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Psychological and Physiological Trauma Research
Seize Your Journeys
_______________________ Traumatic stress is found in many competent, healthy, strong, good people. No one can completely protect themselves from traumatic experiences. Many people have long-lasting problems following exposure to trauma. Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy. What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences. Having symptoms after a traumatic event is NOT a sign of personal weakness. Given exposure to a trauma that is bad enough, probably all people would develop PTSD. By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment. _______________________
FUNCTIONAL NEUROANATOMY In order to best understand this atlas it is important to have a sense of the functional neuroanatomy of the brain. Over the next several pages there is a brief summary of the 5 major brain systems that relate to behavior, along with the general location seen on SPECT of these areas.
The Deep Limbic System
Functions
Problems
The Basal Ganglia System
Functions
Problems
The Prefrontal Cortex
Functions
Problems
The Cingulate Gyrus
Problems
The Temporal Lobes
Functions
Problems
Non-dominant Side (usually the right)
Secure Attachments as a Defense Against Trauma “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses. Particularly early in life, the social context plays a critical role in fuffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses. The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal. Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984). In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 185 _______________________
Sleep Disorders
“The sleep disorders are organized into four major sections according to presumed etiology. Primary Sleep Disorders are those in which none of the etiologies listed below (i.e., another mental disorder, a general medical condition, or a substance) is responsible. Primary Sleep Disorders are presumed to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning factors. Primary Sleep Disorders in turn are divided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-awake transitions). Sleep Disorder Related to Another Mental Disorder involves a prominent complaint of sleep disturbance that results from a diagnosable mental disorder (often a Mood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanisms responsible for the mental disorder also affect sleep-awake regulation. Sleep Disorder Due to a General Medical Condition involves a prominent complaint of sleep disturbance that results from the direct physiological effects of a general medical condition on the sleep-wake system. Substance-Induced Sleep Disorder involves prominent complaints of sleep disturbance that result from the concurrent use, or recent discontinuation of use, of a substance (including medications). That systematic assessment in individuals who present with prominent complaints of sleep disturbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medical conditions, and substance (including medication) use that may be responsible for the sleep disturbance. Five distinct sleep stages can be measured by polysomnography: rapid eye movement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep (stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, which is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREM sleep (also known collectively as slow-wave sleep) are the deepest levels of sleep and occupy about 10%-20% of sleep time. REM sleep, during which the majority of typical storylike dreams occur, occupies about 20%-25% of total sleep. These sleep stages have a characteristic temporal organization across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-half of the night and increase in duration in response to sleep deprivation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. REM sleep periods increase in duration toward the morning. Human sleep also varies characteristically across the life span. After relative stability with large amounts of slow-wave sleep in childhood and early adolescence, sleep continuity and depth deteriorate across the adult age range. This deterioration is reflected by increased wakefulness and stage 1 sleep and decreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individual. Polysomnography is the monitoring of multiple electrophysiological parameters during sleep and generally includes measurement of EEG activity, electroculographic activity, and electromyographic activity. Additional polysomnographic measures may include oral or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbon dioxide concentration; these measures are used to monitor respiration during sleep and to detect the presence and severity of sleep apnea. Measurement of peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic studies are conducted during the person’s usual sleeping hours—that is, at night. However, daytime polysomnographic studies also are used to quantify daytime sleepiness. The most common daytime procedure is the Multiple Sleep Latency Test (MSLT), in which the individual is instructed to lie down in a dark room and not resist falling asleep; this protocol is repeated fives times during the day. Sleep latency (the amount of time required to fall asleep) is measured on each trial and is used as an index of physiological sleepiness. The converse of the MSLT is also used: In the Repeated Test of Sustained Wakefulness (RTSW), the individual is placed in a quiet, dimly lit room and instructed to remain awake; this protocol is repeated several times during the day. Again, sleep latency is measured, but is it used here as an index of the individual’s ability to maintain wakefulness. Standard terminology for polysomnographic measures is used throughout the test in this section. Sleep continuity refers to the overall balance of sleep and wakefulness during a night of sleep. “Better” sleep continuity indicates consolidated sleep and wakefulness; “worse” sleep continuity indicates disrupted sleep with more wakefulness. Specific sleep continuity measures include sleep latency—the amount of time required to fall asleep (expressed in minutes); intermittent wakefulness—the amount of awake time after initial sleep onset (expressed in minutes); and sleep efficiency—the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep architecture refers to the amount and distribution of specific sleep stages. Sleep architecture measures include absolute amount of REM sleep and each NREM sleep stage (in minutes), relative amount of REM seep and NREM sleep stages (expressed as a percentage of total sleep time), and latency between sleep onset and the first REM period (REM latency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in The International Classification of Sleep Disorders: (ICSD) diagnostic and Coding Manual, published in 1990 by the American Sleep Disorders Association. _________________
Substance Dependence “Features The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. A diagnosis of Substance Dependence can be applied to every class of substances except caffeine. The symptoms of Dependence are similar across the various categories of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for Hallucinogenic Dependence). Although not specifically listed as a criterion item, “craving” (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence. Dependence is defined as a cluster of three or more of the symptoms listed below occurring at any time in the same 12-month-period. Tolerance (Criterion 1) is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Furthermore, for a specific drug, varied degrees of tolerance may develop for its different central nervous system effects. For example, for opioids, tolerance to respiratory depression and tolerance to analgesia develop at different rates. Individuals with heavy use of opioids and stimulants can develop substantial (e.g., 10-f0ld) levels of tolerance, often to a dosage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually less extreme than for amphetamine. Many individuals who smoke cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis or phencyclidine (PCP) are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals). Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents or with other substances. In such situations, laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drink, whereas others of similar weight and drinking histories had slurred speech and incoordination. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the persons is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms, which are generally the opposite of the acute effects of the substance, vary greatly across the calluses of substances, and separate criteria sets for Withdrawal are provided for most of the classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as with nicotine and cannabis. No significant withdrawal is seen even after repeated use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. However, for most classes of substances, a past history of tolerance or withdrawals is associated with a more severe clinical course (i.e., an earlier onset of Dependence, higher levels of substance intake, and a greater number of substance-related problems). Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without obvious signs of tolerance or withdrawal. Conversely, some general medical and postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Physiological Dependence are provided to indicate the presence or absence of tolerance or withdrawal. The following items describe the pattern of compulsive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many unsuccessful efforts to decrease or discontinue use (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person’s daily activities revolve around the substance. Important social, occupational, ore recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies in order to use the substance in private or to spend more time with substance-using friends. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g., sever depressive symptoms or damage to organ systems), the person continues to use the substance (Criterion 7). The key issue in evaluating this criterion is not eh existence of the problem, but rather the individual’s failure to abstain from using the substance despite having evidence of the difficulty it is causing.
Specifiers Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence: With Physiological Dependence. This specifier should be used when Substance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulsive use (at least three items from Criteria 3-7).”
Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. P. 193-195.
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PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com __________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373
Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association.
________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ DID-PTSD-EMDR Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com
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NeuroBiology of Trauma
Bipolar I Disorder
Title: Delirium induced by verapamil. Author(s): Jacobse, Frederick M. Sack, David A. James, Steven P. Source: American Journal of Psychiatry , Vol 144(2), Feb 1987. pp. 248. Publisher: US: American Psychiatric Assn Abstract: Presents the case of a 24-yr-old female with delirious psychosis induced by a standard 320-mg dose of verapamil HCl. The S had a history of bipolar I disorder since the age of 18. Verapamil was administered in response to mood cycling, and after 1 wk, the S still suffered severe depression and experienced an episode of formicatory hallucination that caused her to scream, bang her head, and tear her hair. _____
Title: Identification of dysthymia and cyclothymia by the General Behavior Inventory. Author(s): Depue, Richard A. , U of Minnesota, MN, US; Fuhrman, Michael J. Source: Advances in personality assessment, Vol. 6. Butcher, James N. (Ed); Spielberger, Charles D. (Ed); pp. 13-29. Hillsdale, NJ, England: Lawrence Erlbaum Associates, Inc, 1987. x, 169 pp. Abstract: (from the chapter) dysthmia and bipolar affective disorder the importance of this work is that it supports a continuum model of behavioral disturbance between cyclothymia and full syndromal bipolar affective disorders / the basic assumption of this model is that the episodic characteristics and the core behavior comprising the primary features of cyclothymic disorder are qualitatively similar to, although quantitatively less severe than, those of bipolar I disorder General Behavior Inventory (GIB) _____
Title: Bipolar II--combine or keep separate? Author(s): Endicott, Jean , Columbia U, New York State Psychiatric Inst, Research Assessment & Training Unit et al. Source: Journal of Affective Disorders , Vol 8(1), Jan-Feb 1985. pp. 17-28. Publisher: United Kingdom: Elsevier Science Abstract: Reviews findings on the prior course, characteristics of index episode, and familial aggregation of 56 patients with bipolar II disorder, 122 with bipolar I disorder, and 204 with recurrent unipolar disorder. Data on the patients and 924 of their relatives support the separation of bipolar II from both bipolar I and recurrent unipolar disorder. Results suggest that bipolar II patients and their relatives are heterogeneous as to genotype and include some individuals who are at risk to "switch" to bipolar I disorder at some time in the future. (26 ref) _____
Title: Bipolar II--a distinct diagnostic entity? Author(s): Goodnick, Paul J. , U Chicago, Illinois State Psychiatric Inst; Dunner, David L. ; Fieve, Ronald R. Source: Israel Journal of Psychiatry & Related Sciences , Vol 18(3), 1981. pp. 221-227. Publisher: Israel: Gefen Publishing House Abstract: Biological studies usually find bipolar II indices to be similar to bipolar I, with the exception of urinary 17-hydroxycorticosteroids and 3-methoxy-4-hydroxyphenylethyleneglycol. Pharmacological investigations also have usually found bipolar IIs to have responses similar to bipolar Is. However, an extensive genetic study of 614 relatives of patients with primary affective disorders demonstrated that bipolar IIs have a pattern of inheritability midway between bipolar Is and unipolars. Clinical reports show that bipolar IIs stand out in their higher degree of suicidality and borderline features. The authors suggest that bipolar II may be a distinct diagnostic category. (31 ref) _____
Title: False memories of cult abuse. Author(s): Yeager, Catherine A.; Lewis, Dorothy Otnow Source: American Journal of Psychiatry, Vol 154(3), Mar 1997. pp. 435. Publisher: US: American Psychiatric Assn Abstract: Reports a case of false memories in a 39 yr old female patient who insisted she had been sexually molested by her parents and victimized in a satanic cult. She presented with signs and symptoms that met Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for dissociative identity disorder as well as bipolar I disorder. It was found that her first recollections of incest emerged after she attended meetings for incest survivors. Similarly, her memories of cult abuse began after she participated in meetings for ritual abuse survivors. This case illustrates the need for clinicians to keep an open mind regarding a patient's productions, explore the context in which memories first emerged, and attempt to obtain as much objective data as possible regarding the nature of childhood experiences. _____
Title: A pilot study of lithium carbonate plus divalproex sodium for the continuation and maintenance treatment of patients with bipolar I disorder. Author(s): Solomon, David A., Rhode Island Hosp, Mood Disorders Program, Providence, US; Ryan, Christine E.; Keitner, Gabor I.; Miller, Ivan W. Source: Journal of Clinical Psychiatry , Vol 58(3), Mar 1997. pp. 95-99. Publisher: US: Physicians Postgraduate Press Abstract: Compared the efficacy of lithium plus divalproex sodium with the efficacy of lithium alone for the continuation and maintenance treatment of patients with bipolar I disorder. 12 Ss were recruited and followed prospectively for up to 1 yr. Each S received lithium at serum levels of 0.8 to 1.0 mmol/L and a management/education session weekly or every 2 wks. Ss received either divalproex sodium or placebo in conjunction with lithium. Divalproex sodium was adjusted to achieve a serum concentration of 50 to 125 mug/mL. Adjunctive medications were used on an as-needed basis to treat psychosis, depression, and anxiety. Ss treated with the combination of lithium and divalproex were significantly less likely to suffer a relapse or recurrence, but were significantly more likely to suffer at least 1 moderate or severe adverse side effect. There was no significant difference between groups in the use of adjunctive medication. Results provide preliminary evidence of the risks and benefits of combining lithium with divalproex sodium for the continuation and maintenance treatment of bipolar I disorder. _____
Title: Dose-related thrombocytopenia and macrocytic anemia associated with valproate use in bipolar disorder. Author(s): Fawcett, Robert G. Source: Journal of Clinical Psychiatry , Vol 58(3), Mar 1997. pp. 125. Publisher: US: Physicians Postgraduate Press Abstract: Reports the case of a 48-yr-old woman with bipolar I disorder who developed thrombocytopenia and anemia associated with valproate treatment. Related findings point to a myelodysplastic effect of valproate, reflected in this patient's minimally dysplastic bone marrow. Several reports indicate that thrombocytopenia is related to dosage level of valproate, and that valproate may be safely used in lower doses in patients who develop similar side effects. _____
Title: Treatment of acute mania with gabapentin. Author(s): Stanton, Sean P.; Keck, Paul E. Jr.; McElroy, Susan L. Source: American Journal of Psychiatry, Vol 154(2), Feb 1997. pp. 287. Publisher: US: American Psychiatric Assn Abstract: Presents the case of 40-yr-old White man with Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) bipolar I disorder and alcohol dependence who was successfully treated with gabapentin. In the 4 mo before the S's admission to a psychiatric hospital, he had experienced severe irritability, violent outbursts, racing thoughts, marked distractibility, greater libido, grandiose persecutory delusions, less need for sleep, pressured speech, and auditory hallucinations. The S had also experienced a bilateral frontal lobe injury with bilateral intracranial hematomas after a motor vehicle accident 2 yrs earlier. A regime of gabapentin, 900 mg/day, was initiated and increased daily by 900 mg until a dose level of 3600 mg/day was achieved. The S's score on the Young Mania Rating Scale decreased from 34 at baseline to 17 after 10 days of gabapentin administration. The response of this S's manic symptoms to gabapentin monotherapy suggests that gabapentin may have antimanic efficacy. _____
Title: Mood disorders. Author(s): Essau, Cecilia Ahmoi , U Bremen, Klinische Psychologie, Bremen, Germany; Petermann, Ulrike Source: Developmental psychopathology: Epidemiology, diagnostics and treatment. Essau, Cecilia Ahmoi (Ed); Petermann, Franz (Ed); pp. 265-310. Amsterdam, Netherlands: Harwood Academic Publishers, 1997. xvii, 478 pp. Abstract: (from the chapter) Discusses the following topics as they pertain to children and adolescents: definition and classification (major depressive disorder, dysthymic disorder, bipolar I disorder, bipolar II disorder, cyclothymic disorder, and other mood disorders), risk factors (sociodemographic, biological, family and psychological, and social factors), comorbidity, long-term course and outcome (age of onset, duration of episodes, relapse, psychosocial impairment, health service utilization, and assessment), and treatment (pharmacotherapy, psychological interventions, and preventive programs). _____
Title: Jews and their intraethnic vulnerability to affective disorders, fact or artifact? II: Evidence from a cohort study. Author(s): Kohn, Robert , Butler Hosp, Providence, RI, US; Levav, Itzhak; Dohrenwend, Bruce P.; Shrout, Patrick E.; Skodol, Andrew E. Source: Israel Journal of Psychiatry & Related Sciences, Vol 34(2), 1997. pp. 149-156. Publisher: Israel: Gefen Publishing House Abstract: This study, which complements a prior review (Kohn and Levav, 1994) of published studies, explored vulnerability to affective disorders in 4,914 Israel-born offspring of immigrants from Europe (Ashkenazim) and North Africa. Ss were examined by psychiatrists using the Schedule for Affective Disorders and Schizophrenia, Israel version, and were diagnosed with Research Diagnostic Criteria. Unlike previous studies, this study found that Israelis of North African origin had significantly higher rates of affective disorders. The Ashkenazim, however, had higher rates of bipolar I disorder at the definite level of diagnosis. Differential patterns in help-seeking may account for the divergent findings between this community-based study and earlier treatment-based reports. Results suggest the need to further investigate social and genetic etiological factors that may explain the differential rates. _____
Title: Treatment of elderly institutionalized bipolar patients with clozapine. Author(s): Shulman, Richard W. , Sunnybrook Health Science Ctr, Psychopharmacology Research Program, North York, O, Canada; Sungh, Anu; Shulman, Kenneth Source: Psychopharmacology Bulletin, Vol 33(1), 1997. pp. 113-118. Publisher: US: Psychopharmacology Bulletin Abstract: In an open trial, clozapine was used to treat 3 elderly (mean age 72+-2.5 yrs) institutionalized male patients with bipolar I disorder, most recent episode manic, severe with psychotic features. All patients were refractory or intolerant of treatment with lithium, valproate, benzodiazepines, and traditional neuroleptics both alone and in combination. Response to clozapine was determined using the Severity of Illness score on the Clinical Global Impression (CGI) scale (1=normal, not at all ill, 7=among the most extremely ill). Pre-clozapine severity of illness scores on the CGI averaged 6.33+-0.6; post-clozapine CGI scores averaged 2.0+-1.0 (t = 13.00, df = 2, p<.01). The therapeutic dosage of clozapine varied (range=25-112.5 mg/day). There were no significant drops in granulocyte counts. Follow-up revealed sustained improvement over an average of 11 mo. Results suggest that clozapine may be an effective alternative treatment for similar patients and that prospective trials are warranted. _____
Title: Serum lithium levels and psychosocial function in patients with bipolar I disorder. Author(s): Solomon, David A. , Butler Hosp, Mood Disorders Program, Providence, RI, US; Ristow, W. Richard; Keller, Martin B.; Kane, John M.; et al. Source: American Journal of Psychiatry , Vol 153(10), Oct 1996. pp. 1301-1307. Publisher: US: American Psychiatric Assn Abstract: Compared the effect of 2 different serum lithium levels on the psychosocial functioning (PS) of patients with bipolar I disorder. 90 patients with bipolar I disorder were enrolled in a prospective, double-blind, maintenance trial of lithium. The patients were randomly assigned to treatment with doses of lithium adjusted to achieve a serum lithium concentration of either 0.8 to 1.0 mmol/liter (standard) or 0.4 to 0.6 mmol/liter (low). The Longitudinal Interval Follow-Up Evaluation was used to assess PS in the areas of work, interpersonal relationships, and global functioning. All observed values were analyzed with a mixed-effects analysis of covariance. Independent variables included treatment group (low or standard lithium serum level), relapse status, socioeconomic status, time from random treatment assignment to assessment, termination of protocol before or after relapse, length of remission before random treatment assignment, polarity of the last mood episode before random treatment assignment, and number of mood episodes in the 3 years before random treatment assignment. Relapse was associated with large negative effects on PS. Patients in higher socioeconomic brackets had better PS than did those in lower brackets. _____
Title: Antidepressant effects of lamotrigine in rapid cycling bipolar disorder. Author(s): Calabrese, Joseph R.; Fatemi, S. Hossein; Woyshville, Mark J. Source: American Journal of Psychiatry, Vol 153(9), Sep 1996. pp. 1236. Publisher: US: American Psychiatric Assn Abstract: Presents evidence of lamotrigine's potential acute antidepressant effect and lack of any mania-inducing properties in a 49-yr-old male patient with rapid cycling bipolar disorder who had been nonresponsive to lithium monotherapy and also predisposed to antidepressant-induced mania. These observations suggest that lamotrigine may have properties that complement lithium and the other anticonvulsants in the treatment of bipolar disorder. _____
Title: Prodromal and residual symptoms in bipolar I disorder. Author(s): Keitner, Gabor I., Rhode Island Hosp, Dept of Psychiatry, Mood Disorders Program, Providence, RI, US; Solomon, David A.; Ryan, Christine E.; Miller, Ivan W.; Mallinger, Alan Source: Comprehensive Psychiatry , Vol 37(5), Sep-Oct 1996. pp. 362-367. Publisher: United Kingdom: Elsevier Science Abstract: Examined the nature of prodromal and residual symptoms of mania and depression elicited from 74 patients with bipolar I disorder. In 45 cases, an adult family member provided similar information. Three clinicians classified the symptoms into 6 broad categories: behavioral, cognitive, mood, neurovegetative, social, and other. The clinicians also categorized symptoms as typical or idiosyncratic. 78% of Ss reported prodromal depressive symptoms and 87% reported prodromal manic symptoms; greater than half of Ss disclosed residual symptoms of depression (54%) and mania (68%). Within each of these 4 illness categories, cognitive symptoms were consistently the most common symptoms reported by patients. A substantial number of symptoms were idiosyncratic, particularly those reported for residual depression. Agreement between patient and family members on reported symptoms was strong for the prodromal phase of both polarities, but less so for the residual phases. Results suggest that patients with bipolar I disorder and their family members can identify prodromal and residual symptoms, that these symptoms are quite common, and that prodromal symptoms may be more prevalent or easier to identify than residual symptoms. _____
Title: Personality traits in subjects with bipolar I disorder in remission. Author(s): Solomon, David A., Butler Hosp, Mood Disorders Program, Providence, RI, US; Shea, M. Tracie; Leon, Andrew C.; Mueller, Timothy I.; et al. Source: Journal of Affective Disorders, Vol 40(1-2), Sep 1996. pp. 41-48. Publisher: United Kingdom: Elsevier Science Abstract: Compared the personality traits of Ss with bipolar I disorder in remission to the personality traits of Ss with no history of any mental illness. Ss were assessed as part of a prospective, multicenter, naturalistic study of mood disorders. Diagnoses were rendered according to Research Diagnostic Criteria, through use of the Schedule for Affective Disorders and Schizophrenia--Lifetime Version. A total of 30 euthymic bipolar I Ss were compared to 974 never-ill Ss on 17 personality scales selected for their relevance to mood disorders. The subjects with bipolar I disorder in remission had more aberrant scores on 6 of the 17 personality measures, including Emotional Stability, Objectivity, Neuroticism, Ego Resiliency, Ego Control, and Hysterical Factor. These findings indicate that patients with bipolar I disorder in remission have personality traits that differ from those of normal controls. _____
Title: A pharmacoeconomic model of divalproex vs. lithium in the acute and prophylactic treatment of bipolar I disorder. Author(s): Keck, Paul E. Jr., U Cincinnati, Coll of Medicine, Biological Psychiatry Program, Cincinnati, OH, US; Nabulsi, Azmi A.; Taylor, Jennifer L.; Henke, Curtis J.; et al. Source: Journal of Clinical Psychiatry , Vol 57(5), May 1996. pp. 213-222. Publisher: US: Physicians Postgraduate Press Abstract: Developed a decision-analytic model to estimate the costs of treating patients with bipolar I disorder for 1 yr with divalproex or lithium. For 88 patients (aged 12+ yrs), data on length and frequency of hospitalization, rates of adverse events associated with either therapy, and the overall treatment costs of were obtained from a university database. Ss were classified according to lithium or divalproex response or nonresponse. Distribution of bipolar patients by subtypes, and probabilities of response to treatment with lithium and divalproex were derived from published studies. A panel of 5 psychiatrists provided data on the resources utilized in the prophylactic care of the Ss over 1 yr, at 3 mo intervals. According to the model, in the acute and prophylactic treatment of Ss over 1 yr, divalproex was less costly than lithium because of a more rapid rate of antimanic activity associated with oral loading. _____
Title: Dietary interferences with lithium therapy. Author(s): Castrogiovanni, P., U Degli Studi di Siena, Istituto di Clinica delle Malattie Nervose e Mentali, Cattedra di Psichiatria, Siena, Italy; Pieraccini, F. Source: European Psychiatry , Vol 11(1), 1996. pp. 53-54. Abstract: Presents the case of a 56-yr-old female with a history of bipolar I disorder treated with lithium carbonate. By drinking 10 g of sodium bicarbonate mixed with water, the S unknowingly reduced her lithium blood level without any change in lithium carbonate dosage. (0 references) _____
Title: Polypharmacy in bipolar I disorder. Author(s): Solomon, David A., Rhode Island Hosp, Mood Disorders Program, Providence, RI, US; Keitner, Gabor I.; Ryan, Christine E.; Miller, Ivan W. Source: Psychopharmacology Bulletin , Vol 32(4), 1996. pp. 579-587. Publisher: US: Psychopharmacology Bulletin Abstract: There are currently 3 mood stabilizers available for the maintenance treatment of patients with bipolar I disorder: lithium, valproate, and carbamazepine. Unfortunately, monotherapy with each of these conventional agents often fails. Although the efficacy of polypharmacy is largely unknown, data indicate that it is the rule rather than the exception. The few controlled trials that have been conducted indicate that (1) the specific combination of lithium plus imipramine provides no advantage over lithium monotherapy (notwithstanding the inadequacy of lithium monotherapy), (2) the specific combination of lithium and the depot neuroleptic flupenthixol provides no advantage over lithium monotherapy, and (3) the combination of lithium plus carbamazepine may be as effective as lithium plus haloperidol for acute and continuation treatment. Most of the literature on polypharmacy consists of case reports, retrospective chart reviews, and open-label prospective studies, and describes the use of numerous combinations of medications, including lithium plus valproate, lithium plus carbamazepine, and valproate plus carbamazepine. Preliminary findings suggest these combinations may be effective, and that clozapine and high-dose levothyroxine may each be useful as well when combined with other drugs. _____
Title: Clinical evidence for genomic imprinting in bipolar I disorder. Author(s): Grigoroiu-Serbanescu, Maria, Inst of Neurology & Psychiatry, Bucharest, Romania; Nothen, M.; Propping, P.; Poustka, F.; et al. Source: Acta Psychiatrica Scandinavica, Vol 92(5), Nov 1995. pp. 365-370. Publisher: United Kingdom: Blackwell Publishing Abstract: Examined genomic imprinting in the transmission of bipolar disorder (BPD) in probands. 100 Ss completed the Diagnostic Interview for Genetic Studies and Family Interview for Genetic Studies (NIMH-Molecular Genetics Initiative, 1992 and 1991), and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) Personality Disorders (R. L. Spitzer et al, 1987). 720 living 1st and 2nd degree relatives were also interviewed. Results show that paternal transmission was associated with a significantly younger age of onset of BPD in probands and a higher rate of affective disorders in 1st and 2nd degree relatives. Effects of the transmitting parent's sex on age of onset in probands decreased, but remained significant. Probands' sex did not influence age of onset. Severity of BPD, in terms of number of illness episodes and annual frequency, was not influenced by the sex of the transmitting parent. _____
Title: The self-psychological approach to the bipolar spectrum disorders. Author(s): Deitz, I. Jeffrey, Training & Research Inst for Self Psychology, New York, NY, US Source: Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry, Vol 23(3), Fal 1995. pp. 475-492. Publisher: US: Guilford Publications Abstract: Presents a self-psychological perspective on the psychodynamics and therapy of bipolarity that acknowledges the pathogenicity of an inborn deficit in psychic structure or function. Current psychiatric nosology and clinical experience now recognize several forms of mood disturbance that differ from typical depressive disorders. Subsumed under the heading of the bipolar spectrum of mood disorders, these conditions include bipolar I disorder, bipolar II disorder, and dysphoric mania. Three case vignettes (a 43-yr-old woman, a man in his late thirties, and a 42-yr-old woman) are presented that demonstrate the application of a self-psychological orientation and technique with these respective disorders that acknowledge the pathogenic presence of an inborn deficit in mood regulation, leading to development of faulty self structure and/or function, in the bipolar patient. _____
Title: T-sub-2 hyperintensities in bipolar disorder: Magnetic resonance imaging comparison and literature meta-analysis. Author(s): Altshuler, Lori L., Veterans Affairs Medical Ctr-West Los Angeles, Brentwood Div, CA, US; Curran, John G.; Hauser, Peter; Mintz, Jim; et al. Source: American Journal of Psychiatry, Vol 152(8), Aug 1995. pp. 1139-1144. Publisher: US: American Psychiatric Assn Abstract: Evaluated the presence of signal hyperintensities in bipolar Ss using magnetic resonance imaging (MRI) of the brain for 29 Ss with bipolar I disorder, 26 Ss with bipolar II disorder, and 20 normal controls. The presence and location of signal hyperintensities in the periventricular white matter, subcortical gray matter, and deep white matter were evaluated. No significant differences were found between groups for subcortical gray or deep white matter hyperintensities. Periventricular hyperintensities were found in 62% of bipolar I Ss, 38% of bipolar II Ss, and 30% of comparison Ss. Within patient groups, medication use was not significantly different for those with or without the presence of white matter hyperintensities. A meta-analysis of the literature revealed that the odds of having a T2 hyperintensity are significantly greater for bipolar I than for normal comparison Ss. _____
Title: Cerebrospinal fluid total protein in patients with affective disorders. Author(s): Pazzaglia, Peggy J., NIH/NIMH Biological Psychiatry Branch, Bethesda, MD, US; Post, Robert M.; Rubinow, David; Kling, Mitchell A.; et al. Source: Psychiatry Research, Vol 57(3), Aug 1995. pp. 259-266. Publisher: United Kingdom: Elsevier Science Abstract: Evaluated CSF total protein in 240 medication-free patients with affective disorders and compared the findings with those in 55 normal controls. Subtype diagnoses indicated that 47 men and 61 women were bipolar I, 26 men and 41 women were bipolar II, and 22 men and 43 women were unipolar. Men had significantly elevated values compared with women. In men with bipolar I disorder, mean CSF protein levels were found to be significantly elevated over those in controls. Moreover, CSF protein levels in male bipolar I patients were found to be positively correlated with severity of depression at the time of the lumbar puncture and with duration of illness. It thus appears that increased protein levels may be associated with illness severity or progression in male patients with bipolar I disorder. _____
Title: A family study of manic-depressive (bipolar I) disease: Is it a distinct illness separable from primary unipolar depression? Author(s): Winokur, George, U Iowa Coll of Medicine, Dept of Psychiatry, Iowa City, US; Coryell, William; Keller, Martin; Endicott, Jean; et al. Source: Archives of General Psychiatry, Vol 52(5), May 1995. pp. 367-373. Publisher: US: American Medical Assn Abstract: Examined the presence of affective disorder, bipolar and unipolar, in the family members of probands with bipolar (n = 251) and primary unipolar (n = 313) illness. A possible severity continuum was also evaluated among Ss with mood-incongruent and mood-congruent psychotic features and with no psychotic features by determining amount of familial depression and mania in these proband groups. Relatives of Ss were interviewed, family history data were gathered and evaluated, and Ss were interviewed using the Schedule for Affective Disorders and Schizophrenia--Lifetime Version. The variable of familial bipolar I or schizoaffective mania is significantly higher in the 1st-degree relatives of Ss with bipolar I or schizoaffective mania than in the 1st-degree relatives of Ss with primary unipolar disease. Findings support the idea that bipolar I disorder is an independent illness. _____
Title: Practice guideline for treatment of patients with bipolar disorder. Institutional Author(s): American Psychiatric Assn, Washington, DC, US Source: Washington, DC, US: American Psychiatric Publishing, Inc., 1995. xi, 74 pp. Abstract: (from the introduction) This guideline seeks to provide guidance to psychiatrists who treat patients with bipolar I disorder (manic-depressive illness). The pharmacologic, other somatic, and psychotherapeutic treatments that are used for patients with bipolar I disorder are summarized. Although many of the treatments discussed in this guideline may be effective for patients with bipolar II disorder or for patients with schizoaffective disorder, bipolar type, the focus is to guide the treatment of patients with bipolar I disorder. . . . The guideline begins at the point where the psychiatrist has established the diagnosis of bipolar I disorder and has evaluated the patient for the presence of comorbid psychiatric conditions (e.g., alcohol and/or substance abuse or dependence disorder, personality disorders) as well as general medical conditions (e.g., thyroid disease, Cushing's disease, cerebral neoplasms) that could mimic bipolar disorder or be important to its treatment. _____
Title: Practice guideline for the treatment of patients with bipolar depression. Author(s): Hirschfeld, Robert M. A.; Clayton, Paula J.; Cohen, Irvin; Fawcett, Jan; et al. Source: American Journal of Psychiatry, Vol 151(12, Suppl), Dec 1994. pp. 40. Publisher: US: American Psychiatric Assn Abstract: Provides guidance to psychiatrists treating patients with bipolar I disorder (manic-depressive illness). Pharmacologic, other somatic, and psychotherapeutic treatments that are used for patients with bipolar I disorder are summarized. Bipolar I disorder is discussed as it is defined in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) unless a broader meaning is specified. The guideline begins at the point where the psychiatrist has established the diagnosis of bipolar I disorder and has evaluated the patient for the presence of comorbid psychiatric conditions or general medical conditions that could mimic bipolar disorder or be important to its treatment. Different treatment strategies are discussed that may be used at different times. _____
Title: Suicidality in patients with pure and depressive mania. Author(s): Dilsaver, Steven C., U Texas, Harris Country Psychiatric Ctr, Houston, US; Chen, Yuan-Who; Swann, Alan C.; Shoaib, Arif M.; et al. Source: American Journal of Psychiatry, Vol 151(9), Sep 1994. pp. 1312-1315. Publisher: US: American Psychiatric Assn Abstract: Determined rate and severity of suicidality among 93 patients who met Research Diagnostic Criteria (RDC) for bipolar I disorder or schizoaffective disorder. All met RDC for primary mania and the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) criteria for bipolar disorder, manic or mixed. Ss with depressive mania (DPM) met RDC for mania and major depressive disorder concurrently. Severity of current suicidality was measured using the Schedule for Affective Disorders and Schizophrenia suicide subscale. Relationships of age, gender, type of affective illness, psychosis, race, and mania subtype to suicidality were assessed. Only 1 S with pure mania was suicidal, but 24 Ss with DPM were suicidal. Gender and psychosis were not related to suicidality. African-Americans were less likely to be suicidal than were Caucasians. Subtype of mania had the strongest relationship to suicidality. _____
Title: Clozapine treatment of nonpsychotic rapid cycling bipolar disorder: A report of three cases. Author(s): Suppes, Trisha, U Texas Southwestern Medical Ctr, Dept of Psychiatry, Dallas, US; Phillips, Katharine A.; Judd, Catherine R. Source: Biological Psychiatry, Vol 36(5), Sep 1994. pp. 338-340. Publisher: United Kingdom: Elsevier Science Abstract: Presents the cases of 3 women (aged 25, 42, and 45 yrs) with severe, treatment-refractory nonpsychotic rapid-cycling bipolar I disorder that responded to clozapine treatment. The 1st 2 Ss experienced remission on clozapine and pursued educational or work goals that had been previously unattainable. The 3rd S had a moderate response to the treatment and reported a significant subjective sense of improvement. In all cases, time to response was 2 to 4 mo, and improvement persisted for 12 to 20 mo. _____
Title: A linkage study with D5 dopamine and !a-sub(2c)-adrenergic receptor genes in six multiplex bipolar pedigrees. Author(s): Byerley, W., U Utah School of Medicine, Dept of Psychiatry, Salt Lake City, US; Hoff, M.; Holik, J.; Coon, H. Source: Psychiatric Genetics, Vol 4(3), Fal 1994. pp. 121-124. Publisher: US: Lippincott Williams & Wilkins Abstract: Six kindreds containing multiple cases of manic-depressive illness (MDI) were genotyped with highly polymorphic microsatellite polymorphisms for the D5 dopamine and alpha-sub(2c)-adrenergic receptor genes. All Ss were interviewed using the Schedule for Affective Disorders and Schizophrenia; diagnoses were derived using Research Diagnostic Criteria (RDC). The families contained 18 cases of bipolar I disorder, 9 cases of bipolar II, and 18 cases of recurrent major depression. Genotypes were read independently by 2 persons blind to the diagnostic status of the family members; no genotypes were inferred by the file readers. Evidence of linkage was not found assuming either autosomal dominant or recessive transmission, although K1509 and K1575 were relatively uninformative for linkage. The non-parametric sibling pair test did not yield evidence of linkage. Data should be interpreted with caution, given the likelihood of genetic heterogeneity for MDI. _____
Title: Analysis of GABA-sub(A ) receptor subunit genes in multiplex pedigrees with manic depression. Author(s): Coon, H., U Utah School of Medicine, Dept of Psychiatry, Salt Lake City, US; Hicks, A. A.; Bailey, M. E. S.; Hoff, M.; et al. Source: Psychiatric Genetics, Vol 4(3), Fal 1994. pp. 185-191. Publisher: US: Lippincott Williams & Wilkins Abstract: Investigated gamma-aminobutyric acid (GABA) neurotransmitter receptors as a system of possible candidate genes for manic depression. Tests of this hypothesis can now be carried out due to the recent characterization of simple sequence repeat polymorphisms for the GABA-sub(A ) receptor alpha1, alpha2, alpha4, alpha5, alpha6, beta1, beta3 and gamma2 subunit genes. Using both parametric and non-parametric methods and lod score analysis, linkage between manic depression and these polymorphisms was tested in 6 multi-generational pedigrees. The 6 pedigrees contained 45 affected cases, 18 with bipolar I disorder, 9 with bipolar II disorder, and 18 with recurrent major depression. Diagnoses were made based on Research Diagnostic Criteria (RDC); high molecular weight DNA was isolated from either peripheral blood leukocytes or established cell line using a standard extraction method. No evidence of linkage was found, and results were also negative assuming recessive inheritance. _____
Title: Cation transport mediated by Na-super(+),K-super(+)-adenosine triphosphatase in lymphoblastoma cells from patients with bipolar I disorder, their relatives, and unrelated control subjects. Author(s): Cherry, Lorraine, U Texas Medical School, U Texas Mental Sciences Inst, Dept of Psychiatry & Behavioral Sciences, Houston, US; Swann, Alan C. Source: Psychiatry Research, Vol 53(2), Aug 1994. pp. 111-118. Publisher: United Kingdom: Elsevier Science Abstract: Examined cation transport in bipolar affective disorder, and measured parameters related to Na-super(+),K-super(+)-adenosine triphosphatase, the enzyme that carries out active transport of sodium and potassium, in lymphoblastoid cells cultured from 9 male patients (aged 41-86 yrs) with bipolar affective disorder, 7 age-matched nonaffected family relatives, and 8 unrelated controls. Patients had lower ion transport per cell and per transport enzyme site than did related or unrelated controls. The rate of transport per cell appeared higher in nonaffected relatives of patients than in unrelated controls, though this difference did not reach significance. Data suggest that abnormally regulated ion transport may be associated with bipolar affective disorder independently of clinical state. _____
Title: Reduction of brain phosphocreatine in bipolar II disorder detected by phosphorus-31 magnetic resonance spectroscopy. Author(s): Kato, Tadafumi, Shiga U of Medical Science, Dept of Psychiatry, Japan; Takahashi, Saburo; Shioiri, Toshiki; Murashita, Jun; et al. Source: Journal of Affective Disorders, Vol 31(2), Jun 1994. pp. 125-133. Publisher: United Kingdom: Elsevier Science Abstract: Measured brain phosphorus metabolism by phosphorus-31 magnetic resonance spectroscopy in 15 patients with bipolar II disorder (BP II) and 14 patients with bipolar I disorder (BP I). Phosphocreatine levels were significantly lower in patients with BP II in all 3 psychiatric states (hypomanic, euthymic, and depressed) compared to 59 normal controls. High values of phosphomonoester were found in BP II patients in the hypomanic and depressive states. Euthymic BP I patients had lower pH values. Results suggest that brain high energy phosphate metabolism may be impaired in BP II and that there may be pathophysiological differences between BP I and BP II. _____
Title: Lithium maintenance therapy for bipolar I patients: Possible refractoriness to reinstitution after discontinuation. Author(s): Murray, John B., St John's U, Psychology Dept, Jamaica, NY, US Source: Psychological Reports, Vol 74(2), Apr 1994. pp. 355-361. Publisher: US: Psychological Reports Abstract: Reviews the research literature on negative responsiveness in some bipolar I patients on attempts to reinstitute lithium (Li) treatment once discontinued. Some reports have indicated that certain patients, when treatment was discontinued, experienced recurrence of symptoms; when Li was reinstituted, the drug was no longer effective. T. Suppes et al (1991) found that the rate of recurrence of new episodes of illness in bipolar I patients taken off effective long-term Li was much higher than during Li treatment, and the risk of recurrence may have exceeded that predicted from spontaneous cycling rate in untreated bipolar patients. _____
Title: Bipolar affective puerperal psychosis associated with consanguinity. Author(s): Craddock, Nick, U Wales Coll of Medicine, Dept of Psychological Medicine, Cardiff, Wales; Brockington, Ian; Mant, Rebecca; Parfitt, Elizabeth; et al. Source: British Journal of Psychiatry, Vol 164, Mar 1994. Special issue: Depression. pp. 359-364. Publisher: United Kingdom: Royal College of Psychiatrists Abstract: During a linkage study of bipolar disorder, the authors identified a British family in which puerperal psychosis was associated with consanguinity in 3 sisters. All 3 Ss had lifetime Research Diagnostic Criteria diagnoses of bipolar I or manic disorder. An inbred brother also had bipolar I disorder. The only female member of the sibship to escape puerperal psychosis was outbred. Findings are consistent with several genetic models for bipolar disorder in this family. One possibility is a single major susceptibility locus of recessive effect. Under this assumption, the family could be used for homozygosity mapping to help localize the putative recessive locus. _____
Title: Phosphorus-31 magnetic resonance spectroscopy and ventricular enlargement in bipolar disorder. Author(s): Kato, Tadafumi, Shiga U of Medical Science, Dept of Psychiatry, Otsu, Japan; Shioiri, Toshiki; Murashita, Jun; Hamakawa, Hiroshi Source: Psychiatry Research: Neuroimaging, Vol 55(1), Mar 1994. pp. 41-50. Abstract: Examined whether reduced levels of phosphomonoesters (PME) were correlated with ventricular enlargement in 40 patients (mean age 42 yrs) with bipolar disorder (BD) and 60 age-matched normal controls. PME was measured by phosphorous-31 magnetic resonance spectroscopy, and ventricular enlargement was assessed by 3 methods of magnetic resonance imaging (MRI): Evans ratio (ER), Huckman number, and the minimum distance of caudate nuclei (MDCN). Ventricular size, as measured by ER and MDCN, was greater in 39 Ss with BD than in control Ss. PME values were negatively correlated with age in BD Ss, but not in controls. However, decreased levels of PME were found only in Ss with bipolar I disorder. Lowered intracellular pH among Ss with BD was positively correlated with lithium treatment. No correlation was found between PME and ventricular enlargement. _____
Title: Diagnostic issues in pedigree assessment. Series Title: Publication series of the Department of Psychiatry of Albert Einstein College of Medicine of Yeshiva University; 8 Author(s): Endicott, Jean, Columbia U, Coll of Physicians & Surgeons, Dept of Psychiatry, New York, NY, US; Baron, Miron Source: Genetic studies in affective disorders: Overview of basic methods, current directions, and critical research issues. Papolos, Demitri F. (Ed); Lachman, Herbert M. (Ed); pp. 28-45. Oxford, England: John Wiley & Sons, 1994. xvi, 236 pp. Abstract: (from the chapter) focuses on a number of issues related to diagnostic assessment, using the study of bipolar I disorder as the prototypic condition to illustrate the decisions that must be made by investigators who are conducting genetic linkage studies / these include those issues related to the initial selection of the families, those regarding which condition will be considered "affected" for the analyses, and those determining how to collect and record diagnostic information _____
Title: Familial psychiatric illness and obstetric complications in early-onset affective disorder: A case-control study. Author(s): Guth, Christian W., Wagner-Jauregg-Krankenhaus, Linz, Austria; Jones, Peter; Murray, Robin Source: British Journal of Psychiatry, Vol 163, Oct 1993. pp. 492-498. Publisher: United Kingdom: Royal College of Psychiatrists Abstract: Early-onset affective disorder is associated with obstetric complications and a high familial risk of psychiatric illness, in particular psychosis. In a matched case-control study, the authors investigated 47 adult inpatients with major depressive disorder or bipolar 1 disorder, who had earlier in life presented to a child psychiatry department. Cases were matched on sex, social class, and ethnic group with 47 controls who were admitted to hospitals for affective disorders in adult life but had no psychiatric contact before the age of 21 yrs. Both psychiatric disorder in 1st-degree relatives and a history of obstetric complications were associated with early onset. Childhood symptoms did not predict type of adult affective disorder. _____
Title: The distinction of bipolar II disorder from bipolar I and recurrent unipolar depression: Results of a controlled family study. Author(s): Heun, Reinhard , U Mainz, Germany; Maier, W. Source: Acta Psychiatrica Scandinavica , Vol 87(4), Apr 1993. pp. 279-284. Publisher: United Kingdom: Blackwell Publishing Abstract: Examined differences among bipolar II, bipolar I, and recurrent unipolar depression by their familial load for affective disorders. 80 bipolar, 108 unipolar, and 80 control Ss and their 1st-degree relatives were diagnosed according to Research Diagnostic Criteria using the Schedule for Affective Disorders and Schizophrenia--Lifetime Version. The morbid risks for bipolar I disorder were equivalent in relatives of bipolar I (3.6%) and bipolar II (3.5%) Ss and lower in relatives of unipolar Ss (1.0%). The morbid risks of relatives for bipolar II disorder distinguished bipolar II Ss (6.1%) from bipolar I Ss (1.8%), from unipolar depressives (0.3%), and from controls (0.5%). The author suggests that to promote future evaluation, bipolar II disorder should be included in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) as a distinct diagnostic category. _____
Title: Bipolar I: A five-year prospective follow-up. Author(s): Keller, Martin B., Brown U, Providence, RI, US; Lavori, Philip W.; Coryell, William; Endicott, Jean; et al. Source: Journal of Nervous & Mental Disease, Vol 181(4), Apr 1993. pp. 238-245. Publisher: US: Lippincott Williams & Wilkins Abstract: Explored the course of bipolar I illness in 172 Ss who were followed up prospectively for up to 5 yrs. Ss were grouped into 3 categories based on whether the symptoms of the index episode were only depressed, only manic, or mixed/cycling. Data were available for recovery from the index episode, subsequent relapse, and rates of recovery from the 1st prospective episode. Pure manic Ss had a significantly faster rate of recovery than the mixed/cycling Ss, and the pure depressive Ss had an intermediate rate. After 5 yrs of follow-up, the mixed/cycling Ss continued to have the lowest cumulative probability of recovery from the index episode. Mixed/cycling Ss also had a substantially faster time to relapse after recovery from the index episode compared with pure manic Ss. For those Ss who relapsed, the mixed/cycling Ss had the lowest cumulative probability of recovery from the 1st prospectively observed episode. _____
Title: Assessment of lineality in bipolar I linkage studies. Author(s): Simpson, Sylvia G., Johns Hopkins Hosp, Baltimore, MD, US; Folstein, Susan E.; Meyers, Deborah A.; DePaulo, J. Raymond Source: American Journal of Psychiatry, Vol 149(12), Dec 1992. pp. 1660-1665. Publisher: US: American Psychiatric Assn Abstract: Interviewed family members of 34 bipolar I probands to reclassify families initially categorized as unilineal by family history. Only 22 families were unilineal or probably unilineal, and 12 families were probably bilineal. The probably bilineal families had a significantly higher proportion of siblings with unipolar disorder. The affected sibs from the probably bilineal families tended to have earlier onsets but had significantly fewer symptoms in the most severe depressive episode. The phenotypic differences between the affected sibs of the different linealities suggest differences in genetic mechanisms. _____
Title: Risks of affective illness among first-degree relatives of bipolar I old-order Amish probands. Author(s): Pauls, David L., Yale U School of Medicine, Child Study Ctr, New Haven, CT, US; Morton, Lois A.; Egeland, Janice A. Source: Archives of General Psychiatry, Vol 49(9), Sep 1992. pp. 703-708. Publisher: US: American Medical Assn Abstract: Investigated the effect of age, sex of 1st-degree relatives, sex of proband, probands' age at onset, birth cohort of 1st-degree relatives, and generation on affected status of 1st-degree relatives in Amish families of 38 probands with bipolar I disorder. The age-corrected rates of bipolar I plus bipolar II disorder and major depressive disorder were 12.4% and 11.6%, respectively. Rates of illness were not different in male and female relatives or in the relatives of male and female probands. Ages at onset, when using definitions similar to those used in other studies, were also consistent with previous reports. Relatives of probands with an earlier onset were at an increased risk for development of illness. _____
Title: Alcohol and other drug abuse: Changing lives through research and treatment. Author(s): Primm, Beny , US Dept of Health & Human Services, Alcohol, Drug Abuse, & Mental Health Administration Office for Treatment Improvement, Rockville, MD, US Source: Journal of Health Care for the Poor & Underserved, Vol 3(1), Sum 1992. pp. 1-17. Publisher: US: Sage Publications Abstract: Discusses the high prevalence of comorbid alcohol, other drug, and mental disorders in the US and argues that medical education needs to stress the substance abuse (SAB) health needs of the poor and underserved. Approximately one-half of all people with a lifetime diagnosis of schizophrenia have experienced some type of SAB. SAB is identified in nearly 84% of individuals with antisocial personalities. Persons with Bipolar I disorders have a SAB rate of over 60%. _____
Title: Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Author(s): Suppes, Trisha, McLean Hosp Mailman Research Ctr, Labs for Psychiatric Research & Psychotic Disorders Program, Belmont, MA, US; Baldessarini, Ross J.; Faedda, Gianni L.; Tohen, Mauricio Source: Archives of General Psychiatry, Vol 48(12), Dec 1991. pp. 1082-1088. Publisher: US: American Medical Assn Abstract: Investigated the risk over time of recurrence of a manic or depressive episode following discontinuation of apparently effective long-term Li treatment in patients with bipolar I disorder. Data were derived from 14 studies. There was a marked difference in risk of bipolar I disorder episodes during continued vs discontinued Li treatment, with a 28-times higher monthly risk after stopping Li use; this supports the conclusion that long-term Li treatment can exert a powerful protective action in many responsive bipolar patients. There was a high early risk of recurrence of mania following abrupt discontinuation of Li. The overall survival time to 50% recurrence of 5 mo not only was shorter than during Li treatment but was also shorter than in previous untreated or spontaneous cycles of bipolar disorder. _____
Title: Decreased platelet serotonin uptake in bipolar 1 patients. Author(s): Marazziti, Donatella, U Pisa, Psychiatric Clinic Inst, Italy; Lenzi, Alessandro; Galli, Letizia; San Martino, Silvio; et al. Source: International Clinical Psychopharmacology, Vol 6(1), Spr 1991. pp. 25-30. Publisher: US: Lippincott Williams & Wilkins Abstract: Compared -1-4C-5-hydroxytryptamine (5-HT) uptake parameters (Vmax and Km) in 12 female patients (aged 22-43 yrs) diagnosed as affected by bipolar I disorder, with the uptake parameters of 12 healthy controls (aged 26-38 yrs). The uptake assay was performed according to the method of R. C. Arora and H. Y. Meltzer (1981). Vmax was significantly lower in bipolar Ss than in healthy Ss, with no modification of the Km. The changes in the Vmax indicate that they are related to changes in the number of carrier proteins for 5-HT. Findings support the notion of a complex alteration in the platelet 5-HT transporter mechanism occurring with mood disorders. _____
Title: The impact of phenotypic variation on genetic analysis: Application to X-linkage in manic-depressive illness. Author(s): Baron, Miron, Columbia U, Coll of Physicians & Surgeons, New York, NY, US; Hamburger, R.; Sandkuyl, L. A.; Risch, N.; et al. Source: Acta Psychiatrica Scandinavica , Vol 82(3), Sep 1990. pp. 196-203. Publisher: United Kingdom: Blackwell Publishing Abstract: Examined 5 large multiplex kindreds ascertained through probands with bipolar I disorder. 85% of the relatives were examined using a modified version of the Schedule for Affective Disorders and Schizophrenia. When applied to manic depressive disease, results indicate that previous evidence for a major gene localized on the distal long arm of the X-chromosome cannot be ascribed to phenotypic uncertainties (i.e., a type I error). X-linkage of manic depressive disease was robust over a range of phenotypic patterns. The X-linked type of manic depression seems to be a severe form of the illness, as evidenced by early age of onset, predominance of the bipolar form, and multiple episodes of unipolar depression. _____
Title: The unipolar)ipolar distinction in the characterological mood disorders. Author(s): Klein, Daniel N., State U New York, Stony Brook, US; Taylor, Ellen B.; Harding, Kathryn; Dickstein, Susan Source: Journal of Nervous & Mental Disease, Vol 178(5), May 1990. pp. 318-323. Publisher: US: Lippincott Williams & Wilkin Abstract: 13 cyclothymic and 32 primary early-onset dysthymic outpatients, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-III--Revised (DSM-III--R), were compared on demographic, clinical, personality, and family history variables. The cyclothymics exhibited significantly higher levels of depressive symptomatology and extraversion and had a higher rate of bipolar I disorder in their 1st-degree relatives than the dysthymics. In addition, a significantly greater proportion of cyclothymics than dysthymics had a family history of drug abuse. The groups did not differ significantly on gender, overall rates of affective disorders in relatives, or a number of symptoms that have been reported to distinguish unipolar and bipolar depressives. Data support extending the unipolar-bipolar distinction to the characterological mood disorders. _____
Title: Suicide in subtypes of primary major depression. Author(s): Rihmer, Zoltan, National Inst for Nervous & Mental Diseases, Budapest, Hungary; Barsi, Judit; Arato, Mihaly; Demeter, Erzsebet Source: Journal of Affective Disorders, Vol 18(3), Mar 1990. pp. 221-225. Publisher: United Kingdom: Elsevier Science Abstract: Analyzed the diagnostic subclassification and demographic and clinical features of 100 consecutive suicide victims with primary major depression (DP) in Hungary. At the time of their suicide, 46 Ss had bipolar II depression, 1 had bipolar I disorder, and 53 had nonbipolar major DP. Since the lifetime prevalence rates of bipolar II and bipolar I DPs are relatively low compared with primary major nonbipolar DP, findings suggest that bipolar II disorder gives a particularly high risk of suicide among the different subtypes of primary major affective illness. 59 Ss had medical contact during the depressive episode, but the DP was frequently undiagnosed, untreated, or undertreated. _____
Title: Bipolar affective disorder and high achievement: A familial association. Author(s): Coryell, William, U Iowa, Iowa City, US; Endicott, Jean; Keller, Martin; Andreasen, Nancy; et al. Source: American Journal of Psychiatry, Vol 146(8), Aug 1989. pp. 983-988. Publisher: US: American Psychiatric Assn Abstract: Studied 442 adult probands with nonbipolar major depression, 64 with bipolar II disorder, and 88 with bipolar I disorder. Although the proband groups did not differ in occupational or educational achievement, the 1st-degree relatives of probands with bipolar disorders had significantly higher mean levels of achievement. This pattern applied whether or not the relatives themselves had bipolar illness. The authors conclude that the socioeconomic advantage previously associated with affective disorder in general (e.g., C. Bagley) may be limited to the bipolar forms. _____
Title: Serum thyroxine levels in schizophrenic and affective disorder diagnostic subgroups. Author(s): Mason, John W., Veterans Administration Medical Ctr, West Haven, CT, US; Kennedy, James L.; Kosten, Thomas R.; Giller, Earl L. Source: Journal of Nervous & Mental Disease, Vol 177(6), Jun 1989. pp. 351-358. Publisher: US: Lippincott Williams & Wilkins Abstract: Serum free thyroxine (FT-sub-4) and total thyroxine (TT-sub-4) levels were measured at 2-wk intervals in 29 male inpatients (aged 20-58 yrs) in 4 diagnostic groups: paranoid schizophrenia (PS); undifferentiated schizophrenia; bipolar I disorder (BP), manic; and major depressive disorder, endogenous type. Findings showed a difference in the direction of both TT-sub-4 and FT-sub-4 change during clinical recovery in the PS group compared with the other 3 groups. Analysis of the change between admission and discharge values revealed significant differences between the mean rise in the PS group vs the mean decreases in the other 3 groups for TT-sub-4 and FT-sub-4. The significant difference observed between the FT-sub-4 levels of BP vs PS Ss at the time of hospital admission may have potential usefulness in the differential diagnosis of these 2 disorders. _____
Title: A family study of bipolar I disorder in adolescence: Early onset of symptoms linked to increased familial loading and lithium resistance. Author(s): Strober, Michael, U California, Neuropsychiatric Inst, Los Angeles, US; Morrell, Wendy; Burroughs, Jane; Lampert, Carlyn; et al. Source: Journal of Affective Disorders, Vol 15(3), Nov-Dec 1988. Special issue: Childhood affective disorders. pp. 255-268. Publisher: United Kingdom: Elsevier Science Abstract: Compared lifetime rates of psychiatric illness in relatives of 50 13-17 yr old probands with bipolar (BP) I disorder and in relatives of 31 age-matched schizophrenic controls. Familial aggregation of major affective disorders was observed in BP probands, with the rate of BP I disorder greatly exceeding that reported in relatives of adult BP probands. Adolescent probands with childhood onset of psychiatric disturbance were distinguished from probands who had no premorbid childhood psychiatric abnormality in 2 ways: (1) significantly increased aggregation of BP I disorder in 1st-degree relatives and (2) poorer antimanic response to lithium carbonate. _____
Title: The course of manic-depressive illness. Author(s): Keller, Martin B., Massachusetts General Hosp, Outpatient Research in Psychiatry, Boston, US Source: Journal of Clinical Psychiatry, Vol 49(Suppl), Nov 1988. pp. 4-6. Publisher: US: Physicians Postgraduate Press Abstract: Analyzed data on the course of illness in bipolar I disorder patients (63 with manic symptoms only [MSO]; 25 with depressed symptoms only [DSO]; and 67 with a combination of depressed and manic symptoms [DMS], either mixed or cycling). Ss received different types of treatment; to be considered recovered, Ss either had to have been asymptomatic or had to have had only 1 or 2 symptoms of minimal severity for 8 consecutive weeks. Results show that MSO Ss recovered at a much faster rate than did DMS Ss. DSO Ss at entry had intermediate courses. By 8 wks, 61% of the MSO Ss were recovered, compared with 44% of the DSO Ss and 33% of the DMS Ss. _____
Title: Carbamazepine and hyponatremia in patients with affective disorder. Author(s): Yassa, Ramzy, Douglas Hospital Ctr, Verdun, PQ, Canada; Iskandar, Hani; Nastase, Cristina; Camille, Yves Source: American Journal of Psychiatry, Vol 145(3), Mar 1988. pp. 339-342. Publisher: US: American Psychiatric Assn Abstract: Assessed 20 carbamazepine-treated adult patients for the development of hyponatremia. 18 Ss fulfilled Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for bipolar I disorder, 1 had bipolar II, and 1 had unipolar depression. None of the Ss had readings below 135 meq/liter of sodium before carbamazepine therapy, but 5 (25%) did have such readings after carbamazepine therapy. Three of these Ss developed frank symptoms of hyponatremia within 1-3 mo of the start of therapy. In one S hyponatremia developed after rechallenge with carbamazepine. The present authors suggest that caution be used in prescribing carbamazepine to patients with low or borderline low sodium values. _____
Title: Serum testosterone differences between patients with schizophrenia and those with affective disorder. Author(s): Mason, John W., Veterans Administration Medical Ctr, New Haven, CT, US; Giller, Earl L. ; Kosten, Thomas R. Source: Biological Psychiatry, Vol 23(4), Feb 1988. pp. 357-366. Publisher: United Kingdom: Elsevier Science Abstract: Measured serum testosterone levels (ng/dl) at 2-wk intervals during the course of hospitalization in 35 adult male inpatients in 4 diagnostic groups, including undifferentiated schizophrenia, paranoid schizophrenia, bipolar I disorder--manic, and major depressive disorder (endogenous type). The mean testosterone levels during hospitalization were significantly higher in the schizophrenic Ss than in the affective disorder Ss. Group differences were largely due to high testosterone levels in the paranoid schizophrenic subgroup. A longitudinal, as well as cross-sectional, view of the hormonal and clinical data suggested that the testosterone system was linked to both state and trait psychological factors. _____
Title: Delusional depression: Further evidence for genetic contribution. Author(s): Lykouras, Lefteris, Athens U Medical School, Eginition Hosp, Greece; Vassilopoulos, Dimitris; Voulgari, Argyro ; Stefanis, Costas ; et al. Source: Psychiatry Research, Vol 21(3), Jul 1987. pp. 277-283. Publisher: United Kingdom: Elsevier Science Abstract: To quantify the contribution of genetic factors in the pathogenesis of delusional depression, the incidence of major depression in 1,865 1st-degree relatives (i.e., parents and siblings) of 77 delusional (mean age 53.1 yrs) and 76 nondelusional (mean age 50.9 yrs) depressive patients and 153 age- and sex-matched controls was calculated in a case-control study. Assessments were based on interviews, medical records, and other available data. It was found that the morbid risk for psychiatric disorders, including major depression and bipolar I disorder, did not distinguish the 2 proband groups. However, the 1st-degree relatives of both groups were at a 5-7 times higher risk of major depression than the relatives of controls. Segregation analysis showed that a model of multifactorial inheritance fit the results best. _____
Title: The familial transmission of bipolar illness. Author(s): Rice, John, Jewish Hosp, Dept of Psychiatry, St Louis, MO; Reich, Theodore; Andreasen, Nancy C.; Endicott, Jean; et al. Source: Archives of General Psychiatry, Vol 44(5), May 1987. pp. 441-447. Publisher: US: American Medical Assn Abstract: Investigated the familial transmission of bipolar illness using data from the National Institute of Mental Health Collaborative Depression Program involving 2,225 relatives and 612 probands (aged 17 yrs or older). Data from 187 families of bipolar patients (149 probands with a diagnosis of bipolar I disorder and 38 with a diagnosis of schizoaffective, manic subtype) were analyzed. After defining the bipolar phenotype for analysis, a morbid risk estimate in relatives was obtained using 2 methods. The method of survival analysis was used to obtain the Kaplan-Meier estimate of the time to onset of bipolar illness. Relatives of probands with early onset were found to have a greater risk than relatives of probands with late onset. No evidence was found for sex-specific prevalences or for a sex-specific mode of transmission. _____
Title: Enhanced corticotropin response to corticotropin-releasing hormone as a predictor of mania in euthymic bipolar patients. Author(s): Vieta, Eduard, U Barcelona, Hosp Clinic, Dept of Psychiatry, Barcelona, Spain; Martinez-de-Osaba, M. J.; Colom, F.; Martinez-Aran, A.; Benabarre, A.; Gasto, C. Source: Psychological Medicine, Vol 29(4), Jul 1999. pp. 971-978. Publisher: US: Cambridge Univ Press Abstract: Dysregulation of corticotropin (ACTH) and cortisol response after corticotropin-releasing hormone (CRH) stimulation has been reported in bipolar patients. Most findings involve the pathophysiology of the depressive phase of the illness and its prediction. However, the possible predictive value of the CRH challenge test with respect to manic episodes remains unknown. The ACTH and free cortisol response to the injection of 100 mug of synthetic human CRH and plasma cortisol-binding globulin levels were measured in 42 lithium-treated patients suffering from Research Diagnostic Criteria bipolar I disorder in remission, and 21 age- and sex-matched normal controls. A 1-yr follow-up was conducted to assess any possible relationship between outcome and the hormonal response. Bipolar patients showed higher baseline and peak ACTH concentrations than control Ss. A higher area under ACTH concentration curve after CRH stimulation predicted manic/hypomanic relapse within 6 mo by multiple regression analysis. _____
Title: Use of clonazepam in an elderly bipolar patient with tardive dyskinesia: A case report. Author(s): Gerding, Lori B., Medical U of South Carolina, Charleston, SC, US; Labbate, Lawrence A. Source: Annals of Clinical Psychiatry, Vol 11(2), Jun 1999. pp. 87-89. Publisher: Netherlands: Kluwer Academic Publishers Abstract: Tardive dyskinesia (TD) is an adverse effect of long-term neuroleptic use. An effective treatment for TD is needed, especially if chronic neuroleptic therapy is indicated. Additionally, the treatment of TD in the elderly is not well established. This article presents the case study of an 81-yr-old male with a 50-yr history of bipolar I disorder who developed TD at age 75 yrs following use of various neuroleptic drugs including thioridazine, haloperidol, and risperidone. The Ss showed a significant reduction in dyskinetic and dystonic movements when treated with clonazepam. _____
Title: Impact of comorbid affective and alcohol use disorders on suicidal ideation and attempts. Author(s): Waller, Sharon J., Beth Israel Deaconess Medical Ctr, Dept of Psychiatry, Boston, MA, US; Lyons, John S.; Costantini-Ferrando, Maria F. Source: Journal of Clinical Psychology, Vol 55(5), May 1999. pp. 585-595. Publisher: US: John Wiley & Sons Abstract: The effect of concurrent affective and alcohol use disorders on suicidal ideation and behavior was investigated. The Diagnostic Interview Schedule Version III-R (DIS) was administered to 307 adult veteran men ranging in age from 23 to 78. Participants were classified into one of four groups based on their final DIS diagnosis--lifetime unipolar depression and lifetime bipolar I disorder with or without a lifetime alcohol use disorder. Logistic regression analyses indicated that veterans with a major affective disorder were at greater risk for suicidality than veterans without an affective disorder. However, veterans with unipolar depression were at no greater risk for suicidality than those with bipolar I disorder. Unipolar and bipolar I disorders with a concurrent alcohol use disorder were always associated with an increased risk for suicidality. _____
Title: Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features. Author(s): Cassano, Giovanni B., U Pisa, Inst of Psychiatry, Pisa, Italy; Pini, Stefano; Saettoni, Marco; Dell'Osso, Liliana Source: American Journal of Psychiatry, Vol 156(3), Mar 1999. pp. 474-476. Publisher: US: American Psychiatric Assn Abstract: Investigated frequencies and clinical correlates of multiple associations of panic disorder, obsessive-compulsive disorder (OCD), and social phobia in patients with severe mood disorders. 77 consecutively hospitalized adults (mean age 33.5 yrs) with psychotic symptoms and with a diagnosis of bipolar I disorder, major depression, or schizoaffective disorder, bipolar type participated. Principal diagnosis and comorbidity were assessed by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) Patient Version. Of the entire cohort, 33.8% had a single anxiety disorder and 14.3% had 2 or 3 comorbid diagnoses. Ss with multiple comorbidity had significantly higher scores on the Brief Psychiatric Rating Scale and SCL-90 and abused stimulants more frequently than did those without anxiety disorders. Multiple associations of panic disorder, OCD, and social phobia are not rare among Ss with affective psychoses and are likely to be associated with more severe psychopathology than is found in Ss without anxiety disorders. _____
Title: Severe peripheral polyneuropathy and rhabdomyolysis in lithium intoxication: A case report. Author(s): Su, Kuan-Pin, Taipei City Psychiatric Ctr, Taipei, Taiwan; Lee, Yue-Joe; Lee, Ming-Been Source: General Hospital Psychiatry, Vol 21(2), Mar-Apr 1999. pp. 136-137 Publisher: United Kingdom: Elsevier Science Abstract: This letter to the editor concerns a case report of a 61 yr old female who had bipolar I disorder for more than 30 yrs, and had been maintained on single lithium therapy (900 mg/day) for 11 yrs. She was sent to the emergency room in a coma and the authors suspected lithium intoxication. After two hemodialysis treatments, Ss serum lithium level was reduced to < 0.1 mg/dl, yet extensive symptoms persisted and she was sent to intensive care for a full screening for the cause of rhabdomyolysis. At posttreatment, the rhabdomyolysis improved and she regained consciousness, but there was digital sensory loss in all 4 limbs. Further tests indicated diffuse sensorimotor peripheral polyneuropathy with axonal degradation. Her condition improved and stabilized after 4 weeks of continued treatment. 11 reports of polyneuropathy following lithium intoxication have been published since 1977. The authors suggest that (a) subclinical rhabdomyolysis may be common in conditions having a strong relationship to lithium intoxication, and (b) a systematic clinical search for symptoms and signs as well as an electrophysiological search for peripheral neuropathy and myopathy in patients on lithium therapy is needed. _____
Title: Polarity sequence, depression, and chronicity in bipolar I disorder. Author(s): Turvey, Carolyn, U Iowa, Dept of Psychiatry, Iowa City, IA, US; Coryell, William H.; Arndt, Stephan; Solomon, David A.; Leon, Andrew C.; Endicott, Jean; Mueller, Timothy; Keller, Martin; Akiskal, Hagop Source: Journal of Nervous & Mental Disease, Vol 187(3), Mar 1999. pp. 181-187. Publisher: US: Lippincott Williams & Wilkins Abstract: Although studies have shown that episodes in which major depression (MD) precedes mania lead to higher morbidity than biphasic episodes which begin with mania, little is known about the prognostic significance of polarity sequence (PS) for long-term outcome. This study examined PS across multiple episodes among 165 bipolar I Ss followed prospectively for up to 15 yrs. Analyses examined wether PS was associated with episode duration in each of the 1st 4 prospectively observed episodes and whether affective polarity at the beginning of an episode was consistent across the 4 episodes. Whether or not episodes beginning with MD were associated with greater overall morbidity was also assessed. Assessments including the Schedule for Affective Disorders and Schizophrenia and versions of the Longitudinal Interview Follow-up Evaluation. Episodes beginning with MD were significantly longer than those beginning with mania for the 1st 3 prospectively observed episodes when pooling all episode types--monophasic, biphasic, and polyphasic. Furthermore, affective polarity at onset for the 1st prospectively observed episode was associated with polarity at onset for the remaining 3 episodes. Ss whose 1st episode began with MD had higher overall morbidity during the entire follow-up period. _____
Title: Case study: Carbamazepine treatment of juvenile-onset bipolar disorder. Author(s): Woolston, Joseph L., Yale U School of Medicine, Child Study Ctr, New Haven, CT, US Source: Journal of the American Academy of Child & Adolescent Psychiatry, Vol 38(3), Mar 1999. pp. 335-338. Publisher: US: Lippincott Williams & Wilkins Abstract: The literature devoted to juvenile-onset bipolar disorder has rapidly expanded in the past 5 yrs with an emphasis on new concepts of prevalence and comorbid conditions. In the process of enlarging the knowledge base about the phenomenology of juvenile-onset bipolar disorder, this new literature has generated considerable controversy but has provided little information about pharmacotherapy. This article presents 3 case studies of 12- and 13-yr-old girls and a 14-yr-old boy, in which carbamazepine appeared to be a safe and effective treatment for juvenile-onset bipolar disorder. All 3 cases had typical bipolar I symptom profiles including clearly defined manic episodes with primarily euphoric mood states. Controlled studies are necessary before any definitive conclusions can be reached about the efficacy of carbamazepine in the treatment of this form of bipolar disorder. _____
Title: Long-term prognosis of bipolar I disorder. Author(s): Turvey, Carolyn L., U Iowa, Dept of Psychiatry, Iowa City, IA, US; Coryell, W. H.; Solomon, D. A.; Leon, A. C.; Endicott, J.; Keller, M. B.; Akiskal, H. Source: Acta Psychiatrica Scandinavica, Vol 99(2), Feb 1999. pp. 110-119. Publisher: United Kingdom: Blackwell Publishing Abstract: Examined the contribution of demographic, syndromal, and longitudinal course variables to the long-term prognosis of 165 patients with bipolar disorder or schizoaffective mania, mainly affective type, prospectively observed over 10 yrs as part of the National Institute of Mental Health Collaborative Study of Depression (N. C. Andreasen et al, 1977, 1992). Although most baseline clinical and demographic variables were not strong prognostic indicators, switching polarity within episodes was. Most episodes among Ss with a poor prognosis were polyphasic, while most episodes among the Ss with a better prognosis were monophasic. There was no evidence of shortening of cycle lengths over follow-up for either the poor-prognosis group or the entire sample. The relevance of the findings to the "kindling" model is discussed. _____
Title: A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Author(s): Calabrese, Joseph R., Case Western Reserve U, Cleveland, OH, US; Bowden, Charles L.; Sachs, Gary S.; Ascher, John A.; Monaghan, Eileen; Rudd, G. David Source: Journal of Clinical Psychiatry, Vol 60(2), Feb 1999. pp. 79-88. Publisher: US: Physicians Postgraduate Press Abstract: This is the first controlled multicenter study evaluating lamotrigine monotherapy in the treatment of bipolar I depression. 195 outpatients (aged 19-75 yrs) with bipolar I disorder experiencing a major depressive episode received lamotrigine or placebo as monotherapy for 7 wks. Psychiatric evaluations, including the Hamilton Rating Scale for Depression (HAM-D), the Montgomery-Asberg Depression Rating Scale (MADRS), Mania Rating Scale, and the Clinical Global Impressions scale for Severity (CGI-S) and Improvement (CGI-I) were completed at each weekly visit. Lamotrigine 200 mg/day demonstrated significant antidepressant efficacy on the 17-item HAM-D, HAM-D Item 1, MADRS, CGI-S, and CGI-I compared with placebo. Improvements were seen as early as week 3. Lamotrigine 50 mg/day also demonstrated efficacy compared with placebo on several measures. The proportions of patients exhibiting a response on CGI-I were 51%, 41%, and 26% for lamotrigine 200 mg/day, lamotrigine 50 mg/day, and placebo groups, respectively. Adverse events and other safety results were similar across treatment groups, except for a higher rate of headache in the lamotrigine groups _____
Title: A method for classifying the course of bipolar I disorder. Author(s): Kalbag, Aparna S., U Colorado at Boulder, Boulder, CO, US; Miklowitz, David J., U Colorado at Boulder, Boulder, CO, US; Richards, Jeffrey A., U Colorado at Boulder, Boulder, CO, US Address: Miklowitz, David J., Dept of Psychology, U Colorado at Boulder, Campus Box 345, Boulder, CO, US Source: Behavior Therapy , Vol 30(3), 1999. pp. 355-372. Publisher: US: Assn for the Advancement of Behavior Therapy Abstract: Our objective was to determine whether the long-term course of bipolar disorder could be classified into distinct categories based on specifiable course characteristics. We used retrospective data on the severity, duration, and polarity of episodes, and on interepisode functioning, to describe the life trajectories of 56 bipolar patients (aged 34.3-42 yrs). Using pictorial representations from a Life Chart software program, we identified seven distinct course types. Interrater reliability for classification of patients into these course types was high. Post-hoc analysis revealed significant relationships between the broader dimensions underlying the proposed course types and traditional course of illness variables. This course classification method may provide a means for documenting progress in behavior therapy outcome studies. _____
Title: Diagnostic certainty of a voluntary bipolar disorder case registry. Author(s): Cluss, Patricia A., U Pittsburgh, School of Medicine, Western Psychiatric Inst & Clinic, Dept of Psychiatry, Pittsburgh, PA, US; Marcus, Steven C.; Kelleher, Kelly J.; Thase, Michael E.; Arvay, Lisa A.; Kupfer, David J. Source: Journal of Affective Disorders, Vol 52(1-3), Jan-Mar 1999. pp. 93-99. Publisher: United Kingdom: Elsevier Science Abstract: The development and implementation of a bipolar disorder case registry and the assessment of diagnostic certainty of the resulting sample are described. 804 individuals (aged 18-65+ yrs) who self-reported a history of bipolar disorder were recruited. Telephone interviewers gathered demographic information and clinical, medical, and treatment history information. 100 randomly-selected registrants completed an in-person structured diagnostic interview. Self-report of diagnosis was compared to the results of the diagnostic interview. 93% of registrants interviewed met criteria for a lifetime bipolar spectrum diagnosis; of those, 76.3% were diagnosed with bipolar I disorder. Agreement between self-reported and structured clinical interview diagnoses was 93%, indicating that self-report of a bipolar diagnosis is highly reliable. Two-thirds had experienced at least one other lifetime Axis I diagnosis, with substance abuse/dependence (55.9%) and panic disorder (19.4%) the most common comorbidities. Persons with bipolar disorder can accurately identify themselves as having the disorder via a telephone interview, indicating that a case registry method is a useful strategy for recruiting very large samples of persons with this disorder. _____
Title: Mood stabilizers and the evolution of maintenance study designs in bipolar I disorder. Author(s): Calabrese, Joseph R., Case Western Reserve U School of Medicine, Dept of Psychiatry, Mood Disorders Program, Cleveland, OH, US; Rapport, Daniel J. Source: Journal of Clinical Psychiatry, Vol 60(Suppl 5), 1999. pp. 5-13. Publisher: US: Physicians Postgraduate Press Abstract: The designs employed in bipolar maintenance studies have evolved greatly over the last 28 yrs. Consequently, there has been minimal consensus set for methods used to demonstrate the ability of any new putative mood stabilizers to prevent relapse and recurrence in bipolar disorder. The methods that have evolved the most include enrollment procedures, randomization schemes, use of outcome measures, statistical analyses, and country-specific commercial and regulatory issues. The authors contrast the various methods employed in 1st- and 2nd generation placebo-controlled bipolar I maintenance studies. The authors also explore the advantages and disadvantages associated with various designs. _____
Title: Treatment of bipolar mixed state with olanzapine. Author(s): Sharma, Verinder, London Psychiatry Hosp, Mood Disorders Unit, London, ON, Canada; Pistor, Lino Source: Journal of Psychiatry & Neuroscience, Vol 24(1), Jan 1999. pp. 40-44. Publisher: Canada: Canadian Medical Assn Abstract: An open trial was conducted to determine the efficacy of olanzapine in the treatment of bipolar mixed state in 9 inpatients (aged 21-56 yrs) with treatment-resistant bipolar I disorder, most recent episode mixed. Olanzapine was added to the existing drug regimes of these Ss who had failed to respond to adequate trials of mood stabilizers used alone or in combination with neuroleptics. Ss were administered the Clinical Global Impression (CGI) Scale, the Brief Psychiatric Rating Scale (BPRS), and the Global Assessment of Functioning (GAF) Scale before the initiation of olanzapine. These scales were repeated and patients were rated on the improvement subscale of the CGI at the time of discharge (length of hospital stay ranged from 3-316 days). Pretreatment means (and standard deviations [SDs]) for the CGI scale, BPRS, and GAF were 5.7 (1.1), 60.7 (13.7) and 17.8 (7.5), respectively. Post-treatment means and SDs for the scales were 1.9 (0.6), 6.3 (3.3), and 71.7 (5.6), respectively. Paired t-tests on all measures indicated significant improvement in symptoms. The mean improvement subscale score of the CGI was 1.3 (SD 0.5) at discharge. Olanzapine was well-tolerated and was effective in the acute treatment of bipolar mixed state. _____
Title: Switching to moclobemide to reverse fluoxetine-induced sexual dysfunction in patients with depression. Author(s): Ramasubbu, Rajamannar, Royal Ottawa Hosp, Specialty Program, Ottawa, ON, Canada Source: Journal of Psychiatry & Neuroscience, Vol 24(1), Jan 1999. pp. 45-50. Publisher: Canada: Canadian Medical Assn Abstract: Used a prospective open trail to examine the efficacy of substituting moclobemide, a reversible monoamine oxidase-A inhibitor, for fluoxetine for reversing fluoxetine-induced sexual dysfunction in patients with depression. Five outpatients (aged 27-50 yrs) with depressive disorders (dysthymia, major depression, or bipolar I disorder) who experienced sexual side effects during treatment with standard doses of fluoxetine (20 to 40 mg per day) discontinued fluoxetine and initiated moclobemide (300 to 600 mg per day) after a 2-wk washout period. Libido, orgasmic function (in women) or erectile and ejaculatory function (in men), and overall improvement in sexual function during a follow-up period of 2 mo to 3 yrs. Results: Among patients receiving fluoxetine questioned about sexual side effects, 4 (1 man and 3 women) had treatment-related diminished libido with poor orgasmic response or partial erectile failure, and 1 female patient had enhanced sexual desire with intense clitoral stimulation. In all patients, sexual disturbances resolved completely after the 2-wk washout period and a switch to treatment with moclobemide. Moclobemide was well tolerated, with no sexual side effects and an antidepressant effect comparable to that of fluoxetine. _____
Title: Olanzapine for mixed episodes of bipolar disorder. Author(s): Zullino, Daniele, Clinique de Cery, Dept Universitaire de Psychiatrie Adulte, Prilly-Lausanne, Switzerland; Baumann, Pierre Source: Journal of Psychopharmacology, Vol 13(2), 1999. pp. 198. Publisher: US: Sage Publications Abstract: Notes the difficulty in the pharmacologic treatment of mixed bipolar states. The authors briefly report the case of a 50-yr-old woman with a 10-year history of bipolar I disorder, including 21 hospitalizations for mania or mixed episodes, and the results of 3 weeks of treatment with olanzapine (15 mg/day). _____
Title: Association of recurrent sucidal ideation with nonremission from acute mixed mania. Author(s): Goldberg, Joseph F., New York Hosp, Payne Whitney Clinic, New York, NY, US; Garno, Jessica L.; Leon, Andrew C.; Kocsis, James H.; Portera, Laura Source: American Journal of Psychiatry, Vol 155(12), Dec 1998. pp. 1753-1755. Publisher: US: American Psychiatric Assn Abstract: Examined suicidality in relation to acute symptom remission in inpatients with mixed and pure bipolar disorder. Using chart reviews of 184 adult inpatients with bipolar I disorder, the authors assessed patients' past and current suicidality, other psychopathology, treatment, and remission. Past, current, and recurrent suicidality were significantly more common among patients with mixed mania than among those with pure mania. The probability of remission declined by 49% for every suicide attempt made before the index manic episode. Mixed mania, multiple previous hospitalizations, and previous suicide attempts were significantly associated with current suicidality. _____
Title: Bipolar II depressed outpatients are frequent: A 423-case study. Author(s): Benazzi, Franco Source: Canadian Journal of Psychiatry, Vol 43(9), Nov 1998. pp. 954. Publisher: Canada: Canadian Psychiatric Assn Abstract: Sought to find the proportion of persons with bipolar II disorder among outpatients with a major depressive episode who had been diagnosed with a major depressive, bipolar I, or bipolar II disorder. 423 consecutive major depressive, bipolar I, and bipolar II disorder outpatients presenting for treatment of a major depressive episode to a private practice were interviewed. Bipolar II disorder was present in 44.9% of patients, bipolar I disorder in 4%, and major depressive disorder in 51%. Results suggest that bipolar II disorder is common among unipolar and bipolar outpatients with a major depressive episode. _____
Title: Algorithms for dsm-iv psychiatric diagnoses using the fh-rdc in a community sample. Author(s): Farwell, Dianna, U South Carolina, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 59(5-B), Nov 1998. pp. 2151. Publisher: US: Univ Microfilms International Abstract: Objectives. This study used the Family History-Research Diagnostic Criteria (FH-RDC) in a population of late adolescents to: (1) develop algorithms for constructing diagnoses for 25 disorders in the FH-RDC using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (2) compare diagnoses in older adolescents as determined by the FH-RDC and K-SADS-P and (3) compare the weighted prevalence estimates of disorders for the community sample of 4,113 students and their relatives to the lifetime prevalence estimates reported in the DSM-IV. Methods. Data were obtained from a second wave of a longitudinal study of major depressive disorder in a community sample of adolescents (Garrison et al., 1991, 1992). Algorithm development was completed by comparing the FH-RDC to the diagnostic criteria in the DSM-IV. The Kappa statistic compared the agreement of diagnoses in older adolescents as determined by the FH-RDC algorithms with the K-SADS-P diagnoses when both interview schedules were completed by the same informant (n = 364). Prevalence estimates for the community sample using the FH-RDC algorithms were compared to lifetime prevalence estimates in the DSM-IV. Results. No cases of bulimia, obsessive compulsive disorder, panic with agoraphobia and schizophrenia were identified using either the FH-RDC or the K-SADS-P. Dysthymia, bipolar I disorder, bipolar II disorder, generalized anxiety disorder, anorexia and schizoaffective disorder indicated no agreement above chance. Remaining Kappas ranged from 0.09 for phobias to 0.41 for conduct disorder showing poor agreement above chance. In the community sample anorexia was the only disorder to fall within the range of reported prevalence estimates for females in the DSM-IV. Conclusions. This is the first study to compare the K-SADS-P to the FH-RDC. The results were similar to other studies that compared the FH-RDC to the SADS-L. Overall, results indicated lower prevalence estimates from the FH-RDC than those reported in the DSM-IV. The results suggest revisions to the FH-RDC to enhance the quality of data collected for adults, and to develop a child and adolescent version of the FH-RDC. _____
Title: Mania associated with donepezil. Author(s): Benazzi, Franco, Public Hosp "Morgagni", Forli, Italy Source: International Journal of Geriatric Psychiatry, Vol 13(11), Nov 1998. pp. 814-815. Publisher: US: John Wiley & Sons Abstract: Presents the cases of 2 women who became manic after treatment with donepezil, a new cholinesterase inhibitor for the therapy of Alzheimer's disease (AD). The Ss were a 78-yr-old with a major depressive episode associated with memory impairment and a 64-yr-old with bipolar I disorder (depressed) and memory problems. When donepezil was added to their current drug regimens both Ss experienced mania, which subsided when the donepezil was discontinued. Findings suggest that donepezil, despite in cholinergic action, may have some mood- elevating effects, alone or in combination with other psychoactive drugs. _____
Title: Premorbid functioning in adolescent onset bipolar I disorder: A preliminary report from an ongoing study. Author(s): Kutcher, Stan, Dalhousie U, Dept of Psychiatry, Halifax, NS, Canada; Robertson, Heather A.; Bird, Diane Source: Journal of Affective Disorders, Vol 51(2), Nov 1998. Special issue: Current issues in childhood biopolarity. pp. 137-144. Publisher: United Kingdom: Elsevier Science Abstract: Examined premorbid academic and peer functioning and psychiatric illness in a rigorously diagnosed sample of 28 adolescent onset bipolar I patients (mean age 16.7 yrs). Premorbid functioning was assessed by parental report and review of the Ontario School Record (OSR). Premorbid psychiatric diagnoses were assigned on the basis of all information gathered. Overall, findings suggest that this cohort demonstrates good to excellent peer and academic functioning prior to illness onset. Rates of premorbid psychiatric illnesses were similar to that described in epidemiologic samples. Results are discussed in relation to current understanding of early onset bipolar illness and directions for future research. _____
Title: Bipolar I affective disorder: Predictors of outcome after 15 years. Author(s): Coryell, William, U Iowa, Coll of Medicine, Psychiatry Research, Iowa City, IA, US; Turvey, Carolyn; Endicott, Jean; Leon, Andrew C.; Mueller, Timothy; Solomon, David; Keller, Martin Source: Journal of Affective Disorders, Vol 50(2-3), Sep 1998. Special issue: George Winokur. pp. 109-116. Publisher: United Kingdom: Elsevier Science Abstract: In this study, 113 patients (aged 17+ yrs) with bipolar affective disorder were followed semiannually for 5 yrs and annually for a subsequent 15 yrs. Of these, 23 (20.4%) had a poor long-term outcome indicated by the presence of mania or major depressive disorder throughout the 15th yr. Among the baseline demographic and clinical variables tested, only active alcoholism and low levels of optimum functioning in the preceding 5 yrs characterized poor outcome patients. The persistence of depressive symptoms in the first 2 yrs of follow-up predicted depressive symptoms 15 yrs later but the early persistence of manic symptoms seemed to have no predictive value. A regression analysis eliminated alcoholism as an independent predictor. Thus, only poor optimal functioning in the 5 yrs before baseline assessment, and the persistence of depressive symptoms in the 2 subsequent yrs, were independently associated with poor, long-term prognosis. _____
Title: Bipolar disorders in DSM-IV: Impact of inclusion of rapid cycling as a course modifier. Author(s): Dunner, David L., U Washington, Dept of Psychiatry & Behavioral Sciences, Seattle, WA, US Source: Neuropsychopharmacology, Vol 19(3), Sep 1998. pp. 189-193. Publisher: United Kingdom: Nature Publishing Abstract: In this paper, we review the process for inclusion of rapid cycling as a course modifier to bipolar disorders in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). This process involved definition of bipolar II disorder, delineating the duration of manic episode for bipolar I disorder, and clarification of the diagnosis of cyclothymic disorder and mixed mania. _____
Title: New perspectives in the treatment of acute mania: A single case report. Author(s): Erfurth, Andreas, U Munich, Dept of Psychiatry, Munich, Germany; Grunze, Heinz Source: Progress in Neuro-Psychopharmacology & Biological Psychiatry, Vol 22(6), Aug 1998. pp. 1053-1059. Publisher: United Kingdom: Elsevier Science Abstract: There is increasing evidence that standard treatment of mania with lithium or neuroleptics fails in many subtypes of mania, e.g. dysphoric mania or rapid cycling, and that new strategies are needed. This single case report describes the possibilities and pitfalls in alternative attempts to tackle a severe manic syndrome successfully. In this patient, a 49-yr-old saleswoman with the diagnosis of bipolar I disorder, lamotrigine and valproate, the latter only in an iv formulation, led to relief from manic symptoms. It is concluded that the success of this treatment may be due to a common underlying mechanism of action of these drugs, most likely on the level of ion channel regulation, and that farther experience with alternative formulations of standard treatments such as valproate iv should be collected. _____
Title: Bipolar disorder and panic disorder in families: An analysis of chromosome 18 data. Author(s): MacKinnon, Dean F., Johns Hopkins U, School of Medicine, Dept of Psychiatry, Baltimore, MD, US; Xu, Jianfeng; McMahon, Francis J.; Simpson, Sylvia G.; Stine, O. Colin; McInnis, Melvin G.; DePaulo, J. Raymond Source: American Journal of Psychiatry, Vol 155(6), Jun 1998. pp. 829-831. Publisher: US: American Psychiatric Assn Abstract: Performed an analysis of the authors' published chromosome 18 linkage data on 28 families in which there was bipolar disorder to test the potential of comorbid panic disorder to define a genetic subtype of bipolar disorder. Families ascertained through probands with bipolar I disorder were stratified into 3 groups based on a history of panic disorder, panic attacks, or no panic attacks in the probands. Multipoint nonparametric linkage analysis was performed on data from bipolar I and II family members in each group. Linkage scores for 5 consecutive 18q marker loci were highest in the families of the probands with panic disorder and lowest for the families of the probands without panic attacks. These results supports the authors' previously reported clinical hypothesis of a genetic subtype of bipolar disorder identified by comorbid panic disorder. _____
Title: No association between the tyrosine hydroxylase microsatellite marker HUMTH01 and schizophrenia or bipolar I disorder. Author(s): Burgert, E., U Freiburg, Inst fuer Humangenetik & Anthropologie, Freiburg, Germany; Crocq, M.-A.; Bausch, E.; Macher, J.-P. Morris-Rosendahl, D. J. Source: Psychiatric Genetics, Vol 8(2), Sum 1998. pp. 45-48. Publisher: US: Lippincott Williams & Wilkins Abstract: Linkage and association studies have implicated the involvement of the tyrosine hydroxylase (TH) gene on chromosome 11p15 in schizophrenia (SCZ) and bipolar disorder (BPD). An association of BPD with a polymorphic tetranucleotide repeat, HUMTH01, located in the first intron of the human TH gene has been reported. Subsequently a rare allele, E-sub(p ) ([TCAT]-sub-1-sub-0) of this microsatellite marker has been found in French and Tunisian SCZ patients only. The current study genotyped a different sample of unrelated French SCZ and BPD patients and matched controls for this polymorphic tetranucleotide repeat sequence. The E-sub(p ) allele was insignificantly more common in controls than in SCZ patients, thus not showing a particular association with SCZ. Nevertheless, there was a non-significant trend towards an association between HUMTH01 allele D ([TCAT]-sub-9) and SCZ. No association was apparent between HUMTH01 and BPD. _____
Title: Olanzapine in treatment-resistant bipolar disorder. Author(s): McElroy, Susan L., U Cincinnati, Coll of Medicine, Dept of Psychiatry, Cincinnati, OH, US; Frye, Mark; Denicoff, Kirk; Altshuler, Lori; Nolen, Willem; Kupka, Ralph; Suppes, Trisha; Keck, Paul E. Jr.; Leverich, Gabrielle S.; Kmetz, Geri F.; Post, Robert M. Source: Journal of Affective Disorders, Vol 49(2), May 1998. pp. 119-122. Publisher: United Kingdom: Elsevier Science Abstract: 14 patients with bipolar I disorder by DSM-IV criteria who experiencing persistent affective symptoms inadequately responsive to at least one standard mood stabilizer were treated with open-label olanzapine by one of the authors. Response was assessed with the Clinical Global Impression Scale modified for use in bipolar disorder (CGI-BP). Patients received olanzapine at a mean SD dosage of 14.1+-7.2 (range 5-30) mg/day for a mean+-SD of 101.4+-56.3 (range 30-217) days of treatment. Of the 14 patients, 8 (57%) displayed much or very much overall improvement in their illness. In general, olanzapine was well tolerated. The most common side effects were sedation, tremor, dry mouth, and appetite stimulation with weight gain. Data were obtained nonblindly and without a randomized control group, and olanzapine was added to ongoing psychotropic regimens. Olanzapine may have antimanic and mood-stabilizing effects in some patients with bipolar disorder, and is generally well tolerated. Controlled studies of olanzapine in bipolar disorder appear warranted. _____
Title: Tobacco smoking and bipolar disorder. Author(s): Gonzalez-Pinto, Ana, U Kentucky Mental Research Ctr, Eastern State Hosp, Lexington, KY, US; Gutierrez, Miguel; Ezcurra, Jesus; Aizpuru, Felipe; Mosquera, Fernando; Lopez, Purificacion; de Leon, Jose Source: Journal of Clinical Psychiatry, Vol 59(5), May 1998. pp. 225-228. Publisher: US: Physicians Postgraduate Press Abstract: Determined whether tobacco smoking would be associated with bipolar disorder. Ss were 51 patients with bipolar I disorder and 517 controls. Smoking history of bipolar patients was assessed with the Fagerstrom Test for Nicotine Dependence and was verified by family members of the patients. The frequencies of ever smoking and current daily smoking were 63% and 51%, respectively, for the bipolar patients and 45% and 33% respectively, for the controls. The differences were significant for bipolar vs control males. Bipolar disorder in both genders was also significantly associated with heavy smoking. _____
Title: Premature polypsychopharmacology. Author(s): Preda, Adrian, Yale U, School of Medicine, Dept of Psychiatry, New Haven, CT, US; Madlener, Alex ; Hetherington, Pamela Source: Journal of the American Academy of Child & Adolescent Psychiatry, Vol 37(4), Apr 1998. pp. 348-349. Publisher: US: Lippincott Williams & Wilkins Abstract: Describes a 10-yr-old female admitted to a psychiatry inpatient unit with the provisional diagnosis of bipolar I disorder (BD), manic with psychotic features. Prior to admission unsuccessful attempts at treatment had included the use of sertraline, methylphenidate, valproic acid, thioridazine, perphennazine, and lorazepam. After an extensive review of the records and family evaluation, the authors discontinued the medications because of their concern that the symptoms were not due to BD or a psychotic disorder. Rather, the symptom complex appeared to be better explained by psychological conflict caused by the divorce of the S's parents. After 2 wks of individual psychotherapy, the S was discharged without medications and without bipolar or psychotic symptoms. Discharge diagnoses were adjustment disorder and oppositional defiant disorder. The authors state that multiple drug treatment in children should be considered only after diagnostic clarification, consideration of psychological factors, and adequate drug monotherapy. _____
Title: Comorbidity of personality disorders with bipolar mood disorders. Author(s): Ucok, Alp, Istanbul Medical School, Dept of Psychiatry, Mood Disorders Unit, Istanbul, Turkey; Karaveli, Deniz; Kundakci, Turgut; Yazici, Olcay Source: Comprehensive Psychiatry, Vol 39(2), Mar-Apr 1998. pp. 72-74. Publisher: United Kingdom: Elsevier Science Abstract: Assessed the prevalence of personality disorders in a group of outpatients with bipolar I disorder. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) Personality Disorders (SCID-II) was administered to 90 bipolar outpatients (mean age 36.1 yrs) who met the DSM-III-R criteria, and 58 control Ss. Of the patients and controls, 47.7% and 15.5%, respectively, had at least 1 personality disorder. At least 1 personality disorder in clusters A, B, and C, and obsessive compulsive, paranoid, histrionic, and borderline personality disorders were significantly more prevalent in bipolar Ss. Suicide attempts were more frequent in patients with a history of personality disorder. _____
Title: Can interpersonal life events predict recurrences in bipolar disorder? Author(s): Mofson, Marcia S., U Texas Southwestern Medical Center at Dallas, US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 58(8-B), Feb 1998. pp. 4461. Publisher: US: Univ Microfilms International Abstract: Although considered primarily biological in nature, bipolar disorder is a stress-sensitive illness. Literature reviewed has shown that a high percentage of bipolar patients experience stressful life events, particularly interpersonal events, prior to episodes of mania or depression. The congruency hypothesis (Hammen, Marks, Mayol, & deMayo, 1985) suggests that episodes of illness are most likely to follow life events which match the individual's type of vuinerability. This study explored the existence of an identifiable "interpersonal vulnerability," including interpersonal sensitivity, beliefs about relationships, interpersonal problem-solving skill, and social support, and examined factors which differentiated persons who were most likely to experience recurrences following life events. Seventeen individuals were included in the final sample, meeting inclusion criteria of diagnosis of Bipolar I disorder, non-rapid cycling, at least 30 years old, with distinct "well periods" between episodes of illness. Participants were given an extensive life history interview, including course of illness, significant life events, and treatment history, and completed self-report measures of factors of interpersonal vulnerability. Life events were categorized as interpersonal, non-interpersonal, or reproductive, based on the Life Events and Difficulties Schedule (LEDS). Occurrence and polarity of episodes were determined based on DSM-III-R criteria. A time period of six months was utilized to determine whether an episode was preceded by a life event. For the entire sample, the likelihood that episodes of illness were preceded or not preceded by life events was equivalent, for early episodes (1 and 2) and for later episodes, and for both interpersonal events and non-interpersonal events. No association was found between type of life event and polarity of episodes. A group of individuals was found for whom >90% of episodes followed life events. These individuals showed a trend toward more dysfunctional beliefs about relationships, lower perceived social support, and had significantly higher rates per month of both life events and episodes. Results of this study are related to literature review. The possible role of cognitions on vulnerability is discussed, as well as theoretical and clinical implications of being able to identify and intervene with vulnerable individuals. _____
Title: Rapid efficacy of olanzapine augmentation in nonpsychotic bipolar mixed states. Author(s): Ketter, Terence A.; Winsberg, Mirene E.; DeGolia, Sallie G.; Dunai, Magdolna; Tate, Debbie L.; Strong, Connie M. Source: Journal of Clinical Psychiatry , Vol 59(2), Feb 1998. pp. 83-85. Publisher: US: Physicians Postgraduate Press Abstract: Presents cases of 2 patients, a 34-yr-old man and a 47-yr-old woman, with bipolar I disorder with nonpsychotic mixed states who had rapid dramatic improvement with the addition of olanzapine to mood stabilizers. The addition of olanzapine yielded direct mood stabilization or provided an indirect benefit by improving sleep. Hospitalization was avoided in 1 case and limited to only 2 days in the other. Thus, olanzapine augmentation appeared to limit not only patient suffering but also hospitalization costs. _____
Title: Lithium plus valproate as maintenance polypharmacy for patients with bipolar I disorder: A review. Author(s): Solomon, David A., Brown U, Dept of Psychiatry & Human Behavior, Rhode Island Hosp, Mood Disorders Program, Providence, RI, US; Keitner, Gabor I.; Ryan, Christine E.; Miller, Ivan W. Source: Journal of Clinical Psychopharmacology, Vol 18(1), Feb 1998. pp. 38-49. Publisher: US: Lippincott Williams & Wilkins Abstract: Reviews evidence of the need for polypharmacy, describes the prevalence of this clinical practice, and specifically examines the effectiveness of combining lithium and valproate in treating bipolar I disorder. Findings from some open-label trials and retrospective chart reviews suggest that polypharmacy may be useful, but in the few controlled trials that have been conducted, the results have been negative. Some preliminary evidence suggests that the combination of lithium and valproate can be effective for patients who do not respond to monotherapy, and it seems to be no more dangerous than monotherapy. Concomitant administration of lithium plus valproate does not significantly alter lithium pharmacokinetics, and there is no indication of pharmacodynamic interactions that oppose each other. The authors conclude that a properly designed study is necessary to definitively determine the efficacy of this combination. _____
Title: Pharmacological treatment of bipolar disorders. Author(s): Keck, Paul E. Jr. , U Cincinnati, Coll of Medicine, Dept of Psychiatry & Pharmacology, Cincinnati, OH, US; McElroy, Susan L. Source: A guide to treatments that work. Nathan, Peter E. (Ed); Gorman, Jack M. (Ed); pp. 249-269. London,: Oxford University Press, 1998. xxx, 594 pp. Abstract: (from the chapter) This chapter reviews treatment of bipolar I disorder. Since the pharmacological management of bipolar I disorder involves the acute treatment of manic and depressive episodes and maintenance treatment to prevent cycling and recurrent affective episodes, we review studies of both acute and maintenance treatment. Because studies of the pharmacological treatment of bipolar disorder vary in design, we attempt to make careful distinction between conclusions based on randomized, controlled trials as compared to case reports, case series, or open trials. _____
Title: Gabapentin in the treatment of adolescent mania: A case report. Author(s): Soutullo, Cesar A., U Cincinnati, Coll of Medicine, Biological Psychaitry Program, Cincinnati, OH, US; Casuto, Leah S.; Keck, Paul E. Jr. Source: Journal of Child & Adolescent Psychopharmacology, Vol 8(1), 1998. pp. 81-85. Publisher: US: Mary Ann Liebert Publishers Abstract: Describes the use of add-on gabapentin in the treatment of a 13-yr-old male with bipolar I disorder, manic episode, and attention deficit hyperactivity disorder (ADHD). The S showed a marked response within 1 mo. He remained euthymic 7 mo after gabapentin was added. His Young Mania Rating Scale (R. C. Young et al, 1978) score was 27 when gabapentin was added, 9 after 1 mo, 15 after 4 mo, and 6 after 7 mo. Controlled studies are needed to evaluate the possible anti-manic, mood stabilizing, and/or anti-depressant properties of gabapentin in youth. _____
Title: Bipolar depression: Specific treatments. Author(s): Potter, William Z., Lilly Corporate Ctr, Lilly Research Labs, Indianapolis, IN, US Source: Journal of Clinical Psychiatry , Vol 59(Suppl 18), 1998. pp. 30-36. Publisher: US: Physicians Postgraduate Press Abstract: From the perspective of pharmacologic treatment, bipolar depression is considered in this article belonging to a spectrum of affective disorders. Insufficient controlled data permit only general recommendations for treatment of the spectrum of affective disorders, except perhaps for the classic form bipolar I disorder. While the field waits for prospective controlled trials, a wide range of drugs is currently available for the treatment of bipolar depression. The potential advantages of having an increase number of agents with different mechanisms of actions are suggested by the many small studies claiming some degree of advantage in one or another subgroup of patients with bipolar depression. Several antidepressants and one anticonvulsant have the virtue of clinical experience that contributes to a body of information about side effects and the potential for producing benefit in at least some bipolar depressed patients. By default, and because they appear to have less chance of precipitating mania and are otherwise safe, selective serotonin reuptake inhibitors are probably the most comfortable first-line treatment for bipolar depression. _____
Title: Diagnostic revisions for DSM-IV. Author(s): Dunner, David L., U Washington, Medical Ctr, Dept of Psychiatry, Seattle, WA, US Source: Mania: Clinical and research perspectives. Goodnick, Paul J. (Ed); pp. 3-10. Washington, DC, US: American Psychiatric Association, 1998. xxiv, 412 pp. Abstract: (from the chapter) In this chapter the author reviews the diagnostic revisions proposed for Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) in the area of bipolar mood disorders. The major proposals include establishment of duration criteria for manic episodes of bipolar I disorder, separation of bipolar II from bipolar I and disorders not otherwise specified (NOS), and adding rapid cycling as a parenthetical modifier to bipolar I and bipolar II disorders. Truncated rapid cycling is subsumed in cyclothymic disorder. One area that still requires further research is the definition of bipolar mixed. There is a small but growing database reflecting its differentiation from other more typical manic syndromes. _____
Title: SSRI supplementation of antimanic medication in dysphoric mania. Author(s): Rihmer, Z., National Inst for Psychiatry & Neurology, In & Outpatient Dept of Psychiatry No. XIII, Budapest, Hungary; Kiss, G. H.; Kecskes, I.; Pestality, P.; Gyoergy, S. Source: Pharmacopsychiatry, Vol 31(1), Jan 1998. pp. 30-31. Publisher: Germany: Georg Thieme Verlag Abstract: The authors report on a 42-year-old female inpatient with bipolar I disorder, whose dysphoric mania responded rapidly and completely while her antimanic medication (lithium, carbamazepine, clozapine, haloperidol and clonazepam) was supplemented by 20 mg of paroxetine daily. The practical and theoretical importance of this case is briefly discussed. _____
Title: Expanded CAG/CTG repeats in bipolar disorder: No correlation with phenotypic measures of illness severity. Author(s): Craddock, Nick, U Wales, Coll of Medicine, Dept of Psychological Medicine, Cardiff, Wales; McKeon, Patrick; Moorhead, Steve; Guy, Carol; Harrison, Dale; Mynett-Johnson, Lesley; Claffey, Eileen; Feldman, Eleanor; McGuffin, Peter; Owen, Michael J.; O'Donovan, Michael C. Source: Biological Psychiatry, Vol 42(10), Nov 1997. pp. 876-881. Publisher: United Kingdom: Elsevier Science Abstract: Examines whether intergenerational expansion of trinucleotide repeat (TNR) DNA sequences in bipolar disorder is responsible for the tendency for age of onset to become earlier in younger generations (anticipation) observed in some bipolar pedigrees, and whether length polymorphism accounts for variability in clinical phenotype. Repeat expansion detection was used to study a sample of 133 Caucasian Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) bipolar I probands (mean age 42 yrs) from the British Isles. No evidence was found to support the notion that TNR genes are major determinants of phenotypic severity or age at onset in the population examined. It is concluded that for most cases of bipolar disorder, TNR genes may operate as susceptibility genes rather than as single genes of major effect. _____
Title: Is divalproex a cost-effective alternative in the acute and prophylactic treatment of bipolar I disorder? Author(s): Dardennes, Roland M.; Even, Christian Source: Journal of Clinical Psychiatry, Vol 58(11), Nov 1997. pp. 495-496. Publisher: US: Physicians Postgraduate Press Abstract: Comments on the article by P. E. Keck et al which concludes that divalproex is a less costly treatment than lithium in the acute and prophylactic treatment of patients with bipolar I disorder. The authors assert that there is no hard data available on which to base this conclusion. The authors suggest that the Keck et al conclusion should read that if the prophylactic efficacy of divalproex is demonstrated to be generally and significantly shorter than lithium's length-of-stay, then divalproex is a less costly treatment than lithium in the acute and prophylactic treatment of patients with bipolar I disorder. _____
Title: Is divalproex a cost-effective alternative in the acute and prophylactic treatment of bipolar I disorder: Reply. Author(s): Keck, Paul E. Jr. , U Cincinnati, Coll of Medicine, Biological Psychiatry Prog, Cincinnati, OH, US; Bennett, Jerry A.; Stanton, Sean P. Source: Journal of Clinical Psychiatry, Vol 58(11), Nov 1997. pp. 496. Publisher: US: Physicians Postgraduate Press Abstract: Responds to the comments by R. M. Dardennes and C. Even (1997) regarding the authors' conclusion of divalproex as a more cost-effective treatment than lithium for patients with bipolar I disorder. The authors reaffirm that their conclusion was based only on the available data, which was limited. The authors point out that their pharmacoeconomic model relies on more speculative inferences regarding treatment costs, but that the model will allow for recalculation of costs when such data are available. _____
Title: Psychosensory symptoms in bipolar disorder. Author(s): Ali, S. Omar , National Inst of Mental Health, Biological Psychiatry Branch, Section on Psychobiology, Bethesda, MD, US; Denicoff, Kirk D.; Ketter, Terence A.; Smith-Jackson, Earlian E.; Post, Robert M. Source: Neuropsychiatry, Neuropsychology, & Behavioral Neurology, Vol 10(4), Oct 1997. pp. 223-231. Publisher: US: Lippincott Williams & Wilkins Abstract: Investigated psychosensory symptoms and their relationship to retrospective and prospective courses of illness, as well as therapeutic outcomes, in patients with bipolar disorder. Using the Silberman-Post Psychosensory Rating Scale (SP-PSRS), psychosensory symptoms were assessed in 51 patients (aged 19-74 yrs) who met Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) criteria for bipolar disorder and in 39 healthy, normal controls. Psychosensory scores from patients with bipolar disorder were compared with scores from healthy controls and with a variety of retrospective and prospective course of illness and treatment variables. Psychosensory symptoms occurred frequently in patients with bipolar I and II disorders, but were rare in controls. When depressed, patients with bipolar II disorder reported more psychosensory symptoms when compared to patients with bipolar I disorder, and those with a history of rapid cycling reported more psychosensory symptoms when compared to patients without a history of rapid cycling. Although the presence of psychosensory symptoms is associated with some bipolar subtypes (patients with bipolar IT disorder and patients with a history of rapid cycling), they do not appear to predict treatment response. _____
Title: The epidemiology of DSM-III-R bipolar I disorder in a general population survey. Author(s): Kessler, Ronald C., Harvard Medical School, Dept of Health Care Policy, Boston, MA, US; Rubinow, D. R.; Holmes, C.; Abelson, J. M.; Zhao, S. Source: Psychological Medicine, Vol 27(5), Sep 1997. pp. 1079-1089. Publisher: US: Cambridge Univ Press Abstract: Presents data on the general population epidemiology of Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) bipolar I disorder in the United States. Data come from the US National Comorbidity Survey (NCS), a general population survey of DSM-III-R disorders which used a modified version of the Composite International Diagnostic Interview (CIDI) to make diagnoses. A clinical reappraisal study of 59 Ss showed that the only manic symptom profile that could validly be assessed with the CIDI is characterized by euphoria, grandiosity and the ability to maintain energy without sleep, which described half of all clinically validated bipolar I cases in the NCS. Further analysis focused on this symptom profile, which involved 29 cases. Lifetime prevalence was estimated to be 0.4% and 12-month prevalence only slightly lower. Caseness was negatively related to income, education and age, positively related to urbanicity, and elevated among the previously married, never married and non-whites. All cases reported at least one other NCS/DSM-III-R disorder and 59.3% reported that their episode of bipolar disorder occurred at a later age than at least 1 other NCS/DSM-III-R disorder. Although 93.2% of lifetime cases reported some lifetime treatment, only 44.7% of recent cases were in treatment. _____
Title: "A pharmacoeconomic model of divalproex vs. lithium in the acute and prophylactic treatment of bipolar I disorder": Reply. Author(s): Keck, Paul E. Jr.; Bennett, Jerry A.; Stanton, Sean P. Source: Journal of Clinical Psychiatry, Vol 58(8), Aug 1997. pp. 364. Publisher: US: Physicians Postgraduate Press Abstract: Responds to the comments of C. B. Baker et al (1997) regarding the article by P. E. Keck et al about a pharmocoeconomic model of divalproex vs lithium treatment in bipolar disorder. The authors agree with Baker et al that it is far from clear as to whether lithium can be administered more quickly than the standard titration techniques common in clinical practice. The authors also agree that the predictive lithium dosing techniques deserve further study, as argued by Baker et al. _____
Title: High intracellular calcium concentrations in transformed lymphoblasts from subjects with bipolar I disorder. Author(s): Emamghoreishi, Masoumeh; Schlichter, Lyanne; Li, Peter P.; Parikh, Sagar Source: American Journal of Psychiatry, Vol 154(7), Jul 1997. pp. 976-982. Publisher: US: American Psychiatric Assn Abstract: Examined whether intracellular Ca-2+ abnormalities are trait related. Basal Ca-2+ concentration was measured by using ratiometric fluorescence assay with fura-2 for T lymphocytes and Epstein-Barr-virus-immortalized B lymphoblasts from physically healthy Ss with Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnoses of bipolar mood disorder (bipolar I, N = 28; bipolar II, N = 11) or major depressive disorder (N = 14), mixed psychiatric patients with nonmood disorders (N = 14), and 20 healthy Ss. Phytohemagglutinin-stimulated (10 Rg/ml) intracellular Ca-2+ levels were also determined in T lymphocytes. The basal Ca-2+ concentration was significantly higher in the B lymphoblasts from patients with bipolar I disorder, but not bipolar II disorder or major depression, than in healthy Ss or psychiatric patients with nonmood disorders. Contrasts of diagnoses within gender revealed significantly higher basal Ca-2+ concentrations in T lymphocytes in male bipola |
