Psychologically stressful events in the precipitation of manic episodes

The Occurrence of Funeral Mania After Bereavement: A Case Report

Stressful or traumatic life events can lead to emergence of mood episodes. Events such as migration, relocation, job loss, bankruptcy, economic loss, divorce, natural disasters, accidental injury, or the loss of a loved one can trigger the first episode of bipolar disorder. After such life events, symptoms of depressive episodes often appear. Funeral mania, on the other hand, is defined as the emergence of manic episodes following the death of a close family member. Information on funeral mania, which occurs shortly after the loss of a loved one, is limited with a few case reports. In this study, a 26-year-old female patient who presented with the symptoms of a manic episode for the first time after her father’s death and who had no previous psychiatric disease or treatment history was presented in the light of findings in the literature. It is noteworthy that the patient, who was followed up with the diagnosis of bipolar disorder (mania period) according to DSM-5 diagnostic criteria, had a temporal closeness between her mood symptoms and her father’s death, and had not developed such a reaction to previous traumatic life events. Therefore, the diagnosis was evaluated as funeral mania. It should be kept in mind that, although rare, symptoms of mania can be seen among possible grief reactions.

An Acute Manic Episode During 2019-nCoV Quarantine

BACKGROUND

The 2019-nCov pandemic is currently a stressor for the general public worldwide. In China, people who have a history of contact with infected or suspected individuals need to quarantine for at least 2 weeks. Many people experienced anxiety, panic and depression in the quarantine period. However, acute manic episode triggered by stressful events is not common and was neglected.

CASE PRESENTATION

A 32-year-old woman with direct contact history with her infected colleagues showed elevated mood and increased activity when she was identified negative of nuclear acid amplification test, after experiencing extreme stress in quarantine. She was diagnosed with acute manic episode finally. The social zeitgeber and reward hypersensitivity theoretical models have attempted to use psychobiological perspectives to determine why life stress can trigger a mood episode, including (hypo)mania. Besides, the temporal correlation between her somatic symptoms and psychological stimuli indicated a possibility of functional disturbance under acute stress.

CONCLUSION

Quarantine is a major stressful event disrupting social zeitgebers for people who have had contact with infected individuals, especially for vulnerable individuals with a hypersensitive reward system. Stress could act as a trigger in the onset of manic episode, so psychological support should be more targeted at the vulnerable individuals in the initial phase of emergent crisis.

A systematic review and meta-analysis of the prevalence of bipolar disorder among homeless people

Background

Bipolar disorder (BD) is a common severe mental disorder among homeless people and is associated with an increased risk of disability and mortality from suicide, medical causes (including HIV/AIDS, hepatitis infection, hypertension, and tuberculosis), as well as substance use disorders. However, a systematic synthesis of the existing evidence on the subject is lacking. To fill this gap in the literature, this study aimed to carry out systematic review and meta-analysis to determine the consolidated prevalence of BD among homeless people.

Methods

In this systematic review and meta-analysis, we searched Embase, PubMed, and Scopus to identify pertinent studies that reported the prevalence of BD among homeless people in March 2019. Random effect meta-analysis was employed to pool data from the eligible studies. Subgroup and sensitivity analysis was conducted and Cochran’s Q- and the I² test were utilized to quantify heterogeneity. Publication bias was assessed by using Egger’s test and visual inspection of the symmetry in funnel plots.

Results

Of 3236 studies identified, 10 studies with 4300 homeless individuals were included in the final analysis. Among the 10 studies, five studies used the Diagnostic Statistical Manual of Mental disorders (DSM), three studies used Mini-International Neuropsychiatric Interview (MINI), one study used Schedule for Clinical Assessment of Neuropsychiatry (SCAN), and one study used Composite International Neuropsychiatric Interview (CIDI) to assess BD among homeless individuals. Based on the results of the random effect model, the prevalence of BD among homeless people was 11.4% (95% CI; 7.5–16.9). The prevalence of BD was 10.0% (95% CI; 3.1–27.9) in Europe and it was 13.2% (95% CI; 8.9–19.3) in other countries. Moreover, the prevalence of BD was 11.5% (95% CI; 5.5–22.3) for studies that used DSM to assess BD and it was 11.0% (95% CI; 6.1–19.2) for studies that used other instruments (MINI, SCAN, and CIDI).

Conclusion

Our meta-analysis demonstrated that BD is highly prevalent among homeless individuals, underlying the importance of early screening and targeted interventions for BD among homeless individuals.

Novel Treatment Targets Based on Insights in the Etiology of Depression: Role of IL-6 Trans-Signaling and Stress-Induced Elevation of Glutamate and ATP

Inflammation and psychological stress are risk factors for major depression and suicide. Both increase central glutamate levels and activate the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Both factors also affect the function of the chloride transporters, Na-K-Cl-cotransporter-1 (NKCC1) and K-Cl-cotransporter-2 (KCC2), and provoke interleukin-6 (IL-6) trans-signaling. This leads to measurable increases in circulating corticosteroids, catecholamines, anxiety, somatic and psychological symptoms, and a decline in cognitive functions. Recognition of the sequence of pathological events allows the prediction of novel targets for therapeutic intervention. Amongst others, these include blockade of the big-K potassium channel, blockade of the P2X4 channel, TYK2-kinase inhibition, noradrenaline α2B-receptor antagonism, nicotinic α7-receptor stimulation, and the Sgp130Fc antibody. A better understanding of downstream processes evoked by inflammation and stress also allows suggestions for tentatively better biomarkers (e.g., SERPINA3N, MARCKS, or ¹³C-tryptophan metabolism).

Stressful Life Events and Relapse in Bipolar Affective Disorder: A Cross-Sectional Study from a Tertiary Care Center of Southern India

BACKGROUND

Bipolar affective disorder (BAD) is a severe mental illness which results in serious lifelong struggles and challenges. The full impact of stressful life events (SLEs) on the course of BAD is poorly understood.

MATERIALS AND METHODS

A cross-sectional study was conducted on 128 consecutive patients with BAD currently admitted with a relapse. Our objectives were (1) to estimate the proportion, type, and timing of preonset SLEs in relapsed BAD patients and (2) to study the association between SLEs and selected clinical variables in this group. Semi-structured proforma, Young Mania Rating Scale, Hamilton Rating Scale for Depression, Presumptive Stressful Life Events Scale, and Brief Psychiatric Rating Scale were used. Statistical analysis was done using R software for Windows.

RESULTS

About 69.5% (89/128) of patients reported preonset SLEs - among which 50 (56.2%) had mania and 39 (43.8%) had depression. Conflict with in-laws and financial problems were the commonly reported SLEs. The mean duration between SLEs and the relapse was 19.73 ± 4.8 days. BPRS score was significantly high in subjects with preonset SLEs (P = 0.022). No significant association was detected between SLEs and the type of episode during relapse (P = 0.402).

CONCLUSION

This study emphasizes the significance of SLEs in the relapse and longitudinal course of BAD. Understanding the association of SLEs and relapse in BAD will help in predicting further relapses and developing newer pharmacological and nonpharmacological measures targeting this aspect, thereby maximizing both symptom reduction and quality of life in patients with BAD.

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.

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.

The prevalence and effect of life events in 222 bipolar I and II patients: a prospective, naturalistic 4 year follow-up study

BACKGROUND

Life events may very well increase the likelihood of affective episodes in bipolar disorder, but prospective data on survival are inconsistent.

METHODS

The authors examined the prevalence of negative and goal-attainment life events within 6 months prior to the index episode and after the index episode and their impact on the risk of relapse. Two hundred twenty-two consecutively admitted ICD-10 bipolar I (n=126) and II (n=96) patients were followed-up naturalistically over a period of 4 years.

RESULTS

One-hundred thirty-eight (62.2%) of the patients had at least one life event 6 month before the index episode. Seventy patients (31.5%) experienced one, 48 (21.6%) two, and 20 (9.0%) three (or more) life events. Regarding life events after the index episode, 110 (49.5%) patients had at least one life event. Fifty-four patients (24.3%) experienced one, 31 (14.0%) two, and 25 (11.3%) three (or more) life events. The number of life events was larger in patients with bipolar II disorder than in patients with bipolar I disorder (p=0.004). Using a Cox regression analysis, the risk of a depressive relapse in bipolar I patients was associated with the number of life events after the index episode (p=0.002). This was independent of the quality of the life event.

LIMITATIONS

Standardized life event scales, defined dosages of drugs or blood sampling during all visits were not performed.

CONCLUSIONS

Our data suggest a high and continuous number of life events prior to affective episodes. Life events after the index episode worsened the course of bipolar I patients with more depressive episodes. This underlines the importance of detection and treatment of emerging life events.

Life-event specificity: bipolar disorder compared with unipolar depression

BACKGROUND

Little is known about the impact of different types of stressful events (for example divorce v. bereavement) on unipolar depression compared with bipolar disorder. Inconsistencies exist concerning the association between independent events (beyond an individual's control, such as bereavement) and bipolar disorder.

AIMS

To examine the role of specific, independent and dependent events in mood disorders.

METHOD

Life-event information was collected from 512 people with bipolar disorder, 1448 people with unipolar depression and over 600 controls.

RESULTS

Various events were associated with unipolar depression and bipolar disorder, but some event specificity was detected. For example, financial crisis was more strongly related to bipolar disorder rather than unipolar depression. Independent events were only related to unipolar depression and not bipolar disorder.

CONCLUSIONS

The events that were linked to bipolar disorder and unipolar depression were similar. Independent events were not associated with bipolar episodes, suggesting that life stress may be a consequence of, rather than a trigger for, bipolar episodes.

The precipitants of manic/hypomanic episodes in the context of bipolar disorder: a review

BACKGROUND

Mania/hypomania is the hallmark feature of bipolar disorder. This paper aims to review the current evidence in relation to factors hypothesised to precipitate bipolar mania/hypomania, and suggest areas for future research.

METHODS

A selective review of original and review papers was conducted. The electronic databases 'PsycINFO' and 'PubMed' were searched using the following search strings: "bipolar disorder" or "mania" or "hypomania" or "manic-depression" with "triggers" or "precipitants" or "precedents" or "predictors".

RESULTS

There is evidence that goal attainment events, antidepressant medication, disrupted circadian rhythms, spring/summer seasonal conditions, and more tentatively, stressful life events and high emotional expression, may precipitate bipolar mania/hypomania in susceptible individuals. Evidence from case reports and clinical observations are also reported.

DISCUSSION

The pathways to bipolar mania/hypomania may be many and varied, and many of these pathways may be outside the awareness of individuals with bipolar disorder. Greater awareness of the broad number of precipitating factors is needed to inform self-management and psycho-educational programs to build resilience to further episodes. Future research is needed to explore what other factors may precipitate bipolar mania/hypomania, and to determine why some factors may precipitate mania/hypomania in some individuals with bipolar I or II disorder but not in others.

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.

Adverse life event reporting and worst illness episodes in unipolar and bipolar affective disorders: measuring environmental risk for genetic research

BACKGROUND

Studies exploring gene-environment interplay in affective disorders now include very large numbers of participants. Methods for evaluating the role of adversity in such studies need to be developed that do not rely on lengthy and labour-intensive interviews. In the present study, a brief questionnaire method for measuring 11 adverse events reported before interview and before their worst illness episodes by bipolar, unipolar and healthy control participants, participating in genetic association studies, was evaluated.

METHOD

Five hundred and twelve bipolar disorder (BD) participants, 1447 participants with recurrent unipolar depression (UPD) and 1346 psychiatrically healthy control participants underwent the researcher-administered version of the List of Threatening Experiences Questionnaire (LTE-Q) for the 6 months before their worst affective episodes for UPD and BD participants, and for the 6 months before interview for the UPD participants and controls.

RESULTS

UPD and BD cases were significantly more likely to report at least one event, as well as more events in the 6 months before interview and before their worst illness episodes, than healthy controls. Both manic and depressive episodes were significantly associated with adverse events in the BD cases. Depressed mood at the time of interview influenced event reporting in UPD and control participants but not the BD cases. Age was negatively correlated with the number of events reported by controls.

CONCLUSIONS

The researcher-administered LTE-Q provides a measure of case-control differences for adversity that is applicable in large genetic association studies. Confounding factors for event reporting include present mood and age.

Does gene deletion of AMPA GluA1 phenocopy features of schizoaffective disorder?

Glutamatergic dysfunction is strongly implicated in schizophrenia and mood disorders. GluA1 knockout (KO) mice display schizophrenia- and depression-related abnormalities. Here, we asked whether GluA1 KO show mania-related abnormalities. KO were tested for behavior in approach/avoid conflict tests, responses to repeated forced swim exposure, and locomotor responses under stress and after psychostimulant treatment. The effects of rapid dopamine depletion and treatment with lithium or GSK-3β inhibitor on KO locomotor hyperactivity were tested. Results showed that KO exhibited novelty- and stress-induced locomotor hyperactivity, reduced forced swim immobility and alterations in approach/avoid conflict tests. Psychostimulant treatment and dopamine depletion exacerbated KO locomotor hyperactivity. Lithium, but not GSK-3β inhibitor, treatment normalized KO anxiety-related behavior and partially reversed hyperlocomotor behavior, and also reversed elevated prefrontal cortex levels of phospho-MARCKS and phospho-neuromodulin. Collectively, these findings demonstrate mania-related abnormalities in GluA1 KO and, combined with previous findings, suggest this mutant may provide a novel model of features of schizoaffective disorder.

Psychosocial Interventions for Bipolar Disorder: Perspective from the Behavioral Approach System (BAS) Dysregulation Theory

Research has emerged providing consistent support for the behavioral approach system (BAS) dysregulation theory of bipolar disorder. The objective of the current article is to examine the extent to which findings from the BAS dysregulation theory can inform psychosocial interventions for bipolar disorder. Towards this end, we first provide an overview of the BAS dysregulation theory. Second, we review extant research on psychosocial interventions for bipolar disorder. And, third, we discuss means by which research and theory in line with the BAS dysregulation model can inform psychosocial interventions for bipolar disorder. Particular attention is given to the clinical implications of research suggesting that bipolar disorder is characterized by high drive/incentive motivation, ambitious goal-setting, and perfectionism in the achievement domain.

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.

The genetics of bipolar disorder: genome 'hot regions,' genes, new potential candidates and future directions

Bipolar disorder (BP) is a complex disorder caused by a number of liability genes interacting with the environment. In recent years, a large number of linkage and association studies have been conducted producing an extremely large number of findings often not replicated or partially replicated. Further, results from linkage and association studies are not always easily comparable. Unfortunately, at present a comprehensive coverage of available evidence is still lacking. In the present paper, we summarized results obtained from both linkage and association studies in BP. Further, we indicated new potential interesting genes, located in genome 'hot regions' for BP and being expressed in the brain. We reviewed published studies on the subject till December 2007. We precisely localized regions where positive linkage has been found, by the NCBI Map viewer (http://www.ncbi.nlm.nih.gov/mapview/); further, we identified genes located in interesting areas and expressed in the brain, by the Entrez gene, Unigene databases (http://www.ncbi.nlm.nih.gov/entrez/) and Human Protein Reference Database (http://www.hprd.org); these genes could be of interest in future investigations. The review of association studies gave interesting results, as a number of genes seem to be definitively involved in BP, such as SLC6A4, TPH2, DRD4, SLC6A3, DAOA, DTNBP1, NRG1, DISC1 and BDNF. A number of promising genes, which received independent confirmations, and genes that have to be further investigated in BP, have been also systematically listed. In conclusion, the combination of linkage and association approaches provided a number of liability genes. Nevertheless, other approaches are required to disentangle conflicting findings, such as gene interaction analyses, interaction with psychosocial and environmental factors and, finally, endophenotype investigations.

Social rhythm regularity and the onset of affective episodes in bipolar spectrum individuals

OBJECTIVES

Research suggests that bipolar disorder individuals may have less social rhythm regularity than normal controls and that this may contribute to their affective symptoms and episodes. This study examined whether regularity prospectively predicted time to onset of major depressive, hypomanic and manic episodes in a sample with bipolar spectrum disorders.

METHODS

We recruited 414 undergraduate students from Temple University and University of Wisconsin diagnosed with cyclothymia, bipolar II disorder, or with no affective disorder (normal controls). Participants completed the Social Rhythm Metric at Time 1 and structured interviews approximately every four months for an average follow-up period of 33 months.

RESULTS

Participants diagnosed with cyclothymia and bipolar II disorder reported significantly fewer regular activities than normal controls, and approximately half of these participants experienced a worsening course of their illness over the study duration. Survival analyses indicated that both diagnosis and social rhythm regularity significantly predicted the time to participants' first prospective onset of major depressive, hypomanic and manic episodes.

CONCLUSION

Consistent with the social zeitgeber theory, bipolar spectrum participants reported less social rhythm regularity than normal controls, which prospectively predicted the survival time to affective episodes.

Phenomic, convergent functional genomic, and biomarker studies in a stress-reactive genetic animal model of bipolar disorder and co-morbid alcoholism

We had previously identified the clock gene D-box binding protein (Dbp) as a potential candidate gene for bipolar disorder and for alcoholism, using a Convergent Functional Genomics (CFG) approach. Here we report that mice with a homozygous deletion of DBP have lower locomotor activity, blunted responses to stimulants, and gain less weight over time. In response to a chronic stress paradigm, these mice exhibit a diametric switch in these phenotypes. DBP knockout mice are also activated by sleep deprivation, similar to bipolar patients, and that activation is prevented by treatment with the mood stabilizer drug valproate. Moreover, these mice show increased alcohol intake following exposure to stress. Microarray studies of brain and blood reveal a pattern of gene expression changes that may explain the observed phenotypes. CFG analysis of the gene expression changes identified a series of novel candidate genes and blood biomarkers for bipolar disorder, alcoholism, and stress reactivity.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

The role of psychosocial stress in the onset and progression of bipolar disorder and its comorbidities: The need for earlier and alternative modes of therapeutic intervention

Psychosocial stress plays an important role at multiple junctures in the onset and course of bipolar disorder. Childhood adversity may be a risk factor for vulnerability to early onset illness, and an array of stressors may be relevant not only to the onset, recurrence, and progression of affective episodes, but the highly prevalent substance abuse comorbidities as well. A substantial group of controlled studies indicate that various cognitive behavioral psychotherapies and psychoeducational approaches may yield better outcomes in bipolar disorder than treatment as usual. Yet these approaches do not appear to be frequently or systematically employed in clinical practice, and this may contribute to the considerable residual morbidity and mortality associated with conventional treatment. Possible practical approaches to reducing this deficit (in an illness that is already underdiagnosed and undertreated even with routine medications) are offered. Without the mobilization of new clinical and public health approaches to earlier and more effective treatment and supportive interventions, bipolar illness will continue to have grave implications for many patients' long-term well being.

Brief psychotic disorder mimicking the symptoms of cerebrovascular attack evoked by symptoms that symbolized death in a patient with terminal stage stomach cancer: case report and review of the literature

OBJECTIVE

We report here a terminally ill patient with stomach cancer who developed a brief psychotic disorder mimicking cerebrovascular attack after a short episode of nasal bleeding. Close examination of the patient revealed that nasal bleeding was an event that symbolized deterioration of the general condition leading to death for the patient.

METHODS

A 77-year-old male, who was diagnosed as having stomach cancer and was receiving palliative care, presented with tremor and insomnia just after a short episode of nasal bleeding and showed reduced response to stimuli mimicking cerebrovascular attack. Laboratory data were unremarkable. The next day, catatonic behavior developed. He had no history of psychiatric illness or drug or alcohol abuse. After receiving haloperidol, psychiatric symptoms disappeared and he returned to the previous level of functioning within 3 days. The patient explained that he had seen a patient whose general condition deteriorated after nasal bleeding and regarded nasal bleeding as a symptom of deteriorating general condition leading to death and thereafter became afraid of the nasal bleeding.

RESULTS AND SIGNIFICANCE OF RESULTS

Although, nasal bleeding is common and usually not severe in medical settings, for the patient, it was an event that symbolized deterioration of the general condition leading to death. Brief psychotic disorder in cancer patients is rare in the literature, although patients receiving terminal care share various kinds of psychological burden. Medical staff in the palliative care unit should be aware of the psychological distress experienced by each patient and consider brief psychotic disorder as part of the differential diagnosis when patients show unexplained neurological-like and/or psychiatric symptoms.

Molecular genetics of bipolar disorder

Bipolar disorder (BPD) is an often devastating illness characterized by extreme mood dysregulation. Although family, twin and adoption studies consistently indicate a strong genetic component, specific genes that contribute to the illness remain unclear. This study gives an overview of linkage studies of BPD, concluding that the regions with the best evidence for linkage include areas on chromosomes 2p, 4p, 4q, 6q, 8q, 11p, 12q, 13q, 16p, 16q, 18p, 18q, 21q, 22q and Xq. Association studies are summarized, which support a possible role for numerous candidate genes in BPD including COMT, DAT, HTR4, DRD4, DRD2, HTR2A, 5-HTT, the G72/G30 complex, DISC1, P2RX7, MAOA and BDNF. Animal models related to bipolar illness are also reviewed, with special attention paid to those with clear genetic implications. We conclude with suggestions for strategies that may help clarify the genetic bases of this complex illness.

The critical effect of object loss in the development of episodic manic illness

This article is a detailed psychoanalytically oriented case study of a patient whose mania followed the loss of a parent. Repetitive childhood trauma such as recurrent separations from parents because of political repression, fears of being abandoned, extremely contradictory parental expectations, multiple mothering, and restricted peer interaction forced the excessive use of primitive defense mechanisms, especially denial leading to grandiosity, resulting in po-rous ego boundaries and later serious conflict related to magical thinking and world destruction fantasies. These issues were compounded during latency by emigration to this country from eastern Europe and having to adapt to an entirely new culture. Successful mourning was precluded due to the blurring of self and object representations and the overwhelming need to minimize the finality of death by means of manic regression, the clinical stages of which are described precisely.

The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.

Major stressful life events and other risk factors for first admission with mania

OBJECTIVES

To investigate whether first admission with mania is associated with the occurrence of death in the family or with major stressful life events and to explore whether the associations change with age.

METHODS

Case register study with linkage of the Danish Psychiatric Central Research Register, including data on all admissions at psychiatric wards in Denmark from 1981 to 1998, and the Civil Registration System, including data on death and on socio-demographic variables. All patients who got a diagnosis of mania/mixed episode at the first ever admission at a psychiatric ward and a random gender- and age-matched control group of subjects who had never been admitted to psychiatric ward were identified.

RESULTS

A total of 1565 patients and 31,300 control subjects were identified. Suicide of a mother or of a sibling was associated with a highly increased risk of being admitted for the first time ever at a psychiatric ward with a diagnosis of mania/mixed episode. Death of a relative by other causes than suicide was not associated with increased risk of getting hospitalized with mania. Recent unemployment, recent divorce, but also a recent marriage showed moderate effects. No interaction was found on the association between life events and the first admission with mania, totally, or for men or women, separately regarding ageing.

CONCLUSIONS

The occurrence of death in the family and the experience of major life events are associated with increased risk of first admission with bipolar disorder. The susceptibility to major life stressors of inducing mania does not seem to change throughout life.

Life events and affective disorders

OBJECTIVE

To summarize research in life events and affective disorders

METHOD

Review of the literature.

RESULTS AND CONCLUSION

Many studies have shown that episodes of unipolar depression are preceded by life events at higher rates than in control samples. A variety of stressful events are involved with only limited specificity but some relationship to social exit events. Life events also affect remission and relapse of depression. Effects of life events are less when the disorder has already been recurrent, particularly where illness is severe. Effects of life events are also weaker in bipolar disorder than unipolar, but major life events may be important in first onset. Recent evidence suggests a specific role of social rhythm disruption events in manic relapses. Causative chains are multifactorial and complex, and genetic factors can influence life event exposure.

Social support in elderly patients with bipolar disorder

OBJECTIVE

The role of social support in bipolar disorder is poorly understood. It is known that young and middle-aged patients with impaired social support are more likely to be treatment resistant and have increased hospitalization. However, the role of social support in elderly patients with bipolar disorder has not been studied. Our purpose was to evaluate social support in older adults with bipolar disorder compared with peer controls and younger bipolar patients. In addition, we looked at the role of social support in the age of illness onset.

METHODS

We evaluated social support of 29 older subjects with bipolar disorder (age 50 or older) and 56 younger subjects with bipolar disorder using the Duke Social Support Index, comparing them to non-psychiatric, peer controls. Using logistic regression we then examined the relationship of demographic, social support factors, and age of onset.

RESULTS

Both older and younger bipolar subjects perceived their social support as inadequate (OR = 14.98; OR = 9.05) compared with similar aged controls. Younger bipolar subjects also had less social interactions than younger controls (OR = 4.63). These findings remained significant when controlled for gender, marital status, race, and education. No significant differences were noted between early-onset and late-onset bipolar subjects.

CONCLUSIONS

Older and younger bipolar patients have decreased perceptions of social support than older controls. No effect was found based on the age of illness onset. In addition, younger subjects had less social interactions than peer controls.

Kindling and second messengers: an approach to the neurobiology of recurrence in bipolar disorder

Since bipolar disorder is inherently a longitudinal illness characterized by recurrence and cycling of mood episodes, neurobiological theories involving kindlinglike phenomena appear to possess a certain explanatory power. An approach to understanding kindlinglike phenomena at the molecular level has been made possible by advances in research on second-messenger systems in the brain. The time frame of interest has shifted from the microseconds of presynaptic events to hours, days, months, and even years in the longer duration of events beyond the synapse--through second messengers, gene regulation, and synthesis of long-acting trophic factors. These complex interlocking systems may explain how environmental stress could interact over time with genetic vulnerability to produce illness. In its two sections, this paper will review an approach to understanding two major aspects of the neurobiology of bipolar disorder: kindling phenomena and second-messenger mechanisms. We will suggest that these two fields of research together help explain the biology of recurrence.

Mania and bipolar disorder: Current concepts on assessment, diagnosis and management

Mania is a common psychiatric syndrome characterized by pathological mood elevation, grandiose thinking and motor overactivity. Although current consensus upholds a true distinction between unipolar depression and bipolar disorders, the distinction between various bipolar sub-categories is still a matter for debate, as is the exact distinction between schizophrenia and mania. Most cases are functional in origin but many organic causes have been identified as well as iatrogenic causes from prescribed medication, particularly in susceptible individuals. The underlying aetiology is still poorly understood, although a number of biochemical abnormalities have recently been identified, and the evidence for a genetic role is strong. Its prevalence is universal, with some differences between gender and ethnicity reported, and it displays marked Axis I and II comorbidity. Treatment, both acute and long term, still relies on various traditional combinations of neuroleptics, benzodiazepines and mood stabilisers, particularly Lithium, which now appears to be less effective than previously thought and a shift towards using other mood stabilisers from the anticonvulsant class is now apparent. The exact role for psychological treatment remains unclear with more research required. Good medical management includes; adequate treatment, physical and laboratory investigations, dedicated follow-up and supervision by hospital psychiatrists and community-based care agencies.

Social influences on bipolar affective disorders

The impact of psychosocial adversity on the onset and course of bipolar disorder has been assessed in studies that have relied on methods of eliciting life event histories and evaluating family atmosphere. The results of life event studies have been inconsistent, perhaps because the relationship between bipolar disorder and major stress is only pronounced in first or early episodes. If this is so, this phenomenon itself invites explanation, whether in social or biological terms. The two studies to data of family atmosphere suggest an association between high expressed emotion and relapse. The relationship between psychosocial stress and bipolar disorder requires further and more detailed research.

Recent life events and completed suicide in bipolar affective disorder. A comparison with major depressive suicides

While recent psychosocial stress has been shown to be associated with the initiation of both first and subsequent illness episodes in bipolar affective disorder, its relationship to completed suicide in bipolar disorder is not known. As a part of a nationwide psychological autopsy study, two populations representing all suicides in Finland in DSM-III-R bipolar disorder or unipolar major depression were comprehensively examined and compared. Recent life events were retrospectively examined by interviewing next of kin using a 32-item Recent Life Change Questionnaire. Life event data was available on 25 bipolar and 56 unipolar cases. In about two-thirds of both bipolar (64%) and unipolar (66%) victims, at least one life event was reported to have occurred during the last 3 months and in 42% of both groups during the final week. The events of bipolar victims were more commonly classified as possibly dependent on their own behaviour (bipolars 88% vs. unipolars 63%, P = 0.004). Among bipolars, more males than females had had recent life events (males 86% vs. females 37%, P = 0.03). The majority of completed suicides in both bipolar and unipolar affective disorders seem to be associated with recent psychosocial stress; however, the stressors are commonly likely to be dependent on the victim's behaviour.

A study of life events in mania

After clinical recovery, 46 manic patients were screened for evidence of life events during a period of 6 months before the first episode of mania (DSMIIIR criteria) and 6 months after the episode. Within-patient group comparisons showed that patients who reported life events had a significantly higher presumptive mean stress score before manic episode as compared with the period after the illness. When life events were considered in relation to age, sex, marital status and family history of affective disorder, on a logistic regression equation, it was found that life events before mania were significantly associated with males and with a younger age of onset. The implications of these findings are discussed.

Life events, social support and depression

This paper reviews current findings regarding social stress and support in clinical depression. Comparisons of recent life events at depressive onset and in general population controls show consistently raised event rates. The events span a range of threatening and undesirable experiences, with limited selectivity to exit events and interpersonal losses. Effects are similar in endogenous and non-endogenous symptom pictures, and there are suggestive findings in bipolar disorder, but these require further study. Events are also related to outcome and to relapse. Effects are moderate in degree, but relatively short-term of over six months to a year. For social support there are greater problems in the extent to which social support may be determined by the individual's own behaviour. Absence of social support appears to be associated with onset and relapse of depression, both acting independently and modifying effects of life events. Social stress findings have implications for prevention. The occurrence of major life events signals a period of increased risk when supportive interventions may prevent evolution of distress to disorder.

Life events and relapse in established bipolar affective disorder

A New Zealand cohort of 58 patients with bipolar affective disorder was studied prospectively with three-monthly interviews in order to determine the relationship between life events and their relapses. Careful attention was paid to dating life events and the earliest signs of relapse and to assessing the independence of life events from the illness. No statistically significant association was found between life events and the likelihood of relapses, either mania or depression, for the 71% of patients who experienced at least one relapse during the two-year study. This finding is at variance with a companion study, with identical methodology, which found a small increase of life events before relapse. These data add further weight to the previous reports that life events are significant precipitants of bipolar illness only for earlier episodes in the course of this chronic disorder.

Life events and psychosis. Initial results from the Camberwell Collaborative Psychosis Study

Data from the Camberwell Collaborative Psychosis Study were used to examine the proposition that there is an excess of life events preceding the onset of psychoses of all types. Of 97 patients from the study who had episodes within the past year that were datable, 51 had developed psychotic symptoms from an essentially symptom-free state, 29 had been suffering only from neurotic symptoms, and 17 had experienced a marked exacerbation of psychotic symptoms. DSM-III diagnoses were collapsed into three major groups: 51 cases of schizophrenia; 31 cases of mania; and 14 cases of depressive psychosis. Life-event histories were taken for the six months before onset, and when these were compared with equivalent histories from a psychiatrically healthy sample from the local general population, there was a significant excess of life events, particularly in the three months before onset of psychosis. This was apparent in all groups, and remained even when events were restricted to the independent category. The excess of events began rather earlier than has been found in previous studies. In our view, this study provides some of the strongest evidence for a link between life events and the emergence of psychotic symptoms.

Life events and relapse in bipolar affective disorder

In a 2 year study of life events and relapse in a cohort of 62 patients with bipolar affective disorder, an excess of events was found during the month immediately preceding relapse. Of 52 relapses 19% were preceded by a severe event in the previous month, compared to a background rate of 5% of patients experiencing a severe event each month at other times. The rate of life events prior to relapse was not apparently different between manic and depressive relapse, though the number of depressive episodes was small.

De novo mania among elderly people

De novo mania is defined as the occurrence of a first manic episode in a patient with no history of mood disorder, after exclusion of organic etiologies. Although it is believed to be rare in elderly populations, the authors nonetheless report 6 cases encountered over a 2-year period. The literature regarding mania among elderly people is reviewed, and the authors formulate their recommendations in view of more frequent recognition and better management of these patients.

[Manic disorder in the aged: a review of the literature]

Very little has been written about mania in the elderly population. Most authors of the 1960s and 1970s situate the age of onset of affective disorders well before the geriatric period. In the 1980 some authors reached quite different conclusions about the age of onset. One study calculated an increased frequency of manic psychosis with advanced age. However, it seems difficult to compare these studies. A few cases of primary mania in the elderly have been published and it is important that more of these cases be reported. Mania diagnosis in this group of patients is not easy to make: past history may be difficult to assess, false first diagnosis may still occur in some cases, the course and the presentation of the illness may be less typical, there may be a picture of pseudodementia, confusion, depressed mood, etc. Mania may be secondary to physical illness (organic affective syndrome). Moreover, a frank manic picture may be mistaken for dementia (or for organic brain syndrome) even if it is indeed a primary affective illness.

Sex differences in the age of onset of bipolar affective illness

Data from a UK national sample showed differences between the sexes in age-specific inception rates for mania. Women had a higher inception rate than men during the middle years. The cumulative admission rates were nearly equal between the sexes.

Antidepressant treatment and the occurrence of mania in bipolar patients admitted for depression

We examined the records of 33 patients who had 70 inpatient admissions with a diagnosis of bipolar affective disorder, depressed. During 14 of these admissions, a switch occurred from depression into mania. We compared the treatment patients were on at the time of their switch to treatment during the 56 admissions where there was no switch. We conclude that clinicians must be prepared for depressed bipolar patients to switch to mania regardless of treatment status.

Life events and the onset of mania

Thirty manic in-patients were interviewed in hospital using the LEDS, and 24 were re-interviewed 6-12 months after discharge. Data for life events were analysed by: comparing events before onset of mania and before re-interview; and comparing these manic patients with patients in other studies which examined life events and the onset of schizophrenia and depression. No relationship was found between life events and the onset of mania in this preliminary study. Previous studies reporting a link between events and the onset of mania have serious methodological flaws, and definitive data have yet to be produced.

Critical role of the hypothalamic pituitary adrenal axis in amphetamine-induced sensitization of behavior

Behavioral sensitization can be observed with repeated administration of amphetamine where the intensity of motor stimulation increases over time. The process of sensitization has been well characterized, however, the neurochemical mechanisms that are critical for the development of sensitization are not known. In the present study, the role of the hypothalamic pituitary adrenal axis (HPA) in the development of behavioral sensitization to amphetamine was explored by pretreating rats with an intravenous administration of an antiserum to corticotropin-releasing factor in a volume that has been shown to block significantly stress- and cocaine-induced activation of the HPA. Four groups of eight rats were pretreated intravenously with either heparinized saline or CRF antiserum and subcutaneously with saline or d-amphetamine in a balanced design. The rats were then returned to their home cages and left undisturbed for seven days after which they were given three consecutive behavioral tests with saline SC, 0.75 mg/kg d-amphetamine SC, and 3.0 mg/kg d-amphetamine SC. The rats pretreated with intravenous CRF antiserum showed a significant attenuation of the development of d-amphetamine-induced sensitization but the antiserum did not alter the magnitude of the behavioral response to the initial, sensitizing dose of d-amphetamine. These results suggest that activation of the hypothalamic pituitary adrenal axis may be of critical importance to the development of behavioral sensitization to amphetamine.

Life events and mania: a case-controlled study

Life events were evaluated in 14 patients with bipolar affective disorder in the year preceding a mania as well as in 14 patients with bipolar affective disorder without a mania matched for age, sex, and time of recall. There were a significantly greater number of uncontrolled and unanticipated life events in the patients with as compared to those without a mania. However, neither the total number of life events nor measures of distress and stress distinguished bipolar patients with as compared to those without mania.