Lifetime mania is related to post-traumatic stress symptoms in high school students exposed to the 2009 L'Aquila earthquake.

BACKGROUND: Bipolar patients seem to be at high risk of trauma exposure and, when exposed, of PTSD. When comorbid, PTSD has shown a negative impact on the course of the bipolar illness. Conversely, a correlation between even manic symptoms and an increased risk for suicide has also been reported in PTSD patients. The aim of this study was to investigate the relationships between lifetime mood spectrum symptoms and PTSD in a sample of earthquake survivors. METHODS: A total of 475 young adults who survived the L'Aquila 2009 earthquake, 21months earlier, were assessed by the Moods Spectrum-Self Report (MOODS-SR) and the Trauma and Loss Spectrum Self Report (TALS-SR). RESULTS: Significantly higher MOODS-SR and TALS-SR domain scores were found in PTSD survivors compared to those without. The mood depressive (O.R.=1.17, 95% CI: 1.10-1.25), cognition depressive (O.R.=1.07, 95% CI: 1.01-1.14) and energy manic (O.R.=1.13, 95% CI: 1.02-1.25) MOODS-SR domains were significantly associated with an increased likelihood of PTSD. CONCLUSIONS: Our data corroborate the strong relationship between mood disorder and PTSD highlighting a relationship between lifetime depressive and manic symptoms and PTSD, with a particular impact of the latter on the number of traumatic exposures and maladaptive behaviors.

TEMPS-A (Rome): psychometric validation of affective temperaments in clinically well subjects in mid- and south Italy.

BACKGROUND: Our aim was to study the psychometrics and factor structure replicability of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in its Italian (Rome) Version. The questionnaire is a self-report 110-item measure that postulates five affective temperaments-the depressive, cyclothymic, irritable, hyperthymic, and anxious-which embody both strengths and liabilities along affective reactivity. In Italian, the TEMPS has previously been validated in its original 32-item version, the TEMPS-I (Pisa), one which did not yet include an anxious subscale. METHODS: The present sample consisted of 948 nonclinical subjects (27.39 years+/-8.22 S.D.). There were 476 men (50.2%: 28.56 years+/-8.63 S.D.) and 472 women (49.8%: 26.21 years+/-7.61 S.D.). Reliability and validity were assessed by standard psychometric tests. RESULTS: Principal Components Analysis with Varimax rotation resulted in a 3-factor solution: the first with highest explained variance (8.84%) represents Dysthymic, Cyclothymic and Anxious (Dys-Cyc-Anx) temperaments combined; the second identifies Irritable temperament (5.65% of variance); and the third Hyperthymic temperament (5.16% of variance). Cronbach Alpha coefficients for the three subscales were respectively .89, .77 and .74. The rates for the Dys-Cyc-Anx were 2.7%, and for the Irritable 3.1%. Despite the low rate of the Hyperthymic temperament (.2%), nonetheless 16% were between 1st and 2nd SD. Exploratory factor analysis revealed a positive loading combining Dys-Cyc-Anx with the Irritable; the Hyperthymic loaded negatively on this factor. In terms of dominant temperaments, based on z-scores, 2.7% were dysthymic, 1.7% cyclothymic, .7% hyperthymic, 3.5% irritable and 3% anxious. LIMITATION: Although developed for self-rated use, the Italian authors nonetheless administered the TEMPS-A in an interview format. It is uncertain in what ways this procedure could have influenced our results, if any. Another limitation is that we did not assess test-retest reliability. CONCLUSIONS: These data identify at least 3-factors, Dys-Cyc-Anx and Irritable (which are correlated), and Hyperthymic, which is uncorrelated with the others. Though our data are reminiscent of the neuroticism-extraversion distinction, importantly traits are operationalized in affective terms. Beyond the well-known relationship between the Dysthymic and Cyclothymic subscales and that between the Dysthymic and Anxious, the present data reveal a strong relationship between the Cyclothymic and Anxious as well, which is of great relevance for bipolar II. It is also provocative that much of hyperthymia (16%) in the +SD is between the 1st and 2nd SD, thereby "normalizing" this temperament in Italy, as previously reported by TEMPS-I (Pisa) from Northern Italy (and TEMPS-A from Lebanon and Argentina).

Validation of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A): Portuguese-Lisbon version.

BACKGROUND: The TEMPS-A has been validated in 8 languages, the original being American English, and includes among others such Latin languages as Italian, French, and Spanish-Buenos Aires. This is the first Portuguese-Lisbon validation. METHODS: The sample included 1173 students from six different universities and representing most disciplines (such as medicine, law, humanities, engineering, etc.), both sexes (67% female), and ages between 17 and 58 (x+/-SD=21+/-4). Standard psychometric tests were used for internal consistency, validity, and factor analysis. RESULTS: The study upheld the 5 Factor proposed structure of TEMPS-A. Cronbach alpha varied from 0.67 for the depressive and 0.83 for the anxious, with the others in-between. We could retain all 110 items of the Interview Schedule. The highest mean scores were found for the hyperthymic, and the lowest for the irritable. As expected, depressive and anxious subscales had strong correlations, followed by the cyclothymic and anxious, and cyclothymic and irritable; in exploratory factor analysis, these subscales constituted Factor I, contrasted to the depressive and the hyperthymic as a biphasic continuum (Factor II). Females scored higher on the depressive, cyclothymic and anxious, and the males on hyperthymic and irritable. Overall, however, no temperament was "dominant" in this population, all temperaments z-scores being 3.3-4%! LIMITATIONS: Study limited to university students of young age. CONCLUSIONS: TEMPS-A Lisbon is a reliable and valid instrument. The only relatively weak factor is the depressive, which is similar to other language versions. Gender differences and correlations of temperaments are generally similar to other countries. What appears relatively special to the Portuguese is the relatively "balanced" mix of temperaments in this university student population.

A study of affective temperaments in Hungary: internal consistency and concurrent validity of the TEMPS-A against the TCI and NEO-PI-R.

BACKGROUND: TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego - Autoquestionnaire) is a new self-assessed temperament 110-item scale with depressive (D), cyclothymic (C), hyperthymic (H), irritable (I) and anxious (A) subscales. To date, it has been translated into 25 languages, and validated in 10. The present Hungarian version provides the most complete external validation across the Beck Depression Scale (BDI), Profile of Mood States (POMS), the BarOn Emotional Quotient Inventory (BarOn EQ-i), Temperament and Character Inventory (TCI), and the NEO Personality Inventory - Revised (NEO-PI-R). We were particularly interested in concurrent validation against the TCI and the NEO-PI-R, the most important of the new personality instruments. METHODS: 1132 clinically-well subjects (27% male) from the general population and university students (16-81 years) were administered the above scales and instruments. The data were tested with standard psychometric batteries. RESULTS: Factor analysis revealed 5 factors approximating the original D, C, I, H, and A subscales, which in their superfactor confirmed an Emotional (D, C, I, A) vs. Hyperthymic structure. Except for the D (a=0.65), the Cronbach alpha for the remainder temperaments ranged from 0.75-0.81. Dominant temperaments ranged from the I (2.7%) to the C (4.2%); the highest prevalence was observed among men with C=6% and H=5.4%. The BDI and POMS correlated significantly with the relevant subscales, as did the BarOn. Of the many significant possible correlations with the TCI, the most noteworthy were novelty seeking and harm avoidance with D, A, C, as well as C, and persistence with H. As for the NEO-PI-R, we were struck by the positive correlation of openness with C, and conscientiousness negatively with C; most other positive correlations such as neuroticism with all temperaments but the hyperthymic were expected and strongly supportive of concurrent validity. LIMITATIONS: Higher educational background of the subjects studied relative to that of the general population of Hungary. The distribution of the data may have in some instances deviated somewhat from the underlying assumptions for the standard psychometric tests for normality. We did not conduct test-retest reliability. CONCLUSIONS: The factorial structure of the TEMPS-A shows good reliability and internal consistency. Although the superstructure is reminiscent of neuroticism-extraversion, within it are embedded discernible classical affective temperaments. A provocative finding is the high prevalence of cyclothymia in Hungarian males (6%), which is rather unique when compared with the other 10 countries studied to date. This finding, coupled with high male hyperthymia (5.4%), may explain the high lifetime prevalence of bipolar disorders reported from Hungary. Inter alia, our psychometric data along with the foregoing epidemiologic considerations, are very much in line with the cyclothymic-bipolar spectrum model proposed by the senior author [Akiskal, H.S., Djenderedjian, A.H., Rosenthal, R.H., Khani, M.K., 1977. Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am. J. Psychiatry 134, 1227-1233].

Bipolar disorders and affective temperaments: a national family study testing the "endophenotype" and "subaffective" theses using the TEMPS-A Buenos Aires.

BACKGROUND: The purpose of this study is to examine the prevalence of affective temperaments between clinically unaffected relatives of bipolar patients and secondarily to investigate the impact of these "subaffective" forms on their quality of life (QoL). METHODS: The study was performed in seven sites across Argentina. We administered the scales TEMPS-A and Quality of Life Index to a sample of 114 non-ill first degree relatives of bipolar disorder patients ("cases") and 115 comparison subjects without family history of affective illness ("controls"). We used The Mood Disorder Questionnaire to rule out clinical bipolarity. RESULTS: Mean scores on all TEMPS-A subscales were significantly higher in cases, except for hyperthymia. The prevalence of affective temperaments, according to Argentinean cut-off points, was also higher, with statistical significance for cyclothymic and anxious temperaments. Regarding QoL, we found no significant differences between both groups, except for interpersonal functioning, which was better in controls. A detailed subanalysis showed significant effects of QoL domains for all temperaments, except for the hyperthymic. LIMITATIONS: We used self-report measures. A larger sample size would have provided us greater statistical power for certain analyses. CONCLUSIONS: Our findings support the concept of a spectrum of subthreshold affective traits or temperaments - especially for the cyclothymic and anxious - in bipolar pedigrees. We further demonstrated that, except for the hyperthymic, quality of life was affected by these temperaments in "clinically well" relatives. Overall, our data are compatible with the "endophenotype" and "subaffective" theses for affective temperaments.

Pain complaints in latino adults of mexican origin with and without major depressive episode: a cross-sectional study.

BACKGROUND: The aim of this retrospective, cross-sectional study was to determine the prevalence of 5 pain complaints among Latino adults of Mexican origin meeting the criteria for major depressive episode (MDE). METHOD: In a mental health clinic for the indigent, consecutively evaluated Latino adults of Mexican origin received structured diagnostic psychiatric interviews based on modules extracted from the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinical Version. All were specifically asked whether they had experienced headache, backache, abdominal pain, myalgia, or arthralgia "in the last week." Patients meeting the criteria for MDE were compared to patients without MDE from the same clinic. Associations and statistical significance of the differences between groups were determined using logistic regression models. The data were collected between August 2003 and November 2004. RESULTS: Two hundred ten patients had an MDE, and 35 individuals without an MDE comprised the comparison group. Eighty-eight percent of the patients with MDE versus 53% of the controls had at least 1 pain complaint (p < .0001). Patients with MDE were 8.3 times more likely to have 1 or more pain complaints than the comparison patients (p < .0001). The significant relationship between depression and pain applied when we examined those with ≥ 2, ≥ 3, and ≥ 4 pain complaints. Twenty-eight percent of the MDE subjects had all 5 pain complaints compared to 3% of subjects without MDE (p = .013). CONCLUSIONS: The method of assessment of the presence of pain led to the detection of a remarkably high prevalence of pain complaints. The findings presented have important implications not only for the practice of those who are widely recognized as being primary care physicians but also for practitioners of all clinical disciplines.

Temperament and personality dimensions in suicidal and nonsuicidal psychiatric inpatients.

BACKGROUND: Suicide is a serious public health problem. In the international literature there is evidence to support the notion that certain temperaments and personality traits are often associated with suicidal behavior. SAMPLING AND METHODS: In this study, 150 psychiatric inpatients were investigated using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire, the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Beck Hopelessness Scale and evaluated for suicide risk by means of the critical items of the Mini International Neuropsychiatric Interview. RESULTS: Statistical analysis, including logistic regression analysis and multiple regression analysis, showed that suicide risk contributed to the prediction of hopelessness. Among the temperaments, only the hyperthymic temperament, as a protective factor, and the dysthymic/cyclothymic/anxious temperament contributed significantly to the prediction of hopelessness. Irritable temperament and social introversion were predictive factors for suicidal risk. Hopelessness and depression were associated with higher suicidal behavior and ideation, but, unexpectedly, depression as measured by the MMPI did not contribute significantly to the multiple regressions. CONCLUSIONS: The present study indicated that, although suicidal psychiatric patients have MMPI-2 profiles in the pathological range, they exhibit several differences from nonsuicidal patients. Patients at risk of suicide have specific temperaments as well as personality and defense mechanism profiles. They are more socially introverted, depressed and psychasthenic, and use hysterical and schizoid mechanisms more often. Generalizability of the findings was limited by the small sample size and the mix of bipolar disorder I, bipolar disorder II, major depressive disorder and psychotic disorder patients.

The clinical-familial correlates and naturalistic outcome of panic-disorder-agoraphobia with and without lifetime bipolar II comorbidity.

BACKGROUND: Much of the literature on panic disorder (PD)-bipolar disorder (BP) comorbidity concerns BP-I. This literature emphasizes the difficulties encountered in pharmacologic treatment and outcome when such comorbidity is present. The present report explores these issues with respect to BP-II. METHODS: The sample comprised 326 outpatients (aged 34.5 +/- 11.5 years old; 222 females) with Diagnostic and Statistical Manual of Mental Disorders 3rd edn, revised (DSM-III-R) PD-agoraphobia; among them 52 subjects (16%) were affected by lifetime comorbidity with BP-II. Patients were evaluated by means of the Structured Clinical Interview for DSM-IV (SCID), the Panic-Agoraphobia Interview, and the Longitudinal Interview Follow-up Examination (Life-Up) and treated according to routine clinical practice at the University of Pisa, Italy, for a period of 3 years. Clinical and course features were compared between subjects with and without BP-II. All patients received the clinicians' choice of antidepressants and, in the case of the subsample with BP-II, mood stabilizers (for example, valproate, lithium) were among the mainstays of treatment. RESULTS: In comparison to patients without bipolar comorbidity, those with BP-II showed a significantly greater frequency of social phobia, obsessive-compulsive disorder, alcohol-related disorders, and separation anxiety during childhood and adolescence. Regarding family history, a significantly greater frequency of PD and mood disorders was present among the BP-II. No significant differences were observed in the long-term course of PD or agoraphobic symptoms under pharmacological treatment or the likelihood of spontaneous pharmacological treatment interruptions. CONCLUSION: Although the severity and outcome of panic-agoraphobic symptomatology appear to be similar in patients with and without lifetime bipolar comorbidity, the higher number of concomitant disorders in our PD patients with BP-II does indicate a greater complexity of the clinical picture in this naturalistic study. That such complexity does not seem to translate into poorer response and outcome in those with comorbid soft bipolarity probably reflects the fact that we had brought BP-II under control with mood stabilizers. We discuss the implications of our findings as further evidence for the existence of a distinct anxious-bipolar diathesis.

Differential patterns of lifetime multiple anxiety disorder comorbidity between Latino adults with bipolar I and major depressive disorders.

BACKGROUND: To determine the lifetime rates of panic disorder, obsessive-compulsive disorder (OCD), social phobia, and posttraumatic stress disorder (PTSD) among adult Latino patients with major depressive disorder (MDD) and bipolar disorder (BPD), and whether there are dose-response relationships between loading for comorbid anxiety disorders, the probability of having BPD, and attributes of severity of illness. METHODS: In a public sector clinic for the indigent located in a semiclosed rural community, 187 consecutively presenting affectively ill Latino patients were evaluated by use of the Structured Clinical Interview for DSM-IV. Polarity and the lifetime prevalence of panic disorder, OCD, social phobia, and PTSD were determined. Logistic regression was used to test associations. Trends in positive predictive values (PPVs) and likelihood ratios were assessed to determine whether dose-response relationships existed between loading for comorbid anxiety disorders and the likelihood of having BPD as opposed to MDD, psychosis, suicidal ideation, and suicide attempts. RESULTS: Of 187 subjects, 118 (63.1%) had MDD and 69 (36.9%) had BPD. The odds ratio of a patient with BPD, relative to MDD, of having panic disorder was 4.6 (p< .0001), OCD 7.6 (p< .0001), social phobia 6.0 (p< .0001) and PTSD 5.3 (p< .0001). The PPV of having BPD was 91.3% and of having psychotic features 83.0% if one had all four anxiety disorders. There was a dose-response relationship between loading for comorbid anxiety disorders and the likelihood of having had a suicide attempt (but not suicidal ideation). CONCLUSIONS: As previously reported by us for juvenile patients, Latino adults with BPD had a remarkably high risk of having each anxiety disorder relative to patients with MDD. The results indicate that the risk of having BPD, having a psychosis, and making a suicide attempt becomes increasingly great as the number of comorbid anxiety disorders increases. These data, which are consistent with the notion of anxious bipolarity, provide further support for a possible anxious diathesis in bipolar disorder.

In search of Aristotle: temperament, human nature, melancholia, creativity and eminence.

Is suffering associated with melancholia and "madness" necessary for artistic creativity and eminence? Or do creativity and leadership have something to do with the temperaments associated with affective disease? We integrate concepts dating back to Greek psychological medicine and philosophy--especially work attributed to Aristotle--with modern data-based examination of the role of cyclothymic and related temperaments in the interface between mixity, the bipolar spectrum and normality. We place our query within the general framework of evolutionary biology and human nature. In doing so, we propose that affective disease--including mania and associated psychotic states--exist because they serve as the genetic reservoir for adaptive temperaments and the genes for genius. Affective disorder can therefore be regarded as the price of exceptional greatness. Thus, creative and eminent individuals, by virtue of their being exceptional, occupy a somewhat unstable terrain between temperament and affective disease.

Suitability of the TEMPS-A for population-based studies: ease of administration and stability of affective temperaments in its Lebanese version.

BACKGROUND: The Temperament Evaluation of Memphis Pisa Paris and San Diego Auto-questionnaire (TEMPS-A) has been translated and validated into several languages, and used in different subgroups (e.g. clinical, students, company, employees and those with different educational levels). METHODS: Lebanon is the only country that has validated the TEMPS-A in a national cohort, as part of the Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (LEBANON). In this paper, we test the suitability of the TEMPS-A for large scale epidemiologic population-based studies. RESULTS: 82.1% of the respondents found the TEMPS-A to be easy to understand. The global reports of the Lebanese of their own temperaments paralleled those of the formal sub-scores on the five affective temperament subscales. The majority of respondents (90.3%) felt that their answers on the Lebanese-Arabic TEMPS-A scale represented them throughout their adulthood; the minority who did not were more likely to be older, and to have scored higher on the cyclothymic, and lower on the hyperthymic subscales. LIMITATION: Although the TEMPS-A has been designed for self-administration (auto-questionnaire), this was not practical in all subjects. We nonetheless feel that the interview format is viable as it introduces flexibility with certain subjects in population studies. CONCLUSIONS: The TEMPS-A appears to be suitable for use in epidemiologic surveys and research.

Validation of the TEMPS-A Buenos Aires: Spanish psychometric validation of affective temperaments in a population study of Argentina.

BACKGROUND: The TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego) is a 110-item questionnaire in five scales which has been translated into over 25 language versions: American, Italian (only for Interview version or TEMPS-I), French, Lebanese, Hungarian, Japanese and Turkish versions have already been validated. There are two Spanish versions, one from Barcelona, and the present one from Buenos Aires. This study represents the first attempt at validating the TEMPS-A in Spanish. METHODS: 932 clinically well subjects were studied, of both sexes (62% female) with mean+/-SD age of 35.4+/-18.1. Standard psychometric tests of reliability and validation were performed. RESULTS: Chronbach alphas were 0.7 (depressive) and 0.8 (anxious, cyclothymic, irritable and hyperthymic). In exploratory factor analyses, the hyperthymic was distinct from the others. As expected, the depressive and anxious correlated strongly, so did the cyclothymic and anxious. Dominant temperaments ranged from 2.1% to 4.5% of the population under study, except for the hyperthymic which had a negligible rate of 0.2% (but accounted for 13% between +1 SD and +2 SD). LIMITATION: We did not examine test-to-test reliability. CONCLUSIONS: This is the first validation of the TEMPS-A in Spanish, the Buenos Aires version with the original 110 items, with very good psychometric properties.

Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality.

OBJECTIVES: To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality. METHODS: The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SCID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. RESULTS: Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. LIMITATIONS: Single interviewer using the SCID; cross sectional exploratory study. CONCLUSIONS: BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.

The 5HTTLPR polymorphism of the serotonin transporter gene is associated with affective temperaments as measured by TEMPS-A.

BACKGROUND: Increasing evidence supports the notion of a continuum between affective temperaments and major mood disorders, suggesting that these temperament types represent the subclinical manifestations of affective disorders and often present an increased vulnerability for these diseases. METHODS: The Hungarian rendition of the full-scale 110-item version of the TEMPS-A questionnaire and 5HTTLPR genotype was investigated in a sample of 139 unrelated Caucasian females with no current or lifetime Axis I psychiatric disorders. RESULTS: A significant association was found between the s allele and the TEMPS scores of the depressive, anxious, irritable, and particularly the cyclothymic temperaments; no such association emerged with respect to the hyperthymic temperament. LIMITATION: The database is entirely female. Given that the hyperthymic type predominates in males, our results could have been different if men were included in our sample. CONCLUSIONS: Our results are in good agreement with earlier studies reporting a strong association between the s allele of the 5HTTLPR and major as well as subthreshold forms of depression, and extend this association to the normative temperament level. Indeed, these temperaments might best be regarded as proximate behavioural endophenotypes. Our data raise the provocative possibility that the genetic potential for mood episodes lies in these temperaments. Further studies are needed to delineate the role of gender in the associations under consideration, as well as to investigate the genetic background of the hyperthymia-mania part of the affective spectrum. Given that affective temperaments are widely distributed in the general population, the strategy employed by us is of potential public health significance in terms of detecting individuals in the community at risk for affective spectrum disorders.

Bipolar II and anxious reactive "comorbidity": toward better phenotypic characterization suitable for genotyping.

OBJECTIVE: In DSM-IV, bipolar II (BP-II) disorder is defined by depression and hypomania. There is little appreciation of affective instability, often associated with anxiety-particularly panic disorder and agoraphobia (PDA)-comorbidity. This association has genetic-familial implications, which we believe must be incorporated in refining the BP-II phenotype suitable for genotyping purposes. METHOD: We examined in a semi-structured format 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features and separated them into two subgroups according to the co-occurring criteria for PDA. They were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL 90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features, as well as Axis I and II comorbidity and temperamental dispositions, particularly cyclothymic instability. RESULTS: Fifty (46.7%) of our patients met the DSM-IV criteria for PDA. In terms of significant results, PDA+ was more frequently female, had higher number of hypomanic episodes, and stressors; they were also more often BP-II, and cyclothymic. Ratings of reactivity, somatization, OCD and phobic anxiety too were significantly higher among the PDA+. In related analyses, most AD (75.7%) met criteria for BP-II; the BP-II subgroup was characterized by PDA, as well as borderline personality features and cyclothymic and hyperthymic temperaments. LIMITATIONS: Correlational clinical study in which clinicians could not be kept entirely blind to the variables under investigation. CONCLUSIONS: In line with the description by the French psychiatrist Pierre Kahn a century earlier, cyclothymic reactivity and neurotic features (i.e., atypicality and panic attacks) appear relevant to the definition of what today we consider BP-II disorder. These data, which are in line with current familial-genetic models of this disorder, suggest that the DSM-IV characterization of BP-II must be enriched by greater emphasis on temperamentally based mood and anxious reactivity. Such phenotypic characterization is likely to assist in better genotyping. Previous work by us further suggests the relevance of bulimic and addictive tendencies, as well as "borderline personality" diagnosis in the proband and/or the family. We submit that these conditions, rather than being "comorbid," constitute, along with BP-II, a spectrum of overlapping underlying genetic diatheses.

Bulimia nervosa in atypical depression: the mediating role of cyclothymic temperament.

OBJECTIVE: Recent data indicate significant clinical, biological, and treatment response overlap between eating and bipolar disorders, especially when soft symptoms of either spectrum disorders are considered. The aim of the present analyses is to evaluate the lifetime prevalence of bulimia nervosa (BN) in patients with atypical depression (AD) and to delineate any demographic, clinical, personality or temperamental factors that may characterize this subgroup. METHOD: We examined in a semi-structured format 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features and we separated them into two groups according to the co-occurring criteria for BN. They were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL 90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features, as well as Axis I and II comorbidity and temperamental dispositions. RESULTS: Seventeen (17.8%) percent of AD met the DSM-IV criteria for Bulimia Nervosa (BN+). These patients, compared with those who did not meet criteria for BN (BN-), were indistinguishable on all demographic and most psychopathologic and clinical features (including bipolar I and II), but were significantly higher in lifetime comorbidity for Narcissistic, Histrionic, Borderline and Dependent personality disorders as well as that for Cyclothymic temperament. BN+ also scored higher on the ADDS items of reactivity of mood and interpersonal sensitivity. LIMITATIONS: Correlational clinical study in which doctors could not be entirely blind to the variables under investigation. CONCLUSIONS: Cyclothymic temperament and related mood reactivity and interpersonal sensitivity may account for much of the relationship between AD and BN. Narcissistic, histrionic and borderline traits, too, seem to be related to the presence of a cyclothymic disposition. The data overall, in particular the cyclothymic reactivity in the absence of differences in BP-I and II, all support the hypothesis that places BN in the "ultra-soft" bipolar realm.

Validating the bipolar spectrum in the French National EPIDEP Study: overview of the phenomenology and relative prevalence of its clinical prototypes.

BACKGROUND: Few studies have been undertaken to ascertain the feasibility of using the bipolar (BP) spectrum in clinical practice. The only systematic national study is the French EPIDEP Study of consecutive inpatients and outpatients presenting with major depressive episodes (MDE). The protocol was developed in 1994 and implemented in 1995; publication of its first data began in 1998. This report provides the complete data set of the EPIDEP. METHODS: Forty-eight psychiatrists, practicing in 15 sites in four regions of France (Paris, Besançon, Bordeaux and Marseille), were all trained on a common protocol based on DSM-IV criteria for MDE (n=537) subdivided into BP-I (history of mania), BP-II (history of hypomania), as well as extended definitions of the "softer spectrum" beyond BP-I and BP-II. Measures tapping into this spectrum included the Hypomania Checklist (HCA), the cyclothymic (CT), depressive (DT) and hyperthymic (HT) temperament scales. These measures and course permitted post-hoc assignment of MDE in the bipolar spectrum, based in part on the Akiskal, H.S., Pinto, O., 1999. [The evolving bipolar spectrum: Prototypes I, II, III, IV. Psychiatr. Clin. North Am. 22, 517-534] proposal: depression with history of spontaneous hypomanic episodes (DSM-IV, BP-II), cyclothymic depressions (BP-II(1/2)), antidepressant-associated hypomania (BP-III) and hyperthymic depressions (BP-IV). <> was thereby limited to an exclusion diagnosis for the remainder of MDE. LIMITATION: In the clinical setting, psychiatrists cannot be entirely blind to the observations in the various clinical evaluations and instruments. However, the systematic multisite collection of such data tended to minimize any such biases. RESULTS: After excluding patients lost to follow-up, among 493 presenting with MDE with complete data files, the BP-II rate was estimated at index at 20%; 1 month later, systematic probing for hypomania doubled the rate of BP-II to 39%. The comparison between BP-II and UP showed differential phenomenology, such as hypersomnia, increased psychomotor activation, guilt feelings and suicidal thoughts in BP-II. Related data demonstrated the importance of CT in further qualifying of MDE to define a distinct, more severe ("darker") BP-II(1/2) variant of BP-II. Moreover, BP-III, arising from DT and associated with antidepressants, emerged as a valid soft bipolar variant on the basis of the phenomenology of hypomania and bipolar family history. Finally, we found preliminary evidence for the inclusion of BP-IV into the bipolar spectrum, its total hypomania score falling intermediate between BP-II and strict UP. Using this broader diagnostic framework, the bipolar spectrum (the combined "hard" BP-I phenotype, BP-II and the soft spectrum) accounted for 65% of MDE. CONCLUSION: The EPIDEP study achieved its objectives by demonstrating the feasibility of identifying the bipolar spectrum at a national level, and refining its phenomenology through rigorous clinical characterization and validation of bipolar spectrum subtypes, including MDE with brief hypomanias, cyclothymia and hyperthymia. The spectrum accounted for two out of three MDE, making "strict UP" less prevalent than BP as redefined herein. Our findings were anticipated by Falret, who in 1854 had predicted that many melancholic patients in the community would 1 day be classified in his circular group. We also confirmed Baillarger's observation in the same year that episodes (in this study, hypomanic episodes) could last as short as 2 days. Our findings deriving from a systematic French national database a century and a half later invite major shifts in clinical and public health services, as well as in the future conduct of psychopharmacologic trials. In this respect, the systematic training of clinicians in four regions of France represents a national resource for affective disorders and can serve as a model to effect change in diagnostic practice in other countries.

The theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolar disorder and human nature.

We sketch out putative evolutionary roles for affective temperaments within the theoretical framework of mood disorders conceptualized as extremes in an oligogenic model of inheritance, whereby the constituent traits in their dilute phenotypes confer adaptive advantages to individuals and/or their social group. Depressive traits, among other functions, would subserve sensitivity to the suffering of other members of the species, overlapping with those of the generalized anxious temperament, thereby enhancing the survival of not only kin but also other conspecifics. The pursuit of romantic opportunities in cyclothymia suggests that it may have evolved as a mechanism in reproductive success; cyclothymics' creative bent in poetry, music, painting, cooking or fashion design (among men, in particular) also appears useful for sexual seduction. Hyperthymic traits would lend distinct advantages in leadership, exploration, territoriality and mating. These are just some of the possibilities of the rich and complex temperamental traits subserving bipolarity within an evolutionary framework. We test selected aspects of these hypotheses with the use of correlations between the constituent traits of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS) and correlations between the TEMPS and the Temperament and Character Inventory (TCI). Such data support the counterbalancing protective influence of harm avoidance on the risk-taking behavior of cyclothymic individuals, in both men and women. Finally, we outline a hypothesis on the evolutionary function of anxious-depressive traits for women.

Temperament profiles in physicians, lawyers, managers, industrialists, architects, journalists, and artists: a study in psychiatric outpatients.

BACKGROUND: With the possible exception of cyclothymia in artists, there is a paucity of data in the literature on the temperament in different professions. METHODS: For this exploratory study, we sought to generate preliminary data on temperaments among psychiatric outpatients, including physicians (n=41), lawyers (n=30), managers and executives (n=35), industrialists (n=48), architects (n=27), journalists (n=34), and a mixed group of artists (n=48). They were compared with age, sex, social class, and affective disorder matched outpatients outside of these professions, drawn from the same clinical settings to serve as our Comparison Group (CG, n=120). We used an interview version of the Akiskal-Mallya criteria for temperaments. We finally used the DSM-III-R obsessive compulsive personality (OC traits). RESULTS: Compared with the CG, lawyers and physicians had high rates of dysthymic temperament and OC traits. Managers, like lawyers and doctors, had high rates on OC traits but were different in being very low on cyclothymic and twice as hyperthymic than the CG was. Industrialists, who, by definition, were self-made, had even higher rates of hyperthymic traits. Both architects and artists seemed to have benefited from being cyclothymic (3-4 times higher than CG's); interestingly, architects had higher levels of OC traits, and artists were less obsessional than the CG was. Overall, among managers/executives and lawyers, 41% met criteria for affective temperaments, whereas the equivalent rate among the remainder was 77%. LIMITATION: Given that this is a chart review of existing clinical records, it was not possible to be blind to the profession of the patients. A mixed group of artists may have obscured differences among artists from different domains of art (e.g., poets vs. performing artists), and the same can be said of physicians (e.g., internists vs. surgeons). A disclaimer would be appropriate: Ours is not a study on eminence in the different professions but on the temperament and personality profiles that distinguish among them. CONCLUSIONS: Despite the foregoing limitations and overlapping attributes in the different professions, they nonetheless emerged as having distinct temperamental and personality profiles. Dysthymic and obsessional attributes are notable in lawyers and physicians. We confirm the role of cyclothymia in artists and architects. The role of the hyperthymic temperament in managers, self-made industrialists, and journalists, to the best of our knowledge, is being reported for the first time. The role of cyclothymic and hyperthymic temperaments appears to be moderated by obsessional traits across the entire professional realm examined. In particular, artists' creative imagination appears "liberated" by low levels of OC traits, whereas among architects, relatively high levels of OC traits seem to contribute to the execution of their work. More tentatively, judging from the overall levels of affective temperaments in the remaining professions, on average, more of the managers/executives than self-made industrialists could be described as "colder" in temperament, and more of the physicians "warmer" than lawyers are. Journalists, as a group, appeared to possess the broadest representation of affective temperaments. The foregoing conclusions must be regarded as tentative, even hypothetical, in need of verification among professionals without major psychiatric disorders. Nonetheless, temperament profiles among psychiatrically ill professionals in the seven professional realms studies can help predict how they relate to their doctors, family members, colleagues, coworkers, and clients/patients. Such knowledge, in turn, can help the therapeutic process.

Gender, suicidality and bipolar mixed states in adolescents.

BACKGROUND: The purpose of this study was to determine the relationship between mixed states and suicidality among adolescent outpatients presenting with a DSM-IV defined major depressive episode (MDE). METHODS: Two-hundred and forty-seven adolescents meeting the criteria for MDE were screened for the presence of concurrent, intra-MDE hypomania/mania (i.e., mixed states). All patients were asked whether they had current suicidal ideation or had recently attempted any self-destructive physical act associated with the thought of dying (i.e., a suicide attempt). The data were subjected to analysis using univariate logistic regression. RESULTS: One hundred of the 247 (40.5%) adolescents were bipolar type I or type II. Of these, 82% were in mixed states. Of the patients with suicidal ideation, 62.8% were girls, and of those with histories of a suicide attempt, 69.4% were girls. Girls had more than twice the risk of having suicidal ideation (OR=2.2, p=0.004) and nearly 3 times the risk of having histories of a suicide attempt than boys (OR=2.87, p<0.0001). Being in a mixed state per se did not predict either suicidal ideation or a suicide attempt among all of the 247 patients. However, mixed states apparently independently contributed to the risk of (non-fatal) suicidal behavior among girls only. Of the mixed states, girls had nearly 4 times the risk of having made a suicide attempt compared with those without mixed states (OR=3.9, p=0.003). Age, presence of psychotic features and family history of mood disorder had little or no bearing on suicidality. LIMITATIONS: Correlational chart review study, no data collection on Axis I and Axis II comorbidity and adverse life-events. CONCLUSIONS: This report of greater suicidality in adolescent girls in a mixed state parallels the well-known adult literature of high frequency of mixed states in women. The findings are of relevance to the controversy of antidepressants and suicidality in juvenile depressives in that they identify a vulnerable group. In line with earlier suggestions by the senior author [Akiskal, H.S., 1995. Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar? J. Am. Acad. Child Adolesc. Psych. 34, 754-763], our data highlight the public health importance of the wider recognition of bipolar mixed states in juvenile patients masquerading as unipolar depression. Finally, it appears to us that it is the failure of our formal nosology on mixed states--rather than the antidepressants per se--which is the root problem in this controversy.