Bipolar sensation seeking is associated with a propensity to abuse rather than to temperamental characteristics

Morningness-eveningness preference and sensation seeking

The aim of this study was to explore the relationship between circadian preference and sensation seeking. To this aim 1041 university students (408 males and 633 females), ranging in age between 18 and 30 years, filled the reduced version of the Morningness-Eveningness Questionnaire (MEQr) and the Sensation Seeking Scale-Form V (SSS-V). Males scored higher than females in SSS-V total score and all subscales, except experience seeking (ES). As regards circadian preference, evening types scored higher than morning types in SSS-V total score and all subscales, except boredom susceptibility (BS) where they significantly differed only from intermediate types. On the whole our results highlight a significant relationship between circadian preference and sensation seeking.

The relationship of personality traits to substance abuse in patients with bipolar disorder

Purpose

The aim of this study is to determine if personality traits contribute to the likelihood of substance abuse in Bipolar Disorder (BD).

Subjects/materials and methods

Fifty-nine patients meeting DSM-IV criteria for BD: 20 without any history of Substance Related Disorder (SRD), 21 with a lifetime history of SRD but without current SRD, and 18 with current SRD. Patients filled out the TCI, the differences were analyzed by ANOVA and the likelihood was obtained by Multinomial Logistic Regression.

Results

Only Novelty Seeking (NS) is statistically different between the groups. Patients with BD with current SRD have higher rates in NS than those with past SRD, and those without a history of SRD. NS was confirmed as a predicting variable, both to current SRD (OR [CI 95%] = 1.039/1.351; p = 0.011) and past SRD (OR [CI 95%] = 1.004/1.277; p = 0.042) on patients with BD.

Discussion

The results shown would appear to confirm the relationship of NS with the SRD, so long as there is no clear evidence that indicates the association of NS with BD.

Conclusions

There appears a greater predisposition to develop SRD in those patients with a higher degree of NS. The use of the Cloninger's TCI could be used in BD to determine the risk of developing an SRD. Early detection might help improve prognosis.

Characteristics of stress-coping behaviors in patients with bipolar disorders

Appropriate stress-coping strategies are needed to improve the outcome in the treatment of bipolar disorders, as stressful life events may aggravate the course of the illness. The aim of this study was to compare stress-coping behaviors between bipolar patients and healthy controls. A total of 206 participants comprising 103 bipolar patients fulfilling the Diagnostic and Statistical Manual for Axis I disorder fourth edition (DSM-IV) diagnostic criteria for bipolar I and II disorders and controls matched by age and sex were included in this study. Stress-coping behaviors were assessed using a 53-item survey on a newly-designed behavioral checklist. The characteristics of stress-coping behaviors between the two groups were compared by using t-test and factor analysis. Social stress-coping behaviors such as 'journey', 'socializing with friends', and 'talking something over' were significantly less frequent in bipolar patients than controls. On the other hand, pleasurable-seeking behaviors such as 'smoking', 'masturbation', and 'stealing' were significantly more frequent in bipolar patients than controls. These results suggest that bipolar patients may have more maladaptive stress-coping strategies than normal controls. It is recommended to develop and apply psychosocial programs to reduce maladaptive stress-coping behaviors of bipolar patients.

Substance use disorders in hospitalized psychiatric patients: the experience of one psychiatric emergency service in Turin

In the present study we sought: 1) to estimate the frequency of substance use disorders (SUD), and 2) to investigate whether there is a mere association between diagnosis and SUD in a large cohort of patients with severe psychiatric disorders representative of the usual setting and modality of care of a psychiatric emergency service in a geographically well-defined catchment area in Italy, independent of sociodemographic features, anamnestic data and clinical status. The study was conducted between January 2007 and December 2008. The following rating scales were performed: the Clinical Global Impression-Severity (CGI-S), the Global Assessment of Functioning scale (GAF) and the Brief Psychiatric Rating Scale (BPRS). Factors found to be associated (p<0.05) with SUD[+] in the univariate analyses were subjected to multilevel logistic regression model with a backward stepwise procedure. Among 848 inpatients of our sample 29.1% had a SUD codiagnosis. Eleven factors accounted for 30.6% of the variability in SUD[+]: [a] a Personality Disorder diagnosis, [b] a Depressive Disorder diagnosis, [c] male gender, [d] previous outpatient contacts, [e] single marital status, [f] no previous psychiatric treatments, [g] younger age, [h] lower scores for BPRS Anxiety-depression and [i] BPRS Thought Disturbance, [l] higher scores for BPRS Activation and [m] BPRS Hostile-suspiciousness. The findings are important in identifying (1) the complexity of the clinical presentation of SUD in a inpatients sample, (2) the need for collaboration among health care workers, and (3) the need to develop and apply treatment programs that are targeted at particular risk groups.

Sensation seeking in major depressive patients: relationship to sub-threshold bipolarity and cyclothymic temperament

BACKGROUND

High levels of sensation seeking (SS) have been traditionally reported for lifetime bipolar disorder (BD) and/or substance use disorder (SUD) rather than major depressive disorder (MDD). Nonetheless, a renewed clinical attention toward the burden of sub-threshold bipolarity in MDD, solicits for a better assessment of "unipolar" major depressive episodes (MDEs) via characterization of putative differential psychopathological patterns, including SS and predominant affective temperament.

METHODS

Two hundred and eighty currently depressed cases of MDD and 87 healthy controls were screened using the Zuckerman's sensation seeking scale-Form-V, the Hypomania Check List-32-item (HCL-32), the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire-110-item, the Barratt Impulsivity Scale-11-item, the State-Trait Anxiety Inventory modules and the Structured Clinical Interview for DSM-IV axis-I disorders. Cases were divided into HCL-32(+)(sub-threshold bipolar)/HCL-32(-)("true" unipolar depressed) depending on the HCL-32 total score.

RESULTS

Upon correlation and multivariate regression analyses, the HCL-32(+) patients showed the highest levels of SS, higher prevalence of cyclothymic temperament, and higher rates of multiple lifetime axis-I co-morbidities, including SUD.

LIMITS

Recall bias on some diagnoses, including BD, grossly matched healthy control group, lack of ad-hoc validated measures for ADHD, SUD, or axis-II disorders.

CONCLUSIONS

In our sample, the occurrence of higher levels of SS in "sub-threshold" bipolar cases outlined a differential psychopathological profile compared to DSM-defined "true unipolar" cases of MDE. If confirmed by replication studies, these findings may aid clinicians in delivering a more accurate diagnosis and a safer use of antidepressants in some MDD cases.

Exercise and mental illness: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

Regular exercise is thought to be associated with low rates of mental illness, but this association has been inadequately studied. The purpose of this study was to test the hypotheses that the recommended amount of self-reported vigorous exercise would be cross-sectionally associated with reduced prevalence and incidence of various DSM-IV psychiatric disorders, as well as increased rates of remission.

METHOD

Data were collected from 2001 to 2005 as part of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a 2-wave face-to-face survey conducted by the National Institute on Alcohol Abuse and Alcoholism. For this study, the sample consisted of 23,505 nondisabled adults aged between 18 and 65 years.

RESULTS

Individuals who engaged in vigorous exercise at Wave 2 were significantly more likely than were nonexercisers to be diagnosed with a current psychiatric disorder (adjusted odds ratio [AOR] = 1.22, 95% CI, 1.12-1.34 for the nationally recommended amount vs no exercise), significantly less likely to attain remission from a psychiatric disorder between waves (AOR = 0.77, 95% CI, 0.65-0.91), and significantly more likely to relapse or be newly diagnosed with a psychiatric disorder between waves (AOR = 1.15, 95% CI, 1.02-1.30). Alcohol dependence and bipolar II disorder were the disorders most strongly associated with exercise.

CONCLUSIONS

This investigation suggests that the pursuit of vigorous exercise is associated with a vulnerability to mental illness. This surprising finding may be due to reward-related factors that influence both exercise engagement and the expression of certain psychiatric disorders. Prospective trials will be helpful in further clarifying the associations between exercise and mental illness, as the relationships between the 2 are more complex than previously believed.

Biopsychosocial model of hypersexuality in adolescent girls with bipolar disorder: strategies for intervention

TOPIC

Engagement in high-risk behaviors, impaired judgment, and hypersexuality present unique health challenges to adolescent girls with bipolar disorder (BD). Behavioral management of sexuality does not routinely fall under the purview of psychiatric care, but requires preventive measures.

PURPOSE

This paper presents a biopsychosocial model of hypersexuality in girls with BD, describes factors that lead to high-risk sexual behaviors, and provides a framework for cognitive-behavioral intervention.

SOURCES USED

The study used a review of empirically based clinical and research literature.

CONCLUSIONS

Sexual health education, improved treatment adherence, symptom monitoring, interpersonal skills training, parental involvement, and clinician education can improve hypersexual behavior in girls with BD.

Delineating the psychic structure of substance abuse and addictions: should anxiety, mood and impulse-control dysregulation be included?

Current "official" nosology (e.g. DSM IV) is largely limited to physical manifestations of addiction that can be objectively observed and are suited to the maintaining of an "atheoretical" perspective. However, addicted subjects display additional psychiatric symptoms that affect their well-being and social functioning and, in accordance with DSM IV, are typically relegated to the domain of psychiatric "comorbidity." We contend that the relationship of these psychiatric symptoms with addiction is very close, as demonstrated by the high frequency of association observed. We further assert that substance use may modify pre-existing psychic structures such as temperament and related subthreshold conditions and lead to addiction as a specific mental disorder, inclusive also of symptoms pertaining to mood/anxiety, or impulse-control dimensions. The present contribution addresses the weaknesses of the current DSM-based nosology of addiction-related mental comorbidity. We highlight the overlap of the biological substrates and the neurophysiology of addictive processes and psychiatric symptoms associated with addiction, and propose the inclusion of specific mood, anxiety, and impulse-control dimensions in the psychopathology of addictive processes. We postulate that addiction reaches beyond the mere result of drug-elicited effects on the brain and cannot be peremptorily equated only with the use of drugs despite the adverse consequences produced. We infer that mood, anxiety and impulse-control dysregulation is at the very core of both the origins and clinical manifestations of addiction and should be incorporated into the nosology of the same, emphasising how addiction is a relapsing chronic condition in which psychiatric manifestations play a crucial role. To conclude, addictionology cannot be severed from its psychopathological connotations, in view of the undeniable presence of symptoms, of their manifest contribution to the way addicted patients feel and behave, and to the role they play in maintaining the continued use of substances.

Substance use in severe mental illness: self-medication and vulnerability factors

The aim of this article is to examine the onset and clinical correlates of substance use in patients with psychotic disorders. One hundred and eight inpatients and outpatients with DSM-IV psychotic disorders were evaluated with the SCI-SUBS, an instrument designed to explore the spectrum of substance use and its clinical correlates. Comparisons were made between subjects with (n=47) and without (n=61) a DSM-IV diagnosis of substance use disorder (SUD). In patients with an early onset of psychosis (<17 years), the onset of SUD was subsequent. Patients with SUD had higher substance sensitivity, higher sensation-seeking traits and were more likely to self-medicate than patients without SUD. The reasons for self-medication endorsed by patients with SUD included relieving depression, achieving or maintaining euphoria, improving self-confidence and social abilities. Our results, based on a cross-sectional study, suggest that early onset of psychosis, substance sensitivity and sensation-seeking traits represent vulnerability factors for SUD. The relationships between SUD and psychosis should be examined systematically and clarified in longitudinal studies.

An electrophysiological endophenotype of hypomanic and hyperthymic personality

BACKGROUND

Hyperthymic Temperament (HYT) and a closely related trait, Hypomanic Personality (HYP), have both been related to bipolar affective disorder (BAD). Intensity dependence of auditory evoked potentials (IAEP) is a suggested inverse indicator of serotonergic neurotransmission and has been found to be elevated in BAD. Therefore the present study explored for the first time whether subclinical variance of HYT/HYP is also associated with IAEP in a healthy sample. As several traits from biological personality research are correlated with HYT/HYP and also with BAD, the specificity of results against these traits was further analyzed by calculating multiple regression analyses.

METHODS

Evoked potentials were recorded from a sample (N=87) homogenous for confounding variables influencing IAEP. For this reason, only 19 to 27-year-old non-smoker psychiatrically healthy male students were included.

RESULTS

Significant correlations were found between IAEP and both HYP and HYT. Including Sensation or Novelty Seeking and Extraversion in Regression Analyses did not weaken the associations of HYP with IAEP much, but did affect those of HYT. However, these competing biological personality traits were hardly able to predict IAEP themselves. Impulsivity, though, was able to reduce the predictive power of HYP and HYT and to explain unique IAEP-variance. This was even more the case for Behavioral-Activation-System-Sensitivity (BAS) subscale Fun Seeking clearly dominating all regression analyses.

LIMITATIONS

Homogeneity of sample.

CONCLUSIONS

The impact of BAS is in agreement with the assumption that heightened BAS-sensitivity is an underlying biological cause for HYP/HYT and for BAD. Future studies on BAD should include BAS and Impulsivity besides HYP/HYT to further explore uniqueness of the latter and to develop questionnaires based on those items of a hyperthymic-hypomanic-impulsive-funseeking item pool, which possess the most external validity.

The spectrum of substance abuse in bipolar disorder: reasons for use, sensation seeking and substance sensitivity

OBJECTIVES

To examine the spectrum of alcohol and substance abuse, including reasons for use, in patients with bipolar I disorder, compared with patients with substance use disorder and healthy controls, with a specific focus on the relationship between substance use, substance sensitivity, other comorbid psychiatric symptoms and traits related to sensation seeking.

METHODS

This study included 104 patients with bipolar I disorder (BPD I), of whom 57 (54.8%) met DSM-IV criteria for lifetime alcohol or substance use disorder (BPD + SUD), 35 patients with substance use disorder (SUD) and no psychiatric disorder and 50 healthy controls. Assessments included the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS).

RESULTS

Patients with BPD + SUD and SUD had significantly higher scores on the SCI-SUBS domains of self-medication, substance sensitivity and sensation seeking compared with patients with BPD and healthy controls. Reasons for substance use did not differ between patients with BPD + SUD and patients with SUD. Those most frequently cited were: improving mood; relieving tension; alleviating boredom; achieving/maintaining euphoria; and increasing energy.

CONCLUSIONS

Recourse to substances is associated with increased mood and anxiety symptoms, substance sensitivity, and sensation seeking among patients with BPD + SUD and SUD. Substance sensitivity and sensation seeking traits should be investigated in all patients with BPD as possible factors associated with a development of SUD, in order to warn patients of the specific risks related to improper use of medications and substances.

Reasons for substance use and vulnerability factors in patients with substance use disorder and anxiety or mood disorders

This cross-sectional study examined the reasons for substance use and the presence of vulnerability factors such as substance sensitivity, sensation seeking, and symptoms related to the attention deficit hyperactivity disorder (ADHD) in patients with substance use disorder (SUD) and comorbid mood and anxiety disorders by using the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS), a novel instrument designed to explore the spectrum of substance use and its clinical correlates. Study participants included 61 patients with SUD and mood or anxiety disorder, and two comparison groups including 35 patients with SUD only and 50 controls not in treatment for mental disorders or SUD. We found that patients with co-morbid mood or anxiety disorder had significantly higher scores on the SCI-SUBS domains 'substance sensitivity' and 'self-medication' as compared to those with SUD only. Scores on 'sensation seeking' and 'ADHD' domains were similar between both groups of patients and higher than in controls. Patients with comorbid mood or anxiety disorders showed a higher sensitivity to substances and were more prone to self-medication than those with SUD only. These characteristics should be taken into account in the diagnostic assessment and in long-term treatment to decrease the risk of relapse.

Personality: is it a viable endophenotype for genetic studies of bipolar affective disorder?

Progress in identifying the genetic basis of bipolar affective disorder has been disappointing, most probably because of the genetic and phenotypic heterogeneity of the condition. These setbacks have led to the adoption of alternative strategies such as the use of endophenotypes or intermediate traits to identify those individuals at genetic risk for developing the disorder. Gottesman and Gould [Am J Psychiatry (2003), 160:636], in a review of the endophenotypic concept, have suggested five criteria that should be characteristic of a trait in order for it to qualify as an endophenotype. These five criteria are used in order to assess the viability of using personality traits as endophenotypes for genetic analyses of bipolar disorder. A review of the literature suggests that certain personality traits or temperaments are associated with the illness in a state independent manner, that personality is at least partly heritable, and that various temperaments aggregate in the non-affected relatives of bipolar probands. Nevertheless, it is unclear whether specific personality traits co-segregate with affectively ill individuals. We conclude that personality profiling of probands and their relatives may facilitate molecular genetic work, but given the fact that personality is itself a complex trait, its use as an endophenotype has certain limitations.

Toward a unitary perspective on the bipolar spectrum and substance abuse: opiate addiction as a paradigm

Bipolar spectrum disorders and addiction often co-occur and constitute reciprocal risk factors that the authors believe are best considered under a unitary perspective. In particular, we submit that patients whose disorders fall under the bipolar spectrum - and its hyperthymic and cyclothymic temperamental substrates are at increased risk for substance use, possibly moving towards addiction through exposure to intrinsically dependence-producing substances. In our experience, the contribution of bipolar spectrum disorders to the addictive process is often clinically missed, because attenuated and subclinical expressions of such mood disorders as bipolar II and cyclothymia are not adequately appreciated by our current formal diagnostic system (e.g. DSM-IV, as well as research and clinical practice based on it). The use of agonist treatment in dual diagnosis heroin addicts has allowed us to gather valuable knowledge about the intrinsic, and historically and clinically documented mood-regulating effects of opiates. From the therapeutic point of view, the challenge of double diagnosis requires double competence from clinicians. The combination of opiate agonists and mood stabilizers often produces results difficult to obtain with the use of the two types of drugs separately. We therefore submit that the present conceptualization of the link between bipolar spectrum and addictive disorders has not only heuristic and scientific values, but also an important message for the clinician.

Age at onset in bipolar affective disorders: a review

Bipolar affective disorder (BPAD) is a multifactorial disorder with various clinical presentations. Etiologic heterogeneity may partly underlie the phenotypic heterogeneity. Efforts to dissect BPAD have been based on the course of the disorders (BP I versus BP II or rapid cycling), comorbidity pattern (panic attacks, suicide attempts, addiction or hyperactivity), differences between the sexes, and clinical pattern (cycloid and puerperal psychosis). The present article provides a comprehensive review of the existing data, showing that age at onset (AAO) identifies homogeneous sub-groups of patients with BPAD. Recent work has demonstrated the existence of three--early, intermediate and late--onset bipolar sub-groups based on AAO, following Kendell's criteria for validity (The American Journal of Psychiatry 2003; 160: 999). We will also show how these distinctions may be of use in the search for genetic vulnerability factors and other pathogenic influences. Following Kendell's criteria, we show that AAO of bipolar disorders has been tested with most of the available strategies for establishing the validity of clinical syndromes. We also present data from genetic epidemiologic studies in bipolar disorder, showing that AAO sub-groups may reduce the underlying genetic heterogeneity. No accurate AAO thresholds to define valid sub-groups have been identified precisely. Until recently, studies defined early- and late-onset as corresponding to early or mid-adulthood, not taking into account juvenile-onset bipolar disorder. A recently proposed theoretical model with three AAO sub-groups (onset age 17, 27 and 46) is discussed.

The impact of stress on addiction

This article will review data obtained from both clinical and preclinical investigations demonstrating that exposure to stress has a significant impact on drug addiction. The preclinical literature suggests that stress increases reward associated with psychomotor stimulants, possibly through a process similar to sensitization. While it is not conclusive that a similar process occurs in humans, a growing clinical literature indicates that there is a link between substance abuse and stress. One explanation for the high concordance between stress-related disorders and drug addiction is the self-medication hypothesis, which suggests that a dually diagnosed person often uses the abused substance to cope with tension associated with life stressors or to relieve symptoms of anxiety and depression resulting from a traumatic event. However, another characteristic of self-administration is that drug delivery and its subsequent effects on the hypothalamo-pituitary-adrenal (HPA) axis are under the direct control of the individual. This controlled activation of the HPA axis may result in the production of an internal state of arousal or stimulation that is actually sought by the individual (i.e., the sensation-seeking hypothesis). During abstinence, exposure to stressors or drug-associated cues can stimulate the HPA axis to remind the individual about the effects of the abused substance, thus producing craving and promoting relapse. Continued investigations into how stress and the subsequent activation of the HPA axis impact addiction will result in the identification of more effective and efficient treatment for substance abuse in humans. Stress reduction, either alone or in combination with pharmacotherapies targeting the HPA axis may prove beneficial in reducing cravings and promoting abstinence in individuals seeking treatment for addiction.