicide attempts in bipolar disorder

BACKGROUND

Suicide attempts (SA) are more frequent in bipolar disorder (BD) than in most other mental disorders. Prevention strategies would benefit from identifying the risk factors of SA recurrence in BD. Substance use disorders (SUD) (including tobacco-related) are strongly associated with both BD and SA, however, their specific role for the recurrence of SA in BD remains inadequately investigated. Thus, we tested if tobacco smoking - with or without other SUDs - was independently associated with recurrent SA in BD.

METHODS

916 patients from France and Norway with ascertained diagnoses of BD and reliable data about SA and SUD were classified as having no, single, or recurrent (≥2) SA. Five SUD groups were built according to the presence/absence/combination of tobacco, alcohol (AUD) and cannabis use disorders. Multinomial logistic regression was used to identify the correlates of SA recurrence.

RESULTS

338 (37%) individuals reported at least one SA, half of whom (173, 51%) reported recurrence. SUD comorbidity was: tobacco smoking only, 397 (43%), tobacco smoking with at least another SUD, 179 (20%). Regression analysis showed that tobacco smoking, both alone and comorbid with AUD, depressive polarity of BD onset and female gender were independently associated with recurrent SA.

LIMITATIONS

Lack of data regarding the relative courses of SA and SUD and cross-national differences in main variables.

CONCLUSION

Tobacco smoking with- or without additional SUD can be important risk factors of SA recurrence in BD, which is likely to inform both research and prevention strategies.

Suicide in Parkinson's disease

Persons with Parkinson's disease (PwP) have many known risk factors for suicide and suicidal ideation (SI). Despite this, there is limited understanding of suicidality in this population. We conducted a systematic review to synthesise the available literature on suicidality in PwP and highlight areas for potential intervention and further research. We identified 116 articles discussing SI, suicidal behaviours, suicide attempts and/or fatal suicide in PwP. These articles describe prevalence, suicide methods, risk factors for suicide and SI and treatment of suicidality. In this review, we summarise the current literature and provide suggestions for how clinicians can identify and treat PwP who are at risk for suicide, for example, through aggressive treatment of depression and improved screening for access to lethal means.

A preliminary investigation of impulsivity, aggression and white matter in patients with bipolar disorder and a suicide attempt history

BACKGROUND

Impulsivity and aggression may be associated with suicide attempts in bipolar disorder (BD), but findings have been inconsistent. Abnormalities in anterior white matter tracts that project to the frontal lobes mediate top-down regulation of emotion and may contribute to this clinical phenomenology.

METHODS

We assessed white matter (i.e., fractional anisotropy) in anterior and posterior brain regions using diffusion tensor imaging in 18 patients with BD and no prior suicide attempt (BD-S), 12 patients with BD and a prior suicide attempt (BD+S), and 12 healthy volunteers. Patients completed the Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency (UPPS-P) Impulsive Behavior Scale and Impulsive Premeditated Aggression Scale (IPAS). All individuals completed the Barratt Impulsiveness Scale (BIS-11).

RESULTS

Patients with BD+S had higher overall impulsivity (assessed using both the UPPS-P Impulsive Behavior Scale and BIS-11) and premeditated aggression compared to patients with BD-S. There were no significant group differences on measures of fractional anisotropy (FA). In patients with BD+S, however, higher FA in the anterior (but not the posterior) brain regions correlated with greater overall impulsivity on the UPPS-P Impulsive Behavior Scale. There were no significant correlations between either anterior or posterior brain regions with clinical measures in patients with BD-S.

LIMITATIONS

Cross-sectional study, sample size and possible contribution of psychotropic medications.

CONCLUSION

Impulsivity and aggression may be risk factors for a suicide attempt in BD. White matter in the anterior limb of the internal capsule and anterior corona radiata may play a role in this phenomenology.

Impulsivity differences between bipolar and unipolar depression

BACKGROUND

Even though particularly bipolar depression and unipolar depression seem to be similar, they show differences in terms of the etiology, phenomenology, course, and treatment process. Bipolar depression is associated with mood lability, motor retardation, and hypersomnia to a larger extent. Early age of onset, a high frequency of depressive episodes, and history of bipolar disease in the family are suggestive of bipolar disorder (BD) rather than major depression. Bipolar and unipolar disorders are also associated with increased impulsivity during illness episodes. However, there is little information about impulsivity during euthymia in these mood disorders. The aim of this study was to illustrate the difference in impulsivity in euthymic bipolar and unipolar patients.

MATERIALS AND METHODS

Impulsivity was evaluated by the Barratt Impulsiveness Scale (BIS-11A), in 78 interepisode BD patients, 72 interepisode unipolar disorder patients, and 70 healthy controls. The diagnosis was established by severe combined immunodeficiency. One-way between-groups ANOVA was used to compare the BIS-11A mean scores for all three groups.

RESULTS

Impulsivity scores of the bipolar and unipolar disorder patients were significantly higher than controls on total and all subscales measures. There was no difference between the bipolar and unipolar disorder groups on total, attentional, and nonplanning impulsivity measures. However, BD patients scored significantly higher than the unipolar patients on motor impulsivity measures.

CONCLUSIONS

Both interepisode bipolar and unipolar disorder patients had increased impulsivity compared to healthy individuals. There was no significant difference on attention and nonplanning impulsivity subscales; however, on the motor subscale, bipolar patients were more impulsive than unipolar disorder patients.

Psychological characteristics of caregivers of pediatric patients with chronic rheumatic disease in relation to treatment adherence

BACKGROUND

Adherence to treatment for chronic diseases is lower in children than in adults, less extensively studied in children and is associated with multiple related factors. The aim of this study is to perform a descriptive analysis of psycho-cognitive aspects of primary caregivers of pediatric patients with chronic rheumatic diseases, as well as socioeconomic and clinical factors, family functioning and treatment satisfaction.

METHODS

Primary caregivers of 90 patients were included. Pairs (caregiver plus patient) were grouped as presenting good adherence (n = 50) or poor adherence (n = 40) according to the Morisky Adherence Test. Psycho-cognitive aspects were evaluated by Adult Self-Report and Wechsler Adult Intelligence Scale tests. For statistical comparisons, quantitative variables with normal distribution were analyzed by Student's t test, and those with non-Gaussian distribution with the Mann Whitney test. Categorical variables were analyzed by Chi square test. A multivariate logistic regression analysis was performed to estimate the contribution of the independent variables to adherence.

RESULTS

Compared to caregivers in the good adherence group, caregivers in the poor adherence group were more likely to be classified as clinical on the scales for attention problems and externalizing problems, which include impulsiveness and aggressiveness. They also scored higher on the depressive problem scale. In addition, the average number of children per caregiver and the mean age of caregivers and patients were significantly higher in the poor adherence group, while the proportion of caregivers with higher education was lower. The poor adherence group also included a higher incidence of pediatric patients assuming sole responsibility for managing medications. Economic status, clinical factors, treatment satisfaction, family functioning and caregiver cognitive profile were not related to adherence, except for working memory index.

CONCLUSION

Older patients, patients as the one solely responsible for medication management, and caregivers with externalizing problems, were observed to be the most strongly associated to poor adherence. Interventions aimed at adolescent patients are needed. Also, psychological programs and interventional studies to better determine caregivers' behavioral/emotional status, and parent-child relationships are recommended.

Impulsivity and Saliva Cortisol in Patients with Suicide Attempt and Controls

OBJECTIVES

The objective of this study was to prove concepts in the characterization of suicidal patients and the possible usefulness of those markers to potentially identify patients with a higher risk for suicidality.

METHODS

Patients with a recent suicide attempt were compared with patients suffering from depression, adjustment disorder, anxiety, or eating disorders without suicidality, healthy controls and remitted patients with a history of at least 1 suicide attempt (≥1 year). We analyzed impulsivity (Barratt Impulsivity Scale, BIS) and saliva cortisol concentrations.

RESULTS

Independently of suicidality and disease state patients display higher BIS scores than healthy controls. Saliva cortisol levels tend to be higher in patients in the acute disease state than in remitted patients and healthy controls.

CONCLUSIONS

Saliva cortisol may be a useful marker that reveals alterations in nonsuicidal patients suffering from depression, adjustment disorder, anxiety, or eating disorders who might be at risk.

Suicidal patients in a psychiatric emergency unit: clinical characteristics and aggression profile

OBJECTIVE

To explore and describe a profile of patients admitted to a psychiatric emergency facility, comparing patients with and without a recent suicide attempt in terms of their clinical characteristics and aggression.

METHODS

This was an exploratory comparative study where patients were assessed using the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Participants with a suicide attempt in the last 24 hours (SA) were compared to participants with a prior history of suicide attempt but no recent attempt (PHSA).

RESULTS

63 individuals (SA: 26; PHSA: 37) were selected. Both groups had similar demographic and clinical characteristics. The most prevalent diagnoses were mood (57.1%) and personality (50.8%) disorders. The majority of patients in both groups had a history of aggression episodes. Physical aggression in the week prior to admission was more prevalent in the PHSA group (51.4 vs. 19.2%, p = 0.017). The PHSA group also presented higher activation scores (p = 0.025), while the SA group presented higher affect scores on BPRS dimensions (p = 0.002).

CONCLUSION

The majority of individuals with a history of suicide attempt also presented a history of aggression. Inpatients with recent suicide attempt were hospitalized mainly due to the risk of suicide, while those with no recent suicide attempt were hospitalized mainly due to the risk of hetero-aggression. These findings support the hypothesis of an aggressive profile in suicidal patients and may open up a path for future research.

Genome-wide association analyses of lesion counts in group-housed pigs

Aggression in group-housed pigs is a welfare concern and can negatively affect production. Skin lesions are reliable indicators of aggression and are moderately heritable, suggesting that selective breeding may reduce aggression. To further understand the genetic control of behavioral traits, such as the aggressive response to regrouping, associated single nucleotide polymorphisms (SNPs) can be identified within the genome, and the region in which these SNPs are located can be related to known genes. To investigate SNPs associated with aggression, 1093 purebred Yorkshire pigs were strategically remixed into new groups of familiar and unfamiliar animals at three life stages and lesion counts were recorded. Genomic best linear unbiased prediction (GBLUP) models were fitted for each trait. The genetic additive effect was obtained from a genetic relationship matrix constructed from the 50 924 SNPs. SNP effects and their variances were estimated from the GBLUP objects. SNPs that were associated with a significant portion of the trait variance were identified for lesions to the anterior (three SNPs, FDR <5%) and central (one SNP, FDR <5%) portions of the body in grow-finish pigs. These SNPs were located on chromosome 11, suggesting that chromosome 11 contains a region explaining variation in lesion counts that should be further explored to identify genes underlying biological control of aggression.

Aggression among 216 patients with a first-psychotic episode of bipolar I disorder

Background

Aggression by patients with bipolar I disorder (BD-I) is not uncommon. Identifying potential risk factors early in the illness-course should inform clinical management and reduce risk.

Methods

In a study sample of 216 initially hospitalized, first-psychotic episode subjects diagnosed with DSM-IV-TR BD-I, we identified recent (within 1 month before hospitalization) aggression by ratings on the Brief Psychiatric Rating Scale-Expanded and review of detailed clinical research records. We compared subjects with versus without aggressive behavior for associations with selected demographic and clinical factors.

Results

Aggression was identified in 23/216 subjects (10.6%). It was associated significantly with recent suicide attempt (OR = 4.86), alcohol abuse (OR = 3.63), learning disability (OR = 3.14), and initial manic episode (OR = 2.59), but not with age, sex, onset-type, personality disorder, time to recovery, or functional status.

Conclusions

Among first-major episode BD-I patients with psychotic features, recent serious aggression towards others was identified in 10.6%. The odds of aggression increased by 4.9-times in association with a recent suicide attempt, more than 3-times with alcohol-abuse or learning disability, and by 2.6-times if the episode polarity was manic. The findings encourage closer management of alcohol misuse, suicide risk, and manic symptoms, and early detection of learning problems in BD-I patients.

Distinct patterns of blood oxygenation in the prefrontal cortex in clinical phenotypes of schizophrenia and bipolar disorder

BACKGROUND

Schizophrenia (SZ) and bipolar disorder (BD) are characterized by different clinical symptoms, and have previously been considered as categorically separate. However, several lines of evidence controversially suggest that these two disorders may run on a continuum. While it is therefore important to evaluate the subtle differences between SZ and BD, few studies have investigated the difference of brain functioning between the two by focusing on the common symptoms of cognitive functioning and impulsivity, rather than positive/negative and mood symptoms. Recent developments in near-infrared spectroscopy (NIRS) technology have enabled noninvasive assessment of brain function in people with psychiatric disorders.

METHODS

Near-infrared spectroscopy (NIRS) using 24-channels was conducted during the verbal fluency task (VFT) and Stroop color-word task (SCWT) in 38 patients diagnosed with SZ, 34 patients with BD, and 26 age- and sex-matched healthy controls.

RESULTS

Oxyhemoglobin changes in the prefrontal cortex (PFC) were significantly lower particularly in the SZ compared to control group during the VFT. On the other hand, these were significantly lower particularly in the BD and SZ group to control group during the SCWT. Regression analysis showed that hemodynamic changes were significantly correlated with verbal memory and impulsivity in both disorders.

CONCLUSION

These findings suggest that different hemodynamic responses in the prefrontal cortex might reflect cognitive functioning and impulsivity, providing a greater insight into SZ and BD pathophysiology.

The relationship of impulsivity and cortical thickness in depressed and non-depressed adolescents

Major Depressive Disorder (MDD) is recognized to be heterogeneous in terms of brain structure abnormality findings across studies, which might reflect previously unstudied traits that confer variability to neuroimaging measurements. The purpose of this study was to examine the relationships between different types of trait impulsivity and MDD diagnosis on adolescent brain structure. We predicted that adolescents with depression who were high on trait impulsivity would have more abnormal cortical structure than depressed patients or non-MDD who were low on impulsivity. We recruited 58 subjects, including 29 adolescents (ages 12-19) with a primary DSM-IV diagnosis of MDD and a history of suicide attempt and 29 demographically-matched healthy control participants. Our GLM-based analyses sought to describe differences in the linear relationships between cortical thickness and impulsivity trait levels. As hypothesized, we found significant moderation effects in rostral middle frontal gyrus and right paracentral lobule cortical thickness for different subscales of the Barratt Impulsiveness Scale. However, although these brain-behavior relationships differed between diagnostic study groups, they were not simple additive effects as we had predicted. For the middle frontal gyrus, non-MDD participants showed a strong positive association between cortical thickness and BIS-11 Motor scores, while MDD-diagnosed participants showed a negative association. For Non-Planning Impulsiveness, paracentral lobule cortical thickness was observed with greater impulsivity in MDD, but no association was found for controls. In conclusion, the findings confirm that dimensions of impulsivity have discrete neural correlates, and show that relationships between impulsivity and brain structure are expressed differently in adolescents with MDD compared to non-MDD.

Modeling suicide in bipolar disorders

INTRODUCTION

Suicide is a multicausal human behavior, with devastating and immensely distressing consequences. Its prevalence is estimated to be 20-30 times greater in patients with bipolar disorders than in the general population. The burden of suicide and its high prevalence in bipolar disorders make it imperative that our current understanding be improved to facilitate prediction of suicide and its prevention. In this review, we provide a new perspective on the process of suicide in bipolar disorder, in the form of a novel integrated model that is derived from extant knowledge and recent evidence.

METHODS

A literature search of articles on suicide in bipolar disorder was conducted in recognized databases such as Scopus, PubMed, and PsycINFO using the keywords "suicide", "suicide in bipolar disorders", "suicide process", "suicide risk", "neurobiology of suicide" and "suicide models". Bibliographies of identified articles were further scrutinized for papers and book chapters of relevance.

RESULTS

Risk factors for suicide in bipolar disorders are well described, and provide a basis for a framework of epigenetic mechanisms, moderated by neurobiological substrates, neurocognitive functioning, and social inferences within the environment. Relevant models and theories include the diathesis-stress model, the bipolar model of suicide and the ideation-to-action models, the interpersonal theory of suicide, the integrated motivational-volitional model, and the three-step theory. Together, these models provide a basis for the generation of an integrated model that illuminates the suicidal process, from ideation to action.

CONCLUSION

Suicide is complex, and it is evident that a multidimensional and integrated approach is required to reduce its prevalence. The proposed model exposes and provides access to components of the suicide process that are potentially measurable and may serve as novel and specific therapeutic targets for interventions in the context of bipolar disorder. Thus, this model is useful not only for research purposes, but also for future real-world clinical practice.

Self-reported inhibition predicts history of suicide attempts in bipolar disorder and major depression

BACKGROUND

Studies have reliably identified an association between suicide attempts and executive functions such as decision making (DM) and inhibitory control (IC) in patients with mood disorders. As such, the present study aimed to investigate the association between inhibition, DM, impulsivity and the history of suicide attempts in individuals with bipolar (BD) or major depressive disorder (MDD), identifying which assessment instruments may be most strongly associated with suicide in clinical samples.

METHODS

The sample included 80 control subjects and two groups of patients with BD and MDD, matched by age and education (26 with a history of suicide attempts [MD+], and 26 with no such history [MD-]). Participants completed behavioral and self-report measures of DM and IC, which were compared between groups using ANCOVA, followed by logistic regression for patients with mood disorders only, and the presence or absence of a history of suicide as the outcome.

RESULTS

Cognitive performance did not differ between groups. The MD+ group showed significantly higher motor and attentional impulsivity on the BIS-11 than the MD- and control groups. A regression analysis containing these scores showed that motor impulsivity was the only significant predictor of a history of suicide (OR = 1.14; 95%CI 1.00-1.30).

CONCLUSIONS

Self-reported motor impulsivity was a significant predictor of suicide. These findings underscore the importance of self-report measures in neuropsychological assessment, and their contributions to the management and prognosis of patients with mood disorders. Lastly, they point to the role of impulsivity as a target for interventions and public policy on suicide prevention.

Childhood trauma, dimensions of psychopathology and the clinical expression of bipolar disorders: A pathway analysis

BACKGROUND

This study aims at testing for paths from childhood abuse to clinical indicators of complexity in bipolar disorder (BD), through dimensions of affective dysregulation, impulsivity and hostility.

METHOD

485 euthymic patients with BD from the FACE-BD cohort were included from 2009 to 2014. We collect clinical indicators of complexity/severity: age and polarity at onset, suicide attempt, rapid cycling and substance misuse. Patients completed questionnaires to assess childhood emotional, sexual and physical abuses, affective lability, affect intensity, impulsivity, motor and attitudinal hostility.

RESULTS

The path-analysis demonstrated significant associations between emotional abuse and all the affective/impulsive dimensions (p < 0.001). Sexual abuse was moderately associated with emotion-related dimensions but not with impulsivity nor motor hostility. In turn, affect intensity and attitudinal hostility were associated with high risk for lifetime presence of suicide attempts (p < 0.001), whereas impulsivity was associated with a higher risk of lifetime presence of substance misuse (p < 0.001). No major additional paths were identified when including Emotional and Physical Neglect in the model.

CONCLUSIONS

This study provides refinement of the links between early adversity, dimensions of psychopathology and the complexity/severity of BD. Mainly, dimensions of affective dysregulation, impulsivity/hostility partially mediate the links between childhood emotional to suicide attempts and substance misuse in BD.

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

OBJECTIVE

To evaluate aggressiveness during a major depressive episode (MDE) and its relationship with bipolar disorder (BD) in a post hoc analysis of the BRIDGE-II-MIX study.

METHOD

A total of 2811 individuals were enrolled in this multicenter cross-sectional study. MDE patients with (MDE-A, n = 399) and without aggressiveness (MDE-N, n = 2412) were compared through chi-square test or Student's t-test. A stepwise backward logistic regression model was performed.

RESULTS

MDE-A group was more frequently associated with BD (P < 0.001), while aggressiveness was negatively correlated with unipolar depression (P < 0.001). At the logistic regression, aggressiveness was associated with the age at first depressive episode (P < 0.001); the severity of mania (P = 0.03); the diagnosis of BD (P = 0.001); comorbid borderline personality disorder (BPD) (P < 0.001) but not substance abuse (P = 0.63); no current psychiatric treatment (P < 0.001); psychotic symptoms (P = 0.007); the marked social/occupational impairment (P = 0.002). The variable most significantly associated with aggressiveness was the presence of DSM-5 mixed features (P < 0.001, OR = 3.815). After the exclusion of BPD, the variable of lifetime suicide attempts became significant (P = 0.013, OR = 1.405).

CONCLUSION

Aggressiveness seems to be significantly associated with bipolar spectrum disorders, independently from BPD and substance abuse. Aggressiveness should be considered as a diagnostic criterion for the mixed features specifier and a target of tailored treatment strategy.

Personality traits and suicide attempts with and without psychiatric disorders: analysis of impulsivity and neuroticism

BACKGROUND

There is a critical need for empirical data concerning the association of personality traits and attempted suicide with and without psychiatric disorders in mainland China. The objective of the present study is to provide such data by determining the prevalence of psychiatric disorders and analyzing the levels of impulsivity and neuroticism among people who have attempted suicide, and to examine the association between these personality traits and suicide attempt in people with or without psychiatric disorders.

METHODS

We administered self-reported tests and clinical interviews to 196 people who have attempted suicide who were admitted to a hospital emergency room or our psychiatric settings after a suicide attempt.

RESULTS

One hundred and fifty-six subjects (79.6%) met the criteria for Axis I disorders and eleven (6.6%) met the criteria Axis II personality disorders. Those who have attempted suicide who did not have psychiatric disorders exhibited a greater degree of background characteristics (e.g., high lethality, more interpersonal conflicts and more alcohol use), lower levels of suicidality (suicide risk, depressive symptoms) and differences of personality traits (e.g., more impulsive and less neuroticism) as compared to those who do have psychiatric disorders. Profile differences existed even after control for the stressful life event.

CONCLUSION

Our findings suggest that some personality traits differ between people who have attempted suicide depending on whether or not they have psychiatric disorders. Based on these findings, investigating the impact of personality traits on suicidal behavior in therapeutic settings would provide critical data to improve patient treatment and outcomes.

Considerations on nonclinical approaches to modeling risk factors of suicidal ideation and behavior

Given the serious nature of suicidal ideation and behavior (SIB) and the possibility of treatment-emergent SIB, pharmaceutical companies are now applying more proactive approaches in clinical trials and are considering the value of nonclinical models to predict SIB. The current review summarizes nonclinical approaches to modeling three common risk factors associated with SIB: aggression, impulsivity, and anhedonia. For each risk factor, a general description, advantages and disadvantages, species considerations, nonclinical to clinical translation, and pharmacological validation with respect to treatments associated with SIB are summarized. From this review, several gaps were identified that need to be addressed before use of these nonclinical models can be considered a viable option to predict the relative risk for SIB. Other future directions that may compliment these nonclinical approaches, including the use of selectively-bred or genetically-modified rodent models, transgenic models, gene expression profiling, and biomarker analysis, are discussed. This article was developed with the support of the DruSafe Leadership Group of the International Consortium for Innovation and Quality in Pharmaceutical Development (IQ, www.iqconsortium.org).

Suicidality and Activation of the Kynurenine Pathway of Tryptophan Metabolism

A recent report by the World Health Organization declared suicide to be a major global problem. With more than 800,000 lives lost each year, suicide is calculated to be the 14th leading cause of death around the world. While the biological mechanisms causing suicidal ideation and behavior are not fully understood, increased levels of inflammation, arising from various sources, have been detected in the central nervous system and the peripheral blood of suicidal patients and suicide completers. Inflammation induces the kynurenine pathway of tryptophan metabolism, which generates a range of metabolites with potent effects on neurotransmitter systems as well as on inflammation. Recent evidence indicates that a dysregulation of the enzymes in the kynurenine pathway may be present in suicidal patients, with a resulting imbalance of metabolites that modulate glutamate neurotransmission and neuroinflammation. As the body of research in these areas grows, targeting the kynurenine pathway enzymes and metabolites may provide novel therapeutic opportunities for detection, treatment, and ultimately prevention of suicidal behavior.

Lipids, aggression, suicidality and impulsivity in drug-naïve/drug-free patients of schizophrenia

AIM

Present study aimed at determining lipid profiles in acutely symptomatic drug-naïve/drug-free patients of schizophrenia, comparing them with healthy controls and exploring relationships between various lipid fractions, aggression, suicidality and impulsivity in this population.

MATERIALS AND METHODS

This was a cross-sectional hospital-based study, comparing patients with schizophrenia (M=46, F=14; mean age 32.40±6.6 years; 48 drug-free for 10.50±9.2 weeks) with 60 age-sex matched healthy controls. Upon recruitment, fasting venous blood samples of all subjects were analysed for total cholesterol, HDL, LDL, VLDL and TG levels, and patients were rated on PANSS for symptom severity, Modified Overt Aggression Scale for aggression, Impulsivity Rating Scale for impulsivity and Scale for Suicide Ideation for suicidality.

RESULTS

The socio-demographic characteristics of the patients were comparable to controls. In patients, total cholesterol, HDL and LDL levels were found to be significantly lower (p<0.01) than the control group. When explored further in patients, lower total cholesterol and LDL levels showed significant negative correlations with scores on impulsivity (p<0.01) and suicidality (p<0.05); and TG level showed a negative correlation with impulsivity (p<0.05).

CONCLUSIONS

This study adds to a growing literature on a complex relationship between lipid fractions and impulsivity, suicidality and aggression in schizophrenia; providing interesting insights into the biochemical basis of human behaviour and confirming these in a developing-world population. The implications are many, including a need to review judiciously the promotion of weight loss and cholesterol reduction programmes in constitutionally vulnerable population, at least during their acutely-symptomatic states.