Katia M'Bailara

Affective lability and affect intensity as core dimensions of bipolar disorders during euthymic period

Bipolar disorders are usually defined by alternative mood states, but a more precise characterization of the euthymic period could provide further insights into the pathophysiology of bipolar disorders. Surprisingly, few studies have investigated core affective dimensions in euthymic bipolar patients. In this study, we assessed 179 euthymic bipolar patients (score<12 on the Montgomery-Asberg Depression Scale and a score<6 on the Bech-Rafaelsen Mania Scale) compared with 86 control subjects using French versions of the Affective Lability Scale (ALS) and the Affect Intensity Measure (AIM). Data were analyzed by logistic regression. Our results showed that euthymic bipolar subjects reported having more intense emotions than controls and also had a higher affective lability. High scores in both affective dimensions were associated with a significantly higher risk for psychiatric axis I comorbidity. Moreover, a high affective lability score was associated with an earlier age of onset for bipolar disease. Affective lability and affect intensity might be two core dimensions of bipolar disorder during euthymic periods, suggesting that bipolar disorder is not circumscribed to mood episodes but also affects emotional reactivity between episodes. Both dimensions could account for the stress reactivity of bipolar patients that may lead to relapses.

Duration of untreated bipolar disorder: missed opportunities on the long road to optimal treatment

Objective:  Duration of untreated illness represents a potentially modifiable component of any diagnosis‐treatment pathway. In bipolar disorder (BD), this concept has rarely been systematically defined or not been applied to large clinically representative samples.

Clinical expression of bipolar disorder type I as a function of age and polarity at onset: convergent findings in samples from France and the United States.

BACKGROUND The clinical presentation, course, and comorbidities of bipolar disorder type I are highly heterogeneous, and this variability remains poorly predictable. Certain onset characteristics (eg, age and polarity at onset) may delineate subgroups differing in clinical expression and outcome. METHOD We retrospectively investigated the association between both age and polarity at onset and the clinical characteristics of bipolar I disorder (DSM-IV) in 2 independent adult samples: 480 French patients assessed in 1992-2006 (patients had been recruited from 3 university-affiliated psychiatry departments) and 714 US patients assessed in 1991-2003 (data were extracted from the Bipolar Disorder Phenome Database). RESULTS Polarity at onset correlated with subsequent predominance (P < .001). Most patients experienced a depressive onset (57.9% in France vs 71.0% in the United States; P < .001) associated with a higher density of depressive episodes, suicidal behavior, and alcohol misuse. A manic onset was associated with a higher density of manic episodes. Early onset was frequent in both countries (42% in France vs 68% in the United States; P < .001) and was associated with suicidal behavior and cannabis and cocaine/opiate misuse. Sensitivity for the prediction of clinical characteristics was 1%-35% for age at onset and 26%-47% for polarity at onset. CONCLUSIONS Onset characteristics are associated with subsequent predominant polarity, suicidal behavior, and substance misuse in bipolar I disorder. These findings may facilitate personalized treatment strategies based on type of onset and may also facilitate early focused strategies for preventing comorbidity. Given the relatively low sensitivity and specificity of these onset characteristics for predicting clinical variables, the relevance of age and polarity at onset as specifiers in nosographical classifications will require further studies. However, polarity at onset may be the more relevant specifier, with further investigation required for age at onset.

Mind wandering and driving: responsibility case-control study

Objective To assess the association between mind wandering (thinking unrelated to the task at hand) and the risk of being responsible for a motor vehicle crash. Design Responsibility case-control study. Setting Adult emergency department of a university hospital in France, April 2010 to August 2011. Participants 955 drivers injured in a motor vehicle crash. Main outcome measures Responsibility for the crash, mind wandering, external distraction, negative affect, alcohol use, psychotropic drug use, and sleep deprivation. Potential confounders were sociodemographic and crash characteristics. Results Intense mind wandering (highly disrupting/distracting content) was associated with responsibility for a traffic crash (17% (78 of 453 crashes in which the driver was thought to be responsible) v 9% (43 of 502 crashes in which the driver was not thought to be responsible); adjusted odds ratio 2.12, 95% confidence interval 1.37 to 3.28). Conclusions Mind wandering while driving, by decoupling attention from visual and auditory perceptions, can jeopardise the ability of the driver to incorporate information from the environment, thereby threatening safety on the roads.

Evidence for Two Types of Bipolar Depression Using a Dimensional Approach

Background: Although there is a great heterogeneity of depressive states in bipolar patients, there is only one definition in international classifications for describing them. However, this variety seems particularly important to recognize because of the possible exacerbation of some of these bipolar depressive states by antidepressants. We aimed at assessing whether it is possible to distinguish different forms of bipolar depression using a dimensional approach. Methods: We characterized 60 bipolar patients with a Major Depressive Episode (DSM-IV) using a new tool (MAThyS; Multidimensional Assessment of Thymic States), assessing five fundamental dimensions (emotional reactivity, cognitive speed, psychomotor function, motivation, and sensory perception) of mood states. Results: A cluster analysis using the items of the dimensional scale revealed two types of depressive state: group 1 (n = 38), which had a low score, is characterized by an inhibition in all dimensions, whereas group 2 (n = 22) is characterized by an overactivation. The emotional reactivity is the most relevant dimension for discriminating these two types of depression (group 1: hyporeactivity; group 2: hyperreactivity), whereas sadness is not. Conclusions: Bipolar depressive states are not homogeneous. A dimensional approach based on emotional reactivity could be useful for discriminating the different forms of bipolar depression. Bipolar depressions may be classified as hyporeactive or hyperreactive. This classification might have therapeutic implications, because hyperreactive depression should belong to the broad spectrum of mixed states.

Defining bipolar mood states with quantitative measurement of inhibition/activation and emotional reactivity

OBJECTIVES Mood state heterogeneity in bipolar disorder leads to confusion in diagnosis and therapeutic strategies. Recently, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that two-thirds of bipolar-depressed patients had concomitant manic symptoms, these characteristics being linked to a more severe form of bipolar disorder. Moreover, manic symptoms occurring during bipolar depression are associated with mood switches induced by antidepressant. It is thus important to best characterize mood episodes with mixed features in order to improve our understanding of the etiopathology and to choose the most appropriate treatment. As dimensional approach can better describe phenomena that are distributed continuously without clear boundaries, we used the MATHYS scale, constructed on a dimensional approach. The aim of the study is to determine whether two dimensions (activation/inhibition and emotional reactivity) improve assessment of bipolar states in which both manic and depressive symptoms are associated. METHODS We included 189 bipolar patients and 90 controls. Bipolar patients were distinguished between those with a major depressive episode without manic symptoms, a major depressive episode with manic symptoms, a mixed state and a manic state. The MATHYS scale provides a total score, quantifying an inhibition/activation process, and a score for emotional reactivity (intensity of emotions). RESULTS We demonstrated that there is a continuum ranging from inhibition to activation (respectively from major depressive episodes without manic symptoms to manic states), with a gradual increase in the severity of the activation. Regarding emotional reactivity, results are quiet different since only major depressive episodes without manic symptoms are characterized by emotional hypo-reactivity while major depressive episodes with manic symptoms, manic and mixed states exhibited emotional hyper-reactivity. CONCLUSIONS The MATHYS scale, providing a score for inhibition/activation process and a score for emotional reactivity, is clearly useful to distinguish bipolar depressive episodes without manic symptoms from those with manic symptoms. This last type of depression appears to belong to a broad spectrum of mixed state. To go further we need to explore if these two types of depression are underlined by different mechanisms and what is the most appropriate treatment for each of them.

Emotional dysfunction as a marker of bipolar disorders.

BACKGROUND Assessment of emotional reactivity, defined as rapid emotional responses to salient environmental events, has been neglected in mood disorders. This article reviews data showing the relevance of using emotional reactivity to better characterize bipolar mood episodes. METHOD We reviewed clinical data on emotional reactivity during all phases of bipolar disorders (euthymic, manic, mixed and depressive states) and brain-imaging, neurochemical, genetic studies related to emotional reactivity disturbances. RESULT Euthymic bipolar patients show mild abnormalities (hypersensitivity to emotional stimuli and higher arousability) in comparison to controls. Both manic and mixed states are characterized by a significant increase in emotional reactivity. Furthermore, emotional reactivity may discriminate between two types of bipolar depression, the first being characterized by emotional hypo-reactivity and global behavioral inhibition, the second by emotional hyper-reactivity. Brain-imaging studies can help to identify the underlying mechanisms involved in disturbances of emotional reactivity. CONCLUSION Emotional reactivity can be used to refine more homogeneous pathophysiological subtypes of mood episodes. Future research should explore possible correlations between biomarkers, response to treatments and these clinical phenotypes.

Emotional hyperreactivity as a core dimension of manic and mixed states

Despite its obvious importance in mood disorders, characterization of emotional reactivity has been neglected in bipolar disorders. Concerning manic states and the current classification, the main criterion is the presence of an elevated or expansive mood. In contrast to this characteristic and often prolonged mood state, emotional reactivity refers to a brief evoked response to salient emotional stimuli. The goal of this study was to assess the intensity of emotional responses triggered by viewing slides in bipolar patients with manic or mixed states. Our hypothesis was that all emotional responses are exacerbated, whatever the valence of the stimuli. We compared 33 patients with manic or mixed states with 33 matched euthymic patients and 33 healthy control subjects. Arousal and attribution of valence were assessed while subjects viewed slides taken from the International Affective Picture System (positive, neutral and negative slides). Patients with manic or mixed states reported a higher arousal when viewing all types of slides in comparison with the other groups. Concerning attribution of valence, patients with manic or mixed states assessed neutral slides as more pleasant. When bipolar patients with manic and mixed states are placed in front of positive, neutral and negative slides, the slides trigger a higher intensity of emotions, whatever the valence of the emotional stimuli. These results strengthen the importance of emotional hyperreactivity as a core dimension in manic and mixed states in bipolar disorder.

Assessing needs in parents of children with autism spectrum disorder: A crucial preliminary step to target relevant issues for support programs

Abstract Background Raising a child with an autism spectrum disorder (ASD) implies significant stress levels and changes in family functioning. Most studies deal with parental difficulties, whereas those focusing on parental self-reported support needs related to ASD are fewer, especially in France. Our objective was to explore in a French sample the needs of parents of children with ASD so as to provide recommendations for support. Method Parents were interviewed (N = 162, including 84 controls), and content analysis was performed from parental responses. Results Six dimensions of need emerged: material, information, guidance, daily management, relational support, and emotional support. Needs priorities were different for parents with a child with ASD involving the transmission of knowledge and skills as well as emotional and relational support. Conclusions This study highlights the need to develop support programs focused on the needs of the parents that reflect educational, behavioural, and psychological dimensions.

From inhibition to activation, from emotional hyporeactivity to emotional hyperreactivity: Two pathways to discriminate mood in bipolar disorders

To better explore the clinical heterogeneity of bipolar mood states, we developed a dimensional scale for assessing all mood episodes (depressive, hypomanic, manic, mixed states) using the same tool. The Multidimensional Assessment of Thymic States (MATHYS) (Henry et al., 2008) provides two scores, a total score measuring a level of activation and a sub-score of emotional reactivity. The aim of this study was to establish the appropriate cut-off in total activation versus inhibition and in the emotional reactivity sub-score in bipolar disorders. Patients (n=187) during an acute episode and controls (n=89) filled in the MATHYS. Receiver Operating Characteristic (ROC) curves were obtained to estimate the sensitivity and specificity of the global score and the emotional reactivity sub-score of the MATHYS, in order to differentiate patients from controls. ROC curves showed very satisfactory sensitivity and specificity levels both for the total score and the sub-score of emotional reactivity, thus providing an appropriate cut-off. Concerning the total score between 0 and 200, patients with a score lower than 91 had significant global inhibition and those with a score higher than 109 had significant global activation. Regarding the emotional reactivity sub-score between 0 and 40, patients with a score lower than 16 had significant emotional hyporeactivity and those with a score higher than 24 had significant emotional hyperreactivity. Our results provide cut-offs for the MATHYS to identify patients in an acute phase.