The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions

Development of a self-report screening instrument for emotional dysregulation: the Reactivity, Intensity, Polarity and Stability questionnaire, screening version (RIPoSt-SV)

BACKGROUND

Emotional dysregulation (ED) refers to the inability to manage emotional experiences or expressions hindering goal-oriented behavior. Moderate impairment on at least two domains among temper control, affective lability, and emotional over-reactivity has been proposed to identify ED in adults with attention-deficit/hyperactivity disorder (ADHD). No screening measure designed for use in diverse psychiatric samples exists. We aimed to develop a self-report screening tool for ED based on the 40-item version of the Reactivity, Intensity, Polarity, and Stability questionnaire (RIPoSt-40).

METHODS

150 adult outpatients with non-psychotic conditions were enrolled between February and July 2023 at the Second Psychiatry Unit of Pisa University Hospital. Clinically significant ED (CSED) was defined based on the previously suggested approach for ADHD. Differences between patients with and without CSED were tested. To develop our screening instrument, a decision tree algorithm was trained by hyperparameter tuning through 5-fold cross-validation in 120 subjects and tested on the remaining 30.

RESULTS

75 subjects met criteria for CSED (50 %). CSED was associated with lower age and higher prevalence of psychiatric conditions, including minor mood disorders, ADHD, cannabis use disorders, and eating disorders. We identified a decision tree consisting of six items from RIPoSt-40 that effectively detected CSED, with accuracy, sensitivity, specificity, positive and negative predictive values of 80 % or higher in both the training and testing sets.

LIMITATIONS

Tertiary-level; no consensus on criteria; sample size.

CONCLUSION

The screening version of the Reactivity, Intensity, Polarity, and Stability questionnaire (RIPoSt-SV) demonstrates promise as a valuable tool for ED screening in clinical settings.

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

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 disorders and emotional dysregulation are associated with insufficient weight loss after bariatric surgery: a 1-year observational follow-up study

PURPOSE

Subjects with obesity, especially those seeking bariatric surgery, exhibit high rates of mental disorders and marked psychopathological traits. The primary objective of this prospective, non-interventional study was to investigate whether the presence of different psychiatric disorders, attention deficit/hyperactivity disorder (ADHD) symptomatology and emotional dysregulation influenced weight loss at 1-year follow-up after surgery.

METHODS

Subjects consecutively referred for pre-surgical evaluation at the Obesity Center of Pisa University Hospital were recruited. Psychiatric diagnoses were made through the Mini-International Neuropsychiatric Interview (MINI) and ADHD symptomatology was assessed with the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). Emotional dysregulation was investigated through the WRAADDS and self-report questionnaires. After surgery, weight and obesity-related comorbidities were monitored during follow-up.

RESULTS

Of the 99 participants recruited, 76 underwent surgery and 65 could be reevaluated 1 year after surgery. Subjects with insufficient weight loss (excess body mass index loss ≤ 53%, n = 15) had more frequent lifetime binge eating disorder (BED) and BED-mood disorders comorbidity than subjects with favorable post-surgical outcome. Additionally, they scored higher on both physician-administered and self-report scales assessing emotional dysregulation, which represents a nuclear symptom of ADHD in adults. At the logistic regression analysis, older age, higher preoperative excess body mass index and greater affective instability were predictors of reduced weight loss at 1-year follow-up.

CONCLUSION

Emotional dysregulation seems to be associated with a worse outcome after bariatric surgery. Further studies with larger samples and longer follow-up are needed to confirm the influence of different psychiatric disorders and psychopathological traits on post-surgical outcome.

LEVEL OF EVIDENCE

V, prospective descriptive study.

What influences psychological functioning in patients with mood disorders? The role of clinical, sociodemographic, and temperamental characteristics in a naturalistic study

BACKGROUND

The present study aims to assess clinical and psychological correlates of psychological functioning in patients with mood disorders, in a naturalistic setting. In particular, we aimed to describe which sociodemographic, clinical, and temperamental dispositions are more frequently associated with poor psychological functioning, and to describe the association between cognitive and psychological functioning in euthymic patients with major depression and bipolar disorder.

METHODS

Inclusion criteria were as follows: (1) diagnosis of major depression, or bipolar disorder type I or II; (2) age between 18 and 65 years; and (3) being in a stable phase of the disorder. Patients' psychiatric symptoms, quality of life, affective temperaments, and impulsivity were investigated with validated assessment instruments.

RESULTS

166 patients have been recruited, mainly female (55.4%), whose mean age was 47.1 ± 14.2 years. 42.6% of individuals reported a diagnosis of major depression. According to regression analyses, poor cognitive performance (p < 0.05), reduced perceived quality of life (p < .0001), lifetime suicide attempts (p < 0.01), and increased trait-related impulsivity (p <0 .001) strongly correlated with poor psychological functioning. Moreover, cyclothymic and irritable dispositions were also associated with poor social functioning (p < 0.01), whereas hyperthymic affective disposition was associated to a better psychological performance (p < 0.01).

CONCLUSIONS

Our results support the evidence that patients with mood disorders should be assessed for psychological functioning and affective dispositions, to identify patients at higher risk to develop worse long-term outcomes and to develop targeted interventions.

Trait-Related Impulsivity, Affective Temperaments and Mood Disorders: Results from a Real-World Multicentric Study

Trait-related impulsiveness is highly prevalent in patients with mood disorders, being associated with negative outcomes. The predictive role of affective temperaments on trait-related impulsivity is still understudied. The aim of the present study is to investigate the relationship between impulsivity and affective temperaments in a sample of euthymic patients with mood disorders. This is a real-world multicentric observational study, carried out at the outpatient units of seven university sites in Italy. All patients filled in the short version of Munster Temperament Evaluation of the Memphis, Pisa, Paris and San Diego and the Barratt Impulsiveness Scale. The study sample included 653 participants, mainly female (58.2%), with a mean age of 46.9 (±14.1). Regression analyses showed that higher levels of trait-related impulsivity were associated to suicide attempts (p < 0.000), the presence of psychotic symptoms during acute phases (p < 0.05), a seasonal pattern (p < 0.05), a lower age at onset of the disorder (p < 0.05), cyclothymic (p < 0.01) and irritable temperaments (p < 0.01). The results of our study highlight the importance to screen patients with mood disorders for impulsivity and affective temperaments in order to identify patients who are more likely to present a worse outcome and to develop personalized and integrated early pharmacological and psychosocial treatment plans. Novelties of the present paper include the recruitment of patients in a stable phase, which reduced possible bias in patients’ self-reports, and the multicentric nature of the study, resulting in the recruitment of a large sample of patients with mood disorders, geographically distributed across Italy, thus improving the generalizability of study results.

Affective temperament and mood spectrum symptoms in workers suffering from work-related stress disorders

INTRODUCTION

Adjustment Disorders (AD) which develop in response to work-related stressors represent a model of psychiatric occupational disease. Major Depressive Episodes (MDE) although often associated to work-related stressors are unlikely recognized by insurance institutes as occupational diseases. Affective temperament and mood spectrum symptoms are possible factors of vulnerability to stress. The aim of this study was to investigate if temperaments and mood spectrum symptoms had a different distribution among workers exposed to occupational stress and suffering from different psychiatric disorders (AD, MDE).

METHODS

156 AD and 97 MDE patients were recruited and evaluated with scales for perceived stress (PSM) and work-related stress (JCQ), for psychopathological symptoms (BDI-II, SAS), for affective temperament (TEMPS-A[P]) and for lifetime mood spectrum symptoms (MOODS-SR). Group comparisons and correlation analyses between variables were performed by parametric or non-parametric statistical tests according to variables distribution.

RESULTS

The diagnostic groups did not differ for perceived and occupational stress levels. MDE patients reported significantly higher BDI-II score and MOODS-SR scores than AD ones. The hyperthymic temperament was significantly more frequent in AD than in MDE group. The hyperthymic score, differently from other dimensions of temperament and from mood spectrum components, negatively correlated or did not correlate with psychopathological symptoms severity and perceived stress levels.

LIMITATIONS

Predictive limitation because of cross-sectional design.

CONCLUSIONS

The hyperthymic temperament as opposed to lifetime subtreshold mood symptoms appears to be more represented in patients suffering from occupational AD than in MDE ones. Acknowledging vulnerability factors to job stress could support clinicians in occupational diseases prevention and management.

The assessment of cyclothymic-hypersensitive temperament in youth with mood disorders and attention deficit hyperactivity disorder

BACKGROUND

Cyclothymic-hypersensitive temperament (CHT) has been related to both depression and bipolarity, as well as to suicidality. Recently, a psychometrically sound way of assessment has been validated in youth (Cyclothymic-Hypersensitive Temperament Questionnaire, CHTQ), but data on clinical populations are still scant. Aim of our study is to further explore the structure and other psychometric properties of the revised version of CHTQ and its clinical implications in clinical samples.

METHODS

The study is based on a dataset of patients with unipolar depression, bipolar disorder and attention deficit and hyperactivity disorder (ADHD) (243 patients, 135 males, mean age 14.22 ± 2.16 years, age range 9-18 years), compared to a community sample of adolescents (398 subjects, 95 boys, mean age 15.47 ± 1.96 years, age range 10-18 years) RESULTS: The two-correlated factor structure of CHT has been confirmed, with a moodiness/hypersensitiveness factor, correlated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, correlated with externalizing symptoms. All CHTQ scores correlate with global functioning. CHTQ total scores discriminate patients from healthy controls. Only CHTQ impulsiveness/emotional dysregulation subscale score is higher in bipolar patients, compared to unipolar depression and ADHD, whereas neither CHTQ moodiness/hypersensitiveness subscale score nor CHTQ total score discriminate between clinical groups.

LIMITATION

Data on current mood states are unavailable. Patients were recruited in a third level clinic. The unipolar depression group is relatively small.

CONCLUSION

CHT may be a rapid and reliable screening and diagnostic tool in the clinical practice with youth, exploring the cyclothymic dimension in different psychiatric disorders.

Quarantine and Mental Health Challenges for Occupational Medicine: The Case Report of a Nurse Infected With SARS-CoV-2

This case study draws attention to the psychosocial difficulties that emerged in the context of the coronavirus disease 2019 (COVID-19) outbreak in relation to the remote management of subjects with psychiatric vulnerabilities following exposure to prolonged quarantine. The case involves a 56-year-old hospital nurse, followed by the Occupational Health Department of a major university hospital in central Italy for mood instability in the context of a cyclothymic temperament. She was quarantined for occupationally acquired COVID-19 and remained positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via swab test for more than 2 months between March and May 2020. In this case study, we discuss the challenges presented by the risk of a prolonged quarantine in a psychologically vulnerable employee, the need for occupational medicine to provide adequate health surveillance of all health care workers during the COVID-19 pandemic, the effectiveness of telepsychiatry, and the difficulties in formulating a proper treatment strategy.

Peripheral non-enzymatic antioxidants as biomarkers for mood disorders: Evidence from a machine learning prediction model

BACKGROUND

Oxidative stress is related to the pathogenesis of mood disorders, and the level of oxidative stress may differ between bipolar disorder (BD) and major depressive disorder (MDD). This study aimed to detect the differences in non-enzymatic antioxidant levels between BD and MDD and assess the predictive values of non-enzymatic antioxidants in mood disorders by applying a machine learning model.

METHODS

Peripheral uric acid (UA), albumin (ALB), and total bilirubin (TBIL) were measured in 1,188 participants (discover cohort: 157 with BD and 544 with MDD; validation cohort: 119 with BD and 95 with MDD; 273 healthy controls). An extreme gradient boosting (XGBoost) model and a logistic regression model were used to assess the predictive effect.

RESULTS

All three indices differed between patients with mood disorders and healthy controls; in addition, the levels of UA in patients with BD were higher than those of patients with MDD. After treatment, UA levels increased in the MDD group, while they decreased in the BD group. Finally, we entered age, sex, UA, ALB, and TBIL into the XGBoost model. The area under the curve (AUC) of the XGBoost model for distinguishing between BD and MDD reached 0.849 (accuracy = 0.808, 95% CI = 0.719-0.878) and for distinguishing between BD with depression episode (BD-D) and MDD was 0.899 (accuracy = 0.891, 95% CI = 0.856-0.919). The models were validated in the validation cohort. The most important feature distinguishing between BD and MDD was UA.

CONCLUSION

Peripheral non-enzymatic antioxidants, especially the UA, might be a potential biomarker capable of distinguishing between BD and MDD.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Neurocognition Function of Patients With Bipolar Depression, Unipolar Depression, and Depression With Bipolarity

Much evidence shows that some Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)-defined unipolar depression (UD) with bipolarity manifests bipolar diathesis. Little is known about the cognitive profiles of patients with depression with bipolarity (DWB). The study aimed to investigate the differences in cognitive profiles among patients with bipolar depression (BD), major depressive disorder (namely, UD), and DWB. Drug-naïve patients with BD, UD, and DWB and healthy controls (HC) were recruited (30 cases in each group). Cognitive function was evaluated by THINC-it (THINC-intelligent tool), Wisconsin Card Sorting Test (WCST), and continuous performance test (CPT). For THINC-it, no significant differences of the Z-scores in both objective and subjective factors were found between the DWB group and BD group, but the Z-scores in the BD group were significantly lower than those in the UD group. For WCST, significant differences were found between the BD group and DWB group in the number of responses, categories completed, trails to completed first category, perseverative responses, and perseverative errors. All the indices of WCST in the DWB group were significantly worse than those in the UD group except for trails to completed first category and total number of response correct. For CPT, only scores of leakage responses and false responses in the four-digit number in the BD group and DWB group were significantly higher than those in the UD group; no significant difference was found between the BD group and DWB group. The results indicated that patients with DWB might perform differently from those with UD but similarly to those with BD with cognition impairment.

Comparison of Emotional Dysregulation Features in Cyclothymia and Adult ADHD

Background and Objectives: Emotional dysregulation is central to the problem of the overlap between attention-deficit/hyperactivity disorder (ADHD) and cyclothymia. The aim of the study was to evaluate comorbidity rates between ADHD and cyclothymic disorder and to explore demographic and clinical differences among the groups, focusing on affective temperament and emotional dysregulation. Materials and Methods: One hundred sixty-five outpatients attending the Second Psychiatry Unit at the Santa Chiara University Hospital (Pisa) were consecutively recruited: 80 were diagnosed with ADHD, 60 with cyclothymic disorder, and 25 with both conditions. Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS-M) and the 40-item version of Reactivity, Intensity, Polarity, and Stability questionnaire (RI-PoSt-40) were administered. Results: Cyclothymic patients were more frequently female and older with respect to the ADHD groups. Both comorbid and non-comorbid ADHD patients showed significantly lower educational attainment and more frequently had substance use disorders. Panic disorder was common in non-comorbid cyclothymic patients, who showed significantly higher rates of familial panic disorder, major depressive disorder and suicide attempts in comparison with patients only diagnosed with ADHD. Cyclothymic patients without ADHD were also characterized by fewer hyperthymic temperamental traits, higher depressive and anxious dispositions, and a greater negative emotionality. No significant differences among groups were observed for cyclothymic temperament and overall negative emotional dysregulation, but comorbid patients with both conditions scored the highest in these subscales. This group also showed significantly higher affective instability with respect to ADHD patients without cyclothymia and was less frequently diagnosed with bipolar disorder type II than patients from both the other groups. Conclusions: ADHD and cyclothymia often co-occur and show similar levels of emotional dysregulation. However, cyclothymic patients may be more prone to negative emotionality in clinical settings. Subjects with “sunny” cyclothymic features might escape the attention of clinicians unless ADHD is present.

Affective Temperaments, Panic Disorder and Their Bipolar Connections

Background and Objectives: The role of affective temperament in the genesis and outcome of major mood disorders is well studied, but there are only a few reports on the relationship between panic disorder (PD) and affective temperaments. Accordingly, we aimed to study the distribution of affective temperaments (depressive (DE); cyclothymic (CT); irritable (IRR); hyperthymic (HT) and anxious (ANX)) among outpatients with PD. Materials and Methods: Affective temperaments of 118 PD outpatients (80 females and 38 males) with or without agoraphobia but without any other psychiatric disorder at the time of inclusion were evaluated using the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and compared with the affective temperament scores of control subjects. All patients were followed up for at least 1.5 years in order to detect the onset of any major affective disorders, substance use disorders and suicide attempts. Results: Among females, the dominant ANX and DE temperaments were four and three times as common as in a large normative Hungarian sample (for both cases p < 0.01). Among male PD patients, only the dominant DE temperament was slightly overrepresented in a non-significant manner. Females with PD obtained significantly higher scores on ANX, DE and CT subscales of the TEMPS-A, whereas males with PD showed significantly higher scores on ANX, DE and HT temperament subscales compared with the members of a large normative Hungarian sample and also with a gender- and age-matched control group. During the follow-up, newly developed unipolar major depression and bipolar spectrum (bipolar I or II and cyclothymic) disorders appeared in 64% and 22% of subjects, respectively. Conclusions: Our preliminary findings suggest that a specific, ANX-DE-CT affective temperament profile is characteristic primarily for female patients, and an ANX-DE-HT affective temperament profile is characteristic for male patients with PD, respectively. These findings are in line with expectations because PD is an anxiety disorder par excellence on the one hand, whereas, on the other hand, it is quite frequently comorbid with mood (including bipolar) disorders.

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.

Affective Temperaments and Illness Severity in Patients with Bipolar Disorder

Background and objectives: Bipolar disorder (BD) is one of the most burdensome psychiatric illnesses, being associated with a negative long-term outcome and the highest suicide rate. Although affective temperaments can impact on BD long-term outcome, their role remains poorly investigated. The aims of the present study are to describe the clinical characteristics of patients with BD more frequently associated with the different affective temperaments and to assess the relation between affective temperaments and severity of clinical picture in a sample of patients with BD. Materials and Methods: A total of 199 patients have been recruited in the outpatients units of two university sites. Patients’ psychiatric symptoms, affective temperaments, and quality of life were investigated through validated assessment instruments. Results: Predominant cyclothymic and irritable temperaments are associated to higher number of relapses, poorer quality of life, higher rates of aggressive behaviors, and suicide attempts. Conversely, the predominant hyperthymic disposition was a protective factor for several outcome measures, including relapse rate, severity of anxiety, depressive and manic symptoms, suicidality, and earlier age at onset. One limitation of the present study is that the recruitment took place in two university sites; therefore, our findings cannot be fully generalized to the whole community of BD patients. Other limitations are the lack of a control group and the cross-sectional design of the study. Conclusions: The early identification of affective temperaments can help clinicians to identify those BD patients who are more likely to show a poor long-term outcome. An early screening of affective temperaments can be useful to develop targeted integrated pharmacological and psychosocial interventions.

A prospective longitudinal study searching for predictors of response to group psychoeducation in bipolar disorder

BACKGROUND

The efficacy of adjunctive group psychoeducation in bipolar disorder has been proven although treatment response differ among individuals. The aim of this study was to characterize responders and non-responders to group psychoeducation in order to identify baseline variables that could predict treatment response.

METHODS

The sample was composed of 103 medicated euthymic patients with bipolar disorder referred to 21 sessions of group psychoeducation (6 months). Sociodemographic and clinical variables, temperament, circadian rhythms, BDNF, cognitive and psychosocial functioning were collected. At the 18-month endpoint, the patients were split in two groups on the basis of having suffered any recurrence. Significant group differences were included in a logistic regression analysis.

RESULTS

Ninety patients out of 103 engaged in group psychoeducation, 47 of whom (52.2%) responded to psychoeducation and 43 (47.8%) did not. Recurrences occurred more often in the follow-up, the most common being depression. Responders and non-responders differed in gender, age at diagnosis, latency of diagnosis, temperament, attention composite score and BDNF. Lower age at diagnosis of bipolar disorder, lower cyclothimic temperament scores and being male -which was associated with bipolar type I and a trend to more previous manic episodes- were significantly related to a better response to psychoeducation in the regression analysis.

LIMITATIONS

No control group.

CONCLUSIONS

This study identifies age at diagnosis as a significant modifiable risk factor of treatment response, highlighting the need for early identification of bipolar disorder. Existing programs should be adjusted to the characteristics of specific subpopulations in the framework of a personalized approach.

Psychiatric Aspects of Obesity: A Narrative Review of Pathophysiology and Psychopathology

In the last decades, obesity has become a major concern for clinical and public health. Despite the variety of available treatments, the outcomes remain—by and large—still unsatisfactory, owing to high rates of nonresponse and relapse. Interestingly, obesity is being associated with a growing surge of neuropsychiatric problems, certainly related to the pathogenesis of this condition, and likely to be of great consequence as for its treatment and prognosis. In a neurobiologic direction, a sturdy body of evidence has recently shown that the immune–metabolic–endocrine dyscrasias, notoriously attached to excess body weight/adiposity, affect and impair the morpho-functional integrity of the brain, thus possibly contributing to neuroprogressive/degenerative processes and behavioral deviances. Likewise, in a neuropsychiatric perspective, obesity displays complex associations with mood disorders and affective temperamental dimensions (namely cyclothymia), eating disorders characterized by overeating/binge-eating behaviors, ADHD-related executive dysfunctions, emotional dysregulation and motivational–addictive disturbances. With this review, we attempt to provide the clinician a synoptic, yet exhaustive, tool for a more conscious approach to that subset of this condition, which could be reasonably termed “psychiatric” obesity.

Cyclothymic-hypersensitive temperament in youths: Refining the structure, the way of assessment and the clinical significance in the youth population

BACKGROUND

Although a better understanding of the prodromes of affective disorders in youth has important clinical and research implications, empirical data are still unconclusive. Cyclothymic-hypersensitive temperament (CHT) has been linked to both depression and bipolarity, as well as to suicidality. Its conceptualization is still debated, as well as a comprehensive, psychometrically sound way of assessment.

METHODS

factor structure, reliability, measurement invariance, convergent and divergent validity of the previously published CHT questionnaire (a youth version derived from Temperament Evaluation in Memphis Pisa and San Diego (TEMPS) was assessed in a school-based sample of 2959 students aged from 10 to 14 years (mean age = 11.8 ± 0.97 years). Furthermore, accuracy, sensitivity and specificity were calculated for a new cut-off score related to the presence of general psychopathology symptoms.

RESULTS

CHT is better conceptualized in a two-correlated factors model, a moodiness/hypersensitiveness factor, more associated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, more associated with externalizing symptoms. The revised 22-items version of the CHT questionnaire with a cut-off score of 15 for females and 17 for males results accurate, sensitive and specific enough for the recognition of cyclothymic adolescents with clinical symptoms.

LIMITATION

the cross sectional design and the self-report nature of the measures limit the findings.

DISCUSSION

Cyclothymic-hypersensitive temperament is a relevant concept in the realm of affective disorder and can be reliably assessed in youths. It may describe youths with the coexistence of both internalizing and externalizing symptoms that can be difficult to diagnose with a DSM perspective.

The impact of premenstrual dysphoric disorder among 92 bipolar patients

Objectives

To evaluate the impact of Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV)-defined premenstrual dysphoric disorder (PMDD) lifetime co-morbidity among 92 bipolar patients.

Method

Ninety-two women with a lifetime diagnosis of DSM-IV-defined Bipolar Disorder (BD) either type I or type II were consecutively enrolled to determine co-morbidity rates with PMDD and associated clinical features. Measures included the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I) and the Clinical Global Impression (CGI) rating scale.

Results

In our sample, 25 (27.2%) patients reported a lifetime history of PMDD according to DSM-IV criteria (PMDD+). PMDD+ reported higher rates of Cyclothymia and BP-II than PMDD− (respectively 72% vs. 36% and 88% vs. 60%). On the contrary, the carbohydrate-craving feature was more represented among PMDD− than PMDD+ (25% vs. 4%). PMDD was also significantly associated with post-partum depression (36% vs. 15%), Obsessive-Compulsive (24% vs. 7.5%) and Body Dysmorphic Disorders (24% vs. 6%). Finally, PMDD+ reported higher total number of Axis I co-morbid disorders than PMDD−.

Conclusions

In our cohort of BD women, PMDD is a frequent co-morbid condition, in particular among patients with BD-II or Cyclothymia. Multiple co-morbidities also represent a clinical variable associated with PMDD. Further perspective studies are necessary to better define the relationships between PMDD and BD.

The link between bipolarity and substance use: A controlled clinic based study

OBJECTIVES

Because of high rates of co-occurrence, common familial risk, and phenotypic similarities, we conjectured that substance use and bipolar disorder might have a common substrate of origin in bipolarity and that they might lie on a continuum of bipolarity. Thus it was aimed to investigate the association between bipolarity and substance use through a controlled, clinic based study.

METHODS

Cross sectional assessment and comparison of bipolarity as trait in four groups, namely the substance use disorder (SUD), bipolar disorder (BPAD), dual diagnosis (DD), and the healthy control (HC) groups. Bipolar spectrum diagnostic scale (BSDS) was used. The quality of life in these four groups was also assessed using WHOQOL-Bref scale.

RESULTS

The mean Bipolar spectrum diagnostic scale (BSDS) score in SUD was 11.0 ± 5.3 which was more than that of HC (6.2 ± 3.9) and lesser than that in BPAD (18.4 ± 4.2) and DD (20.6 ± 3.6). Differences among all four groups were statistically significant. SUD group was found to have significantly higher score than healthy control. The BSDS score of DD and BPAD groups were higher than those of SUD but the difference between BPAD and DD was non-significant.

DISCUSSION

The results showed a potential association between substance dependence and bipolarity. Mood dysregulation appears to be the link between the two. The gradient of bipolarity detected by BSDS screener suggests a continuum model between substance use and bipolar disorder. However, this is a clinic based study and only male patients have been taken for study.

Clinical phenotype and genetic risk factors for bipolar disorder with binge eating: an update

Introduction: Clinical and genetic study of psychiatric conditions has underscored the co-occurrence of complex phenotypes and the need to refine them. Bipolar Disorder (BD) and Binge Eating (BE) behavior are common psychiatric conditions that have high heritability and high co-occurrence, such that at least one quarter of BD patients have BE (BD + BE). Genetic studies of BD alone and of BE alone suggest complex polygenic risk models, with many genetic risk loci yet to be identified. Areas covered: We review studies of the epidemiology of BD+BE, its clinical features (cognitive traits, psychiatric comorbidity, and role of obesity), genomic studies (of BD, eating disorders (ED) defined by BE, and BD + BE), and therapeutic implications of BD + BE. Expert opinion: Subphenotyping of complex psychiatric disorders reduces heterogeneity and increases statistical power and effect size; thus, it enhances our capacity to find missing genetic (and other) risk factors. BD + BE has a severe clinical picture and genetic studies suggests a distinct genetic architecture. Differential therapeutic interventions may be needed for patients with BD + BE compared with BD patients without BE. Recognizing the BD + BE subphenotype is an example of moving towards more precise clinical and genetic entities.

The relationship between attention deficit hyperactivity disorder, bipolarity and mixed features in major depressive patients: Evidence from the BRIDGE-II-Mix Study

OBJECTIVE

This study primarily focused on the relationship between comorbid attention deficit-hyperactivity disorder (ADHD), mixed features and bipolarity in major depressive patients.

METHODS

The sample comprised 2777 patients with Major Depressive Episode (MDE) enrolled in a multicentre, multinational study originally designed to assess different definitions of mixed depression. Socio-demographic, familial and clinical characteristics were compared in patients with (ADHD + ) and without (ADHD-) comorbid ADHD.

RESULTS

Sixty-one patients (2.2%) met criteria for ADHD. ADHD was associated with a higher number of (hypo)manic symptoms during depression. Mixed depression was more represented in ADHD + patients than in ADHD- using both DSM-5 and experimental criteria. Differences were maintained after removing overlapping symptoms between (hypo)mania and ADHD. ADHD in MDE was also associated with a variety of clinical and course features such as onset before the age of 20, first-degree family history of (hypo)mania, past history of antidepressant-induced (hypo)manic switches, higher number of depressive and affective episodes, atypical depressive features, higher rates of bipolarity specifier, psychiatric comorbidities with eating, anxiety and borderline personality disorders.

LIMITATIONS

The study was primarily designed to address mixed features in ADHD, with slightly reduced sensitivity to the diagnosis of ADHD. Other possible diagnostic biases due to heterogeneity of participating clinicians.

CONCLUSIONS

In a sample of major depressive patients, the comorbid diagnosis of current ADHD is associated with bipolar diathesis, mixed features, multiple psychiatric comorbidity and a more unstable course. Further prospective studies are necessary to confirm the possible mediating role of temperamental mood instability and emotional dysregulation in such a complex clinical presentation.

Factors associated with false positives in MDQ screening for bipolar disorder: Insight into the construct validity of the scale

BACKGROUND

Identifying bipolar patients in the first phases of the illness is essential to establish adequate treatment. The goal of this study was to examine the discriminant ability of the Mood Disorders Questionnaire (MDQ) in recognizing bipolar patients referred to a tertiary care structure.

METHODS

Between 2006 and 2012, we assessed 843 individuals referred to the Mood Disorders Program by family physicians in the community. The Structured Clinical Interview for DSM-IV-TR (SCID) was used to assess diagnoses. A nurse collected the information about lifetime symptoms of (hypo)mania in 759 individuals using the MDQ. Univariate chi-square test and logistic regression were used for the statistical analysis.

RESULTS

Overall, 86% of the sample had a current anxiety or depressive disorder. When compared to the diagnoses formulated through the SCID, the sensitivity of the MDQ was 75.0%, the specificity was 74%, the positive predictive value was 55%, and the negative predictive value was 88%. Among non-bipolar patients, current post-traumatic stress disorder, borderline personality disorder, current or early remission substance use disorder, and the history of childhood abuse were independently associated with false positive screening using the MDQ.

LIMITATIONS

Individuals with current substance use disorders were under-represented, whether or not the patients were aware of their diagnosis of bipolar disorder was not recorded, and the history of childhood abuse was collected based on an open interview.

CONCLUSIONS

The self-rated measure of the symptoms listed by the MDQ seems to measure a dimension shared by both bipolar disorder and other conditions characterized by affective instability and impulsivity.

The (Suicidal-) Depressive Position: A Scientifically Informed Reformulation

Despite considerable progress in depression research and treatment, the disorder continues to pose daunting challenges to scientists and practitioners alike. This article presents a novel conceptualization of the psychological dynamics of depression which draws from Melanie Klein's notion of the positions, reformulated using social-cognitive terms. Specifically, Klein's notion of position, consisting of anxieties (persecutory vs. "depressive"), defense mechanisms ("primitive"/split based vs. neurotic/repression based), and object relations (part vs. whole) is reformulated to include (1) affect, broadly defined, (2) affect regulatory strategies (defense mechanisms, coping strategies, and motivation regulation), and (3) mental representations of self-with-others, all pertaining to the past, present, and future. I reformulate the depressive position to include-beyond sadness, anxiety, and anhedonia-also anger/agitation, shame, disgust, and contempt, all of which are down-regulated via diverse mechanisms. In the depressive position, the self is experienced as wronged and others as punitive, albeit seductive. Attempts to appease internal others (objects) are projected into the future, only to be thwarted by awkward and inept interpersonal behavior. This might propel the use of counter-phobic, counter-dependent, and "manic" affect regulatory mechanisms, potentially leading to suicidal depression.

Diagnosis and Treatment of Cyclothymia: The "Primacy" of Temperament

Background: Contrary to DSM-5 definition based on recurrence of low grade hypomanic and depressive symptoms, cyclothymia is better defined in a neurodevelopmental perspective as an exaggeration of cyclothymic temperament. Emotional dysregulation with extreme mood instability and reactivity is the core features of the complex symptomatology.

Method: In the present article, we critically reviewed the literature on the diagnosis and treatment of cyclothymia, focusing on the temperamental and neurodevelopmental perspectives.

Results: Current epidemiological and clinical research showed the high prevalence and the validity of cyclothymia as a distinct form of bipolarity, frequently associated with multiple comorbidities with anxiety, impulse control, substance use, and so called “personality” disorders. Many patients receive correct diagnosis and treatments after many years of illness, when the superposition of complications reduces the possibility of complete remission. A therapeutic model combining the focus on symptomatic presentations with a temperamental perspective seems to represent an effective approach for cyclothymic patients with complex clinical presentations.

Conclusion: Cyclothymic mood instability is an understudied issue despite the evidence of its clinical relevance. Unresolved issues concern its diagnostic delimitation and the possible relationships with emotional dysregulation observed in other neurodevelopmental disorders. We need to confirm the specificity of the disorder and to improve its recognition in early phase of the life, especially in youth. Early recognition means avoiding unnecessary complications and establishing specific treatments and clinical management since the beginning.

The impact of affective temperaments on clinical and functional outcome of Bipolar I patients that initiated or changed pharmacological treatment for mania

BACKGROUND

Affective temperaments have been shown to impact on the clinical manifestations and the course of bipolar disorder. We investigated their influence on clinical features and functional outcome of manic episode.

METHOD

In a naturalistic, multicenter, national study, a sample of 194 BD I patients that initated or changed pharmacological treatment for DSM-IV-TR manic episode underwent a comprehensive evaluation including briefTEMPS-M, CTQ, YMRS, MADRS, FAST, and CGI-BP. Factorial, correlation and comparative analyses were conducted on different temperamental subtypes.

RESULTS

Depressive, cyclothymic, irritable and anxious temperaments resulted significantly correlated with each other. On the contrary, hyperthymic temperament scores were not correlated with the other temperamental dimensions. The factorial analysis of the briefTEMPS-M sub-scales total scores allowed the extraction of two factors: the Cyclothymic-Depressive-Anxious (Cyclo-Dep-Anx) and the Hyperthymic. At final evaluation Dominant Cyclo-Dep-Anx patients reported higer scores in MADRS and in CTQ emotional neglect and abuse subscale scores than Dominant Hyperthymic patients. The latter showed a greater functional outcome than Cyclo-Dep-Anx patients.

CONCLUSIONS

Affective temperaments seem to influence the course of mania. Childhood emotional abuse and neglect were related to the cyclothymic disposition. Cyclothymic subjects showed more residual depressive symptoms and Hyperthymic temperament is associated with a better short-term functional outcome.

Non suicidal self-injury in referred adolescents with mood disorders and its association with cyclothymic-hypersensitive temperament

BACKGROUND

Non suicidal self-injuries (NSSIs) are deliberate self-harm behaviors without suicidal intent, usually starting in adolescence, with increasing rates of occurrence both in epidemiological and clinical samples. Several studies associated cyclothymic-hypersensitive temperament (CHT) with self-harm behaviors and suicidal risk. Aim of this study is to explore the association between NSSIs and CHT in a clinical sample of adolescents. We hypothesized that CHT may differentiate NSSI from non-NSSI adolescents with mood disorders, when other psychopathological features are controlled for.

METHODS

A consecutive sample of 89 adolescents with mood disorders were assessed for presence and phenomenology of NSSIs, CHT, demographics, comorbid categorical psychiatric diagnoses, dimensional psychopathology, impairment and previous suicide attempts.

RESULTS

NSSIs were reported in 52% of the sample, with higher rates in females and in bipolar disorder. Regression analyses showed that CHT, but not age, gender, bipolar vs depression diagnosis, functional impairment, was associated with NSSIs.

DISCUSSION

CHT may be in close association with NSSIs in adolescents with mood disorders. An assessment of CHT in adolescents referred for mood disorder may help to detect specific psychological features of NSSIs, which may improve diagnostic and treatment strategies.

LIMITATIONS

Given the cross-sectional design, a developmental relation between CHT and NSSIs cannot be determined. The small sample size and the selection bias of severely impaired patients limit the generalization of the results. More sophisticated measures of CHT may consent to explore other dimensions of the cyclothymic construct (i.e., emotional intensity, emotional reactivity, emotional stability, positive vs. negative emotions, interpersonal sensitivity, impulsivity).

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.

Personality disorder symptom severity predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum disorder

Although personality disorders (PDs) are highly comorbid with bipolar spectrum disorders (BSDs), little longitudinal research has been conducted to examine the prospective impact of PD symptoms on the course of BSDs. The aim of this study is to examine whether PD symptom severity predicts shorter time to onset of bipolar mood episodes and conversion to bipolar I disorder over time among individuals with less severe BSDs. Participants (n = 166) with bipolar II disorder, cyclothymia, or bipolar disorder not otherwise specified completed diagnostic interview assessments of PD symptoms and self-report measures of mood symptoms at baseline. They were followed prospectively with diagnostic interviews every 4 months for an average of 3.02 years. Cox proportional hazard regression analyses indicated that overall PD symptom severity significantly predicted shorter time to onset of hypomanic (hazard ratio [HR] = 1.42; p < .001) and major depressive episodes (HR = 1.51; p < .001) and conversion to bipolar I disorder (HR = 2.51; p < .001), after controlling for mood symptoms. Results also suggested that cluster B severity predicted shorter time to onset of hypomanic episodes (HR = 1.38; p = .002) and major depressive episodes (HR = 1.35; p = .01) and conversion to bipolar I disorder (HR = 2.77; p < .001), whereas cluster C severity (HR = 1.56; p < .001) predicted shorter time to onset of major depressive episodes. These results support predisposition models in suggesting that PD symptoms may act as a risk factor for a more severe course of BSDs. (PsycINFO Database Record

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.

Alcohol use disorders are associated with increased affective lability in bipolar disorder

BACKGROUND

Affective dysregulation is a core feature of bipolar disorder (BD), and inter-episodic affect lability is associated with more severe outcomes including comorbidity. Rates of daily tobacco smoking and substance use disorders in BD are high. Knowledge regarding relationships between affective lability and abuse of the most commonly used substances such as tobacco, alcohol and cannabis in BD is limited.

METHODS

We investigated whether dimensions of inter-episodic affective lability as measured with the Affective Lability Scale - short form (ALS-SF) were associated with lifetime daily tobacco use or alcohol (AUD) or cannabis use disorders (CUD) in a sample of 372 French and Norwegian patients with BD I and II.

RESULTS

ALS-SF total score and all sub-dimensions (anxiety-depression, depression-elation and anger) were significantly associated with AUD, while only the depression-elation sub-dimension was associated with CUD, after controlling for possible confounders such as gender, age at interview, age at illness onset, BD subtype, duration of illness and other substance use disorders. Daily tobacco smoking was not significantly associated with affective lability.

LIMITATIONS

Data for recent substance use or psychiatric comorbidities such as personality or hyperkinetic disorders were not available, and could have mediated the relationships.

CONCLUSION

AUD is associated with several dimensions of inter-episodic affective lability in BD, while CUD is associated with increased oscillations between depression and elation only. Increased affective lability may partly explain the increased illness severity of patients with BD and AUD or CUD. Affective lability should be treated in order to prevent these comorbidities.

Binge Eating Disorder and Bipolar Spectrum disorders in obesity: Psychopathological and eating behaviors differences according to comorbidities

BACKGROUND

Obesity is not a mental disorder, yet DSM-5 recognizes a strong association between obesity and psychiatric syndromes. Disorders within the Bipolar Spectrum (BSD) and Binge Eating Disorder (BED) are the most frequent psychiatric disorders among obese patients. The aim of this research is to investigate the psychopathological differences and the distinctive eating behaviors that accompany these comorbidities in obese patients.

METHODS

One hundred and nineteen obese patients (40 males; 79 females) underwent psychological evaluation and psychiatric interview, and a dietitian evaluated their eating habits. Patients were divided into four groups according to comorbidities, and comparisons were run accordingly.

RESULTS

Forty-one percent of participants presented BED+BSD comorbidity (Group 1), 21% BED (Group 2) and 8% BSD (Group 3); only 29% obese participants had no comorbidity (Group 4). Female gender was overrepresented among Groups 1 and 2. BSD diagnosis varied according to comorbidities: Type II Bipolar Disorder and Other Specified and Related Bipolar Disorder (OSR BD) were more frequent in Group 1 and Type I Bipolar Disorder in Group 3. A trend of decreasing severity in eating behaviors and psychopathology was evident according to comorbidities (Group 1=Group2>Group3>Group 4).

LIMITATIONS

Limitations include the small sample size and the cross-sectional design of the study.

CONCLUSIONS

BED and BSD are frequent comorbidities in obesity. Type II Bipolar Disorder and OSR BD are more frequent in the group with double comorbidity. The double comorbidity seems associated to more severe eating behaviors and psychopathology. Distinctive pathological eating behaviors could be considered as warning signals, symptomatic of psychiatric comorbidities in Obesity.

Affective temperaments and emotional traits are associated with a positive screening for premenstrual dysphoric disorder

OBJECTIVES

Preliminary evidence indicates that premenstrual dysphoric disorder (PMDD) may be frequently co-morbid with bipolar spectrum disorders. In addition, the manifestations of PMDD seem similar to a subthreshold depressive mixed state. Nevertheless, the associations between PMDD and affective temperaments and emotional traits have not been previously investigated.

METHODS

A consecutive sample of 514 drug-free Brazilian women (mean age: 22.8; SD=5.4years) took part in this cross-sectional study. Screening for PMDD was obtained with the validated Brazilian Portuguese version of the Premenstrual Symptoms Screening Tool (PSST). Affective temperaments and emotional dimensions were evaluated with the Affective and Emotional Composite Temperament Scale (AFECTS). In addition, socio-demographic and data on menstrual cycle were collected.

RESULTS

According to the PSST, 83 (16.1%) women screened positive for PMDD, while 216 (42.0%) women had no/mild premenstrual symptoms. The cyclothymic temperament was independently associated with PMDD (OR=4.57; 95% CI: 2.11-9.90), while the euthymic temperament had an independent association with a lower likelihood of a positive screening for PMDD (OR=0.28; 95% CI: 0.12-0.64). In addition, anger and sensitivity emerged as emotional dimensions significantly associated with PMDD.

CONCLUSIONS

A positive screening for PMDD was associated with a predominant cyclothymic temperament, while an euthymic temperament was associated with a lower likelihood for a positive screening for PMDD. These data deserve replication in prospective studies.

The prevalence and predictors of bipolar and borderline personality disorders comorbidity: Systematic review and meta-analysis

INTRODUCTION

Data about the prevalence of borderline personality (BPD) and bipolar (BD) disorders comorbidity are scarce and the boundaries remain controversial. We conducted a systematic review and meta-analysis investigating the prevalence of BPD in BD and BD in people with BPD.

METHODS

Two independent authors searched MEDLINE, Embase, PsycINFO and the Cochrane Library from inception till November 4, 2015. Articles reporting the prevalence of BPD and BD were included. A random effects meta-analysis and meta-regression were conducted.

RESULTS

Overall, 42 papers were included: 28 considering BPD in BD and 14 considering BD in BPD. The trim and fill adjusted analysis demonstrated the prevalence of BPD among 5273 people with BD (39.94 ± 11.78 years, 44% males) was 21.6% (95% CI 17.0-27.1). Higher comorbid BPD in BD were noted in BD II participants (37.7%, 95% CI 21.9-56.6, studies=6) and North American studies (26.2%, 95% CI 18.7-35.3, studies=11). Meta regression established that a higher percentage of males and higher mean age significantly (p<0.05) predicted a lower prevalence of comorbid BPD in BD participants. The trim and fill adjusted prevalence of BD among 1814 people with BPD (32.22 ± 7.35 years, 21.5% male) was 18.5% (95% CI 12.7-26.1).

LIMITATIONS

Paucity of longitudinal/control group studies and accurate treatment records.

CONCLUSIONS

BPD-BD comorbidity is common, with approximately one in five people experiencing a comorbid diagnosis. Based on current diagnostic constructs, and a critical interpretation of results, both qualitative and quantitative syntheses of the evidence prompt out the relevance of differences rather similarities between BD and BPD.

Neuropsychological performance and affective temperaments in Euthymic patients with bipolar disorder type II

Affective temperament has been suggested as a potential mediator of the effect between genetic predisposition and neurocognitive functioning. As such, this report seeks to assess the extent of the correlation between affective temperament and cognitive function in a group of bipolar II subjects. 46 bipolar II outpatients [mean age 41.4 years (SD 18.2); female 58.9%] and 46 healthy controls [mean age 35.1 years (SD 18); female 56.5%] were evaluated with regard to their demographic and clinical characteristics, affective temperament, and neurocognitive performance. Crude bivariate correlation analyses and multiple linear regression models were constructed between five affective temperament subscales and eight neurocognitive domains. Significant correlations were identified in bipolar patients between hyperthymic temperament and verbal memory and premorbid IQ; cyclothymic temperament and attention; and irritable temperament, attention, and verbal fluency. In adjusting for potential confounders of the relationship between temperament and cognitive function, the strongest mediating factors among the euthymic bipolar patients were found to be residual manic and depressive symptoms. It is therefore concluded that affective temperaments may partially influence the neurocognitive performance of both healthy controls and euthymic patients with bipolar disorder type II in several specific domains.

Characteristics and correlates of stealing in college students

BACKGROUND

Stealing is a fairly common behaviour among young adults. Understanding the potential associations and characteristics of individuals who steal may help educational institutions, health services and young people themselves resolve difficulties before the behaviour impacts on their academic performance and health.

AIMS

We aim to test the hypothesis that desires to steal among students would be associated with worse academic achievements and higher rates of mood and impulse control disorders.

METHODS

One thousand eight hundred and five students completed the College Student Computer User Survey online and were included in this analysis at a large Midwestern United States University. Responders were grouped according to self-reported stealing urges and behaviours and were compared on measures of psychosocial function, mental health disorders and impulsivity.

RESULTS

Urges to steal were associated with worse depressive symptoms, higher levels of perceived stress and a number of psychiatric disorders including bipolar disorder and multiple disorders of impulse control (kleptomania, compulsive sexual behaviour, skin picking, trichotillomania and compulsive buying). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE AND/OR FUTURE RESEARCH: These following data indicate that stealing for many college students may be considered within a spectrum of impulsive behaviours. • Illegal behaviours among students point to mental health difficulties among them. • Our findings may provide clinicians, researchers and health professionals with a clearer picture of a range of impulsive behaviours among college students and promote treatment for this group. • Our findings could also inform preventative approaches to impulsive problems in young adults.

Clinical characteristics of patients assessed within an Improving Access to Psychological Therapies (IAPT) service: results from a naturalistic cohort study (Predicting Outcome Following Psychological Therapy; PROMPT)

BACKGROUND

A substantial number of patients do not benefit from first line psychological therapies for the treatment of depression and anxiety. Currently, there are no clear predictors of treatment outcomes for these patients. The PROMPT project aims to establish an infrastructure platform for the identification of factors that predict outcomes following psychological treatment for depression and anxiety. Here we report on the first year of recruitment and describe the characteristics of our sample to date.

METHODS

One hundred and forty-seven patients awaiting treatment within an Improving Access to Psychological Therapies (IAPT) service were recruited between February 2014 and February 2015 (representing 48 % of those eligible). Baseline assessments were conducted to collect information on a variety of clinical, psychological and social variables including a diagnostic interview using the Mini International Neuropsychiatric Interview (MINI).

RESULTS

Our initial findings showed that over a third of our sample were not presenting to IAPT services for the first time, and 63 % had been allocated to receive higher intensity IAPT treatments. Approximately half (46 %) were taking prescribed psychotropic medication (most frequently antidepressants). Co-morbidity was common: 72 % of the sample met criteria for 2 or more current MINI diagnoses. Our initial data also indicated that 16 % met criteria for borderline personality disorder and 69 % were at high risk of personality disorder. Sixty-one percent scored above the screening threshold for bipolarity. Over half of participants (55 %) reported experiencing at least one stressful life event in the previous 12 months, whilst 67 % reported experiencing at least one form of childhood trauma.

CONCLUSIONS

Our results to date highlight the complex nature of patients seen within an urban IAPT service, with high rates of psychiatric comorbidity, personality disorder, bipolarity and childhood trauma. Whilst there are significant challenges associated with researching IAPT populations, we have also confirmed the feasibility of undertaking such research.

Separation anxiety disorder from the perspective of DSM-5: clinical investigation among subjects with panic disorder and associations with mood disorders spectrum

OBJECTIVE/INTRODUCTION

High levels of comorbidity between separation anxiety disorder (SEPAD) and panic disorder (PD) have been found in clinical settings. In addition, there is some evidence for a relationship involving bipolar disorder (BD) and combined PD and SEPAD. We aim to investigate the prevalence and correlates of SEPAD among patients with PD and whether the presence of SEPAD is associated with frank diagnoses of mood disorders or with mood spectrum symptoms.

METHODS

Adult outpatients (235) with PD were assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Panic Disorder Severity Scale (PDSS), the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and the Mood Spectrum Self-Report Instrument (MOODS-SR, lifetime version).

RESULTS

Of ther 235 subjects, 125 (53.2%) were categorized as having SEPAD and 110 (46.8%) as not. Groups did not differ regarding onset of PD, lifetime prevalence of obsessive compulsive disorder (OCD), social phobia, simple phobia, BD I and II, or major depressive disorder (MDD). SEPAD subjects were more likely to be female and younger; they showed higher rates of childhood SEPAD, higher PDSS scores, and higher MOODS-SR total and manic component scores than subjects without SEPAD. Discussion SEPAD is highly prevalent among PD subjects. Patients with both PD and SEPAD show higher lifetime mood spectrum symptoms than patients with PD alone. Specifically, SEPAD is correlated with the manic/hypomanic spectrum component.

CONCLUSION

Our data confirm the high prevalence of SEPAD in clinical settings. Moreover, our findings corroborate a relationship between mood disorders and SEPAD, highlighting a relationship between lifetime mood spectrum symptoms and SEPAD.

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.

The Role of Temperament in the Etiopathogenesis of Bipolar Spectrum Illness

Bipolar disorder constitutes a challenge for clinicians in everyday clinical practice. Our knowledge concerning this clinical entity is incomplete, and contemporary classification systems are unable to reflect the complexity of this disorder. The concept of temperament, which was first described in antiquity, provides a helpful framework for synthesizing our knowledge on how the human body works and what determines human behavior. Although the concept of temperament originally included philosophical and sociocultural approaches, the biomedical model is dominant today. It is possible that specific temperaments might constitute vulnerability factors, determine the clinical picture, or modify the course of illness. Temperaments might even act as a bridge between genes and clinical manifestations, thus giving rise to the concept of the bipolar spectrum, with major implications for mental health research and treatment. More specifically, it has been reported that the hyperthymic and the depressive temperaments are related to the more "classic" bipolar disorder, whereas cyclothymic, anxious, and irritable temperaments are related to more complex manifestations and might predict poor response to treatment, violent or suicidal behavior, and high comorbidity. Incorporating of the concept of temperament and the bipolar spectrum into the standard training of psychiatric residents might well result in an improvement of everyday clinical practice.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

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

Neuropsychological performance of patients with soft bipolar spectrum disorders

OBJECTIVES

There is much evidence that shows that a substantial number of individuals with DSM-IV-defined unipolar depression (UP) manifest hypomanic sub-syndrome and bipolar diathesis. Other definitions have conceptualized the term soft bipolar spectrum (SBP) for these individuals. Little is known about the cognitive profiles of individuals with SBP. We hypothesized that they are representative of individuals with bipolar II disorder and are different from that of 'strict' UP.

METHODS

Consecutive referrals suffering major depressive episodes were categorically assigned to groups of either bipolar I disorder (n = 98), bipolar II disorder (n = 138), or UP (n = 300). Based on the SBP criteria by Akiskal and Pinto (17), patients with UP were subdivided into 81 SBP and 219 strict UP. We administered self- and clinician-administered scales to evaluate affective temperaments, and neuropsychological tests to assess seven cognitive domains.

RESULTS

Patients with SBP performed significantly better than strict UP patients in the domains of processing speed (p = 0.002), visual-spatial memory (p = 0.017), and verbal working memory (p = 0.017). Compared to patients with bipolar I disorder, patients with SBP were significantly better in set shifting (p < 0.001) and visual-spatial memory (p = 0.042). Patients with SBP performed similarly to patients with bipolar II disorder in all of the cognitive domains tested (p > 0.05). There was a group × cognitive domain interaction effect between bipolar I disorder, bipolar II disorder, SBP, and strict UP groups [Pillai's F = 2.231, df = (18,1437), p = 0.002].

CONCLUSIONS

Our data suggest that patients with SBP differ from patients with UP not only in external validators (e.g., family history of bipolar disorder) and hypomanic symptoms, but also in neuropsychological performance and that the profiles of cognitive functioning were different across bipolar I disorder and 'bipolar II spectrum' that subsumes bipolar II disorder and SBP.

Personality dysfunction is the cause of recurrent non-cognitive mental disorder: a testable hypothesis

OBJECTIVE

The objective of this study is to examine the evidence for a new hypothesis explaining the relationship between personality and mental state disorders.

DESIGN

At present, the attribution of personality disorder as a primary diagnosis only applies to patients who are antisocial, and particularly regarded as psychopathic, as in these patients, the mental state disorder that are associated are regarded in many respects as atypical and not representative of other mental disorders. The case is made in this paper that personality dysfunction lies behind the persistence of all non-cognitive mental disorders and that our failure to recognise this follows from our collective refusal to assess personality status early in life.

METHOD

Narrative review of relevant literature, which is limited as personality status is not often assessed early in life.

RESULTS

Support is adduced that personality dysfunction lies behind the persistence of all non-cognitive mental disorders (i.e. those that are not specifically neurodevelopmental and linked to cognitive impairment). The potential importance of this hypothesis is presented with regard to treatment and management strategy, emphasising that without specific intervention for personality dysfunction, many patients are destined for persistent morbidity.