Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities

BACKGROUND

The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior.

METHOD

We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed.

RESULTS

Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood.

CONCLUSIONS

Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.

Clinical and neuropsychological characteristics of euthymic bipolar patients having a history of severe suicide attempt

OBJECTIVE

Identifying bipolar patients at high-suicide risk is a major health issue. To improve their identification, we compared dimensional and neuropsychological profile of bipolar patients with or without history of suicide attempt, taking into account suicidal severity (i.e. admission to intensive ward).

METHOD

A total of 343 adult euthymic bipolar out-patients recruited in the French FondaMental Advanced Centres of Expertise for Bipolar Disorder were divided into three subgroups: 214 patients without history of suicide attempt, 88 patients with past history of non-severe suicide attempt and 41 patients with past history of severe suicide attempt. General intellectual functioning, speed of information processing, verbal learning and memory, verbal fluency and executive functioning were assessed.

RESULTS

Severe suicide attempters had lower affective intensity and lability than non-severe attempters. Severe suicide attempters outperformed non-severe attempters for verbal learning and non-attempters for Stroop word reading part after adjustment for study centre, age, gender, educational level, antipsychotics use, depression score, anxious and addictive comorbidities.

CONCLUSION

Neuropsychological tasks commonly used to assess bipolar patients do not seem accurate to identify suicide attempters in euthymic patients. In the future, decision-making and emotional recognition tasks should be assessed. Moreover, clinical and neuropsychological profiles should be considered together to better define suicidal risk.

Positive and negative life events and reasons for living modulate suicidal ideation in a sample of patients with history of suicide attempts

BACKGROUND

The influence of life events on suicidal behavior remains inconclusive, while reasons for living (RFL) may be protective.

OBJECTIVES

To analyze the association between positive and negative life events and suicidal ideation (SI) and the interaction between life events and RFL on SI.

METHOD

Patients with history of suicide attempts (n = 338) underwent a comprehensive clinical evaluation, including SI (Beck's Suicidal Ideation scale), RFL (Reasons for Living Inventory, RFLI) and life events (family, school, student or professional, social, health and religion-related and other life events) during the last twelve months.

RESULTS

The only negative life events associated with SI were health-related events (OR = 2.01 95%CI[1.04;3.92]). Family-related positive life events and RFL were negatively associated with SI (OR = 0.73 95%CI[0.58;0.91] and OR = 0.98 95%CI[0.97;0.98], respectively). No significant interaction between the number of positive life events and RFLI total score with current SI (p = 0.57) was detected. Family-related positive life events and RFL did not have any additive effect on SI. Positive life events did not moderate the association between health-related negative life events and SI.

LIMITATIONS

This was a retrospective study, the presence of axis II disorders was not investigated and results cannot be generalized due to the sample choice (only suicide attempters).

CONCLUSIONS

Patients with history of suicide attempts could be less sensitive to negative life events, except for those related to health. Clinicians should pay more attention to somatic problems in patients at risk of suicide. Family support, positive psychology and therapies that strengthen RFL should be developed to prevent suicide.

Measurement of symptoms in idiopathic hypersomnia

Objective

To validate the Idiopathic Hypersomnia Severity Scale (IIHSS), a self-report measure of hypersomnolence symptoms, consequences, and responsiveness to treatment.

Methods

The 14-item IHSS (developed and validated by sleep experts with patients' feedback) was filled in by 218 participants (2.3% missing data). Among the 210 participants who fully completed the IHSS, there were 57 untreated and 43 treated patients with idiopathic hypersomnia (IH) aged 16 years or older, 37 untreated patients with narcolepsy type 1 (NT1), and 73 controls without sleepiness. IHSS psychometric properties, discriminant diagnostic validity, and score changes with treatment were assessed.

Results

The IHSS showed good internal consistency and content validity. Factor analysis indicated a 2-component solution with good reliability expressed by satisfactory Cronbach α values. IHSS scores were reproducible without changes in the test–retest evaluation (13 treated and 14 untreated patients). Convergent validity analysis showed that IHSS score was correlated with daytime sleepiness, depressive symptoms, and quality of life in patients with IH. The IHSS score was lower in treated than untreated patients (5–8 unit difference, without ceiling effect). The cutoff value for discriminating between untreated and treated patients was 26/50 (sensitivity 55.8%, specificity 78.9%). IHSS scores were higher in drug-free IH patients than NT1 and controls. The best cutoff value to differentiate between untreated IH patients and controls was 22 (sensitivity 91.1%, specificity 94.5%), and 29 with NT1.

Conclusions

The IHSS is a reliable and valid clinical tool for the quantification of IH symptoms and consequences that might be useful for patient identification, follow-up, and management.

Changes in Sleep Pattern During the COVID-19 Lockdown in Patients With Narcolepsy, Idiopathic Hypersomnia, and Restless Legs Syndrome

BACKGROUND AND OBJECTIVES

To explore the first COVID-19 lockdown impact on sleep symptoms in patients with narcolepsy, idiopathic hypersomnia (IH) and restless legs syndrome (RLS).

METHODS

Between March and May 2020, a sample of adult patients regularly followed-up in a Reference Hospital Sleep Unit (299 with narcolepsy, 260 with IH, 254 with RLS) was offered an online survey assessing their sleep-wake habits, daily activities, medication intake, and validated scales: International RLS Study Group questionnaire, Narcolepsy Severity Scale (NSS), IH Severity Scale (IHSS), Epworth Sleepiness Scale (ESS), Insomnia Severity Index, Beck Depression Inventory-II, and European Quality of Life (QoL) scale. The survey was proposed once, and the questions were answered for the pre-lockdown (recall of the month before the confinement) and the lockdown (time of study) periods.

RESULTS

Overall, 331 patients completed the survey (response rate 40.7%): 102 with narcolepsy, 81 with IH and 148 with RLS. All patients reported later bedtimes, with reduced differences for time in bed (TIB) and total sleep time (TST) over-24h between weekdays and weekends. Narcoleptic patients spent more TIB and increased TST overnight, with more daytime napping. They had more awakenings, higher ESS scores, lower QoL, and no NSS changes. IH patients had also increased TIB, TST overnight and 24-h on weekdays. Nocturnal sleep latency and number of awakenings increased, but with no change in ESS, QoL, and IHSS scores. RLS patients reported a longer nocturnal sleep latency, more awakenings, more naps, a decreased TIB and TST overnight. RLS severity increased while QoL decreased. A significant portion of patients reported disease worsening during lockdown (narcolepsy:39.4%, IH:43.6%, RLS:32.8%), and some patients stopped or lowered their medication (narcolepsy:22.5%, IH:28%, RLS:9.5%).

CONCLUSION

During the lockdown, all patients reported later bedtimes; those with narcolepsy and IH extended their sleep duration unlike RLS patients. These changes were often associated with negative consequences on QoL. In the current context of recurrent COVID-19 waves, the recent development of teleconsultations should enable physicians to monitor patients with chronic sleep disorders more closely, to recommend optimized sleep schedules and duration, in order to prevent psychological problems and improve their QoL.

Impact of bipolar disorder on eating disorders severity in real-life settings

BACKGROUND

Comorbidity of bipolar disorder (BD) and eating disorders (ED) is common and increases the course and severity of BD. However, the impact of comorbid BD on the clinical profile of ED patients remains unclear. Most studies have focused on patients primarily assessed for BD and data on patients with a primary diagnosis of ED are sparse. We investigated the association between a dual diagnosis and severity in terms of clinical, neuropsychological dimensions and daily functioning.

METHOD

Two hundred and sixty-one patients with ED were consecutively recruited. BD was screened with the MINI and further confirmed in the French expert centre network. The severity of ED symptoms was assessed with the EDE-Q and EDI-2, daily functioning with the FAST. The neurocognitive assessment targeted attention, set-shifting and decision-making.

RESULTS

Forty-nine patients screened positive for BD, but diagnosis was confirmed in only thirty patients (11.5% of the cohort). After multiple adjustments, comorbidity was associated with greater severity on the total score and three subscales of the EDE-Q and on four of the ten dimensions of the EDI-2. Comorbid BD was associated with lower daily functioning but not with lower neuropsychological performance.

LIMITATIONS

Sample referred to specialist clinics not large enough to authorize an analysis by subtype and cross-sectional evaluation.

CONCLUSION

The association between ED and BD increases ED severity for most of these core features. It negatively impacts daily functioning. The results also highlight issues about the validity of screening tools to detect BD in patients with ED.

Association of Sleep Disruption With Daytime Sleepiness in Patients With Restless Legs Syndrome

BACKGROUND AND OBJECTIVES

Patients with restless legs syndrome (RLS) often complain of nighttime hyperarousal which can be severe. Whether nocturnal hyperarousal is associated with excessive daytime sleepiness (EDS) remains understudied. This study aimed to compare the frequencies of self-reported and objective EDS between patients with RLS and controls, and to identify factors associated with EDS.

METHODS

In this case-control study, consecutive untreated adult patients with moderate-to-severe RLS, and controls from the general population completed the Epworth Sleepiness Scale (ESS), Insomnia Severity Index, and Beck Depression Inventory II (BDI-II), at the Sleep Unit in Montpellier, France. International RLS study group severity scale (IRLSSQ) and RLS characteristics were recorded for patients. All patients and a subgroup of controls underwent a polysomnography (PSG) followed by multiple sleep latency test ([MSLT], abnormal latency <8 minutes). Logistic regression models were used to analyze the associations between clinical factors and (1) patients vs controls, and (2) self-reported EDS (ESS >10 vs ≤ 10), (3) objective EDS (MSLT <8 minutes vs ≥ 8).

RESULTS

We recruited 162 patients with RLS (mean age 55.9 ± 12.5 y.o., 55.6% female) and 321 controls (mean age 56.1 ± 15.0, 55.1% female, 59 with MSLT). Patients with RLS had more insomnia and depressive symptoms than controls. Self-reported EDS (odds ratios [OR] = 13.7, 95% CI = [8.5-22.1], p < 0.0001) and objective EDS (OR = 7.0, 95% CI = [1.6-30.3], p = 0.009) were more frequent in patients than controls, in crude and adjusted models. Among patients, self-reported EDS was associated with increased IRLSSQ and BDI-II scores, and objective EDS. Objective EDS was associated with older age, male, withdrawal drug status before PSG, higher ESS score, shorter and fragmented sleep, periodic legs movements during sleep (PLMS), PLMS associated with arousals (PLMAs), and arousal indexes in patients with RLS. Associations between objective EDS, PLMS, PLMA, and arousal indexes remained significant after multiple adjustments. Multivariable analysis found that PLMA and ESS score were independently associated with objective EDS in RLS.

DISCUSSION

Self-reported EDS is a very frequent complaint in patients with RLS. Objective EDS is also frequent, especially in patients with severe PLMS, PLMA, and arousal indexes. Thus, EDS must be assessed and managed in current practice.

PET Study of Microglial Activation in Kleine-Levin Syndrome

OBJECTIVES

Kleine-Levin syndrome (KLS) is a rare recurrent hypersomnolence disorder associated with cognitive and behavioral disturbances, of unknown origin, but inflammatory mechanisms could be involved. We aimed to explore in vivo microglia activation using [18F]DPA-714 PET imaging in patients with KLS compared with controls, and during symptomatic vs asymptomatic periods.

METHODS

Patients with KLS and controls underwent a standardized clinical evaluation and PET imaging, using a radiolabeled ligand specific to the 18 kDa translocator protein. Images were processed on the PMOD (peripheral module) interface using a standard uptake value (SUV). Five regions of interest (ROIs) were analyzed: hypothalamus, thalamus, frontal area, cerebellum, and whole brain. SUV ratios (SUVr) were calculated by normalizing SUV with cerebellum uptake.

RESULTS

Images of 17 consecutive patients with KLS (7 during episodes, 10 out of episodes) and 14 controls were analyzed. We found no SUV/SUVr difference between KLS and controls, between patients in and out episodes in all ROIs, and no correlation between SUVr and episode duration at the time of PET scan. No association was found between SUVr and sex, disease duration, or orexin levels.

DISCUSSION

Our findings do not support the presence of neuroinflammation in KLS. Further research is needed to identify relevant biomarkers in KLS.