Impact of childhood trauma on cognitive profile in bipolar disorder

Processing speed mediates the relationship between DDR1 and psychosocial functioning in euthymic patients with bipolar disorder presenting psychotic symptoms

The DDR1 locus is associated with the diagnosis of schizophrenia and with processing speed in patients with schizophrenia and first-episode psychosis. Here, we investigated whether DDR1 variants are associated with bipolar disorder (BD) features. First, we performed a case‒control association study comparing DDR1 variants between patients with BD and healthy controls. Second, we performed linear regression analyses to assess the associations of DDR1 variants with neurocognitive domains and psychosocial functioning. Third, we conducted a mediation analysis to explore whether neurocognitive impairment mediated the association between DDR1 variants and psychosocial functioning in patients with BD. Finally, we studied the association between DDR1 variants and white matter microstructure. We did not find any statistically significant associations in the case‒control association study; however, we found that the combined genotypes rs1264323AA-rs2267641AC/CC were associated with worse neurocognitive performance in patients with BD with psychotic symptoms. In addition, the combined genotypes rs1264323AA-rs2267641AC/CC were associated with worse psychosocial functioning through processing speed. We did not find correlations between white matter microstructure abnormalities and the neurocognitive domains associated with the combined genotypes rs1264323AA-rs2267641AC/CC. Overall, the results suggest that DDR1 may be a marker of worse neurocognitive performance and psychosocial functioning in patients with BD, specifically those with psychotic symptoms.

Impact of cognitive reserve on bipolar disorder: a systematic review

Background

Cognitive reserve (CR) is a complex concept that includes premorbid IQ, years of education, and exposure to neuropsychological stimuli through work and leisure. Previous studies have suggested that CR has a positive impact on several aspects of bipolar disorder. Synthesizing the evidence to date is an important work in providing directions for future studies. The objectives of this systematic review to summary impact of CR on onsetting, relapsing bipolar episodes, buffering cognitive dysfunctions, and maintaining quality of life (QOL) in bipolar disorder.

Methods

Two researchers independently reviewed selected paper from three database as PubMed, PsychINFO, and Web of Science. The search keywords were "bipolar disorder" and "cognitive reserve." The selected studies were classified as the levels of evidence according to the criteria of the Oxford Center for Evidence- Based Medicine. The results of the selected studies were summarized according to the objectives.

Results

Thrity six studies were included in this review. People with high CR may have fewer bipolar episodes and alleviate cognitive impairments and dysfunction. CR may keep the functional level in patients with bipolar disorder.

Conclusion

The results of this systematic review suggest that CR may be involved in preventing relapse of bipolar episodes and may alleviate cognitive dysfunction. However, effect on prevention of onset-risk and relapse of bipolar episodes need further investigation in prospective studies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021270293, the protocol was registered with PROSERO (CRD42021270293).

Association between childhood trauma, cognition, and psychosocial function in a large sample of partially or fully remitted patients with bipolar disorder and healthy participants

BACKGROUND

Childhood trauma (CT) are frequently reported by patients with bipolar disorder (BD), but it is unclear whether and how CT contribute to patients' cognitive and psychosocial impairments. We aimed to examine the impact of CT on cognition and psychosocial functioning in a large sample of 345 patients with BD and 183 healthy control participants (HC) using the Childhood Trauma Questionnaire, neurocognitive tests and ratings of mood symptoms and functioning.

RESULTS

Patients showed broad cognitive impairments across memory, attention and executive function and functional disability despite being in partial or full remission and had higher levels of CT than HC. Higher levels of CT correlated with impairments across almost all cognitive domains and lower psychosocial functioning across BD patients and HC. Of these, the associations between CT and poorer working memory and lower psychosocial functioning, respectively, prevailed after adjusting for clinical and demographical variables. Diagnosis of BD and estimated verbal intelligence did not moderate these associations. Analysis of CT sub-categories showed that working memory impairments were related particularly to childhood physical and emotional abuse, while psychosocial difficulties were related to physical and emotional neglect.

CONCLUSIONS

CT may have negative implications for working memory and psychosocial functioning across both BD and healthy populations. If the findings are replicated, this would suggest that early interventions that reduce the frequency of CT in vulnerable families may aid children's cognitive and psychosocial development.

Better than expected: the gap between self-reported and objective measures of cognitive performance in remitted bipolar disorder

Background

Studies comparing objective and self-reported cognitive functioning as well as influencing factors in individuals with remitted bipolar disorder are scarce and contradictory.

Methods

The aim of this study was to compare executive functioning and other objective and self-reported cognitive impairment between 26 individuals with remitted bipolar disorder (15 BD I) and 24 healthy controls using a cross-sectional design. Executive functions were measured by the TAP Go/No-go subtest as well as the Stroop Task. Self-rated functioning was assessed using the Attention Deficit Experience Questionnaire. In addition, possible predictors of self-reported and objective cognitive functioning were examined to perform regression analyses.

Results

Individuals with remitted bipolar disorder did not differ significantly in executive functions or other objective cognitive domains from the healthy control group, but showed a significantly lower level of self-reported cognitive functioning and self-esteem. While self-esteem was the strongest predictor in healthy controls for self-reported cognitive functioning, severity of illness and subthreshold depressive mood were the most important predictors in individuals with remitted bipolar disorder.

Conclusion

The results once again demonstrate the cognitive heterogeneity in bipolar disorder. In the treatment of cognitive deficits, factors such as subthreshold depressive symptomatology and self-esteem should be focused on in addition to cognitive training in remitted patients.

Older age bipolar disorder

PURPOSE OF REVIEW

Older age bipolar disorder (OABD) refers to patients with bipolar disorder aged 50 years and over. There is a paucity of evidence-based guidelines specific to OABD, but in recent years, several studies have been published on OABD. The current review synthesizes previous literature (up to January 1, 2021) as well as most recent literature on OABD (since January 1, 2021).

RECENT FINDINGS

This review covers the following themes: diagnosis and specifiers, clinical course, psychosocial functioning, cognition, physical comorbidities, and pharmacotherapy. On the basis of the latest data, specific clinical recommendations are proposed for each theme.

SUMMARY

OABD forms a more complex subgroup of bipolar disorder, with an increased risk of cognitive deficits, physical comorbidities, impaired psychosocial functioning, and premature death. The distinctions between BD-I and BD-II and between EOBD and LOBD do not clinically represent relevant subtypes for OABD patients. Mental healthcare professionals should treat all OABD patients with an integrative care model that takes into account cognitive and physical comorbidities and that contains elements aimed at improvement of psychosocial functioning and quality of life. Older age itself should not be a reason to withhold lithium treatment. Future research should collect data on essential data domains using validated measurement scales.

Association of childhood trauma with cognitive domains in adult patients with mental disorders and in non-clinical populations: a systematic review

Although the association between cognitive performances and the onset of psychiatric disorders has been widely investigated, limited research on the role of childhood trauma or early life stress (CT/ELS), and whether this role differs between clinical and non-clinical cohorts is available. This systematic review aims at filling this gap, testing whether the occurrence of CT/ELS and its subtypes are associated with cognitive domains (general cognitive ability, executive functions, working memory, attention, processing speed, verbal/visual memory) in patients with psychiatric disorders and in non-clinical populations. This study followed the PRISMA 2020 guidelines and the Newcastle-Ottawa scale for quality assessment. The search was performed until May 2022. Seventy-four studies were classified as eligible. The graphical representations of the results reported an association between exposure to CT/ELS and worse general cognitive ability, verbal/visual memory, processing speed and attention in patients affected by anxiety, mood and psychotic disorders, and that specific CT/ELS subtypes (physical neglect, physical/sexual abuse) can differentially influence specific cognitive abilities (executive functions, attention, working memory, verbal/visual memory). In non-clinical cohorts we found associations between CT/ELS exposure and impairments in executive functions, processing speed and working memory, while physical neglect was related to general cognitive ability and working memory. Concerning the emotional abuse/neglect subtypes in both populations, the results indicated their involvement in cognitive functioning; however, the few studies conducted are not enough to reach definitive conclusions. These findings suggest an association of CT/ELS with specific cognitive deficits and psychopathology.

Childhood trauma and cognitive functioning in mood disorders: A systematic review

BACKGROUND

Cognitive impairment is a core feature of mood disorders and has been identified as an important treatment target. A better understanding of the factors contributing to cognitive impairment in mood disorders would be beneficial in developing interventions to address cognitive impairment. One key factor is childhood trauma. The aim of this review was to systematically synthesise and review research examining associations between reported childhood trauma and cognitive functioning in mood disorders.

METHODS

Studies in adult samples examining the relationship between objective cognitive function and reported childhood trauma in major depressive disorder and/or bipolar disorder (in-episode or euthymia) were identified. Searches were conducted on PubMed, Embase and PsycINFO until January 2022. A narrative review technique was used due to the heterogeneity of group comparisons, cognitive tests and data analysis across studies.

RESULTS

Seventeen studies met the criteria for inclusion (mood disorders N = 1723, healthy controls N = 797). Evidence for childhood trauma being related to poorer cognitive functioning was consistent across global cognitive functioning and executive function domains for euthymic patients and psychomotor speed for in-episode patients. There was mixed evidence for verbal learning and memory and executive function for in-episode patients. Identification of patterns within other domains was difficult due to limited number of studies.

CONCLUSION

Findings from this review suggest childhood trauma is associated with poorer cognitive functioning in people with mood disorders. Targeted interventions to improve cognition may be warranted for this group.

Association of childhood trauma with cognitive impairment and structural brain alterations in remitted patients with bipolar disorder

BACKGROUND

Cognitive impairment affects many patients with bipolar disorder (BD). No pro-cognitive treatment with robust efficacy exists partly due to limited insight into underlying neurobiological abnormalities.

METHODS

This magnetic resonance imaging (MRI) study investigates structural neuronal correlates of cognitive impairment in BD by comparing brain measures in a large sample of cognitively impaired versus cognitively intact patients with BD or cognitively impaired patients with major depressive disorder (MDD) and healthy controls (HC). Participants underwent neuropsychological assessments and MRI scans. The cognitively impaired and - intact BD and MDD patient groups were compared with each other and HC regarding prefrontal cortex measures, hippocampus shape/volume, and total cerebral white (WM) and grey matter (GM).

RESULTS

Cognitively impaired BD patients showed lower total cerebral WM volume than HC, which scaled with poorer global cognitive performance and more childhood trauma. Cognitively impaired BD patients also showed lower adjusted GM volume and thickness in the frontopolar cortex than HC but greater adjusted GM volume in the temporal cortex than cognitively normal BD patients. Cognitively impaired BD patients showed decreased cingulate volume than cognitively impaired MDD patients. Hippocampal measures were similar across all groups.

LIMITATIONS

The cross-sectional study design prevented insights into causal relationships.

CONCLUSIONS

Lower total cerebral WM and regional frontopolar and temporal GM abnormalities may constitute structural neuronal correlates of cognitive impairment in BD, of which the WM deficits scale with the degree of childhood trauma. The results deepen the understanding of cognitive impairment in BD and provide a neuronal target for pro-cognitive treatment development.

Intellectual performance correlates of trauma exposure in adolescent psychiatric inpatients

Half of individuals have experienced a trauma adequate to meet criteria for PTSD. Intelligence may correlate with trauma, with the causal direction unclear. The Childhood Trauma Questionnaire (CTQ) was administered to 733 child and adolescent inpatients. Intelligence and academic achievement was assessed using the Wechsler Scales. Clinician diagnoses came from the electronic medical record, as did data on exposure to substance abuse and other stressors. Multivariate analyses assessed associations between intelligence, diagnoses, experiences, and CTQ. Cases who met criteria for physical and sexual abuse performed more poorly across all intellectual domains. Other than for PTSD, there were no diagnostic differences in CTQ scores. Emotional abuse or neglect were not associated with intelligence, although exposure to substance abuse was associated with increased CTQ scores and lower intelligence. Exposure to substance abuse as a covariate did not eliminate the influence of CTQ scores on intelligence, but was consistently related to intelligence beyond CTQ scores. Intelligence and substance abuse are known to have genomic influences and recent studies have suggested a genomic signature associated with childhood abuse. Future genomic studies of the consequences of trauma exposure could add intelligence polygenic scores into their models, while considering genomic and nongenomic elements of family experiences.

Association between childhood maltreatment and social functioning in individuals with affective disorders: A systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment has been linked to impairments in social functioning and social cognition in adults with affective disorders. However, conclusions have been limited by inconsistent findings across different maltreatment subtypes and social domains. We conducted a systematic review and meta-analysis to quantify associations between childhood maltreatment (overall and subtypes - physical, emotional and/or sexual abuse, and/or physical and/or emotional neglect) and different domains of social functioning and social cognition in adults with affective disorders (bipolar disorder or major depressive disorder). We also examined effect moderators and mediators of these associations.

METHODS

A systematic search was performed on 12.12.2022 which identified 29 studies included in qualitative synthesis (n = 3022 individuals with affective disorders), of which 27 (n = 2957) were pooled in meta-analyses. Across studies, five social functioning and five social cognition domains were examined, of which four domains of social functioning and two domains of social cognition had sufficient data for meta-analysis (PROSPERO CRD42022288976).

RESULTS

Social functioning: childhood maltreatment was associated with lower global social functioning (r = -0.11 to -0.20), poorer interpersonal relations (r = -0.18 to -0.33), and with aggressive behaviour (r = 0.20-0.29) but was unrelated to vocational functioning. Emotional abuse and emotional neglect showed the largest magnitudes of effect. Social cognition: there was no meta-analytic evidence of associations between maltreatment and social cognition domains. Exploratory moderation analyses did not identify any consistent moderators. Narrative synthesis identified attachment style as possible moderator, and sensory patterns, anxiety, and depressive symptoms as possible mediators between childhood maltreatment and social outcomes. Overall, the available evidence was limited, particularly in relation to social cognition.

CONCLUSIONS

Adults with affective disorders are at risk of social functioning difficulties after childhood maltreatment exposure, an effect observed across multiple maltreatment subtypes, social functioning domains, and diagnoses. Addressing social functioning problems may benefit maltreated adults with both bipolar disorder and major depressive disorder.

Childhood trauma relates to worse memory functioning in bipolar disorder

BACKGROUND

Childhood trauma is commonly experienced by individuals diagnosed with bipolar disorder (BP). In BP, childhood trauma is related to a more severe clinical course, but its association with cognition remains unclear.

METHODS

This study evaluated 405 adult participants diagnosed with BP and 136 controls. Participants completed the Childhood Trauma Questionnaire and a comprehensive neuropsychological battery. High versus low childhood trauma was defined with one standard deviation above the control participant's mean Childhood Trauma Questionnaire score. Neuropsychological data was transformed into eight cognitive factors, including four executive functioning, auditory and visual memory, fine motor, and emotion processing. Multivariate analysis of covariance evaluated group differences in cognition, while adjusting for covariates.

RESULTS

There were significant differences among the three groups, F(16, 968) = 4.05, p < .001, Wilks' Λ = 0.88, partial η² = 0.06. Comparing the high and low trauma BP groups, high trauma was related to lower auditory and visual memory factor scores (p < .05). As compared to controls, the BP high trauma group had lower scores on six of eight factors (all p < .01), while the BP low trauma group had lower scores on four of eight factors (all p < .01).

LIMITATIONS

Analyses of factor score do not address which aspect of the memory process is affected and biomarkers may help guide interventions addressing underlying biological process.

CONCLUSIONS

Adults diagnosed with BP with higher childhood trauma have worse memory functioning, beyond the lower childhood trauma BP group, highlighting the importance of understanding the long-term cognitive outcomes of childhood trauma.

Can Dissociation Mediate the Relationship between Emotional Dysregulation and Intelligence? An Empirical Study Involving Adolescents with and without Complex Trauma Histories

The main aim of the study was to map the psychological functioning of individuals with adverse childhood experiences, with the objective to characterize developmental trajectories. Specifically, we investigated the relations among three of the seven domains of impairment in children and adolescents who had been exposed to complex trauma. To this end, we tested a mediation model with emotional dysregulation as the independent variable, intelligence as the dependent variable, and dissociation as the mediator. The research sample was composed of 64 participants (10-19 years old); 31 adolescents formed the clinical group and 33 the non-clinical group; for the clinical group, we recruited adolescents who were residents of therapeutic communities and had a history of complex trauma. Both groups completed the Difficulties in emotion regulation scale (DERS), Adolescent dissociative experience scale (A-DES), Trauma symptom checklist for children (TSCC), and Wechsler scales. The data analysis yielded significant results for the control group only. We suggest that healthy adolescents adopt a non-pathological dissociative cognitive style in response to increased emotional dysregulation, thus explaining their enhanced cognitive performance.

The interaction of the oxytocin receptor gene and child abuse subtypes on social cognition in euthymic patients with bipolar disorder type I

Background

Most studies on cognitive impairment in bipolar disorder have neglected the role of early stress, despite the high frequency of childhood maltreatment in this clinical group. The aim of this study was to establish a connection between a history of emotional, physical, and sexual abuse in childhood and social cognition (SC) in patients with bipolar disorder type I (BD-I) in euthymia, and to test a possible moderating effect of the single nucleotide polymorphism rs53576 in the oxytocin receptor gene (OXTR).

Methods

One hundred and one participants were included in this study. History of child abuse was evaluated using the Childhood Trauma Questionnaire-Short Form. Cognitive functioning was appraised using The Awareness of Social Inference Test (social cognition). The interaction effect between the independent variables OXTR rs53576 (AA/AG and GG) and the absence or presence of any one type of child maltreatment or a combination of types was analyzed using a generalized linear model regression.

Results

BD-I patients who had been victims of physical and emotional abuse in childhood and were carriers of the GG genotype at OXTR rs53576 displayed greater SC alterations, specifically in emotion recognition.

Discussion

This gene-environment interaction finding suggests a differential susceptibility model of a genetic variants that can be plausibly associated with SC functioning and might help to identify at-risk clinical subgroups within a diagnostic category. Future research aimed at testing the interlevel impact of early stress constitutes an ethical-clinical duty given the high rates of childhood maltreatment reported in BD-I patients.

Cognitive impairment, childhood trauma, sedentary behaviour, and elevated C-reactive protein levels in major affective disorders

Elevated C-reactive protein (CRP) levels were associated with cognitive decline, sedentary behaviour, and childhood trauma in patients with major affective disorders. This study aims to examine the association of peripheral CRP levels, cognitive function, childhood trauma, sedentary behaviour, and quality of life in individuals with major affective disorders, including bipolar disorder (BD), major depressive disorder (MDD), and individuals without mood disorders (controls). We included outpatients with BD (n = 42), MDD (n = 27), and healthy controls (n = 40). All participants were assessed by a questionnaire, structured clinical interview, and the following scales: international physical activity questionnaire, childhood trauma questionnaire, 17-item Hamilton Depression Rating Scale (HDRS₁₇), and World Health Organization Quality of Life instrument, brief version (WHOQOL-BREF). Other measures were included: hs-CRP levels, anthropometric measures, and cognitive tests (Trail-making test part A and part B, Stroop test, phonemic verbal fluency test, and semantic verbal fluency test). Our results indicated that BD outpatients were less significantly physically active on leisure domain than controls. Levels of hs-CRP ≥ 5 mg/L were significantly linked with a history of childhood sexual abuse and childhood physical abuse, as well as worse neurocognitive performance in major depressive disorders, mainly in BD. There was a significant negative correlation between Trail-making part B score and WHOQOL-BREF total score. The findings support the hypothesis that levels of hs-CRP ≥ 5 mg/L may be a possible predictor of cognitive dysfunction, childhood sexual abuse and sedentary behaviour in major affective disorders.

Association between lifetime and recent stressful life events and the early course and psychopathology in patients with newly diagnosed bipolar disorder, first-degree unaffected relatives and healthy controls: Cross-sectional results from a prospective study

OBJECTIVE

There is an accumulation of stressful life events prior to the first mood episode, but the impact of previous severe life events on psychopathology in patients with bipolar disorder (BD) is not well studied. We aimed to examine the number of recent and lifetime life events in patients with newly diagnosed BD, their unaffected relatives (UR), and healthy controls (HC) as well as the impact of severe lifetime life events on the early course of BD.

METHODS

We compared the number of recent and lifetime life events in 398 patients with newly diagnosed BD, 109 UR, and 214 HC. We subsequently dichotomized the patients with BD by >2 lifetime life events to investigate the associations of severe lifetime life events with clinical characteristics and affective symptoms.

RESULTS

Patients with newly diagnosed BD reported significantly more life events in the last 12 months and lifetime before compared with UR and HC. Patients who reported >2 lifetime life events (n = 160) compared with patients with 0-2 life events (n = 238) had a significantly longer diagnostic delay (9.5 years ± 8.2 vs. 6.2 years ± 6.9), presented with more anxiety and depressive symptoms and had at least one previous suicide attempt (30.6% vs. 15.6%) and one previous admission (51.3% vs. 36.6%).

CONCLUSION

The experience of severe lifetime life events seems to impact the early course in BD in terms of longer diagnostic delay, more severe psychopathology including more admissions and a more than doubled risk for previous suicide attempts.

Identifying neurocognitive heterogeneity in Older Adults with Bipolar Disorder: a cluster analysis

BACKGROUND

Cognitive profiles of BD patients show a demonstrated heterogeneity among young and middle-aged patients, but this issue has not yet deeply explored in Older Adults with bipolar disorder (OABD). The aim of the present study was to analyze cognitive variability in a sample of OABD.

METHODS

A total of 138 OABD patients and 73 healthy controls were included in this study. A comprehensive neuropsychological assessment was administered. We performed a k-means cluster analysis method based on the neurocognitive performance to detect heterogeneous subgroups. Demographic, clinical, cognitive and functional variables were compared. Finally, univariate logistic regressions were conducted to detect variables associated with the severity of the cognitive impairment.

RESULTS

We identified three distinct clusters based on the severity of cognitive impairment: (1) a preserved group (n = 58; 42%) with similar cognitive performance to HC, (2) a group showing mild cognitive deficits in all cognitive domains (n = 64; 46%) and, finally, (3) a group exhibiting severe cognitive impairment (n = 16; 12%). Older age, late onset, higher number of psychiatric admissions and lower psychosocial functioning were associated with the greatest cognitive impairment. Lower age, more years of education and higher estimated IQ were associated with a preserve cognitive functioning.

LIMITATIONS

The small sample size of the severely impaired group.

CONCLUSIONS

Cognitive heterogeneity remains at late-life bipolar disorder. Demographic and specific illness factors are related to cognitive dysfunction. Detecting distinct cognitive subgroups may have significant clinical implications for tailoring specific intervention strategies adapted to the level of the impairment and also to prevent cognitive decline.

Identifying social cognition subgroups in euthymic patients with bipolar disorder: a cluster analytical approach

BACKGROUND

Bipolar disorder (BD) is associated with social cognition (SC) impairments even during remission periods although a large heterogeneity has been described. Our aim was to explore the existence of different profiles on SC in euthymic patients with BD, and further explore the potential impact of distinct variables on SC.

METHODS

Hierarchical cluster analysis was conducted using three SC domains [Theory of Mind (ToM), Emotional Intelligence (EI) and Attributional Bias (AB)]. The sample comprised of 131 individuals, 71 patients with BD and 60 healthy control subjects who were compared in terms of SC performance, demographic, clinical, and neurocognitive variables. A logistic regression model was used to estimate the effect of SC-associated risk factors.

RESULTS

A two-cluster solution was identified with an adjusted-performance group (N = 48, 67.6%) and a low-performance group (N = 23, 32.4%) with mild deficits in ToM and AB domains and with moderate difficulties in EI. Patients with low SC performance were mostly males, showed lower estimated IQ, higher subthreshold depressive symptoms, longer illness duration, and poorer visual memory and attention. Low estimated IQ (OR 0.920, 95% CI 0.863-0.981), male gender (OR 5.661, 95% CI 1.473-21.762), and longer illness duration (OR 1.085, 95% CI 1.006-1.171) contributed the most to the patients clustering. The model explained up to 35% of the variance in SC performance.

CONCLUSIONS

Our results confirmed the existence of two discrete profiles of SC among BD. Nearly two-thirds of patients exhibited adjusted social cognitive abilities. Longer illness duration, male gender, and lower estimated IQ were associated with low SC performance.

High incidence of PTSD diagnosis and trauma-related symptoms in a trauma exposed bipolar I and II sample

BACKGROUND

Post-traumatic stress disorder (PTSD) is an established comorbidity in Bipolar Disorder (BD), but little is known about the characteristics of psychological trauma beyond a PTSD diagnosis and differences in trauma symptoms between BD-I and BD-II.

OBJECTIVE

(1) To present characteristics of a trauma-exposed BD sample; (2) to investigate prevalence and trauma symptom profile across BD-I and BD-II; (3) to assess the impact of a lifetime PTSD diagnosis vs. a history of trauma on BD course; and (4) to research the impacts of sexual and physical abuse.

METHODS

This multi-center study comprised 79 adult participants with BD with a history of psychological trauma and reports baseline data from a trial registered in Clinical Trials (https://clinicaltrials.gov; ref: NCT02634372). Clinical variables were gathered through clinical interview, validated scales and a review of case notes.

RESULTS

The majority (80.8%) of our sample had experienced a relevant stressful life event prior to onset of BD, over half of our sample 51.9% had a lifetime diagnosis of PTSD according to the Clinician Administered PTSD scale. The mean Impact of Event Scale-Revised scores indicated high levels of trauma-related distress across the sample, including clinical symptoms in the PTSD group and subsyndromal symptoms in the non-PTSD group. Levels of dissociation were not higher than normative values for BD. A PTSD diagnosis (vs. a history of trauma) was associated with psychotic symptoms [2(1) = 5.404, p = 0.02] but not with other indicators of BD clinical severity. There was no significant difference between BD-I and BD-II in terms of lifetime PTSD diagnosis or trauma symptom profile. Sexual abuse significantly predicted rapid cycling [2(1) = 4.15, p = 0.042], while physical abuse was not significantly associated with any clinical indicator of severity.

CONCLUSION

Trauma load in BD is marked with a lack of difference in trauma profile between BD-I and BD-II. Although PTSD and sexual abuse may have a negative impact on BD course, in many indicators of BD severity there is no significant difference between PTSD and subsyndromal trauma symptoms. Our results support further research to clarify the role of subsyndromic PTSD symptoms, and highlight the importance of screening for trauma in BD patients.

Cognitive performance in older-age bipolar disorder: Investigating psychiatric characteristics, cardiovascular burden and psychotropic medication

OBJECTIVE

This study aimed to explore a large range of candidate determinants of cognitive performance in older-age bipolar disorder (OABD).

METHODS

A cross-sectional study was performed in 172 BD patients aged ≥50 years. Demographics, psychiatric characteristics and psychotropic medication use were collected using self-report questionnaires and structured interviews. The presence of cardiovascular risk factors was determined by combining information from structured interviews, physical examination and laboratory assessments. Cognitive performance was investigated by an extensive neuropsychological assessment of 13 tests, covering the domains of attention, learning/ memory, verbal fluency and executive functioning. The average of 13 neuropsychological test Z-scores resulted in a composite cognitive score. A linear multiple regression model was created using forward selection with the composite cognitive score as outcome variable. Domain cognitive scores were used as secondary outcome variables.

RESULTS

The final multivariable model (N = 125), which controlled for age and education level, included number of depressive episodes, number of (hypo)manic episodes, late onset, five or more psychiatric admissions, lifetime smoking, metabolic syndrome and current use of benzodiazepines. Together, these determinants explained 43.0% of the variance in composite cognitive score. Late onset and number of depressive episodes were significantly related to better cognitive performance whereas five or more psychiatric admissions and benzodiazepine use were significantly related to worse cognitive performance.

CONCLUSION

Psychiatric characteristics, cardiovascular risk and benzodiazepine use are related to cognitive performance in OABD. Cognitive variability in OABD thus seems multifactorial. Strategies aimed at improving cognition in BD should include cardiovascular risk management and minimizing benzodiazepine use.

Defining Heterogeneous Cognitive Trajectories in Bipolar Disorder: A Perspective

Bipolar disorder (BD) is a highly disabling mental illness that affects approximately 1% of the global population. Cognitive capacity is a strong predictor of "everyday" functional outcome in BD and should thus be considered a key treatment target. Interventions to improve cognition have been largely unsuccessful, likely due to the substantial heterogeneity inherent to the illness. It is known that 40%-60% of people with BD have cognitive impairment, yet impairment is not "one size fits all"; in fact, the literature supports discrete cognitive subtypes in BD (e.g., intact, globally impaired, and selectively impaired). Gaining a better understanding of these cognitive subtypes, their longitudinal trajectories, and their biological underpinnings will be essential for improving patient outcomes. The prevailing hypothesis for the development of cognitive impairment in BD postulates a stepwise cumulative effect of repeated mood episodes causing wear-and-tear on the brain. However, a paucity of data supports this idea at the group level. We propose that studying heterogeneity longitudinally will allow for clearer delineation of the natural history of cognitive trajectories in BD. In sum, parsing heterogeneity in BD will allow us to identify causal mechanisms and optimize treatment at the level of the individual.

Adverse Childhood Experiences and Rate of Memory Decline From Mid to Later Life: Evidence From the English Longitudinal Study of Ageing

Evidence on the role of early-life adversity in later-life memory decline is conflicting. We investigated the relationships between adverse childhood experiences (ACEs) and memory performance and rate of decline over a 10-year follow-up among middle-aged and older adults in England. Data were from biennial interviews with 5,223 participants aged 54 years or older in the population-representative English Longitudinal Study of Ageing from 2006/2007 to 2016/2017. We examined self-reports of 9 ACEs prior to age 16 years that related to abuse, household dysfunction, and separation from family. Memory was assessed at each time point as immediate and delayed recall of 10 words. Using linear mixed-effects models with person-specific random intercepts and slopes and adjusted for baseline age, participants' baseline age squared, sex, ethnicity, and childhood socioeconomic factors, we observed that most individual and cumulative ACE exposures had null to weakly negative associations with memory function and rate of decline over the 10-year follow-up. Having lived in residential or foster care was associated with lower baseline memory (adjusted β = -0.124 standard deviation units; 95% confidence interval: -0.273, -0.025) but not memory decline. Our findings suggest potential long-term impacts of residential or foster care on memory and highlight the need for accurate and detailed exposure measures when studying ACEs in relation to later-life cognitive outcomes.

Clinical characteristic of prodromal symptoms between bipolar I and II disorder among Chinese patients: a retrospective study

BACKGROUND

This study aimed to identify the clinical characteristic of prodromal symptoms in Chinese patients with bipolar disorder (BD), prior to the first affective episode. It further aimed to characterize the prodromal traits between bipolar disorder type I (BD-I) and type II (BD-II).

METHODS

120 individuals with BD-I (n = 92) and BD- II (n = 28) were recruited to the study. Semi-structured interviews were then administered to evaluate prodromal symptoms in patients, within 3 years of BD onset, by using the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R).

RESULTS

In the prodromal phase of the first depressive episode, patients with BD-II experienced more prodromal symptoms (p = 0.0028) compared to BD-I. Additionally, more frequent predictors were reported in patients with BD-II than BD-I including educational and occupational dysfunction (p = 0.0023), social isolation (p < 0.001), difficulty making decisions (p = 0.0012), oppositionality (p = 0.012), and suspiciousness/persecutory ideas (p = 0.017). There were also differences in the duration of the precursors. The duration of "weight loss or decrease in appetite" (p = 0.016) lasted longer in patients with BD-I, while "obsessions and compulsions" (p = 0.023) started earlier in patients with BD-II and occurred during the pre-depressive period. The prevalence and duration of each reported prodrome, preceding a first (hypo) manic episode, showed no difference between patients with BD-I and BD-II.

CONCLUSIONS

Specific affective, general, or psychotic symptoms occurred prior to both affective episodes. The characteristic of prodromal symptoms were key predictors for later episodes of BD including attenuated mania-like symptoms, subthreshold depressed mood, mood swings/lability, and anxiety. In the pre-depressive state, when compared to BD-II, BD-I presented with more prodromal symptoms in nonspecific dimensions, which indicated the substantial burden of BD-II. In conclusion, this study extends the understanding of the characteristics of prodromes of BD-I and BD-II.

Childhood Maltreatment in Bipolar Disorders

In this chapter, we will focus on childhood maltreatment and its role in the vulnerability to BD.We will review how childhood maltreatment and trauma not only predispose to the development of BD but also to a more unstable, pernicious, and severe clinical expression of the disorder. This environmental risk factor is suggested to be part of a multiple hit model of vulnerability, involving not only early stressors (prenatal and postnatal ones) but also interactions with the genetic background of individuals and with other stressors occurring later in life. We will also review how childhood maltreatment and trauma may modify the brain functioning and circuits and alter some biological pathways in BD, hence leading to psychopathology. Finally, we will briefly discuss the implications for clinical practice and treatment.

Childhood neglect is associated with corticostriatal circuit dysfunction in bipolar disorder adults

Bipolar disorder (BD) is characterized with cognitive impairment, which may be mediated by corticostriatal dysfunction. Here we examined whether history of childhood trauma, a risk factor for BD, was linked to corticostriatal dysfunction in BD patients. Furthermore, the possible associations between childhood trauma and cognitive impairment were examined. Thirty-eight BD participants who met the DSM-IV diagnostic criteria were enrolled. Childhood trauma was identified via the Childhood Trauma Questionnaire (CTQ). Participants completed the Wisconsin Card-Sorting Test (WCST). Resting-state functional magnetic resonance imaging (rsfMRI) was performed in participants using a 3T scanner. Bilateral caudate to whole-brain functional connectivity (FC) were analyzed, and childhood trauma was entered as a regressor of interest when controlling for age. Results showed the level of physical neglect was negatively correlated with left-caudate-seed FC to the frontoparietal network, including the right supramarginal gyrus, left inferior parietal lobule, right middle frontal gyrus, and right superior parietal lobule. The level of physical neglect was also negatively correlated with WCST performance. And the left-caudate-seed FCs to the frontoparietal network were positively correlated with WCST performance. Unequivocally, the specific impacts of physical neglect on brain connectivity and executive function in the BD population merit further investigation.

Immature defense mechanisms mediate the relationship between childhood trauma and onset of bipolar disorder

BACKGROUND

Accumulating evidence has converged to suggest that childhood trauma may contribute to bipolar disorder (BD). This study aimed to investigate the patterns of childhood trauma among patients with bipolar I (BD-I) and bipolar II (BD-II) disorders, according to DSM-IV and in contrast with healthy volunteers. We also explored whether the relationship between childhood trauma and onset of bipolar disorder is mediated by immature defense mechanisms.

METHODS

Participants were patients with BD-I (n=44) and BD-II (n = 42), and healthy controls (HCs, n = 43). Childhood traumatic experiences and defense mechanisms were assessed by the Childhood Trauma Questionnaire (CTQ) and the Defense Style Questionnaire (DSQ), respectively.

RESULTS

BD patients experienced more severe childhood trauma than HCs. Physical neglect sub-score and total score of the CTQ had both direct and indirect effects on the diagnosis of BD-I, and an immature defense style mediated the indirect effects. The diagnosis of BD-II was mainly related to the physical neglect and emotional abuse subs-core and total score of the CTQ, as mediated by the immature defense mechanisms. BD-I and BD-II significantly differed in the emotional abuse sub-score of the CTQ.

CONCLUSIONS

Physical neglect sub-score and total score of the CTQ were associated with the diagnosis of BD (both BD-I and BD-II), as mediated by an immature defense style. Furthermore, emotional abuse might be an important risk factor for BD-II compared to BD-I. These findings may inform risk reduction and psychosocial intervention strategies to prevent and treat patients with bipolar disorders.

The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress

Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.

Trajectories of functioning in bipolar disorders: A longitudinal study in the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort

OBJECTIVE

We aimed at identifying distinct trajectories of functioning and at describing their respective clinical characteristics in a cohort of individuals with bipolar disorders.

METHODS

We included a sample of 2351 individuals with bipolar disorders who have been followed-up to 3 years as part as the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort. Global functioning was measured using the Functioning Assessment Short Test. We used latent class mixed models to identify distinct longitudinal trajectories of functioning over 3 years. Multivariable logistic regression models were used to identify the baseline factors that were associated with the membership to each trajectory of functioning.

RESULTS

Three distinct trajectories of functioning were identified: (1) a majority of individuals (72%) had a stable trajectory of mild functional impairment, (2) 20% of individuals had a stable trajectory of severe functional impairment and (3) 8% of individuals had a trajectory of moderate functional impairment that improved over time. The membership to a trajectory of stable severe versus stable mild functional impairment was associated with unemployment, a higher number of previous hospitalizations, childhood maltreatment, a higher level of residual depressive symptoms, higher sleep disturbances, a higher body mass index and a higher number of psychotropic medications being prescribed at baseline. The model that included these seven factors led to an area under the curve of 0.85.

CONCLUSION

This study enabled to stratify individuals with bipolar disorders according to three distinct trajectories of functioning. The results regarding the potential determinants of the trajectory of severe functional impairment needs to be replicated in independent samples. Nevertheless, these potential determinants may represent possible therapeutic targets to improve the prognosis of those patients at risk of persistent poor functioning.

Minimum clinically important differences for the Functioning Assessment Short Test and a battery of neuropsychological tests in bipolar disorders: results from the FACE-BD cohort

AIMS

Establishing the minimum clinically important difference (MCID) in functioning and cognition is essential to the interpretation of the research and clinical work conducted in bipolar disorders (BD). The present study aimed to estimate the MCID for the Functioning Assessment Short Test (FAST) and a battery of neuropsychological tests in BD.

METHODS

Anchor-based and distributive methods were used to estimate the MCID for the FAST and cognition using data from a large, multicentre, observational cohort of individuals with BD. The FAST and cognition were linked with the Clinical Global Impressions Scale-Severity (CGI-S) and Global Assessment of Functioning (GAF) using an equipercentile method. The magnitude of the standard error measurement (s.e.m.) provided another estimate of the MCID.

RESULTS

In total, 570 participants were followed for 2 years. Cross-sectional CGI-S and GAF scores were linked to a threshold ⩽7 on the FAST for functional remission. The MCID for the FAST equalled 8- or 9-points change from baseline using the CGI-S and GAF. One s.e.m. on the FAST corresponded to 7.6-points change from baseline. Cognitive variables insufficiently correlated with anchor variables (all ρ <0.3). One s.e.m. for cognitive variables corresponded to a range of 0.45 to 0.93-s.d. change from baseline.

CONCLUSIONS

These findings support the value of the estimated MCID for the FAST and cognition and may be a useful tool to evaluate cognitive and functional remediation effects and improve patient functional outcomes in BD. The CGI-S and GAF were inappropriate anchors for cognition. Further studies may use performance-based measures of functioning instead.

Clinical, genetic, and brain imaging predictors of risk for bipolar disorder in high-risk individuals

Introduction: Early detection and intervention in bipolar disorder (BD) might reduce illness severity, slow its progression, and, in specific cases, even ward off the full-blown disorder. Therefore, identifying at-risk individuals and targeting them promptly before the illness onset is of the utmost importance. In the last decades, there has been a significant effort aimed at identifying genetic and molecular factors able to modulate risk and pharmacological outcomes.Areas covered: We performed a narrative review of articles aimed at identifying clinical, genetics, molecular, and brain imaging markers of BD specifically focusing on samples of individuals at high-risk for BD. Special emphasis was put on studies applying an integrative design, e.g. studies combining different markers such as genetic and brain imaging.Expert opinion: Findings from studies in risk individuals are still too sparse to allow drawing definite conclusions. However, the high potentiality of longitudinal studies in individuals considered at risk to develop BD supports the need for more efforts. Future investigations should focus on more homogeneous subpopulations and evaluate the cross-linking between clinical, genetic, and brain morphostructural/functional neuroimaging characteristics as predictors of risk for BD.

Reliability and Validity of THINC-it in Evaluating Cognitive Function of Patients with Bipolar Depression

PURPOSE

The THINC-integrated tool (THINC-it) as a brief screening tool can assesses cognitive impairment in patients with major depressive depression (MDD). Here, we aim to evaluate the reliability and validity of the THINC-it in a bipolar depression (BD-D) group in comparison with a healthy control (HC) group.

MATERIALS AND METHODS

Both groups were matched according to age, gender, years of education, and IQ. All participants completed the THINC-it test, including Spotter, Symbol Check, Codebreaker, Trails, and the Perceived Deficits Questionnaire for Depression-5-item (PDQ-5-D). The concurrent validity and internal consistency of the THINC-it test were analyzed, and 30 healthy controls were randomly sampled to retest THINC-it to verify the reliability of the THINC-it retest. The correlation between THINC-it and Hamilton Depression Scale (HAMD-17) and Sheehan Disability Scale (SDS) was also analyzed.

RESULTS

Fifty-eight patients with BD-D and 61 HCs were included for final analysis. There were significant mean difference (MD) standard errors (SE) between two groups in PDQ-5-D, Spotter and Codebreaker (all P<0.01), Trails (P=0.015). There was no significant difference in Symbol Check (MD (SE)=-0.01 (0.18), P=0.938; 95% CI=-0.38 to 0.35). The Cronbach's α of PDQ-5-D was 0.640. The intraclass correlation coefficient (ICC) was between 0.440 and 0.757. The highest concurrent validity was PDQ-5-D (r=0.812, P<0.001). PDQ-5-D was positively correlated with HAMD-17 and SDS score (P<0.01). The objective test had no significant correlation with HAMD-17 and SDS scores (P>0.05).

CONCLUSION

This study found that THINC-it can accurately present the cognitive impairment of patients with BD-D. It can be potentially applied in assessing the cognitive function of patients with BD-D although Symbol Check may not accurately reflect the level of cognitive function. The concurrent validity and retest reliability are lower than expected, we need to further increase the sample size to study.

High BDNF serum levels are associated to good cognitive functioning in bipolar disorder

Background:

Neurotrophins such as brain-derived neurotrophic factor (BDNF), inflammation and oxidative damage may contribute to the pathophysiology of bipolar disorder (BD) in terms of illness activity. To date, there is a lack of studies linking the cognitive impairment observed in BD with these neurobiological mechanisms. This study aimed to investigate the role of these neurobiological factors in clinical and cognitive outcomes in a sample of bipolar individuals.

Methods:

We measured serum BDNF, cytokines and oxidative stress markers in a sample of 133 individuals: 52 euthymic bipolar patients, 32 manic patients and 49 healthy controls. They were all assessed with a comprehensive cognitive battery. Sociodemographic and clinical data were collected. Multiple linear regression models were built to study associations of neurotrophins and inflammatory and oxidative measures with cognitive functioning.

Results:

BDNF levels were decreased in euthymic (p = 0.039) and manic (p < 0.001) individuals. Conversely, inflammatory (interleukin 6 (IL-6)) (p = 0.019) and oxidative stress (p = 0.003) measures were increased in bipolar individuals compared to controls. BDNF levels were associated with executive functioning (β = 0.01, p = 0.02) and verbal memory (β = 0.013, p = 0.005), together with other demographic variables. In particular, verbal memory was also associated with obesity (β=-0.04, p = 0.005). Neither inflammatory markers, oxidative stress markers nor other relevant clinical variables showed any association with cognitive outcome.

Conclusions:

Of all the peripheral neurobiological factors analysed, BDNF was the only one significantly associated with cognitive dysfunction in bipolar disorder individuals. This study emphasizes the role of BDNF not only across mood phases but also in cognitive functioning.

A Systematic Review of Studies Reporting Data-Driven Cognitive Subtypes across the Psychosis Spectrum

The delineation of cognitive subtypes of schizophrenia and bipolar disorder may offer a means of determining shared genetic markers and neuropathology among individuals with these conditions. We systematically reviewed the evidence from published studies reporting the use of data-driven (i.e., unsupervised) clustering methods to delineate cognitive subtypes among adults diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder. We reviewed 24 studies in total, contributing data to 13 analyses of schizophrenia spectrum patients, 8 analyses of bipolar disorder, and 5 analyses of mixed samples of schizophrenia and bipolar disorder participants. Studies of bipolar disorder most consistently revealed a 3-cluster solution, comprising a subgroup with 'near-normal' (cognitively spared) cognition and two other subgroups demonstrating graded deficits across cognitive domains. In contrast, there was no clear consensus regarding the number of cognitive subtypes among studies of cognitive subtypes in schizophrenia, while four of the five studies of mixed diagnostic groups reported a 4-cluster solution. Common to all cluster solutions was a severe cognitive deficit subtype with cognitive impairments of moderate to large effect size relative to healthy controls. Our review highlights several key factors (e.g., symptom profile, sample size, statistical procedures, and cognitive domains examined) that may influence the results of data-driven clustering methods, and which were largely inconsistent across the studies reviewed. This synthesis of findings suggests caution should be exercised when interpreting the utility of particular cognitive subtypes for biological investigation, and demonstrates much heterogeneity among studies using unsupervised clustering approaches to cognitive subtyping within and across the psychosis spectrum.

Clinical outcomes and childhood trauma in bipolar disorder: A community sample of young adults

Childhood trauma is a complex experience, much reported by subjects with bipolar disorder. There are still few studies that assess its consequences in a community sample of bipolar in early stage. The aim of the present study is to assess the association between childhood trauma and clinical outcomes, including the global functioning, in a community sample of young adults with bipolar disorder. This is a cross-sectional study with a community sample of subjects with bipolar disorder, from 23 to 30 years old, with and without childhood trauma. The trauma experiences during childhood were assessed by Childhood Trauma Questionnaire (CTQ). The functioning was assessed by Functioning Assessment Short Test (FAST). Ninety subjects with bipolar disorder were included in the study (30 with childhood trauma and 60 without childhood trauma). Young adults with bipolar disorder and childhood trauma showed higher prevalence of current suicide risk, higher severity of depressive symptoms, and higher functioning impairment as compared to subjects with bipolar disorder without childhood trauma. The childhood trauma experiences appear to be an environmental risk factor for worse clinical outcomes and higher functional impairment.

Perceived childhood adversities: Impact of childhood trauma to estimated intellectual functioning of individuals with bipolar disorder

Maltreatments in childhood may have implications for neurodevelopment that could remain throughout life. Childhood trauma seems to be associated with the onset of bipolar disorder (BD), and its occurrence might accentuate the overall disease impairments related to cognitive deficits in BD. We aimed to evaluate the effects of a history of childhood trauma to estimated intellectual functioning (IQ) of individuals with BD. We included 72 subjects with BD during euthymia. Participants underwent a clinical interview and were assessed through the Childhood Trauma Questionnaire (CTQ) and Wechsler Abbreviated Scale of Intelligence (WASI). Most prevalent trauma subtypes were emotional abuse and neglect (54.1%). A linear regression model that included perceived childhood trauma, family history of severe mental disorders, age at diagnosis and psychotic symptoms during the first episode as main factors showed that only childhood trauma had a significant effect in predicting estimated IQ. Therefore, the history of childhood trauma in individuals with BD may play a role in intellectual development, suggesting that adversities during development result in decreased general cognitive abilities. These results reinforce the need to promote early interventions to protect childhood and to promote the well-being of children, contributing to the growth of healthy adults.

Effects of childhood trauma on adult moral decision-making: Clinical correlates and insights from bipolar disorder

BACKGROUND

Childhood adversity has been shown to exert profound effects on basic psychological processes well into adulthood. Some of these processes, such as those related to reward and emotion, play critical roles in moral decision-making. As a population with high rates of childhood trauma as well as heterogenous clinical presentation, individuals with bipolar disorder (BD) constitute an enriched group in which to examine the correlates of trauma and other clinical variables with moral cognition.

METHODS

62 euthymic BD patients and 27 controls responded to moral dilemma scenarios and completed the Childhood Trauma Questionnaire.

RESULTS

Results revealed a main effect of diagnosis on moral decision-making only when both personal force and an intention were required, indicating a more utilitarian style in BD patients relative to controls. Several interesting patterns also emerged regardless of diagnostic status. Higher ratings of physical neglect were significantly associated with higher ratings of acceptability (a utilitarian tendency) across dilemma types, and a similar pattern was observed at the trend level for experiences of emotional neglect. Significant main effects on moral decision-making were also observed for sex, illness duration, and history of psychotic features in the BD sample.

LIMITATIONS

The present study is limited by the self-reported nature of the CTQ and by the small number of trials of moral dilemmas. In addition, practical and clinical implications of the moral dilemmas paradigm are limited due to its abstract nature.

CONCLUSIONS

Our results indicate that certain clinical features as well as childhood maltreatment (in particular neglect) may significantly impact moral decision making in adult life. Surprisingly, childhood trauma was associated with a more utilitarian style, which is in the opposite direction from previous effects shown in PTSD. Although speculative, our results suggest that there may be a protective quality associated with utilitarian moral decision-making tendencies.

Lowered quality of life in mood disorders is associated with increased neuro-oxidative stress and basal thyroid-stimulating hormone levels and use of anticonvulsant mood stabilizers

RATIONALE, AIMS

Major affective disorders including bipolar disorder (BD) and major depressive disorder (MDD) are associated with impaired health-related quality of life (HRQoL). Oxidative stress and subtle thyroid abnormalities may play a pathophysiological role in both disorders. Thus, the current study was performed to examine whether neuro-oxidative biomarkers and thyroid-stimulating hormone (TSH) levels could predict HRQoL in BD and MDD.

METHODS

This cross-sectional study enrolled 68 BD and 37 MDD patients and 66 healthy controls. The World Health Organization (WHO) QoL-BREF scale was used to assess 4 QoL subdomains. Peripheral blood malondialdehyde (MDA), advanced oxidation protein products, paraoxonaxe/CMPAase activity, a composite index of nitro-oxidative stress, and basal TSH were measured.

RESULTS

In the total WHOQoL score, 17.3% of the variance was explained by increased advanced oxidation protein products and TSH levels and lowered CMPAase activity and male gender. Physical HRQoL (14.4%) was associated with increased MDA and TSH levels and lowered CMPAase activity. Social relations HRQoL (17.4%) was predicted by higher nitro-oxidative index and TSH values, while mental and environment HRQoL were independently predicted by CMPAase activity. Finally, 73.0% of the variance in total HRQoL was explained by severity of depressive symptoms, use of anticonvulsants, lower income, early lifetime emotional neglect, MDA levels, the presence of mood disorders, and suicidal ideation.

CONCLUSIONS

These data show that lowered HRQoL in major affective disorders could at least in part result from the effects of lipid peroxidation, protein oxidation, lowered antioxidant enzyme activities, and higher levels of TSH.

Factors associated with poor functional outcome in bipolar disorder: sociodemographic, clinical, and neurocognitive variables

OBJECTIVE

The current investigation aimed at studying the sociodemographic, clinical, and neuropsychological variables related to functional outcome in a sample of euthymic patients with bipolar disorder(BD) presenting moderate-severe levels of functional impairment.

METHODS

Two-hundred and thirty-nine participants with BD disorders and with Functioning Assessment Short Test(FAST) scores equal or above 18 were administered a clinical and diagnostic interview, and the administration of mood measure scales and a comprehensive neuropsychological battery. Analyses involved preliminary Pearson bivariate correlations to identify sociodemographic and clinical variables associated with the FAST total score. Regarding neuropsychological variables, a principal component analysis (PCA) was performed to group the variables in orthogonal factors. Finally, a hierarchical multiple regression was run.

RESULTS

The best fitting model for the variables associated with functioning was a linear combination of gender, age, estimated IQ, Hamilton Depression Rating Scale (HAM-D), number of previous manic episodes, Factor 1 and Factor 2 extracted from the PCA. The model, including all these previous variables, explained up to 29.4% of the observed variance.

CONCLUSIONS

Male gender, older age, lower premorbid IQ, subdepressive symptoms, higher number of manic episodes, and lower performance in verbal memory, working memory, verbal fluency, and processing speed were associated with lower functioning in patients with BD.

Characterizing decision-making and reward processing in bipolar disorder: A cluster analysis

The presence of abnormalities in emotional decision-making and reward processing among bipolar patients (BP) has been well rehearsed. These disturbances are not limited to acute phases and are common even during remission. In recent years, the existence of discrete cognitive profiles in this psychiatric population has been replicated. However, emotional decision making and reward processing domains have barely been studied. Therefore, our aim was to explore the existence of different profiles on the aforementioned cognitive dimensions in BP. The sample consisted of 126 euthymic BP. Main sociodemographic, clinical, functioning, and neurocognitive variables were gathered. A hierarchical-clustering technique was used to identify discrete neurocognitive profiles based on the performance in the Iowa Gambling Task. Afterward, the resulting clusters were compared using ANOVA or Chi-squared Test, as appropriate. Evidence for the existence of three different profiles was provided. Cluster 1 was mainly characterized by poor decision ability. Cluster 2 presented the lowest sensitivity to punishment. Finally, cluster 3 presented the best decision-making ability and the highest levels of punishment sensitivity. Comparison between the three clusters indicated that cluster 2 was the most functionally impaired group. The poorest outcomes in attention, executive function domains, and social cognition were also observed within the same group. In conclusion, similarly to that observed in "cold cognitive" domains, our results suggest the existence of three discrete cognitive profiles concerning emotional decision making and reward processing. Amongst all the indexes explored, low punishment sensitivity emerge as a potential correlate of poorer cognitive and functional outcomes in bipolar disorder.

Schizotypal personality traits and social cognition are associated with childhood trauma exposure

OBJECTIVES

Childhood trauma is a common risk factor for adult psychiatric disorders, such as schizophrenia (SZ) and bipolar-I disorder (BD). However, its association with schizotypal personality traits, as well as cognitive and social cognitive abilities, is less well studied in these populations.

METHODS

In a cohort of 79 SZ cases, 84 BD cases, and 75 healthy controls (HCs), clinically significant levels of childhood trauma exposure (according to scores on the Childhood Trauma Questionnaire; CTQ) were evident in 54 SZ, 55 BD, and 26 HC individuals. Trauma-exposed and non-exposed groups were compared on schizotypal personality features (schizotypy) measured with the Schizotypal Personality Questionnaire (SPQ). Cognitive assessments included executive function, working memory, attention, and immediate and delayed memory. Social cognitive measures assessed facial emotion processing and theory-of-mind abilities.

RESULTS

Trauma-exposed participants showed higher levels of schizotypy, especially suspiciousness, relative to non-exposed individuals, regardless of clinical or HC status. Furthermore, trauma-exposed individuals showed deficits specifically in social cognitive, but not general cognitive abilities, regardless of clinical or HC status. These trauma-related results were found in the context of higher schizotypy levels in both SZ and BD relative to HC, and lower cognitive and social cognitive performance in SZ, relative to BD and HC groups.

CONCLUSIONS

These findings suggest that childhood trauma exposure impacts long-term schizotypy outcomes, especially paranoid ideation (suspiciousness), as well as complex social cognitive abilities in both healthy and psychotic populations. However, cognitive deficits associated with psychotic illness may not be distinguishable from those related to trauma exposure in previous studies.

PRACTITIONER POINTS

Findings Childhood trauma exposure is associated with increased schizotypal features (in particular paranoid ideation) and complex social cognitive abilities, independently of the diagnosis of psychotic disorder. Cognitive and social cognitive deficits were larger in schizophrenia compared to bipolar-I cases and healthy controls, but increased schizotypal features were observed in both schizophrenia and bipolar-I disorder relative to healthy controls. Limitations We were unable to distinguish the specific effects of particular childhood trauma exposures due to the high rate of exposure to more than one type of maltreatment. Retrospective assessment of childhood trauma in adulthood cannot be externally validated, and associations with behavioural traits in later life may be confounded by other factors not studied here.

Early life experiences and social cognition in major psychiatric disorders: A systematic review

Objective:

To present a systematic review of the literature on the associations between early social environment, early life adversity, and social cognition in major psychiatric disorders, including schizophrenia, bipolar disorder, borderline personality disorder, major depressive disorder and posttraumatic stress disorder.

Method:

Relevant studies were identified via electronic and manual searches of the literature and included articles written in English and published in peer-reviewed journals up to May 2018. Quality assessment was performed using the quality evaluation scale employed in previous systematic reviews.

Results:

A total of 25 studies were included in the systematic review with the quality assessment scores ranging from 3 to 6 (out of 6). The vast majority of the studies reviewed showed a significant association between early childhood social experience, including both insecure attachment and adversity relating to neglect or abuse, and poorer social cognitive performance.

Conclusion:

We discuss these findings in the context of an attachment model, suggesting that childhood social adversity may result in poor internal working models, selective attention toward emotional stimuli and greater difficulties with emotional self-regulation. We outline some of the steps required to translate this understanding of social cognitive dysfunction in major psychiatric disorders into a target for interventions that mitigate the adverse effects of childhood maltreatment and poor parental attachment on social cognition.

Heterogeneity of functional outcomes in patients with bipolar disorder: a cluster-analytic approach

OBJECTIVE

The aim was to examine the heterogeneity of psychosocial outcomes in euthymic bipolar disorder (BD) patients and analyse the potential influence of distinct variables on functioning.

METHOD

Using a hierarchical cluster exploratory analysis, 143 euthymic patients with diagnosis of BD were grouped according to their functional performance based on domains scores of the Functioning Assessment Short Test (FAST). The resulting groups were compared on sociodemographic, clinical and neurocognitive variables to find factors associated with each functional cluster.

RESULTS

Patients were grouped in three functional profiles: patients with good functioning in all the FAST areas, patients with an intermediate profile showing great difficulties in the occupational domain and milder difficulties in most of the rest domains, and a third group with serious difficulties in almost all functional areas. Both functionally impaired groups were characterized by higher subthreshold symptoms (depressive and manic) and higher unemployment rates. The most functionally impaired group also showed lower scores on some measures of processing speed.

CONCLUSION

Two of three functional profiles showed some kind of impairment which was associated with subsyndromal symptoms and cognitive performance. These patterns should be taken into consideration to develop more individualized interventions to restore, or improve, psychosocial outcomes.

Bipolar disorders

Bipolar disorders are chronic and recurrent disorders that affect >1% of the global population. Bipolar disorders are leading causes of disability in young people as they can lead to cognitive and functional impairment and increased mortality, particularly from suicide and cardiovascular disease. Psychiatric and nonpsychiatric medical comorbidities are common in patients and might also contribute to increased mortality. Bipolar disorders are some of the most heritable psychiatric disorders, although a model with gene-environment interactions is believed to best explain the aetiology. Early and accurate diagnosis is difficult in clinical practice as the onset of bipolar disorder is commonly characterized by nonspecific symptoms, mood lability or a depressive episode, which can be similar in presentation to unipolar depression. Moreover, patients and their families do not always understand the significance of their symptoms, especially with hypomanic or manic symptoms. As specific biomarkers for bipolar disorders are not yet available, careful clinical assessment remains the cornerstone of diagnosis. The detection of hypomanic symptoms and longtudinal clinical assessment are crucial to differentiate a bipolar disorder from other conditions. Optimal early treatment of patients with evidence-based medication (typically mood stabilizers and antipsychotics) and psychosocial strategies is necessary.