Cilly Klüger Issler

Social Dysfunction in Bipolar Disorder: Pilot Study:

Objective: The purpose of the present study was to assess the social skills of euthymic patients with bipolar disorder. Methods: A group of 25 outpatients with bipolar disorder type I were evaluated in comparison with a group of 31 healthy volunteers who were matched in terms of level of education, age, sex and intelligence. Both groups were assessed using a self-report questionnaire, the Brazilian Inventário de Habilidades Sociais (IHS, Social Skills Inventory). Two Wechsler Adult Intelligence Scale subtests (Picture Arrangement and Comprehension) were also used in order to assess subject ability to analyse social situations and to make judgements, respectively. Results: Patients with bipolar disorder had lower IHS scores for the domains that assessed conversational skills/social self-confidence and social openness to new people/situations. Patients with anxiety disorders had high scores for the domain that assessed self-confidence in the expression of positive emotions. No differences were found between patients and controls in performance on the Wechsler Adult Intelligence Scale Picture Arrangement and Comprehension subtests. Conclusions: Euthymic patients with bipolar disorder present inhibited and overattentive behaviour in relation to other people and their environment. This behaviour might have a negative impact on their level of social functioning and quality of life.

Clinical expression of obsessive-compulsive disorder in women with bipolar disorder.

OBJECTIVE To study clinical and psychopathological features of obsessive-compulsive disorder (OCD) in women with bipolar disorder (BD). METHODS Fifteen outpatients with concurrent bipolar disorder I (80.0%) or II (20.0%) and obsessive-compulsive disorder were studied. Most of them (80.0%) sought treatment for bipolar disorder. They were ascertained by means of the Structured Clinical Interview for DSM-IV (SCID/P), semi-structured interviews to investigate obsessions, compulsions and sensory phenomena that may precede compulsions and an additional module for the diagnosis of chronic motor and vocal tics. Severity of symptoms was assessed by the Yale-Brown Obsessive-Compulsive Rating Scale, Hamilton Depression Rating Scale and Young Mania Rating Scale. RESULTS Obsessive-compulsive disorder presented early onset (before the age of 10) in 9 (60%) cases, preceded bipolar disorder in 10 (66.7%) and displayed chronic waxing and waning course in 13 (86.7%) of them. There was wide overlap between types of obsessive-compulsive symptoms and all patients experienced sensory phenomena preceding the compulsions. There was no clear-cut impact of depressive and manic episodes on the intensity of obsessive-compulsive symptoms, which increased in depression and decreased in mania in 40.0% of the cases, had the opposite pattern in 26.7% of the patients and fluctuated inconsistently in the rest of them. Tics disorders were diagnosed in 5 (33.3%) patients. CONCLUSIONS Our results suggest that in women with comorbid bipolar disorder and obsessive-compulsive disorder the latter presents features that may be typical of the association of the two disorders, such as early onset and sensory phenomena preceding compulsions. A prospective controlled study is necessary to confirm these observations, due to some limitations of our study: small exclusively female sample, heterogeneity concerning the type of bipolar disorder and the disorder that determined sought of treatment and retrospective non-controlled design.

Comorbidade com transtornos de ansiedade em transtorno bipolar

High comorbidity between bipolar and anxiety disorders is frequently described in epidemiological and clinical studies. This association has important implications for diagnoses, clinical outcome, therapeutic intervention and prognoses of bipolar disorder that are presented in this review.

Obesity and metabolic syndrome in Brazilian patients with bipolar disorder.

Objective: We aimed to determine the prevalence of obesity and metabolic syndrome (O/MetS) in a sample of Brazilian outpatients with bipolar disorder. Methods: Eighty-four patients with bipolar disorder were evaluated. We used the definition of MetS established in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, modified by the American Heart Association (AHA). Patients were classified as obese if their body mass index (BMI) was ≥ 30 kg/m2. Results: We found that 28.6% of our sample met the AHA criteria for MetS and 35.7% were obese. The percentage of patients meeting each criterion of the AHA was as follows: 46% for abdominal obesity; 44% for hypertriglyceridemia or cholesterol-lowering medication use; 26% for low high-density lipoprotein cholesterol or being on a lipid-lowering medication; 45% for hypertension; and 20% for high fasting glucose or anti-diabetic medication use. Conclusions: The prevalence of obesity in our sample of outpatients with bipolar disorder was higher than that observed for the general population of Brazil. The rate of MetS was similar to that observed for the general population. Our data indicate the need for prevention, early detection and treatment of O/MetS in patients with bipolar disorder.

Bipolar disorder and comorbid obsessive-compulsive disorder is associated with higher rates of anxiety and impulse control disorders

Issler CK, Monkul ES, Amaral JAMS, Tamada RS, Shavitt RG, Miguel EC, Lafer B. Bipolar disorder and comorbid obsessive-compulsive disorder is associated with higher rates of anxiety and impulse control disorders. Objective: Although bipolar disorder (BD) with comorbid obsessive-compulsive disorder (OCD) is highly prevalent, few controlled studies have assessed this comorbidity. The objective of this study was to investigate the clinical characteristics and expression of comorbid disorders in female BD patients with OCD. Method: We assessed clinically stable female outpatients with BD: 15 with comorbid OCD (BD+OCD group) and 15 without (BD/no-OCD group). All were submitted to the Structured Clinical Interview for DSM-IV, with additional modules for the diagnosis of kleptomania, trichotillomania, pathological gambling, onychophagia and skin picking. Results: The BD+OCD patients presented more chronic episodes, residual symptoms and previous depressive episodes than the BD/no-OCD patients. Of the BD+OCD patients, 86% had a history of treatment-emergent mania, compared with only 40% of the BD/no-OCD patients. The following were more prevalent in the BD+OCD patients than the BD/no-OCD patients: any anxiety disorder other than OCD; impulse control disorders; eating disorders; and tic disorders. Conclusion: Female BD patients with OCD may represent a more severe form of disorder than those without OCD, having more depressive episodes and residual symptoms, and being at a higher risk for treatment-emergent mania, as well as presenting a greater anxiety and impulse control disorder burden.

A clinical study comparing manic and mixed episodes in patients with bipolar disorder

OBJECTIVE Mixed episodes have been described as more severe than manic episodes, especially due to their longer duration and their association with higher rates of suicide attempts, hospitalization and psychotic symptoms. The purpose of this study was to compare the severity between mixed and pure manic episodes according to DSM-IV criteria, through the evaluation of sociodemographic data and clinical characteristics. METHOD Twenty-nine bipolar I patients presenting acute mixed episodes were compared to 20 bipolar I patients with acute manic episodes according to DSM-IV criteria. We analyzed (cross-sectionally) episode length, presence of psychotic symptoms, frequency of suicide attempts and hospitalization, Young Mania Rating Scale scores, Hamilton Depression Rating Scale scores and the Clinical Global Assessment Scale scores. RESULTS Young Mania Rating Scale scores were higher in manic episodes than in mixed episodes. There were no differences in gender frequency, CGI scores and rates of hospitalization, suicide attempts and psychotic symptoms, when mixed and manic episodes where compared. Patients with mixed episodes were younger. CONCLUSION In our sample, mixed states occurred at an earlier age than manic episodes. Contrary to previous reports, we did not find significant differences between manic and mixed episodes regarding severity of symptomatology, except for manic symptoms ratings, which were higher in acute manic patients. In part, this may be explained by the different criteria adopted on previous studies.

Antidepressant treatment-emergent affective switch in bipolar disorder: a prospective case-control study of outcome

OBJECTIVE: Treatment-emergent affective switch has been associated to cycle acceleration and poorer outcome, but there are few studies addressing this issue. The aim of this study was to prospectively compare the outcome of patients presenting treatment-emergent affective switch with patients with spontaneous mania, regarding presence and polarity of a new episode and time to relapse. METHOD: Twenty-four patients with bipolar disorder according to the DSM-IV were followed for 12 months. Twelve patients had treatment-emergent affective switch and twelve had spontaneous mania. Patients were evaluated weekly with the Young Mania Rating Scale and the Hamilton Depression Scale until remission of the index episode, and monthly until completion of the 12-month follow-up. RESULTS: Eleven patients with treatment-emergent affective switch had a recurrence on follow-up, all of them with major depressive episodes. In the group with spontaneous mania, six patients had a recurrence: two had a depressive episode, and four had a manic episode (p = 0.069 for new episode, p = 0.006 for polarity of the episode). Patients with treatment-emergent affective switch relapsed in a shorter period than patients with spontaneous mania (p = 0.016). CONCLUSIONS: In this first prospective study, treatment-emergent affective switch patients were at greater risk of relapses, especially depressive episodes, and presented a shorter duration of remission when compared with patients with spontaneous mania.

Reply to Dr. Kauer-Sant'Anna and Dr. Yatham's letter "comment on 'Antidepressant treatment-emergent affective switch in bipolar disorder: a prospective case-control study of outcome'"

OBJECTIVE Treatment-emergent affective switch has been associated to cycle acceleration and poorer outcome, but there are few studies addressing this issue. The aim of this study was to prospectively compare the outcome of patients presenting treatment-emergent affective switch with patients with spontaneous mania, regarding presence and polarity of a new episode and time to relapse. METHOD Twenty-four patients with bipolar disorder according to the DSM-IV were followed for 12 months. Twelve patients had treatment-emergent affective switch and twelve had spontaneous mania. Patients were evaluated weekly with the Young Mania Rating Scale and the Hamilton Depression Scale until remission of the index episode, and monthly until completion of the 12-month follow-up. RESULTS Eleven patients with treatment-emergent affective switch had a recurrence on follow-up, all of them with major depressive episodes. In the group with spontaneous mania, six patients had a recurrence: two had a depressive episode, and four had a manic episode (p = 0.069 for new episode, p = 0.006 for polarity of the episode). Patients with treatment-emergent affective switch relapsed in a shorter period than patients with spontaneous mania (p = 0.016). CONCLUSIONS In this first prospective study, treatment-emergent affective switch patients were at greater risk of relapses, especially depressive episodes, and presented a shorter duration of remission when compared with patients with spontaneous mania.

Comment on Tükel et al., “The clinical impact of mood disorder comorbidity on obsessive-compulsive disorder” (Eur Arch Psychiatry Clin Neurosci, 256(4):240–245)

In the article ‘‘The clinical impact of mood disorder comorbidity on obsessive-compulsive disorder’’ the authors evaluated the differences between unipolar depressive disorder and bipolar disorder comorbidity in the obsessive compulsive disorder (OCD) demographics, symptomatology, course of illness, family history and other comorbid axis I disorders. They found higher frequency of symmetry, ordering and arranging symptoms among bipolar plus OCD patients. These findings corroborate previous findings by Issler et al. [4], who evaluated the clinical characteristics of 15 outpatients with bipolar disorder plus OCD. In addition to symptoms of symmetry, ordering and arranging, they found that aggression, contamination, hoarding and miscellaneous obsessions prevailed over somatic, religious and sexual ones; cleaning, checking, ordering and several other compulsions prevailed over counting, repeating rituals and hoarding compulsions. However, Tükel et al. also found a lack of association between early age at onset of OCD and bipolar disorder. This finding disagrees with previous studies that found a specific association between bipolar comorbidity and early age at OCD onset [1, 5] or high frequency of early OCD onset among female bipolar patients [4], even though this presentation occurs mainly in men [3]. One possible explanation for these inconsistencies is the fact that age at onset of OCD may be defined differently by each author. In the study conducted by Tükel et al. there is no clear description of what was considered age at onset of OCD what makes it difficult to draw any conclusion. To illustrate this point of view we analyzed data from 161 patients evaluated by our group and found that defining age at onset as the earliest age the patient remembers having any obsessive compulsive symptom (OCS) has different impact than defining age at onset as the earliest age the patient remembers having being bothered by his or her symptoms (subclinical OCD). For example, we found that the association between male sex and early OCD onset is only found when age at onset of subclinical OCD is considered (P = 0.047, Unpublished data). This is a consequence of the fact that women from our sample reported a longer interval between age at OCS onset and age at subclinical OCD onset than men. Therefore, to avoid future inconsistencies it is important that researches work with valid definitions of age at onset of OCD or clearly describe the definition used in any specific article. The commented study also did not include information regarding comorbid tic disorders and other OCD spectrum disorders such as trichotillomania and body dysmorphic disorder. A study by our group [2] has associated tic disorders and early onset with the comorbidity with bipolar disorder. Besides, tic disorders, that is observed in 13% [3] to 37.5% [6] in samples of OCD patients from both genders, but is more frequent among men [1, 6] was described in 33% of 15 bipolar women with OCD, 80% of them having early onset of the anxiety disorder [4]. Since the early onset OCD is also associated to a higher genetic load we speculate that early onset OCD cases, that frequently present symmetry, ordering and arranging symptoms, carry a higher genetic vulnerability not only for OCD but for Bipolar, tic disorders, and other OCD spectrum disorders. Future studies taking into account this hypothesis may help to increase our understanding of the bipolar-OCD comorbidity.

Estado-misto: considerações diagnósticas e terapêuticas a partir de um relato de caso

A clinical case-report is presented to discuss the evolution of the mixed state concept and the limitations faced on its clinical management. It is emphasized the role of electroconvulsive therapy on this case. The following data were obtained by patient and family interview as well as medical notes.