Effects of trauma on bipolar disorder: the mediational role of interpersonal difficulties and alcohol dependence

The purpose of early maladaptive schemas (EMS) in the relationship dysfunction among people with bipolar disorder in the euthymic phase

OBJECTIVES

Although free from characterized manic and depressive episodes, the euthymic period in bipolar disorder (BD) remains characterized by a whole host of difficulties, particularly relational. These difficulties are factors of vulnerabilities and relapses. People's perception of their own relationships has an impact on their symptomatology, their responses to treatment and on relapse rates. Young's early maladaptive schemas (EMS) approach proves to be relevant for understanding the construction of these perceptions and working on them. Nevertheless, to this date, few studies have investigated which EMS are related to relationship dysfunction in this particular population. Determining the link between EMS and relationship difficulties would be relevant to understand psychosocial impairment of people with BD in euthymic states. The present study aims to investigate the associations between the different domains of EMS and relationship dysfunction among patients with bipolar disorder in the euthymic phase.

METHODS

Data are extracted from the FACE-BD cohort, within the BD Expert Center in Versailles. Inclusion criteria were to be aged between 18 and 65 and to be an outpatient with a diagnosis of bipolar disorder (DSM-IV-TR). Patients had to be euthymic at the time of inclusion, according to DSM-IV-TR criteria with a cut-off score of 14 on the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale. Non-inclusion criteria were meeting at the time of the study the criteria for characteristic depressive episode, hypomania or mania according to the DSM-IV-TR. Sociodemographic data, clinical features associated with relationship dysfunction were assessed. EMS and EMS domains were assessed with the YSQ-R short form (Young Schema Questionnaire 3 Short Form) and current relationship dysfunction were assessed with the FAST (Functioning assessment short test subscale). Successive simple linear regression analyses were performed to investigate the association between the severity scores of each EMS and the intensity of relationship dysfunction. Furthermore, successive simple linear regression analyses investigated the association between EMS domain scores and intensity of relationship dysfunction. Multiple linear regression analyses were performed to test the association between EMS scores, then EMS domains, and the intensity of relationship dysfunction after adjusting for age as well as the intensity of residual depressive and manic symptoms.

RESULTS

Relationship dysfunction is partly associated with EMS activation in particular in the separation and rejection domain (P<0.0001), the other-directedness domain (P=0.031) and the over-vigilance and inhibition domain (P=0.005). Having residual depressive symptoms is also among the factors contributing to the relationship dysfunctions of people with bipolar disorder in the euthymic phase.

DISCUSSION

This is the first study demonstrating that the activation of several domains of EMS is a risk factor of relationships difficulties for people in euthymic phase of bipolar disorder. It is necessary to identify which EMS are specifically activated and their domains of belonging in order to prevent and reduce them. EMS are a lever for functional remission. It is therefore relevant to refer people reporting relationship problems to schema therapy consistent with a personalized care. Finally, future studies should focus on the mechanisms underlying the complex relationship between EMS domains and relationship dysfunction in people with bipolar disorder in the euthymic phase. It may also be relevant for future research to control for different types of relationship dysfunction. EMS may be differentially associated with several types of interpersonal problems. The relations between different adaptation styles and EMS should be further investigated to offer more personalized care, with the aim to improve functional remission.

Bipolar disorder and cumulative trauma: A systematic review of prevalence and illness outcomes

BACKGROUND

The experience of cumulative trauma may be common in bipolar disorder (BD). However, it is not frequently reported as most studies focus on childhood trauma without examining differences in the amount of trauma experienced. This systematic review aimed to determine the prevalence of lifetime cumulative trauma in BD as well as explore associated illness outcomes.

METHODS

A systematic review was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Both the prevalence and outcomes of cumulative trauma in BD were assessed. Five electronic databases were searched (Embase, MEDLINE, PsycINFO, Web of Science, and PTSD Pubs) for records from January 2010 until December 2022.

RESULTS

A total of 20 studies, with 9304 participants were included in the narrative synthesis. At least one-third of BD participants had experienced cumulative trauma, with a prevalence range from 29% to 82%. The main outcomes associated with a history of cumulative trauma were earlier age of onset, longer episode duration, more lifetime mood episodes, greater likelihood of experiencing psychotic features, and higher likelihood of past suicide attempts.

LIMITATIONS

This review has been limited by the lack of studies directly assessing cumulative trauma in BD.

CONCLUSIONS

Cumulative trauma is prevalent in BD. Preliminary evidence indicates an association with a range of adverse outcomes, emphasizing the need for clinicians to obtain a detailed trauma history and to consider these risks in the management of the disorder. Future studies should report on the prevalence of cumulative trauma, particularly in adulthood as this area remains unexplored.

Cumulative trauma in bipolar disorder: An examination of prevalence and outcomes across the lifespan

BACKGROUND

Trauma is highly prevalent in bipolar disorder, and while considerable research has been undertaken in relation to childhood trauma, little is known about the experience and the impact of exposure to multiple trauma types across the lifespan, otherwise known as cumulative trauma. This study aimed to examine the prevalence of cumulative trauma in bipolar disorder and explore its association with illness and other outcomes.

METHODS

Participants were recruited online globally and comprised 114 adults aged 23 to 73 years with BD-I (41.2 %) or BD-II (58.8 %). Participants completed an online questionnaire containing items regarding symptoms and trauma history followed by a diagnostic interview to confirm their BD diagnosis and assess BD symptoms.

RESULTS

Cumulative trauma accounted for most of the trauma exposure across both childhood (n = 89; 78.1 %) and adulthood (n = 72; 63.2 %). Those with lifetime cumulative trauma (n = 64; 56 %) were more likely to experience at least one other co-morbid mental health condition in addition to their BD diagnosis (88 %) and report significantly lower ratings of perceived social support compared to those who did not experience any cumulative trauma (N = 15; 13 %).

LIMITATIONS

This study has been limited by the cross-sectional retrospective design as well as the use of self-selection to participate.

CONCLUSIONS

Cumulative trauma is highly prevalent in bipolar disorder and is associated with greater likelihood of experiencing a psychiatric comorbidity and decreased levels of social support. More research is needed to explore the nature of this relationship and determine whether increasing social support may be of benefit.

The association between childhood trauma and the age of onset in drug-free bipolar depression

OBJECTIVE

This study aimed to investigate the relationship between childhood trauma and clinical correlates in bipolar depression.

METHODS

A total of 61 bipolar depression patients were enrolled and assessed based on the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Patient Health Questionaire-15 (PHQ-15), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) systems.

RESULTS

The age of onset in bipolar depression patients with either trauma or abuse or neglect was significantly lower than in patients without these factors. There were statistically significant negative correlations between the age of onset and the number of different trauma types in bipolar depression patients. Multiple variable regression showed a significant association between the number of trauma types and the age of onset. Furthermore, there was a significant negative correlation between the age of onset with CTQ-SF total score (CTS), emotional abuse score and emotional neglect score, and physical neglect score. However, multiple variable regression analysis revealed that there was a significant association between emotional abuse score and the age of onset of bipolar depression patients.

CONCLUSION

Our results suggest that childhood trauma may be associated with physical symptoms and the age of onset in bipolar depression patients.

The relationship between childhood trauma and the course of disease in female patients with bipolar disorder

PURPOSE

This study aimed to determine the history of childhood trauma and the relationship between childhood trauma and the course of the disease in female patients with bipolar disorder.

DESIGN AND METHODS

This study was conducted on 80 female patients in an acute women's psychiatric clinic in a psychiatric hospital in Turkey between April and July 2016.

FINDINGS

Emotional abuse had a statistically negative effect on the onset of bipolar disorder (F = 7.830; p < 0.01). In addition, physical neglect had a statistically positive effect on the duration of treatment (F = 6.811; p < 0.05).

PRACTICE IMPLICATIONS

Psychiatric nurses must systematically assess childhood trauma and plan psychotherapeutic interventions accordingly.

A longitudinal study of post-traumatic stress, depressive and anxiety symptoms trajectories in subjects with Bipolar Disorder during the COVID-19 pandemic

Background

Bipolar disorder (BD) is recognized to be at high risk for developing negative psychopathological sequelae to potentially traumatic events. Nevertheless, scant data are still available about the effects of the COVID-19 emergency on the clinical course of BD. The present study examined prospectively the development and trajectories of post-traumatic stress, depressive, and anxiety symptoms among subjects with BD that were followed in an outpatient psychiatric clinic at the time of pandemic onset.

Methods

A cohort of 89 subjects with BD was enrolled during the first wave of the COVID-19 pandemic, and assessed at baseline (T0), 2-months (T1), and 6-months (T2) follow-up. A K-means cluster analysis was used to identify distinct trajectories of depressive, anxiety, and post-traumatic stress symptoms during the three time points.

Results

We identified three trajectories: the Acute reaction (13.5%); the Increasing severity (23.6%); and the Low symptoms (62.9%) groups, respectively. In the Acute reaction group a significant prevalence of female gender was reported with respect to the Low symptoms one. Subjects in the Increasing severity group reported significantly lower employment rate, and higher rate of relatives at risk for COVID-19 medical complications. Subjects in the Increasing Severity group reported higher rates of previous hospitalization and manic symptoms at baseline than those included in the Low symptoms one.

Conclusions

Our results describe three distinct symptom trajectories during the COVID-19 emergency in a cohort of subjects suffering from BD, suggesting the need of a long-term follow-up for detecting the impact of the COVID-19 pandemic in this vulnerable population.

Predictors of conversion from major depressive disorder to bipolar disorder

The present study has two main aims: (1) To assess whether childhood trauma helps to differentiate Major Depressive Disorder (MDD) from Bipolar Disorder (BD) in a cross-sectional design; and (2) Describe the rate of conversion from MDD to BD, as well as the clinical and demographic predictors of conversion from MDD to BD in a prospective cohort design. We conducted a prospective cohort study in two phases, in the city of Pelotas, RS, Brazil. In the first phase, 565 subjects diagnosed with MDD, and 127 with BD according to the Mini International Neuropsychiatric Interview were included. In the second phase, only individuals with MDD were reevaluated for potential conversion to BD. The rate of conversion from MDD to BD in 3 years was 12.4%. Predictors of conversion from MDD to BD included lower educational level, use of illicit substances, younger age of the first depressive episode, and family history of BD. Childhood trauma was not a significant risk factor for conversion to BD in our prospective study. Our findings can contribute to the prevention and identification of conversion from MDD to BD, as well as to the establishment of more targeted therapeutic interventions, improving the prognosis of these individuals.

Impact of Childhood Trauma and Attachment on Resilience in Remitted Patients with Bipolar Disorder

BACKGROUND

Childhood trauma has been reported to be associated with severe course of illness, insecure attachment, and lower resilience in bipolar disorder. We aimed to examine the impact of childhood trauma on resilience and possible mediating role of attachment on this impact in bipolar disorder.

METHODS

The study group comprised of 110 remitted patients with bipolar disorder. Hamilton Depression Rating Scale (HAM-D) and Young Mani Rating Scale (YMRS) are administered to verify remission. Childhood trauma questionnaire (CTQ-SF), Experiences in Close Relationships-revised (ECR-R), and Resilience Scale for Adults (RSA) scales administered to all patients.

RESULTS

More than half of patients in bipolar disorder group reported childhood trauma. HAM-D scores were positively associated with childhood trauma total scores and emotional abuse scores, negatively associated with resilience, with attachment-related anxiety. Total childhood trauma scores were associated with lower scores of resilience, higher scores of attachment-related anxiety and avoidance. Resilience scores were negatively associated with attachment-related anxiety and avoidance. Impact of childhood trauma on resilience was partly mediated by attachment-related anxiety and avoidance, respectively.

LIMITATIONS

The cross-sectional design of this study is a limitation in terms of determining causality of the identified relationships.

CONCLUSIONS

Childhood traumas are associated with lower resilience and higher attachment-related anxiety and avoidance. Attachment-related anxiety and avoidance partly mediated the negative effect of childhood trauma on resilience. Since resilience is associated with increased quality of life in bipolar disorder, it might be helpful to develop attachment-informed psychosocial interventions to ameliorate the detrimental effect of childhood trauma on resilience.

Determinants of the remission heterogeneity in bipolar disorders: The importance of early maladaptive schemas (EMS)

BACKGROUND

A crucial health issue is to understand the remission heterogeneity of Bipolar Disorders by considering symptomatology as well as functioning. A new perspective could be elements of the construction of individual identity. This exploratory study aimed to explore the remission heterogeneity of patients with BD in terms of Early Maladaptive Schemas (EMS) by preferring a person-oriented approach.

METHODS

This study included euthymic patients recruited into the FACE-BD cohort. The remission was assessed by the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale for its symptomatic dimension and by the Functioning Assessment Short Test for its functional dimension. The activation of the eighteen EMS was assessed by the Young Schema Questionnaire 3 Short Form. Clustering was performed to identify profiles according to the patients' remission. Clusters identified were compared on the EMS activation by using analysis of variance and post-hoc tests.

RESULTS

Among the 100 euthymic patients included, four profiles of remission were identified: cluster 1 "Global Remission" (34%), cluster 2 "Hypomanic residual" (20%), cluster 3 "Depressive residual and functional impairment" (36%) and cluster 4 "Global handicap" (10%). Two out of three EMS discriminated against these profiles. The activation of specific EMS clarifies the singularity of each remission profile.

LIMITATIONS

For the symptomatic dimension, cut-offs chosen could be discussed as well as the scale assessing residual depressive symptoms.

CONCLUSIONS

This study participates in a comprehensive model of remission by integrating the symptomatology, the functioning, and the EMS. Identifying and treating EMS may improve patients remission to reach recovery.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]

OBJECTIVES

Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders.

METHODS

This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas » AND « bipolar disorder » as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias).

RESULTS

Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles.

CONCLUSIONS

Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

What is the relationship between post-traumatic stress disorder, extreme appraisals of internal state and symptoms in bipolar disorder?

BACKGROUND

It is important to understand the factors associated with more severe mood symptoms in bipolar disorder. The integrative cognitive model of bipolar disorder proposes that extreme appraisals of changes to internal states maintain and exacerbate mood symptoms.

AIMS

The current study aimed to investigate if post-traumatic stress disorder (PTSD) is related to current depressive and manic bipolar symptoms, and whether this relationship is mediated by appraisals of internal state.

METHOD

Participants with bipolar disorder (n = 82) from a randomized controlled trial of cognitive therapy for bipolar disorder (the TEAMS trial) completed self-reported questionnaires assessing appraisals of internal state, generalized anxiety symptoms, and self-reported and observer-rated depressive and manic symptoms. Clinical interviews assessed PTSD co-morbidity.

RESULTS

Participants with bipolar and co-morbid PTSD (n = 27) had higher depressive symptoms and more conflicting appraisals than those without PTSD. Regression analyses found PTSD to be associated with depressive symptoms but not manic symptoms. Conflicting appraisals were found to be associated only with manic symptoms meaning that the planned mediation analysis could not be completed.

CONCLUSIONS

Findings provide partial support for the integrative cognitive model of bipolar disorder and highlight the need for transdiagnostic treatments in bipolar disorder due to the prevalence and impact of trauma and co-morbidity. Working on trauma experiences in therapy may impact on depressive symptoms for those with bipolar disorder and co-morbid PTSD.

Clinical outcomes and childhood trauma in bipolar disorder: A community sample of young adults

Childhood trauma is a complex experience, much reported by subjects with bipolar disorder. There are still few studies that assess its consequences in a community sample of bipolar in early stage. The aim of the present study is to assess the association between childhood trauma and clinical outcomes, including the global functioning, in a community sample of young adults with bipolar disorder. This is a cross-sectional study with a community sample of subjects with bipolar disorder, from 23 to 30 years old, with and without childhood trauma. The trauma experiences during childhood were assessed by Childhood Trauma Questionnaire (CTQ). The functioning was assessed by Functioning Assessment Short Test (FAST). Ninety subjects with bipolar disorder were included in the study (30 with childhood trauma and 60 without childhood trauma). Young adults with bipolar disorder and childhood trauma showed higher prevalence of current suicide risk, higher severity of depressive symptoms, and higher functioning impairment as compared to subjects with bipolar disorder without childhood trauma. The childhood trauma experiences appear to be an environmental risk factor for worse clinical outcomes and higher functional impairment.

Prevalence of Trauma in an Australian Inner City Mental Health Service Consumer Population

This study examined the rates and types of trauma reported by consumers utilising an inner city mental health service in Sydney, Australia. The study also explored whether consumers felt that it had been helpful to be asked about their experience of trauma, whether they thought that these questions should be asked routinely and if they wanted to talk about these experiences. Ninety-one consumers from an inner city mental health service were assessed. Eighty-eight percent of the consumers assessed reported that they had experienced at least one traumatic event, while 79% reported having experienced two or more events. A majority of consumers identified that they thought it was helpful to be asked about trauma and that it should be part of an assessment. However, less than one-third of these consumers surveyed wanted to talk about the trauma at the time of assessment. Concerns that clinicians may have in regards to addressing trauma in mental health assessment are not matched by consumers' expressed beliefs on the issue.

Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures

INTRODUCTION

Borderline Personality Disorder (BPD) and Bipolar Affective Disorder (BD) have clinical characteristics in common which often make their differential diagnosis difficult. The history of early life stress (ELS) may be a differentiating factor between BPD and BD, as well as its association with clinical manifestations and specific neuroendocrine responses in each of these diagnoses.

OBJECTIVE

Assessing and comparing patients with BD and BPD for factors related to symptomatology, etiopathogenesis and neuroendocrine markers.

METHODOLOGY

The study sample consisted of 51 women, divided into 3 groups: patients with a clinical diagnosis of BPD (n = 20) and BD (n = 16) and healthy controls (HC, n = 15). Standardized instruments were used for the clinical evaluation, while the history of ELS was quantified with the Childhood Trauma Questionnaire (CTQ), and classified according to the subtypes: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic-pituitary-adrenal (HPA) axis was evaluated by measuring a single plasma cortisol sample.

RESULTS

Patients with BPD presented with more severe psychiatric symptoms of: anxiety, impulsivity, depression, hopelessness and suicidal ideation than those with BD. The history of ELS was identified as significantly more prevalent and more severe in patients (BPD and BP) than in HC. Emotional abuse, emotional neglect and physical neglect also showed differences and were higher in BPD than BD patients. BPD patients had greater severity of ELS overall and in the subtypes of emotional abuse, emotional neglect and physical neglect than BD patients. The presence of ELS in patients with BPD and BP showed significant difference with lower cortisol levels when compared to HC. The endocrine evaluation showed no significant differences between the diagnoses of BPD and BD. Cortisol measured in patients with BPD was significantly lower compared to HC in the presence of emotional neglect and physical neglect. A significant negative correlation between the severity of hopelessness vs cortisol; and physical neglect vs cortisol were found in BPD with ELS. The single cortisol sample showed a significant and opposite correlations in the sexual abuse diagnosis-related groups, being a negative correlation in BD and positive in BPD.

DISCUSSION

Considering the need for a multi-factorial analysis, the differential diagnosis between BPD and BD can be facilitated by the study of psychiatric symptoms, which are more severe in the BPD patients with a history of early life stress. The function of the HPA axis assessed by this cortisol measure suggests differences between BPD and BP with ELS history.

CONCLUSION

The integrated analysis of psychopathology, ELS and neuroendocrine function may provide useful indicators to differentiate BPD and BD diagnoses. These preliminary data need to be replicated in a more significant sample with improved and multiple assessments of HPA axis activity.

Trauma exposure interacts with the genetic risk of bipolar disorder in alcohol misuse of US soldiers

OBJECTIVE

To investigate whether trauma exposure moderates the genetic correlation between substance use disorders and psychiatric disorders, we tested whether trauma exposure modifies the association of genetic risks for mental disorders with alcohol misuse and nicotine dependence (ND) symptoms.

METHODS

High-resolution polygenic risk scores (PRSs) were calculated for 10 732 US Army soldiers (8346 trauma-exposed and 2386 trauma-unexposed) based on genome-wide association studies of bipolar disorder (BD), major depressive disorder, and schizophrenia.

RESULTS

The main finding was a significant BD PRS-by-trauma interaction with respect to alcohol misuse (P = 6.07 × 10^-3 ). We observed a positive correlation between BD PRS and alcohol misuse in trauma-exposed soldiers (r = 0.029, P = 7.5 × 10^-3 ) and a negative correlation in trauma-unexposed soldiers (r = -0.071, P = 5.61 × 10^-4 ). Consistent (nominally significant) result with concordant effect, directions were observed in the schizophrenia PRS-by-trauma interaction analysis. The variants included in the BD PRS-by-trauma interaction showed significant enrichments for gene ontologies related to high voltage-gated calcium channel activity (GO:0008331, P = 1.51 × 10^-5 ; GO:1990454, P = 4.49 × 10^-6 ; GO:0030315, P = 2.07 × 10^-6 ) and for Beta1/Beta2 adrenergic receptor signaling pathways (P = 2.61 × 10^-4 ).

CONCLUSIONS

These results indicate that the genetic overlap between alcohol misuse and BD is significantly moderated by trauma exposure. This provides molecular insight into the complex mechanisms that link substance abuse, psychiatric disorders, and trauma exposure.

Childhood maltreatment is associated with attachment insecurities, dissociation and alexithymia in bipolar disorder

Child maltreatment is a public health issue that is a well-established risk factor for many psychological conditions, including bipolar disorder. The current study is one of the first to investigate associations among child maltreatment, dissociative symptomatology, alexithymia, anxiety, depression, and attachment insecurities. 40 patients with bipolar disorder-I and 40 healthy subjects matched for age, gender, and education participated in the study. The Dissociative Experiences Scale (DES), Somatoform Dissociation Questionnaire (SDQ), Childhood Trauma Questionnaire (CTQ-28), Toronto Alexithymia Scale (TAS-20), Depression Anxiety Stress Scale (DASS-21), and Experiences in Close Relationships-Revised (ECR-R) were completed by participants. In comparison to control participants, patients with bipolar disorder-I reported significantly more frequent abusive experiences in childhood, higher levels of attachment insecurities, more severe pathological and somatoform dissociation, as well as higher scores on measures of alexithymia, anxiety, depression and psychological stress. Reports of psychopathology among first-degree relatives (OR = 102.169, 95%IC = 4.596-2271.255; P < 0.01) and childhood emotional trauma (OR = 1.032; 95%CI = 0.782-1.363, P = 0.05) significantly contributed to bipolar disorder-I diagnosis. In contrast, absorption was negatively associated with bipolar illness (OR = 0.852; 95% CI = 0.747-0.973, P < 0.05). Our results showed significant associations between childhood trauma exposure and risk of bipolar disorder. Moreover, the results demonstrate that emotional abuse exposure predicts bipolar illness.

The association between childhood trauma, parental bonding and depressive symptoms and interpersonal functioning in depression and bipolar disorder

Objectives

This study explores rates of a history of childhood trauma in adult patients with bipolar disorder and depression and the impact of such trauma and parental bonding patterns on depressive mood and interpersonal functioning at the time of assessment.

Methods

A cross-sectional design was used and a sample of 49 participants was recruited from a mental health outpatient service in Northern Ireland. Data were subject to correlations, one-way analysis of variance and hierarchal regression analyses. A cut-off point of r=±0.25 was used to select variables for inclusion in the hierarchal regression analyses.

Results

High rates of childhood trauma were present in both samples: 74% in bipolar disorder and 82% in depression. Childhood trauma and poor parental bonding (with mother) were significant predictors of higher rates of current inter-episode depressive mood and interpersonal difficulties.

Conclusions

This finding adds to the evidence that routine assessment of early childhood experience is likely to prove helpful in clinical care.

Gray matter brain volumes in childhood-maltreated patients with bipolar disorder type I: A voxel-based morphometric study

BACKGROUND

Childhood maltreatment (CM) may be related to clinical expression and outcome of bipolar disorder (BD). Several neuroimaging studies have detected brain morphological changes in specific neural networks of adults who suffered maltreatment in their childhood. We investigated alterations in gray matter volume (GMV) to determine a possible neuroanatomical basis of vulnerability in patients with CM having type I BD (BD-I).

METHODS

We assessed 39 euthymic DSM-IV BD-I patients with (n=20) and without (n=19) a history of CM and 20 healthy controls without maltreatment as defined by the Childhood Trauma Questionnaire (CTQ). Voxel-based morphometry (VBM) was used to compare GMV differences between patients and controls and perform linear correlations in overall BD group between GMV and CTQ scores.

RESULTS

BD-I patients had significant negative correlations between CTQ total score and GMV in the right dorsolateral prefrontal cortex (PFC) and the right thalamus; between physical abuse and GMV in the right dorsolateral PFC; between physical neglect and GMV in the thalamus bilaterally; and between emotional neglect and GMV in the right thalamus.

LIMITATIONS

Pharmacological treatment could have altered GMV findings. Results emerged only when using SVC approach. CTQ, a retrospective self-report, has the risk of potential recall bias. The cross-sectional design limits longitudinal and neurodevelopmental inferences.

CONCLUSIONS

The severity of self-reported CM in BD-I patients is associated with morphological changes in GMV of specific neural networks relevant to responses to stress and to modulate emotional behavior.

Exposure to Political Violence in Northern Ireland and Outcome of First Episode Psychosis

The impact of political violence on individuals presenting with an episode of first episode psychosis has not been examined. Individuals were assessed for exposure to political violence in Northern Ireland (the "Troubles") by asking for a response to 2 questions: one asked about the impact of violence "on your area"; the second about the impact of violence "on you or your family's life." The participants were separated into 2 groups (highandlowimpact) for each question. Symptom profiles and rates of substance misuse were compared across the groups at baseline and at 3-year follow up. Of the 178 individuals included in the study 66 (37.1%) reported ahighimpact of the "Troubles" on their life and 81 (45.5%) ahighimpact of the "Troubles" on their area. There were no significant differences in symptom profile or rates of substance misuse betweenhighandlowgroups at presentation. At 3-year follow-uphighimpact of the "Troubles" on life was associated with higher Positive and Negative Symptom Scale (PANSS) Total (P= .01), PANSS-Positive (P< .05), and PANSS-General (P< .01) scores and lower global assessment of functioning disability (P< .05) scores, after adjusting for confounding factors. Impact of the "Troubles" on area was not associated with differences in symptom outcomes. This finding adds to the evidence that outcomes in psychosis are significantly impacted by environmental factors and suggests that greater attention should be paid to therapeutic strategies designed to address the impact of trauma.

Differences in Trauma Experience Between Patients With Bipolar I Disorder, Patients With Major Depressive Disorder, and Healthy Controls

The aim of this study was to compare differences in traumatic experiences between patients with bipolar I disorder, patients with major depressive disorder (MDD), and controls. The traumatic experiences (as measured by the Trauma Experience Questionnaire) of 40 participants with bipolar I disorder were compared with those of 38 participants with MDD and 92 controls. Participants with bipolar I disorder exhibited a significantly higher frequency of traumatic experiences and higher impact ratings when traumas did occur than did patients with MDD and controls. In addition, the present impact of past trauma for patients in the bipolar I disorder and MDD groups was significantly higher than for controls. The bipolar I disorder group reported more severe traumatic experiences than did both the MDD and control groups, and the MDD group in turn reported more severe traumatic experiences than did the control group.

The impact of past direct-personal traumatic events on 12-month outcome in first episode psychotic mania: trauma and early psychotic mania

OBJECTIVE

Past traumatic events have been associated with poorer clinical outcomes in people with bipolar disorder. However, the impact of these events in the early stages of the illness remains unclear. The aim of this study was to investigate whether prior traumatic events were related to poorer outcomes 12 months following a first episode of psychotic mania.

METHODS

Traumatic events were retrospectively evaluated from patient files in a sample of 65 participants who had experienced first episode psychotic mania. Participants were aged between 15 and 28 years and were treated at a specialised early psychosis service. Clinical outcomes were measured by a variety of symptomatic and functioning scales at the 12-month time-point.

RESULTS

Direct-personal traumatic experiences prior to the onset of psychotic mania were reported by 48% of the sample. Participants with past direct-personal trauma had significantly higher symptoms of mania (p=0.02), depression (p=0.03) and psychopathology (p=0.01) 12 months following their first episode compared to participants without past direct-personal trauma, with medium to large effects observed. After adjusting for baseline scores, differences in global functioning (as measured by the Global Assessment of Functioning scale) were non-significant (p=0.05); however, participants with past direct-personal trauma had significantly poorer social and occupational functioning (p=0.04) at the 12-month assessment with medium effect.

CONCLUSIONS

Past direct-personal trauma may predict poorer symptomatic and functional outcomes after first episode psychotic mania. Limitations include that the findings represent individuals treated at a specialist early intervention centre for youth and the retrospective assessment of traumatic events may have been underestimated.

Effects of childhood trauma and clinical features on determining quality of life in patients with bipolar I disorder

BACKGROUND

We explored how childhood trauma (CHT) affects the clinical expression of disorder and quality of life in patients with bipolar I (BP-I) disorder.

METHODS

Euthymic patients (n=116) who subsequently received a diagnosis of BP-I disorder were consecutively included and were interviewed using the following sociodemographic and clinical data forms; Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Childhood Abuse and Neglect Questionnaire (CANQ) and the 36-item Medical Outcome Study Short Form Health Survey (SF-36). The quality of life of BP-I patients with and without a history of CHT were examined.

RESULTS

The percentage of trauma was 61.2%. Patients who had CHT had higher frequencies of depressive episodes (t=-2.38, p=0.019), total episodes (t=-2.25, p=0.026), attempted suicide more often (χ(2)=18.12, p=0.003) and had lower scores on the pain subscale of the SF-36 (z=-2.817, p=0.005). In patients with mixed or rapid-cycling episodes, SF-36 subscale scores except general health and pain were found to be lower.

LIMITATIONS

Our sample may fail to reflect the general BD population; the patients were included consecutively and consisted of a majority of female patients.

CONCLUSIONS

CHT plays an important role in the clinical expression of BP-I disorder and having mixed/rapid-cycling episodes negatively affects both physical and mental components, as measured by the SF-36. While both males and females reported experiencing sexual abuse, female BP-I patients complained about pain more often. It is suggested that treatment of BP-I patients with a history of CHT should differ from that provided for patients with no CHT history.

Chronic stressors and trauma: prospective influences on the course of bipolar disorder

BACKGROUND

Exposure to life stress is known to adversely impact the course of bipolar disorder. Few studies have disentangled the effects of multiple types of stressors on the longitudinal course of bipolar I disorder. This study examines whether severity of chronic stressors and exposure to trauma are prospectively associated with course of illness among bipolar patients.

METHOD

One hundred and thirty-one participants diagnosed with bipolar I disorder were recruited through treatment centers, support groups and community advertisements. Severity of chronic stressors and exposure to trauma were assessed at study entry with in-person interviews using the Bedford College Life Event and Difficulty Schedule (LEDS). Course of illness was assessed by monthly interviews conducted over the course of 24 months (over 3000 assessments).

RESULTS

Trauma exposure was related to more severe interpersonal chronic stressors. Multiple regression models provided evidence that severity of overall chronic stressors predicted depressive but not manic symptoms, accounting for 7.5% of explained variance.

CONCLUSIONS

Overall chronic stressors seem to be an important determinant of depressive symptoms within bipolar disorder, highlighting the importance of studying multiple forms of life stress.

Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness

BACKGROUND

Interpersonal trauma exposure and trauma-related disorders in people with severe mental illness (SMI) are often not recognized in clinical practice.

OBJECTIVE

To substantiate the prevalence of interpersonal trauma exposure and trauma-related disorders in people with SMI.

METHODS

We conducted a systematic review of four databases (1980-2010) and then described and analysed 33 studies in terms of primary diagnosis and instruments used to measure trauma exposure and trauma-related disorders.

RESULTS

Population-weighted mean prevalence rates in SMI were physical abuse 47% (range 25-72%), sexual abuse 37% (range 24-49%), and posttraumatic stress disorder (PTSD) 30% (range 20-47%). Compared to men, women showed a higher prevalence of sexual abuse in schizophrenia spectrum disorder, bipolar disorder, and mixed diagnosis groups labelled as having SMI.

CONCLUSIONS

Prevalence rates of interpersonal trauma and trauma-related disorders were significantly higher in SMI than in the general population. Emotional abuse and neglect, physical neglect, complex PTSD, and dissociative disorders have been scarcely examined in SMI.

Prevalence of child sexual abuse among adults and youths with bipolar disorder: a systematic review

To estimate the prevalence and social and demographic correlates of child sexual abuse among people with bipolar disorder, the findings of all the pertinent studies were qualitatively and semi-quantitatively analyzed. Five databases were searched. Blind assessments of study eligibility and quality were conducted by two independent researchers. Twenty studies, meeting minimum quality standards and including 3407 adults and youths with bipolar disorder across 10 countries and 3 continents, were examined. The prevalence of child sexual abuse was 24% (23% without outliers); however, such prevalence rate might be underestimated, because many studies restricted definitions to the most severe forms of abuse. Child sexual abuse was a common experience for both males and females, while it was more frequent for adults than for youths. Compared to healthy individuals, patients with bipolar disorder reported higher rates of child sexual abuse; compared to populations with other mental disorders, participants with bipolar disorder reported similar or lower rates of such abuse. Individuals with bipolar disorder are at risk of having a history of child sexual abuse, although such risk seems to be neither more specific to nor stronger for these individuals, compared to people with other psychiatric disorders.

Post-traumatic stress disorder as a comorbidity: impact on disease outcomes

Post-traumatic stress disorder (PTSD) is associated with many psychiatric and nonpsychiatric comorbidities. Growing evidence suggests that PTSD as a comorbidity may impair drug adherence, quality of life and sleep quality, as well as increase rehospitalization rates, disease relapses, intensity of symptoms, morbidity and mortality. The aim of this article is to examine the literature regarding the effects of PTSD comorbidity on physical and mental health.

BDNF function as a potential mediator of bipolar disorder and post-traumatic stress disorder comorbidity

Bipolar disorder (BD) and post-traumatic stress disorder (PTSD) frequently co-occur among psychiatric patients, leading to increased morbidity and mortality. Brain-derived neurotrophic factor (BDNF) function is associated with core characteristics of both BD and PTSD. We propose a neurobiological model that underscores the role of reduced BDNF function resulting from several contributing sources, including the met variant of the BDNF val66met (rs6265) single-nucleotide polymorphism, trauma-induced epigenetic regulation and current stress, as a contributor to the onset of both illnesses within the same person. Further studies are needed to evaluate the genetic association between the val66met allele and the BD-PTSD population, along with central/peripheral BDNF levels and epigenetic patterns of BDNF gene regulation within these patients.

Childhood maltreatment and clinical outcomes of bipolar disorder

OBJECTIVE

Adverse life events, especially early trauma, play a major role in the course and expression of bipolar disorder (BD). The aim of this article is to present a systematic review about the impact of childhood trauma on the clinical course of BD.

METHOD

A computer-aided search was performed in Medline, ISI database, EMBASE, PsychInfo, Centre for Reviews and Dissemination, and Databases of Thomson Reuters at April 2011, supplemented by works identified from the reference lists of the first selected papers. Two investigators systematically and independently examined all articles, selecting those according inclusion and exclusion criteria.

RESULTS

Four hundred fifteen articles were identified, of which 19 remained in the review after exclusion criteria were applied. In general, childhood maltreatment predicted worsening clinical course of BD. After assessing the quality of the data and of the measurements, childhood maltreatment can be strongly associated to early onset of disorder, suicidality, and substance abuse disorder in patients with BD.

CONCLUSION

Data suggest that childhood abuse and neglect are risk factors associated with worsening clinical course of BD. The conclusions should be interpreted with caution because all the studies included are cross-sectional and the majority are showing inconsistencies regarding childhood trauma as independent variable and how it is assessed.

Enquiring about traumatic experiences in bipolar disorder: a case note and self- report comparison

OBJECTIVES

This study examined: (i) the prevalence of lifetime trauma, childhood trauma and trauma related to civil unrest in a Bipolar Disorder sample, and (ii) the agreement between rates of disclosure of trauma in case notes and self-report questionnaires.

METHODS

The case notes of sixty participants, recruited from a geographically well-defined mental health service in Northern Ireland, were examined for reports of experiences of lifetime, childhood and traumatic events related to civil conflict. The participants also completed self-report measures of trauma.

RESULTS

Considerable differences were found between the prevalence of trauma as measured by self-report questionnaires and case notes reports. The prevalence of lifetime trauma as measured by the Trauma History Questionnaire was 61.7% (compared to case notes prevalence of 33.3%). The prevalence of moderate and severe levels of childhood trauma as measured by the Childhood Trauma Questionnaire was 65% (case notes 21.7%). Rates of trauma related to civil unrest were 35% (case notes 3.3%). Poor levels of agreement were found between all self-report trauma measures and case notes reports. Agreement on two categories of trauma (childhood emotional neglect and childhood physical neglect) reached statistical significance but kappa scores suggest this agreement was poor (κ=.14, p<.05; κ=.127, p<.05).

CONCLUSIONS

It is probable that the increased rate of trauma disclosed in the self-report questionnaire arises because clinicians during initial assessment and subsequent treatment do not consistently enquire about trauma. The need for staff training is discussed.

The association between childhood trauma and memory functioning in schizophrenia

OBJECTIVE

Both neurocognitive impairments and a history of childhood abuse are highly prevalent in patients with schizophrenia. Childhood trauma has been associated with memory impairment as well as hippocampal volume reduction in adult survivors. The aim of the following study was to examine the contribution of childhood adversity to verbal memory functioning in people with schizophrenia.

METHODS

Eighty-five outpatients with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of chronic schizophrenia were separated into 2 groups on the basis of self-reports of childhood trauma. Performance on measures of episodic narrative memory, list learning, and working memory was then compared using multivariate analysis of covariance.

RESULTS

Thirty-eight (45%) participants reported moderate to severe levels of childhood adversity, while 47 (55%) reported no or low levels of childhood adversity. After controlling for premorbid IQ and current depressive symptoms, the childhood trauma group had significantly poorer working memory and episodic narrative memory. However, list learning was similar between groups.

CONCLUSION

Childhood trauma is an important variable that can contribute to specific ongoing memory impairments in schizophrenia.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.

Positive aspects of mental illness: a review in bipolar disorder

INTRODUCTION

There is growing interest to understand the role of positive psychological features on the outcomes of medical illnesses. Unfortunately this topic is less studied in relation to mental health, and almost completely neglected in relation to one of the most common severe psychiatric illnesses, bipolar disorder. Certain specific psychological characteristics, that are generally viewed as valuable and beneficial morally or socially, may grow out of the experience of having this affective disorder.

OBJECTIVE

We describe the sources, research and impact of these positive psychological traits in the lives of persons with bipolar disorder based on the few published literature available to date. These include, but are not limited to: spirituality, empathy, creativity, realism, and resilience.

METHODS

After an extensive search in the literature, we found 81 articles that involve descriptions of positive psychological characteristics of bipolar disorder.

RESULTS

We found evidence for enhancement of the five above positive psychological traits in persons with bipolar disorder.

CONCLUSIONS

Bipolar disorder is associated with the positive psychological traits of spirituality, empathy, creativity, realism, and resilience. Clinical and research attention to preserving and enhancing these traits may improve outcomes in bipolar disorder.

Preferential association between childhood emotional abuse and bipolar disorder

Childhood trauma has been suggested to be involved in the susceptibility to bipolar disorder. However, case-control studies are lacking, and the preferential implication and the dose-effect of different trauma subtypes remain poorly investigated. Two hundred six bipolar patients and 94 controls completed the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994). The CTQ total score was higher for bipolar patients than for controls. The presence of multiple trauma was significantly more frequent in bipolar patients than in controls (63% vs. 33%). Multiple logistic regression suggested that only emotional abuse was associated with bipolar disorder with a suggestive dose-effect. Clinical practice should include systematic assessment of childhood trauma among bipolar patients with a particular focus on emotional abuse.

Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania

OBJECTIVES

To assess the prevalence and correlates of childhood and adolescent sexual and/or physical abuse (SPA) in bipolar I disorder (BDI) patients treated for a first episode of psychotic mania.

METHODS

The Early Psychosis Prevention and Intervention Centre admitted 786 first-episode psychosis patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. A total of 704 files were available; 43 were excluded because of a nonpsychotic diagnosis at endpoint and 3 due to missing data regarding past stressful events. Among 658 patients with available data, 118 received a final diagnosis of BDI and were entered in this study.

RESULTS

A total of 80% of patients had been exposed to stressful life events during childhood and adolescence and 24.9% to SPA; in particular, 29.8% of female patients had been exposed to sexual abuse. Patients who were exposed to SPA had poorer premorbid functioning, higher rates of forensic history, were less likely to live with family during treatment period, and were more likely to disengage from treatment.

CONCLUSIONS

SPA is highly prevalent in BDI patients presenting with a first episode of psychotic mania; exposed patients have lower premorbid functional levels and poorer engagement with treatment. The context in which such traumas occur must be explored in order to determine whether early intervention strategies may contribute to diminish their prevalence. Specific psychological interventions must also be developed.

Beyond genetics: childhood affective trauma in bipolar disorder

OBJECTIVES

Despite the demonstrated high heritability of bipolar disorder, few susceptibility genes have been identified and linkage and/or association studies have produced conflicting results. This search for susceptibility genes is hampered by several methodological limitations, and environmental risk factors for the disease (requiring incorporation into analyses) remain misunderstood. Among them, childhood trauma is probably the most promising environmental factor for further investigation. The objectives are to review the arguments in favor of an association between childhood trauma and bipolar disorder and to discuss the interpretations of such an observation.

METHODS

We computed a literature search using PubMed to identify relevant publications concerning childhood trauma and bipolar disorder. We also present some personal data in this field.

RESULTS

Growing evidence suggests that incidences of childhood trauma are frequent and severe in bipolar disorder, probably affect the clinical expression of the disease in terms of suicidal behavior and age at onset, and also have an insidious influence on the affective functioning of patients between episodes. The relationships between childhood trauma and bipolar disorder suggest several interpretations, mainly a causal link, a neurodevelopmental consequence, or the intergenerational transmission of traumatic experiences. The neurobiological consequences of childhood trauma on a maturing brain remain unclear, although such stressors may alter the organization of brain development, leading to inadequate affective regulation.

CONCLUSIONS

Childhood trauma is associated with bipolar disorder and its clinical expression and may interact with genetic susceptibility factors. Although not completely understood, the relationships between childhood trauma and bipolar disorder require further attention. Several suggestions for further exploration of this environmental factor and of its interaction with susceptibility genes are proposed.