Jessica L. Garno

Temperament and character dimensions in bipolar I disorder: A comparison to healthy controls

Research on phenotypic markers of vulnerability to bipolar disorder has focused on the identification of personality traits uniquely associated with the illness. To expand knowledge in this area, we compared Cloningers seven temperament and character dimensions in 85 euthymic/subsyndromal bipolar I inpatients and outpatients and 85 age and sex matched community controls. We also examined associations between Cloningers personality traits and mood state in the patient group. Bipolar subjects were administered the Structured Clinical Interview for DSM-IV (SCID), Hamilton Rating Scale for Depression, and Clinician-Administered Rating Scale for Mania. Controls received the SCID, a family psychiatric history questionnaire, and urine toxicology screen to confirm healthy status. Both groups competed the 240-item Temperament and Character Inventory (TCI). A multivariate analysis of covariance, accounting for demographic factors, was conducted to compare the groups on the TCI. Bipolar I patients scored higher on harm avoidance, lower on self-directedness, and higher on self-transcendence compared to controls. Harm avoidance and self-directedness were correlated with residual depressive symptoms positively and negatively, respectively; persistence was correlated with residual manic symptoms; and selftranscendence was correlated with residual psychotic symptoms in patients. The results indicate that bipolar I subjects do possess personality traits that are significantly different from non-ill individuals. However, only a prospective, longitudinal study may determine whether these traits mark a vulnerability to the disorder, or represent the scarring effect of affective episodes and chronic subsyndromal symptoms.

Predictors of trait aggression in bipolar disorder

OBJECTIVES Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. METHODS Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). RESULTS In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). CONCLUSIONS Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.

Attention and psychomotor functioning in bipolar depression.

The objective of this study was to assess psychomotor functioning and attention in individuals with bipolar disorder during the depressed phase of illness. Measures of attention and psychomotor functioning were administered to a sample of 24 bipolar I and II patients and a matched sample of healthy controls. Relative to the healthy controls, the bipolar sample demonstrated evidence of psychomotor slowing and revealed deficits on measures of effortful attention, yet demonstrated comparable performance on measures of automatic attention. In the bipolar sample, we detected significant correlations among measures of psychomotor functioning and some aspects of attention and a strong relationship between the severity of depression and psychomotor functioning, but no direct relationship between attention deficits and depressive symptomatology. These results suggest an attentional impairment during the depressed phase of bipolar disorder that may be specific to effortful processing, while automatic processes remain relatively intact. Associations among indices of attention deficits and psychomotor slowing may be indicative of similarities in the underlying neurobiology of these frequently co-occurring symptom domains in depressed individuals with bipolar disorder.

Clinical and cognitive correlates of suicide attempts in bipolar disorder: is suicide predictable?

OBJECTIVE We conducted a retrospective investigation of potential clinical, demographic, and neuropsychological risk factors for suicide attempts in patients diagnosed with bipolar disorder. METHOD Participants included 67 adult inpatients and outpatients aged 18-60 years meeting DSM-IV criteria for bipolar disorder (bipolar I and II disorders, bipolar disorder not otherwise specified). We assessed demographic factors, mood symptoms, psychosis, trauma history, trait impulsivity, trait aggression, and reasons for living. The primary outcome measures were the Barratt Impulsiveness Scale-version II, Aggression Questionnaire, and 10 cognitive outcome variables. The cognitive outcome variables assessed cognitive performance across several domains, including processing speed, attention, verbal learning, and executive function. Another aspect of cognitive function, decision making, was assessed using the Iowa Gambling Task. The study was conducted from July 2007-July 2009. RESULTS We found that nonattempters reported significantly higher trait impulsivity scores on the Barratt Impulsiveness Scale compared to attempters (t(57) = 2.2, P = .03) and that, among attempters, lower trait impulsivity score was associated with higher scores of lethality of prior attempts (r(25) = -0.53, P = .01). Analyses revealed no other group differences on demographic, clinical, or neurocognitive variables when comparing attempters versus nonattempters. Regression models failed to identify any significant predictors of past suicide attempt. CONCLUSIONS The largely negative results of our study are particularly important in highlighting the clinical dilemma faced by many clinicians when trying to predict which patients will make serious suicide attempts and which patients are at a lower risk for acting on suicidal thoughts. A limitation of our work is that we examined stable trait measures of impulsivity among a euthymic sample rather than mood state or the impact of mood state on traits. Overall, we conclude that suicidal behavior is extremely difficult to predict, even when comprehensive clinical and neurocognitive information is available.

Age at onset of bipolar disorder and risk for comorbid borderline personality disorder.

OBJECTIVES The relationship between bipolar disorder and cluster B personality disorders remains phenomenologically complex and controversial. We sought to examine the relationship between early age at onset of bipolar disorder and development of comorbid borderline personality disorder. METHODS A total of 100 adults in an academic specialty clinic for bipolar disorder underwent structured diagnostic interviews and clinical assessments to determine lifetime presence of comorbid borderline personality disorder, histories of childhood trauma, and clinical illness characteristics. RESULTS Logistic regression indicated that increasing age at onset of bipolar disorder was associated with a lower probability of developing comorbid borderline personality disorder (odds ratio = 0.91, 95% confidence interval: 0.83-0.99) while controlling for potential confounding factors, including a history of severe child trauma/abuse. CONCLUSION Early onset of bipolar disorder increases the probability of developing comorbid borderline personality disorder, independent of the effects of severe childhood trauma/abuse. In patients with borderline personality disorder, prospective studies of new-onset bipolar disorder may underestimate the prevalence of true comorbidity unless they capture the primary risk window for first-episode mania arising before the end of adolescence.