Rapid cycling in unipolar and bipolar affective disorders

Prevalence and outcomes of rapid cycling bipolar disorder: Mixed method systematic meta-review

Rapid-cycling in bipolar disorder (RC-BD) is associated with greater illness morbidity and inferior treatment response but many aspects remain unclear, prompting this systematic review of its definitions, prevalence, and clinical characteristics. We searched multiple literature databases through April 2022 for systematic reviews or meta-analyses on RC-BD and extracted associated definitions, prevalence, risk-factors, and clinical outcomes. We assessed study quality (NIH Quality Assessment Tool) and levels of evidence (Oxford criteria). Of 146 identified reviews, 22 fulfilling selection criteria were included, yielding 30 studies involving 13,698 BD patients, of whom 3777 (27.6% [CI: 26.8-28.3]) were considered RC-BD, as defined in 14 reports by ≥4 recurrences/year within the past 12 months or in any year, without considering responsiveness to treatment. Random-effects meta-analytically pooled one-year prevalence was 22.3% [CI: 14.4-32.9] in 12 reports and lifetime prevalence was 35.5% [27.6-44.3] in 18 heterogenous reports. Meta-regression indicated greater lifetime prevalence of RC-BD among women than men (p=0.003). Association of RC-BD with suicide attempts, and unsatisfactory response to mood-stabilizers was supported by strong evidence (Level 1); associations with childhood maltreatment, mixed-features, female sex, and type-II BD had moderate evidence (Level 2). Other factors: genetic predisposition, metabolic disturbances or hypothyroidism, antidepressant exposure, predominant depressive polarity (Level 3), along with greater illness duration and immune-inflammatory dysfunction (Level 4) require further study. RC-BD was consistently recognized as having high prevalence (22.3%-35.5% of BD cases) and inferior treatment response. Identified associated factors can inform clinical practice. Long-term illness-course, metabolic factors, and optimal treatment require further investigation.

Clinical characteristics and prescriptions associated with a 2-year course of rapid cycling and euthymia in bipolar disorder: a multicenter treatment survey for bipolar disorder in psychiatric clinics

Objective

In patients with bipolar disorder (BD), rapid cycling (RC) presents a risk for a more severe illness, while euthymia (EUT) has a better prognosis. This study focused on the progression of RC and EUT, which are contrasting phenomenology, and aimed to clarify the influence of patient backgrounds and prescription patterns on these different progressions, using a large sample from the first and second iterations of a multicenter treatment survey for BD in psychiatric clinics (MUSUBI).

Methods

In the cross-sectional study (MUSUBI), a questionnaire based on a retrospective medical record survey of consecutive BD cases (N = 2,650) was distributed. The first survey was conducted in 2016, and the second one in 2017. The questionnaire collected information on patient backgrounds, current episodes, and clinical and prescribing characteristics.

Results

In the first survey, 10.6% of the participants had RC and 3.6% had RC for two consecutive years, which correlated with BP I (Bipolar disorder type I), suicidal ideation, duration of illness, and the use of lithium carbonate and antipsychotic medications. Possible risk factors for switching to RC were comorbid developmental disorders and the prescription of anxiolytics and sleep medication. Moreover, 16.4% of the participants presented EUT in the first survey, and 11.0% presented EUT for two consecutive years. Possible factors for achieving EUT included older age; employment; fewer psychotic symptoms and comorbid personality disorders; fewer antidepressants, antipsychotics, and anxiolytics, and more lithium prescriptions.

Conclusion

RC and EUT generally exhibit conflicting characteristics, and the conflicting social backgrounds and factors contributing to their outcomes were distinctive. Understanding these clinical characteristics may be helpful in clinical practice for management of patients with BD.

Rapid cycling mood disorder: A review

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

Eyeblink conditioning anomalies in bipolar disorder suggest cerebellar dysfunction

OBJECTIVES

Accumulating research implicates the cerebellum in non-motor psychological processes and psychiatric diseases, including bipolar disorder (BD). Despite recent evidence that cerebellar lesions have been documented to trigger bipolar-like symptoms, few studies have directly examined the functional integrity of the cerebellum in those afflicted with BD.

METHODS

Using a single-cue delay eyeblink conditioning procedure, the functional integrity of the cerebellum was examined in 28 individuals with BD (9 manic, 8 mixed, and 11 euthymic) and 28 age-matched healthy controls.

RESULTS

Analysis of the bipolar group as a whole indicated a conditioned response acquisition and timing deficit compared to controls. However, when the bipolar group was categorized according to mood state (mixed, manic, euthymic), individuals tested during mixed episodes were strikingly impaired, performing significantly worse than all other groups on both the acquisition and timing of conditioned responses.

CONCLUSIONS

These findings extend prior research implicating cerebellar functional abnormalities in BD and suggest that cerebellar dysfunction may be associated with mood state and course of illness.

Rapid switching of mood in families with familial bipolar disorder

OBJECTIVE

Rapid switching of moods in bipolar disorder has been associated with early age at onset, panic comorbidity, and suicidality. This study aims to confirm these associations and investigate other potential correlates of rapid switching of mood using families from a multisite bipolar linkage study.

METHODS

The subjects were comprised of 1,143 probands and relatives with diagnosis of bipolar disorder. All subjects were interviewed directly with a standard diagnostic instrument, and all subjects who met criteria for bipolar disorder were asked if their moods had ever switched rapidly.

RESULTS

Individuals with rapid mood switching had significantly earlier age at onset (18 versus 21 years, p < 0.00001), higher comorbid anxiety (47% versus 26%, p < 0.00001) and substance use disorders (52% versus 42%, p = 0.0006), higher rate of violent behavior (6% versus 3%, p < 0.004), suicidal behavior (46% versus 31%, p < 0.00001), and nonsuicidal self-harm (13% versus 6%, p < 0.0002). Multiple logistic regression analysis found significant net effects on rapid mood switching for early emergence of symptoms [odds ratio (OR) = 0.62; 95% confidence interval (CI): 0.45-0.85]; anxiety comorbidity (OR = 2.31; 95% CI: 1.34-3.98); and hypersensitivity to antidepressants (OR = 2.05; 95% CI: 1.49-2.83) as the strongest predictors.

CONCLUSIONS

This confirms earlier reports associating rapid switching with a more complex clinical course, in particular early emergence of bipolar symptomatology, antidepressant activation, and anxiety comorbidity. These results support a clinical differentiation of bipolar disorder into subtypes based on symptom stability.

Rapid cycling bipolar disorder--diagnostic concepts

OBJECTIVES

This paper reviews the literature to examine the DSM-IV diagnostic criteria for rapid cycling in bipolar disorder.

METHODS

Studies on the clinical characteristics of rapid cycling bipolar disorder were reviewed. To identify relevant papers, literature searches using PubMed and MEDLINE were undertaken.

RESULTS

First observed in the prepharmacologic era, rapid cycling subsequently has been associated with a relatively poor response to pharmacologic treatment. Rapid cycling can be conceptualized as either a high frequency of episodes of any polarity or as a temporal sequence of episodes of opposite polarity. The DSM-IV defines rapid cycling as a course specifier, signifying at least four episodes of major depression, mania, mixed mania, or hypomania in the past year, occurring in any combination or order. It is estimated that rapid cycling is present in about 12-24% of patients at specialized mood disorder clinics. However, apart from episode frequency, studies over the past 30 years have been unable to determine clinical characteristics that define patients with rapid cycling as a specific subgroup. Furthermore, rapid cycling is a transient phenomenon in many patients.

CONCLUSIONS

While a dimensional approach to episode frequency as a continuum between the extremes of no cycling and continuous cycling may be more appropriate and provide a framework to include ultra-rapid and ultradian cycling, the evidence does not exist today to refine the DSM-IV definition in a less arbitrary manner. Continued use of the DSM-IV definition also enables comparisons between past and future studies, and it should be included in the next release of the ICD. Further scientific investigation into rapid cycling is needed. In addition to improving the diagnostic criteria, insight into neurophysiologic mechanisms of mood switching and episode frequency may have important implications for clinical care.

Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders

OBJECTIVES

The Diagnostic and Statistical Manual of Mental Disorders guidelines provide only a partial solution to the nosology and treatment of bipolar disorder in that disorders with common symptoms and biological correlates may be categorized separately because of superficial differences related to behavior, life history, and temperament. The relationship is explored between extremely rapid switching forms of bipolar disorder, in which manic and depressive symptoms are either mixed or switch rapidly, and forms of borderline personality disorder in which affective lability is a prominent symptom.

METHODS

A MedLine search was conducted of articles that focused on rapid cycling in bipolar disorder, emphasizing recent publications (2001-2004).

RESULTS

Studies examined here suggest a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. We propose a model for the development of 'borderline' behaviors on the basis of unstable mood states that sheds light on how the psychological and somatic interventions may be aimed at 'breaking the cycle' of borderline personality disorder development. A review of pharmacologic studies suggests that anticonvulsants may have similar stabilizing effects in both borderline personality disorder and rapid cycling bipolar disorder.

CONCLUSIONS

The same mechanism may drive both the rapid mood switching in some forms of bipolar disorder and the affective instability of borderline personality disorder and may even be rooted in the same genetic etiology. While continued clinical investigation of the use of anticonvulsants in borderline personality disorder is needed, anticonvulsants may be useful in the treatment of this condition, combined with appropriate psychotherapy.

Rapid cycling bipolar disorder: historical overview and focus on emerging treatments

OBJECTIVE

Rapid cycling bipolar disorder presents a significant challenge with respect to treatment. The cyclical nature of bipolar disorder has been well recognised for over a century, and following Dunner and Fieve's landmark paper in 1974, investigators have increasingly turned their attention to issues such as the definition of rapid cycling, demographic characterisation, treatment response and pharmacologic intervention.

METHODS

A literature search using Medline was performed, and selected articles which consider important developments in the definition, demographics and course of rapid cycling are reviewed. In addition, a systematic review of the literature published during the past 5 years (1999-2004) relating to treatment was conducted.

RESULTS

Relevant articles are reviewed.

CONCLUSIONS

This review highlights the important developments in our understanding of rapid cycling bipolar disorder, and focuses particularly on the recent literature regarding treatment.

Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders

Until recently it was believed that no more than 1% of the general population has bipolar disorder. Emerging transatlantic data are beginning to provide converging evidence for a higher prevalence of up to at least 5%. Manic states, even those with mood-incongruent features, as well as mixed (dysphoric) mania, are now formally included in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of bipolar patients over a lifetime; current evidence supports a broader definition of mixed states consisting of full-blown mania with two or more concomitant depressive symptoms. The largest increase in prevalence rates, however, is accounted for by 'softer' clinical expressions of bipolarity situated between the extremes of full-blown bipolar disorder where the person has at least one manic episode (bipolar I) and strictly defined unipolar major depressive disorder without personal or family history for excited periods. Bipolar II is the prototype for these intermediary conditions with major depressions and history of spontaneous hypomanic episodes; current evidence indicates that most hypomanias pursue a recurrent course and that their usual duration is 1-3 days, falling below the arbitrary 4-day cutoff required in DSM-IV. Depressions with antidepressant-associated hypomania (sometimes referred to as bipolar III) also appear, on the basis of extensive international research neglected by both ICD-10 and DSM-IV, to belong to the clinical spectrum of bipolar disorders. Broadly defined, the bipolar spectrum in studies conducted during the last decade accounts for 30-55% of all major depressions. Rapid-cycling, defined as alternation of depressive and excited (at least four per year), more often arise from a bipolar II than a bipolar I baseline; such cycling does not in the main appear to be a distinct clinical subtype - but rather a transient complication in 20% in the long-term course of bipolar disorder. Major depressions superimposed on cyclothymic oscillations represent a more severe variant of bipolar II, often mistaken for borderline or other personality disorders in the dramatic cluster. Moreover, atypical depressive features with reversed vegetative signs, anxiety states, as well as alcohol and substance abuse comorbidity, is common in these and other bipolar patients. The proper recognition of the entire clinical spectrum of bipolarity behind such 'masks' has important implications for psychiatric research and practice. Conditions which require further investigation include: (1) major depressive episodes where hyperthymic traits - lifelong hypomanic features without discrete hypomanic episodes - dominate the intermorbid or premorbid phases; and (2) depressive mixed states consisting of few hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-blown major depressive episodes - included in Kraepelin's schema of mixed states, but excluded by DSM-IV. These do not exhaust all potential diagnostic entities for possible inclusion in the clinical spectrum of bipolar disorders: the present review did not consider cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden, intermittently explosive or agitated psychiatric conditions for which the bipolar connection is less established. The concept of bipolar spectrum as used herein denotes overlapping clinical expressions, without necessarily implying underlying genetic homogeneity. In the course of the illness of the same patient, one often observes the varied manifestations described above - whether they be formal diagnostic categories or those which have remained outside the official nosology. Some form of life charting of illness with colored graphic representation of episodes, stressors, and treatments received can be used to document the uniquely varied course characteristic of each patient, thereby greatly enhancing clinical evaluation.

Seasonality of manic depressive illness in Canada

OBJECTIVE

The objective of the study was to determine if a seasonal pattern existed for hospital admissions of manic depressive illness to a Ontario provincial psychiatric hospital.

METHOD

Admission records were reviewed for the 75 year period of the study. In the analysis factors including: mood state on admission, gender and the influence of psychotropic medications were considered.

RESULTS

For mania and depression there was no statistically significant seasonal pattern of admissions. For mixed state admissions peaked in the summer.

CONCLUSIONS

The results of this study contradict the seasonal pattern traditionally reported in the literature. The limitations of this study, which include changes in diagnostic criteria over time and admission date not identical to onset of affective episode, need to be acknowledged.

Rapid-cycling bipolar disorder. An overview of research and clinical experience

Although many studies of RCBD have been reported over the last 2 decades, knowledge remains limited. Higher incidence in women is the sole clearly replicated finding in most studies. This finding might be mediated by cyclothymia, a temperament that is of higher prevalence in women and that might be considered as a normal variant of RC. Many questions remain unanswered. Review of putative risk factors, such as hypothyroidism and treatment with antidepressants, provides no conclusive answers. There is clinical evidence to implicate both factors. In principle, the thyroid connection can be approached rationally, yet there seems to be no relationship between thyroid status and response to thyroid augmentation. For this reason and given the potential risks of long-term thyroid use, this strategy should not be the first one to be tried in RC. Cumulatively, naturalistic studies over the past 30 years have strongly implicated antidepressants in switching and cycle acceleration, yet the double-blind, controlled, prospective studies that are needed to provide definitive answers are unlikely to be conducted for ethical reasons discussed in this article. Bipolar family history of RC probands appears indistinguishable from non-RC probands, indicating that most likely RCBD does not breed true. Although RC seems to be more lithium resistant with less likelihood of being symptom-free after 2 to 5 years of follow-up, many of these patients nonetheless have resolution of the RC course. There is no marked difference in suicide rates. An association of RC with bipolar type II, D-M-I pattern and those who switch into mania or hypomania on antidepressants is a provocative possibility: Antidepressants might introduce RC by first inducing a switch during a depressive episode, creating a D-M-I pattern, a pattern that is poorly responsive to lithium, which eventually degenerates into RC. Again, this sequence might be mediated by the high prevalence of cyclothymia in bipolar II patients. Thus, data from phenomenology, family history, and long-term outcome do not support RC as a separate entity. RC appears to be a temporary complicated phase in the illness, not a stable feature. This was noted by Kraepelin: I think I am convinced that that kind of classification must of necessity wreck on the irregularity of the disease. The kind and duration of the attacks and the intervals by no means remain the same in the individual case but may frequently change, so that the case must be reckoned always to new forms. Data by Gottschalk et al testify to the chaotic mood swings of contemporary bipolar disorder. Moreover RC is seen in other medical diseases, such as epilepsy, in which patients have phases of increase in frequency of episodes (seizures) that become refractory to treatment. Further longitudinal prospective studies are required to understand the complexity of this intriguing phenomenon and to provide better treatments. Algorithms deriving from tertiary research or university-based clinical experience may not generalize to RC or otherwise treatment-resistant bipolar patients seen in more routine practice. Illness severity in RCBD generally precludes double-blind controlled investigations. Meanwhile, clinicians may rely on discontinuing antidepressants, maintaining patients on combined mood stabilizers--of which valproate is probably the most useful--and making judicious use of atypical neuroleptics. Benzodiazepines and alcohol (which produce withdrawal), caffeine, stimulants, exposure to bright light, and sleep deprivation during excited phases should be avoided. Thyroid and nimodipine augmentation can be considered in those with the most malignant course. These are patients who need the maximal support that their psychiatrist can provide them. Office visits must be arranged as the last appointment of the day.

Treatment of rapidly cycling bipolar patient by using extended bed rest and darkness to stabilize the timing and duration of sleep

BACKGROUND

The modern practice of using artificial light to extend waking activities into the nighttime hours might be expected to precipitate or exacerbate bipolar illness, because it has been shown that modifying the timing and duration of sleep can induce mania in susceptible individuals. With this possibility in mind, we treated a patient with rapidly cycling bipolar illness by creating an environment that was likely to increase and to stabilize the number of hours that he slept each night.

METHODS

We asked the patient to remain at bed rest in the dark for 14 hours each night (later this was gradually reduced to 10 hours). Over a period of several years, his clinical state was assessed with twice-daily self-ratings, once-weekly observer ratings, and continuous wrist motor activity recordings. Times of sleeping and waking were recorded with sleep logs, polygraphic recordings, and computer-based event recordings.

RESULTS

The patient cycled rapidly between depression and mania and experienced marked fluctuations in the timing and duration of sleep when he slept according to his usual routine, but his sleep and mood stabilized when he adhered to a regimen of long nightly periods of enforced bed rest in the dark.

CONCLUSIONS

Fostering sleep and stabilizing its timing by scheduling regular nightly periods of enforced bed rest in the dark may help to prevent mania and rapid cycling in bipolar patients.

Bipolar disorder in adult patients with Tourette's syndrome: a clinical study

BACKGROUND

Although recent clinical and epidemiological studies indicate that Tourette's syndrome (TS) is associated with a higher than expected rate of bipolar disorder (BPD), the clinical characteristics of BPD in patients with TS have not been widely investigated.

METHODS

Thirty adult TS patients with comorbid BPD were selected from a consecutive series of 90 referred TS patients and examined using structured psychiatric rating scales.

RESULTS

The full clinical spectrum of BPD was found, including bipolar I disorder, schizoaffective bipolar disorder, bipolar II disorder, and cyclothymic disorder. Atypical vegetative depressive symptoms, rapid cycling patterns, and seasonal patterns of recurrence were also documented. In the present clinical sample, BPD mainly occurred in patients with mild tic symptoms and was invariably associated with a high lifetime prevalence of general psychopathology, including generalized anxiety disorder, obsessive-compulsive disorder, panic, phobias, eating disorders, self-injurious behavior, attention-deficit hyperactivity disorder, impulse control disorders, and personality disorders.

CONCLUSIONS

The results of this clinical study indicate that BPD and nonaffective psychopathology may be prominent comorbid disorders in a subpopulation of patients with TS.

Clinical definitions of sensitisation in affective disorder: a case register study of prevalence and prediction

The observation of a progressive recurrence in affective disorder has been interpreted as a process of sensitisation. The clinical applicability of such a theoretical model was investigated using the Danish case register, which includes all hospital admissions with primary affective disorder in Denmark from 1971 to 1993. A total of 8,737 patients admitted to a psychiatric hospital at least twice constituted the study sample. Information on treatment intervention was not available. Measures describing the initial course of admission episodes were defined in three different ways: 1) a short period between initial episodes 2) decreasing intervals between initial episodes or 3) a combination of 1) and 2). Socio-demographic variables such as gender, age at onset and marital status differentiated between the three types of measures and the measures also demonstrated different effects in predicting the risk of further recurrence. In unipolar disorder, patients with a decreasing interval between episodes had the greatest risk of further recurrence, whereas for bipolar patients, a short period between episodes played a more important role than the sequence of episodes in itself.

Management of suicidal behavior in children and adolescents

Many therapeutic approaches to managing suicidal behavior among youth have been used, including in-school education programs, screening programs, telephone hotlines, cognitive behavioral therapies, medication management, and inpatient milieux treatment programs. These interventions have been applied based on educational and therapeutic principles drawn from prior work with adolescents in varied scholastic and psychiatric settings. This article reviews: the assessment of risk factors among suicide attempters, emotional states, family, social isolation, interpersonal loss, substance and alcohol abuse, and treatment strategies.

Rapid-cycling affective disorder in the elderly: clinical subtype or specific course of manic-depressive illness?

Rapid cycling is a relatively unusual presentation of bipolar affective disorder in the elderly. Four cases or rapid-cycling affective disorder (RCAD) in elderly women (aged 78-86 yr) are presented. Two patients began their bipolar illness in adulthood (aged 30 and 49 yr), and rapid cycles appeared secondarily in their elderly years (82 and 76 yr). The other two began their illness immediately with rapid cycles respectively at the age of 62 and 66. Added to the nine cases of RCAD in the elderly previously reported in the literature, a meta-analysis conducted on this small sample suggests that immediate entry in rapid cycles seems more likely to be associated with a late occurrence of bipolar illness (after 60 years of age)(P = .0035, Fisher's Exact Test, two-tailed), and that very short cycles (< 2 weeks each) are more likely to be associated with female gender (P = .0047, Fisher's Exact Test, two-tailed). Despite the small size of the sample, these results give some arguments to the hypothesis that RCAD is not a homogeneous syndrome but could be considered as a pattern of evolution, as well as clinical subtype, of the bipolar illness.

Ultra-rapid and ultradian cycling in bipolar affective illness

BACKGROUND

Rapid-cycling bipolar disorder is defined as four or more affective episodes yearly. The conventionally recognised limit in episode duration is usually considered 24 hours (i.e. a cycle duration of 48 hours). We report a small series of intensively observed bipolar patients who showed much faster patterns of mood oscillation.

METHODS

Detailed, systematic, longitudinal assessment of five bipolar patients during extended in-patient psychiatric evaluation were conducted, including retrospective life charting and prospective evaluation of daily mood by self and blinded observer ratings, and motor activity recording.

RESULTS

Our data demonstrate a spectrum of cycling frequencies in rapid-cyclers, including distinct, clinically robust mood shifts that occur at frequencies faster than once per 24 hours. Affective oscillations spanned a range of cycling frequencies from four episodes per year (rapid cycling) to those occurring within the course of weeks to several days (ultra-rapid cycling), to distinct, abrupt mood shifts of less than 24 hours duration (ultra-ultra rapid or ultradian cycling). The time of onset and duration of these ultradian affective fluctuations are highly variable and they are observed in bipolar patients without evidence of personality disorder.

CONCLUSIONS

The potential clinical and theoretical implications of these first systematic observations of ultra-rapid and ultradian cycling in the context of the evolution of otherwise classical bipolar affective illness are discussed.

Effect of tricyclic antidepressants on switching to mania and on the onset of bipolarity in depressed 6- to 12-year-olds

The authors present data on the rates of onset of bipolar phenomena, at 2- to 3-year follow-up, in depressed 6- to 12-year olds. The subjects had participated in the nortriptyline drug study. There were high rates of onset of bipolarity and of switching to mania while patients were on tricyclic antidepressants (TCAs). Mania developed only in subjects who had received TCAs at some time in the past or were receiving them concurrent with the onset of mania. These findings were analyzed with respect to the influence of multiple covariates, including family history of manic disorders and pubertal status. The authors discuss the implications of these findings for the prescription of TCAs to children who present with major depressive disorder and have a family history of bipolarity or a history of bipolar symptoms. The relevance of these findings for the later development of rapid cycling is discussed and compared with predictors of rapid cycling in adults.

Cyclical self-injurious behavior, contingent water mist treatment, and the possibility of rapid-cycling bipolar disorder

Cyclical self-injurious behavior (SIB) in the form of self-slapping was treated in a 45-year-old, profoundly retarded woman who had a life-long history of SIB. Her SIB alternated between high (mean = 8.54 responses per min; SD = 6.77 and low (mean = 0.05 responses per min; SD = 0.20) frequencies every 8 weeks on average. Instances of self-slapping produced water mist treatment paired with a verbal command, "No hitting". Absence of self-slapping and/or completion of a work task led to a variety of outcomes, including brief back rubs, sips of water, small edibles, and praise. Water mist treatment reduced the frequency of SIB within treatment days during high frequency periods, but produced no reduction across treatment days. Treatment onset was associated with a slight increase in the frequency of SIB during three of the five low frequency periods. However, water mist treatment suppressed SIB completely in sessions during low frequency periods and the suppression continued across treatment days. Water mist treatment produced no discernible changes in the length of the high and low frequency periods of SIB.

Lithium alone or in combination with carbamazepine for the treatment of rapid-cycling bipolar affective disorder

The authors retrospectively examined the clinical outcome (after 1, 2 and 5 years of beginning the therapeutic protocols) for 16 rapid-cycling bipolar affective disorder patients given either lithium alone or lithium plus carbamazepine. The results suggest that both therapeutic protocols have been safe and clinically effective. However, improvement was observed earlier in the patients given lithium and carbamazepine.