Racing thoughts revisited: A key dimension of activation in bipolar disorder

Spanish validation of the short version of the racing and crowded thoughts questionnaire (RCTQ-13)

BACKGROUND

The Racing and Crowded Thoughts Questionnaire (RCTQ-13) is the most widely used specific scale for the measurement of racing thoughts, but there is currently no Spanish version that allow the evaluation in Spanish-speaking patients. The objective of this study is to translate, adapt, and validate the RCTQ-13 in a Colombian population with affective disorders.

METHODS

The questionnaire was translated and back-translated, and corrections were implemented following a pilot test to improve comprehensibility. We included patients with Bipolar I Disorder and with Major depressive disorder seen in three centers in the city of Medellín, Colombia. We evaluate structural validity with confirmatory factor analysis, internal consistency, and test-retest reliability. Construct validity was also assessed with the comparison between euthymic, maniac, and depressive episodes and the correlation with worry, rumination, and mania scales. Responsiveness was measured 1 month after the first evaluation. Based on item response theory (IRT), we also estimated item difficulty, discrimination, and fit using a generalized partial credit model.

RESULTS

Two hundred fifty subjects were included. Confirmatory factor analysis revealed that the three-factor structure of the scale was appropriate. Internal consistency was adequate for the entire scale (Cronbach's alpha = 0.95, 95% CI: 0.94-0.96) and for each factor. Test-retest reliability was good (intraclass correlation coefficient = 0.82, 95%IC: 0.70-0.88). For construct validity, we observed differences between patients with different types of affective episodes, a moderate positive correlation with the Penn State Worry Scale (r = 0.55) and the Ruminative Response Scale (r = 0.42), and a low negative correlation with the Young Mania Rating Scale (r = - 0.10). Responsiveness was proved to be adequate. Under IRT, the response thresholds for the response options are organized for all items. The infit was adequate for all items and the outfit was acceptable.

CONCLUSIONS

The Spanish version of the RCTQ-13 is a reliable, valid, and responsive scale and can be used for the clinical assessment of the construct of racing and crowded thoughts in patients with the spectrum of affective disorders in whom this experience can be expressed with different nuances. Further research is needed to expand the relationship with rumination and worry.

Identifying different patterns of emotion dysregulation in adult ADHD

BACKGROUND

Emotion dysregulation (ED) is a core intrinsic feature of adult presenting Attention Deficit Hyperactivity Disorder (ADHD). However, the clinical expressions of ED are diverse and several questionnaires have been used to measure ED in adults with ADHD. Thus, to date, the characteristics of ED in adult ADHD remain poorly defined. The objective of this study is to identify the different patterns of ED in adults with ADHD.

METHODS

A large sample of 460 newly diagnosed adults with ADHD were recruited. Patients completed a total of 20 self-reported questionnaires. Measures consisted in the several facets of ED, but also other clinical features of adult ADHD such as racing thoughts. A factor analysis with the principal component extraction method was performed to define the symptomatic clusters. A mono-dimensional clustering was then conducted to assess whether participants presented or not with each symptomatic cluster.

RESULTS

The factor analysis yielded a 5 factor-solution, including "emotional instability", "impulsivity", "overactivation", "inattention/disorganization" and "sleep problems". ED was part of two out of five clusters and concerned 67.52% of our sample. Among those patients, the combined ADHD presentation was the most prevalent. Emotional instability and impulsivity were significantly predicted by childhood maltreatment. The ED and the "sleep problems" factors contributed significantly to the patients' functional impairment.

CONCLUSIONS

ED in ADHD is characterized along emotional instability and emotional impulsivity, and significantly contributes to functional impairment. However, beyond impairing symptoms, adult ADHD may also be characterized by functional strengths such as creativity.

Disentangling racing thoughts from mind wandering in adult attention deficit hyperactivity disorder

Introduction

Mental restlessness reported by adult with Attention Deficit Hyperactivity Disorder (ADHD) has been mainly explained by excessive mind wandering. However, the description of a mind constantly on the go is also akin to racing thoughts, predominantly described in bipolar disorder. This paper aimed at disentangling mind wandering from racing thoughts in adult with ADHD. Associations between those mental phenomena and the ADHD symptomatology were also investigated.

Methods

To this aim, 84 adults with ADHD completed self-reported questionnaires, including the Mind Wandering-Deliberate and Mind Wandering-Spontaneous questionnaires, the Racing and Crowded Thoughts Questionnaire and the Daydreaming Frequency Scale. Factorial analysis and multiple linear regressions were performed.

Results

The factor analysis yielded a two-factor solution. The first factor encompassed the three facets of racing thoughts and was predicted by emotional lability. The second comprised deliberated-MW, spontaneous-MW and daydreaming, but was neither related to the ADHD symptoms, nor functional impairment.

Discussion

These findings suggest that MW and racing thoughts are two distinguishable mental phenomena. Racing thoughts appear to be a relevant hypothesis to explain the mental restlessness in adult ADHD.

Diet and physical activity and metabolic disorders in patients with schizophrenia and bipolar affective disorder in the Polish population

Introduction

There are numerous reports of a higher prevalence of metabolic disorders in patients with schizophrenia and bipolar disorder (BD), yet its connections to diet and physical activity remain not fully explained. This article aimed to evaluate diet, physical activity and selected biochemical and anthropometric parameters associated with metabolism in patients with schizophrenia and BD and to analyse the relationships between these variables in the subjects.

Materials and Methods

A total of 126 adults participated in the study: 47 patients with schizophrenia, 54 patients with BD and 25 patients in mental illness remission (reference group). Data were collected on the underlying illness and concomitant illnesses, and the severity of symptoms of the current episode was assessed using the following scales: PANSS, MADRS and YMRS. An assessment of the subjects' diet (KomPAN questionnaire) and their physical activity (International Physical Activity Questionnaire) was carried out. Anthropometric and blood pressure measurements were taken and BMI and WHR were calculated. Serum concentrations of fasting glucose, TSH, total cholesterol, LDL and HDL fractions, triglycerides and leptin, ghrelin and resistin were determined. For statistical analysis, the significance level was set at 0.05. For multiple comparisons one way ANOVA or Kruskal Wallis were used with post hoc Tukey and Dunn tests, respectively. To determine correlation of variables, Pearson's linear correlation coefficient or Spearman's rank correlation coefficient were used.

Results

A total of 50.8% of the subjects had at least one metabolic disorder-most commonly excessive body weight (66.7%) and abdominal obesity (64.3%). Patients did not differ significantly in terms of physical activity, but they did differ in mean time spent sitting-with this being significantly longer for all groups than in the general population. The subjects differed in diet: patients with BD consumed less unhealthy foods than patients with schizophrenia. The highest correlations between physical activity, diet and variables defining metabolic disorders were found in patients with BD. Only in patients with schizophrenia were there significant correlations between the course of the disease and physical activity.

Discussion

The results suggest the existence of associations between diet, physical activity, and metabolic disorders in both BD and schizophrenia patients. They also suggest a tendency among those patients to spend long periods of time sitting.

Investigating racing thoughts via ocular temporal windows: deficits in the control of automatic perceptual processes

BACKGROUND

Racing thoughts have been found in several states of bipolar disorder (BD), but also in healthy populations with subclinical mood alterations. The evaluation of racing thoughts relies on subjective reports, and objective measures are sparse. The current study aims at finding an objective neuropsychological equivalent of racing thoughts in a mixed group of BD patients and healthy controls by using a bistable perception paradigm.

METHOD

Eighty-three included participants formed three groups based on participants' levels of racing thoughts reported via the Racing and Crowded Thoughts Questionnaire. Participants reported reversals in their perception during viewing of the bistable Necker cube either spontaneously, while asked to focus on one interpretation of the cube, or while asked to accelerate perceptual reversals. The dynamics of perceptual alternations were studied both at a conscious level (with manual temporal windows reflecting perceptual reversals) and at a more automatic level (with ocular temporal windows derived from ocular fixations).

RESULTS

The rate of windows was less modulated by attentional conditions in participants with racing thoughts, and most clearly so for ocular windows. The rate of ocular windows was especially high when participants with racing thoughts were asked to focus on one interpretation of the Necker cube and when they received these instructions for the first time.

CONCLUSIONS

Our results indicate that in subjects with racing thoughts automatic perceptual processes escape cognitive control mechanisms. Racing thoughts may involve not only conscious thought mechanisms but also more automatic processes.

Psychopathological Dissection of Bipolar Disorder and ADHD: Focussing on Racing Thoughts and Verbal Fluency

In the present study, we propose a review and a synthesis of the work of our group about the phenomenology and the cognitive mechanisms of racing thoughts in bipolar disorder (BD) and ADHD. Contrary to the mainstream idea according to which racing thoughts are pathognomonic of BD, our work suggests that racing thoughts are enhanced in ADHD compared to hypomanic episodes of BD, whereas in euthymic episodes of BD self-reported racing thoughts are similar to the rates reported by healthy controls. Using verbal fluency tasks, we found many similarities between bipolar and ADHD subjects with one clear difference: lexical search strategy in hypomania is based on phonemic similarities rather than semantic-relatedness. However, this distinction observed in this cognitive task is certainly difficult to grasp during a clinical interview aiming to differentiate mild hypomania from combined ADHD presentation. The main landmark to distinguish them remains the episodic nature of bipolar disorders as opposed to the lifelong presentation of ADHD symptoms, a dichotomous view that is not so clear-cut in clinical practice.

An overactive mind: Investigating racing thoughts in ADHD, hypomania and comorbid ADHD and bipolar disorder via verbal fluency tasks

BACKGROUND

Adults with Attention Deficit Hyperactivity Disorder (ADHD) often report mental restlessness akin to racing thoughts found in hypomanic and mixed episodes of bipolar disorder (BD). Past research has suggested that racing thoughts in BD can be tackled via process-oriented verbal fluency measures. In ADHD, it is still unknown whether racing thoughts is due to comorbid BD, and its neuropsychological underpinnings remain to be investigated. To this aim, this study investigates process-oriented verbal fluency measures in adults with ADHD compared to adults with BD in a hypomanic episode, adults with ADHD + BD and healthy controls.

METHODS

Three verbal fluency tasks, i.e., the free, the letter and the semantic conditions, were administered to 37 adults with ADHD, 25 adults with BD in a hypomanic episode, 22 adults with comorbid ADHD + BD (euthymia) and 31 healthy subjects. Word production, clustering, and switching were analysed in verbal fluency tasks.

RESULTS

Adults with ADHD, ADHD + BD and hypomania showed increased switches in the free verbal fluency task, compared to healthy controls, despite equivalent number of words produced. Unlike the ADHD and ADHD + BD groups, phonological clustering measures in the semantic task were increased in the hypomanic group compared to healthy controls.

LIMITATIONS

BD groups were under medication.

CONCLUSIONS

Semantic overactivation, reflected by increased switches in the unconstrained verbal fluency task, appear to be a common mechanism involved in racing thoughts in both ADHD and BD. By contrast, unusual sounds-based associations are specific of hypomanic speech and might contribute to the distinction trait and state racing thoughts.

Vocalization and physiological hyperarousal in infant-caregiver dyads where the caregiver has elevated anxiety

Co-regulation of physiological arousal within the caregiver-child dyad precedes later self-regulation within the individual. Despite the importance of unimpaired self-regulatory development for later adjustment outcomes, little is understood about how early co-regulatory processes can become dysregulated during early life. Aspects of caregiver behavior, such as patterns of anxious speech, may be one factor influencing infant arousal dysregulation. To address this, we made day-long, naturalistic biobehavioral recordings in home settings in caregiver-infant dyads using wearable autonomic devices and miniature microphones. We examined the association between arousal, vocalization intensity, and caregiver anxiety. We found that moments of high physiological arousal in infants were more likely to be accompanied by high caregiver arousal when caregivers had high self-reported trait anxiety. Anxious caregivers were also more likely to vocalize intensely at states of high arousal and produce intense vocalizations that occurred in clusters. High-intensity vocalizations were associated with more sustained increases in autonomic arousal for both anxious caregivers and their infants. Findings indicate that caregiver vocal behavior differs in anxious parents, cooccurs with dyadic arousal dysregulation, and could contribute to physiological arousal transmission. Implications for caregiver vocalization as an intervention target are discussed.

Investigating racing thoughts in insomnia: A neglected piece of the mood-sleep puzzle?

BACKGROUND

Cognitive arousal is thought to play a key role in insomnia disorder. However, although patients frequently complain about racing thoughts appearing at bedtime, studies have considered 'cognitive arousal' as a synonym of rumination and worry, but not as racing thoughts per se. The latter have been mainly linked to hypomanic/manic episodes of bipolar disorder (BD). Here we aimed at investigating self-reported racing thoughts in insomnia disorder, and their specific contribution to insomnia severity, as compared to worry and rumination.

METHODS

72 adults with insomnia disorder, 49 patients with BD in a hypomanic episode and 99 healthy individuals completed the Racing and Crowded Thoughts Questionnaire (RCTQ). Mood symptoms were assessed in patients with insomnia disorder.

RESULTS

RCTQ scores were overall higher in insomnia disorder, especially in sleep-onset insomnia, compared to the hypomanic and healthy groups. Moreover, racing thoughts showed an increase in the evening and at bedtime in sleep-onset insomnia. Importantly, racing thoughts at bedtime, but not rumination and worry, were associated with insomnia severity.

DISCUSSION

Our results are the first to show that racing thoughts is a transdiagnostic symptom in mood and sleep disorders. Racing thoughts, not only rumination and worry, might contribute to the maintenance of sleep difficulties in insomnia. Clinical trials' registration number: NCT04752254.

Vocal features obtained through automated methods in verbal fluency tasks can aid the identification of mixed episodes in bipolar disorder

There is a lack of consensus on the diagnostic thresholds that could improve the detection accuracy of bipolar mixed episodes in clinical settings. Some studies have shown that voice features could be reliable biomarkers of manic and depressive episodes compared to euthymic states, but none thus far have investigated whether they could aid the distinction between mixed and non-mixed acute bipolar episodes. Here we investigated whether vocal features acquired via verbal fluency tasks could accurately classify mixed states in bipolar disorder using machine learning methods. Fifty-six patients with bipolar disorder were recruited during an acute episode (19 hypomanic, 8 mixed hypomanic, 17 with mixed depression, 12 with depression). Nine different trials belonging to four conditions of verbal fluency tasks-letter, semantic, free word generation, and associational fluency-were administered. Spectral and prosodic features in three conditions were selected for the classification algorithm. Using the leave-one-subject-out (LOSO) strategy to train the classifier, we calculated the accuracy rate, the F1 score, and the Matthews correlation coefficient (MCC). For depression versus mixed depression, the accuracy and F1 scores were high, i.e., respectively 0.83 and 0.86, and the MCC was of 0.64. For hypomania versus mixed hypomania, accuracy and F1 scores were also high, i.e., 0.86 and 0.75, respectively, and the MCC was of 0.57. Given the high rates of correctly classified subjects, vocal features quickly acquired via verbal fluency tasks seem to be reliable biomarkers that could be easily implemented in clinical settings to improve diagnostic accuracy.

Beyond motor hyperactivity: Racing thoughts are an integral symptom of adult attention deficit hyperactivity disorder

Adults with ADHD experience mental restlessness, akin to racing thoughts, but data on this symptom in ADHD remain scarce. Our study aims at investigating self-reported racing thoughts in adults with ADHD, and its relationship with affective dysregulation and insomnia. We were also interested in whether racing thoughts may aid differential diagnosis with bipolar disorder (BD). 182 adults with ADHD, 30 ADHD+BD, 31 hypomanic BD, and 20 euthymic BD patients completed the Racing and Crowded Thoughts Questionnaire (RCTQ). ADHD, anxiety, insomnia and depression symptoms, as well as affective temperament were also assessed in ADHD and ADHD+BD subjects. Results show that RCTQ scores were higher in ADHD compared to hypomania and euthymia and were associated with cyclothymic traits and anxiety. Moreover, in ADHD and ADHD+BD, racing thoughts increased in the evening and at bedtime and were associated with insomnia severity. In conclusion, self-reported racing thoughts are a neglected but an intrinsic feature of adult ADHD that is particularly related to cyclothymia and anxiety, but cannot differentiate ADHD and BD.

Pattern of occurrence of obsessive-compulsive symptoms in bipolar disorder

Apparent comorbidity between Bipolar Disorder (BD) and Obsessive-Compulsive Disorder (OCD) is a common condition, but its meaning has not been clarified yet. The present study aimed to evaluate the pattern of occurrence of obsessive-compulsive symptoms (OCS) in the different phases of BD. One hundred and sixty-five BD patients, 62 (37.5%) euthymic, 34 (20.6%) in hypomanic/manic phase, 43 (26%) in depressive phase and 26 (15.7%) in mixed state, were assessed with the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Hamilton Depression Rating Scale (HAM-D), the Young Mania Rating Scale (YMRS) and the Ruminative Response Scale (RRS). In the whole sample, the severity of OCS was associated to the severity of depressive symptoms. The highest severity of OCS (YBOCS total score) was observed in the mixed group and the lowest scores in the hypomanic/manic group. Our findings suggest that OCS in BD patients appear as a state-dependent phenomenon cycling with the mood phases, particularly exacerbating in the context of depressive and mixed states.

Psychopathology of Mixed States

Mixed states are frequent clinical pictures in psychiatric practice but are not well described in nosologic systems. Debate exists as to defining mixed states. We review factor and cluster analytical studies and prominent clinical/conceptual models of mixed states. While mania involves standard manic symptoms and depression involves standard depressive symptoms, core additional features of the mixed state are, primarily, psychomotor activation and, secondarily, dysphoria. Those features are more pronounced in mixed mania than in mixed depression but are present in both.

Thought and language disturbance in bipolar disorder quantified via process-oriented verbal fluency measures

Bipolar disorder (BD) is characterized by speech abnormalities, reflected by symptoms such as pressure of speech in mania and poverty of speech in depression. Here we aimed at investigating speech abnormalities in different episodes of BD, including mixed episodes, via process-oriented measures of verbal fluency performance - i.e., word and error count, semantic and phonological clustering measures, and number of switches-, and their relation to neurocognitive mechanisms and clinical symptoms. 93 patients with BD - i.e., 25 manic, 12 mixed manic, 19 mixed depression, 17 depressed, and 20 euthymic-and 31 healthy controls were administered three verbal fluency tasks - free, letter, semantic-and a clinical and neuropsychological assessment. Compared to depression and euthymia, switching and clustering abnormalities were found in manic and mixed states, mimicking symptoms like flight of ideas. Moreover, the neuropsychological results, as well as the fact that error count did not increase whereas phonological associations did, showed that impaired inhibition abilities and distractibility could not account for the results in patients with manic symptoms. Rather, semantic overactivation in patients with manic symptoms, including mixed depression, may compensate for trait-like deficient semantic retrieval/access found in euthymia. "For those who are manic, or those who have a history of mania, words move about in all directions possible, in a three-dimensional 'soup', making retrieval more fluid, less predictable." Kay Redfield Jamison (2017, p. 279).