The biology of aggressive behavior in bipolar disorder: A systematic review

The contribution of alexithymia, childhood maltreatment, impulsivity, C-reactive protein, lipid profile, and thyroid hormones to aggression and psychological distress (depression and anxiety) in schizophrenia

There are individual effects of alexithymia, childhood maltreatment, impulsivity, and some biological markers on aggression and psychological distress in schizophrenia. However, the combined effects of these psychological and biological markers have not yet been fully studied. This study therefore aimed to investigate the influence of these psychological and biological markers on aggression and psychological distress (e.g., depression and anxiety) in inpatients with schizophrenia (n = 355). Participants completed self-report and clinician-rated scales, and blood samples were collected. There were no significant differences between patients with and without alexithymia regarding biological markers. Patients with childhood maltreatment exhibited higher levels of free triiodothyronine (FT3) and C-reactive protein (CRP), as well as lower total cholesterol (TC) levels, compared to non-traumatized individuals. Aggression was positively predicted by psychological distress, alexithymia, childhood maltreatment, impulsivity, CRP, and FT3, and negatively by TC and low-density lipoprotein cholesterol. Negative symptoms, childhood maltreatment, alexithymia, aggression, and CRP positively, and high-density lipoprotein cholesterol negatively emerged as predictors of psychological distress. The study highlights the connections between childhood maltreatment, alexithymia, impulsivity, and potentially related biological dysregulation in explaining aggression and negative mood states as a bio-psychological model of aggression and mood in schizophrenia.

Association between primary angle closure glaucoma and uric acid levels in serum and aqueous humor

Purpose

To evaluate abnormalities in serum and aqueous humor uric acid (UA) levels in primary angle closure glaucoma (PACG).

Methods

Patients with PACG and age-similar and gender-similar controls (patients scheduled for cataract extraction) were enrolled prospectively. Serum UA levels were determined by enzymatic colorimetry; aqueous humor UA levels by Enzyme-Linked ImmunoSorbent Assay. A t-test was used to compare UA levels between PACG patients and controls, with one-way ANOVA used to compare levels across PACG subgroups with differing disease severity. Comparisons between PACG patients and controls were adjusted for systemic and ocular confounding factors using binary logistic regression.

Results

In all, 131 PACG patients and 112 controls were included. The serum UA level was 266 ± 69 μmol/L in the PACG group and 269 ± 73 μmol/L in the control group (p = 0.71). The aqueous humor UA level was 35.4 ± 8.2 μmol/L in the PACG group and 53.9 ± 18.6 μmol/L in the control group (p < 0.001). This difference remained significant after adjusting for age, gender, systolic blood pressure, diastolic blood pressure, body mass index, axial length, central corneal thickness, anterior chamber depth, lens thickness, white-to-white distance, corneal endothelial cell density, and serum UA level (odds ratio: 0.88, 95 % confidence interval: 0.83-0.93, p < 0.001).

Conclusion

Aqueous humor UA levels differ between PACG patients and controls, but serum UA levels do not. This indicates that local UA plays a role in the pathogenesis of PACG, but systemic UA does not.

Prevention of suicidal behavior with lithium treatment in patients with recurrent mood disorders

Suicidal behavior is more prevalent in bipolar disorders than in other psychiatric illnesses. In the last thirty years evidence has emerged to indicate that long-term treatment of bipolar disorder patients with lithium may reduce risk of suicide and attempts, with possibly similar benefits in recurrent major depressive disorder. We review and update selected research literature on effects of lithium treatment in reducing suicidal behavior and consider proposals that higher levels of lithium in drinking water may be associated with lower suicide rates. We summarize results of a growing number of randomized, controlled studies of lithium treatment for suicide prevention including comparisons with placebos or alternative treatments, and comment on the severe challenges of such trials. The basis of a proposed protective effect of lithium against suicidal behaviors remains uncertain but may include protective effects against recurrences of depressive phases of mood disorders, especially with mixed features or agitation, and possibly through beneficial effects on impulsivity, agitation and dysphoric mood.

Clinical features in co-occuring obsessive-compulsive disorder and bipolar disorder: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) frequently co-occurs with various psychiatric conditions and may impact as many as one-fifth of individuals diagnosed with bipolar disorder (BD). Despite the expanding body of literature on the coexistence of OCD and BD, there is a notable lack of comprehensive data pertaining to the distinct features of obsessive-compulsive symptoms that define this comorbidity. To bridge this knowledge gap, we conducted a systematic search of PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO until August 7th, 2023. We performed random-effects meta-analyses to compare individuals with both OCD and BD to those with OCD in terms of OCD symptomatology as well as the specific categories of obsessions and compulsions. Out of the 10,393 records initially screened, 17 studies were ultimately incorporated into the qualitative assessment, with 15 of them being included in the quantitative analysis. Individuals with OCD and BD experienced fewer lifetime contamination obsessions (OR=0.71; 95 %CI=0.53, 0.95; p = 0.021) and more sexual obsessions (OR=1.77; 95 %CI=1.03, 3.04; p = 0.04) compared to individuals with OCD without BD. No significant difference was observed for other types of obsessions or compulsions or for the severity of OCD symptoms, although BD type may play a role according to meta-regression analyses. The detection of the presence of sexual or contamination obsessions through a detailed interview may be the focus of clinical attention when assessing OCD in the context of comorbid BD. Sub-phenotyping complex clinical presentation of comorbid psychiatric disorders can aid in making more informed decisions when choosing an appropriate treatment approach.

Early sexual or physical abuse in female and male mood disorder patients

Early abuse has been associated with psychiatric morbidity but comparisons of bipolar (BD) and major depressive (MDD) disorder subjects with versus without early sexual or physical abuse are rare. Patients (n = 684) diagnosed with a DSM-5-TR major mood disorder were evaluated and followed for several years at mood disorder centers to compare details of history and clinical status in participants with versus without early sexual or physical abuse. Early history of sexual (16.2%) or physical abuse (11.9%) was prevalent; 5.15% reported both. Both types of abuse were much more prevalent with BD than MDD. Sexual abuse was associated with younger illness-onset and somewhat younger menarche in females; both abuse-types were associated with familial mood disorders, especially BD. Prospective, long-term illness episode-frequency, depressions or [hypo]manias/year and %-time [hypo]manic all were greater following sexual abuse but morbidity measures did not differ following physical abuse. Prevalence of suicidal behavior ranked: double (48.5%) > physical (32.1%) > sexual (30.3%) abuse, and with BD > MDD (OR = 2.31). Recall bias and not using psychometric instruments to define abuse severity or type may limit interpretation of findings. Early sexual (more than physical) abuse, led to greater morbidity and both abuses were strongly associated with familial mood disorders and greater suicidal risk, especially with double-abuse and BD diagnosis. We support a bilateral relationship between abuse and diagnosis of BD: abuse may facilitate early appearance of BD but also may result from the actions of abusive BD family members.

The maladaptive domains according to the alternative model of personality disorders (AMPD) criterion B in patients with affective disorders and temperamental triads related to these domains: two unique profiles

OBJECTIVES

The study aimed to (i) compare the maladaptive domains and facets according to the Alternative Model of Personality Disorders (AMPD) Criterion B in patients with a type II bipolar disorder (BD-II) or major depressive disorder (MDD) with healthy controls (HCs), and (ii) investigating the relationship between affective temperaments and these domains and facets in the total sample.

METHODS

Outpatients diagnosed with current BD-II (n = 37; female 62.2%) or MDD (n = 17; female 82.4%) based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and community HCs (n = 177; female 62.1%) in Kermanshah from July to October 2020 included this case-control study. All participants completed the Personality Inventory for DSM-5 (PID-5), the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and the second version of the Beck Depression Inventory (BDI-II). Data were analyzed using analysis of variance (ANOVA), Pearson correlation, and multiple regression.

RESULTS

The score of patients with BD-II in all five domains and those with MDD in three domains including negative affectivity, detachment, and disinhibition are significantly higher than the HCs (p < 0.05). Depressive temperament (related to negative affectivity, detachment, and disinhibition) and cyclothymic temperament (related to antagonism and psychoticism) were the most important correlates of the maladaptive domains.

CONCLUSIONS

Two unique profiles are proposed, including three domains of negative affectivity, detachment, and disinhibition associated with the depressive temperament for MDD, and two domains of antagonism and psychoticism related to cyclothymic temperament for BD-II.

Affective temperaments mediate aggressive dimensions in bipolar disorders: A cluster analysis from a large, cross-sectional, international study

BACKGROUND

Affective temperaments show potential for aggressive behavior (AB) preventive strategies in bipolar disorder (BD). We aim to define intra-diagnostic subgroups of patients with BD based on homogeneous behaviors related to AB. Subsequently, to assess whether affective temperament dimensions may contribute to the presence and severity of AB.

METHODS

Patients with BD were recruited. AB was evaluated through the modified overt aggression scale (MOAS); affective temperaments were assessed with the TEMPS-A. A cluster analysis was conducted based on TEMPS-A and MOAS scores. Stepwise backward logistic regression models were used to identify the predictive factors of cluster membership.

RESULTS

799 patients with BD were enrolled. Three clusters were determined: non-aggressive (55.5 %), self-aggressive (18 %), and hetero-aggressive (26.5 %). Depressive, irritable, and anxious temperament scores significantly increased from the non-aggressive (lower) to the self-aggressive (intermediate) and the hetero-aggressive group (highest). A positive history of a suicide attempt (B = 5.131; OR = 169.2, 95 % CI 75.9; 377) and rapid cycling (B = -0.97; OR = 0.40, 95 % CI 0.17; 0.95) predicted self-aggressive cluster membership. Atypical antipsychotics (B = 1.19; OR = 3.28, 95 % CI 2.13; 5.06) or SNRI treatment (B = 1.09; OR = 3, 95 % CI 1.57; 5.71), psychotic symptoms (B = 0.73; OR = 2.09, 95 % CI 1.34; 3.26), and history of a suicide attempt (B = -1.56; OR = 0.20, 95 % CI 0.11; 0.38) predicted hetero-aggressive cluster membership.

LIMITATIONS

Recall bias might have affected the recollection of AB.

CONCLUSIONS

Clinical factors orientate the prevention of different ABs in BD. Affective temperaments might play a role in preventing AB since patients with more pronounced affective temperaments might have an increased risk of showing AB, in particular hetero-AB.

Interaction between Sirtuin 1 (SIRT1) polymorphisms and childhood maltreatment on aggression risk in Chinese male adolescents

BACKGROUND

Aggressive behavior is a highly prevalent and serious public health problem among adolescents. However, the etiology and pathogenesis of aggressive behavior remain unclear. Childhood maltreatment is an acknowledged factor for aggressive behavior. SIRT1 is closely related to the occurrence and development of psychiatric disorders. We aimed to reveal the interactive effect between SIRT1 and childhood maltreatment on aggressive behavior among Chinese adolescents.

METHODS

Aggressive behavior and childhood maltreatment were evaluated by the Buss and Warren's Aggression Questionnaire (BWAQ) and short form Childhood Trauma Questionnaire (CTQ-SF), respectively. This study comprised 436 aggression cases and 435 controls. Four SIRT1 tagSNPs were selected for genotyping. Interaction between SIRT1 and childhood maltreatment was estimated by logistic regression models.

RESULTS

Individuals carrying SIRT1 rs4746720 minor allele and TAAC haplotype derived from SIRT1 variants was associated with reduced aggression risk when childhood maltreatment occurred (all P < 0.01). An antagonistic additive interaction between SIRT1 rs4746720 and childhood maltreatment on aggressive behavior (S = 0.421; 95%CI: 0.234 to 0.758) was further testified. No main effect of the SIRT1 SNPs or the haplotype block was observed (all P > 0.05).

LIMITATIONS

Since participants were only males, our findings were unable to be directly extended to females. Cross-sectional design, self-reported measurements and limited sample size were adopted.

CONCLUSION

This study provides the first evidence of SIRT1 × childhood maltreatment interaction on aggressive behavior in male adolescents. The minor allele of SIRT1 rs4746720 presents a protective effect on combination with childhood maltreatment on the risk of aggressive behavior.

Machine Learning Prediction of Comorbid Substance Use Disorders among People with Bipolar Disorder

Substance use disorder (SUD) is a common comorbidity in individuals with bipolar disorder (BD), and it is associated with a severe course of illness, making early identification of the risk factors for SUD in BD warranted. We aimed to identify, through machine-learning models, the factors associated with different types of SUD in BD. We recruited 508 individuals with BD from a specialized unit. Lifetime SUDs were defined according to the DSM criteria. Random forest (RF) models were trained to identify the presence of (i) any (SUD) in the total sample, (ii) alcohol use disorder (AUD) in the total sample, (iii) AUD co-occurrence with at least another SUD in the total sample (AUD+SUD), and (iv) any other SUD among BD patients with AUD. Relevant variables selected by the RFs were considered as independent variables in multiple logistic regressions to predict SUDs, adjusting for relevant covariates. AUD+SUD could be predicted in BD at an individual level with a sensitivity of 75% and a specificity of 75%. The presence of AUD+SUD was positively associated with having hypomania as the first affective episode (OR = 4.34 95% CI = 1.42–13.31), and the presence of hetero-aggressive behavior (OR = 3.15 95% CI = 1.48–6.74). Machine-learning models might be useful instruments to predict the risk of SUD in BD, but their efficacy is limited when considering socio-demographic or clinical factors alone.

Undetermined predominant polarity in a cohort of bipolar disorder patients: Prevalent, severe, and overlooked

OBJECTIVES

Predominant polarity (PP) is a concept used to define patients with bipolar disorder (BD) as presenting a tendency to manifest depressive (DPP) or manic (MPP) episodes. Still, the high percentage of patients with an undetermined PP (UPP), has been overlooked in most studies. Thus, we aimed to study UPP and outline its socio-demographic, clinical, and treatment-related features.

METHODS

Patients were recruited from a BD specialized unit. The sample was divided into three groups according to PP and socio-demographic and clinical variables were compared. Significant variables at univariate comparisons were included in multivariate logistic regression with UPP as the dependent variable.

RESULTS

A total of 708 BD patients were included, of which 437 with UPP (61.7%). UPP was associated with a higher number of affective relapses, when compared with DPP or MPP (χ2= 28.704, p<0.001). Mixed episodes (OR=1.398; CI=1.118-1.749), aggressive behaviour (OR=1.861; CI=1.190-2.913), seasonality (OR=2.025; CI= 1.289-3.501) and treatment with lamotrigine (OR= 2.101; CI=1.244-3.550) were significantly associated with UPP at the logistic regression.

LIMITATIONS

Recall bias may have occurred due to mixed episode diagnostic criteria change over the years. No data on the patients' follow-up has been reported on predominant polarity changes.

CONCLUSIONS

UPP is associated with a higher number of relapses, and different clinical variables related to a severe course of illness. Considering PP in patients with BD may guide the choice for differential treatment approaches having an impact on BD course of illness and patients' prognosis and recovery.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

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

Homicidal ideation and psychiatric comorbidities in the inpatient adolescents aged 12-17

OBJECTIVES

Adolescents with a homicidal tendency is a growing concern in the United States. Studies in the past have showcased the relationship between homicidal ideation (HI) and psychiatric illnesses, but very limited information is available on the adolescent and inpatient population. We aim to evaluate the prevalence of demographic characteristics and psychiatric disorders in adolescents with and without HI.

MATERIALS AND METHODS

Adolescent (age 12-17) population admitted to the hospital with the diagnosis of homicidal ideation was identified from the 2016-2018 National Inpatient Sample Dataset (NISD). Patients without HI were defined as the control group. The prevalence of psychiatric comorbidities between the groups was compared by applying the Rao-Scott adjusted chi-square test. We used multivariable logistic regression to generate odds ratio (OR) of homicidal ideation as an outcome; we adjusted age, sex, race, socioeconomic status, substance use disorders, alcohol use disorders, and psychiatric comorbidities.

RESULTS

A total of 18,935 patients (mean age: 14.5) with HI diagnosis were identified in this study. Majority of the patients were male subjects in the HI group compared to the control group (58.7 vs. 41.2%, p < 0.001). Racially, HI was more prevalent in white race (56.0 vs. 52.6%, p < 0.001) and black race (22.3 vs. 17.8%, p < 0.001), compared to Hispanic race (14.9 vs. 21.3%, p < 0.001). Major depression (Odds ratio [OR]: 2.66, p < 0.001), bipolar disorder (OR: 3.52, p < 0.001), anxiety disorder (OR: 1.85, p < 0.001), ADHD, and other conduct disorders (OR: 4.01, p < 0.001), schizophrenia (OR: 4.35, p < 0.001) are strong predictors of HI. Suicidality was prevalent in 66.9% of patients with HI.

CONCLUSION

We found a higher prevalence of psychiatric illnesses such as depression, anxiety, and bipolar disorder in adolescents with homicidal ideation in the inpatient setting. White and black races were more prevalent in patients with homicidal ideation. Further large-scale longitudinal research studies are warranted to establish the correlation between psychiatric disorders and homicidal ideation among adolescents.

Risk of cancer in bipolar disorder and the potential role of lithium: International collaborative systematic review and meta-analyses

We examined bipolar disorder (BD) as a risk factor for developing cancer and the role of lithium on cancer incidence. We conducted two systematic review and meta-analyses of population-based studies providing data on these associations. We screened articles indexed in MEDLINE, Scopus, Embase, and PsycINFO up to August 2020. The first random-effects meta-analysis, based on 4,910,661 individuals from nine studies estimated an increased risk of cancer of any kind [RR = 1.24 (1.05-1.46); p < 0.01], especially breast cancer [RR = 1.33 (1.15-1.55); p < 0.01] in BD. The second random-effects meta-analysis, based on 2,606,187 individuals from five studies did not show increased risk of cancer in people with BD using lithium, and even suggested a small protective effect both in overall [RR = 0.94 (0.72-1.22); p = 0.66] and urinary cancer [RR = 0.93 (0.75-1.14); p = 0.48] although these findings did not reach statistical significance. The current evidence highlights that cancer risk is increased in individuals with BD, particularly breast cancer in women. Lithium may have a potential protective effect on cancer, including urinary cancer. The role of lithium as a mainstay of treatment for BD is reinforced by this study.

Clinical correlates of seasonality in bipolar disorder: A specifier that needs specification?

OBJECTIVE

Seasonal pattern (SP) is a bipolar disorder (BD) specifier that indicates a tendency towards affective relapses during specific moments of the year. SP affects 15%-25% of BD patients. In the past, SP was applied only to depressive relapses while, in DSM-5, SP may be applied to both depressive and (hypo)manic episodes. We examined the association between different clinical correlates of BD and SP according to its current definition in a cohort of patients with BD type I (BDI) and II (BDII).

METHODS

Patients were recruited from a specialized unit and assessed according to the season of relapse and type of episode per season. SP and non-SP patients were compared looking into sociodemographic and clinical correlates. Significant variables at univariate comparisons were included in multivariate logistic regression with SP as the dependent variable.

RESULTS

708 patients were enrolled (503 BDI, 205 BDII), and 117 (16.5%) fulfilled DSM-5 criteria for SP. The mean age was 45.3 years (SD = 14.18), and 389 were female (54.9%). The logistic regression model included a significant contribution of BDII (OR = 2.23, CI 1.4-3.55), family history of mood disorder (OR = 1.97, CI 1.29-3.01), undetermined predominant polarity (OR = 0.44, CI 0.28-0.70), and aggressive behavior (OR = 0.42, CI 0.23-0.75).

CONCLUSION

Our results outline a novel positive association of SP with undetermined predominant polarity, BDII, family history of mood disorder, and with fewer aggressiveness-related symptoms. Seasonality is associated with a biphasic pattern with similar dominance of (hypo)mania and depression and is more frequent in BDII as compared to BDI. Seasonal episodes may be easier to predict, but difficult to prevent.