Manual Of Diagnosis Research Articles

Mania and Pachygyria

Mania and Pachygyria

Anxiety rating scales in Parkinson's disease: A validation study of the Hamilton anxiety rating scale, the Beck anxiety inventory, and the hospital anxiety and depression scale

Anxiety is a prevalent and disabling condition in Parkinson's disease (PD). The lack of anxiety rating scales validated for this population hampers research into anxiety in PD. The aim of this study is to assess the clinimetric properties of the Hamilton anxiety rating scale (HARS), the Beck anxiety inventory (BAI), and the hospital anxiety and depression scale (HADS) in PD patients. Three hundred forty-two PD patients underwent a standardized assessment including a structured interview for diagnostic and statistical manual diagnoses of anxiety disorders and completion of the HARS, BAI, and HADS. Inter-rater reliability of the HARS was assessed in 60 patients; test-retest reliability of the BAI and HADS in 213 and 217 patients, respectively. Thirty-four percent of patients suffered from an anxiety disorder, whereas an additional 11.4% had clinically significant anxiety symptoms in the absence of a diagnosis of anxiety disorder. Acceptability, score distribution, and known groups validity over different levels of anxiety were adequate. Inter-rater reliability for the HARS and test-retest reliability for the BAI and HADS were good. The HARS, but not the BAI and HADS, had a satisfactory inter-item correlation, convergent validity and factorial structure. For all scales, the positive predictive value was poor, and the negative predictive value was moderate. Given the adequate known groups validity of all three rating scales, each of these scales is likely to be useful in clinical practice or research for evaluation of symptom severity. Limitations in the construct validity of the anxiety scales in this study raise questions regarding suitability for their use in PD.

Baseline and prodromal characteristics of first- versus multiple-episode mania in a French cohort of bipolar patients

ObjectiveTo identify some of the main features of bipolar disorder for both first-episode (FE) mania and the preceding prodromal phase, in order to increase earlier recognition. MethodsOne thousand and ninety manic patients (FE=81, multiple-episodes [ME]=1009) were assessed for clinical and temperamental characteristics. ResultsCompared to ME, FE patients reported more psychotic and less depressive symptoms but were comparable with respect to temperamental measures and comorbid anxiety. The following independent variables were associated with FE mania: a shorter delay before correct diagnosis, greater substance use, being not divorced, greater stressors before current mania, a prior diagnosis of an anxiety disorder, lower levels of depression during index manic episode, and more suicide attempts in the past year. ConclusionIn FE patients, the diagnosis of mania may be overlooked, as they present with more psychotic symptoms than ME patients. The prodromal phase is characterised by high levels of stress, suicide attempts, anxiety disorders and alcohol or substance abuse. Data suggest to consider these prodromes as harmful consequences of temperamental predispositions to bipolar disorder that may concur to precipitate mania onset. Their occurrence should therefore incite clinicians to screen for the presence of such predispositions, in order to identify patients at risk of FE mania.

Aripiprazole in Treating a Manic Episode Associated With Hydrocephalus

To the Editor: Two previous case reports have suggested that hydrocephalus is associated with mood cycles, including manic and depressive episodes. In both cases, mood symptoms were unresponsive to pharmacologic treatment, but resolved after surgical treatment.1,2 Here we report a case of a manic episode associated with normal pressure hydrocephalus. The manic but not the depressive symptoms showed a good response to aripiprazole treatment before surgery. However, because mood symptoms remained after surgery, treatment with aripiprazole was continued at the same dose. Case report: Mr A, a 61-year-old man, suffered from irritability, hypertalkativeness, a decreased need for sleep, grandiosity, and aggression toward his family 1 month previously. According to his family, he was healthy, with good social functioning before admission. Three months ago, a sudden onset of depressive mood, urine incontinence, memory impairment, and ataxia occurred. He was sent to a local hospital and bupropion (150 mg/d) was prescribed. The depressive mood was mildly improved. After admission, Mr A received quetiapine (100 mg/d) to treat manic symptoms (per a DSM-IV diagnosis of mania). However, significant extrapyramidal side effects (EPS) appeared, including tremor, salivation, and akathisia. Meanwhile, urine incontinence and ataxia recurred. Brain magnetic resonance imaging revealed ventricular dilatation, and normal pressure hydrocephalus was diagnosed. After about 1 week, medication was switched to aripiprazole 10 mg/d. The manic symptoms improved significantly within 2 weeks. No EPS were noted. A ventriculoperitoneal (VP) shunt was performed when manic symptoms became stable. Mr A was discharged 6 weeks later in a stable mood condition, but with minor impairments of cognitive function. Studies discussing pharmacologic treatment of manic episodes associated with hydrocephalus are scarce. Contrary to previous reports, our patient showed a good response to aripiprazole (10 mg/d). Aripiprazole is an atypical antipsychotic that has a unique partial agonistic effect at D2 receptors. Its efficacy and safety in the treatment of manic episodes have been demonstrated.3 Interestingly, 2 recent positron emission tomography studies demonstrated that the binding of striatal D2 receptors was reduced in normal pressure hydrocephalus4 and up-regulated after VP shunting.5 Moreover, both studies showed that changes in striatal D2 receptors were correlated with improving emotional and cognitive function. Therefore, our case indicates that antipsychotic agents with partial D2 receptor agonistic effects could stabilize the dopamine neurotransmitter system and help in the treatment of the psychological changes associated with hydrocephalus.

Does lithium protect against dementia?

To investigate whether treatment with lithium in patients with mania or bipolar disorder is associated with a decreased rate of subsequent dementia. Linkage of register data on prescribed lithium in all patients discharged from psychiatric health care service with a diagnosis of mania or bipolar disorder and subsequent diagnoses of dementia in Denmark during a period from 1995 to 2005. A total of 4,856 patients with a diagnosis of a manic or mixed episode or bipolar disorder at their first psychiatric contact were included in the study. Among these patients, 2,449 were exposed to lithium (50.4%), 1,781 to anticonvulsants (36.7%), 4,280 to antidepressants (88.1%), and 3,901 to antipsychotics (80.3%) during the study period. A total of 216 patients received a diagnosis of dementia during follow-up (103.6/10,000 person-years). During the period following the second prescription of lithium, the rate of dementia was decreased compared to the period following the first prescription. In contrast, the rates of dementia during multiple prescription periods with anticonvulsants, antidepressants, or antipsychotics, respectively, were not significantly decreased compared to the rate of dementia during the period with one prescription of these drugs. Continued treatment with lithium was associated with a reduced rate of dementia in patients with bipolar disorder in contrast to continued treatment with anticonvulsants, antidepressants, or antipsychotics. Methodological reasons for these findings cannot be excluded due to the nonrandomized nature of the data.

S23-03 - Lithium treatment and the risk of dementia

IntroductionTo investigate whether treatment with lithium in patients with mania or bipolar disorder is associated with a decreased rate of dementia.MethodsLinkage of register data on prescribed lithium in all patients discharged from psychiatric health care service with a diagnosis of mania or bipolar disorder and subsequent diagnoses of dementia in Denmark during a period from 1995 to 2005.ResultsContinued treatment with lithium was associated with a reduced rate of dementia in patients with bipolar disorder, in contrast to continued treatment with anticonvulsants, antidepressants or antipsychotics. Methodological reasons for these findings cannot be excluded due to the non-randomized nature of data. A total of 4.856 patients with a diagnosis of a manic or mixed episode or bipolar disorder at their first psychiatric contact were included in the study. Among these patients, 2,449 (50.4%) were exposed to lithium, 1,781 were exposed to anticonvulsants (36.7%), 4,280 to antidepressants (88.1%) and 3,901 to antipsychotics (80.3%) during the study period. A total of 216 patients got a diagnosis of dementia during follow-up (103.6 / 10.000 person years). During the period following the second prescription of lithium the rate of dementia was decreased compared to the period following the first prescription. In contrast, the rates of dementia during multiple prescription periods with anticonvulsants, antidepressants or antipsychotics, respectively, were not significantly decreased compared to the rate of dementia during the period with one prescription.ConclusionContinued treatment with lithium was associated with a reduced rate of dementia.

The Cognition Checklist for Mania—Revised (CCL-M-R): Factor-Analytic Structure and Links with Risk for Mania, Diagnoses of Mania, and Current Symptoms

We conducted two studies to examine the Cognition Checklist for Mania-Revised (CCL-M-R; Beck, Colis, Steer, Madrak, & Goldberg, 2006). In the first, we gathered data in an undergraduate sample (N = 208) to examine the factor structure of the measure and the correlations of the subscales with the Hypomanic Personality Scale (HPS; Eckblad & Chapman, 1986). Factor analyses refined subscales, and three of the original four subscales developed by Beck and colleagues (2006) were retained. Persons with higher stores on the HPS were likely to endorse manic cognitions associated with overconfidence and excitement-seeking. In a second study, we gathered data from 61 persons diagnosed with bipolar I disorder, 38 with major depressive disorder (MDD), and 33 with no history of mood disorder. Excitement-seeking scores were robustly related to current manic symptoms, as measured by the Internal State Scale (ISS; Bauer et al., 1991). Thus, CCL-M-R excitement-seeking scores appear to be related to risk for mania and to current symptoms of mania within a clinical sample. Other findings, though, suggest that problems with interpersonal relationships (feeling thwarted by others) may emerge among those clinically diagnosed with bipolar I disorder, even though not endorsed among those at risk. Moreover, difficulties with interpersonal relationships and diminished confidence in those with bipolar I disorder paralleled the difficulties observed among those with MDD. Findings suggest that cognitive profiles associated with mania may depend on mood state and course of the disorder.

The Observer-Rated Scale for Mania (ORSM): development, psychometric properties and utility

Background The diagnosis of mania largely depends on the quality of information the physician is provided with. Often, the patient cannot give an accurate account of the symptom development and thus information from relatives and friends is required. No systematic rating instrument is available, however, to facilitate this. Objective In this study, the psychometric properties of the 49-item Observer-Rated Scale for Mania (ORSM) are reported. Methods The scale was used in 113 inpatients and the following psychometric aspects were assessed: reliability, test–retest reliability, construct validity (factor analysis, discriminant analysis, comparison of means), extreme-group validity, prognostic validity, sensitivity, specificity, positive and negative predictive values. Results The ORSM proved highly valid and reliable. Factor analysis revealed three factors which were labelled euphoric mania, instable mania and psychotic mania. Conclusion The ORSM is a useful instrument to help non-professionals who are in regular contact with the patient diagnosed a manic/mixed episode. It thus complements existing rating scales for mania, which are either designed for professionals or are self-rating instruments.

Pediatric Bipolar Disorder

Clinicians are less sensitive in considering the diagnosis of mania in children because of the variations in clinical presentation and because of the high comorbidity with other psychiatric disorders. More often than the elated and expansive mood, irritability and significant aggression may be the presenting symptoms in these cases. One such case report is discussed highlighting the clinical aspects of pediatric bipolar disorder.

Bethlem's Irish: migration and distress in nineteenth-century London

Association between migration and mental illness is widely reported. This study aimed to gain insight into the mental health of Irish migrants into Britain in the years 1843-53. Casebooks from the period were examined for Irish ethnicity, and clinical profiles were compared with those of age-matched control samples. Irish-born patients were found to have a greater proportion of diagnoses of mania than controls (p < or = 0.01). They were more likely to be admitted for 12 months or longer (p < or = 0.001) and more likely to receive religious attributions for illnesses by the treating physician. The more common diagnosis of mania in the Irish group can be explained in terms of the effects of migration, differences in idioms of distress, or in terms of prejudice.

Examination of concordance between maternal and youth reports in the diagnosis of pediatric bipolar disorder

While concordance between mother and child report continues to be the gold standard in the assessment of pediatric bipolar disorder, uncertainty develops when a mother's report is not endorsed by the youth. To this end we compared discordant (mother positive and youth negative) and concordant (mother and youth positive) cases. Subjects were 98 adolescents (12-19 years of age) derived from family studies of bipolar disorder in youth who had both self-reported and mother-reported assessments. Comparisons were made between discordant (n = 35) and concordant (n = 59) cases on a wide range of clinical correlates. Mothers in both groups reported similar rates of symptoms of mania and depression. Within the concordant group, mothers and youth reported similar rates of symptoms of mania. There were no differences between the concordant and discordant groups in onset, duration, or impairment of mania, rates of psychiatric hospitalization, cognitive variables, or rates of disorders in family members. The similarities between discordant and concordant reports in symptomatology of mania and depression, rates of comorbidities, treatment needs, and other clinical correlates suggest that a mother-based diagnosis of mania should not be discounted in discrepant cases in which the youth fails to endorse the diagnosis.

Sex differences in the behavior of children with the 22q11 deletion syndrome

High rates of psychiatric impairment in adults with 22q11 deletion syndrome (22q11DS, also referred to as DiGeorge or velocardiofacial syndrome) suggest that behavioral trajectories of children with 22q11DS may provide critical etiologic insights. Past findings that report Diagnostic and Statistical Manual (DSM) diagnoses are extremely variable; moreover, sex differences in behavior have not yet been examined. Child Behavior Checklist (CBCL) ratings from 82 children, including 51 with the 22q11DS and 31 control siblings, were analyzed. Strikingly consistent with rates of psychiatric impairment among affected adults, 25% of children with 22q11DS had high CBCL scores for Total Impairment, and 20% had high CBCL Internalizing Scale scores. Males accounted for 90% of high Internalizing scores and 67% of high Total Impairment scores. Attention and Social Problems were ubiquitous; more affected males than females (23% vs. 4%) scored high on Thought Problems. With regard to CBCL/DSM overlap, 20% of affected males as compared with 0 affected females had one or more high CBCL ratings in the absence of a DSM diagnosis. Behaviors of children with 22q11DS are characterized by marked sex differences when rated dimensionally, with significantly more males experiencing Internalizing and Thought Problems. Categorical diagnoses do not reflect behavioral differences between male and female children with 22q11DS, and may miss significant behavior problems in 20% of affected males.

The reliability of compliance assessments performed by doctors and patients during neuroleptic treatment: a comparison of compliance ratings

Objective: To compare compliance assessments made by doctors and patients during neuroleptic drug treatment and to detect any variables explaining the discrepancies between their ratings. Method: Compliance reports regarding neuroleptic medication were collected from 100 in-patients and out-patients and from their doctors. Re-ratings were performed after 1–2 weeks. Compliance ratings were compared with demographic, treatment and symptom-related variables and with the Attitudes to Neuroleptic Treatment (ANT) questionnaire using logistic regression analysis. Results: The doctors' and patients' compliance ratings showed good test–retest reliability (r=0.80, doctors; r=0.81, patients) and concordance (79% of the cases within the limits of ±25%-units deviation). Variables explaining discrepancies between the ratings included female gender, a low level of education, the diagnosis of mania, a high neuroleptic dose and several items from the ANT scale. Conclusion: Manic episodes, negative attitudes to neuroleptic medication and a high-dose treatment increase the risk for deviating views of compliance in the doctor–patient relationship.

Medical Emergency Department Utilization Patterns Among Uninsured Patients With Psychiatric Disorders

This study examined medical emergency department utilization for patterns among uninsured patients with psychiatric disorders. Billing records of 15,672 uninsured adult patients treated in the emergency department of an academic medical center in southeast Texas over a 12-month period were analyzed for information on demographic characteristics, diagnosis, number of emergency department visits, and hospitalization. Overall, 11.8% of the population was diagnosed as having at least one psychiatric disorder during an emergency department visit. Patients with psychiatric disorders had an increased risk of having multiple emergency department visits and hospitalization compared with patients without psychiatric disorders. The risk of multiple emergency department visits was particularly high for patients with either bipolar disorder or psychotic disorders. Uninsured patients with psychiatric disorders appear to be heavy users of medical emergency department services. These findings may be helpful in developing more efficient strategies to serve the mental health needs of the uninsured.

Prepubertal mania: diagnostic differences between US and UK clinicians

To test the hypothesis that US clinicians diagnose prepubertal mania more commonly than UK clinicians. Five vignettes were presented to 73 UK clinicians and 85 US clinicians. Four cases represented complex scenarios where the diagnosis of mania was thought to be controversial, and one case was a 'classical' case of mania in an older child where it was thought there would be good agreement. Clinicians were asked to determine symptoms of mania, and their preferred diagnoses. As predicted, overall there were significantly more diagnoses of mania in the US than the UK (P < or = 0.0001). US clinicians were significantly more likely to diagnose mania in three of the four complex cases, and there was good agreement in the case of classical mania. In addition, UK clinicians were significantly more likely to diagnose pervasive developmental disorders and adjustment disorders, whereas obsessive compulsive disorder was more commonly diagnosed in the US. There may be differences in how clinicians in the US and UK interpret mania-like symptoms in younger children, which may have implications for diagnosis and management.

Disability associated with mood states and comparator conditions: application of the Life Skills Profile measure of disability

To quantify the comparative level of disability experienced by those with mania and depression by contrasting against levels of disability experienced by those with schizophrenia, anxiety disorder and drug and alcohol dependence. Disability data, measured by use of an abbreviated version of the Life Skills Profile, were collected from an Australian national survey assessing more than 20,000 episodes of care, involving in-patients and out-patients. Those with a diagnosis of mania rated as having higher levels of disability than those with depression and somewhat lower levels of disability than those with schizophrenia in the 3 months prior to assessment. Such data from a large national survey underline the increasingly recognized reality that those experiencing manic episodes have high levels of associated disability, and that management interventions are required that address the impact of impaired functioning as well as acute episodes.

DSM categories and dimensions in clinical and research contexts.

An enhancement to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is currently under consideration, one that would enhance both the reliability and validity of the Diagnostic and Statistical Manual (DSM) diagnoses: the addition of a dimensional adjunct to each of the traditional categorical diagnoses of the DSM. We first review the history and context of this proposal and define the concepts on which this dimensional proposal is based. The advantages of dimensional measures over categorical measures have long been known, but we here illustrate what is known with a theoretical and a practical demonstration of the potential effects of this addition. Possible objections to the proposal are discussed, concluding with some general criteria for implementing this proposal.

Bipolar Disorder Clinical Synthesis: Where Does the Evidence Lead?

Bipolar disorder is a common condition diagnosed by the occurrence of pathological mood elevation but most often dominated by dysphoria states. Over the past 10 years, understanding of bipolar disorder and the number of evidence-based treatments have increased dramatically. This article offers strategies for improving diagnostic confidence and simple benchmarks that facilitate integrating principles of evidence-based medicine into the management of patients with bipolar disorder. Simple systematic assessment techniques such as focusing the evaluation to assess the most extreme episode of mood elevation and longitudinal factors such as age of onset and course of illness can avoid errors of omission and raise diagnostic confidence. An iterative measurement-based treatment model that aims to bring patients and their supports into the collaborative care process for progressively better outcomes is recommended.

What symptoms predict the diagnosis of mania in persons with severe/profound intellectual disability in clinical practice?

While researchers have attempted to address the difficulties of diagnosing affective disorders in the intellectually disabled population, diagnosing bipolar disorder in an individual with severe intellectual disability (ID) remains a challenge. The aim of this study was to identify what symptoms can predict a diagnosis of mania in the intellectually disabled population. Three groups of persons with ID participated in this study: (1) individuals with a bipolar diagnosis who were currently manic; (2) individuals with an Axis I diagnosis other than bipolar disorder; and (3) individuals without an Axis I diagnosis. Two recognized measures of mania (i.e. Diagnostic Assessment for the Severely Handicapped-Revised and Parent Version of Young Mania Rating Scale) were used to evaluate symptoms of mania. A logistical regression procedure was conducted on mania items to identify which items correctly identify persons with ID who were currently manic. Psychomotor agitation, decreased sleep, changes in mood and aggression were significantly related to the diagnosis of mania. Further, psychomotor agitation and disturbed sleep were significant predictors of a diagnosis of mania. Problems of sleep and psychomotor agitation should alert clinicians that further assessment of bipolar symptomatology is warranted. Focusing on observable behaviours based on Diagnostic and Statistical Manual of Mental Disorder-IV criteria can be useful in formulating a diagnosis of bipolar disorder in persons with ID.

Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study

Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. Almost 40% (n=194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n=103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression.