Stress reactivity in bipolar patients and its relation to prior history of disorder

Resilience and Attachment in Patients with Major Depressive Disorder and Bipolar Disorder

BACKGROUND

Resilience represents one of the fundamental elements of attachment and has often been investigated in mood disorders. This study aims to investigate possible correlations between attachment and resilience in patients with major depressive disorder (MDD) and bipolar disorder (BD).

METHODS

106 patients (51 MDD, 55 BD) and 60 healthy controls (HCs) were administered the 21-item Hamilton Depression Rating Scale (HAM-D-21), the Hamilton Anxiety Rating Scale (HAM-A), the Young Mania Rating Scale (YMRS), the Snaith-Hamilton Pleasure Scale (SHAPS), the Barratt Impulsiveness Scale-11 (BIS-11), the Toronto Alexithymia Scale (TAS), the Connor-Davidson Resilience Scale (CD-RISC), and Experiences in Close Relationship (ECR).

RESULTS

MDD and BD patients did not significantly differ from each other according to the HAM-D-21, HAM-A, YMRS, SHAPS, and TAS, while they scored higher than HCs on all these scales. Patients in the clinical group scored significantly lower on CD-RISC resilience than HCs (p < 0.01). A lower proportion of secure attachment was found among patients with MDD (27.4%) and BD (18.2%) compared to HCs (90%). In both clinical groups, fearful attachment prevailed (39.2% patients with MDD; 60% BD).

CONCLUSIONS

Our results highlight the central role played by early life experiences and attachment in participants with mood disorders. Our study confirms the data from previous research showing a significant positive correlation between the quality of attachment and the development of resilience capacity, and supports the hypothesis that attachment constitutes a fundamental aspect of resilience capacity.

Dynamic interplay between life events and course of psychotic disorders: 10-year longitudinal study following first admission

BACKGROUND

Life events (LEs) are a risk factor for first onset and relapse of psychotic disorders. However, the impact of LEs on specific symptoms - namely reality distortion, disorganization, negative symptoms, depression, and mania - remains unclear. Moreover, the differential effects of negative v. positive LEs are poorly understood.

METHODS

The present study utilizes an epidemiologic cohort of patients (N = 428) ascertained at first-admission for psychosis and followed for a decade thereafter. Symptoms were assessed at 6-, 24-, 48-, and 120-month follow-ups.

RESULTS

We examined symptom change within-person and found that negative events in the previous 6 months predicted an increase in reality distortion (β = 0.07), disorganized (β = 0.07), manic (β = 0.08), and depressive symptoms (β = 0.06), and a decrease in negative symptoms (β = -0.08). Conversely, positive LEs predicted fewer reality distortion (β = -0.04), disorganized (β = -0.04), and negative (β = -0.13) symptoms, and were unrelated to mood symptoms. A between-person approach to the same hypotheses confirmed that negative LEs predicted change in all symptoms, while positive LEs predicted change only in negative symptoms. In contrast, symptoms rarely predicted future LEs.

CONCLUSIONS

These findings confirm that LEs have an effect on symptoms, and thus contribute to the burden of psychotic disorders. That LEs increase positive symptoms and decrease negative symptoms suggest at least two different mechanisms underlying the relationship between LEs and symptoms. Our findings underscore the need for increased symptom monitoring following negative LEs, as symptoms may worsen during that time.

Association between lifetime and recent stressful life events and the early course and psychopathology in patients with newly diagnosed bipolar disorder, first-degree unaffected relatives and healthy controls: Cross-sectional results from a prospective study

OBJECTIVE

There is an accumulation of stressful life events prior to the first mood episode, but the impact of previous severe life events on psychopathology in patients with bipolar disorder (BD) is not well studied. We aimed to examine the number of recent and lifetime life events in patients with newly diagnosed BD, their unaffected relatives (UR), and healthy controls (HC) as well as the impact of severe lifetime life events on the early course of BD.

METHODS

We compared the number of recent and lifetime life events in 398 patients with newly diagnosed BD, 109 UR, and 214 HC. We subsequently dichotomized the patients with BD by >2 lifetime life events to investigate the associations of severe lifetime life events with clinical characteristics and affective symptoms.

RESULTS

Patients with newly diagnosed BD reported significantly more life events in the last 12 months and lifetime before compared with UR and HC. Patients who reported >2 lifetime life events (n = 160) compared with patients with 0-2 life events (n = 238) had a significantly longer diagnostic delay (9.5 years ± 8.2 vs. 6.2 years ± 6.9), presented with more anxiety and depressive symptoms and had at least one previous suicide attempt (30.6% vs. 15.6%) and one previous admission (51.3% vs. 36.6%).

CONCLUSION

The experience of severe lifetime life events seems to impact the early course in BD in terms of longer diagnostic delay, more severe psychopathology including more admissions and a more than doubled risk for previous suicide attempts.

The promising fNIRS: Uncovering the function of prefrontal working memory networks based on multi-cognitive tasks

The diversity of cognitive task paradigms using functional near-infrared spectroscopy (fNIRS) and the lack of theoretical explanations for these functional imaging atlases have greatly hindered the application of fNIRS in psychiatry. The fNIRS brain imaging based on multiple cognitive tasks could generally reflect the working patterns and neurovascular coupling changes in the prefrontal working memory network. By alternating the stimulation patterns of resting and task states, six typical symptom-related functional brain imaging waveforms related to psychiatric disorders are identified and three joint networks of the prefrontal working memory, namely, the attentional working memory primary coordination network, the perceptual content working memory secondary network, and the emotional-behavioral working memory executive network, are initially represented. This is the first attempt to characterize the cognitive, emotional, and behavioral regulation of the prefrontal working memory network using fNIRS, which may promote the application of fNIRS in clinical settings.

Psychological factors in personal and clinical recovery in bipolar disorder

BACKGROUND

Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy.

METHODS

This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months.

RESULTS

107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes.

LIMITATIONS

Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample.

CONCLUSIONS

Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

Exercise is medicine: a new perspective for health promotion in bipolar disorder

INTRODUCTION

Similar effects in reducing the symptoms of the mood disorder are reported in the literature compared the action of drugs and aerobic exercise sessions, demonstrating the potential of exercise in the control and mood stabilization. Therefore, there are many reasons to believe that the increased cardiorespiratory fitness (VO_2max) can be an important means of protection and a reducing potential of physical and mental damage in bipolar disorders (BD). This review will highlight the current pattern of response of exercise on the pathophysiology of BD, relating the possible mechanisms, and hypotheses based on exercises.

AREAS COVERED

The mechanism of monoaminergic action and its relationship with exercise, role of physical conditioning and increased VO_2Max on neurotrophin release, and new perspectives on long-term exercise will be reviewed.

EXPERT OPINION

The adaptations to training, although little explored in the context of BD, can induce the expression of substances that co-regulate several processes related to the pathophysiology of BD. Furthermore, high intensity interval training (HIIT) can also be adjusted to improve the physical fitness and health in patients with BD. Future research is needed to adopt a training strategy that is both time efficient and adequate for the population in question.

Role of KCNQ potassium channels in stress-induced deficit of working memory

The prefrontal cortex (PFC) mediates higher cognition but is impaired by stress exposure when high levels of catecholamines activate calcium-cAMP-protein kinase A (PKA) signaling. The current study examined whether stress and increased cAMP-PKA signaling in rat medial PFC (mPFC) reduce pyramidal cell firing and impair working memory by activating KCNQ potassium channels. KCNQ2 channels were found in mPFC layers II/III and V pyramidal cells, and patch-clamp recordings demonstrated KCNQ currents that were increased by forskolin or by chronic stress exposure, and which were associated with reduced neuronal firing. Low dose of KCNQ blockers infused into rat mPFC improved cognitive performance and prevented acute pharmacological stress-induced deficits. Systemic administration of low doses of KCNQ blocker also improved performance in young and aged rats, but higher doses impaired performance and occasionally induced seizures. Taken together, these data demonstrate that KCNQ channels have powerful influences on mPFC neuronal firing and cognitive function, contributing to stress-induced PFC dysfunction.

Psychological Distress Symptoms Associated With Life Events in Patients With Bipolar Disorder: A Cross-Sectional Study

Stressful life events, although less serious than traumatic experiences, affect the clinical course of patients with bipolar disorder. We previously found that bipolarity in patients with major depression is related to the severity of psychological distress symptoms associated with onset-related events. Here, we investigated whether, and to what extent, bipolar patients perceive stressful events as psychological distress symptoms, specifically, intrusion, avoidance, and hyperarousal. Further, we investigated the relationship between the clinical features and the severity of psychological distress symptoms associated with stressful life events, according to mood states. We recruited 79 bipolar patients (depression group, n = 32; mania, n = 22; euthymia, n = 25) in this cross-sectional study. We adopted the Impact of Event Scale-Revised (IES-R) to assess the severity of psychological distress symptoms associated with past stressful events. We also evaluated the Hamilton Depression Rating Scale (HDRS) and the Young Mania Rating Scale (YMRS). The mean (standard deviation) IES-R scores of bipolar patients with a depressive episode (38.06 [16.56], p = 0.0005) and of those with a manic/hypomanic episode (44.56 [24.14], p = 0.004) were significantly higher than of those with euthymia (19.81 [12.86]). The HDRS, but not the YMRS, scores showed significant correlations with the IES-R scores, regardless of mood episodes (depression group, r = 0.42; mania, r = 0.64; euthymia, r = 0.70). This study demonstrates that bipolar patients with a manic/hypomanic or depressive episode perceive stressful life events as more severe psychological distress symptoms than do euthymic patients. Moreover, in patients with bipolar disorder, the severity of depressive symptoms, but not of manic symptoms, is positively correlated with that of the psychological distress symptoms, regardless of their mood episodes or euthymic state. Therefore, depressive symptoms may be closely related to the psychological distress symptoms associated with stressful past events in patients with bipolar disorder.

Kindling of Life Stress in Bipolar Disorder: Effects of Early Adversity

Most theoretical frameworks regarding the role of life stress in bipolar disorders (BD) do not incorporate the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. The kindling hypothesis theorizes that over the longitudinal course of recurrent affective disorders, the relationship between major life stressors and episode initiation declines (Post, 1992). The present study aimed to test an extension of the kindling hypothesis in BD by examining the effect of early life adversity on the relationship between proximal life events and prospectively assessed mood episodes. Data from 145 bipolar participants (59.3% female, 75.2% Caucasian, and mean age of 20.19 years; SD = 1.75 years) were collected as part of the Temple-Wisconsin Longitudinal Investigation of Bipolar Spectrum Project (112 Bipolar II; 33 Cyclothymic disorder). Participants completed a self-report measure of early adversity at baseline and interview-assessed mood episodes and life events at regular 4-month follow-ups. Results indicate that early childhood adversity sensitized bipolar participants to the effects of recent stressors only for depressive episodes and not hypomanic episodes within BD. This was particularly the case with minor negative events. The current study extends prior research examining the kindling model in BD using a methodologically rigorous assessment of life stressors and mood episode occurrence. Clinicians should assess experiences of early adversity in individuals with BD as it may impact reactivity to developing depressive episodes in response to future stressors.

Prevention of recurrent affective episodes using extinction training in the reconsolidation window: A testable psychotherapeutic strategy

Stressors may initially precipitate affective episodes, but with sufficient numbers of recurrences, episodes can occur more autonomously. It is postulated the memory engram for these recurrent depressions moves from the conscious representational memory system to the unconscious habit memory system encoded in the striatum. If this were the case, cognitive behavior therapy targeted toward extinction of habit memories could be an effective maneuver for helping reverse the automaticity of affective episode recurrence. Extinction training in the reconsolidation window (which opens about 5min to 1h after active memory recall) can revise, reverse, or eliminate the long term memories associated with PTSD and other anxiety disorders and with drug abuse craving. We hypothesize that similar cognitive behavioral work in the reconsolidation window could inhibit stress-induced and spontaneous affective episodes. Some initial formulations of possible therapeutic strategies are presented and discussed, as well as caveats. It is hoped that preliminary exposition of this theoretical approach to recurrences in the affective disorders based on principles dependent on work in the reconsolidation window will lead to more detailed elaboration of the therapeutic maneuvers most likely to be successful and ones that can be specifically tested for their clinical efficacy.

Cav1.2 channels mediate persistent chronic stress-induced behavioral deficits that are associated with prefrontal cortex activation of the p25/Cdk5-glucocorticoid receptor pathway

Chronic stress is known to precipitate and exacerbate neuropsychiatric symptoms, and exposure to stress is particularly pathological in individuals with certain genetic predispositions. Recent genome wide association studies have identified single nucleotide polymorphisms (SNPs) in the gene CACNA1C, which codes for the Ca_v1.2 subunit of the L-type calcium channel (LTCC), as a common risk variant for multiple neuropsychiatric conditions. Ca_v1.2 channels mediate experience-dependent changes in gene expression and long-term synaptic plasticity through activation of downstream calcium signaling pathways. Previous studies have found an association between stress and altered Ca_v1.2 expression in the brain, however the contribution of Ca_v1.2 channels to chronic stress-induced behaviors, and the precise Ca_v1.2 signaling mechanisms activated are currently unknown. Here we report that chronic stress leads to a delayed increase in Ca_v1.2 expression selectively within the prefrontal cortex (PFC), but not in other stress-sensitive brain regions such as the hippocampus or amygdala. Further, we demonstrate that while Ca_v1.2 heterozygous (Ca_v1.2^+/−) mice show chronic stress-induced depressive-like behavior, anxiety-like behavior, and deficits in working memory 1–2 days following stress, they are resilient to the effects of chronic stress when tested 5–7 days later. Lastly, molecular studies find a delayed upregulation of the p25/Cdk5-glucocorticoid receptor (GR) pathway in the PFC when examined 8 days post-stress that is absent in Ca_v1.2^+/− mice. Our findings reveal a novel Ca_v1.2-mediated molecular mechanism associated with the persistent behavioral effects of chronic stress and provide new insight into potential Ca_v1.2 channel mechanisms that may contribute to CACNA1C-linked neuropsychiatric phenotypes.

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Can anxiety damage the brain?

PURPOSE OF REVIEW

Stress exacerbates mental illnesses such as depression but also appears to increase risk of dementia, suggesting a common mechanism for development of stress-induced affective and cognitive impairment. The purpose of this review is to address the question of whether anxiety 'damages' the brain, and to identify potential mechanisms for the link between stress and neuropsychiatric illness.

RECENT FINDINGS

Anxiety disorders are associated with alterations in fear neurocircuitry such that 'bottom-up' processes in the amygdala which respond to threat are exaggerated, and regulation of these processes by the prefrontal cortex (PFC) and hippocampus is impaired. Chronic stress exposure similarly alters fear neurocircuitry by enhancing amygdalar functioning while causing structural degeneration in the PFC and hippocampus thereby inhibiting PFC/hippocampus control over the stress response. Pharmacological (e.g., antidepressant medications) and nonpharmacological interventions (cognitive-behavioral therapy, exercise) may reverse stress-induced damage in the brain.

SUMMARY

Pathological anxiety and chronic stress lead to structural degeneration and impaired functioning of the hippocampus and the PFC, which may account for the increased risk of developing neuropsychiatric disorders, including depression and dementia. Longitudinal studies are needed to determine whether reversal of stress-induced brain changes by interventions such as cognitive-behavioral therapy can reduce risk of neuropsychiatric illness.

Stress weakens prefrontal networks: molecular insults to higher cognition

A variety of cognitive disorders are worsened by stress exposure and involve dysfunction of the newly evolved prefrontal cortex (PFC). Exposure to acute, uncontrollable stress increases catecholamine release in PFC, reducing neuronal firing and impairing cognitive abilities. High levels of noradrenergic α1-adrenoceptor and dopaminergic D1 receptor stimulation activate feedforward calcium-protein kinase C and cyclic AMP-protein kinase A signaling, which open potassium channels to weaken synaptic efficacy in spines. In contrast, high levels of catecholamines strengthen the primary sensory cortices, amygdala and striatum, rapidly flipping the brain from reflective to reflexive control of behavior. These mechanisms are exaggerated by chronic stress exposure, where architectural changes lead to persistent loss of PFC function. Understanding these mechanisms has led to the successful translation of prazosin and guanfacine for treating stress-related disorders. Dysregulation of stress signaling pathways by genetic insults likely contributes to PFC deficits in schizophrenia, while age-related insults initiate interacting vicious cycles that increase vulnerability to Alzheimer's degeneration.

The role of life events and psychological factors in the onset of first and recurrent mood episodes in bipolar offspring: results from the Dutch Bipolar Offspring Study

BACKGROUND

Life events are an established risk factor for the onset and recurrence of unipolar and bipolar mood episodes, especially in the presence of genetic vulnerability. The dynamic interplay between life events and psychological context, however, is less studied. In this study, we investigated the impact of life events on the onset and recurrence of mood episodes in bipolar offspring, as well as the effects of temperament, coping and parenting style on this association.

METHOD

Bipolar offspring (n = 108) were followed longitudinally from adolescence to adulthood. Mood disorders were assessed with: the Kiddie Schedule of Affective Disorders and Schizophrenia - Present and Lifetime Version or the Structured Clinical Interview for DSM-IV Axis I disorders; life events with the Life Events and Difficulties Schedule; and psychological measures using the Utrecht Coping List, Temperament and Character Inventory and short-EMBU (memories of upbringing instrument). Anderson-Gill models (an extension of the Cox proportional hazard model) were utilized.

RESULTS

Life events were associated with an increased risk for first and, although less pronounced, subsequent mood episodes. There was a large confounding effect for the number of previous mood episodes; findings suggest a possible kindling effect. Passive coping style increased the risk of mood episode onset and recurrent episodes, but also altered the effect of life events on mood disorders. Harm avoidance temperament was associated with mood episode recurrence.

CONCLUSIONS

Life events are especially a risk factor in the onset of mood disorders, though less so in recurrent episodes. Psychological features (passive coping and harm-avoidant temperament) contribute to the risk of an episode occurring, and also have a moderating effect on the association between life events and mood episodes. These findings create potential early intervention strategies for bipolar offspring.

Contributions of the social environment to first-onset and recurrent mania

In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.

The influence of life events on first and recurrent admissions in bipolar disorder

Background

Life events play an important role in the onset and course of bipolar disorder. We will test the influence of life events on first and recurrent admissions in bipolar disorder and their interaction to test the kindling hypothesis.

Methods

We collected information about life events and admissions across the life span in 51 bipolar patients. We constructed four models to explore the decay of life event effects on admissions. To test their interaction, we used the Andersen-Gill model.

Results

The relationship between life events and admissions was best described with a model in which the effects of life events gradually decayed by 25% per year. Both life event load and recurrent admissions significantly increased the risk of both first and subsequent admissions. No significant interaction between life event load and number of admissions was found.

Conclusions

Life events increase the risk of both first and recurrent admissions in bipolar disorder. We found no significant interaction between life events and admissions, but the effect of life events on admissions decreases after the first admission which is in line with the kindling hypothesis.

Resilience and impulsivity in euthymic patients with bipolar disorder

BACKGROUND

Stress plays an important role in the onset and recurrence of bipolar disorder (BD). Resilience is the ability to cope with stress or adversity. Few studies have examined resilience in BD, and this study aimed to investigate the clinical correlates of resilience in euthymic patients with BD.

METHODS

A total of 62 outpatients with BD type I, II, and not otherwise specified (NOS) who were in remission and 62 healthy individuals matched with the BD group in terms of age and sex were recruited. All participants completed the Connor-Davidson Resilience Scale and Barratt Impulsiveness Scale. A psychiatrist interviewed the subjects to assess clinical characteristics. Multiple linear regression analysis was used to determine factors associated with resilience.

RESULTS

The BD group had significantly higher levels of impulsivity and lower levels of resilience compared with the control group. Degree of impulsivity, number of depressive episodes, Clinical Global Impression (CGI) scores, and length of education were significantly correlated with resilience. Attention impulsivity, non-planning impulsivity, and number of depressive episodes were associated with low levels of resilience, even when age, sex, length of education, and CGI scores were controlled.

LIMITATIONS

Because tertiary hospital patients were recruited, the generalizability of the findings is limited.

CONCLUSIONS

This study shows that low levels of resilience are related to high levels of impulsivity and to an increased number of depressive episodes in euthymic patients with BD. Given the reciprocal relationship between resilience and impulsivity, efforts to enhance resilience and reduce impulsivity may make important contributions to the treatment of patients with BD.

Stressful life events in bipolar I and II disorder: cause or consequence of mood symptoms?

BACKGROUND

Life events are assumed to be triggers for new mood episodes in bipolar disorder (BD). However whether life events may also be a result of previous mood episodes is rather unclear.

METHOD

173 bipolar outpatients (BD I and II) were assessed every three months for two years. Life events were assessed by Paykel׳s self-report questionnaire. Both monthly functional impairment due to manic or depressive symptomatology and mood symptoms were assessed.

RESULTS

Negative life events were significantly associated with both subsequent severity of mania and depressive symptoms and functional impairment, whereas positive life events only preceded functional impairment due to manic symptoms and mania severity. These associations were significantly stronger in BD I patients compared to BD II patients. For the opposite temporal direction (life events as a result of mood/functional impairment), we found that mania symptoms preceded the occurrence of positive life events and depressive symptoms preceded negative life events.

LIMITATIONS

The use of a self-report questionnaire for the assessment of life events makes it difficult to determine whether life events are cause or consequence of mood symptoms. Second, the results can only be generalized to relatively stable bipolar outpatients, as the number of severely depressed as well as severely manic patients was low.

CONCLUSIONS

Life events appear to precede the occurrence of mood symptoms and functional impairment, and this association is stronger in BD I patients. Mood symptoms also precede the occurrence of life event, but no differences were found between BD I and II patients.

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.

Role of disrupted in schizophrenia 1 (DISC1) in stress-induced prefrontal cognitive dysfunction

Recent genetic studies have linked mental illness to alterations in disrupted in schizophrenia 1 (DISC1), a multifunctional scaffolding protein that regulates cyclic adenosine monophosphate (cAMP) signaling via interactions with phosphodiesterase 4 (PDE4). High levels of cAMP during stress exposure impair function of the prefrontal cortex (PFC), a region gravely afflicted in mental illness. As stress can aggravate mental illness, genetic insults to DISC1 may worsen symptoms by increasing cAMP levels. The current study examined whether viral knockdown (KD) of the Disc1 gene in rat PFC increases susceptibility to stress-induced PFC dysfunction. Rats were trained in a spatial working memory task before receiving infusions of (a) an active viral construct that knocked down Disc1 in PFC (DISC1 KD group), (b) a 'scrambled' construct that had no effect on Disc1 (Scrambled group), or (c) an active construct that reduced DISC1 expression dorsal to PFC (Anatomical Control group). Data were compared with an unoperated Control group. Cognitive performance was assessed following mild restraint stress that had no effect on normal animals. DISC1 KD rats were impaired by 1  h restraint stress, whereas Scrambled, Control, and Anatomical Control groups were unaffected. Thus, knocking down Disc1 in PFC reduced the threshold for stress-induced cognitive dysfunction, possibly through disinhibited cAMP signaling at neuronal network synapses. These findings may explain why patients with DISC1 mutations may be especially vulnerable to the effects of stress.

Life events and the onset of celiac disease from a patient's perspective

Stressful events have been investigated in various immune-mediated diseases but not in celiac disease. Our aim was to examine the relationship of stressful events assessed by the standardized interview of Paykel with the diagnosis of celiac disease in comparison to patients, with a diagnosis of gastroesophageal reflux disease used as the control group. Adults with celiac disease (n = 186) reported more frequent and more severe life events in the years prior to the diagnosis than control patients (n = 96) (67.2% vs. 37.5%, p < 0.001, mean Paykel score 11.5 vs. 13.4, p = 0.001, respectively). Findings were not significantly different between celiac disease and control patients for the time lapse between the event and the diagnosis (mean 5.5 vs. 5.7 months). Pregnancy was defined as a negative event by 20.3% of celiac women, but never by control women. Findings were confirmed when analyses were repeated in the subgroup of patients of both groups with diagnosis made within one year of onset of symptoms. Data indicate that, before diagnosis, the number of stressful events in celiac disease was more frequent although less severe than in the control group suggesting that life events may favor the clinical appearance of celiac disease or accelerate its diagnosis.

Redox dysregulation in the pathophysiology of schizophrenia and bipolar disorder: insights from animal models

SIGNIFICANCE

Schizophrenia (SZ) and bipolar disorder (BD) are classified as two distinct diseases. However, accumulating evidence shows that both disorders share genetic, pathological, and epidemiological characteristics. Based on genetic and functional findings, redox dysregulation due to an imbalance between pro-oxidants and antioxidant defense mechanisms has been proposed as a risk factor contributing to their pathophysiology.

RECENT ADVANCES

Altered antioxidant systems and signs of increased oxidative stress are observed in peripheral tissues and brains of SZ and BD patients, including abnormal prefrontal levels of glutathione (GSH), the major cellular redox regulator and antioxidant. Here we review experimental data from rodent models demonstrating that permanent as well as transient GSH deficit results in behavioral, morphological, electrophysiological, and neurochemical alterations analogous to pathologies observed in patients. Mice with GSH deficit display increased stress reactivity, altered social behavior, impaired prepulse inhibition, and exaggerated locomotor responses to psychostimulant injection. These behavioral changes are accompanied by N-methyl-D-aspartate receptor hypofunction, elevated glutamate levels, impairment of parvalbumin GABA interneurons, abnormal neuronal synchronization, altered dopamine neurotransmission, and deficient myelination.

CRITICAL ISSUES

Treatment with the GSH precursor and antioxidant N-acetylcysteine normalizes some of those deficits in mice, but also improves SZ and BD symptoms when given as adjunct to antipsychotic medication.

FUTURE DIRECTIONS

These data demonstrate the usefulness of GSH-deficient rodent models to identify the mechanisms by which a redox imbalance could contribute to the development of SZ and BD pathophysiologies, and to develop novel therapeutic approaches based on antioxidant and redox regulator compounds.

Beyond the baby blues: perspectives of women diagnosed with a mood disorder on children, pregnancy and medication

OBJECTIVE

The aim of this study was to explore the views of women diagnosed with a mood disorder about children, medication and pregnancy.

METHOD

Female patients from the Black Dog Institute were invited to complete a questionnaire regarding their views about pregnancy, children and medication during pregnancy. Diagnostic groupings were derived by assessing DSM-IV criteria for mood disorders. Unipolar and bipolar patient responses were analysed to determine any differences between groups.

RESULTS

Women with bipolar disorder were more concerned than those with a unipolar condition about the impact pregnancy would have on their mood, as well as the potential for their offspring to inherit a mood condition. Both groups of women expressed concerns regarding the child-rearing environment, and stated that knowing the risk their child could have of developing a mood disorder would encourage them to be more vigilant parents.

CONCLUSION

While both groups were concerned about the environment in which they would raise their child and wanted to be vigilant parents, women diagnosed with a bipolar condition expressed stronger opinions regarding the impact that their pregnancy could have on their mood disorder, and passing the mood disorder onto their children.

Subthreshold symptoms and time to relapse/recurrence in a community cohort of bipolar disorder outpatients

BACKGROUND

Researchers have previously found that persistent subthreshold symptoms increase the risk and shorten the time until an affective relapse in bipolar disorder (BD) patients. Research has mainly focused on patients from tertiary Care Centers in USA. We tested the hypothesis that even in a different setting, BD outpatients with subsyndromal affective symptoms would re.turn to a subsequent major affective episode significantly faster than completely asymptomatic at baseline. Secondarily, we analysed other variables related to time and risk to relapse.

METHODS

A community cohort of BD outpatients from Madrid (Spain) followed-up in a systematic prospective follow-up protocol for up to five years were evaluated. Patients in clinical euthymia at baseline were included and evaluated quarterly.

RESULTS

Initially, 225 patients were included in the survival analysis. Of them, according to predefined psychometric criteria, 163 were in euthymia (72.4%) and 62 (27.6%) suffered subsyndromal symptoms. Median follow-up was 157.6 weeks (95% CI, 78.14 to 111); 57.3% of patients experienced at least one affective episode during their follow-up. Median survival time to first affective episode was 109 weeks for patients in euthymia at baseline, versus 35 weeks for those with subsyndromal symptoms (p<0.0001). Psychosocial stress (p=0.003; HR 2.20; 95% CI 1.31-3.68) and the affective mood baseline state, subsyndromal vs. euthymic (p=0.046; HR 1.74; 95%CI 1.009-3.020), were related to time to first affective episode.

LIMITATIONS

Naturalistic study, some of the data collected were necessarily retrospective.

CONCLUSIONS

In Spanish non-tertiary psychiatric outpatients, subsyndromal BD symptoms and psychosocial stress at baseline predict earlier episode relapse/recurrence.

Thermotherapy to the facial region in and around the eyelids altered prefrontal hemodynamic responses and autonomic nervous activity during mental arithmetic

To investigate neural mechanisms of local thermotherapy to reduce mental stress, participants were required to perform mental arithmetic after treatment by a heat- and steam-generating sheet on the facial eyelid region while hemodynamic activity and ECGs were monitored. The results indicated that thermotherapy decreased hemodynamic activity in the anterior dorsomedial prefrontal cortex (aDMPFC) involved in sympathetic activity. Consistently, thermotherapy increased parasympathetic activity while it decreased sympathetic activity. Furthermore, thermotherapy increased hemodynamic activity in the dorsolateral prefrontal cortex (DLPFC) during mental arithmetic. These hemodynamic responses in the DLPFC during mental arithmetic were negatively correlated with that in the aDMPFC during thermotherapy. The results suggest that thermotherapy in the facial eyelid region is useful to ameliorate mental fatigue through its effects on the prefrontal cortex.

From stress to postpartum mood and anxiety disorders: how chronic peripartum stress can impair maternal adaptations

The peripartum period, in all mammalian species, is characterised by numerous adaptations at neuroendocrine, molecular and behavioural levels that prepare the female for the challenges of motherhood. These changes have been well characterised and, while they are necessary to ensure the survival and nurturance of the offspring, there is growing belief that they are also required for maternal mental health. Thus, while increased calmness and attenuated stress responsivity are common characteristics of the peripartum period, it also represents a time of increased susceptibility to mood disorders. While a number of risk factors for these disorders are known, their underlying aetiology remains poorly understood, due at least in part to a lack of appropriate animal models. One translatable risk factor is stress exposure during the peripartum period. In the following review we first describe common peripartum adaptations and the impact postpartum mood disorders have on these. We then discuss the known consequences of peripartum stress exposure on such maternal adaptations that have been described in basic research.

Glucocorticoid receptors in the prefrontal cortex regulate stress-evoked dopamine efflux and aspects of executive function

Enhanced dopamine efflux in the prefrontal cortex is a well-documented response to acute stress. However, the underlying mechanism(s) for this response is unknown. Using in vivo microdialysis, we demonstrate that blocking glucocorticoid receptors locally within the rat prefrontal cortex results in a reduction in stress-evoked dopamine efflux. In contrast, blocking glucocorticoid receptors in the ventral tegmental area did not affect stress-evoked dopamine efflux in the prefrontal cortex. Additionally, local administration of corticosterone into the prefrontal cortex increased prefrontal dopamine efflux. The functional impact of enhanced dopamine efflux evoked by acute stress was demonstrated using a cognitive task dependent on the prefrontal cortex and sensitive to impairment in working memory. Notably, stress-induced impairments in cognition were attenuated by blockade of glucocorticoid receptors in the prefrontal cortex. Taken together, these data demonstrate that glucocorticoids act locally within the prefrontal cortex to modulate mesocortical dopamine efflux leading to the cognitive impairments observed during acute stress.

Molecular modulation of prefrontal cortex: rational development of treatments for psychiatric disorders

Dysfunction of the prefrontal cortex (PFC) is a central feature of many psychiatric disorders, such as attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), schizophrenia, and bipolar disorder. Thus, understanding molecular influences on PFC function through basic research in animals is essential to rational drug development. In this review, we discuss the molecular signaling events initiated by norepinephrine and dopamine that strengthen working memory function mediated by the dorsolateral PFC under optimal conditions, and weaken working memory function during uncontrollable stress. We also discuss how these intracellular mechanisms can be compromised in psychiatric disorders, and how novel treatments based on these findings may restore a molecular environment conducive to PFC regulation of behavior, thought and emotion. Examples of successful translation from animals to humans include guanfacine for the treatment of ADHD and related PFC disorders, and prazosin for the treatment of PTSD.

Stressful life events predict delayed functional recovery following treatment for mania in bipolar disorder

Identifying predictors of functional recovery in bipolar disorder is critical to treatment efforts to help patients re-establish premorbid levels of role adjustment following an acute manic episode. The current study examined the role of stressful life events as potential obstacles to recovery of functioning in various roles. 65 patients with bipolar I disorder participated in a longitudinal study of functional recovery following clinical recovery from a manic episode. Stressful life events were assessed as predictors of concurrent vs. delayed recovery of role functioning in 4 domains (friends, family, home duties, work/school). Despite clinical recovery, a subset of patients experienced delayed functional recovery in various role domains. Moreover, delayed functional recovery was significantly associated with presence of one or more stressors in the prior 3 months, even after controlling for mood symptoms. Presence of a stressor predicted longer time to functional recovery in life domains, up to 112 days in work/school. Interventions that provide monitoring, support, and problem-solving may be needed to help prevent or mitigate the effects of stress on functional recovery.

A randomised controlled trial of carer-focussed multi-family group psychoeducation in bipolar disorder

In a RCT of family psychoeducation, 47 carers of 34 patients were allocated to one of three groups; Multifamily Group Psychoeducation, Solution Focussed Group Therapy or Treatment as Usual. Carers in both the MFGP intervention and the SFGP arm demonstrated greater knowledge and reduction in burden than those in the TAU arm.

Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories

Most life stress literature in bipolar disorder (BD) fails to account for the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. According to Post's (1992) influential kindling hypothesis, major life stress is required to trigger initial onsets and recurrences of affective episodes, but successive episodes become progressively less tied to stressors and may eventually occur autonomously. Subsequent research on kindling has largely focused on unipolar depression (UD), and the model has been tested in imprecise and inconsistent ways. The aim of the present paper is to evaluate evidence for the kindling model as it applies to BD. We first outline the origins of the hypothesis, the evidence for the model in UD, and the issues needing further clarification. Next, we review the extant literature on the changing relationship between life stress and bipolar illness over time, and find that evidence from the methodologically strongest studies is inconsistent with the kindling hypothesis. We then integrate this existing body of research with two emerging biopsychosocial models of BD: the Behavioral Approach System dysregulation model, and the circadian and social rhythm theory. Finally, we present therapeutic implications and suggestions for future research.

Increased rates of events that activate or deactivate the behavioral approach system, but not events related to goal attainment, in bipolar spectrum disorders

Research indicates that life events involving goal attainment and goal striving trigger hypomania/mania and that negative life events trigger bipolar depression. These findings are consistent with the behavioral approach system (BAS) dysregulation model of bipolar disorders, which suggests that individuals with bipolar disorders are hypersensitive to cues signaling opportunity for reward and cues signaling failure and loss of rewards. However, no studies to date have investigated whether individuals with bipolar spectrum disorders experience increased rates of these BAS-relevant life events, which would place them at double risk for developing bipolar episodes. The present study found that individuals with bipolar II disorder and cyclothymia experience increased rates of BAS-activating and BAS-deactivating, but not goal-attainment, life events. Finally, for bipolar spectrum individuals only, BAS-activating events predicted BAS-deactivating events' rates.

Lay theories of bipolar disorder: the causes, manifestations and cures for perceived bipolar disorder

This study aimed to investigate lay theories of the cause and treatment of bipolar disorder, and the recognition of its symptoms. This questionnaire-based study included vignette descriptions of mental disorders and 70 items relating to bipolar disorder. It was completed by 173 participants. Bipolar disorder was recognized less than depression but at the same rate as schizophrenia. Contrary to previous research, analysis showed that lay beliefs of the causes of bipolar disorder generally concur with scientific academic theories. Drug treatment was favoured as a cure rather than psychotherapy. Theories of cause and treatment were logically correlated. Overall, the results suggest that lay people have reasonably informed beliefs about the causes and treatments of bipolar disorder, however recognition of the symptoms is poor.

Acute psychological stress reduces working memory-related activity in the dorsolateral prefrontal cortex

BACKGROUND

Acute psychological stress impairs higher-order cognitive function such as working memory (WM). Similar impairments are seen in various psychiatric disorders that are associated with higher susceptibility to stress and with prefrontal cortical dysfunctions, suggesting that acute stress may play a potential role in such dysfunctions. However, it remains unknown whether acute stress has immediate effects on WM-related prefrontal activity.

METHODS

Using functional magnetic resonance imaging (fMRI), we investigated neural activity of 27 healthy female participants during a blocked WM task (numerical N-back) while moderate psychological stress was induced by viewing strongly aversive (vs. neutral) movie material together with a self-referencing instruction. To assess stress manipulation, autonomic and endocrine, as well as subjective, measurements were acquired throughout the experiment.

RESULTS

Successfully induced acute stress resulted in significantly reduced WM-related activity in the dorsolateral prefrontal cortex (DLPFC), and was accompanied by less deactivation in brain regions that are jointly referred to as the default mode network.

CONCLUSIONS

This study demonstrates that experimentally induced acute stress in healthy volunteers results in a reduction of WM-related DLPFC activity and reallocation of neural resources away from executive function networks. These effects may be explained by supraoptimal levels of catecholamines potentially in conjunction with elevated levels of cortisol. A similar mechanism involving acute stress as a mediating factor may play an important role in higher-order cognitive deficits and hypofrontality observed in various psychiatric disorders.

Stress signalling pathways that impair prefrontal cortex structure and function

The prefrontal cortex (PFC) - the most evolved brain region - subserves our highest-order cognitive abilities. However, it is also the brain region that is most sensitive to the detrimental effects of stress exposure. Even quite mild acute uncontrollable stress can cause a rapid and dramatic loss of prefrontal cognitive abilities, and more prolonged stress exposure causes architectural changes in prefrontal dendrites. Recent research has begun to reveal the intracellular signalling pathways that mediate the effects of stress on the PFC. This research has provided clues as to why genetic or environmental insults that disinhibit stress signalling pathways can lead to symptoms of profound prefrontal cortical dysfunction in mental illness.

Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions

This article reviews the role of social factors, notably life events and family relationships, in the course of bipolar illness in adults and youth. We also discuss psychological variables that help explain the vulnerability of bipolar patients to social environments, including personality factors (e.g., neuroticism), reward sensitivity, and difficulty with the accurate perception of facial emotions. Bipolar patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment events may be one pathway to mania. Negative life events predict depressive symptoms, as do levels of familial expressed emotion. Psychosocial interventions can speed recoveries from episodes and delay recurrences over 1-2 year intervals. Future research should examine the nature of vulnerability/stress interactions at different phases of development, and the role of psychosocial interventions in altering these processes.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.

Early intervention in bipolar disorders: clinical, biochemical and neuroimaging imperatives

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

[Emotional reactivity in euthymic bipolar patients]

BACKGROUND

Euthymic states in bipolar disorders are usually considered to be lacking serious psychiatric disorders. Moreover, recent results prove the need to take an interest in a potential emotional dysregulation during these intercrisis periods. Therefore, it seems relevant not only to focus on the emotions tonality (sadness/euphoria) felt by patients, but also on the intensity of their emotional background. Several reasons argue for a disturbance of emotional reactivity in euthymic bipolar patients. First, most bipolar patients spontaneously claim they have a higher sensitivity than average, which may lead to extreme emotional reactions, even during intercrisis periods. Secondly, the emotional reactivity is a way to raise the question of the bipolar patients' vulnerability to stress in euthymic periods. Several studies have shown the impact of stressful life events on the rate of relapse into bipolar disorders. The aim of this study is to examine the emotional reactivity of euthymic bipolar patients in comparison with a control group, using a test of emotional induction. Our hypothesis is that euthymic bipolar patients have a higher emotional reactivity than controls.

METHOD

One hundred and forty-five subjects were recruited: 90 controls and 55 euthymic bipolar patients. The patients were interviewed by a trained psychologist using the French version of the DIGS providing DSM-IV diagnosis. The euthymic state was confirmed with both MADRS (score<12) and Bech's Manic Scale (score<4). The subjective emotional reactivity of the subjects was assessed using a method of emotional induction, based on viewing a set of 18 (positive, negative or neutral) pictures. The subjects have to appreciate the valence (pleasant, neutral or unpleasant thoughts) and assess the arousal (degree of emotion triggered by each picture).

RESULTS

On average, euthymic bipolar patients report the same valence and arousal to positive (F [1.143]=0.18, p=0.68) and negative (F [1.143]=0.52, p=0.47) pictures as control subjects. Neutral pictures, however, were considered more pleasant and moving by euthymic bipolar patients than by control subjects (F [1.143]=8.40, p=0.004).

CONCLUSION

Euthymic bipolar patients seem to present an emotional hyperactivity which occurs especially in neutral situations. These results partly corroborate outcomes of other authors, while providing a new methodology through the emotional induction test. The highlight of emotional hyperreactivity during intercrisis periods allows us to understand differently the topic of specific vulnerability to stress of bipolar patients. This hypersensitivity could lead to thymic decompensations and could be linked with an emotional dysregulation, potential endophenotype of the bipolar pathology. Beyond the interest in understanding the physiopathology of the bipolar disorder, it could be associated with several clinical applications as well as in the psychoeducational field and in the screening of the individual risk within the family of bipolar subjects.

[Specific aspects of treatment for women with bipolar affliction]

This manuscript summarizes specific issues in the disease course and pharmacological treatment of women with bipolar disorders. Gender differences relevant to the female biology manifest in symptoms, outcome, and course. The preponderance of depressive symptoms is typical, and the risk of rapid cycling is estimated to be eight times higher for women than for men. Comorbid anxiety and eating disorders occur more frequently in female patients. In planning treatment it is important to take fertility, contraception, and pregnancy into consideration and adjust the pharmacotherapy to harmonize with the patient's current phase of life. Little is known about potential sexual dysfunctions of bipolar women. Further research should include clinical and observational studies focusing on gender-specific differences in symptomatology, treatment, and long-term outcome of bipolar disorders.

Emotional hyper-reactivity in normothymic bipolar patients

BACKGROUND

Normothymic states in bipolar disorders are generally considered to be devoid of severe symptoms. However, bipolar patients present subsyndromal symptoms for half of their lives, and often have comorbid psychiatric disorders. If we go beyond the concept of temperamental features, can we identify certain emotional characteristics distinguishing normothymic bipolar patients from normal controls? We previously showed, using self-completed questionnaires, that normothymic bipolar patients display higher levels of emotional lability and intensity than controls.

OBJECTIVES

The aim of this study was to assess the emotional reactivity of normothymic bipolar patients, comparing such patients with a normal control group during an experimental mood induction procedure.

METHOD

We evaluated the subjective emotional reactivity of 145 subjects (90 control subjects and 55 normothymic bipolar patients), using an emotional induction method based on the viewing of a set of 18 pictures (6 positive, 6 negative, 6 neutral) extracted from the International Affective Picture System. Subjective valence and arousal were recorded with the Self-Assessment Manikin. We also recorded startle reflexes, triggered by a tone occurring during the viewing of two-thirds of the pictures. We controlled for confounding factors, such as concurrent treatments, in all analyses.

RESULTS

Normothymic bipolar patients and normal controls assessed valence and arousal similarly for positive and negative images. However, neutral images were considered more pleasant [F(1,143) = 8.4; p = 0.004] and induced a higher level of arousal [F(1,143) = 12.3; p = 0.001] in normothymic bipolar patients than in control subjects. Neutral pictures also triggered a stronger startle reflex in normothymic bipolar patients compared to controls [F(3,123) = 3.1; p = 0.03].

CONCLUSION

Normothymic bipolar patients displayed emotional hyper-reactivity, mostly evidenced in neutral situations. This feature may be linked to emotional dysregulation and is a potential endophenotype and/or a risk factor for bipolar disorders. This trait may be responsible for vulnerability to minor stressful events in everyday life. These findings have potential implications for the daily management of bipolar disorder between crises.

Ameliorating prefrontal cortical dysfunction in mental illness: inhibition of phosphotidyl inositol-protein kinase C signaling

BACKGROUND

Bipolar disorder and schizophrenia are associated with profound dysfunction of the prefrontal cortex (PFC), with bipolar disorder most associated with changes in ventromedial PFC and schizophrenia more associated with changes in dorsolateral PFC.

DISCUSSION

Recent genetic and biochemical studies have also linked these illnesses to disinhibition of phosphotidyl inositol-protein kinase C signaling. For example, DAG kinase eta, an enzyme that metabolizes DAG and thus reduces protein kinase C activity, is the gene most altered in bipolar disorder. Similarly, regulator of G protein signaling 4 is the molecule most altered in the PFC of patients with schizophrenia, and this molecule normally serves to inhibit Gq signaling. Animal studies have shown that high levels of phosphotidyl inositol-protein kinase C signaling in the PFC markedly impair PFC function at the behavioral and cellular levels. Most importantly, many effective medications for bipolar disorder and schizophrenia inhibit phosphotidyl inositol-protein kinase C signaling, either through intracellular actions (lithium, valproate) or through extracellular blockade of receptors coupled to this pathway (5HT2 receptors and alpha-1 adrenoceptors). Recent data suggest that lithium and valproate can protect gray matter in patients with bipolar disorder. These findings encourage the development of protein kinase C inhibitors for the treatment of mental illness.

Stressful life events in older bipolar patients

OBJECTIVE

Theories about the impact of stressful life events (SLE) in bipolar disorder have focused on their role early in the disease. Few studies have examined SLE in older bipolar patients. We wanted to assess the impact of SLE in late life bipolar disorder

METHODS

We evaluated negative SLE experienced by older bipolar subjects compared with younger bipolar subjects and older controls for number, type, and their association with phase of illness, age of onset, and previous episodes.

RESULTS

Both younger and older bipolar subjects have more SLE than similarly aged controls. There was no significant difference in the number of stressors that younger and older bipolar subjects experienced, based on mood state, previous episodes, or age-of-onset. Both older and younger depressed bipolar subjects reported more SLE in the previous 12 months compared with those in a manic state.

CONCLUSIONS

Negative SLE are much more prevalent in bipolar patients compared with age-matched controls, and continue to be frequent in later life.

Implementing clinical guidelines for bipolar disorder

PURPOSE

To critically review the evidence concerning the implementation of clinical guidelines for bipolar disorder.

METHODS

A Medline search was made of the literature on the implementation of guidelines in bipolar disorder and mental health. The implementation of non-pharmacological treatments from the 2006 NICE Guideline for Bipolar Disorder was then used as a case example. May's model of normalization of complex interventions was then applied to the NICE guideline recommendations for bipolar disorder.

RESULTS

The effective local implementation of guidelines requires a detailed understanding of local barriers to their implementation. Some recommendations in the NICE Guideline on advanced directives and management of anxiety disorder in bipolar disorder appear to follow the existing trends in practice and are more likely to be implemented. Interventions concerning the psychological management of bipolar depression and maintenance psychological treatments are going to be the most difficult to implement because of shortages of skilled staff, the absence of specific training and supervision, the requirements for staff to adopt practices that are quite different from what they are used to, and some uncertainty about whether these interventions are effective in the most severe patients.

CONCLUSIONS

Without a detailed local understanding of the barriers to implementation and the resources and will to overcome them, there is likely to be a considerable local variation in the implementation of guidelines for bipolar disorder. Recommendations that require little change to working practices and resources are most likely to be implemented.

Molecular mechanisms of stress-induced prefrontal cortical impairment: implications for mental illness

The symptoms of mental illness often involve weakened regulation of thought, emotion, and behavior by the prefrontal cortex. Exposure to stress exacerbates symptoms of mental illness and causes marked prefrontal cortical dysfunction. Studies in animals have revealed the intracellular signaling pathways activated by stress exposure that induce profound prefrontal cortical impairment: Excessive dopamine stimulation of D1 receptors impairs prefrontal function via cAMP intracellular signaling, leading to disconnection of prefrontal networks, while excessive norepinephrine stimulation of alpha1 receptors impairs prefrontal function via phosphatidylinositol-protein kinase C intracellular signaling. Genetic studies indicate that the genes disrupted in serious mental illness (bipolar disorder and schizophrenia) often encode for the intracellular proteins that serve as brakes on the intracellular stress pathways. For example, disrupted in schizophrenia 1 (DISC1) normally regulates cAMP levels, while regulator of G protein signaling 4 (RGS4) and diacylglycerol kinase (DGKH)-the molecule most associated with bipolar disorder- normally serve to inhibit phosphatidylinositol-protein kinase C intracellular signaling. Patients with mutations resulting in loss of adequate function of these genes likely have weaker endogenous regulation of these stress pathways. This may account for the vulnerability to stress and the severe loss of PFC regulation of behavior, thought, and affect in these illnesses. This review highlights the signaling pathways onto which genetic vulnerability and stress converge to impair PFC function and induce debilitating symptoms such as thought disorder, disinhibition, and impaired working memory.

Dysregulation of the behavioral approach system (BAS) in bipolar spectrum disorders: review of theory and evidence

In recent years, a call for increased research on bipolar disorder has been answered with methodologically diverse studies exploring goal striving, life events, cognitive style, decision-making, and neurobiological abnormalities in bipolar disorder. In order to further this spurt of research and to systematize our understanding of bipolar disorder, an integrative perspective is warranted. The behavioral approach system (BAS) dysregulation theory, proposed by Richard Depue and colleagues, provides such an integrated model for understanding psychosocial and biological aspects of bipolar disorder. In this paper, we review studies on life events, cognitive style and other psychosocial and neurobiological factors to examine whether the BAS dysregulation theory is supported by existing data. Then, we draw on recent advances in the study of emotion and motivation, and propose an expansion of the BAS dysregulation model of bipolar spectrum disorders to foster further biopsychosocial investigations of bipolar disorder. This expanded model provides greater specificity in predictions, especially about the nature of BAS dysregulation, environmental factors and psychological processes (e.g., appraisal processes) featured in a causal chain culminating in bipolar symptoms. Finally, we discuss the implications of the expanded BAS model for the course of bipolar spectrum disorders.