Symptom profile consistency in recurrent manic episodes

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

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

Relationship between affective temperaments and aggression in euthymic patients with bipolar mood disorder and major depressive disorder

BACKGROUND

So far there is a scarce of studies dealing with the relationship between different aspects of aggressive behaviour and affective temperaments among various mood disorders. The aim of the present study was to explore in a group of patients with affective mood disorders the relationship between affective temperaments and aggression.

METHODS

100 consecutive outpatients in euthymic phase of mood disorders (46 with bipolar disorder-type I, 18 with bipolar disorder-type II and 36 with major depressive disorder) were self-assessed with the Aggression Questionnaire and the short version of Slovenian Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Autoquestionnaire (TEMPS-A).

RESULTS

The factorial analysis of the TEMPS-A subscales revealed 2 main factors: Factor 1 (prominent cyclothymic profile) consisted of cyclothymic, depressive, irritable, and anxious temperaments and Factor 2 (prominent hyperthymic profile) which was represented by the hyperthymic temperament, and by depressive and anxious temperaments as negative components. Patients with prominent cyclothymic profile got their diagnosis later in their life and had significantly higher mean scores on anger and hostility (non-motor aggressive behaviour) compared with patients with prominent hyperthymic profile.

LIMITATIONS

We included patients with different mood disorders, therefore the sample selection may influence temperamental and aggression profiles. We used self-report questionnaires which can elicit sociable desirable answers.

CONCLUSION

Anger and hostility could represent stable personality characteristics of prominent cyclothymic profile that endure even in remission. It seems that distinct temperamental profile could serve as a good diagnostic and prognostic value for non-motor aspects of aggressive behaviour.

Prevalence rates and clinical implications of bipolar disorder "with mixed features" as defined by DSM-5

BACKGROUND

We investigated the increase in the prevalence of bipolar disorder with mixed features following the replacement of DSM-IV-TR criteria with DSM-5 criteria. Additionally, we examined the clinical implications of the use of "with mixed features" as a specifier with bipolar disorder.

METHOD

We retrospectively reviewed medical charts from 2003 to 2013. A total of 331 patients diagnosed with bipolar disorder using the DSM-IV TR were enrolled and categorized into four groups: manic/hypomanic with mixed features, manic/hypomanic without mixed features, depressed with mixed features, and depressed without mixed features. These classifications were made in accordance with the DSM-5 definition of bipolar disorder "with mixed features." Changes in the prevalence, demographic and clinical characteristics were compared among the groups.

RESULTS

The prevalence rates of mixed features were significantly different when using the DSM-5 criteria vs. the DSM-IV-TR criteria. Patients with mixed features had a younger age of onset, younger age at hospitalization, more frequent hospitalizations for mixed episodes, and greater suicide risk compared with patients without mixed features.

LIMITATIONS

Retrospective study may have resulted in under diagnosis of mixed states.

CONCLUSIONS

An approximately three-fold greater risk for mixed features was observed in patients with bipolar disorder when using the DSM-5 criteria than when using the DSM-IV-TR criteria. The additional patients may represent patients with sub-syndromal mixed features and could indicate that patients with mixed features are underdiagnosed.

Bipolar disorder and criminal offending: a data linkage study

PURPOSE

The current study explored criminal offending among people diagnosed with bipolar disorder with and without comorbid substance use and compared this with a community sample with no history of bipolar disorder.

METHODS

A case-linkage design was used to compare patterns of officially recorded criminal offending between 1,076 people with bipolar disorder drawn from a state-wide psychiatric case register with a community comparison group.

RESULTS

Those with bipolar disorder were significantly more likely than community members to be charged with, convicted of, and be found guilty of, violent, non-violent and intermediate level criminal offences. Those with a comorbid substance use disorder were two times more likely than those without a substance use disorder to offend; both groups had a significantly higher chance of offending than the community sample. Females with bipolar disorder were significantly more likely to have been convicted of violent offences, irrespective of substance use. Significant interactions were found between bipolar disorder and substance use for males and females with respect to violent offending and for males with respect to non-violent offending.

CONCLUSIONS

There is a statistically significant association between bipolar disorder and the likelihood of having a criminal history. Co-occurring substance use differentially impacts on the likelihood of criminal offending for males and females.

Role of behavioral addictions in predicting reactivity in bipolar mood disorder patients

Background:

Behavioral addictions (BAs) can be understood as disorders characterized by repetitive occurrence of reactivity and uncontrolled behaviors. Very few studies have investigated their association with bipolar mood disorders.

Objectives:

The present study aimed to determine the role of behavioral addictions in predicting interpersonal behavioral addictions in bipolar mood disorder patients.

Materials and Methods:

This study had a cross-sectional correlation design. The statistical population was composed of all outpatients with bipolar mood disorders referring to clinical centers in Ardabil. The sample included 60 bipolar mood patients selected from patients referring to clinical centers using the available sampling method. A researcher-made behavioral addiction checklist, Interpersonal Behavioral Addictions Index, and exercise, sexual, and work addiction questionnaires, were used for data collection. The data were analyzed with a Pearson’s correlation coefficient and multivariate regression analysis.

Results:

The results showed a significant negative relationship between behavioral addictions and interpersonal behavioral addictions (P ≥ 0.01). Multivariate regression analysis results also showed that behavioral addictions are significant and can explain 61% of the variance of interpersonal behavioral addictions in bipolar mood patients.

Conclusions:

These results suggest that addictive behaviors can affect behavioral addictions in bipolar mood patients. Behavioral addictions lead to negative emotional regulation strategies and result in increased behavioral addictions in these patients. People with high levels of arousal or those who cannot control their behavioral addictions are probably more prone to addictive behaviors.

Comorbid personality disorders and violent behavior in psychotic patients

Schizophrenia without any comorbidity confers a modest, but statistically significant elevation of the risk for violence. That risk is considerably increased by comorbid antisocial personality disorder or psychopathy as well as by comorbid substance use disorders. These comorbidities are frequent. Conduct disorder and conduct disorder symptoms elevate the risk for aggressive behavior in patients with schizophrenia. Violence among adults with schizophrenia may follow at least two distinct pathways-one associated with premorbid conditions, including antisocial conduct, and another associated with the acute psychopathology of schizophrenia. Aggressive behavior in bipolar disorder occurs mainly during manic episodes, but it remains elevated in euthymic patients in comparison with controls. The risk of violent behavior is increased by comorbidity with borderline personality disorder, antisocial personality disorder, and substance use disorders. These comorbidities are frequent. Borderline personality disorder and bipolar disorder are related in their phenomenology and response to medication. These two disorders share a tendency to impulsiveness, and impulsive behavior, including impulsive aggression, is particularly expressed when they co-occur.

Aggression in bipolar II disorder and its relation to the serotonin transporter

BACKGROUND

Aggression is frequently observed in patients diagnosed with bipolar disorder (BD). Previous studies found a negative association between aggression and serotoninergic function in patients with BD, as well as in healthy subjects. The objective of this study was to determine whether there is an association between aggression and the availability of the serotonin transporter (SERT) in euthymic BD II patients.

METHODS

Thirty-eight age-matched healthy controls (HCs) and 24 BD II patients were recruited. BD II patients were under stable treatment in the euthymic state. The Overt Aggression Scale (OAS) was used for the assessment of aggression. Single photon emission computed tomography with (123)I-ADAM was used for SERT imaging. A specific uptake ratio, which represents availability, was the primary measured outcome.

RESULTS

The total OAS scores, as well as the scores on all of the sub-items, were significantly higher in BD II patients than in the HCs group. There was no significant difference in SERT availability between BD II and HCs subjects in different brain regions. The Pearson's correlation between the total OAS scores and the sub-item aggression and SERT availability was significant.

LIMITATION

The OAS was used for the assessment of the past week of the patients' condition and thus did not reflect their trait status.

CONCLUSIONS

The higher total scores of OAS in euthymic BD II patients than in HCs support the idea that aggression might be a trait marker for BD. Although SERT availability in euthymic BD II patients and in HCs did not differ significantly, the correlation of SERT availability and total OAS provides the possible explanation of aggression in BD II.

Differential effects of dopamine transporter inhibitors in the rodent Iowa gambling task: relevance to mania

RATIONALE

The Iowa Gambling Task (IGT) can be used to quantify impulsive and risky choice behaviors in psychiatric patients, e.g., bipolar disorder (BD) sufferers. Although developing treatments for these behaviors is important, few predictive animal models exist. Inhibition of the dopamine transporter (DAT) can model profiles of altered motor activity and exploration seen in patients with BD. The effect of DAT inhibition on impulsive choices related to BD has received limited study however. We used a rodent IGT to elucidate the effects of similarly acting drugs on risky choice behavior.

OBJECTIVES

We hypothesized that (1) C57BL/6 mice could adopt the "safe" choice options in the IGT and (2) DAT inhibition would alter risk preference.

METHODS

Mice were trained in the IGT to a stable risk-preference and then administered the norepinephrine/DAT inhibitor amphetamine, or the more selective DAT inhibitors modafinil or GBR12909.

RESULTS

Mice developed a preference for the "safe" option, which was potentiated by amphetamine administration. GBR12909 or modafinil administration increased motor impulsivity, motivation significantly, and risk preference subtly.

CONCLUSIONS

The rodent IGT can measure different impulse-related behaviors and differentiate similarly acting BD-related drugs. The contrasting effects of amphetamine and modafinil in mice are similar to effects in rats and humans in corresponding IGT tasks, supporting the translational validity of the task. GBR12909 and modafinil elicited similar behaviors in the IGT, likely through a shared mechanism. Future studies using a within-session IGT are warranted to confirm the suitability of DAT inhibitors to model risk-preference in BD.

Bipolar disorder: "pure" versus mixed depression over a 1-year follow-up

OBJECTIVES

To compare two samples of Bipolar (BD) patients presenting "pure" (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up.

METHODS

A total of 114 depressed outpatients (HDRS > 13) were included. "Pure" depressed (D, n = 76) were divided from "mixed" depressed (Mx, n = 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment.

RESULTS

Mx patients were significantly younger at the onset of BD. Manic features persisted significantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than "pure" depressed patients.

CONCLUSIONS

Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.

AKR1C4 gene variant associated with low euthymic serum progesterone and a history of mood irritability in males with bipolar disorder

BACKGROUND

Irritable mood during mood elevation is common in bipolar disorder. The progesterone metabolite allopregnanolone (ALLO) has been implicated in other disorders presenting with irritability. This study aimed to test whether a history of manic/hypomanic irritability is associated with low serum progesterone levels; and whether single nucleotide polymorphisms (SNPs) in gene coding for steroidogenetic enzymes (HSD3B2, SRD5A1 and AKR1C4 were coupled to previous manic irritability and/or with serum progesterone concentrations.

METHODS

Morning serum progesterone concentrations during euthymic phase of bipolar illness types 1 and 2 were assessed in 71 males and 107 females. Previous manic/hypomanic irritability was assessed using the Affective Disorders Evaluation. Selected SNPs were analyzed: i) aldoketoreductase-type-4 (AKR1C4 - rs17306779, rs3829125, rs10904440, rs12762017, and rs11253048), ii) 3-β-hydroxysteroid-dehydrogenase (HSD3B2 - rs4659174, rs2854964, and rs3765948), iii) steroid-5-α-reductase (SRD5A1 - rs8192139, rs181807, rs3822430, and rs3736316).

RESULTS

In males, progesterone concentrations were lower in those who had shown manic/hypomanic irritability compared with nonirritable (F=7.05, p=0.0099). SNPs rs17306779, rs3829125, and rs10904440 were associated with manic/hypomanic irritability. A cystine to serine change at position 145 in AKR1C4 (rs3829125) was associated with lower serum progesterone (F=6.34, p=0.014). There were no associations in females.

LIMITATIONS

Relatively small sample sizes.

CONCLUSION

Low progesterone levels and a cystine to serine change at position 145 in AKR1C4 gene are associated with manic/hypomanic irritability in males. Given that the enzyme AKR1C4 has both dehydrogenating and reductive activities in the steroidogenetic pathway, a missense variation in the gene may predispose to manic/hypomanic irritability by altering the relationship between progesterone and ALLO concentrations in the brain.

Increased risk-taking behavior in dopamine transporter knockdown mice: further support for a mouse model of mania

Reduced functioning of the dopamine transporter (DAT) has been linked to bipolar disorder (BD). Mice with reduced DAT functioning (knockdown, KD) exhibit a behavioral profile in the mouse Behavioral Pattern Monitor (BPM) consistent with patients with BD mania in the human BPM. Patients with BD also exhibit increased risk taking, which can be quantified using the Iowa Gambling Task (IGT). We hypothesized that DAT KD mice would exhibit increased risk-taking behavior in a novel mouse version of the IGT. DAT KD and wildtype (WT) littermates were trained in the mouse IGT. In session 1, KD mice initially made riskier choices, but later performed comparably to WT mice. Once trained to stable choice performance, DAT KD mice continued to exhibit a trend to choose the riskier options more than WT mice. Finally, we confirmed that these DAT KD mice also exhibited an exploratory profile in the BPM consistent with patients with BD mania, where risky choice behavior modestly correlated with specific exploration. These data demonstrate that DAT KD mice chose the riskier options more than WT mice, providing further support for the use of DAT KD mice as a model of BD mania.

Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline personality disorder

Few studies to date have been performed to investigate impulsivity and aggressivity in patients with bipolar disorder (BD) and borderline personality disorder (BPD); the primary aim of the present study was to evaluate the impact of co-morbidity of BPD on impulsivity and aggressivity in patients affected by BD. A total of 57 patients (male=20, female=37) affected by BD (BD-I 51%; BD-II 49%) in clinical stable remission were recruited; 28 patients were affected by BD (49.1%), 18 by BD and BPD (31.6%) and 11 (19.3%) by BD plus other personality disorders (OPD) (19.3%). They were assessed with the Structured Clinical Interview for DSM-IV (SCID)-I and SCID-II, and were evaluated by means of the Clinical Global Impression (CGI)-severity and Global Assessment Functioning (GAF) scales, the Barratt Impulsivity Scale (BIS-11) and the Aggression Questionnaire (AQ). Mean total scores were significantly higher among BD/BPD patients with respect to BD and to BD/OPD, both on the BIS-11 and the AQ; the rate of attempted suicides was approximately three times higher in BD/BPD patients with respect to BD and 7.6 times higher than in BD/OPD patients. The results of our study suggest that patients with co-morbid BD and BPD are more impulsive and aggressive. Furthermore, this co-morbid condition may be a risk factor for suicidality.

Person characteristics of individuals in functional assessment research

This paper is a review of person characteristics that were present in 173 studies that were reviewed on functional assessment. The purpose was to give the reader an idea about the types of individuals for which functional assessment is appropriate and to outline persons and their characteristics which have the best research support. The majority of participants were diagnosed with intellectual disability and/or autism. Additionally more males that females were included and children were frequently studied versus adolescents and older adults. Finally, while the majority of studies employed experimental functional analysis, the number of participants per study was small. Conversely, functional analysis scales were used in far fewer studies, but with much larger sample sizes. Thus, relatively equal numbers of individuals have been studied with both methods.

Insight in bipolar disorder: relationship to episode subtypes and symptom dimensions

BACKGROUND

The study of insight in bipolar disorder has received limited attention, despite its potential impact on treatment compliance and prognosis. In the current study we compare insight levels during different phases of bipolar disorder, and consider its relationship to symptoms dimensions and epidemiologic variables.

METHODS

Insight ratings obtained from 156 bipolar subjects in any phase of bipolar disorder were compared. A regression analysis was also conducted to identify symptom dimensions predictive of insight levels.

RESULTS

Greater impairments in insight were observed during pure manic episodes than during mixed or depressed episodes, or during euthymia. Depressive symptoms were associated with better insight. Improvements in insight with treatment were neither complete nor universal. Lack of insight was unrelated to age, years of illness, age of first psychiatric illness, or lifetime number of hospitalizations.

CONCLUSIONS

Although psychosis may be associated with impaired insight, other variables also impact on degree of impaired insight. Specifically, depressed mood appears to be associated with preservation of insight. That relationship may transcend strict syndromal diagnosis.

Principal domains of behavioral psychopathology identified by the Bipolar Inventory of Signs and Symptoms Scale (BISS)

Current symptom rating scales and diagnostic categories for bipolar disorder (BD) do not provide dimensional profiles of the types of behavior disturbed in this complex disorder. To overcome these limitations we identified the principal domains of behavioral symptomatology in bipolar individuals, including all mood states, and used a more comprehensive rating scale for BD: the Bipolar Inventory of Signs and Symptoms Scale (BISS). A total of 246 patients with BD (196 with BD type I, and 50 with BD type II) were interviewed using the BISS. Exploratory factor analysis was performed on the BISS results using the maximum likelihood factor extraction method, followed by oblique rotation of the extracted factor loadings. We determined the strength of relationships between factor scores using the Pearson correlation coefficient. The following five factors were extracted: mania, depression, irritability, anxiety and psychosis. Anxiety was significantly correlated with depression and irritability. The mania factor score was only weakly associated with the other four factors. The domains of the BISS capture both the historical categories of depression and mania, plus irritability, psychosis, and an additional principal domain, anxiety. Despite the common occurrence of anxiety in BD, it has not been identified in most prior factor analyses, in part due to limited coverage of anxiety symptoms in the source scales.

Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features

Bipolar mixed states combine depressive and manic features, presenting diagnostic and treatment challenges and reflecting a severe form of the illness. DSM-IV criteria for a mixed state require combined depressive and manic syndromes, but a range of mixed states has been described clinically. A unified definition of mixed states would be valuable in understanding their diagnosis, mechanism and treatment implications. We investigated the manner in which depressive and manic features combine to produce a continuum of mixed states. In 88 subjects with bipolar disorder (DSM-IV), we evaluated symptoms and clinical characteristics, and compared depression-based, mania-based, and other published definitions of mixed states. We developed an index of the extent to which symptoms were mixed (Mixed State Index, MSI) and characterized its relationship to clinical state. Predominately manic and depressive mixed states using criteria from recent literature, as well as Kraepelinian mixed states, had similar symptoms and MSI scores. Anxiety correlated significantly with depression scores in manic subjects and with mania scores in depressed subjects. Discriminant function analysis associated mixed states with symptoms of hyperactivity and negative cognitions, but not subjective depressive or elevated mood. High MSI scores were associated with severe course of illness. For depressive or manic episodes, characteristics of mixed states emerged with two symptoms of the opposite polarity. This was a cross-sectional study. Mixed states appear to be a continuum. An index of the degree to which depressive and manic symptoms combine appears useful in identifying and characterizing mixed states. We propose a depressive or manic episode with three or more symptoms of the opposite polarity as a parsimonious definition of a mixed state.

Bipolar disorder and aggression

AIMS

In clinical practice, overt aggressive behaviour is frequently observed in patients diagnosed with bipolar disorder. It can be dangerous and complicates patient care. Nevertheless, it has not been adequately studied as a phenomenon that is separate from other symptoms such as agitation. The aim of this review is to provide information on the prevalence, clinical context, and clinical management of aggression in patients with bipolar disorder.

METHODS

MEDLINE and PsycInfo data bases were searched for articles published between 1966 and November 2008 using the combination of key words 'aggression' or 'violence' with 'bipolar disorder'. For the treatment searches, generic names of mood stabilisers and antipsychotics were used in combination with key words 'bipolar disorder' and 'aggression'. No language constraint was applied. Articles dealing with children and adolescents were not included.

RESULTS

Acutely ill hospitalised bipolar patients have a higher risk for aggression than other inpatients. In a population survey, the prevalence of aggressive behaviour after age 15 years was 0.66% in persons without lifetime psychiatric disorder, but 25.34% in bipolar I disorder. Comorbidity with personality disorders and substance use disorders is frequent, and it elevates the risk of aggression in bipolar patients. Impulsive aggression appears to be the most frequent subtype observed in bipolar patients. Clinical management of aggression combines pharmacological and non-pharmacological approaches.

DISCUSSION

A major problem with the evidence is that aggression is frequently reported only as one of the items contributing to the total score on a scale or a subscale. This makes it impossible to ascertain specifically aggressive behaviour. Large controlled head-to-head randomised controlled studies comparing treatments for aggressive behaviour in bipolar disorder are not yet available. There is some evidence favouring divalproex, but it is not particularly strong .We do not know if there are any efficacy differences among antipsychotics for this indication.

The factor structure of lifetime depressive spectrum in patients with unipolar depression

BACKGROUND

While previous attempts to elucidate the factor structure of depression tended to agree on a central focus on depressed mood, other factors were not replicated across studies. By examining data from a large number of items covering the range of depressive symptoms, the aim of the present study is to contribute to the identification of the structure of depression on a lifetime perspective.

METHODS

The study sample consisted of 598 patients with unipolar depression who were administered the Mood Spectrum Self-Report (lifetime version) in Italian (N=415) or English (N=183). In addition to classical exploratory factor analysis using tetrachoric correlation coefficients, an IRT-based factor analysis approach was adopted to analyze the data on 74 items of the instrument that explore cognitive, mood and energy/activity features associated with depression.

RESULTS

Six factors were identified, including 'Depressive Mood', 'Psychomotor Retardation', 'Suicidality', 'Drug/Illness related depression', 'Psychotic Features' and 'Neurovegetative Symptoms', accounting overall for 48.3% of the variance of items.

LIMITATIONS

Clinical information on onset of depression and duration of illness is available only for 350 subjects. Therefore, differences between sites can only be partially accounted using available data.

CONCLUSIONS

Our study confirms the central role of depressed mood, psychomotor retardation and suicidality and identifies the factors 'Drug/Illness related depression', 'Psychotic features' and the neurovegetative dysregulation not captured by the instruments most frequently used in previous studies. The identification of patients with specific profiles on multiple factors may be useful in achieving greater precision in neuroimaging studies and in informing treatment selection.

The structure of lifetime manic-hypomanic spectrum

BACKGROUND

The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania.

METHODS

A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach.

RESULTS

Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained.

CONCLUSIONS

Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.

Predictors of trait aggression in bipolar disorder

OBJECTIVES

Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD.

METHODS

Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA).

RESULTS

In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001).

CONCLUSIONS

Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.

Familiality and diagnostic patterns of subphenotypes in the National Institutes of Mental Health bipolar sample

Bipolar-related subphenotypes that cluster within families may help identify subsets of patients that are more genetically homogeneous. Environmental or assessment factors that segregate by family may influence estimates of familiality. We aimed to determine familiality of subphenotypes of bipolar disorder (BP), accounting for effects of age, sex, diagnosis, and site/wave of ascertainment. We studied 589 sibships with 1416 siblings affected with bipolar I (BPI), schizoaffective disorder, bipolar type (SAB), bipolar II (BPII), or recurrent unipolar depression (RUDD). Sibships were from families with > or =2 BPI cases collected by the NIMH Bipolar Genetics Initiative (NIMHBGI). Rapid cycling showed the strongest evidence for familiality [odds ratio (OR) (95%CI) = 2.02 (1.43, 2.85), P = 6.0 x 10(-5)] in a model including age, sex, diagnosis, and site/wave of ascertainment. Additional significantly familial traits were comorbid alcohol abuse/dependence (P = 2 x 10(-4)) and comorbid panic disorder (P = 8 x 10(-3)), as well as psychosis, suicidal thoughts, and rapid mood switching (P = 6 x 10(-3) - 0.03). Omission of the effect of site/wave of ascertainment from the model inflated the significance level of the apparent familial association of almost all subphenotypes from one to four orders of magnitude. We have found evidence of familiality for subphenotypes of BP. In multicenter samples, familiality may be overestimated if variability in diagnosis of subphenotypes between site/wave of ascertainment is not considered.

Long-term inter-episode stability of syndromes underlying mania

OBJECTIVE

To explore the stability of diverse manic presentations across manic recurrences.

METHOD

A total of 253 bipolar patients who experienced two or more hospitalizations, because of consecutive manic (or mixed) episodes, during a 20-year period were included. All patients had second hospitalizations with an mean interval of 773 days, while 126 and 91 patients had third and fourth hospitalizations with mean intervals of 1559 and 2237 days from the index hospitalization, respectively. Seven symptom scores, previously factor-validated, were calculated.

RESULTS

Depressive mood, irritable aggression, psychomotor/thought inhibition, mania, emotional lability/agitation and psychosis were moderately correlated across the index and subsequent hospitalizations.

CONCLUSION

A majority of diverse manic presentations were stable across manic recurrences. The stability was not restricted to two consecutive recurrences but appeared widespread over the long-term course of bipolar disorder. The finding may serve for the development of more effective long-term treatment strategies and a clinically more reasonable subtyping of mania.

Clinical features of antidepressant associated manic and hypomanic switches in bipolar disorder

The present study investigated possible clinical differences between bipolar patients with and without manic or hypomanic switch during antidepressant (AD) treatment. The authors undertook a retrospective assessment of 169 individuals affected by bipolar disorder type I (BP I: n=96) and II (BP II: n=73) who experienced at least one manic or hypomanic episode following depression without any interposed normothymic period ("manic switch") during AD therapy. They were compared with a sex, age (+/-5 years), and ethnicity-matched group of 247 subjects, randomly selected from our pool of bipolar subjects who have never had manic switches. Only 2 of the 169 patients had had spontaneous switches before the AD-related one. Switched subjects were marginally older (t=-2.65, df=414, P=.008) compared to not switched and less frequently delusional (chi2=13.86, P=.0002). Polarity of the onset episode was more frequently depressive in switched patients (chi2=21.93, P=.00002), which had also less previous manic episodes than not switched (t=3.44, df=332, P=.0006). Those differences were more pronounced in the BP I subsample. Switched patients were more frequently BP I (chi2=29.66; P<.00001). Maintenance with mood stabilizers appears to be a strong protective factor; in fact, of the 124 individuals undertaking a mood stabilizer therapy, 21 had a switch and 103 had no switches (chi2=41.10, P<.000001). In conclusion, some clinical variables, such as the number of manic episodes, the presence of delusions, the polarity of onset episode, and the mood-stabilizing treatment, may be involved in AD-related switches. Further studies are required to investigate the causal relationships between those factors.