Comorbidity between bipolar disorder and cluster B personality disorders as indicator of affective dysregulation and clinical severity.

INTRODUCTION: Several lines of evidence have well established a relationship between Bipolar Disorder and Cluster B Personality Disorders. The study compares mood spectrum and temperamental symptoms, personality traits and clinical characteristics among outpatients (n = 63) diagnosed with major depression (MD), bipolar disorder (BD), cluster B personality disorders (PD-B) and comorbidity of BD + PD-B. METHOD: The diagnosis was determined with structured interviews (MINI and SCID II) and symptom assessments with evaluation and diagnostic instruments (MOODS-SR, BI, TEMPS-A and IPDE). Differences between groups were explored with post hoc analysis and analysis of variance. RESULTS: Patients with BD+PD-B comorbidity presented an earlier onset and more severity in suicide attempts, hospitalizations and self-harm behaviors. They showed more characteristics of cyclothymic and irritable temperament and more cluster A and B personality traits, than patients with BD only. PD-B patients obtained intermediate scores in manic like symptoms: higher than patients with depression and lower than patients with bipolar disorder. However, the Bipolarity Index clearly distinguished patients with BD or with comorbidity (BD+PD-B) from the other diagnostic groups (PD-B and MD). CONCLUSIONS: BD+PD-B comorbidity presents a more severe type of emotional dysregulation compared to the other diagnostic groups, including BD and PD-B alone. Assessing temperament, personality traits, emotional dysregulation in mania and depression, self-harm and hospitalizations severity and age onset could facilitate differential diagnosis and enhance effectiveness of treatments for BD, PD-B and their comorbidity.

Psychiatric disorders in patients with psychogenic nonepileptic seizures and drug-resistant epilepsy: a study of an Argentine population.

Epidemiological data show that up to 20-30% of patients with psychogenic nonepileptic seizures (PNESs), resembling drug-resistant epilepsy (DRE), are referred to tertiary epilepsy centers. Furthermore, both disorders present high psychiatric comorbidity, and video-EEG is the gold standard to make differential diagnoses. In this study, we described and compared the clinical presentation and the frequency of psychiatric disorders codified in DSM IV in two groups of patients, one with PNESs and the other with DRE, admitted in a tertiary care epilepsy center of Buenos Aires, Argentina. We included 35 patients with PNESs and 49 with DRE; all were admitted in the video-EEG unit in order to confirm an epilepsy diagnosis and determine surgical treatment possibilities. All patients underwent a neurological and psychiatric assessment, according to standardized protocol (SCID I and II; DSM IV criteria). Student's t test was performed to compare continuous variables and Chi square test to compare qualitative variables. In this study, 33 (67%) patients with DRE and 35 (100%) patients with PNESs met criteria for at least one disorder codified in Axis I of DSM IV (p=0.003). Differences in the frequency of psychiatric disorder presentation were found between groups. Anxiety disorders (16.32% vs 40%; p=0.015), trauma history (24.5% vs 48.57%; p=0.02), posttraumatic stress disorder (4.08% vs 22.85%; p=0.009), and personality cluster B disorders (18.37% vs 42.86%; p=0.02) were more frequent in the group with PNESs. Psychotic disorders were more frequent in the group with DRE (20.4% vs 2.85%; p=0.019). Depression was equally prevalent in both groups. Standardized psychiatric assessment provides information that could be used by the mental health professional who receives the referral in order to improve quality of care and smooth transitions to proper PNES treatment, which should include a multidisciplinary approach including neurology and psychiatry.

Relationship between neurocognitive functioning and episode recurrences in bipolar disorder.

BACKGROUND: The relationship between neurocognitive impairment and clinical course in bipolar disorder (BD) is inconclusive. The aim of this study was to compare time to recurrence between patients with and without clinically significant cognitive impairment. METHODS: Seventy euthymic patients with BD were included. Based on baseline neurocognitive performance, patients were divided into those with (n=49) and those without (n=21) clinically significant cognitive impairment. Both groups of patients were prospectivelly assessed by a modified life chart method during a mean of 16.3 months. RESULTS: Patients with some cognitive domain compromised had an increased risk of suffering any recurrence (HR: 3.13; CI 95%: 1.64-5.96), hypo/manic episodes (HR: 2.42; CI 95%: 1.13-5.19), or depressive episodes (HR: 3.84, CI 95%: 1.66-8.84) compared with those patients without clinically significant cognitive impairment. These associations remained significant after adjusting for several potential counfounders such as number of previous episodes, time since last episode, clinical subtype of BD, exposure to antipsychotics, and subclinical symptoms. LIMITATIONS: We classified patients as with or without clinically significant cognitive impairment, although deficits in different cognitive domains may not be equivalent in terms of risk of recurrence. CONCLUSIONS: The results did not support the hypothesis that the experience of successive episodes is related to a progressive neurocognitive decline. On the contrary, cognitive impairment could be the cause more than the consequence of poorer clinical course. Alternatively, a specific subgroup of patients with clinically significant cognitive impairment and a progressive illness in terms of counts of recurrence and shortening of wellness intervals might explain the association showed in this study.

The neural basis of decision-making and reward processing in adults with euthymic bipolar disorder or attention-deficit/hyperactivity disorder (ADHD).

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) share DSM-IV criteria in adults and cause problems in decision-making. Nevertheless, no previous report has assessed a decision-making task that includes the examination of the neural correlates of reward and gambling in adults with ADHD and those with BD. METHODOLOGY/PRINCIPAL FINDINGS: We used the Iowa gambling task (IGT), a task of rational decision-making under risk (RDMUR) and a rapid-decision gambling task (RDGT) which elicits behavioral measures as well as event-related potentials (ERPs: fERN and P3) in connection to the motivational impact of events. We did not observe between-group differences for decision-making under risk or ambiguity (RDMUR and IGT); however, there were significant differences for the ERP-assessed RDGT. Compared to controls, the ADHD group showed a pattern of impaired learning by feedback (fERN) and insensitivity to reward magnitude (P3). This ERP pattern (fERN and P3) was associated with impulsivity, hyperactivity, executive function and working memory. Compared to controls, the BD group showed fERN- and P3-enhanced responses to reward magnitude regardless of valence. This ERP pattern (fERN and P3) was associated with mood and inhibitory control. Consistent with the ERP findings, an analysis of source location revealed reduced responses of the cingulate cortex to the valence and magnitude of rewards in patients with ADHD and BD. CONCLUSIONS/SIGNIFICANCE: Our data suggest that neurophysiological (ERPs) paradigms such as the RDGT are well suited to assess subclinical decision-making processes in patients with ADHD and BD as well as for linking the cingulate cortex with action monitoring systems.

Psychosis after epilepsy surgery: report of three cases.

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.

[Clinical concepts associated with lithium underutilization in the treatment of bipolar disorder]. / Conceptos clínicos asociados a la subestimación del litio en el tratamiento del Trastorno Bipolar.

OBJECTIVES: Bipolar Disorders are among the ten leading causes of morbity and lithium is considered first-line treatment and the most cost-effective. Nevertheless, its use takes a back seat to other treatment options less effective, safe and more expensive; and the reasons for this remains unclear. The present study investigates clinical concepts related to its underutilization. METHOD: An anonymous questionnaire concerning different aspects of lithium clinical use (compared efficacy, adverse effects, practical aspects regarding its use, use in special populations) was administered during the XXV Congress of the Argentinean Psychiatrist Association. RESULTS: 164 questionnaires were analyzed. Less than one-third of the sample referred lithium as their most frequent treatment option, although almost 60% qualified it as effective. Almost two-thirds considered its utilization as more complex and ill-ascribed adverse effects to it. One third referred not to use it in youth and senior populations. CONCLUSIONS: Contrary to current recommendations, lithium is under utilized. This is the first report on the possible causes leading to such phenomena, which can be related to ill concepts regarding its safety, clinical use and adverse effects; although not to its effectiveness.

[Psychiatric manifestations of non-convulsive status epilepticus]. / Manifestaciones psiquiátricas del status epiléptico no convulsivo.

Non-convulsive status epilepticus (NCSE) is a clinical condition characterized by continuous or intermittent state of epileptic activity without restitution, prolonged for more than thirty minutes. The main difference with convulsive status epilepticus (CSE) , is the absence of predominant motor activity. By reviewing the most recent literature, we intend to describe different aspects of NCSE: clinical presentation, classification, diagnostic criteria, differential diagnosis, imaging studies, and treatment. We emphasized the aspects most related to Psychiatry, without living aside characteristics encompassing its neurological aspects. The broad spectrum of clinical presentations, the rare knowledge about this entity , and the lack of clear diagnostic criteria are some of the difficulties to make the proper diagnosis. Because of its high morbidity and mortality, the aim of the present review is to highlight critical characteristics of NCSE, in order to take them into account during daily medical practice enabling an early and adequate treatment.