Mania following head trauma

Mania Following Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Mania is an uncommon, but debilitating, psychiatric occurrence following TBI. The literature on mania following TBI is largely limited to case reports and case series. In the present review, the investigators describe the clinical, diagnostic, and treatment characteristics of mania following TBI.

METHODS

A systematic search of MEDLINE, EMBASE, and PsycINFO was conducted for English-language studies published from 1980 to July 15, 2021. The included studies provided the required individual primary data and sufficient information on clinical presentation or treatment of manic symptoms. Studies with patients who reported a history of mania or bipolar disorder prior to TBI and studies with patients who sustained TBI before adulthood were excluded.

RESULTS

Forty-one studies were included, which reported information for 50 patients (the mean±SD age at mania onset was 39.1±14.3 years). Patients were more frequently male, aged <50 years, and without a personal or family history of psychiatric disorders. Although 74% of patients reported mania developing within 1 year following TBI, latencies of up to 31 years were observed. Illness trajectory varied from a single manic episode to recurrent mood episodes. Rapid cycling was reported in six patients. Mood stabilizers and antipsychotics were most frequently used to improve symptoms.

CONCLUSIONS

Heterogeneity of lesion locations and coexisting vulnerabilities make causality difficult to establish. Valproate or a second-generation antipsychotic, such as olanzapine or quetiapine, may be considered first-line therapy in the absence of high-level evidence for a more preferred treatment. Early escalation to combined therapy (mood stabilizer and second-generation antipsychotic) is recommended to control symptoms and prevent recurrence. Larger prospective studies and randomized controlled trials are needed to refine diagnostic criteria and provide definitive treatment recommendations.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Hemispheric stroke: Mood disorders

Stroke causes many forms of disability, including emotional and mood disorders. Depression is the most common of these, affecting approximately one-third of stroke patients. Other disorders like mania, bipolar disorder, anxiety disorder, or apathy may also develop following stroke, although they are less common. The development of mood and emotional disorders is dependent on the severity of brain injury, the side of injury, and hemispheric location. Whereas a left hemispheric stroke often results in depression or a catastrophic reaction with anxiety, injury to the right hemisphere has predominantly been associated with the development of emotional indifference (anosodiaphoria) or euphoria. In this chapter, we discuss the mood disorders associated with hemispheric strokes and the neuropsychological mechanisms that might account for the clinical manifestations of these affective disorders.

Differences in course of illness between patients with bipolar II disorder with and without epileptiform discharges or other sharp activity on electroencephalograms: a cross-sectional study

BACKGROUND

A diagnosis of bipolar II disorder requires that the symptoms cannot be better explained by a medical condition. Epilepsy is in some cases associated with an affective syndrome mimicking an unstable bipolar II disorder. Epileptiform discharges on electroencephalograms (EEGs) are typical, but not pathognomonic, for epilepsy. A previous study has found a high frequency of epileptiform discharges and other sharp activity among patients with bipolar disorder. The aim of the study was to identify if epileptic discharges or other sharp activity per se are associated with an altered course of illness among patients with bipolar II disorder.

METHODS

Eighty six patients diagnosed with bipolar II disorder at two psychiatric departments were interviewed about prior course of illness and assessed with EEGs. The patients were split into two groups based on the presence (n = 12) or absence (n = 74) of epileptiform discharges or other sharp activity. Wilcoxon rank sum test, Fisher's exact test, and Pearson's chi squared test were used to assess differences between the groups on six variables of course of illness.

RESULTS

Patients with epileptiform discharges or other sharp activity had a history of more hypomanic episodes per year (median (interquartile range (IQR)) 1.5 (3.2) vs. 0.61 (1.1), p = 0.0090) and a higher hypomania:depression ratio (median (IQR) 3.2 (16) vs. 1.0 (1.0), p = 0.00091) as compared to patients without. None of the patients with epileptiform discharges or other sharp activity had self-reported epileptic seizures in their history.

CONCLUSIONS

Epileptiform discharges or other sharp activity on EEGs are associated with more hypomanic episodes and an increased hypomania:depression ratio. Our results warrant replication in prospective studies, but suggest that EEG findings could be of prognostic importance for patients diagnosed with bipolar II disorder in psychiatric care.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT00201526 ).

Psychopharmacology of traumatic brain injury

The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.

Clinical characteristics of patients with bipolar disorder and premorbid traumatic brain injury: a cross-sectional study

BACKGROUND

About one in ten diagnosed with bipolar disorder (BD) has experienced a premorbid traumatic brain injury (TBI), while not fulfilling the criteria of bipolar and related disorder due to another medical condition (BD due to TBI). We investigated whether these patients have similar clinical characteristics as previously described in BD due to TBI (i.e. more aggression and irritability and an increased hypomania/mania:depression ratio) and other distinct clinical characteristics.

METHODS

Five hundred five patients diagnosed with BD type I, type II, or not otherwise specified, or cyclothymia were interviewed about family, medical, and psychiatric history, and assessed with the Young Mania Rating Scale (YMRS) and the Inventory of Depressive Symptoms Clinician Rated 30 (IDS-C₃₀). Principal component analyses of YMRS and IDS-C₃₀ were conducted. Bivariate analyses and logistic regression analyses were used to compare clinical characteristics between patients with (n = 37) and without (n = 468) premorbid TBI.

RESULTS

Premorbid TBI was associated with a higher YMRS disruptive component score (OR 1.7, 95% CI 1.1-2.4, p = 0.0077) and more comorbid migraine (OR 4.6, 95% CI 1.9-11, p = 0.00090) independently of several possible confounders. Items on disruptive/aggressive behaviour and irritability had the highest loadings on the YMRS disruptive component. Premorbid TBI was not associated with an increased hypomania/mania:depression ratio.

CONCLUSIONS

Disruptive symptoms and comorbid migraine characterize BD with premorbid TBI. Further studies should examine whether the partial phenomenological overlap with BD due to TBI could be explained by a continuum of pathophysiological effects of TBI across the diagnostic dichotomy. Trial registration ClinicalTrials.gov: NCT00201526. Registered September 2005 (retrospectively registered).

Neurobehavioral Management of Traumatic Brain Injury in the Critical Care Setting: An Update

Traumatic brain injury (TBI) is an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI is a major cause of disability and mortality worldwide. Post-traumatic amnesia, or the interval from injury until the patient is oriented and able to form and later recall new memories, is an important index of TBI severity and functional outcome. This article will discuss the updates in the epidemiology, definition and classification, pathophysiology, diagnosis, and management of common acute neuropsychiatric sequelae of traumatic brain injury that the critical care specialist may encounter.

Manic Symptoms Due to Methylphenidate Use in an Adolescent with Traumatic Brain Injury

Almost one-fifth of children who sustain a traumatic brain injury (TBI) are under the risk of attention problems after injury. The efficacy and tolerability of methylphenidate (MPH) in children with a history of TBI have not been completely identified. In this case report, MPH-induced manic symptoms in an adolescent with TBI will be summarized. A male patient aged 17 years was admitted with the complaints of attention difficulties on schoolwork and forgetfullness which became evident after TBI. Long-acting MPH was administered with the dose of 18 mg/day for attention problems. After one week, patient presented with the complaints of talking to himself, delusional thoughts, irritability and sleeplessness. This case highlights the fact that therapeutic dose of MPH may cause mania-like symptoms in children with TBI. Close monitarization and slow dose titration are crucial when considering MPH in children with TBI.

Traumatic brain injury and bipolar psychosis in the Genomic Psychiatry Cohort

Approximately three million individuals in the United States sustain traumatic brain injury (TBI) every year, with documented impact on a range of neurological and psychiatric disturbances including mania, depression, and psychosis. Identification of subsets of individuals that may demonstrate increased propensity for posttraumatic symptoms and who may share genetic vulnerabilities for gene-environment interactions can enhance efforts to understand, predict, and prevent these phenomena. A sample of 11,489 cases from the Genomic Psychiatry Cohort (GPC), a NIMH-managed data repository for the investigation of schizophrenia and bipolar disorder, was used for this study. Cases were excluded if TBI was deemed causal to their mental illness. A k-means clustering algorithm was used to probe differences between schizophrenia and bipolar disorder associated with variables including onset age, hallucinations, delusions, head injury, and TBI. Cases were separated into an optimum number of seven clusters, with two clusters including all cases with brain injury. Bipolar disorder with psychosis and TBI were significantly correlated in one cluster in which 72% of cases were male and 99.2% sustained head injury. This cluster also carried the longest average period of unconsciousness. This study demonstrates an association of TBI with psychosis in a subset of bipolar cases, suggesting that traumatic stressors may have the ability to impact gene expression in a vulnerable population, and/or there is a heightened occurrence of TBI in individuals with underlying psychosis. Further studies should more closely examine the interplay between genetic variation in bipolar disorder and susceptibility to psychosis following TBI. © 2015 Wiley Periodicals, Inc.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder

OBJECTIVES

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures.

METHODS

For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder.

RESULTS

The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed.

CONCLUSIONS

Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

Mood disorders

Mood disturbances, especially depressive disorders, are the most frequent neuropsychiatric complication of traumatic brain injury (TBI). These disorders have a complex clinical presentation and are highly comorbid with anxiety, substance misuse, and other behavioral alterations such as impulsivity and aggression. Furthermore, once developed, mood disorders tend to have a chronic and refractory course. Thus, the functional repercussion of these disorders is huge, affecting the rehabilitation process and the long-term outcome of TBI patients. The pathophysiology of mood disorders involves the interplay of factors that precede trauma (e.g., genetic vulnerability and previous psychiatric history), factors that pertain to the traumatic injury itself (e.g., type, extent, and location of brain damage) and factors that influence the recovery process (e.g., family and social support). It is hardly surprising that mood disorders are associated with structural and functional changes of neural circuits linking brain areas specialized in emotional processing such as the prefrontal cortex, basal ganglia, and amygdala. In turn, the onset of mood disorders may contribute to further prefrontal dysfunction among TBI patients. Finally, in spite of the prevalence and impact of these disorders, there have been relatively few rigorous studies of therapeutic options. Development of treatment strategies constitutes a priority in this field of research.

Secondary mania following cerebral hypoxia

A case of secondary mania subsequent to cerebral hypoxia is presented. The relevant literature is briefly reviewed. The authors suggest that cerebral hypoxia be added to the list of causes of secondary mania.

Mood disorders after TBI

In this article, we examine the epidemiology and risk factors for the development of the most common mood disorders observed in the aftermath of TBI: depressive disorders and bipolar spectrum disorders. We describe the classification approach and diagnostic criteria proposed in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders. We also examine the differential diagnosis of post-TBI mood disorders and describe the mainstay of the evaluation process. Finally, we place a special emphasis on the analysis of the different therapeutic options and provide guidelines for the appropriate management of these conditions.

Three-dimensional mapping of hippocampal and amygdalar structure in euthymic adults with bipolar disorder not treated with lithium

Structural neuroimaging studies of the amygdala and hippocampus in bipolar disorder have been largely inconsistent. This may be due in part to differences in the proportion of subjects taking lithium or experiencing an acute mood state, as both factors have recently been shown to influence gray matter structure. To avoid these problems, we evaluated euthymic subjects not currently taking lithium. Thirty-two subjects with bipolar type I disorder and 32 healthy subjects were scanned using magnetic resonance imaging. Subcortical regions were manually traced, and converted to three-dimensional meshes to evaluate the main effect of bipolar illness on radial distance. Statistical analyses found no evidence for a main effect of bipolar illness in either region, although exploratory analyses found a significant age by diagnosis interaction in the right amygdala, as well as positive associations between radial distance of the left amygdala and both prior hospitalizations for mania and current medication status. These findings suggest that, when not treated with lithium or in an acute mood state, patients with bipolar disorder exhibit no structural abnormalities of the amygdala or hippocampus. Future studies, nevertheless, that further elucidate the impact of age, course of illness, and medication on amygdala structure in bipolar disorder are warranted.

Mood-state effects on amygdala volume in bipolar disorder

BACKGROUND

Prior structural neuroimaging studies of the amygdala in patients with bipolar disorder have reported higher or lower volumes, or no difference relative to healthy controls. These inconsistent findings may have resulted from combining subjects in different mood states. The prefrontal cortex has recently been reported to have a lower volume in depressed versus euthymic bipolar patients. Here we examined whether similar mood state-dependent volumetric differences are detectable in the amygdala.

METHODS

Forty subjects, including 28 with bipolar disorder type I (12 depressed and 16 euthymic), and 12 healthy comparison subjects were scanned on a 3T magnetic resonance image (MRI) scanner. Amygdala volumes were manually traced and compared across subject groups, adjusting for sex and total brain volume.

RESULTS

Statistical analyses found a significant effect of mood state and hemisphere on amygdala volume. Subsequent comparisons revealed that amygdala volumes were significantly lower in the depressed bipolar group compared to both the euthymic bipolar (p=0.005) and healthy control (p=0.043) groups.

LIMITATIONS

Our study was cross-sectional and some patients were medicated.

CONCLUSIONS

Our results suggest that mood state influences amygdala volume in subjects with bipolar disorder. Future studies that replicate these findings in unmedicated patient samples scanned longitudinally are needed.

Psychiatric disorders and traumatic brain injury

Psychiatric disorders after traumatic brain injury (TBI) are frequent. Researches in this area are important for the patients' care and they may provide hints for the comprehension of primary psychiatric disorders. Here we approach epidemiology, diagnosis, associated factors and treatment of the main psychiatric disorders after TBI. Finally, the present situation of the knowledge in this field is discussed.

Homicidal ideation with intent during a manic episode triggered by antidepressant medication in a man with brain injury

BACKGROUND

Mood disorders are more frequent after brain injury and both depressive and manic episodes are associated in these patients with an increased risk of aggression. Antidepressant medications are associated with a risk of manic induction.

CASE REPORT

We describe a case of homicidal ideation with intent during the onset of a manic episode in a patient with prior brain injury on antidepressant medication at low dosage. The manic episode could have been secondary to brain injury and/or triggered by antidepressant medications. This case raises the possibility of the sensitizing role of brain injury for antidepressant-induced mania.

CONCLUSIONS

Further studies are needed to assess the role of brain injury as a risk factor for antidepressant-induced mania. Physicians should be cautious when prescribing antidepressants to patients with prior brain injury and inform them and their relatives of the possibility of a switch into mania.

Quetiapine for mania due to traumatic brain injury

Secondary mania develops in as many as 9% of persons with traumatic brain injuries. The treatment of posttraumatic mania is not well defined, and agents traditionally used for the treatment of idiopathic manic episodes may not be well suited for use among individuals with traumatic brain injuries. Atypical antipsychotics are indicated for the treatment of idiopathic bipolar disorder, and have been used for other purposes among individuals with posttraumatic neuropsychiatric disturbances. This article offers the first description of the treatment of posttraumatic mania using the atypical antipsychotic quetiapine. Beneficial effects of this agent on posttraumatic mania, cognitive impairments, and functional disability in the subacute post-injury period are described. Possible mechanisms of action are discussed and the need for additional investigation of quetiapine for posttraumatic mania is highlighted.

Mania in the medically ill

Manic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. Manic symptoms may be due to an independent psychiatric illness, may be induced or precipitated by a medical condition, or may result from medication or substance use. The presence of manic symptoms in medically ill patients can lead to misdiagnosis or complicate the management of comorbid medical illness. It is of paramount importance to identify the etiology of the mania and, in particular, differentiate primary from secondary mania. Management of mania in the medically ill should focus on treating the underlying medical condition, medication management (antipsychotic agents, mood stabilizers, and/or benzodiazepines), and psychotherapy (if needed). Selecting appropriate medication for treatment requires basic knowledge of the pharmacokinetics of the medications, their side effect profile, and drug-drug interaction. The majority of deficits accompanying secondary mania resolve with treatment of the underlying cause, and supportive psychopharmacology may be all that is needed, but if symptoms persist, patients may need medications for a longer duration.

Secondary mania of vascular origin in elderly patients: A report of two clinical cases

The concept of secondary mania continues to be debated together with unresolved or partially resolved issues such as lateralization, localization, age of onset, disinhibition syndromes, and others. We have described two patients with secondary mania following a stroke. One had a large left hemisphere cerebral infarction and the symptoms arose about 2.5 years later, possibly triggered by a transient ischemic attack involving the right hemisphere. The other had an infarction in the right posterior artery territory extending to the thalamus and internal capsule together with infarctions in the deep border zones of both hemispheres at the level of the centrum semiovale with the manic symptoms concomitant with the onset of the event. The clinical and neuro-anatomic mechanisms that underlie the diverse locations of secondary mania are discussed. The cerebral components of secondary mania and disinhibition syndromes are very similar and it is proposed that disinhibition syndromes, secondary hypomania and secondary mania with and without psychotic symptoms are simply a continuum of severity of mood disorder and secondary mania with psychotic symptoms may be an extreme form. The concept of secondary mania in the elderly is not likely to disappear although several unresolved issues remain. For the neurophysician, geriatrician, and the psychiatrist there is much to be attained by simplifying the issues and accepting the view that secondary mania is a discrete entity.

Traumatic brain injury in the elderly: diagnostic and treatment challenges

The purpose of this review is to introduce geriatric practitioners to issues and challenges presented in the elderly after onset of traumatic brain injury (TBI). Issues discussed include the magnitude of TBI in the elderly, mechanisms of onset, issues specific to both acute and rehabilitation care for the elderly with TBI, and specific physical and behavioral manifestations of TBI that may need to be addressed on an inpatient or outpatient basis. General guidelines are provided for the diagnosis and treatment of older individuals who have TBI, with specific clinical scenarios illustrating key points.

Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders

OBJECTIVE

To estimate the comparative prevalence of bipolar symptoms in respondents with epilepsy vs other chronic medical conditions.

METHODS

The Mood Disorder Questionnaire (MDQ), a validated screening instrument for bipolar I and II symptoms, in conjunction with questions about current health problems, was sent to a sample of 127,800 people selected to represent the US adult population on selected demographic variables. A total of 85,358 subjects (66.8%) aged 18 or older returned the survey and had usable data. Subjects who identified themselves as having epilepsy were compared to those with migraine, asthma, diabetes mellitus, or a healthy comparison group with regard to relative lifetime prevalence rates of bipolar symptoms and past clinical diagnoses of an affective disorder.

RESULTS

Bipolar symptoms, evident in 12.2% of epilepsy patients, were 1.6 to 2.2 times more common in subjects with epilepsy than with migraine, asthma, or diabetes mellitus, and 6.6 times more likely to occur than in the healthy comparison group. A total of 49.7% of patients with epilepsy who screened positive for bipolar symptoms were diagnosed with bipolar disorder by a physician, nearly twice the rate seen in other disorders. However, 26.3% of MDQ positive epilepsy subjects carried a diagnosis of unipolar depression, and 25.8% had neither a uni- nor bipolar depression diagnosis.

CONCLUSION

Bipolar symptoms occurred in 12% of community-based epilepsy patients, and at a rate higher than in other medical disorders. One quarter were unrecognized.

Hippocampal and ventricular volumes in psychotic and nonpsychotic bipolar patients compared with schizophrenia patients and community control subjects: a pilot study

BACKGROUND

Previous reports of ventricular and hippocampal volumes in patients with bipolar disorder (BP) have been inconsistent in their findings. One possibility is that volumetric abnormalities are determined by disease subtype. Prior evidence suggests that psychotic (PBP) and nonpsychotic (NPBP) forms of BP are two subtypes that might differ in pathophysiology.

METHODS

We investigated ventricular and hippocampal volumes in 38 adults with clearly defined PBP (n = 23) and NPBP subtypes, compared with 33 persons with schizophrenia (SZ) and 44 healthy community control subjects (HC). Ventricular and hippocampal volumes were reliably measured on high-resolution anatomic magnetic resonance imaging scans. We used a multivariate analysis of covariance to compare volumes across groups, covarying for total brain volume. Potential effects of BP illness features were explored, contrasting PBP and NPBP.

RESULTS

For ventricular but not hippocampal regions, we found significant volume difference in PBP but not NPBP compared with HC (p < .005). We also observed nonsignificantly smaller left hippocampal volumes in PBP versus HC. Schizophrenic subjects had significantly larger ventricular and smaller left hippocampal volumes than HC.

CONCLUSIONS

These results suggest that PBP but not NPBP is associated with increased ventricle volumes and a trend toward smaller left hippocampal volumes, as observed in SZ.

Psychiatric aspects of traumatic brain injury

TBI is a complex heterogenous disease that can produce a variety of psychiatric disturbances, ranging from subtle deficits in cognition, mood, and behavior to severe disturbances that cause impairment in social, occupational, and interpersonal functioning. With improvement and sophistication in acute trauma care, a number of individuals are able to survive the trauma but are left with several psychiatric sequelae. It is important for psychiatrists to be aware of this entity because an increasing number of psychiatrists will be involved in the care of these patients. Treatment should be interdisciplinary and multifaceted, with the psychiatrist working in collaboration with the patient, caregiver, family, other physicians, and therapists. The goal of treatment should be to stabilize symptoms; maximize potential; minimize disability; and increase productivity socially, occupationally, and interpersonally.

The co-occurrence of mania with medical and other psychiatric disorders

OBJECTIVE

The co-occurrence of mania with other medical and psychiatric disorders has been little studied. The authors reviewed the literature in order to clarify the current state of knowledge of this subject and to identify possible areas of future research.

METHODS

Published articles which specifically addressed associations of mania with medical disorders and other psychiatric syndromes were identified using the Paperchase medical literature search system and by cross-referencing from other published work. The articles were then organized into three categories: 1) medical disorders associated with secondary mania; 2) medical comorbidity in bipolar disorder; and 3) psychiatric comorbidity in bipolar disorder.

RESULTS

The review of medical illness and secondary mania supports the hypothesis that injuries involving right-side and mid-line brain structures are associated with so-called secondary mania. Additionally, an association between bipolar disorder and migraine is identified. Several psychiatric disorders appear to occur with mania at rates higher than expected including obsessive-compulsive disorder, bulimia nervosa, panic disorder, impulse control disorders, and substance abuse.

CONCLUSIONS

The authors discuss the potential implications of these findings and suggest research approaches to further examine the relationships between mania and other medical and psychiatric syndromes.

Case study: bipolar disorder after head injury

A case of bipolar disorder subsequent to a mild head injury in a 15-year-old girl is reported. Review of the literature indicates that this is an extremely rare outcome. Lack of adequate follow-up studies makes it difficult to accurately predict type and severity of psychiatric outcome. Assessment and management involves ongoing consideration of both organic and psychosocial factors even after initial negative investigations.

Traumatic brain injury in individuals convicted of sexual offenses with and without bipolar disorder

The authors examined the occurrence of traumatic brain injury (TBI) in individuals convicted of sexual offenses with and without bipolar disorder and a comparison group of patients with bipolar disorder without a history of sexual offending behaviors. Individuals convicted of sexual offenses and diagnosed with bipolar disorder had greater rates of brain injury resulting from head trauma than individuals convicted of sexual offenses without bipolar disorder and comparison patients with bipolar disorder. TBI predated the first sexual offense and/or the onset of bipolar disorder in most subjects.

Mood and anxiety syndromes in emergency psychiatry

Mood and anxiety disorders are common in the general population and in the emergency setting. As psychiatric emergency care moves from the realm of triage and referral to a more definitive initiation of treatment, clinicians must approach the assessment and initial management of patients with mood and anxiety disorder in a rational and safe way. In the ED, the next step in assessing patients with mood or anxiety symptoms, after any immediate safety concerns are addressed, is to rule out medical or substance-induced causes. Treatment of these patients is directed at the underlying condition. When a primary psychiatric diagnosis is made, initial management, including definitive pharmacologic or psychotherapeutic intervention, can be started in the ED.

Secondary mania in patients with HIV infection

OBJECTIVE

The aim of this study was to identify a cohort of patients with mania secondary to HIV infection, to describe the clinical and radiological features of HIV-related mania, and to describe the treatment outcome of the patients.

METHOD

All patients referred to the HIV consultation-liaison psychiatry service over the 29-month period from January 1993 to June 1995 were screened for the presence of manic symptoms. Diagnosis of mania was made according to DSM-III-R. Cases were defined as secondary mania if there was no clear history of mood disorder, and no family history of mood disorder. Cases were interviewed by the treating psychiatry registrar and psychiatrist to obtain information regarding present and past psychiatric history and family history of psychiatric disorder. The psychiatry registrar and consultant determined treatment.

RESULTS

Twenty-three patients with mania were identified; 19 were considered to have secondary mania. The prevalence of secondary mania over the 29 months was 1.2% for HIV-positive patients, and 4.3% for those with AIDS. The clinical characteristics and response to treatment appeared to be similar to mania associated with bipolar affective disorder (primary mania). Neuroradiological abnormalities were common, occurring in 10 of the 19 patients, but did not appear to be clinically relevant. Cognitive impairment developed in five of the 15 patients where follow-up was possible.

CONCLUSIONS

Mania occurring in advanced HIV disease appears to be more common than expected from epidemiological data regarding bipolar affective disorder. Differentiating secondary from primary mania has implications for the management and prognosis of mania.

Disinhibition syndromes, secondary mania and bipolar disorder in old age

BACKGROUND

The neurological literature concerning disinhibition syndromes and secondary mania has run in parallel to clinical reports of bipolar disorder in old age.

METHODS

A critical review was conducted of both the neurological and geriatric psychiatry literature in an attempt to integrate the two streams.

RESULTS

Disinhibition syndromes include lateralization to the right hemisphere and localization of lesions to the orbito-frontal and basotemporal cortex involving limbic and frontal connections (orbito-frontal circuit). Mania in old age is associated with late onset, heterogeneous neurological disorders and poor outcome.

CONCLUSION

Bipolar disorders in old age may be understood in the context of affective vulnerability influenced by a specific neurobiologic substrate.

LIMITATIONS

The clinical literature consists predominantly of small case series and anecdotal reports.

CLINICAL RELEVANCE

Improved understanding of these syndromes may elucidate the pathogenesis and etiology of bipolar disorders and the neuropsychiatric syndromes affecting mood, motivation and behavioural disinhibition.

Evaluation of brain injury related behavioral disturbances in community mental health centers

As a result of improved emergency trauma services, more individuals suffering a traumatic brain injury are surviving. Unfortunately, most of these survivors suffer chronic neuropsychiatric sequelae related to both the brain damage and the psychosocial impact of the injury on self-esteem, self-image, primary role, and vocational function. Current community supports are often inadequate to deal with the complex array of neurologic and psychiatric difficulties. This article outlines common features of brain injury, explores the link between these features and the common neuropsychiatric sequelae of brain injury, and suggests some principles helpful in the evaluation of the behaviorally challenged brain injured patient.

Neuropsychiatric manifestations of right hemisphere lesions

A wide variety of neuropsychiatric syndromes are associated with right brain dysfunction, including mania, depression, psychosis, hallucinations, personality changes, anxiety, dissociative states, and altered sexual behavior. This review summarizes the anatomic relationships reported between specific neuropsychiatric syndromes and localized right brain lesions. Information is derived from individual case studies and case series. Most neuropsychiatric syndromes are found to be associated with damage to the limbic system. Disruption of body schema and interpersonal functions mediated primarily by the right hemisphere contributes to the neuropsychiatric disability associated with right hemisphere injury. Nonlesion biologic and sociocultural influences including a family history of psychiatric disorder, personal psychiatric history, and the presence of cerebral atrophy increase the vulnerability to neuropsychiatric morbidity following right brain damage. Investigation of the secondary neuropsychiatric disorders occurring with right brain dysfunction contributes to understanding the pathophysiology of idiopathic psychiatric syndromes.

The agitated brain injured patient. Part 1: Definitions, differential diagnosis, and assessment

This two-part review provides a critical analysis of the scientific and clinical literature on the agitated brain injured patient. Part 1 reviews nomenclature and classification issues, differential diagnosis, and assessment instruments designed for evaluation of the patient. Pathophysiology and treatment approaches will be discussed in Part 2 in a subsequent issue of the Archives. The review was unfortunately hampered by a lack of consistency in definitions, little scientific study of the neuroanatomic and neurochemical basis for the disorder, few outcome studies, and no randomized controlled treatment trials. Part 1 sets forth an interdisciplinary definition of agitation, establishes a differential diagnostic approach, and describes and critiques the assessment instruments available for clinical evaluation of the agitated patient. Part 2 will address treatment interventions including pharmacological, environmental, and behavioral approaches to this patient population.

Psychiatric illnesses in the elderly: a review

Neuropsychiatric disorders in the elderly, such as dementia, depression, anxiety, and psychosis, may occur alone or in combination with neurologic or medical illness. Geriatricians must be familiar not only with diagnostic issues but also with treatment options and medication-induced alterations in mental status.

Rapid cycling mania post head injury

A case of post traumatic rapid cycling unipolar mania is described in an individual with no apparent genetic predisposition to an affective disorder. A head injury is proposed as being causative. It is suggested that head injury should be included as a cause of rapid cycling affective disorder.

Benefits and risks of the hypericum extract LI 160: drug monitoring study with 3250 patients

Effectiveness and acceptance of a 4-week treatment with hypericum extract LI 160 were investigated by 663 private practitioners. The results of the 3250 patients (76% women and 24% men), were recorded using data sheets. The age of the patients ranged from 20 to 90 years (mean 51 years). Of the patients, 49% were mildly depressed, 46% intermediate, and 3% severely depressed. In about 30% of the patients, the situation normalized or improved during the therapy. Undesired drug effects were reported in 79 (2.4%) patients and 48 (1.5%) discontinued the therapy. Most frequently noted side effects were gastrointestinal irritations (0.6%), allergic reactions (0.5%), tiredness (0.4%), and restlessness (0.3%).

Treatment of depression

Depressions are the most common psychiatric diseases. For treatment, plant extracts have been used for thousands of years: examples are extracts from the (sleeping) poppy (opium), deadly nightshade (Atropa belladonna), Indian hemp (hashish), henbane (hyoscyamine), thorn apple (scopolamine), and St. John's wort (hypericum oil). In addition, psychotherapeutic measures, like playing music, dancing, playing theatre, and also the temple sleep, were used. In the 19th century, the introduction of brome (1826), codeine (1832), chloral hydrate (1869), and paraldehyde (1882), as well as the barbiturates (at the turn of the century) introduced significant improvements in pharmacotherapy. The modern thymoleptica therapy started in 1957 with the introduction of imipramine. Now about 40 active antidepressants are marketed. New drug developments should be characterized mainly by an improvement in tolerance.

Organic manic syndrome: causative factors, phenomenology and immediate outcome

A prospective study on organic manic syndromes led to identification of 30 cases over a period of 11 months, constituting 1.75% of all admissions and 4.67% of all patients with mania. They were compared with 60 sex- and age-matched bipolar controls. The mean age of onset of illness was not significantly different in the two groups. Family history of affective disorder was more often negative in organic manics. The overall mania rating score was similar in the two groups, but after 3 months organic manics improved less. Compared to the bipolar group, organic manics were more often irritable, made threats, had delusions, and showed cognitive dysfunctions. The implications of these findings on definition of the organic manic syndrome are discussed.

Mixed neurologic and psychiatric disorders: pharmacological issues

The number of patients with mixed neurologic and psychiatric disturbances is large. The psychiatric disturbances are often atypical in presentation and fit poorly into standard psychiatric nomenclature. They can be difficult to treat using standard psychopharmacologic approaches. This report reviews the impact of brain dysfunction on the use of conventional and nonconventional psychotropic agents in this mixed population.