Prodromes, precipitants, and risk factors for relapse in bipolar disorder.

OBJECTIVE: The purpose of this qualitative review is to examine prodromes, precipitants, and risk factors for repeated episodes of mania and depression in bipolar disorder. METHODS: PubMed, EMBASE, and PsychInfo were searched for "bipolar disorder" in conjunction with: "prodromes", "triggers", and "life change events". RESULTS: Phenomenology and prevalence of prodromes, precipitants, and risk factors are described, and their therapeutic implications are outlined. CONCLUSIONS: Most patients with bipolar disorder are able to recognize their prodromes. This ability depends largely on insight. Psychoeducation focused on improving various aspects of insight, including treatment adherence, reduces incidence of relapses in bipolar disorder.

Panic disorder, autonomic nervous system and dissociation - changes during therapy.

OBJECTIVES: Alarming somatic symptoms and in particular the cardiovascular symptoms, are the characteristic features of panic attacks. Increased cardiac mortality and morbidity have been proposed in these patients. Power spectral analysis of electrocardiogram R-R intervals is known to be a particularly successful tool in the detection of autonomic instabilities in various clinical disorders. Heart rate variability (HRV) has been found to be the outcome of rapidly reacting cardiovascular control systems. The aim of our study is to measure very low frequency band (VLF), low frequency band (LF) and high frequency band (HF) components of R-R interval during orthostatic experiment in patients with panic disorder before and after treatment and compares it with healthy controls. METHODS: We assessed heart rate variability in 19 patients with panic disorder before and after 6-weeks treatment with antidepressants combined with cognitive behavioral therapy (CBT) and in 18 healthy controls. Diagnosis was done according to the ICD-10 research diagnostic criteria confirmed with MINI (MINI international neuropsychiatric interview). Patients were treated with CBT and psychotropics. They were regularly every week assessed using CGI (Clinical Global Impression), BAI (Beck Anxiety Inventory) and BDI (Beck Depression Inventory). Heart rate variability was assessed during 3 positions (1st - 5 min supine; 2nd - 5 min standing; 3rd - 5 min supine) before and after the treatment. Power spectra were computed for very low frequency - VLF (0.0033-0.04 Hz), low-frequency - LF (0.04-0.15 Hz) and high frequency - HF (0.15-0.40 Hz) bands using fast Fourier transformation. RESULTS: Nineteen panic disorder patients resistant to pharmacological treatment entered a 6-week open-label treatment study with combination of SSRI and CBT. The combination of CBT and pharmacotherapy proved to be an effective treatment in these patients. The patients significantly improved during the study period in all rating scales. There were highly statistical significant differences between panic patients and control group in all components of power spectral analysis in 2nd (VLF, LF and H in standing) and in two component of 3rd (LF and HF in supine) positions. There was also a statistically significant difference between these two groups in LF/HF ratio in standing position (2nd). During therapy there was a tendency increasing values in all three positions in components of HRV power spectra, but HF in 1st supine position was the only component where the increase reached the level os statistical significance. CONCLUSIONS: These findings demonstrate a lower autonomic activity in panic disorder patients measured during the changes of postural position in comparison with healthy controls and tendency to increase this autonomic power during the treatment.

Cognitive impairment in bipolar disorder.

AIM: Provide an overview of how bipolar disorder affects cognitive function in patients. METHODS: MEDLINE and PsycInfo data bases were searched for articles indexed by the combinations of MESH term or key word "bipolar disorder" with the following terms: "cognition", "memory", "neuropsychology", "neuropsychological tests", "lithium", "anticonvulsants", "antipsychotics", and "schizophrenia". Constraints limiting time period of publications or their language were not applied. Reference lists of publications identified by these procedures were hand-searched for additional relevant citations. RESULTS: There is evidence of stable and lasting cognitive impairment in all phases of bipolar disorder, including the remission phase, particularly in the following domains: sustained attention, memory and executive functions. But research on the cognitive functions has yielded inconsistent results over recent years. There is a growing need for clarification regarding the magnitude, clinical relevance and confounding variables of cognitive impairment in bipolar patients. The impact of bipolar illness on cognition can be influenced by age of onset, pharmacological treatments, individual response, familial risk factors, and clinical features. In addition to the mood state, cognitive performance in bipolar patients is influenced by seasonality. CONCLUSION: Previous optimistic assumptions about the prognosis of bipolar disorder were based on the success of the control of mood symptoms by pharmacotherapy. However, it is now clear that the "remitted" euthymic bipolar patients have distinct impairments of executive function, verbal memory, psychomotor speed, and sustained attention. Mood stabilizers and atypical antipsychotics may reduce cognitive deficits in certain domains and may have a positive effect on quality of life and social functioning.

Quality of life in patients with bipolar disorder--a comparison with schizophrenic patients and healthy controls.

BACKGROUND: In the past, the first goal of bipolar disorder treatment was the reduction of symptoms of mania or depression, rather than the recovery of social functioning. Recently, as a result of an increased emphasis on patient needs, the concept of quality of life (QoL) has been brought into the treatment of physical illnesses. SUBJECTS AND METHODS: The purpose of the present study was to examine QoL data in patients with bipolar disorder in clinical remission and to determine the extent of the effects of demographic and clinical data on QoL in these patients. The second aim was to compare the QoL data of these patients to that of patients with schizophrenia in clinical remission and to that of healthy controls. Data were obtained using a QoL questionnaire (Quality of Life Enjoyment and Satisfaction Questionnaire, or Q-LES-Q) for 41 bipolar patients in clinical remission. The data were then compared with the data of 40 schizophrenic patients in clinical remission and with 40 healthy controls. RESULTS: There were higher mean scores in most Q-LES-Q summary scales in the bipolar patients than in the schizophrenic patients. There were higher mean scores in the bipolar patients in some summary scales than in the healthy controls. CONCLUSIONS: Our results suggest the same or higher subjective QoL in bipolar patients in clinical remission in comparison with healthy controls and higher subjective QoL in bipolar patients in clinical remission than in schizophrenic patients in clinical remission.

Cognitive dysfunction, dissociation and quality of life in bipolar affective disorders in remission.

BACKGROUND: Bipolar disorders are often associated with cognitive deficits, which have an influence on social functioning and the course of the illness. These deficits have an impact on occupational ability and social integration. SUBJECTS AND METHODS: To ascertain cognitive function, level of dissociation and quality of life and their interrelations in patients with bipolar affective disorder in remission. Data from D2 Attention Test, Verbal Fluency Test and Trial Making Test, Dissociative Experiences Scale (DES). Quality of Life Satisfaction and Enjoyment (Q-LES-Q) and M.I.N.I. (MINI-international neuropsychiatric interview were statistically analyzed. RESULTS: There are no significant correlations between applied cognitive tests and dissociation scale DES. There are no significant correlations between applied cognitive tests and dissociation scale DES. There were no differences between employed and unemployed patients in DES, pathological DES and in any of Q-.LES-Q domains. CONCLUSIONS: We need further research to explore the role of cognitive functions and dissociation in bipolar affective disorder and its relationship to cognitive functions, emotional regulation, biological factors and therapy outcome.

Autonomic nervous system in euthymic patients with bipolar affective disorder.

BACKGROUND: Autonomic nervous system (ANS) dysfunction and reduced heart rate variability (HRV) have been reported in a wide variety of psychiatric disorders, but have not been well characterized in bipolar patients in remission. We recorded cardiac activity and assessed HRV in bipolar outpatients in remission. AIMS: Ascertain if ANS decrease with the age of the patient; ascertain relation between activity of ANS and level of dissociation, and other components (age of patients, and age of disorder, dosage of psychotropic medication) METHODS: Autonomic nervous system (ANS) has been evaluated during orthostatic change in three positions (1 - lie down 5 minutes, 2 - stand up 5 minutes, 3 - lie down 5 minutes). The functioning of the ANS has been measured by the diagnostic systems that are using the power spectral analysis which quantifies the heart rate variability (HRV) was assessed using time domain, frequency domain, and nonlinear analyses in 23 bipolar patients in remission. RESULTS: We found highly statistically significant negative correlations between level of dissociation measured by DES (Dissociative Experience Scale) and most of parameters of ANS. We found negative correlations between the age of the patient and activity of ANS, and negative correlations between activity of ANS and duration and onset of disorder. CONCLUSIONS: Autonomic dysregulation is associated with bipolar disorder in remission and has relation to level of dissociation and probably to age of patients and age of onset and duration of disorder.