Manic Syndrome Research Articles

Can low-dose propranolol induce a manic syndrome? Case report of an unexpected side effect.

Propranolol, the first discovered b-adrenergic receptor antagonist, has been prescribed by physicians in various fields for more than three decades. It has been applied for treating psychiatric disorders including schizophrenia, mania and anxiety disorders, as well as for controlling withdrawal symptoms or other side effects. We describe the case of an 11-year-old boy with bipolar-I disorder comorbid with panic disorder who developed manic symptoms with a single dose of 10 mg of propranolol. Results and Conclusion Although depression is a better-known side effect of b-adrenergic antagonists, clinicians should take mania as a rare side effect into consideration as well.

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia.

Some studies indicate that mood self-assessment is more severely impaired in patients with bipolar disorder in a manic episode than in depression. To investigate variations in mood self-assessment in relation to current affective state in a group of individuals with bipolar disorder. A total of 165 patients with a diagnosis of bipolar disorder type I or type II had their affective state assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF). In addition, participants completed a self-report visual analog mood scale (VAMS). Patients were divided into three groups (euthymia, mania, and depression) and compared with regard to VAMS results. Manic patients rated their mood similarly to patients in euthymia in 14 out of 16 items in the VAMS. By contrast, depressed patients rated only two items similarly to euthymic patients. Patients with bipolar disorder in mania, but not those in depression, poorly evaluate their affective state, reinforcing the occurrence of insight impairment in the manic syndrome.

P.2.e.006 Assessment of the association between serum NGF and BDNF levels and hippocampus and amygdala volumes in adolescents with bipolar disorder

Two brief patient-rated scales, the Internal State Scale (ISS) and the Self-Report Manic Inventory (SRMI), have been shown to reliably diagnose mania. In the current study we further evaluated the utility of these scales relative to each other and to the observer-rated Young Mania Rating Scale (YMRS), for quantifying the severity of manic/hypomanic symptoms cross-sectionally and over time, in 20 patients with rapid-cycling bipolar disorder. The self-report scales correlated well with each other and with the YMRS, but each covered a somewhat different domain of the manic syndrome. The SRMI and the ISS were more sensitive than the YMRS to the mood fiuctuations in the euthymic to hypomanic range observed in our subjects. Used in tandem, the two self-report scales may find application in clinical research with outpatients with bipolar disorder, and as an adjunct to clinical monitoring in this patient population.

P.2.e.003 Mania and depression: mixed, not stirred

Two brief patient-rated scales, the Internal State Scale (ISS) and the Self-Report Manic Inventory (SRMI), have been shown to reliably diagnose mania. In the current study we further evaluated the utility of these scales relative to each other and to the observer-rated Young Mania Rating Scale (YMRS), for quantifying the severity of manic/hypomanic symptoms cross-sectionally and over time, in 20 patients with rapid-cycling bipolar disorder. The self-report scales correlated well with each other and with the YMRS, but each covered a somewhat different domain of the manic syndrome. The SRMI and the ISS were more sensitive than the YMRS to the mood fiuctuations in the euthymic to hypomanic range observed in our subjects. Used in tandem, the two self-report scales may find application in clinical research with outpatients with bipolar disorder, and as an adjunct to clinical monitoring in this patient population.

Validation by Rasch analysis of the Mania Scale (EMUN) for measuring manic symptions

The Mania Scale (EMUN) developed at the Universidad Nacional de Colombia was designed to measure the severity of manic symptoms, but has been validated only using classical psychometric theory. The psychometric properties and measuring characteristics of the EMUN scale were determined using an analysis based on item response theory. Two hundred sixty-four patients with manic, hypomanic or mixed episode symptoms were assessed using the EMUN scale. The psychometric characteristics of the scale were analyzed using a Rasch model for partial credit scoring. The analysis based on the item response theory showed that reliability and separation indexes for persons are low in contrast to items. This suggested a narrow representation of the construct evaluated in this sample. Reduced need to sleep has been the most easily detectable symptom in mania. Excepting depressive affect and distractibility, the majority of items fit the model's expectation The rating scale diagnostics showed that the average measures increase monotonically across the rating scale. Two items showed redundancy and can be omitted in future versions of the scale. The person-item map suggested that the syndrome is not fully evaluated by the scale, probably because some depressive symptoms are not included. In this first study to use Rasch analysis to assess the psychometric properties of the EMUN scale, misfit and redundancy of items have been detected. The manic syndrome is not fully evaluated by the scale. The instrument can be improved by adding depressive symptoms.

Validación de la escala para manía de la Universidad Nacional de Colombia usando el análisis de Rasch

Introduction. The Mania Scale (EMUN) developed at the Universidad Nacional de Colombia was designed to measure the severity of manic symptoms, but has been validated only using classical psychometric theory.Objectives. The psychometric properties and measuring characteristics of the EMUN scale were determined using an analysis based on item response theory.Materials and methods. Two hundred sixty-four patients with manic, hypomanic or mixed episode symptoms were assessed using the EMUN scale. The psychometric characteristics of the scale were analyzed using a Rasch model for partial credit scoring.Results. The analysis based on the item response theory showed that reliability and separation indexes for persons are low in contrast to items. This suggested a narrow representation of the construct evaluated in this sample. Reduced need to sleep has been the most easily detectable symptom in mania. Excepting depressive affect and distractibility, the majority of items fit the model's expectation The rating scale diagnostics showed that the average measures increase monotonically across the rating scale. Two items showed redundancy and can be omitted in future versions of the scale. The person-item map suggested that the syndrome is not fully evaluated by the scale, probably because some depressive symptoms are not included.Conclusion. In this first study to use Rasch analysis to assess the psychometric properties of the EMUN scale, misfit and redundancy of items have been detected. The manic syndrome is not fully evaluated by the scale. The instrument can be improved by adding depressive symptoms.

Predicting Disease Progression in Alzheimer's Disease: The Role of Neuropsychiatric Syndromes on Functional and Cognitive Decline

Patients with Alzheimer's disease (AD) have heterogeneous rates of disease progression. The aim of the current study is to investigate whether neuropsychiatric disturbances predict cognitive and functional disease progression in AD, according to failure theory. We longitudinally examined 177 memory-clinic AD outpatients (mean age = 73.1, SD = 8.1; 70.6% women). Neuropsychiatric disturbances at baseline were categorized into five syndromes. Patients were followed for up to two years to detect rapid disease progression defined as a loss of ≥ 1 abilities in Activities of Daily living (ADL) or a drop of ≥ 5 points on Mini-Mental State Examination (MMSE). Hazard ratios (HR) were calculated with Gompertz regression, adjusting for sociodemographics, baseline cognitive and functional status, and somatic comorbidities. Most patients (74.6%) exhibited one or more neuropsychiatric syndromes at baseline. The most common neuropsychiatric syndrome was Apathy (63.8%), followed by Affective (37.3%), Psychomotor (8.5%), Manic (7.9%), and Psychotic (5.6%) syndromes. The variance between the observed (Kaplen Meier) and predicted (Gompertz) decline for disease progression in cognition (0.30, CI = 0.26-0.35), was higher than the variance seen for functional decline (0.22, CI = 0.18-0.26). After multiple adjustment, patients with the Affective syndrome had an increased risk of functional decline (HR = 2.0; CI = 1.1-3.6), whereas the risk of cognitive decline was associated with the Manic (HR = 3.2, CI = 1.3-7.5) syndrome. In conclusion, specific neuropsychiatric syndromes are associated with functional and cognitive decline during the progression of AD, which may help with the long-term planning of care and treatment. These results highlight the importance of incorporating a thorough psychiatric examination in the evaluation of AD patients.

Evaluación de la labilidad afectiva como síntoma del síndrome maniaco

IntroductionMood lability is not considered a clinical symptom in diagnostic systems such as the DSM-IV or the ICD-10. However, some studies have described the presence of this symptom in patients with affective disorders. ObjectiveTo evaluate mood lability as a representative symptom of the manic syndrome. MethodsAn evaluation system for measuring mood lability has been developed and included in the EMUN scale. A total of 202 patients with manic, hypomanic, or mixed episode were assessed. The performance of the symptoms was evaluated using factorial multivariate methods and Rasch analysis. ResultsMood lability appears to be a good marker for manic, hypomanic, or mixed episode. Mania should be re-conceptualized as an activation syndrome instead of an affective syndrome. Depressive symptoms are clinical components of the syndrome. The findings of this study suggest that complementary criteria may be useful in diagnosing manic-depressive disorders.

The prevalence of long-term mental disorders following traumatic brain injury

Objective To investigate prevalence of long-term mental disorders following traumatic brain injury (TBI) in 4 ～ 13 years. Methods Of the 4287 patients with traumatic brain injury by systematic sampling.675 subjects were screened by the manual of the psychiatric consequences following traumatic brain injury. The final diagnoses of mental disorders were determined by two advanced psychiatrists based on CCMD-3 on the criteria of organic mental disorders. Results ① Of the 675 subjects with traumatic brain injury,206 had satisfied diagnosed criteria of one or more organic mental disorder syndromes by CCMD-3, and with dementia 17.48% , amnestic syndrome 1. 04% , personality or behaviour change 13. 84% , psychotic syndrome 1. 19% , depressive syndrome 7.41% ,manic syndrome 0.30% ,hysteric syndrome 0.98% , neurotic syndrome 10. 22%. ②The incidence of the mental disorders in the subjects with severe TBI was significantly higher than that of moderate and mild TBI,separately 66.01% (134/203) ,18.04% (46/255) and 11.98% (26/217 ),λ2 =109.03 and 129.82 separately(P< 0.01). ③The incidence of the personality or behaviour change in male was significantly higher than that of female, separately 15.31% and 6.98% (λ2 =5.65, P<0.05). The incidence of the neurotic syndrome in female was significantly higher than that of male, separately 15. 12% and 8. 55% (λ2 = 6. 02, P < 0.05). Conclusion The high incidence of the mental disorders in the patients with TBI should not neglect. There are more high occurrence rate with more severe degree of brain injuries. Key words: TBI; Mental disorders; Occurrence rate; Long-term following investigation

Estudio de la estructura latente del síndrome maníaco mediante técnicas de escalamiento multidimensional

Introduction and ObjectiveTo date, some reports about dimensions of mania suggest that the importance of affective symptoms is controversial. The objective of this study was to investigate the latent structure of the manic syndrome by using classical methods of factor analysis for ordinal variables and multidimensional scaling. Method404 consecutively admitted patients with DSM-IV criteria for bipolar disorder, manic, hypomanic or mixed were analyzed using the EMUN scale. Factor analysis for ordinal variables and multidimendional scaling were carried out. ResultsFactor analysis evidenced four clinically interpretable factors (activation, cognitive, affective, depression) with activation being the most important domain. Multidimensional scaling confirmed activation as an identifiable factor that is a central constituent of the syndrome, and affective symptoms as a secondary component. Hipersexuality seems to be an isolated symptom, probably reflecting other latent dimensions. ConclusionMania is the expression of four dimensions. The core domain of the syndrome is activation. Although depressive symptoms are not the main component, its evaluation during manic, hypomanic or mixed states is essential.

New-Onset Vascular Mania in a Patient With Chronic Depression

New-Onset Vascular Mania in a Patient With Chronic Depression

Creating a map of psychiatric patients based on psychopathological symptom profiles

In the current debate about the categorical or dimensional classification of mental disorders many fruitful methods to illustrate one or the other aspect are employed, and suggestions are made to combine the two perspectives. We present such an approach to combine both perspectives at the same time. Based on psychopathological AMDP-symptom profiles, a map of psychiatric patients was calculated by robust nonmetric multidimensional scaling (NMDS). The sample from the Ludwig-Maximilians University in Munich included the records of patients, who were admitted and discharged in 2002 and 2003 with a diagnosis of either paranoid schizophrenia, (F20.00, N = 24), bipolar affective disorder, current episode manic without psychotic symptoms (F31.1, N = 32) or severe depressive episode without psychotic symptoms (F32.2, N = 78). In the resulting map of patients we found a clear categorical distinction according to the diagnostic groups, but also high regression values of AMDP-syndromes (manic syndrome: r = 0.83, depressive syndrome: r = 0.68, and paranoid-hallucinatory syndrome, r = 0.62). The map of psychiatric patients presents an approach to consider the categorical and dimensional aspects at the same time. We were able to identify meaningful delineations between diagnostic clusters as well as continuous transitions. This method allows the whole psychopathological profile of each individual patient to be considered and also to identify misdiagnosed cases at a glance.

Pure and mixed manic subtypes: a review of diagnostic classification and validation

To review issues surrounding the diagnosis and validity of bipolar manic states. Studies of the manic syndrome and its diagnostic subtypes were reviewed emphasizing historical development, conceptualizations, formal diagnostic proposals, and validation. Definitions delineating mixed and pure manic states derive some validity from external measures. DSM-IV and ICD-10 diagnosis of bipolar mixed states are too rigid and less restrictive definitions can be validated. Anxiety is a symptom often overlooked in diagnosis of manic subtypes and may be relevant to the mixed manic state. The boundary for separation of mixed mania and depression remains unclear. A 'pure' non-psychotic manic state similar to Kraepelin's 'hypomania' has been observed in several independent studies. Issues surrounding diagnostic subtyping of manic states remain complex and the debates surrounding categorical versus dimensional approaches continue. To the extent that categorical approaches for mixed mania diagnosis are adopted, both DSM-IV and ICD-10 are too rigid. Inclusion of non-specific symptoms in definitions of mixed mania, such as psychomotor agitation, does not facilitate and may hinder the diagnostic separation of pure and mixed mania. The inclusion of a diagnostic seasonal specifier for DSM-IV, which is currently based on seasonal patterns for depression might be expanded to include seasonal patterns for mania. Boundaries between subtypes may be 'fuzzy' rather than crisp, and graded approaches could be considered. With the continued development of new tools, such as imaging and genetics, alternative approaches to diagnosis other than the purely symptom-centric paradigms might be considered.

The Role of Hippocampal GluR1 and GluR2 Receptors in Manic-Like Behavior

The cellular basis underlying the complex clinical symptomatology of bipolar disorder and the mechanisms underlying the actions of its effective treatments have not yet been fully elucidated. This study investigated the role of hippocampal synaptic AMPA receptors. We found that chronic administration of the antimanic agents lithium and valproate (VPA) reduced synaptic AMPA receptor GluR1/2 in hippocampal neurons in vitro and in vivo. Electrophysiological studies confirmed that the AMPA/NMDA ratio was reduced in CA1 regions of hippocampal slices from lithium-treated animals. Reduction in GluR1 phosphorylation at its cAMP-dependent protein kinase A site by the synthetic peptide TAT-S845, which mimics the effects of lithium or VPA, was sufficient to attenuate surface and synaptic GluR1/2 levels in hippocampal neurons in vitro and in vivo. Intrahippocampal infusion studies with the AMPA-specific inhibitor GYKI 52466 [4-(8-methyl-9H-1,3-dioxolo[4,5-h][2,3]benzodiazepin-5-yl)-benzenamine hydrochloride], a GluR1-specific TAT-S845 peptide, showed that GluR1/2 was essential for the development of manic/hedonic-like behaviors such as amphetamine-induced hyperactivity. These studies provide novel insights into the role of hippocampal GluR1/2 receptors in mediating facets of the manic syndrome and offer avenues for the development of novel therapeutics for these disorders.

Mood-Elevating Effects of Opioid Analgesics in Patients With Bipolar Disorder

Mood-Elevating Effects of Opioid Analgesics in Patients With Bipolar Disorder

Manic Switching in Patients Receiving Duloxetine

Back to table of contents Previous article Next article Letters to the EditorFull AccessManic Switching in Patients Receiving DuloxetineCONSUELO de DIOS M.D.ELENA EZQUIAGA M.D.,CONSUELO de DIOS M.D.Search for more papers by this authorELENA EZQUIAGA M.D.Search for more papers by this author,Published Online:1 Jul 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: Duloxetine is a dual antidepressant. According to Viktrup et al. (1) , duloxetine does not induce mania or hypomania in women without a history of major depression. Moreover, pooled data by Dunner et al. (2) show that the estimated risk of duloxetine-related manic switching is 0.1% to 0.2% in patients with major depression. However, the methodological limitations of the study conducted by Dunner et al. as well as the scarcity of other sources of information lead us to believe that the actual risk of manic switching with duloxetine remains unknown. We present two clinical cases in which manic switching occurred after treatment with duloxetine. A 58-year-old man with a 2-month major depressive episode was seen in our outpatient clinic. There were no psychiatric antecedents, and both the patient and his family denied any episodes suggesting mania or hypomania. The patient did not have a family history of bipolar disorder, and his medical history was unremarkable.Treatment with paroxetine (40 mg daily) resulted in initial partial remission, followed by severe relapse. Duloxetine (60 mg daily) was substituted and rapid recovery was obtained. Four months later—while still on duloxetine—admission was necessary because the patient experienced a manic syndrome with psychotic features. General examination and routine studies (rapid plasma reagin, human immunodeficiency virus, thyroid function, blood chemistry, and computed tomography scan) showed results within normal limits.The second patient was a 40-year-old woman who had previously showed symptoms of bulimia and alcohol abuse. She also had interspersed periods of increased activity with times of more inhibition, for which medical care was never required. Several months before, she suffered a transient, acute psychotic episode that required hospital admission and short treatment with an atypical antipsychotic. Her status at the time included anhedonia, hypersomnia, anergy, difficulty in concentrating, and a sense of worthlessness. Six weeks after beginning treatment with duloxetine, the patient’s mood improved. Nevertheless, after 3 months of treatment (120 mg daily), a sudden manic episode with psychotic symptoms was diagnosed, and inpatient management was required. An increased risk of manic switching with venlafaxine (3) , which is also a dual agent, has been reported. Although anecdotal, our two case studies warn against the risk of duloxetine. In both our patients, episodes were extremely severe. One patient had been treated with a selective serotonin reuptake inhibitor, but only after treatment with duloxetine did manic switching occur. In our opinion, clinicians should carefully observe early warning signs of mania in patients with seemingly unipolar depressive disorders who are undergoing treatment with dual antidepressants.Madrid, SpainDr. de Dios has received honoraria for CME activity from Eli Lilly, Pfizer, Bristol-Myers Squibb, and Wyeth; she has lectured and received grants from AstraZeneca, Eli Lilly, Pfizer, Janssen, Bristol-Myers Squibb, and Wyeth; she has also received travel funds from Eli Lilly and Bristol-Myers Squibb. Dr. Ezquiaga has received honoraria for CME activity from Eli Lilly and Lundbeck; she has lectured and received grants from Eli Lilly and Lundbeck; she has also received travel funds from Eli Lilly.

Manic Switching in Patients Receiving Duloxetine

Back to table of contents Previous article Next article Letters to the EditorFull AccessManic Switching in Patients Receiving DuloxetineCONSUELO de DIOS M.D.ELENA EZQUIAGA M.D.,CONSUELO de DIOS M.D.Search for more papers by this authorELENA EZQUIAGA M.D.Search for more papers by this author,Published Online:1 Jul 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: Duloxetine is a dual antidepressant. According to Viktrup et al. (1) , duloxetine does not induce mania or hypomania in women without a history of major depression. Moreover, pooled data by Dunner et al. (2) show that the estimated risk of duloxetine-related manic switching is 0.1% to 0.2% in patients with major depression. However, the methodological limitations of the study conducted by Dunner et al. as well as the scarcity of other sources of information lead us to believe that the actual risk of manic switching with duloxetine remains unknown. We present two clinical cases in which manic switching occurred after treatment with duloxetine. A 58-year-old man with a 2-month major depressive episode was seen in our outpatient clinic. There were no psychiatric antecedents, and both the patient and his family denied any episodes suggesting mania or hypomania. The patient did not have a family history of bipolar disorder, and his medical history was unremarkable.Treatment with paroxetine (40 mg daily) resulted in initial partial remission, followed by severe relapse. Duloxetine (60 mg daily) was substituted and rapid recovery was obtained. Four months later—while still on duloxetine—admission was necessary because the patient experienced a manic syndrome with psychotic features. General examination and routine studies (rapid plasma reagin, human immunodeficiency virus, thyroid function, blood chemistry, and computed tomography scan) showed results within normal limits.The second patient was a 40-year-old woman who had previously showed symptoms of bulimia and alcohol abuse. She also had interspersed periods of increased activity with times of more inhibition, for which medical care was never required. Several months before, she suffered a transient, acute psychotic episode that required hospital admission and short treatment with an atypical antipsychotic. Her status at the time included anhedonia, hypersomnia, anergy, difficulty in concentrating, and a sense of worthlessness. Six weeks after beginning treatment with duloxetine, the patient’s mood improved. Nevertheless, after 3 months of treatment (120 mg daily), a sudden manic episode with psychotic symptoms was diagnosed, and inpatient management was required. An increased risk of manic switching with venlafaxine (3) , which is also a dual agent, has been reported. Although anecdotal, our two case studies warn against the risk of duloxetine. In both our patients, episodes were extremely severe. One patient had been treated with a selective serotonin reuptake inhibitor, but only after treatment with duloxetine did manic switching occur. In our opinion, clinicians should carefully observe early warning signs of mania in patients with seemingly unipolar depressive disorders who are undergoing treatment with dual antidepressants.Madrid, SpainDr. de Dios has received honoraria for CME activity from Eli Lilly, Pfizer, Bristol-Myers Squibb, and Wyeth; she has lectured and received grants from AstraZeneca, Eli Lilly, Pfizer, Janssen, Bristol-Myers Squibb, and Wyeth; she has also received travel funds from Eli Lilly and Bristol-Myers Squibb. Dr. Ezquiaga has received honoraria for CME activity from Eli Lilly and Lundbeck; she has lectured and received grants from Eli Lilly and Lundbeck; she has also received travel funds from Eli Lilly.

Vitamin B12 Deficiency Manifested as Mania

Sir: Multiple psychiatric symptoms may precede pernicious anemia. Only 1 case of full manic syndrome secondary to B12 deficiency has been reported.1 Case report. Ms. A was a 35-year-old woman with no personal or family history of psychiatric disorders, who was admitted to the hospital in February of 2005 with a 3-week history of episodes of manic symptoms of several hours' duration, including grandiosity, hyperactivity, sexual indiscretion, hyperphagia, irritable mood, reckless behavior, flight of ideas, and overbearing manner. These episodes had a sudden onset and conclusion, and the patient was able to remember them. No hallucinations were reported at any time. At admission, she was oriented in all spheres, but was easily distractible. Full manic syndrome (DSM-IV criteria) was present and there was no coexisting delirium. All these psychiatric symptoms disappeared after 1 hour, without any medical intervention. An examination revealed the presence of a left Babinski's reflex and ataxia, as well as a bilateral loss of proprioception, vibration, and sensation of light touch and pain in the lower extremities. Strength and reflex in the lower extremities were diminished. The results of general blood chemistries, a thyroid function test, and a comprehensive drug screen were within normal limits. Although the results of electroencephalogram (EEG) and brain magnetic resonance imaging were normal, the duration, as well as the sudden onset and conclusion of episodes, suggested an epileptic cause for this patient's mania.2 Ms. A was treated with valproic acid for 3 weeks with no improvement. Serum vitamin B12 level was measured and was found to be markedly diminished––less than 60 pg/mL. Vitamin B12 (1000 µg/day) was administered intravenously for 1 week. After the third day of B12 replacement therapy, our patient did not experience new manic episodes. Therapy was continued with 1000 µg intramuscular injections weekly for 1 month and then with monthly intramuscular injections as maintenance treatment. Within 1 month, neurologic symptoms had improved. One year after B12 vitamin replacement started, her mental status was still normal. Although many psychiatric symptoms have been considered to be related to B12 deficiency,3,4 this is the first report of short duration episodes of manic symptoms secondary to B12 deficiency. The absence of previous psychiatric or medical disorders, coupled with her continued clinical remission while she was receiving B12 alone, argues that B12 deficiency was the most likely cause of her psychiatric disorder. Our case could also raise the hypothesis of different neuro-biological mechanisms underlying mood disorders and the importance of B12 and folate in their genesis.5

Temperament and personality in bipolar I patients with and without mixed episodes

Background Personality and temperament are supposed to have an impact on the clinical expression and course of an affective disorder. There is some indication, that mixed episodes result from an admixture of inverse temperamental factors to a manic syndrome. In a preliminary report [Brieger, P., Roettig, S., Ehrt, U., Wenzel, A., Bloink, R., Marneros, A., 2003. TEMPS-a scale in ‘mixed’ and ‘pure’ manic episodes: new data and methodological considerations on the relevance of joint anxious-depressive temperament traits. J. Affect. Disord. 73, 99–104] we reported support for this assumption. The present study completes the preliminary results and compares patients with and without mixed episodes with respect to personality and personality disorders in addition. Methods Patients who had been hospitalized for bipolar I disorder were reassessed after 4.8 years. We examined temperament (TEMPS-A), personality (NEO-FFI) and frequency of personality disorders (SCID-II). Furthermore, illness-related parameters like age at first treatment, depressive and manic symptomatology, frequency and type of episodes and level of functioning were obtained and patients with and without mixed episodes were compared. Results Patients with ( n = 49) and without mixed episodes ( n = 86) did not differ significantly with regard to the illness-related parameters and personality dimensions. The frequency of personality disorders was significantly higher in patients with prior mixed episodes. With respect to temperament, scores of the depressive, cyclothymic, irritable and anxious temperament were significantly higher in patients with mixed episodes. Limitations We were not able to assess premorbid temperament and premorbid personality. Conclusions The findings of the present study support the assumption of Akiskal [Akiskal, H.S., 1992b. The distinctive mixed states of bipolar I, II, and III. Clin. Neuropharmacol. 15 Suppl 1 Pt A, 632–633.] that mixed episodes are more frequent in subjects with inverse temperament.

Manic symptoms and impulsivity during bipolar depressive episodes

In contrast to the extensive literature on the frequent occurrence of depressive symptoms in manic patients, there is little information about manic symptoms in bipolar depressions. Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior. Therefore, we investigated the prevalence of manic symptoms and their relationships to impulsivity and clinical characteristics in patients with bipolar depressive episodes. In 56 bipolar I or II depressed subjects, we investigated the presence of manic symptoms, using Mania Rating Scale (MRS) scores from the Schedule for Affective Disorders and Schizophrenia (SADS), and examined its association with other psychiatric symptoms (depression, anxiety, and psychosis), age of onset, history of alcohol and/or other substance abuse and of suicidal behavior, and measures of impulsivity. MRS ranged from 0 to 29 (25th-75th percentile, range 4-13), and correlated significantly with anxiety and psychosis, but not with depression, suggesting the superimposition of a separate psychopathological mechanism. Impulsivity and history of substance abuse, head trauma, or suicide attempt increased with increasing MRS. Receiver-operating curve analysis showed that MRS could divide patients into two groups based on history of alcohol abuse and suicide attempt, with an inflection point corresponding to an MRS score of 6. Even modest manic symptoms during bipolar depressive episodes were associated with greater impulsivity, and with histories of alcohol abuse and suicide attempts. Manic symptoms during depressive episodes suggest the presence of a potentially dangerous combination of depression and impulsivity.