Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

Prevalence and Correlates of Eating Disorder Symptoms in Adolescents with Bipolar I Disorder

Objective: To investigate the prevalence and correlates of eating disorder symptoms in adolescents with bipolar I disorder (BP I). Methods: We retrospectively collected a DSM-IV-TR-based diagnostic assessment of 179 adolescents with BP I and evaluated clinical variables in those with and without eating disorder symptoms. For comparison, we retrospectively evaluated eating disorder symptoms in adolescents with generalized anxiety disorder (GAD). Results: Thirty-six percent of adolescents with BP I experienced lifetime eating disorder symptoms; among comorbid adolescents, 74% reported eating disorder cognitions and 40% reported symptoms related to bingeing, 25% purging, and 17% restricting. BP I adolescents with (vs. without) eating disorder symptoms had higher Children's Depression Rating Scale-Revised scores (40.5 vs. 34.5; p < 0.001; effect size = 0.59) and were more likely to be female (75% vs. 45%; p < 0.001; odds ratio = 3.8). There were no differences in Young Mania Rating Scale scores (p = 0.70); lifetime presence of attention-deficit/hyperactivity disorder (p = 0.86) and alcohol (p = 0.59) or substance (p = 0.89) abuse/dependence symptoms; age of BP I onset (p = 0.14); inpatient hospitalization status at baseline (p = 0.53); presence of lifetime inpatient hospitalization (p = 0.64) or suicide attempt (p = 0.35); seriousness of suicidality (p = 0.86); body mass index (p = 0.48); and second-generation antipsychotic (SGA; p = 0.32) or non-SGA mood stabilizer (p = 0.09) use. Eating disorder cognitions (rather than behaviors) were higher in the GAD group (58%) compared with the BP I group (27%; p = 0.004). Limitations: A retrospective study is subject to recall bias and limits our understanding of the temporal relationship between eating disorder and mood symptoms. Conclusions: Eating disorder symptoms are frequently comorbid in adolescents with BP I. The comorbidity is associated with more severe depression but does not confer a more severe illness course.

The network structure of mania symptoms differs between people with and without binge eating

OBJECTIVES

People with bipolar disorder who also report binge eating have increased psychopathology and greater impairment than those without binge eating. Whether this co-occurrence is related to binge eating as a symptom or presents differently across full-syndrome eating disorders with binge eating is unclear.

METHODS

We first compared networks of 13 lifetime mania symptoms in 34,226 participants from the United Kingdom's National Institute for Health and Care Research BioResource with (n = 12,104) and without (n = 22,122) lifetime binge eating. Second, in the subsample with binge eating, we compared networks of mania symptoms in participants with lifetime anorexia nervosa binge-eating/purging (n = 825), bulimia nervosa (n = 3737), and binge-eating disorder (n = 3648).

RESULTS

People with binge eating endorsed every mania symptom significantly more often than those without binge eating. Within the subsample, people with bulimia nervosa most often had the highest endorsement rate of each mania symptom. We found significant differences in network parameter statistics, including network structure (M = 0.25, p = 0.001) and global strength (S = 1.84, p = 0.002) when comparing the binge eating with no binge-eating participants. However, network structure differences were sensitive to reductions in sample size and the greater density of the latter network was explained by the large proportion of participants (34%) without mania symptoms. The structure of the anorexia nervosa binge-eating/purging network differed from the bulimia nervosa network (M = 0.66, p = 0.001), but the result was unstable.

CONCLUSIONS

Our results suggest that the presence and structure of mania symptoms may be more associated with binge eating as a symptom rather than any specific binge-type eating disorder. Further research with larger sample sizes is required to confirm our findings.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Eating disorder features in bipolar disorder: clinical implications

BACKGROUND

Bipolar disorder (BD) is associated with elevated rates of eating disorders (EDs), but the nature and impact of specific ED features are unclear.

AIMS

This study sought to identify which ED features are common in BD, and whether these relate to quality of life (QoL) impairment and body mass index (BMI).

METHOD

A clinical sample of 73 adults with BD completed self-report measures of health, ED features, emotion regulation ability, impulsivity, and QoL.

RESULTS

Binge eating (45%), excessive dietary restriction (39%), overvaluation of weight/shape (51%), purging (16%) and driven exercise (27%) were common, and associated with a poorer clinical picture, including poorer QoL and poorer emotion regulation. Furthermore, regular binge eating episodes explained a significant proportion of variance in QoL impairment after controlling for other significant predictors. The best predictors of BMI were number of medical conditions, impulsivity and positive beliefs about binge eating.

CONCLUSIONS

ED features that may not meet criteria for a fully diagnosable ED - particularly overvaluation of weight/shape and binge eating - warrant greater attention, as they may still significantly worsen QoL. Future research should focus on modifying existing psychological interventions to better target ED features among individuals with BD and thereby improve clinical outcomes.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Eating Habits and Eating Disorder Associated Behavior in Bipolar Disorder

A relevant comorbidity of bipolar disorder (BD) is eating disorders (EDs). Crossed vulnerability factors as eating disorder-specific symptoms (EDSSs) may trigger the onset of both disorders in either direction. The Structured Inventory for Anorexic and Bulimic Eating Disorders for Self-Report was used to examine the occurrence of EDs in euthymic/subsyndromal individuals with BD ( n = 86) and healthy controls ( n = 86) matched for age and sex. Furthermore, we explored EDSSs with the subscales "general psychopathology and social integration," "bulimic symptoms," "body image and slimness ideal," "sexuality and body weight," "counteract," and "atypical binge." Higher rates of all EDSSs were reported in BD. Younger individuals with BD showed higher expression in "bulimic symptoms," "body image and slimness ideal," and "atypical binge" subscales. No participants fulfilled ED diagnosis. The findings show a link between EDSS and BD. Clinicians should pay attention to a multimodal intervention, considering risk factors, investigating eating habits and ED associated behaviors.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Mood disorders comorbidity in obese bariatric patients: the role of the emotional dysregulation

BACKGROUND

Obese patients seeking bariatric surgery are known to show high rates of mental disorders, mainly mood and eating disorders. The aim of the present study is to evaluate psychiatric comorbidities, affective temperamental dimensions, emotional dysregulation and impulsivity in a sample of obese bariatric patients, exploring the differences between obese patients with and without mood disorders (MD).

METHODS

A total of 69 obese patients were consecutively enrolled between March and November 2019 during the presurgical evaluation routinely performed before the bariatric intervention. Sociodemographic and clinical features were collected by psychiatrists during a single consultation. Affective temperaments, emotional dysregulation and impulsivity were also investigated through self-report questionnaires. Epidemiological and clinical variables were compared between patients with and without MD.

RESULTS

In our sample, almost 3 out of 4 patients presented a lifetime psychiatric disorder, mainly MD (n=33, 48%), binge eating disorder (BED) (n=34, 49%) and anxiety disorders (n=30, 43%). Compared to N-MD patients, those with MD showed higher rates of psychiatric comorbidity with BED, bulimia and panic disorder. In addition, obese patients with MD showed more frequently cyclothymic, depressive and anxious temperaments, and higher mean scores on the psychometric questionnaires assessing emotional dysregulation and impulsivity compared to obese subjects without MD.

LIMITATIONS

the small sample size, the retrospectively assessment of psychiatric disorders and the self-report questionnaires.

CONCLUSIONS

A subgroup of obese patients, especially among those with MD, show high emotional dysregulation, affective lability and impulsiveness that could represent suitable substrates for the development of compulsive and addictive eating habits.

Are eating disorders associated with bipolar disorder type I? Results of a Lebanese case-control study

OBJECTIVES

To assess the association between disordered eating and bipolar disorder (BD).

METHODS/DESIGN

A case-control study, conducted between April and September 2018, enrolled 50 patients and 50 controls.

RESULTS

Higher eating attitude test scores were significantly associated with the presence of BD. This association remained after the introduction of other factors (marital status, family history of BD, shopping and gambling addictions, sleep quality, and insomnia severity) that were also associated with the presence of BD.

PRACTICAL IMPLICATIONS

This study suggested that eating disorders are associated with BD type I, independent of mediating factors. Health care providers should consider pharmacological or psychotherapeutic interventions that could treat both syndromes sparingly.

Exercise is medicine: a new perspective for health promotion in bipolar disorder

INTRODUCTION

Similar effects in reducing the symptoms of the mood disorder are reported in the literature compared the action of drugs and aerobic exercise sessions, demonstrating the potential of exercise in the control and mood stabilization. Therefore, there are many reasons to believe that the increased cardiorespiratory fitness (VO_2max) can be an important means of protection and a reducing potential of physical and mental damage in bipolar disorders (BD). This review will highlight the current pattern of response of exercise on the pathophysiology of BD, relating the possible mechanisms, and hypotheses based on exercises.

AREAS COVERED

The mechanism of monoaminergic action and its relationship with exercise, role of physical conditioning and increased VO_2Max on neurotrophin release, and new perspectives on long-term exercise will be reviewed.

EXPERT OPINION

The adaptations to training, although little explored in the context of BD, can induce the expression of substances that co-regulate several processes related to the pathophysiology of BD. Furthermore, high intensity interval training (HIIT) can also be adjusted to improve the physical fitness and health in patients with BD. Future research is needed to adopt a training strategy that is both time efficient and adequate for the population in question.

Evening chronotype, disordered eating behavior, and poor dietary habits in bipolar disorder

OBJECTIVE

Our aim was to evaluate the relationship between evening chronotype, a proxy marker of circadian system dysfunction, and disordered eating behavior and poor dietary habits in individuals with bipolar disorder (BD).

METHODS

In this cross-sectional study, we evaluated 783 adults with BD. Chronotype was determined using item 5 from the reduced Morningness-Eveningness Questionnaire. The Eating Disorder Diagnostic Scale (EDDS) and the Rapid Eating Assessment for Participants-Shortened Version (REAP-S) were used to assess disordered eating behavior and dietary habits respectively. General linear models and logistic regression models were utilized to evaluate differences between chronotype groups.

RESULTS

Two hundred and eight (27%) BD participants self-identified as having evening chronotypes. Compared to non-evening types, evening types were younger (P < 0.01) and, after controlling for age, had higher mean EDDS composite z-scores (P < 0.01); higher rates of binge-eating (BE) behavior (P = 0.04), bulimia nervosa (P < 0.01), and nocturnal eating binges (P < 0.01); and a higher body mass index (P = 0.04). Compared to non-evening types, evening chronotypes had a lower REAP-S overall score (P < 0.01) and scored lower on the 'healthy foods' and 'avoidance of unhealthy food' factors. Evening types also skipped breakfast more often (P < 0.01), ate less fruit (P = 0.02) and vegetables (P = 0.04), and consumed more fried foods (P < 0.01), unhealthy snacks (P = 0.02), and soft drinks (P = 0.01).

CONCLUSIONS

Our findings suggest that the circadian system plays a role in the disordered eating and unhealthy dietary behaviors observed in BD patients. The circadian system may therefore represent a therapeutic target in BD-associated morbidity that warrants further investigation.

Higher Prevalence of Metabolic Syndrome in Child-adolescent Patients with Bipolar Disorder

Objective

Previous studies have indicated a convergent and bidirectional relationship between metabolic syndrome (MetS) and bipolar disorder (BD). As most of these studies focused mainly on adults diagnosed with BD, our study aims to investigate and characterize metabolic disturbances in child-adolescents diagnosed with BD.

Methods

We retrospectively examined the medical records of psychiatric hospitalizations with admitting diagnosis of BD in child-adolescents (age < 18 years). Body mass index (BMI), lipid profile, fasting blood glucose, and blood pressure were primary variables. National Cholesterol Education Program criteria were used to define MetS. Reference group data was obtained from the National Health and Nutrition Examination Survey study. Statistical analyses included ttests, chi-square tests, and Fisher’s exact tests.

Results

We identified 140 child-adolescent patients with BD (mean age = 15.12 ± 1.70 years, 53% male). MetS was significantly more common in BD compared to the reference group: 14% (95% confidence interval [95% CI] 8−20) vs. 6.7% (95% CI 4.1−9.2), p = 0.001 with no significant difference by sex. MetS components were higher in the BD group, particularly BMI ≥ 95% (25% vs. 11.8%, p < 0.001) and high blood pressure (17% vs. 8%, p = 0.05). Moreover, female patients had lower odds of high blood pressure (odds ratio = 0.24 [95% CI 0.08−0.69], p = 0.005).

Conclusion

Compared with the general child-adolescent population, the prevalence of MetS was significantly higher in patients with BD of same age. This reiterates the notion of an increased risk of MetS in patients diagnosed with BD; and thus, further exploration is warranted.

The comorbidity of eating disorders in bipolar disorder and associated clinical correlates characterised by emotion dysregulation and impulsivity: A systematic review

BACKGROUND

Individuals with bipolar disorder (BD) have an increased risk of developing eating disorders (ED) or disordered eating symptoms compared to the general population. Eating pathology characterised by binge and/or purge symptomatology are the most common to develop in BD, yet the underlying aetiological mechanisms are relatively unknown. Theoretical models of BD-ED comorbidity suggest that shared pathophysiological factors, including emotion dysregulation and impulsivity may contribute to the development of binge/purge eating pathology in BD.

METHOD

A systematic search was conducted to assess two research questions: 1. What are the prevalence or incidence rates of different ED in BD? 2. Are clinical correlates hallmarked by emotion dysregulation and/or impulsivity (alcohol/substance use disorders, mood instability and suicidality) significantly elevated in BD with ED (BD-ED) groups compared to BD only?

RESULTS

Any type of lifetime or current ED ranged from 1.9% to 33.3% in BD. Type of BD diagnosis did not appear to significantly impact likelihood of ED development. Alcohol use disorder, mood instability and suicidality were significantly higher in BD-ED compared to BD only.

LIMITATIONS

Potential biases within the selected studies; impacting generalisability of results and comparability between studies. Varying treatment interventions (including medications) may confound results and comparability between studies. Assessment of binge eating varied, also limiting comparability.

CONCLUSION

Eating pathology may occur comorbidly with BD due to shared underlying pathophysiological features. This could have significant implications for future interventions; both psychopharmacological and psychotherapeutic. More comprehensive investigations are required to identify the functionality of dysregulated emotion and impulsivity in the development of eating pathology in BD.

The Association Between Affective Temperament Traits and Dopamine Genes in Obese Population

Studies indicate the heritable nature of affective temperament, which shows personality traits predisposing to the development of mental disorders. Dopaminergic gene polymorphisms such as DRD4, COMTVal158Met, and DAT1 have been linked to affective disorders in obesity. Due to possible correlation between the aforementioned polymorphisms and the affective temperament, the aim of our research was to investigate this connection in an obese population. The study enrolled 245 obese patients (178 females; 67 males). The affective temperament was assessed using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego autoquestionnaire (TEMPS-A). Genetic polymorphisms of DAT1, COMTVal158Met and DRD4 were collected from peripheral blood sample and determined using a polymerase chain reaction (PCR). Only in COMT polymorphisms, the cyclothymic and irritable dimensions were significantly associated with Met/Val carriers (p = 0.04; p = 0.01). Another interesting finding was the correlation between the affective temperament and age in men and women. We assume that dopamine transmission in heterozygotes of COMT may determine the role of the affective temperament in obese persons. Dopaminergic transmission modulated by COMT may be responsible for a greater temperament expression in obese individuals. To our knowledge, this is the first study describing the role of affective temperament in the obese population, but more research is needed in this regard.

Early intervention for bipolar disorder in adolescents: A psychosocial perspective

AIM

Early intervention in bipolar disorder (BD) has received increasing attention in recent years. The identification of risk factors has improved, but researchers continue to struggle to find an effective treatment once the illness has become established. The aetiology of BD and feasibility of early intervention present a challenge, making it difficult to decide who to target, as well as how.

METHODS

This essay seeks to address the lack of guidance for managing patients with a possible emerging bipolar illness, by presenting a rough roadmap to psychological care. The psychological techniques currently showing the most potential for this challenging group are reviewed. Markers of risk and supplementary clinical targets, such as anxiety and sleep disruption, are also discussed.

RESULTS

While research in this group remains in its infancy, various avenues of enquiry show promise, such as family-based approaches, CBT that targets features beyond the core illness, psychoeducation, and interventions that consider physical health. However, clearer pathways for establishing the course and stage of the illness are required to inform the intensity and type of treatment.

CONCLUSION

It is argued that treating early, indistinct symptoms of psychological distress, that may or may not signify prodromal BD, is valuable beyond its utility as an early intervention tool, as it has the capacity to improve help-seeking behaviour, quality of life and the likelihood of functional recovery in those who go on to develop the illness as adults.

Features of mood associated with high body weight in females with fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a common syndrome whose main characteristic is chronic widespread musculoskeletal pain, the severity of which is frequently worsened by concomitant obesity. Major depression (MD), particularly as part of a bipolar spectrum disorder (BSD), is associated with both obesity and FM.

OBJECTIVE

To evaluate the relationship between lifetime MD, hypomanic symptoms and the body mass index (BMI) in patients with FM.

METHOD

Of the 115 patients originally screened, 87 women with FM finally entered the study. Forty-nine patients (57%) had a lifetime diagnosis of MD, assessed by a structured clinical interview based on DSM-IV criteria, and four of them (4.6%) had a current MD episode. Lifetime hypomanic symptoms were measured by means of the self-rated Hypomania Checklist. According to the international criteria for BMI, FM patients were classified as under/normal-weight (61%), overweight (30%) and obese (9%).

RESULTS

62 patients (71.2%) with FM had a bipolar spectrum disorder (BSD). Thirty (48.3%) of them met criteria for bipolar II disorder, 32 (51,6%) for bipolar disorder NOS (18 FM patients with MD associated to sub-syndromal hypomanic syndrome and 14 with hypomanic syndrome without MD). No patient had a bipolar I disorder. Only one patient met the criteria for a major depressive disorder (MDD). There was no significant difference in mean BMI between the patients with and without a lifetime diagnosis of MD, but there was a positive association between the level of hypomanic symptoms and BMI values (p<0.009). When hypomania was considered categorically as hypomanic syndrome there was no significant effect on BMI.

CONCLUSIONS

Our finding adds to previous evidence indicating that hypomanic symptoms are a central feature of FM. In the case of the early identification of high-level hypomanic symptoms, body weight should be closely monitored in order to prevent obesity and its detrimental impact on females with FM.

Binge eating behaviours in bipolar disorders

BACKGROUND

Recent research, especially from the USA, suggests that comorbid binge eating (BE) behaviour and BE disorder are frequent in individuals with Bipolar Disorder (BD). Although basic clinical associations between BD and BE have been investigated, less is known about psychological or temperamental dimensions and qualitative aspects of eating habits. In a French cohort of patients with BD, we investigated the prevalence of BE behaviour and any associations with illness characteristics, anxiety, impulsivity, emotional regulation and eating habits.

METHODS

145 outpatients with BD (I and II) were assessed for the presence of BE behaviour using the Binge Eating Scale (BES). Characteristics identified in univariate analyses as differentiating BD cases with and without BE behaviour were then included in a backward stepwise logistic regression (BSLR) model.

RESULTS

In this sample, 18.6% of BD patients met criteria for BE behaviour. Multivariate analysis (BSLR) indicated that shorter duration of BD, and higher levels of anxiety and emotional reactivity were observed in BD with compared to BD without BE behaviour.

LIMITATIONS

Relatively small sample referred to specialist BD clinics and cross-sectional evaluation meant that it was not possible to differentiate between state and trait levels of impulsivity, emotional instability and disinhibition. These dimensions may also overlap with mood symptoms.

CONCLUSION

BE behaviour is common in females and males with BD. Emotional dysregulation and anxiety may represent important shared vulnerability factors for worse outcome of BD and increased likelihood of BE behaviour.

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

Background

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

Methods

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

Results

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

Limitations

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

Conclusions

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

The role of tryptophan metabolism and food craving in the relationship between obesity and bipolar disorder

BACKGROUND & AIMS

Individuals with bipolar disorder (BD) have a significantly increased risk of obesity-related conditions. The imbalance between food intake and energy expenditure is assumed to be a major risk factor for obesity in BD. This study analyzed food craving in relation to anthropometric, metabolic, and neurobiological parameters in a well-characterized cohort of euthymic individuals with BD.

METHODS

One-hundred-thirty-five patients completed the Food-Craving Inventory assessing four categories of food craving (fat, fast-food, sweets and carbohydrate craving). Additionally, clinical, metabolic and anthropometric parameters were assessed.

RESULTS

Higher levels of fat craving were observed in males, versus females, with BD. High levels of carbohydrate craving positively correlated with kynurenine and the kynurenine-to-tryptophan ratio. Higher serum nitrite and neopterin levels were related to fat craving. Parameters of fat metabolism (triglycerides, high-density lipoprotein) were associated with fat and fast-food craving. Anthropometric measures of obesity (e.g. body mass index, waist-to-hip-ratio) were not related to food craving.

CONCLUSIONS

Overweight/obese individuals with BD show an increased driving of tryptophan down the kynurenine pathways, as indicated by an increase in the serum kynurenine-to-tryptophan ratio. The driving of tryptophan down the kynurenine pathway is mediated by immune-inflammatory activity and stress. The correlation of increased kynurenine with food craving, especially carbohydrate craving, probably indicates a regulatory deficit in the maintenance of chronic inflammatory processes in obesity and BD. Food craving seems to be of clinical importance in the treatment of metabolic disturbances in BD, although not associated with anthropometric measures of obesity. Rather, food craving correlates with blood metabolic parameters and an increased activation of the kynurenine pathway, both of which are linked to higher affective symptomatology and the development of cardiovascular diseases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlates of Overweight and Obesity Among Adolescents With Bipolar Disorder in the National Comorbidity Survey-Adolescent Supplement (NCS-A)

OBJECTIVE

Despite substantial evidence on the prevalence and correlates of overweight and obesity (OW/OB) in adults with bipolar disorder (BD), little is known about this topic in adolescents with BD.

METHOD

The method consisted of the National Comorbidity Survey-Adolescent Supplement, a face-to-face survey of mental disorders from 2001 through 2004, using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. Participants were adolescents 13 to 17 years of age, with bipolar disorder I or II (n = 295), major depressive disorder (n = 1,112), or controls with neither mood disorder (n = 8,716). Analyses examined for group differences in the prevalence of OW/OB and for correlates of OW/OB in the group with BD.

RESULTS

There were no significant differences in weight categories across groups. OW and OB in adolescents with BD were associated with significantly higher lifetime rates of suicide attempt (odds ratio 3.02, 95% CI 1.11-8.24), physical or sexual abuse (2.82, 1.20-6.60), binge eating or bulimia (2.66, 1.13-6.26), and conduct disorder (2.60, 1.10-6.13) in covariate-adjusted analyses. OW and OB also were significantly associated with seeing a professional for depression, being hospitalized overnight for depression, and receiving general medical treatment.

CONCLUSION

The similar prevalence of OW/OB in adolescents with and without BD suggests that this potent association in adults likely comprises a consequence of BD or its correlates. In contrast, the strong association of OW/OB with proxies for depression severity, including suicide attempts and hospitalization, is already evident even in this young, nonclinical sample. Studies are warranted to determine whether early intervention of OW/OB in BD might optimize physical and mental health.

Clinical features of bipolar spectrum with binge eating behaviour

OBJECTIVE

To determine whether bipolar spectrum disorder with binge eating behavior (BE) is an important clinical sub-phenotype.

METHODS

Prevalence rates and correlates of different levels of BE were assessed in 1114 bipolar spectrum patients participating in a genetic biobank. BE and eating disorders (EDs) were assessed with the Eating Disorder Diagnostic Scale (EDDS). Psychiatric illness burden was evaluated with measures of suicidality, psychosis, mood instability, anxiety disorder comorbidity, and substance abuse comorbidity. Medical illness burden was evaluated with body mass index (BMI) and the Cumulative Index Rating Scale (CIRS).

RESULTS

Thirty percent of patients had any BE and 27% had BE plus an ED diagnosis. Compared with bipolar spectrum patients without BE, bipolar spectrum patients with BE were younger and more likely to be female; had significantly higher levels of eating psychopathology, suicidality, mood instability, and anxiety disorder comorbidity; had a significantly higher mean BMI and a significantly higher rate of obesity; and had a significantly higher medical illness burden. Bipolar spectrum patients with BE but no ED diagnosis were more similar to bipolar spectrum patients without BE than to those with an ED. Nonetheless, the positive predictive value and specificity of BE predicting an ED was 0.90 and 0.96, respectively.

LIMITATIONS

As only two patients had co-occurring anorexia nervosa, these results may not generalize to bipolar spectrum patients with restricting EDs.

CONCLUSION

Bipolar spectrum disorder with broadly-defined BE may not be as clinically relevant a sub-phenotype as bipolar spectrum disorder with an ED but may be an adequate proxy for the latter when phenotyping large samples of individuals.

Different characteristics associated with suicide attempts among bipolar I versus bipolar II disorder patients

BACKGROUND

Suicide attempts are common in patients with bipolar disorder (BD), and consistently associated with female gender and certain unfavorable BD illness characteristics. Findings vary, however, regarding effects of BD illness subtype and yet other illness characteristics upon prior suicide attempt rates. We explored the effects of demographics and BD illness characteristics upon prior suicide attempt rates in patients stratified by BD illness subtype (i.e., with bipolar I disorder (BDI) versus bipolar II disorder (BDII)).

METHODS

Outpatients referred to the Stanford BD Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD Affective Disorders Evaluation. Rates of prior suicide attempt were compared in patients with and without diverse demographic and BD illness characteristics stratified by BD subtype.

RESULTS

Among 494 BD outpatients (mean ± SD age 35.6 ± 13.1 years; 58.3% female; 48.6% BDI, 51.4% BDII), overall prior suicide attempt rates in were similar in BDI versus BDII patients, but approximately twice as high in BDI (but not BDII) patients with compared to without lifetime eating disorder, and in BDII (but not BDI) patients with compared to without childhood BD onset. In contrast, current threshold-level suicidal ideation and lifetime alcohol use disorder robustly but less asymmetrically increased prior suicide attempt risk across BD subtypes.

LIMITATIONS

American tertiary bipolar disorder clinic referral sample, cross-sectional design.

CONCLUSIONS

Further studies are needed to assess the extent to which varying clinical characteristics of samples of patients with BDI and BDII could yield varying prior suicide attempt rates in patients with BDI versus BDII.

Prevalence and correlates of DSM-5 eating disorders in patients with bipolar disorder

OBJECTIVE

To determine prevalence rates and clinical correlates of current DSM-5 eating disorders in patients with bipolar disorder (BP).

METHODS

Prevalence rates of current DSM-5- and DSM-IV-defined binge eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN) were assessed with the Eating Disorder Diagnostic Scale (EDDS) in 1092 patients with BP. Psychiatric illness burden was evaluated with five proxy measures of BP illness severity. Medical illness burden was evaluated with the Cumulative Index Rating Scale (CIRS).

RESULTS

Twenty-seven percent of patients had a current DSM-5 eating disorder: 12% had BED, 15% had BN, and 0.2% had AN. Rates of DSM-5-defined BED and BN were higher than clinical diagnosis rates and rates of DSM-IV-defined BED and BN. Compared with BP patients without an eating disorder, BP patients with a DSM-5 eating disorder were younger and more likely to be women; had an earlier age of onset of BP; had higher EDDS composite scores and higher degrees of suicidality, mood instability, and anxiety disorder comorbidity; and had a higher mean BMI, higher rate of obesity, and higher CIRS total scores. In a logistic regression model controlling for previously identified correlates of an eating disorder, younger age, female gender, and higher BMI remained significantly associated with an eating disorder.

LIMITATIONS

The EDDS has not been validated in BP patients.

CONCLUSION

DSM-5-defined BED and BN are common in BP patients, possibly more common than DSM-IV-defined BED and BN, and associated with greater psychiatric and general medical illness burden. Further studies assessing DSM-5 eating disorders in people with BP are greatly needed.

Prevalence and correlates of bipolar disorders in patients with eating disorders

BACKGROUND

To investigate the prevalence and correlates of bipolar disorders in patients with eating disorders (EDs), and to examine differences in effects between major depressive disorder and bipolar disorder on these patients.

METHODS

Sequential attendees were invited to participate in a two-phase survey for EDs at the general psychiatric outpatient clinics. Patients diagnosed with EDs (n=288) and controls of comparable age, sex, and educational level (n=81) were invited to receive structured interviews for psychiatric co-morbidities, suicide risks, and functional level. All participants also completed several self-administered questionnaires assessing general and eating-related pathology and impulsivity. Characteristics were compared between the control, ED-only, ED with major depressive disorder, and ED with bipolar disorder groups.

RESULTS

Patients with all ED subtypes had significantly higher rates of major depressive disorder (range, 41.3-66.7%) and bipolar disorder (range, 16.7-49.3%) than controls did. Compared to patients with only EDs, patients with comorbid bipolar disorder and those with comorbid major depressive disorder had significantly increased suicidality and functional impairments. Moreover, the group with comorbid bipolar disorder had increased risks of weight dysregulation, more impulsive behaviors, and higher rates of psychiatric comorbidities.

LIMITATIONS

Participants were selected in a tertiary center of a non-Western country and the sample size of individuals with bipolar disorder in some ED subtypes was small.

CONCLUSION

Bipolar disorders were common in patients with EDs. Careful differentiation between bipolar disorder and major depressive disorder in patients with EDs may help predict associated psychopathology and provide accurate treatment.

Suicidal behavior in adolescents and adults with bulimia nervosa

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prevalence and correlates of binge eating in seasonal affective disorder

Eating pathology in Seasonal Affective Disorder (SAD) may be more severe than hyperphagia during winter. Although research has documented elevated rates of subclinical binge eating in women with SAD, the prevalence and correlates of binge eating disorder (BED) in SAD remain largely uncharacterized. We examined the prevalence and correlates of binge eating, weekly binge eating with distress, and BED as defined by the DSM-IV-TR in SAD. We also tested whether binge eating exhibits a seasonal pattern among individuals with BED. Two samples were combined to form a sample of individuals with SAD (N=112). A third sample included non-depressed adults with clinical (n=12) and subclinical (n=11) BED. All participants completed the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R) and modified Seasonal Pattern Assessment Questionnaire (M-SPAQ). In the SAD sample, 26.5% reported binge eating, 11.6% met criteria for weekly binge eating with distress, and 8.9% met criteria for BED. Atypical symptom severity predicted binge eating and BED. In the BED sample, 30% endorsed seasonal worsening of mood, and 26% reported a winter pattern of binge eating. The spectrum of eating pathology in SAD includes symptoms of BED, which are associated with atypical depression symptoms, but typical depression symptoms.

Evaluation of reproductive function in women treated for bipolar disorder compared to healthy controls

OBJECTIVES

The purpose of the present study was to investigate the reproductive function of women with bipolar disorder (BD) compared to healthy controls.

METHODS

Women diagnosed with BD and healthy controls with no psychiatric history, aged 18-45 years, were recruited from a university clinic and surrounding community. Participants completed a baseline reproductive health questionnaire, serum hormone assessment, and ovulation tracking for three consecutive cycles using urine luteinizing hormone (LH)-detecting strips with a confirmatory luteal-phase serum progesterone.

RESULTS

Women with BD (n = 103) did not differ from controls (n = 36) in demographics, rates of menstrual abnormalities (MAs), or number of ovulation-positive cycles. Of the women with BD, 17% reported a current MA and 39% reported a past MA. Dehydroepiandrosterone sulfate and 17-hydroxyprogesterone levels were higher in controls (p = 0.052 and 0.004, respectively), but there were no other differences in biochemical levels. Medication type, dose, or duration was not associated with MA or biochemical markers, although those currently taking an atypical antipsychotic agent indicated a greater rate of current or past MA (80% versus 55%, p = 0.013). In women with BD, 22% reported a period of amenorrhea associated with exercising or stress, versus 8% of controls (p = 0.064). Self-reported rates of bulimia and anorexia nervosa were 10% and 5%, respectively.

CONCLUSIONS

Rates of MA and biochemical levels did not significantly differ between women with BD and controls. Current atypical antipsychotic agent use was associated with a higher rate of current or past MA and should be further investigated. The incidence of stress-induced amenorrhea should be further investigated in this population, as should the comorbid incidence of eating disorders.

Clinical phenotype of bipolar disorder with comorbid binge eating disorder

BACKGROUND

To explore the relationship between binge eating disorder (BED) and obesity in patients with bipolar disorder (BP).

METHODS

717 patients participating in the Mayo Clinic Bipolar Biobank completed structured diagnostic interviews and questionnaires for demographic and illness-related variables. They also had weight and height measured to determine body mass index (BMI). The effects of BED and obesity (BMI≥30 kg/m(2)), as well as their interaction, were assessed on one measure of general medical burden and six proxies of psychiatric illness burden.

RESULTS

9.5% of patients received a clinical diagnosis of BED and 42.8% were obese. BED was associated with a significantly elevated BMI. Both BED and obesity were associated with greater psychiatric and general illness burden, but illness burden profiles differed. After controlling for obesity, BED was associated with suicidality, psychosis, mood instability, anxiety disorder comorbidity, and substance abuse comorbidity. After controlling for BED status, obesity was associated with greater general medical comorbidity, but lower substance abuse comorbidity. There were no significant interaction effects between obesity and BED, or BMI and BED, on any illness burden outcome.

LIMITATIONS

There may have been insufficient power to detect interactions between BED and obesity.

CONCLUSIONS

Among patients with BP, BED and obesity are highly prevalent and correlated, but associated with different profiles of enhanced illness burden. As the association of BED with greater psychiatric illness burden remained significant even after accounting for the effect of obesity, BP with BED may represent a clinically important sub-phenotype.

Impulsivity, anxiety, and alcohol misuse in bipolar disorder comorbid with eating disorders

Background

Eating disorders (ED) are noted to occur with bipolar disorder (BD), but relationships between additional comorbidities, clinical correlates, and personality factors common to both remain largely unknown.

Methods

Using data from the Prechter Longitudinal Study of Bipolar Disorder, we measured the prevalence and demographic factors of comorbid ED with BD, presence of additional comorbidity of anxiety and substance use disorders, psychosis, suicide attempts, mixed symptoms, childhood abuse, impact of NEO-Personality Inventory (NEO-PI) personality factors, and mood outcome in 354 patients with BD. We analyzed the prevalence of ED using both broad and narrow criteria.

Results and discussion

ED was more common in the Prechter BD sample than the general population, with the majority of those with ED being female. Anxiety disorders, alcohol abuse/dependence, and NEO-PI N5 impulsiveness were independently associated with ED in a multivariable linear regression analysis. BD age at onset was earlier in the ED group than that in the non-ED group and was earlier than the average onset of ED. Anxiety occurred before ED and alcohol use disorders after both BD and ED. Childhood trauma was associated with ED. Impulsivity and anxiety associated with BD may fuel ED and put patients at risk for other impulsivity-related disorders such as alcohol use disorders. ED was associated with more severe and variable moods and more frequent depression. Patients with BD should be regularly screened for ED, anxiety disorders, and alcohol use disorders, and comorbidity should be promptly addressed.

Antipsychotic agents in the treatment of anorexia nervosa: neuropsychopharmacologic rationale and evidence from controlled trials

The search for an effective psychopharmacologic strategy in the treatment of anorexia nervosa (AN) has been elusive for decades and has run the gamut from reserpine to typical antipsychotics, to lithium, to tetrahydrocannabinol, to growth hormone, to anticonvulsants, to antidepressants, to atypical antipsychotics. Only recently has there arisen a potential "diamond in the rough" in the form of the atypical antipsychotic agent, olanzapine, which, in four randomized clinical trials, has shown superiority to placebo (two studies), chlorpromazine (one study), and aripiprazole (one study) in terms of weight gain and/or reduction in obsessional symptoms. The pharmacologic profile of olanzapine and other antipsychotic medications is discussed in light of the known pathophysiology of AN involving serotonin and dopamine systems, as well as brain-derived neurotrophic factor.

Clinical correlates of eating disorder comorbidity in women with bipolar disorder type I

OBJECTIVE

To report on the presence of current and lifetime eating disorders (ED) in a well-defined sample of 137 female individuals with bipolar disorder type I.

METHODS

Trained psychiatrists interviewed the patients, and the diagnoses of BD and comorbidities were confirmed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Axis I Disorders. Clinical and demographic characteristics of both groups (group with ED vs. group without ED) were compared.

RESULTS

Female patients with ED had an earlier onset of BD and an increased number of mood episodes, predominantly depressive. Women in the ED group also had higher rates of comorbidity with substance use disorders and anxiety disorders and reported a history of suicide attempts more frequently than women without ED.

CONCLUSION

The presence of ED is a correlate of severity of BD type I, and interventions should be developed to minimize distress and suicide risk and to improve treatment outcome.

Binge eating disorder and menstrual cycle in unmedicated women with bipolar disorder

OBJECTIVE

Weight increase is a problem in women with bipolar disorder (BD). Furthermore, there is evidence that both binge eating disorder (BED) and menstrual cycle abnormalities occur more frequently in women with affective disorders than in the general population. We investigated whether there is a clinical link between the two disorders and menstrual cycle.

METHOD

Epidemiological and clinical variables associated with both BD and BED were assessed as well as menstrual cycle influence.

RESULTS

The prevalence of BED in the sample was 28.8%. Menstrual cycle significantly influenced BED in all participants in that BED became worse prior to menses. 80% of the participants noticed regular weight gain prior to menses.

DISCUSSION

BED is a common comorbidity in unmedicated subjects with BD, as is overweight. In women with BD menstrual cycle should be taken into consideration, as it can worsen the BD itself and associated comorbidities such as BED and overweight. Alteration in menstrual cycle-associated eating behavior should be routinely assessed in women with BD.

Prevalence and correlates of eating disorders in 875 patients with bipolar disorder

OBJECTIVE

Relatively little is known about the co-occurrence of bipolar and eating disorders. We therefore assessed the prevalence and clinical correlates of eating disorders in 875 patients with bipolar disorder.

METHOD

875 outpatients with DSM-IV bipolar I or II disorder were evaluated with structured diagnostic interviews and clinician- and self-administered questionnaires to determine bipolar and eating disorder diagnoses, other comorbid Axis I disorder diagnoses, and demographic and historical illness characteristics.

RESULTS

125 (14.3%) patients met DSM-IV criteria for at least one comorbid lifetime Axis I eating disorder, with binge eating disorder (N=77) being more common than bulimia nervosa (n=42) and anorexia nervosa (N=27). There were no significant eating disorder comorbidity differences between bipolar I and bipolar II patients. Presence of a lifetime comorbid eating disorder was associated with female gender, younger age, earlier age of onset of mood symptoms and of bipolar disorder, presentation in a mixed episode, greater number of prior mood episodes, history of rapid cycling and suicide attempts, greater mean BMI, obesity and severe obesity, and family history of depression, bipolar disorder, alcoholism, and drug abuse. When the three eating disorder groups were compared, lifetime anorexia nervosa was associated with normal weight and a lifetime anxiety disorder, lifetime bulimia nervosa was associated with overweight, and lifetime binge eating disorder was associated with obesity and severe obesity.

CONCLUSIONS

Patients with bipolar disorder, especially women, not infrequently have comorbid eating disorders, and this comorbidity is associated with an earlier age of onset and more severe course of bipolar illness.

Prevalence of metabolic syndrome in bipolar patients initiating acute-phase treatment: a 6-month follow up

AIMS

To evaluate the prevalence of metabolic syndrome (MetS) and its correlates in patients with bipolar disorder (BD) during acute-phase treatment in southern China.

METHODS

This study included 148 BD patients presenting with acute mood symptoms and 65 healthy controls at entry. Sociodemographic characteristics were noted for all participants. For patients, lifestyle information (alcohol, smoking, and exercise habits) and clinical characteristics were also collected. Patients were followed up for 6 months after the commencement of pharmacological treatment. Using the Chinese Medical Association Diabetes Branch criteria, MetS prevalence rates were calculated at entry and recalculated for patients at months 1, 3, and 6.

RESULTS

At baseline, MetS was presented in 11.5% of the patients; overweight, 34.5%; low high-density lipoprotein cholesterol, 15.5%; hypertriglyceridemia, 29.1%; hypertension, 14.9%; and hyperglycemia, 5.4%. Compared with controls, the patients had a significantly higher prevalence of MetS and all its components except for hyperglycemia (P < 0.05). In the regression analysis, history of hypertension, presence of diabetes, and alcohol drinking were associated with MetS. During the follow-up period, rates of MetS and overweight increased gradually and stably, hypertriglyceridemia and low high-density lipoprotein cholesterol increased significantly in the first month and then remained stable, and hypertension and hyperglycemia remained stable all the time.

CONCLUSIONS

These data show that MetS is highly prevalent in Chinese BD patients. Weight gain and dyslipidemia result from a short period of treatment. Early interventions for weight gain and dyslipidemia are warranted.

A prospective latent analyses study of psychiatric comorbidity of DSM-IV bipolar I and II disorders

OBJECTIVE

To test two hypotheses of psychiatric comorbidity in bipolar disorder (BD): (i) comorbid disorders are independent of BD course, or (ii) comorbid disorders associate with mood.

METHODS

In the Jorvi Bipolar Study (JoBS), 191 secondary-care outpatients and inpatients with DSM-IV bipolar I disorder (BD-I) or bipolar II disorder (BD-II) were evaluated with the Structured Clinical Interview for DSM-IV Disorders, with psychotic screen, plus symptom scales, at intake and at 6 and 18 months. Three evaluations of comorbidity were available for 144 subjects (65 BD-I, 79 BD-II; 76.6% of 188 living patients). Structural equation modeling (SEM) was used to examine correlations between mood symptoms and comorbidity. A latent change model (LCM) was used to examine intraindividual changes across time in depressive and anxiety symptoms. Current mood was modeled in terms of current illness phase, Beck Depression Inventory (BDI), Young Mania Rating Scale, and Hamilton Depression Rating Scale; comorbidity in terms of categorical DSM-IV anxiety disorder diagnosis, Beck Anxiety Inventory (BAI) score, and DSM-IV-based scales of substance use and eating disorders.

RESULTS

In the SEM, depression and anxiety exhibited strong cross-sectional and autoregressive correlation; high levels of depression were associated with high concurrent anxiety, both persisting over time. Substance use disorders covaried with manic symptoms (r = 0.16-0.20, p < 0.05), and eating disorders with depressive symptoms (r = 0.15-0.32, p < 0.05). In the LCM, longitudinal intraindividual improvements in BDI were associated with similar BAI improvement (r = 0.42, p < 0.001).

CONCLUSIONS

Depression and anxiety covary strongly cross-sectionally and longitudinally in BD. Substance use disorders are moderately associated with manic symptoms, and eating disorders with depressive mood.

Where should bipolar disorder appear in the meta-structure?

BACKGROUND

The extant major psychiatric classifications, DSM-IV and ICD-10, are purportedly atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis is greatly enhanced by an understanding of both risk factors and clinical history. In an effort to group mental disorders on the basis of risk factors and clinical manifestations, five clusters have been proposed. The purpose of this paper is to consider the position of bipolar disorder (BPD), which could be either with the psychoses, or with emotional disorders, or in a separate cluster.

METHOD

We reviewed the literature on BPD, unipolar depression (UPD) and schizophrenia in relation to 11 validating criteria proposed by the DSM-V Task Force Study Group, and then summarized similarities and differences between BPD and schizophrenia on the one hand, and UPD on the other.

RESULTS

There are differences, often substantial and never trivial, for 10 of the 11 validators between BPD and UPD. There are also important differences between BPD and schizophrenia.

CONCLUSION

BPD has previously been classified together with UPD, but this is the least justifiable place for it. If it is to be recruited to a 'psychotic cluster', there are several important respects in which it differs from schizophrenia, so the cluster would have a division within it. The alternative would be to allow it to be in an intermediate position in a cluster of its own.

Abnormal temperament in patients with morbid obesity seeking surgical treatment

BACKGROUND

Obesity and its related disorders are growing epidemic across the world. Research on links between the bipolar spectrum and obesity has proliferated in the last few years. As some forms of abnormal temperament are considered as subtypes of the soft bipolar spectrum, we aimed to evaluate abnormal temperaments in morbidly obese patients.

METHODS

Using a short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego, we investigated abnormal depressive, cyclothymic, hyperthymic, irritable or anxious temperament in 213 patients with morbid obesity compared to a control group of 90 patients admitted prior to organ transplantation. Additionally, the Beck-Depression Inventory (BDI) and the Self-Report Manic Inventory (SRMI) were applied to assess current mood status.

RESULTS

The obese group showed statistically significantly more psychiatric comorbidities compared to the control group. Abnormal temperaments were significantly more often observed in patients with morbid obesity rather than in controls. Cyclothymic, irritable and anxious temperaments showed specificity to obesity. Obese patients had significantly higher scores on the BDI, while no difference for SRMI scores was found among the whole groups. All temperaments were positively correlated with BDI and SRMI in the obese group.

LIMITATIONS

The control group was not matched for demographic characteristics.

CONCLUSIONS

Our results need replication but indicate an affective overlap in the form of abnormal temperament and depressive symptoms in obese patients, whereas mood swings should be evaluated and early mood stabilization considered for patients with significant weight gain to prevent obesity or to reduce already existing overweight. Studies of mood stabilizers and prospective observations would shed further insight on this complex interface of a major clinical and public health issue.

Eating disorders and illness burden in patients with bipolar spectrum disorders

OBJECTIVES

The objectives of the study were to evaluate the clinical significance of lifetime eating disorder comorbidity in a well-defined sample of patients with bipolar spectrum disorders and to describe cognitive correlates of disordered eating in this group.

METHOD

Twenty-six bipolar patients with a lifetime history of a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-defined eating disorder (n = 17) or a clinically significant subthreshold eating disorder (n = 9) (ED group) were compared with 46 bipolar patients with no history of an eating disorder (no-ED group) on demographic and clinical characteristics at study presentation, history of bipolar illness, and other psychiatric comorbidity. Measures included the Structured Clinical Interview for the DSM-IV Axis I Disorders, the Clinical Global Impression-Severity Scale-Bipolar Version (CGI-S-BP), and the Eating Disorder Examination. Height and weight were recorded to calculate body mass index.

RESULTS

Patients in the ED group were heavier and were rated as more symptomatic on the CGI-S-BP than were patients in the no-ED group. The ED group also had a higher number of lifetime depressive episodes and greater psychiatric comorbidity, excluding eating and mood disorders. Finally, after controlling for body mass index and CGI-S-BP rating, patients in the ED group had significantly higher Eating Disorder Examination Restraint, Eating Concern, Shape Concern, Weight Concern, and Global scores than did patients in the no-ED group.

CONCLUSIONS

These findings highlight the need for a renewed emphasis on the evaluation and management of weight and eating in the mood disorders. In particular, this research suggests that eating disorder comorbidity may be a marker for increased symptom load and illness burden in bipolar disorder.