Course Of Bipolar Illness Research Articles

Bipolar disorder with personality disorders: A difficult diagnosis

Bipolar disorder poses some diagnostic difficulties because it is colored by the personality of the patients. What complicates the problem are the personality disorders, which make the diagnosis difficult. Comorbid personality disorders are frequent and may complicate the course of bipolar illness. We have much information about treating patients with uncomplicated Bipolar Disorder (BD) but much less knowledge about possibilities for patients with the comorbidity of BD and personality disorder. This review tries to make a point to avoid confusion.

Course of bipolar disorder in patients with Childhood maltreatment

IntroductionPatients with mood disorders have the greater frequency of childhood trauma compared with the general population, and adverse childhood experiences can exert a negative impact on their clinical course. Therefore, many studies confirmed the relationship between childhood traumas and the disadvantageous features of the illness course.ObjectivesThe aim of this study was to determine the impact of negative childhood experiences on the clinical course of bipolar disorder.MethodsIt was a cross-sectional descriptive and analytical study involving patients diagnosed with bipolar disorder and followed in the psychiatric department at the University Hospital of Sfax (Tunisia).Personal information form and Childhood trauma questionnaire (CTQ) were used for data acquisition. Euthymia was defined as a score on the Montgomery-Åsberg Depression Rating Scale (MADRS) not higher than 14 and by a score on the Young Mania Rating Scale (YMRS) not higher than seven.ResultsWe included 35 patients. Their mean age was 46.69 ± 12.01 years with a sex ratio (M/F)=0.45.The average onset of bipolar disorder was 28.37±10.26 years and the average disease duration was 18.26 ± 11.55 years.Almost the third of our population had a suicidal attempt (31.42%) and a violence history (28.57%). A family history of bipolar disorder was found in 57.14% of the patients.The patients have been hospitalized at least once in 42.85% of cases.Our patients have presented psychotic symptoms in 51.42% of cases and mixed characteristics in 57.14% of cases.Emotional, physical and sexual abuse were reported by 42.85%, 37.14% , 31,42% of patients, respectively, while 74,28% and 42.85% of patients reported physical neglect and emotional neglect.Early age at illness onset was significantly associated with total CTQ score (p=0.014) and the subtype sexual abuse (p=0.009). The presence of psychotic symptomswas significantly associated with total CTQ score (p=0.003) and emotional neglect (p=0.025). Physical neglect was associated with mixed characteristics (p=0.015). Emotional abuse was associated with a greater number of hospitalisations (p=0.023).ConclusionsOur results suggest that childhood trauma is associated with a more severe course of bipolar illness. Clinical assessment of patients with bipolar disorder should include investigation of exposure to childhood trauma in order to determine appropriate therapeutic strategies.Disclosure of InterestNone Declared

Commentary on "Synchrony Between Bipolar Mood Cycles and Lunar Tidal Cycles Ended After Initiation of Light Treatment and Treatment of Hypothyroidism".

According to a recent report, mood cycles in a group of patients with rapid cycling bipolar disorder oscillated in synchrony with lunar gravimetric tides. Mood switches in a 67-year-old woman with rapid cycling bipolar II disorder on lithium maintenance treatment were assessed with a χ periodogram and a χ analysis of the mood switches in relation to the lunar tidal cycle. During a period when she was treated with nortriptyline and her thyroid-stimulating hormone levels were elevated, her mood switches had a significant (P<0.05) 29- to 30-day periodicity, and the χ analysis showed that the switches were distributed nonrandomly in relation to the spring-neap lunar tidal cycle (P<0.0001); 14 of 15 switches occurred within 2 days of the spring tides. After nortriptyline was discontinued, thyroid-stimulating hormone levels were normalized with treatment with levothyroxine, and consistent bright light treatment was started, the synchrony between mood cycles and lunar cycles disappeared, and rapid cycling eventually stopped. The possibility that lunar mood cycling is sometimes contingent on antidepressant treatment, decreased thyroid function, and certain types of light-dark cycles needs to be considered in future research on lunar tidal influences on the course of bipolar illness.

Course of bipolar illness worsens after onset of insulin resistance

Cross-sectional studies indicate that comorbid insulin resistance (IR) and type 2 diabetes are associated with a more severe course of bipolar disorder (BD); however, this relationship has not previously been assessed longitudinally. To address this, we reviewed health records of a case series of six patients with BD and comorbid IR. Severity and length of affective episodes (both mania and depression) over the lifetime were recorded using the Affective Morbidity Index; these data were obtained from ongoing prospective follow-up and from detailed retrospective chart reviews. All six patients with a previously episodic, relapsing-remitting course of illness experienced a worsening of morbidity after the onset of laboratory-demonstrated IR. These results suggest that IR may be a potential testable, modifiable factor in the progression of BD from a treatment responsive (episodic) to a non-responsive (chronic) course of illness.

Racial disparities in bipolar disorder treatment and research: a call to action.

ObjectivesHealth disparities between individuals of African and European ancestry are well documented. The disparities in bipolar disorder may be driven by racial bias superimposed on established factors contributing to misdiagnosis, including: evolving empirically based diagnostic criteria (International Classification of Diseases [ICD], Research Diagnostic Criteria [RDC] and Diagnostic and Statistical Manual [DSM]), multiple symptom domains (i.e. mania, depression and psychosis), and multimodal medical and additional psychiatric comorbidity.MethodsFor this paper, we reviewed the phenomenological differences between bipolar individuals of African and European ancestry in the context of diagnostic criteria and clinical factors that may contribute to a potential racial bias.ResultsPublished data show that bipolar persons of African ancestry, compared with bipolar persons of non‐African ancestry, are more often misdiagnosed with a disease other than bipolar disorder (i.e. schizophrenia). Additionally, studies show that there are disparities in recruiting patients of African ancestry to participate in important genomic studies. This gap in biological research in this underrepresented minority may represent a missed opportunity to address potential racial differences in the risk and course of bipolar illness.ConclusionA concerted effort by the research community to increase inclusion of diverse persons in studies of bipolar disorder through community engagement may facilitate fully addressing these diagnostic and treatment disparities in bipolar individuals of African ancestry.

Bipolar disorder in Asia: Illness course and contributing factors.

Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors. A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated. Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes. The effects of treatment and childhood BD course features were not discussed. There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.

Differences in Men and Women with Bipolar-I Diagnosed Patients

The importance of gender on phenomenology and course of bipolar illness has been an increased focus of study over recent years. The purpose of present study was to examine whether gender differences exist in the sociodemographic characterictics, age of onset, severity of disease, number & type of episodes, symptomatology and treatment response of bipolar disorder. The life charts of 300 (193 female; 107 male) patients with BD type-I were evaluated retrospectively. BD diagnosis of patients was given by two experienced clinicians in accordance with DSM-IV-TR criteria. A semi-structured chart which was developed to assess sociodemographic and clinical features of patients and “mirror design” method was utilized for the assessment of patients’ response patterns to maintenance treatment. Bipolar women were significantly more likely to have history of (at least one) any mood episode than bipolar men. However no significant gender differences emerged in number of manic or mix episodes; whereas, women had more depressive episodes. Frequency of psychotic episodes (at least one episode during lifetime) was higher for men than women.. There was also no significant gender difference in terms of response to lithium and anticonvulsant maintenance treatment, mean episode severity and age of onset. The results of the present study show that some gender differences may be evident in patients with BD-I. In the highlight of that investigators studying bipolar disorder may need to consider gender as a variable for assessment and treatment strategies.

Circadian rhythmicity in emerging mood disorders: state or trait marker?

BackgroundCircadian rhythm disturbances overlap with the symptoms of mood episodes and may trigger or prolong mood symptoms. There is limited research on the role of circadian disturbances in mood disorders in young people and/or first episode cases of unipolar and bipolar disorders.MethodsActigraphy was undertaken for about 14 days in 63 post-pubertal individuals aged 13–25 years with a recent onset of a mood disorder meeting recognised diagnostic criteria. We examined associations between three easily interpretable markers of circadian rhythm activity (amplitude, acrophase and rhythmicity index) and demography and clinical characteristics. Then, circadian markers were compared between diagnostic groups, controlling for potential confounders.ResultsLonger duration of illness was correlated with reduced circadian rhythmicity and lower levels of activity over 24 h. A delay in the timing of maximum activity was associated with the level of manic but not depressive symptoms. The circadian rhythmicity index differentiated unipolar from bipolar cases, and in bipolar but not unipolar disorder, the rhythmicity was less robust in those with more severe manic or depressive symptoms.ConclusionsLess robust circadian rhythmicity, especially associated with increasing symptom severity, may represent a more specific or a trait marker of young people with mood disorders who are at higher risk of a bipolar course of illness.

Cognitive impairment in manic bipolar patients: important, understated, significant aspects.

BackgroundBipolar disorder is a chronic mood disorder with episodic progress and high relapse rate. Growing evidence suggests that individuals with bipolar disorder display cognitive impairment which persists even throughout periods of symptom's remission.Method137 bipolar patients met the inclusion criteria (depressive episode: DSM-IV-TR criteria for major depressive episode, HAMD score ≥17; manic/hypomanic episode: DSM-IV-TR criteria for manic/hypomanic episode, YMRS score ≥12, euthymic: 6 months of remission, HAMD score ≤8, YMRS score ≤6; and mixed: DSM-IV-TR criteria for mixed episode, HAMD score >8 and YMRS score >6) and were therefore enrolled in the study. Patients were free of psychotic symptoms (hallucinations/delusions) at the moment of testing. Control group consisted of 62 healthy subjects without history of neurological and/or psychiatric disorder. Cognitive battery has been applied in order to assess verbal memory, working memory, psychomotor speed, verbal fluency, attention and speed of information processing, and executive function. Following data were collected: demographics, psychiatric history, age of illness onset; current and previous treatment (including hospitalizations). Cognitive deficits were assessed in bipolar patients experiencing manic, depressive, mixed episodes or who were euthymic in mood. Results were compared between the subgroups and with healthy individuals. The association of impaired cognition with illness course was analyzed.ResultsBipolar patients showed cognitive deficits in all evaluated domains when compared to controls. The lowest scores were obtained for the verbal fluency test. After adjusting for current episode, manic subgroup showed greater cognitive impairment in verbal and working memory, executive function/reasoning and problem solving, compared to depressive, mixed, and euthymic subgroup. Low-neurocognitive performance was directly associated with a predominance of manic episodes and severe course of bipolar illness. An increased number of past manic episodes was the strongest correlated event with the poorest outcomes in verbal memory testing. Other factors correlated with poor verbal memory scores in manic subgroup were age at illness onset (positive correlation), illness length, and hospitalizations (negative correlations).ConclusionsBipolar patients showed cognitive deficits regardless of the phase of illness. Subjects experiencing a manic episode displayed higher deficits in verbal and working memory, executive function/reasoning, and problem solving. Severe course of illness also showed significant contribution in terms of cognitive impairment.

Multigenerational Positive Family History of Psychiatric Disorders Is Associated With a Poor Prognosis in Bipolar Disorder.

The authors assessed how family history loading affected the course of illness in patients from the United States. A total of 676 outpatients with bipolar disorder from the United States rated their illness and provided a parental and grandparental history of mood disorder, substance abuse, and other clinical conditions. A positive family history for each illness was associated with almost all of the seven poor prognosis factors established in the study (abuse in childhood, early onset, anxiety and substance abuse comorbidity, rapid cycling, multiple episodes, and worsening of severity or frequency of episodes). Family history for psychiatric difficulties in parents and grandparents was associated with a more complex and difficult course of bipolar illness.

Electroconvulsive Therapy in Bipolar Mixed States: An Overlooked Option

aBipolar Disorders Program, Hospital Clinic, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain. *Corresponding author: Andrea Murru, MD, PhD, Bipolar Disorders Program, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, c/Villaroel 170, Barcelona, 08036, Spain (amurru@clinic.ub.es). J Clin Psychiatry 2015;76(9):e1149–e1150 dx.doi.org/10.4088/JCP.14com09407 © Copyright 2015 Physicians Postgraduate Press, Inc. M ixed affective states are complex presentations of bipolar disorder that represent a diagnostic and therapeutic challenge for clinicians and researchers alike. Treatment guidelines do not usually recommend specific treatments for mixed states, as patients suffering from mixed episodes are generally included as a subsample in trials on acute mania. In clinical practice, mixed presentations in bipolar disorder are largely assumed to have a poorer response to treatment than mood episodes without mixed features. The present issue of the Journal presents a compelling article by Medda and colleagues1 on the acute use of electroconvulsive therapy (ECT) in a sample of 197 bipolar patients suffering from a severe, drug-resistant mixed state. The sample presented in this study represents a subset of especially difficult-to-treat bipolar patients. Nonetheless, the study clearly suggests that ECT is an effective treatment in mixed conditions, with 82 patients (41.6%) considered responders and 60 patients (30.5%) considered remitters. In the prediction model presented, the authors underline the role of comorbidity with obsessive-compulsive disorder, baseline manic symptom severity, and duration of the current episode as predictors of nonresponse to ECT.1 Despite the major limitations of the lack of random allocation of the patients included and the lack of evaluation for rapid-cycling, Medda and colleagues1 have the merit to provide insight on the clinical management of especially difficult-to-treat patients derived from their tertiary care unit and to focus on a therapy that is often neglected and rarely investigated. Mixed states represent a well-described clinical feature in the course of bipolar illness. Mixed states have been associated with the use or overuse of antidepressant treatments, which could play a role in their incidence in clinical practice, especially with dual-action serotonin–norepinephrine reuptake inhibitors,2 and with an increased suicidal risk.3 The iatrogenic role of antidepressants in mixed states is far from being demonstrated; yet, a recent international consensus agreed on the recommendation to discontinue antidepressants during manic and depressive episodes in patients who present mixed features or who have a tendency to present predominantly mixed states.4 In the recent update of the American Psychiatric Association diagnostic criteria (DSM-5), the strict criteria for mixed episode have been replaced with episode specifiers that will, as a consequence, increase the prevalence of mixed states in clinical practice,5 possibly broadening the usefulness of treatment recommendations specifically aimed at mixed states. This update creates an urgent need for more trials that provide separate results for mixed-states subsamples. Given the lack of studies designed to address the efficacy of medications in mixed affective symptoms, guidelines do not fully reflect the current evidence.6 The situation seems even worse in the case of depression with mixed features, in which the scarcity of researched treatment options often clashes with a clinical management that relies maybe too strongly on antidepressants.

Start Lithium Early in the Course of Bipolar Illness

The course of bipolar illness seems to worsen over time with increased episode frequency, higher relapse rates, and more cognitive impairment and social disability. Would giving lithium early in the illness be advantageous? To see whether it would yield better response rates than later prescription, researchers examined Danish registry data from 1995 to 2012 on 4714 bipolar patients who began …

Relationship of clinical course of illness variables to medical comorbidities in 900 adult outpatients with bipolar disorder

BackgroundMedical illnesses are highly comorbid with bipolar disorder, but their relationship to illness characteristics has not been previously delineated. MethodsThe incidence of 34 medical conditions and 6 poor prognosis factors (PPFs) was derived from answers to a questionnaire in over 900 outpatients with bipolar disorder who gave informed consent. The relationship of PPFs to the number of medical comorbidities was examined by Mann–Whitney U, Pearson r, and logistic regression. ResultsWhen examined individually, each of the 6 PPFs associated with an adverse course of bipolar disorder was significantly related to the number of medical comorbidities patients had. When age, gender, and independence of their relationships to each other were controlled for via regression, 3 of the PPFs remained significant (anxiety disorder, childhood abuse, and age of onset), and having 20 or more prior episodes was a strong trend. The number of PPFs was correlated with the number of comorbidities, although the above 3 PPFs show a similar magnitude of relationship. ConclusionA history of childhood adversity, early age of onset of bipolar disorder, and an anxiety comorbidity were independently related to the number of medical comorbidities that patients experienced as adults. While the nature and mechanisms of this linkage remain to be further explored, the findings indicate the need for greater attention to and treatment of these 3 PPFs in hopes of ameliorating both the adverse course of bipolar illness and the burden of medical comorbidities with which they are associated.

More stressors prior to and during the course of bipolar illness in patients from the United States compared with the Netherlands and Germany

Considerable data suggest that compared to some European countries, in the U.S. there are more childhood onset bipolar disorders, more adverse courses of illness, and greater treatment resistance. Psychosocial variables related to these findings have not been adequately explored. Therefore we analyzed psychosocial stressors in three time domains: childhood; the year prior to illness Onset; and the Last Episode from questionnaires in 968 outpatients (mean age 41) with bipolar I or II disorder; 676 from four sites in the U.S. and 292 from three in the Netherlands and Germany (abbreviated here as Europe). Compared to the Europeans, those from the U.S. had significantly more stressors in childhood and prior to the last episode. Stressors prior to the last episode were related to: childhood stressors; an earlier age at illness onset; anxiety and substance abuse comorbidity; lower income; both parents having an affective illness; and feeling more stigma. These data suggest a greater prevalence of adverse life events in childhood and over the course of bipolar illness in the U.S. compared to the Netherlands and Germany. Clinical, therapeutic, and public health approaches to these illness-relevant stressors require further exploration.

Extreme attributions predict transition from depression to mania or hypomania in bipolar disorder

BackgroundRelatively little is known about psychological predictors of the onset of mania among individuals with bipolar disorder, particularly during episodes of depression. In the present study we investigated attributional style as a predictor of onset of hypomanic, manic or mixed episodes among bipolar adults receiving psychosocial treatment for depression. We hypothesized that “extreme” (i.e., excessively pessimistic or optimistic) attributions would predict a greater likelihood of developing an episode of mood elevation. MethodOutpatients with DSM-IV bipolar I or II disorder (N = 105) enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were randomly allocated to one of three types of intensive psychotherapy for depression or a brief psychoeducational intervention. Patients completed a measure of attributional style at baseline and were followed prospectively for up to one year. All analyses were by intent to treat. ResultsLogistic regressions and Cox proportional hazards models indicated that extreme (both positively- and negatively-valenced) attributions predicted a higher likelihood of (and shorter time until) transition from depression to a (hypo)manic or mixed episode (ps < .04), independent of the effects of manic or depressive symptom severity at baseline. Extreme attributions were also retrospectively associated with more lifetime episodes of (hypo)mania and depression (ps < .05). ConclusionsEvaluating extreme attributions may help clinicians to identify patients who are at risk for experiencing a more severe course of bipolar illness, and who may benefit from treatments that introduce greater cognitive flexibility.

Herausforderungen der ambulanten Behandlung von Patienten mit bipolar-affektiven Störungen

The course of bipolar illness comprises a wide range, which may vary between one single episode once every five years and a severe ultra rapid cycling course with mood changes within days. Even with optimal pharmacological treatment the functional outcome in bipolar patients is still poor. Underlying pathomechanisms are not fully understood yet. This article addresses three possible illness specific-aspects: cognitive defects, high relapse frequency and poor adherence. Causes as well as therapeutic interventions for these therapeutic pitfalls are summarised.

Bipolar depression in children and adolescents

Children and adolescents with bipolar disorder may have depression as the presenting mood state. It is important for clinicians to distinguish between unipolar and bipolar depression in youth. Depressive episodes are common during the course of bipolar illness in children and adolescents. Evidence-based treatments are needed to guide clinicians' treatment decisions for youth with bipolar depression. This article reviews the prevalence, diagnosis, course, and treatment of bipolar depression in youth, and emphasizes the need for large, controlled treatment studies in the pediatric population.

Ramadan et trouble bipolaire : exemple de perturbation du rythme circadien et son impact sur la maladie

Fasting during the Ramadan month is a cornerstone of Islam. Several disorders of the chronobiological rhythms occur during this month and impact on mood. Through this paper the authors provide a literature review of the impact of fasting on patients with bipolar disorders. A literature review using Mesh keywords through Medline database. From 1970to 2011, articles in French and English were selected. Circadian rhythm refers to the approximately 24-hour cycles that are generated by an organism. Most physiological systems demonstrate circadian variations. Many hormones and other metabolisms, such as gastric pH, insulin, glucose, calcium and plasmatic gastrine, have been shown to exhibit circadian oscillation. The role of social rhythm in behaviors and its influence on circadian rhythms in humans is now obvious. It has been shown that the lack of concentration and irritability increased continuously during Ramadan month and reached its peak at the end of the month. Mood and vigilance are significantly decreased during the fasting month. Several authors have stated that the course of bipolar illness may be affected by the changes in social rhythm that occur during Ramadan (fasting month). Studies which have been devoted to this topic are sparse. Kadri et al., in 2000, studied 20bipolar patientsduring the fasting month of Ramadan of 1417 (Hegirian calendar, corresponding to January 1997). Diagnosis of bipolar disorder was made according to ICD-10criteria. Patients were assessed during the week before Ramadan, the second and the fourth weeks of the fasting month and the first week after its end, with the Hamilton Depression and Bech-Rafaelsen scales. The plasma concentration of lithium was also assessed. The main finding of the study was that 45% of the patients relapsed, 70% during the second week, and the remaining patients at the end of Ramadan. These relapses were not related to plasma concentration of lithium. Most of the relapses were manic (71,4%). Patients who did not relapse had more insomnia and anxiety during the second and third weeks of the study. The side effects of lithium increased and were seen in 48% of the sample, mostly dryness of the mouth with thirst and tremor. However, Farooq et al. in 2006studied 62bipolar patients during the fasting month of Ramadan 1427(from 25September to 24October 2006). Serum lithium, electrolytes, Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were assessed, one week before Ramadan, mid Ramadan and one week after Ramadan. The side effects and toxicity were measured by symptoms and signs checklist. There was no significant difference in mean serum lithium levels at three time points. The scores on HDRS and YMRS showed significant decrease during Ramadan (F=34,12, P=0,00, for HDRS and F=15,6, P=0,000for YMRS). Also the side effects and toxicity did not differ significantly at the three point's assessment. All physiologic parameters are influenced by the circadian rhythm, which is influenced in its turn by the food rhythm. So far, the results of these two main studies, with opposite results, do not help us advise bipolar patients to fast or not to fast. Other studies in this field are badly needed.

Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder

BackgroundPrevious studies in bipolar disorder investigating childhood trauma and clinical presentations of the illness have mainly focused on physical and sexual abuse. Our aim was to explore further the relationship between childhood trauma and disease characteristics in bipolar disorder to determine which clinical characteristics were most strongly associated with childhood trauma total score, as well as subtypes of adverse childhood events, including physical, sexual, emotional abuse and neglect.Methods141 Patients with bipolar disorder were consecutively recruited, and disease history and clinical characteristics were assessed. History of childhood abuse was obtained using the Childhood Trauma Questionnaire (CTQ). Statistical methods used were factor analysis, Poisson and linear regression, and generalized additive modeling (GAM).ResultsThe factor analysis of CTQ identified three factors: emotional abuse/neglect, sexual abuse and physical abuse. There were significant associations between CTQ total score and earlier onset of illness, reduced level of psychosocial functioning (GAF; Global Assessment of Functioning) and decreased number of hospitalization, which mainly were due to the factor emotional abuse/neglect. Physical abuse was significantly associated with lower GAF scores, and increased number of mood episodes, as well as self-harm. Sexual abuse was significantly associated with increased number of mood episodes. For mood episodes and self-harm the associations were characterized by great variance and fluctuations.ConclusionsOur results suggest that childhood trauma is associated with a more severe course of bipolar illness. Further, childhood abuse (physical and sexual), as well as emotional abuse and neglect were significantly associated with accelerating staging process of bipolar disorder. By using specific trauma factors (physical abuse, sexual abuse and emotional abuse/neglect) the associations become both more precise, and diverse.

1992 – Late onset bipolar disorder: challenges in diagnosis and treatment

Mania has been estimated to represent the cause of 4.6% to 18.5% of all geriatric psychiatric admissions and 10% of new-onset mania cases have been found to occur in individuals over the age of 50. Age of onset can have a significant impact on the nature and course of bipolar illness. Review the current literature of pharmacologic management of late-life bipolar disorder and discuss the differential diagnosis. Brief literature review. Case report and literature review. We describe a case of a 76-years-old female with elevated mood, verbosity, distractibility, irritability, inadequate social behavior, reduced requirement of sleep, increased physical activity, impulsive business investments. Several tests were made: analytical study, CT scan and neuropsychological evaluation, none with significant alterations. She was treated with an antipsychotic drug with improvement of symptoms. There is a limited evidence base for treatment of bipolar disorder in the elderly and further controlled studies are needed. Current data suggest that valproate and lamotrigine may be better tolerated as mood stabilizers than lithium. Preliminary reports suggest a role for the use of atypical antipsychotic in older adults with bipolar disorder although potential benefit must be balanced against the potential risks of treatment. In treating elderly bipolar patients, one has to keep in mind that pharmacokinetic and pharmacodynamic changes that occur with ageing, associated with frequent concomitant medical illnesses and their treatments, are likely to increase the risk of adverse events and drug interactions.