Carlo Maggini

Circadian activity rhythm abnormalities in ill and recovered bipolar I disorder patients

OBJECTIVES Most physiological indicators of bipolar disorder (BPD) reflect current acute illness, and rarely have proved to be state-independent. Activity rhythms are highly abnormal in acute phases of BPD; we compared circadian activity rhythms in BPD I patients during ill and recovered states to those of normal controls to test the hypothesis that some abnormalities may persist. METHODS We compared 36 adult DSM-IV BPD I patients during acute mania or mixed states, and during full and sustained clinical recovery, to 32 healthy controls of similar age and sex distribution, using wrist-worn, piezoelectric actigraphic monitoring for 72 h and computed cosinor analysis of circadian activity rhythms. RESULTS We verified expected major differences between manic or mixed-state BPD I patients and matched normal controls, including phase advances averaging 2.1 h in ill BPD I patients and 1.8 h in recovered patients. Moreover, recovered BPD patients differed highly significantly from controls in several measures, including acrophase advance, higher percentage of nocturnal sleep, and lower average daily activity (mesor). Actigraphic measures among recovered BPD patients were independent of ratings of mania (on the Young Mania Rating Scale), depression (on the Hamilton Depression Rating Scale), or rating-scale scored subjective distress, as well as the type and dose of concurrent psychotropic medication. CONCLUSIONS These findings suggest that abnormal activity rhythms, including sustained phase advances, may represent enduring (trait) characteristics of BPD patients even during clinical recovery. If verified, such indices may be useful in supporting diagnoses and as an objective phenotype for genetic or other biological studies.

Relationship between Alexithymia and Panic Disorder: A Longitudinal Study to Answer an Open Question

Background: In the present study, we evaluated whether patients with panic disorder (PD) in complete remission were more alexithymic than normal controls. Methods: Fifty-two PD patients (both during the acute phase of the disorder and after at least 2 months of complete remission) and 52 age- and sex-matched normal subjects completed the Toronto Alexithymia Scale-20 and the Hamilton Rating Scales for Anxiety (Ham-A) and for Depression. Results: A higher rate of alexithymia was found in PD patients than in controls (3.8%) both during the acute phase (44.2%; p < 0.001) and after remission of the disorder (21.2%; p = 0.008). During remission, PD patients showed: (1) Ham-A scores significantly higher than controls (p < 0.001); (2) only an elevation of the ‘difficulty in identifying feeling’ (DIF) dimension of alexithymia, and (3) a positive relationship between Ham-A scores and DIF levels (p < 0.001). Conclusion: After remission of panic attacks, phobic avoidance and anticipatory anxiety, PD patients are more alexithymic (even though the levels of alexithymia decreased after the resolution of the acute phase of PD) and anxious than controls. This finding might be explained by an overlap between cognitive aspects of PD and the DIF dimension of alexithymia, since alexithymic and anxious levels are positively related.

Temperament and personality features in patients with major depression, panic disorder and mixed conditions

METHOD Forty-two patients with Panic Disorder (P), 18 with Major Depression (MD), 35 with both conditions (MIX) and 45 healthy subjects (C) were tested with the Tridimensional Personality Questionnaire and the Structured Interview for DSM-III-R Personality Disorders. RESULTS A different prevalence of Dependent (P = 16.7%, MD = 5.6%, MIX = 41.4%, C = 2.1%) (P < 0.001), Obsessive-Compulsive (P = 4.8%, MD = 27.8%, MIX = 3.4%, C = 0%) (P < 0.001) and Histrionic (P =23.8%, MD = 0%, MIX = 31%, C = 4.2%) (P = 0.001) personality disorders (PD) was found among groups. Harm Avoidance (HA) (P < 0.001) and Reward Dependence (RD) (P <0.001) were higher in patients than in controls. As expected the patients with comorbid conditions (MIX) showed higher HA levels (P < 0.01) and a greater prevalence of PDs, particularly of Cluster C compared to patients with pure disorders. CONCLUSIONS This study suggests that high HA and RD scores are associated with P, MD and MIX, and the former dimension is even higher in MIX patients.

Manic-Depressive Illness: Evolution in Kraepelin's Textbook, 1883–1926

Background: The syndrome of manic‐depressive insanity (MDI), as conceptualized by Emil Kraepelin a century ago, with later refinements, continues to dominate research and clinical practice with mood disorder patients. Current understanding of Kraepelins views by Anglophones is heavily influenced by the late, highly developed, MDI concept represented in the 1921 partial English translation of the last complete edition of his textbook, the product of gradual development over several decades. Method: We reviewed all nine editions and revisions of Kraepelins Textbook (1883–1926) and other writings by him to document the evolution of his views of MDI, and characterized salient developments within biographical and historical contexts. Results: We found support for the traditional impression that Kraepelins clinical perception of similarities of various forms of periodic psychiatric disorders marked by fundamental dysregulation of excitation and inhibition of thought and behavior, as well as of mood—as distinct from chronic psychotic illnesses—encouraged his broad, mature concept of MDI. However, our findings indicate a complex evolution of Kraepelins MDI concept in the 1880s and 1890s, his use of more creative and less empirical clinical methods than traditionally believed, and his considerable personal uncertainty about making clear distinctions among MDI, dementia præcox, intermediate conditions, and paranoid disorders—an uncertainty that persisted to the end of his career in the 1920s. Conclusions: Kraepelin responded to a compelling international need for diagnostic order in nineteenth‐century psychiatry, and effectively promoted his diagnostic proposals with a widely used and influential textbook. Though his methods were less empirical than is usually realized, his legacy includes analysis of large clinical samples to describe psychopathology and illness‐course, along with efforts to define psychobiologically coherent and clinically differentiable entities, as steps toward defining psychiatric syndromes. Modern international “neo‐Kraepelinian” enthusiasm for descriptive, criterion‐based diagnosis should be tempered by Kraepelins own appreciation of the tentative and uncertain nature of psychiatric nosology, particularly in classifying illnesses with both affective and psychotic features.

Morbidity in 303 first‐episode bipolar I disorder patients

OBJECTIVES To test the hypotheses that: (i) depressive-dysthymic-dysphoric (D-type) morbidity is more prevalent than manic-hypomanic-psychotic (M-type) morbidity even from first episodes of bipolar I disorder (BPD-I) and despite treatment; (ii) initial presentations predict later morbidity; (iii) morbidity varies internationally; and (iv) early and later morbidity are similar. METHODS We followed SCID-based, DSM-IV BPD-I patients (n = 303) systematically and prospectively for two years to estimate the percent of weeks in specific morbid states from first lifetime major episodes. RESULTS Total morbidity accounted for 44% of the first two years, and D-type exceeded M-type illnesses by 2.1-fold (30%/14%) among morbidities ranking: mixed states (major + minor) >or= dysthymia >or= mania >or= major depression > hypomania > psychosis. In 164 cases, morbidities at 0.5-2.5 and 2.5-4.5 years were very similar. Depressive or mixed initial episodes predicted a 3.6-fold excess of D-type morbidity, and initial M-type episodes predicted a 7.1-fold excess of M-type morbidity over two years. Morbidity in European (EU) sites was nearly half that in the U.S., and 22% greater overall among men than women. In five comparable studies, illness accounted for 54% of follow-up time, and the ratio of D/M morbidity averaged 3.0. CONCLUSIONS In accord with four midcourse studies, morbidity from BPD-I onset, despite treatment by community standards, averaged 44%, was 68% D-type morbidity, and was strongly predicted by first-episode polarity. Lower morbidity in EU than U.S. sites may reflect differences in healthcare or social systems.

McLean-Harvard International First-Episode Project: Two-Year Stability of ICD-10 Diagnoses in 500 First-Episode Psychotic Disorder Patients

OBJECTIVE Because clinical and biologic research and optimal clinical practice require stability of diagnoses over time, we determined stability of ICD-10 psychotic disorder diagnoses and sought predictors of diagnostic instability. METHOD Patients from the McLean-Harvard International First-Episode Project, conducted from 1989 to 2003, who were hospitalized for first psychotic illnesses (N = 500) were diagnosed by ICD-10 criteria at baseline and 24 months, on the basis of extensive prospective assessments, to evaluate the longitudinal stability of specific categorical diagnoses and predictors of diagnostic change. RESULTS Diagnostic stability averaged 90.4%, ranking as follows: schizoaffective disorder (100.0%) > mania with psychosis (99.0%) > mixed affective episode (94.9%) > schizophrenia (94.6%) > delusional disorder (88.2%) > severe depressive episode with psychotic symptoms (85.2%) > acute psychosis with/without schizophrenia symptoms = unspecified psychosis (all 66.7%) >> acute schizophrenia-like psychosis (28.6%). Diagnoses changed by 24 months of follow-up to schizoaffective disorder (37.5%), bipolar disorder (25.0%), schizophrenia (16.7%), or unspecified nonorganic psychosis (8.3%), mainly through emerging affective features. By logistic regression, diagnostic change was associated with Schneiderian first-rank psychotic symptoms at intake > lack of premorbid substance use. CONCLUSIONS We found some psychotic disorder diagnoses to be more stable by ICD-10 than DSM-IV criteria in the same patients, with implications for revisions of both diagnostic systems.

Body Image Disturbance, Parental Bonding and Alexithymia in Patients with Eating Disorders

Background: To evaluate if body image disturbance and alexithymia, two major clinical features of eating disorders (ED), are predicted by an altered parental bonding. Sampling and Methods: 64 female ED outpatients and 68 female healthy controls were assessed by means of the Parental Bonding Instrument (PBI), the Body Uneasiness Test (BUT), and the Toronto Alexithymia Scale (TAS-20). Pearson’s correlations and multiple stepwise regression analysis were applied to explore the contribution of PBI factors on BUT and TAS scores. Results: BUT weight phobia, body image concerns, avoidance, depersonalization, Global Severity Index and positive symptom total were predicted by low parental care, while compulsive self-monitoring was predicted by parental overprotection. TAS total score and difficulty in describing feelings were predicted by low maternal care. Conclusions: Body image disturbance in ED may be conceptualized as a deficit in self-development, resulting from failures in parent-child interactions which impaired the ability to distinguish bodily needs from emotional experiences.

Weygandt's On the Mixed States of Manic-Depressive Insanity: A Translation and Commentary on Its Significance in the Evolution of the Concept of Bipolar Disorder

Wilhelm Weygandts Über die Mischzustände des manisch-depressiven Irreseins (On the Mixed States of Manic-Depressive Insanity) describes and conceptualizes mixed states of mood, behavior, and thinking commonly found in manic-depressive disorders. These ideas emerged from Weygandts service in the 1890s at the Psychiatric Clinic of the University of Heidelberg, directed by Emil Kraepelin. In the sixth (1899) edition of Kraepelins influential textbook, the concept of manic-depressive illnesses underwent a fundamental shift from a complex group of syndromal subtypes to a single integrated disorder, widely known from the 1921 English translation of the eighth (1920) edition. In the 1899 edition, Kraepelin acknowledged Weygandt for a new section on mixed manic-depressive states within the new integrated view of manic-depressive disorder. We provide biographical notes on Weygandt, a little-known but historically important figure, as well as the first English translation of his monograph and interpretive summaries of his findings. We also consider whether Weygandts important insight that the same person could be both manic and depressed not only at different times but even at the same time served as an important stimulus to Kraepelins unified manic-depressive disorder concept, which survives as bipolar disorder a century later.

Psychopathology, personality, and marital relationship in patients undergoing in vitro fertilization procedures

OBJECTIVE To compare the psychopathology, personality features, and marital relationships of women undergoing in vitro fertilization (IVF) with those of control patients, and to compare IVF inductees with program veterans. DESIGN Cross-sectional clinical study. SETTING A university hospital. PATIENT(S) One hundred and one women undergoing IVF treatment. INTERVENTION(S) Psychometric tests were administered at first visit (baseline) of index treatment cycle. MAIN OUTCOME MEASURE(S) Achievement of pregnancy. RESULT(S) Women undergoing IVF show higher levels of anxiety and emotional tension than do controls. Although the infertile women showed no abnormal personality dimensions, the IVF group did have a particular psychological profile and a different marital relationship pattern when compared with the control participants. Between IVF veterans and inductees, there are significant differences with respect to psychopathology, psychological dimensions, and couple dynamics. The achievement of pregnancy is not associated with any special psychopathological, personality, or marital characteristics among the IVF women. CONCLUSION(S) The most crucial period in IVF procedures may immediately follow the end of the first cycle because of the high risk of patients dropping out of the program. To determine the most effective supporting therapies for women undergoing fertilization procedures it could be useful to consider the psychological and relational differences between veterans and inductees.

Temperament and personality features in panic disorder with or without comorbid mood disorders

Personality and temperament features, assessed with the Structured Interview for DSM‐III‐R Personality Disorders — Revised (SIDP‐R) and the Tridimensional Personality Questionnaire (TPQ), respectively, were evaluated in 62 patients affected by panic disorder with (PD+MD) (n= 22) or without comorbid mood disorder (PD) (n=40). A significant difference in the prevalence of personality disorders (PD+MD, 86% vs. PD, 62%; P <0.05), particularly dependent (PD+DM, 50% vs. PD, 17%; P < 0.01) and borderline (PD+DM, 9% vs. PD, 0%; P=0.05) personality disorders, was observed between the groups. Moreover, patients in the PD+MD group had higher scores for harm avoidance (PD+MD, 22.2±5.6 vs. PD, 26.9±5.1; P < 0.05) than patients in the PD group. The harm avoidance score in PD patients was significantly related to personality disorder and not to MD, suggesting that harm avoidance is not associated with greater severity of the illness. Our data confirm the hypothesis that subjects with higher harm avoidance scores have a greater probability of being affected by cluster C personality disorders and comorbid mood and anxiety disorders.