Elated Mood Research Articles

Bipolar disorder longitudinal study in Nigeria – Preliminary data on demographic and clinical findings of the study cohort

BackgroundBipolar disorder, severe mood disorder characterised by its ability to swing between two contrasting poles of low and elated mood with a return to relatively normal level of functioning, has a lifetime prevalence of up to 2.4%, a heterogenous clinical picture, significant burden of disease, and a high co-morbidity rate. With significant lack of data from the African continent on bipolar disorder, this study was started with an aim to provide insight into the sociodemographic, biological, clinical, and cultural picture of bipolar disorder in Nigeria. MethodsPhase I of the study required the development of a bipolar registry and collection of data in a retrospective manner from patient clinically diagnosed with bipolar disorder at the department of neuropsychiatry, University of Port Harcourt Teaching Hospital in Nigeria. Data collection on demography, illness onset, duration to bipolar diagnosis, mood polarity etc., were extracted manually from patient case files using a data form developed by the research team. ResultBipolar disorder has a mean age at onset of 27.43±10.56 years, with younger age at onset in males. There is a relatively high misdiagnosis rate of bipolar disorder with delay in making a bipolar diagnosis of 19.39 months. The data also show the presence of singular mood polarity in bipolar disorder. ConclusionPreliminary findings from the bipolar disorder longitudinal study in Nigeria has provided much needed data for bipolar disorder in Nigeria. It also makes evident the need for a prospective, multicentre study of the life course of bipolar disorder as intended in the second phase of the study.

Secondary Mania induced by TNF-α inhibitors: A systematic review.

A growing number of studies support a bidirectional relationship between inflammation and bipolar disorders. Tumor necrosis factor‐α (TNF‐α) inhibitors have recently attracted interest as potential therapeutic compounds for treating depressive symptoms, but the risk for triggering mood switches in patients with or without bipolar disorders remains controversial. Thus, we conducted a systematic review to study the anti‐TNF‐α medication‐induced manic or hypomanic episodes. PubMed, Scopus, Medline, and Embase databases were screened for a comprehensive literature search from inception until November 2020, using The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Out of the initial 75 references, the screening resulted in the inclusion of four case reports (each describing one patient) and a cohort study (in which 40 patients out of 7600–0.53% – experienced elated mood episodes after infliximab administration). Of these 44 patients, 97.7% experienced a manic episode and 2.3% hypomania. 93.2% of patients had no history of psychiatric disorder or psychotropic treatment. Only 6.8% had a history of psychiatric disorders with the affective spectrum (4.6% dysthymia and 2.3% bipolar disorder). The time of onset of manic or hypomanic symptoms varied across TNF‐α inhibitors with an early onset for Infliximab and a later onset for Adalimumab and Etanercept. These findings suggest that medications targeting the TNF‐α pathway may trigger a manic episode in patients with or without affective disorders. However, prospective studies are needed to evaluate the relative risk of such side effects and identify the population susceptible to secondary mania.

Usefulness of hangekobokuto (Banxia‐houpo‐tang) to treat panic disorder in patients with bipolar disorder: A case report

ABSTRACTCaseA woman in her early 40s with bipolar disorder had panic disorder. She had to avoid selective serotonin reuptake inhibitors (SSRIs), the standard medication for panic disorder, which could cause a switch to mania in bipolar disorder.OutcomeThe attacks decreased without a switch to mania after she started taking hangekobokuto (banxia‐houpo‐tang). Hangekobokuto is reported to increase serotonin in the brain. According to another report, hangekobokuto reduced c‐fos expression, a marker of neuronal activity in the hippocampus only in the animal model of depression, while SSRIs reduced it in both depressive and control animals. This suggests that, unlike SSRIs, hangekobokuto may not have unnecessary effects which might induce elated mood in non‐depressive cases. Therefore, hangekobokuto might be safer than SSRIs for non‐depressive biplolar patients like this patient.ConclusionHangekobokuto could be one of the options to treat panic disorder in patients with bipolar disorder, although further study is necessary.

Ukrainian Art of the Totalitarianism Epoch: the Case of the “Zhovten” Association

The present article focuses on the transformation of style and sense of Ukrainian art in the 1930s, in the context of the “Zhovten” Association designers’ creativity. Ideological pressure became determinant in the work of Ukrainian artists. Period of repressions led to decay of art in general, and dramatic reduction in style directions. Industrialization in the USSR, carried out in the 1930s, and measures to accelerate the development of industry were the main themes imposed on artists. Ideologically biased theoretical foundations of the new artistic style typical for the 1930s were clearly manifested in the declaration of the “Zhovten” Association. The ranks of this association, founded in 1930, included some former members of the Association of Revolutionary Art of Ukraine and the Association of Contemporary Artists of Ukraine. The theory spelled out in the declaration of unification was significantly ahead of its practical implementation, the artists themselves gradually switched to new forms and content in their works, without breaking ties with the national and European school. The “Zhovten” Association became a true litmus test of those phenomena that dominated in the art of the Stalin era. At the same time, it crossed out all the achievements of the associations-predecessors, creating a version of the all-Union ideologically engaged associations in Ukraine. A sharp change took place in the artistic environment when the question of form ceased to be a vital topic. The attention was focused on the content of artworks. The ostentatious elated mood of works of art hid the realities of the time like a screen. It camouflaged serious constraint in artistic statements, offering the only “correct” chartered way forward that made it impossible for any artist to make their own graphic statements. A tangible ideological pressure prompted the artists to abandon their creative originality, and strive for maximum realism. They added cliché images to their works: portraits of ideologists, workers, flags, Soviet symbols, and the like. At the same time, the authors lost their creative identities, and their artworks were deprived of any artistic value.

S88. GRANDIOSE IDEAS IN SCHIZOPHRENIA: THE ROLE OF OPTIMISM BIAS AND HALLUCINATIONS

BackgroundGrandiose delusions (GDs) are defined as false beliefs about having an inflated worth, power, or a special identity which are firmly sustained despite undeniable evidence to the contrary. GDs have received little attention although it is the second most commonly encountered delusional beliefs (Stompe, et al., 2006). Consequently, there is no intervention program targeting GD and only few studies have explored the psychological processes underpinning GDs. Considering that delusions have an origin in autobiographical memory (Berna et al., 2017) and thus also in how individuals project themselves into the future, the aim of this present study was to explore the role of future projection, sensibility to reward and punishment, and anticipatory pleasure in GDs in schizophrenia (SZ) disorder.Methods133 SZ patients completed measures of positive and negative symptoms, sensibility to reward and punishment, anticipatory pleasure, depression, and an experimental task in which individuals were asked to project themselves into positive, negative and neutral future situations and evaluate to what extent they believed the situation would happen in the future.ResultsFor the first set of analyses (Independent samples test), the sample was divided into two groups according to GD scores. Patients with higher GD scores (PANSS 5 score > 3; High GG M = 4; Low GD M = 1) obtained higher scores on sensibility to reward and self-future projection into positive situations as well as on positive symptoms. No significant differences were found regarding the other measures. Secondly, positive symptoms, sensibility to reward and positive future expectations were entered in the regression analysis. Results showed that hallucinations (B = 0.359, p = 0.0001) and positive future expectations (B = 0.216, p = 0.011) were significantly associated with GD (R2 = 0.317, p = 0.009).DiscussionThis present study showed that sensibility to reward and especially higher optimism bias for the future may be important psychological processes associated with GDs in SZ patients. Optimism bias for the future may play a role in amplifying and reinforcing elated mood built upon pre-existing inflated (or accurate) perceptions of self (Freeman & Garety, 2003). Together with cognitive bias such as jumping to conclusions (Garety et al., 2012), they may provide evidence for the plausibility of GDs. Concerning the association between GDs and hallucinations, it is possible that patients experiencing hallucinations may interpret this phenomenon as a kind of special ability or power, resulting in turn in GDs maintenance.

Measuring racing thoughts in healthy individuals: The Racing and Crowded Thoughts Questionnaire (RCTQ)

Racing thoughts refer to an acceleration and overproduction of thoughts, which have been associated with manic and mixed episodes. Phenomenology distinguishes ‘crowded’ from ‘racing’ thoughts, associated with mixed depression and mania, respectively. Recent data suggest racing thoughts might also be present in healthy individuals with sub-affective traits and symptoms. We investigated this assumption, with a 34-item self-rating scale, the Racing and Crowded Thoughts Questionnaire (RCTQ), and evaluated its reliability, factor structure, and concurrent validity. 197 healthy individuals completed the RCTQ, the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego – autoquestionnaire (TEMPS-A), the Beck Depression Inventory (BDI), the Altman Self-Rating Mania scale (ASRM), and the Ruminative Response Scale (RRS). Exploratory factor analysis yielded a three-factor solution, labeled ‘thought overactivation’, ‘burden of thought overactivation’, and ‘thought overexcitability’. Internal consistency of each of the three subscales of the RCTQ was excellent. The TEMPS-A cyclothymia score was associated with the three factors, suggesting good concurrent validity. The ‘thought activation’ subscale was selectively associated with current elated mood and included items conveying both the notion of increased amount and velocity of thoughts, whereas the ‘burden of thought overactivation’ subscale was associated with current low mood. The ‘thought overexcitability’ subscale included items conveying the notion of distractibility, and was associated with both elated and low mood. Rumination was not a significant predictor of RCTQ subscores. These results suggest that the RCTQ has good psychometric properties. Racing and crowded thoughts, as measured by the RCTQ, are a multi-faceted phenomenon, distinct from rumination, and particularly associated with mood instability even in its milder forms.

Pediatric mania: The controversy between euphoria and irritability

IntroductionPediatric bipolar disorder (BD) is a highly morbid pediatric psychiatric disease, consistently associated with family psychiatric history of mood disorders, with high levels of morbidity and disability and with a great risk of suicide.ObjectivesWhile there is a general consensus on the symptomatology of depression in childhood, the phenomenology of pediatric mania is still highly debated and the course and long-term outcome of pediatric BD still need to be clarified.AimsTo assess the prevalence, demographics, clinical correlates and course of these euphoric versus irritable pediatric mania.MethodsSystematic review of the available studies assessing the phenomenology, course and outcome of pediatric mania.ResultsEighteen studies reported the number of subjects presenting with either irritable or elated mood during mania. Irritability has been reported to be the most frequent clinical feature of pediatric mania reaching a sensitivity of 95–100% in several samples. Only half the studies reviewed reported on number of episodes or cycling patterns and the described course was mostly chronic and ultra-rapid whereas the classical episodic presentation was less common. Few long-term outcome studies have reported a diagnostic stability of mania from childhood to young adult age.ConclusionsSevere irritability is the most common presentation of abnormal mood described in children with bipolar disorder. Longitudinal studies of samples with irritable versus elated mood presentation and chronic versus episodic course may help clarify whether these are factors predicting different long-term course, treatment-response and outcome of pediatric onset bipolar disorder.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Pediatric Mania: The Controversy between Euphoria and Irritability.

: Pediatric Bipolar Disorder (BD) is a highly morbid pediatric psychiatric disease, consistently associated with family psychiatric history of mood disorders and associated with high levels of morbidity and disability and with a great risk of suicide. While there is a general consensus on the symptomatology of depression in childhood, the phenomenology of pediatric mania is still highly debated and the course and long-term outcome of pediatric BD still need to be clarified. We reviewed the available studies on the phenomenology of pediatric mania with the aim of summarizing the prevalence, demographics, clinical correlates and course of these two types of pediatric mania. Eighteen studies reported the number of subjects presenting with either irritable or elated mood during mania. Irritability has been reported to be the most frequent clinical feature of pediatric mania reaching a sensitivity of 95–100% in several samples. Only half the studies reviewed reported on number of episodes or cycling patterns and the described course was mostly chronic and ultra-rapid whereas the classical episodic presentation was less common.Few long-term outcome studies have reported a diagnostic stability of mania from childhood to young adult age. Future research should focus on the heterogeneity of irritability aiming at differentiating distinct subtypes of pediatric psychiatric disorders with distinct phenomenology, course, outcome and biomarkers. Longitudinal studies of samples attending to mood presentation, irritable versus elated, and course, chronic versus episodic, may help clarify whether these are meaningful distinctions in the course, treatment and outcome of pediatric onset bipolar disorder.

Confabulation: What is associated with its rise and fall? A study in brain injury

The aim of this study was to investigate cognitive and emotional factors associated with the presence and clinical course of confabulation.24 confabulating participants were compared with 11 brain injured and 6 healthy controls on measures of temporal context confusions (TCC), mood state (elation, depression) and lack of insight. Measures of autobiographical memory and executive function were also available. Changes in confabulation and these other measures were monitored over 9 months in the confabulating group.We found that TCC were more common in confabulating patients than in healthy controls, and that the decline in these errors paralleled the recovery from confabulation. However, TCC were not specific to the presence of confabulation in brain injury; and their decline was not correlated with change in confabulation scores over 9 months. We found that elated mood and lack of insight discriminated between confabulating and non-confabulating patients, but these measures did not correlate with either the severity of confabulation or change in confabulation scores through time. What seems to have been most strongly associated with the severity of confabulation scores at ‘baseline’ and changes through time (over 9 months) were the severity of memory impairment (especially on autobiographical memory) and errors on executive tests (particularly in making cognitive estimates). Greater autobiographical memory and executive impairment were associated with more severe confabulation.The findings were consistent with the view that confabulation results from executive dysfunction where autobiographical memory is also impaired; and that it resolves as these impairments subside.

Bupropion-Induced Psychotic Mania: Risk Factor, Clinical Course and Dosage

Bupropion is a dopamine/norepinephrine reuptake inhibitor and considered to carry a much lower risk of inducing mood shift compared with other antidepressants. We described here a patient who experienced the first episode of mania with psychotic features after escalating the dose of bupropion in the treatment of major depression disorder. Miss C is a 40-year-old female, who was diagnosed major depressive disorder with melancholic features and received bupropion 150 mg daily. The dose of bupropion was escalated to 300 mg daily due to the incomplete response. Three days later, she dramatically exhibited elated mood, hostility, irritability, hyper-talkative, hyperactivity, hyper-sexuality, marked delusion of religion, persecution, and grandiosity. The manic symptoms were subsided after discontinuation of bupropion immediately and prescribed quetiapine 300 mg daily within one week. The risk factors for mood shift including iron deficient anemia, melancholic features, clinical course, and the dosage of bupropion is discussed.

2247 – Manic episode in an elderly patient secondary to the application of corticosteroid eye drops: a case report

An eighty-one-year-old lady presented with mood changes within days of the commencement of prednisolone eye drops, which was prescribed following a cataract operation. She had a history of chronic schizophrenia, with one previous episode of hypomania in the early1990s. She was admitted to our institution on this occasion, with symptoms including elated mood, disinhibition, insomnia, pressured speech, flight of ideas and grandiose ideation. This was a distinctly different presentation from her previous relapses and the duration of this episode was prolonged. Her symptoms persisted despite an aggressive titration of psychotropic medications. After a review of her medication, the possible causal relationship between the prednisolone eye drops and manic episode was made. As the steroid eye drops were necessary following her eye operation, we allowed the completion of its course. Within days of its discontinuation, we saw a dramatIc improvement in her mental state and she was discharged. She currently remains in remission two months from the cessation of prednisolone. The postulation that the prednisolone eye drops triggered this manic episode can be substantiated by the clear observation that her symptoms completely resolved after the steroid course was completed. This appeared to be the one single factor which coincided with the emergence, maintenance and termination of her symptoms. Steroid-induced psychiatric symptoms are a well documented phenomenon, but are typically seen with higher doses and systemic administration of corticosteroids. This case report is of a rare presentation, and to our knowledge there are no similar cases described.

Elevated Affective Lability and Poor Response Inhibition: An Investigation based on Emotional and Non-Emotional Go/No-Go Tasks

The aim of the current study was to test the association between affective lability and the magnitude of response inhibition deficits using four different versions of go/no-go tasks that were composed of (a) affective faces, (b) affective words, (c) neutral faces, or (d) neutral words, with an undergraduate sample that displayed a wide range of emotional instability and impulsivity (N = 45). We hypothesized that heightened affective lability would be significantly associated with deficits in response inhibition, particularly in the context of emotional go/no-go tasks that presented salient and potent emotional materials. Overall findings showed that the magnitude of difficulty in inhibiting potent but irrelevant stimuli on emotional go/no-go tasks was significantly associated with heightened affective lability (characterized by unstable shifts between elated and depressed moods) after taking into consideration the contribution of negative affect and impulsiveness. In contrast, non-emotional go/no-go performance did not significantly predict affective lability. Further, depression-elation mood shifts were significantly associated with greater difficulty in inhibiting irrelevant positive rather than negative emotional information. This line of research may help improve our understanding on the nature of poor inhibitory control associated with conditions characterized by emotional dysregulation.

A Randomized Controlled Trial of Risperidone, Lithium, or Divalproex Sodium for Initial Treatment of Bipolar I Disorder, Manic or Mixed Phase, in Children and Adolescents

There was a paucity of comparative pharmacological research for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. To investigate which medication to administer first to antimanic medication-naive subjects. The Treatment of Early Age Mania (TEAM) study recruited 6- to 15-year-old children and adolescents with DSM-IV bipolar I disorder (manic or mixed phase) at 5 US sites from 2003 to 2008 into a controlled, randomized, no-patient-choice, 8-week protocol. Blinded, independent evaluators conducted all baseline and end-point assessments. Subjects received a titrated schedule of lithium, divalproex sodium, or risperidone. Medications were increased weekly only if there was inadequate response, and no dose-limiting adverse effects, to maximum doses of lithium carbonate (1.1-1.3 mEq/L), divalproex sodium (111-125 μg/mL), and risperidone (4-6 mg). Primary outcome measures were the Clinical Global Impressions for Bipolar Illness Improvement-Mania and the Modified Side Effects Form for Children and Adolescents. There were 279 antimanic medication-naive subjects (mean [SD] age, 10.1 [2.8] years; 50.2% female) who had the following characteristics: 100% elated mood and/or grandiosity, 77.1% psychosis, 97.5% mixed mania, 99.3% daily rapid cycling, and mean (SD) mania duration of 4.9 (2.5) years. The mean (SD) titrated lithium level was 1.09 (0.34) mEq/L, and the mean (SD) divalproex sodium level was 113.6 (23.0) μg/mL. The mean (SD) titrated risperidone dose was 2.57 (1.21) mg. Higher response rates occurred with risperidone vs lithium (68.5% vs 35.6%; χ(2)(1) = 16.9, P < .001) and vs divalproex sodium (68.5% vs 24.0%; χ(2)(1) = 28.3, P < .001). Response to lithium vs divalproex sodium did not differ. The discontinuation rate was higher for lithium than for risperidone (χ(2)(1) = 6.4, P = .011). Increased weight gain, body mass index, and prolactin level occurred with risperidone vs lithium (F(1,212) = 45.5, P < .001; F(1,212) = 39.1, P < .001; and F(1,213) = 191.4, P < .001, respectively) and vs divalproex sodium (F(1,212) = 34.7, P < .001; F(1,212) = 45.3, P < .001; and F(1,213) = 209.4, P < .001, respectively). The thyrotropin level increased in subjects taking lithium (t(62) = 11.3, P < .001). Risperidone was more efficacious than lithium or divalproex sodium for the initial treatment of childhood mania but had potentially serious metabolic effects. clinicaltrials.gov Identifier: NCT00057681

Boundaries of the Psychosis Phenotype

Since Emil Kraepelin classified psychosis into 3 major categories (organic, affective, and schizophrenic) in the late 19th century, the unitary concept of psychosis was abandoned. This categorical conceptualization of psychosis was more or less accepted by clinicians through the 20th century with some refinements. During my residency training, teachers would highlight qualitative differences in reality distortions across disorders; for instance, unusual visual perceptual distortions associated with substance abuse or the affective tone of delusional thinking in psychosis associated with bipolar illness. Such observations were used to support the categorical view of psychosis and stress phenomenological and biological differences in psychosis across various major psychotic disorders. In the past several years, extensive epidemiological and clinical research has yielded information that challenges the categorical models of psychosis. Epidemiological studies of self-reported psychotic symptoms of hallucinations and delusions show that about a quarter of the general population endorse such symptoms. Multivariate taxometric analyses of these epidemiological survey data suggest a dimensional rather than taxonomic structure for these psychotic experiences.1 Within this dimensional model of psychosis, symptoms vary in severity with most persistent and severe psychosis needing treatment (see Jim van Os and Richard Linscott in the current issue2). There is no discontinuity of psychosis across major psychotic disorders such as schizophrenia and bipolar disorders, although the frequency of symptoms and severity may vary. Less severe symptoms may indicate vulnerability to develop schizophrenia or bipolar disorder or even the prodromal phase particularly in individuals with a family history of these disorders. The dimensional model further posits that the underlying biological underpinnings are uniform. This thesis is supported by neurocognitive and neurophysiological findings in individuals with schizotypal personality disorders, with magical thinking, perceptual distortions, and rare hallucinations indicating the lower end of the psychosis dimension. Furthermore, the dimensional model would suggest that psychotic symptoms occurring in different psychiatric disorders such schizophrenia and bipolar disorder share the same neurobiology and etiological factors. The hypothesis of an extensive overlap in the phenomenology and etiopathophysiology of psychosis occurring across different disorders is a fundamental challenge to the Kraepelinian conceptualization of major psychotic disorders. Several lines of evidence support this hypothesis: phenomenological similarities in psychosis across disorders are frequently observed in clinical practice. Slight qualitative differences in reality distortions can easily be due to the modulating effects of the other features of the disorder. For instance, depressed or elated mood may modulate the expression of psychotic symptoms in affective illness. Studies have extensively compared brain function and structure in order to define the underlying neurobiology of psychosis in different conditions. Findings suggest a large overlap in cognitive impairments in schizophrenia and psychotic affective disorders.3 Similarly, sensory gating, sensory-motor gating, eye tracking, and other information processing impairments known to mark schizophrenia liability are frequently observed in other psychotic disorders.4 Brain imaging studies show some overlap but there are significant differences brain structure between schizophrenia and bipolar disorder.5 Most of these findings come from studies in patient cohorts that support the notion of shared neurobiology, but very few studies compare neurobiology among nonill relatives of psychotic disorders. Similar neurobiological findings in relatives of probands with different psychotic disorders would implicate shared etiological, likely genetic, factors. The Bipolar and Schizophrenia Network on Intermediate Phenotypes (B-SNIP) was organized specifically to address this issue. The consortium has recruited about a thousand families of schizophrenia and bipolar disorder with psychosis probands and administered a comprehensive battery that includes cognitive, neurophysiological, and brain imaging measures. Findings from this project will clarify the extent of overlap in the etiopathophysiology of psychosis in schizophrenia and bipolar disorders. Previous genetic studies have identified several linkage “hot-spots” (such as 18p11, 22q11, 13q32, 10p14, and 1q32) and candidate genes (such as DISC1, NRG1, Dysbindin, NOS1, GRM4, and G30/G72) that are implicated both in schizophrenia and bipolar disorder.6 Together, these data suggest psychotic symptoms that occur in different conditions are in most part similar in phenomenology, neurobiology, and etiology. However, studies have also found significant differences in brain function and structure between schizophrenia and bipolar disorder cohorts. These findings may be driven by unique aspects of each of these disorders. For instance, neurobiology associated with the affective component of the bipolar disorder, or the primary negative symptoms in schizophrenia, may explain the differences found in neurobiology between the 2 disorders. Studies similar to the B-SNIP project that also include families of probands with nonpsychotic bipolar and schizoid disorders are needed to clarify to what extent the neurobiology of psychosis is uniform across disorders.

A Case of Blonanserin-Induced Mania in Schizophrenia

Schizophrenia is a psychiatric disease which requires a long term treatment. Thus, patient’s therapeutic compliance can be very crucial to the disease’s prognosis. Moreover, the adverse effects of drugs are also important to determine the patient’s therapeutic compliance. The atypical antipsychotic drugs have been improved in the way to strengthen therapeutic effects and to reduce adverse effects. Blonanserin, an atypical antipsychotic, is a selective serotonin-dopamine agonist which blocks the dopamine D2/D3 receptors and serotonin 5-HT2A receptor. Blonanserin is well known to include parkinsonism, akathisia and insomnia. In this case report, Blonanserin treatment was given to patients who admitted to the closed ward due to psychotic symptoms such as idea of reference, persecutory delusion, auditory hallucination and blunted affect. The patients showed manic symptoms including elated mood, talkativeness, hyperactivity after the increase of Blonanserin dose up to 24 mg. Such manic symptoms were improved after Blonanserin dose was decreased to 16 mg. Many researches have reported newly-evoked manic/hypomanic episodes in schizophrenic patients after the use of atypical antipsychotics such as Risperidone, Olanzapine and Ziprasidone. However, there is no report of Blonanserin-induced manic/hypomanic episode. Therefore, further study is necessary to evaluate the manic/hypomanic episodes which are thought to be the adverse effects of Blonanserin. (Korean J Schizophr Res 2012;15:46-49)

Lamotrigine-Induced Manic Switch

To the Editor: Lamotrigine is currently used for treatment of bipolar depression alone or as an adjunct to other drugs. The exact mechanism of the antidepressant action of lamotrigine is not known. Lamotrigine used as an adjuvant mood stabilizer has been reported to induce mania1 and hypomania2 in case reports. Here we present 2 cases of lamotrigine-induced switch, 1 in which lamotrigine was used as a single agent and another in which it was added in a very small dose as an adjuvant. Case 1. Mr A, a 24-year-old single male university graduate, had a family history of bipolar affective disorder in a grandfather and unspecified psychosis in a maternal uncle. He presented in 2008 with a 2-year history of episodic illness characterized by an episode of mania (DSM-IV criteria) lasting for 6 months treated with olanzapine (10 mg/d) and risperidone (2 mg/d) and an episode of moderate depression with somatic symptoms lasting for 11.5 months characterized by pervasive low mood, anhedonia, loss of interest in pleasurable activities, hopelessness, wish to die, somatic symptoms, and disturbed biofunctions. Results of routine investigations and workup for organicity were within normal limits. He was started on lamotrigine 25 mg at bedtime, and the dose was gradually increased to 200 mg. Two weeks after initiation of the drug, he developed irritability and anger outbursts on a dose of 150 mg. When the dose was increased to 200 mg/d, he developed mania along with mood-congruent psychotic symptoms (his Young Mania Rating Scale3 [YMRS] score was 20). As a result, lamotrigine was tapered and stopped over 2 weeks and lithium was added (300–1,200 mg/d) along with risperidone (2–3 mg/d). His symptoms improved over 2 weeks. He has remained well after discharge from the hospital. Case 2. Mr B, a 23-year-old single man, had a family history of alcohol dependence syndrome in his father and past history of childhood oppositional defiant disorder, cannabis dependence syndrome (currently abstinent), and harmful alcohol use. He presented with an episodic illness since 19 years of age characterized by 1 manic episode (DSM-IV criteria) without psychotic symptoms lasting 3 months treated with risperidone 4 mg/d and clonazepam 1.5 mg/d. He discontinued these medications after 1 year. He had another episode of mania (DSM-IV criteria) lasting for 3 months at 21 years of age and was treated with lithium carbonate 1,600 mg/d, risperidone 8 mg/d, and trihexyphenidyl 4 mg/d. He continued taking lithium, and risperidone was tapered off. He most recently presented in 2008 with pervasive low mood, loss of interest in pleasurable activities, hopelessness, somatic symptoms, and disturbed biofunctions of 3 weeks’ duration. He was diagnosed with bipolar affective disorder, current episode moderate depression with somatic symptoms. Lamotrigine 25 mg/d was added to lithium. A week later, he started to exhibit elated mood, overactivity (goal directed), overfamiliarity with people, grandiose plans of starting a business, increased cigarette smoking, and decreased need for sleep. He was admitted and diagnosed with bipolar affective disorder, current episode mania (lamotrigine induced). Urine cannabis screen was negative. He rated 13 on the YMRS and was started on sodium valproate 1,000 mg/d and tablet clonazepam 3 mg/d along with the lithium carbonate he was receiving. His symptoms improved over a duration of 3 weeks, and he was discharged. He has remained well after discharge on regular medications. In the first case, manic symptoms developed when lamotrigine was gradually hiked to 200 mg/d. The patient was not on any other medications during this time, and lamotrigine was the sole agent that might have induced a manic switch. This is possibly the first such case reported. In the second case, the patient developed a manic switch on the addition of a very small dose of lamotrigine. Lamotrigine may induce a switch through its ability to decrease glutamate release, thereby reducing binding to the N-methyl-D-aspartate receptor complex.4

MDMA and methamphetamine: some paradoxical negative and positive mood changes in an acute dose laboratory study

This study investigated the acute mood effects of oral MDMA, methamphetamine, and placebo in a double-blind laboratory study. Fifty-two healthy participants comprised abstinent recreational users of stimulant drugs, 27 female and 25 male, mean age 24.8 years. Three test sessions involved acute 100 mg oral 3.4-methylendioxymethamphetamine (MDMA), 0.42 mg/kg oral methamphetamine, and matching placebo. Drug administration was counterbalanced, testing was double-blind, and medical supervision was present throughout. Car-driving performance on a laboratory simulator was assessed after 3 and 24 h, with the findings being presented elsewhere. Positive and negative moods (PANAS self-ratings) were completed before drug administration, 3, 4.5, and 24 h later. Blood samples were taken to monitor drug plasma levels. Following MDMA, there were no significant increases in positive moods, whereas negative moods were significantly higher than under placebo. Methamphetamine led to significant increases in both positive and negative moods. The MDMA findings contrast with the elated moods, typically noted by dance clubbers on Ecstasy. However, they are consistent with some previous laboratory findings, since a wide array of positive and negative mood changes have been demonstrated. One possible explanatory factor was the neutral environmental situation, particularly if a primary action of MDMA is to intensify ongoing psychological states. Other explanatory factors, such as dosage, gender, post-drug timing, neurohormonal aspects, and social factors, are also discussed. In the laboratory, acute methamphetamine led to significantly higher positive moods. However, against expectations, MDMA did not generate a significant increase in positive moods.

Bipolar disorder from childhood to adolescence: A review about diagnostic difficulties and comorbidities

Bipolar disorder, the course of which shows alterations between depressive and elated moods, is a chronic psychiatric disorder impairing the patients’ psychosocial functioning dramatically. Childhood bipolar disorder, which has recently begun to be researched, is a clinical condition that represents some differences than the adult type bipolar disorder. These differences mostly mislead the clinicians and cause diagnostic confusion. Therefore, diagnostic consistency and good understanding of co-morbid disorders are important from the treatment perspective. Particularly the comorbidities and various clinical presentations may prevent clinicians from reaching correct treatment strategies. Diagnostic consistency and comorbidities of bipolar disorder in children and adolescents were reviewed in this article.

Differences between bipolar I and bipolar II disorders in clinical features, comorbidity, and family history

BackgroundThe present study was designed to investigate whether bipolar II disorder (BP-II) has different characteristics from bipolar I disorder (BP-I), not only in manic severity but also in clinical features, prior course, comorbidity, and family history, sufficiently enough to provide its nosological separation from BP-I. MethodsComprehensive clinical evaluation was performed based on information available from ordinary clinical settings. Seventy-one BP-I and 34 BP-II patients were assessed using the Diagnostic Interview for Genetic Studies, Korean version. Psychiatric assessment for first-degree relatives (n=374) of the probands was performed using the modified version of the Family History-Research Diagnostic Criteria. ResultsThe frequency of depressive episodes was higher in BP-II (p=0.009) compared to BP-I. Further, seasonality (p=0.035) and rapid-cycling course (p=0.062) were more common in BP-II. Regarding manic expression, ‘elated mood’ was predominant in BP-II whereas ‘elated mood’ and ‘irritable mood’ were equally prevalent in BP-I. With regard to depressive symptoms, psychomotor agitation, guilty feeling, and suicidal ideation were more frequently observed in BP-II. BP-II patients exhibited a higher trend of lifetime co-occurrence of an axis I diagnosis (p=0.09), and a significantly higher incidence of phobia and eating disorder. The overall occurrence rate of psychiatric illness in first-degree relatives was 15.4% in BP-I and 26.5% in BP-II (p=0.01). Major depression (p=0.005) and substance-related disorder (p=0.051) were more prevalent in relatives of BP-II probands. ConclusionDistinctive characteristics of BP-II were identified in the current study and could be adopted to facilitate the differential diagnosis of BP-I and BP-II in ordinary clinical settings.

Rapid Cycling Associated With Menstrual Periods in an Adolescent: Electrophysiological Underpinnings for Bipolarity

Rapid Cycling Associated With Menstrual Periods in an Adolescent: Electrophysiological Underpinnings for Bipolarity