Clinical features of soft bipolarity in major depressive inpatients

Affective Temperaments and Clinical Course of Bipolar Disorder: An Exploratory Study of Differences among Patients with and without a History of Violent Suicide Attempts

Background and Objectives: Suicide is the leading cause of death in patients with Bipolar Disorder (BD). In particular, the high mortality rate is due to violent suicide attempts. Several risk factors associated with suicide attempts in patients with BD have been identified. Affective temperaments are associated with suicidal risk, but their predictive role is still understudied. The aim of this study is to assess the relationship between affective temperaments and personal history of violent suicide attempts. Materials and Methods: 74 patients with Bipolar Disorder type I (BD-I) or II (BD-II) were included. All patients filled in the short version of Munster Temperament Evaluation of the Memphis, Pisa, Paris and San Diego (short TEMPS-M) and the Temperament and Character Inventory, revised version (TCI-R). The sample was divided into two groups on the basis of a positive history for suicidal attempts and the suicidal group was further divided into two subgroups according to violent suicide attempts. Results: Violent suicide attempts were positively associated with the cyclothymic temperament and inversely to the hyperthymic one. BD-I patients and patients with a clinical history of rapid cycling were significantly more represented in the group of patients with a history of violent suicide attempts. Conclusions: Our study highlights that several clinical and temperamental characteristics are associated with violent suicide attempts, suggesting the importance of affective temperaments in the clinical management of patients with BPI.

Bipolar disorder in Asia: Illness course and contributing factors

BACKGROUND

Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors.

METHODS

A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated.

RESULTS

Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes.

LIMITATIONS

The effects of treatment and childhood BD course features were not discussed.

CONCLUSIONS

There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

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

The relationship between borderline personality disorder and bipolar disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.

Anger induced by interferon-alpha is moderated by ratio of arachidonic acid to omega-3 fatty acids

OBJECTIVE

Anger worsens in some patients during interferon-alpha (IFN-α) therapy. Elevated anger has also been associated with lower long-chain omega-3 (LCn-3) fatty acid levels. We examined whether fatty acids could influence vulnerability to anger during IFN-α exposure.

METHODS

Plasma arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) levels were determined prior to IFN-α therapy by mass spectroscopy. Repeated-measure analyses examined the relationship between AA/EPA+DHA and the subsequent development of labile anger and irritability in 82 subjects who prospectively completed the Anger, Irritability, and Assault Questionnaire (AIAQ) during the first eight weeks of IFN-α therapy.

RESULTS

Prior to IFN-α therapy, AA/EPA+DHA did not correlate with either labile anger or irritability. Pre-treatment AA/EPA+DHA did correlate with the subsequent maximal increase in labile anger during IFN-α therapy (r=0.33; p=0.005). Over time, labile anger increased more in subjects with above median AA/EPA+DHA ratios (p<0.05). Of the 17 subjects ultimately requiring psychiatric intervention for anger, 14/17 had above-median AA/EPA+DHA ratios (p=0.009). There was also an interaction with the tumor necrosis factor-alpha (TNF-α) promoter polymorphism (A-308G), such that only those with both elevated AA/EPA+DHA and the A allele had increased labile anger (p=0.001). In an additional 18 subjects, we conversely observed that selective serotonin reuptake inhibitor treatment was associated with increased irritability during IFN-α therapy.

CONCLUSION

LCn-3 fatty acid status may influence anger development during exposure to elevated inflammatory cytokines, and may interact with genetic risk for increased brain TNF-α. LCn-3 supplements may be one strategy for minimizing this adverse side effect of IFN-α.

Cyclothymic and hyperthymic temperaments may predict bipolarity in major depressive disorder: a supportive evidence for bipolar II1/2 and IV

BACKGROUND

The concept of soft bipolar spectrum has not been fully confirmed. The aim of the present study is to investigate the validity of bipolar II1/2 and IV concept.

METHODS

The subjects were 46 consecutive outpatients. The individual temperament of each patient was recorded using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A). The operational definition of bipolar II1/2 was those who had depression with cyclothymic temperament and that of bipolar IV was those who had depression with hyperthymic temperament. Finally, drug responses were investigated.

RESULTS

DSM-IV-TR diagnoses were bipolar I (N=1), bipolar II (N=9), major depressive disorder (N=34) and depressive disorder not otherwise specified (N=2). Excluding one bipolar I patient, who had both cyclothymic and hyperthymic temperaments, patients with bipolar II1/2 (N=32) and IV (N=13) as well as bipolar II (N=9) were classified into the soft bipolar spectrum, although there was considerable overlap. The categorization of soft bipolar spectrum and unipolar depression significantly predicted depressive, cyclothymic, irritable, and anxious temperaments. Moreover, soft bipolar spectrum patients with lithium treatment were significantly more in remission than those without lithium treatment. In addition, more of those with selective serotonin reuptake inhibitors (SSRIs) had a significant tendency to lower remission than those without SSRIs.

LIMITATIONS

This is a cross-sectional study with a relatively small number of subjects.

CONCLUSIONS

The present findings suggest that cyclothymic and hyperthymic temperaments may predict bipolarity, and the validity of bipolar II1/2 and IV concept is supported.

Labile anger during interferon alfa treatment is associated with a polymorphism in tumor necrosis factor alpha

OBJECTIVE

Inflammatory cytokines may influence both labile anger and depression. Both psychiatric conditions can occur during interferon alfa-based treatments. Evidence also indicates a central nervous system role for tumor necrosis factor alpha (TNF-alpha), whose expression may be increased by interferon alfa. A polymorphism in the promoter region of TNF-alpha has been associated with various inflammatory illnesses. We therefore hypothesized that this TNF-alpha polymorphism would influence susceptibility to psychiatric symptoms during interferon alfa therapy.

METHODS

One hundred five patients with hepatitis C, initially without active major depression (major depressive disorder), were treated with interferon alfa and then prospectively monitored using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Beck Depression Inventory II, the Anger Irritability and Assault Questionnaire, and circulating TNF-alpha levels. The A-308G polymorphism (rs1800629) was determined using the 5'-nuclease assay. Repeated-measure mixed-effect analyses compared changes in symptoms over time.

RESULT

Beck Depression Inventory II score increased during interferon alfa therapy (F = 6.2; P < 0.001), with 27% developing MDD. The TNF-alpha A allele was associated with worsened labile anger (F = 2.5; P < 0.05) and fatigue (F = 2.9; P < 0.05) during treatment but not with major depression incidence (chi = 0.0; P = 0.99) or increased Beck Depression Inventory II (F = 1.2; P = 0.31). Labile anger was not predicted by the serotonin transporter polymorphism (F = 0.8; P = 0.59).

DISCUSSION

During treatment with an exogenous cytokine, vulnerability to worsening labile anger-distinct from major depression-is associated with genetic variability in TNF-alpha. This has implications both for patients being treated with interferon alfa and our understanding of genetic vulnerability for different subtypes of dysphoric and mood disorders.