EU_Psych_Angst.qxp 24/6/08 03:52 Page 20
Affective Spectrum Disorders Bipolar Spectrum
M was less rapidly cycling (2.6%) than Md (12.7%) and MD (18.4%). The disability/impairment. Overall, the outcome of M patients was more benign.
morbid risk data of unipolar depression among parents and siblings did not Angst et al.
14
followed up 406 patients (admitted to hospital between
differ between the three groups, but compared with the other two groups 1959 and 1963) every five years over a period of 21–26 years until 1985,
there was a trend (non-significant) among manics for a lower morbid risk and collected mortality data regularly until 2003, by which time over
of bipolar-I disorder (M 0%, Md 1.8% and MD 2.9%) and bipolar-II 80% of the sample had died. Thirty of 155 patients (18.7%) who had
disorder (M 2.6%, Md 5.8% and MD 4.7%). manic episodes showed signs of mania only. Fourteen of these patients
were M and 16 were Md cases. Compared with the 130 bipolar-I
A chart review by Pfohl et al.
9
of 247 hospital admissions for mania patients, the 30 manics (M/Md) had higher educational levels, a lower
compared manic with bipolar patients and found no significant morbid risk of affective disorders and a significantly better course with
difference in clinical validators, including gender distribution, although a fewer recurrences and lower suicide rates. These findings are compatible
family history of M tended to be twice as frequent among manic patients with Nurnberger et al.
8
regarding lower rates of suicide attempts and
whereas a family history of depression was less frequent (non-significant). rapid cycling. The personality of manics was more frequently manic than
A six-month to four-year follow-up study by Starkstein et al.
10
found 12 melancholic and they were more aggressive. The related mortality study
15
manic patients and compared them with seven bipolar patients using showed that manic patients died significantly less often from suicide, but
computed tomography (CT) scans and neuro-psychological tests. They more frequently from cardiovascular disease (standardised mortality
reported no gender difference between the two groups. The manic ratios [SMR] 2.9) than bipolar-I patients (SMR 2.0), with both groups
patients showed less cognitive impairment but higher frequencies of differing significantly from the Swiss population.
cortical lesions (right frontal), whereas subcortical lesions (right head of
the caudate and thalamus) predominated among bipolar patients. Studies in Non-Western Cultures
Makanjuola
16,17
examined patients from psychiatric units responsible for
Long-term Follow-up Studies of Manic Patients a catchment area containing about one million Yoruba Nigerians. The
Keller et al.
11
found that 7% of 155 patients with bipolar-I disorder author found a strong predominance of M (n=55), defined by at least
suffered from M (median follow-up 1.5 years). Their prognosis was better two episodes, over bipolar disorders (n=13). Thirty-six other patients
(shorter illness, lower chronicity) than that of the bipolar-I patients. manifested single-episode mania. Males predominated in the manic
Solomon et al.
12
followed 27 manic and schizo-manic patients who had group (62%). All three groups had previous histories of mania (average
no previous history of depression over a period of 15–20 years in the of 5.9 years), earlier records were available and relatives were also
context of the Collaborative Depression Study, examining them every six interviewed. A Tunisian study also found relatively high rates (37.5%) of
months during the first five years and annually thereafter with M, with an over-representation of males compared with bipolar
retrospective weekly assessments of mood status. Twenty subjects disorder.
18
Aghanwa
19
found excessively high rates of M, particularly
developed major depressive episodes, two developed Md and five among females, compared with bipolar disorder in Fiji. A family history of
remained M patients, manifesting one to eight new hypomanic episodes psychiatric disorders was rarer among the manic group, which did not
during follow-up. The seven subjects who did not develop major otherwise differ from the bipolar group.
depressive episodes were all inpatients at study intake, and five of them
had psychotic symptoms. The authors concluded that M is a genuine but Psychotic Mania
relatively rare diagnostic entity. Shulman and Tohen
3
studied 50 elderly Compared with bipolar disorder, rates of psychotic features among M
manic patients, six of whom (12%) were found to have M with at least disorders were found to be at least equal,
14
if not higher, especially with
three episodes. These patients were followed up for three to 10 years regard to mood-incongruent features.
4,7,13
Psychotic mania was not
(mean 5.6 years), and five were female and one male. The age of onset found to correlate with the number of manic symptoms.
20
of the manic patients was earlier than that of the 44 bipolar patients.
Hypomania
In a four-year follow-up study of 272 hospitalised manic patients, Yazici et al.
4
The definition of m as a disorder and of hypomanic syndromes as a
identified 224 as bipolar-I and 48 (16.3%) as M, meeting the study’s criterion diagnostic specifier for bipolar depression is a matter of ongoing debate.
of four manic episodes over four years. The authors stressed that the Subjects experiencing hypomanic episodes without depression (m) are rare
occurrence of Md episodes in some of the patients cannot be excluded, which and not usually seen in psychiatric care. However, they can be identified
would classify them as Md. Compared with the bipolar-I patients, those with in epidemiological samples followed prospectively. In the Zurich Study,
M had more psychotic symptoms (85 versus 71%), were slightly more which followed a cohort who were between 20 and 40 years of age, 23
often male (44 versus 37%) and less often had a family history subjects (3.6%) were diagnosed as presenting with hypomanic episodes.
21
of depression (2 versus 7%). Their age and age at onset were also lower. Of The stability of the hypomanic syndrome across several interviews was very
special interest is the authors’ finding that during the free intervals, manics low, therefore it did not correspond to persistent hyperthymia. Two-thirds
were more often hyperthymic (13 versus 5%) and less often cyclothymic of the hypomanic subjects were male. An average of 30 days were spent
(0 versus 6%). Manic patients seemed to be less responsive to lithium cumulatively in hypomania over the previous 12 months. Compared with
prophylaxis, a finding at variance with Nurnberger et al.
8
Perugi et al.
13
selected controls, hypomanics had higher incomes, were more frequently married
87 inpatients with a history of mood disorders longer than 10 years and at and divorced and had more children. They also rated higher on all of the
least three major affective episodes. Nineteen of these patients (21.8%) had following measures: aggression, risk-taking behaviour, physical and social
M. Compared with the 68 bipolar patients, they did not differ in their family overactivity, elevated and irritable mood, sleep disturbances, substance
history of major depression or bipolar disorder, but they were characterised by abuse and binge eating. They also broke the law and received court
more psychotic symptoms, a hyperthymic temperament, lower hostility, sentences more frequently. On the General Behavior Inventory (GBI) of
anxiety and suicidality scores and less work, financial and social Depue,
22
they scored highly for hypomania but not cyclothymia or
20 EUROPEAN PSYCHIATRIC REVIEW
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76