H. Lövdahl

The phenomenology of recurrent brief depression with and without hypomanic features

BACKGROUND The nosologic status of recurrent brief depression (RBD) is debated. We studied the phenomenology of RBD in a clinical sample of outpatients. METHODS Forty patients (mean age 33; 73% females) and 21 age- and gender-matched mentally healthy controls were examined (clinical interview, M.I.N.I. neuropsychiatric interview, MADRS, Stanley Foundation Network Entry Questionnaire). Exclusion criteria were bipolar I or II disorders, a history of psychosis, concurrent major depressive episode, organic brain or personality disorders (clusters A and B). RESULTS The mean age of onset of RBD was 20 years with a mean of 14 episodes/year with brief (mean 3 days) severe depressive episodes. Nineteen (47%) reported additional short episodes of brief hypomania (>1 day duration; RBD-H) of which nine (23%) never had experienced a major depression. Twenty-one (53%) patients reported RBD only (RBD-O) with or without (n=12) past history of major depression or dysthymia. During the last depressive episode, 76% of the RBD-O and 90% of the RBD-H patients had a melancholic depression. Seventy-one % of the RBD-O and 79% of the RBD-H reported at least two out of three atypical symptoms. Nineteen (48%) of the patients reported anger attacks and panic disorder, the latter being more prevalent in the RBD-H subgroup (68% versus 29%, p=0.012). LIMITATIONS Cross-sectional study of self-referrals or patients referred by primary care physicians or psychiatrists. CONCLUSIONS The study supports the validity of RBD as a disorder separate from bipolar II, cyclothymia and recurrent major depression. A brief episode of hypomanic symptoms is a severity marker of RBD.

Neuropsychological function in unmedicated recurrent brief depression

BACKGROUND Recurrent brief depression (RBD) is a mood disorder characterized by mild to severe depressive episodes lasting less than 2 weeks and occurring approximately once a month with complete recovery between episodes. The aim of this study was to describe neuropsychological impairments associated with RBD, relating cognitive performance to clinical features and comorbidity. METHODS Forty-six ICD-10 defined RBD patients (mean age 33.8) and 24 matched controls were assessed on working memory/attention tasks, executive functions, verbal/visual memory, and psychomotor speed. RESULTS Patients were significantly impaired across all domains of cognition except for verbal learning and non-semantic verbal fluency. Neuropsychological performance was not related to depression severity, duration of depressive episodes, interval duration, psychiatric or somatic comorbidity, or attributable to a general reduction in processing speed or effort. Patients reporting previous major depressive episodes were impaired on one measure of psychomotor speed. Previous episodes of hypomania were not related to neuropsychological performance. LIMITATIONS The relatively high number of self-referrals, high female-to-male ratio in the patient sample, and the relatively high level of education and intellectual capacity among participants may limit the possibility to generalize our results to the RBD population in general. CONCLUSIONS Unmedicated RBD patients demonstrate significant neuropsychological impairment that also may persist into euthymic states. Examining cognitive functions might be equally important in RBD as in major depression with consequences for functional diagnostics and treatment strategies.

Motor function may differentiate attention deficit hyperactivity disorder from early onset bipolar disorder

BackgroundDifferentiating between bipolar spectrum disorder (BD) and attention deficit hyperactivity disorder (ADHD) in childhood and adolescence is difficult because the clinical presentation is influenced by ongoing neural development, causing considerable symptom overlap. Motor problems and neurological soft signs have been associated with ADHD for decades. Little is known about motor skills in BD. Here we assess the diagnostic accuracy of neuromotor deviations in differentiating ADHD from BD in clinical practice. We also investigate if these deviations exist in concurrent ADHD and BD, thus indicating true comorbidityMethods64 patients 6-18 years (31 girls, 33 boys) fulfilling the diagnostic criteria of BD, ADHD combined subtype (ADHD-C) or comorbid BD and ADHD-C, were compared using an age-standardized neuromotor test; NUBU. Categorical variables were analyzed using cross table with two-tailed chi square test or Fishers exact test when appropriate. Continuous variables were analyzed by Kruskal-Wallis test and, if significant, Mann-Whitney U test and ROC plots.ResultsThe ADHD-C group and the comorbid ADHD-C and BD group both showed significantly more neurological soft signs (p less than 0.01) and lower mean static coordination percentile (p less than 0.01) than the BD group. The positive predictive value of NUBU in the diagnosis of ADHD-C with or without concurrent BD was 89% (80-95) for total soft signs and 87% (79-95) for static coordination below the 7.5 percentile.ConclusionAn age-standardized neuromotor test battery may promote diagnostic accuracy in differentiating ADHD from BD in clinical practice, and help evaluating whether symptoms of ADHD in children who have BD reflect symptom overlap or real comorbidity. This may have important implications for everyday diagnostic work.

Temperament and character in patients with bipolar II disorder and recurrent brief depression

OBJECTIVES We compared the temperament and character profiles of 21 patients with bipolar II disorder, 40 patients with recurrent brief depression (RBD; at least monthly depressive episodes meeting the diagnostic criteria for major depressive episode except for duration that is less than 2 weeks, typically 2-3 days, without fixed relation to menstrual cycle) of which 21 had no history of hypomania and 19 had experienced hypomanic episodes, and 21 age- and sex-matched controls. METHODS Assessments included the Montgomery-Åsberg Depression Rating Scale, Hypomania Checklist, and Temperament and Character Inventory-125. Patients with cluster A and B personality disorders were excluded. RESULTS Bipolar II and RBD patients had higher harm avoidance (HA) and lower self-directedness (SD) compared with controls. Excluding panic disorder comorbidity effaced this difference in HA and SD (bipolar II only) and harm avoidance. No other differences were found. CONCLUSIONS In this first study comparing personality profiles of patients with bipolar II vs RBD, when controlling for confounders, neither bipolar II nor RBD patients differed significantly from healthy controls. The lower SD scores among RBD patients may reflect sampling bias (a higher rate of Axis 2 cluster C disorders).

Executive deficits in early onset bipolar disorder versus ADHD: Impact of processing speed and lifetime psychosis

Executive deficits are reported in both early onset bipolar disorder (BD) and attention-deficit hyperactivity disorder (ADHD), and controversies regarding comorbidity and symptom overlap have complicated the research on executive function in BD. Reports of the negative impact of executive difficulties on academic functioning indicate a need for a greater focus on executive difficulties in early onset psychiatric disorders. Executive function and processing speed in youths with BD (n = 4), ADHD (n = 26) and BD + ADHD (n = 13) were compared with controls (n = 69). All clinical groups demonstrated executive impairment. The combined group was most impaired. There were no significant differences between the groups. Executive deficit in the BD group was associated with a history of psychotic symptoms. The BD-nonpsychotic group was impaired only with regard to processing speed. Processing speed adjustment improved working memory and normalized interference control in both BD and ADHD. Conclusion: executive deficits in BD may be determined by a history of psychotic symptoms rather than by comorbid ADHD. Some aspects of executive problems appear speed-related.

Somatic and cognitive symptoms as indicators of potential endophenotypes in bipolar spectrum disorders: An exploratory and proof-of-concept study comparing bipolar II disorder with recurrent brief depression and healthy controls

BACKGROUND We examined whether somatic symptoms reported by patients with bipolar spectrum disorder (BSD), in this study defined as bipolar II (BD-2) or recurrent brief depression with (RBD-H) or without (RBD-O) a history of hypomanic symptoms might point to the possible underlying disease markers (endophenotypes). We hypothesized that somatic symptoms that are possible indirect indicators of endophenotypes should be more prevalent among patients than among healthy controls; should not correlate with neuroticism; should not correlate with the severity of current mental status (e.g., anxiety, depression); and should not correlate with the use of psychotropic drugs including antiepileptics or be explained by co-morbid medical diseases. METHODS Sixty-one patients (BD-2: n=21; RBD-H: n=19; RBD-O: n=21) were compared with 21 healthy controls. Assessments included a 123-item somatic symptom checklist; assessments for neuroticism, anxiety and depression. Candidate somatic symptoms were selected using a 4-step inclusion/exclusion procedure. RESULTS Seven symptoms survived in all three groups: general (fatigue, feeling exhausted); sensory (leaden sensation in legs, pain in the body, impaired sense of smell); cognitive (loss of memory) and autonomic (excessive perspiration). In addition 15 symptoms survived in one or two groups (examples: impaired hearing, hypersensitivity to sound, inability to find words). LIMITATIONS Possible selection bias and small sample size precludes firm conclusions with regards to specific symptoms. CONCLUSION Our approach identified symptoms for which an association with BSDs has been suggested previously, as well as symptoms not commonly associated with BSDs. The findings support the feasibility and validity of using assessment of somatic symptoms as an approach to identify potential endophenotypes in BSDs.

Working memory in recurrent brief depression: an fMRI pilot study.

BACKGROUND We examined women with recurrent brief depression (RBD) with and without episodes of hypomania with an n-back working memory paradigm to assess how working memory load affects the neurological network corresponding to working memory for these groups. METHOD Participants (n=33) were medication-free and mostly euthymic while performing a 1-back and a 2-back task in the fMRI scanner. Differential activation results between the tasks were assessed globally and within seven predefined regions of interest associated with working memory activation. The patient groups were compared with healthy women and matched for age, handedness, and length of education. RESULTS Poor task modulation was observed in both RBD groups in the prefrontal cortex (BA9) in the 1-back task and activation during the 2-back task, particularly in a subgroup with a history of brief hypomanic episodes (RBD-H) compared with the subgroup without such episodes (RBD-O). Task modulation in the right parahippocampal gyrus (BA27) distinguished the RBD-O group, and task modulation in the right insula clearly distinguished the RBD-H group. LIMITATIONS Small sample size and recruitment of most patients through media that may induce a selection bias towards better-functioning subjects. CONCLUSION The observed lack of deactivation within the right insula has also been reported in patients with bipolar I disorders. Activation differences in BA9 and the parahippocampal region between RBD patients with and without a history of hypomania suggest different functional hypersensitivity of early limbic regions and ability to sustain attention and working memory, respectively, possibly identifying functional differences between the two subgroups.

Differentiating Between Comorbidity and Symptom Overlap in ADHD and Early Onset Bipolar Disorder

Reported rates of comorbidity between early onset bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) have a wide range, perhaps due to developmental issues and differences in interpretation of overlapping symptoms. We compared questionnaire-based and neuropsychological measures of inattention and impulsivity/hyperactivity, in children/adolescents with ADHD combined subtype (ADHD-C; n26), concurrent ADHD-C and BD (n15), BD (n25) with Controls (n69). Sub-analyses were performed on BD with and without inattention symptoms. The two ADHD-C groups displayed neuropsychological impairments that were not found in the BD group in spite of subjective and questionnaire-rated inattention. The findings caution against over-diagnosis of ADHD in BD.

Erratum to “Somatic and cognitive symptoms as indicators of potential endophenotypes in bipolar spectrum disorders: An exploratory and proof-of-concept study comparing bipolar II disorder with recurrent brief depression and healthy controls” [J. Affect. Disord. 166 (2014) 59–70]

Erratum to “Somatic and cognitive symptoms as indicators of potential endophenotypes in bipolar spectrum disorders: An exploratory and proof-of-concept study comparing bipolar II disorder with recurrent brief depression and healthy controls” [J. Affect. Disord. 166 (2014) 59–70] H. Lovdahl , E. Boen , E.A. Malt , U.F. Malt a,b,d a Department of Psychosomatic Medicine, Division of Surgery & Neuroscience, Oslo University Hospital – Rikshospitalet, Oslo, Norway b Institute of Clinical Medicine, University of Oslo, Oslo, Norway c Department of Clinical Psychiatry, Sorlandet Hospital, Arendal, Norway d Normood (Norwegian Research Network on Mood Disorders), Norway e Department of Adult Habilitation, Division of Psychiatry, Akershus University Hospital, Lorenskog, Norway