Evidence for Two Types of Bipolar Depression Using a Dimensional Approach
Université Victor Segalen Bordeaux 2, Burdeos, Aquitaine, France Psychotherapy and Psychosomatics
(Impact Factor: 9.2).
02/2007; 76(6):325-31. DOI: 10.1159/000107559
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.
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.
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.
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.
Available from: Katia M'Bailara
- "Individuals with BD experience a wide range of emotional disturbances including mood symptoms, emotional liability and reactivity, irritability, anxiety and anger, suggesting the existence of inappropriate or inadequate emotion regulation during acute illness and inter-episode phases (Henry et al., 2007, 2008; M 0 Bailara et al., 2009). Regulation of emotions in BD has been described as altered, both in terms of higher levels of arousal (being emotionally alert or reactive to a stimulus) and hyper-intensity (characterized by an excessive level of a specific emotional reaction) whatever the valence (positive/negative) (M 0 Bailara et al., 2009). "
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Emotional dysregulation, characterized by high levels of both arousal and intensity of emotional responses, is a core feature of bipolar disorders (BD). In non-clinical populations, the 40-item Affect Intensity Measure (AIM) can be used to assess the different dimensions of emotional reactivity.
We analyzed the factor structure of the AIM in a sample of 310 euthymic patients with BD using Principal Component Analysis and examined associations between AIM sub-scale scores and demographic and illness characteristics.
The French translation of the AIM demonstrated good reliability. A four-factor solution similar to that reported in non-clinical samples (Positive Affectivity, Unpeacefulness [lack of Serenity], Negative Reactivity, Negative Intensity), explained 47% of the total variance. Age and gender were associated with Unpeacefulness and Negative reactivity respectively. ‘Unpeacefulness’ was also positively associated with psychotic symptoms at onset (p=0.0006), but negatively associated with co-morbid substance misuse (p=0.008). Negative Intensity was positively associated with social phobia (p=0.0005).
We cannot definitively exclude a lack of statistical power to classify all AIM items. Euthymia was carefully defined, but a degree of ‘contamination’ of the self-reported levels of emotion reactivity may occur because of subsyndromal BD symptoms. It was not feasible to control for the possible impact of on-going treatments.
The AIM scale appears to be a useful measure of emotional reactivity and intensity in a clinical sample of patients with BD, suggesting it can be used in addition to other markers of BD characteristics and sub-types.
Available from: Tae-Youn Jun
- "Additionally, the most prevalent manic symptoms in subjects with a depressive mixed state were elevated/irritable mood, psychomotor agitation, distractibility , and increased talkativeness. These findings are consistent with those of an earlier study that reported that the mixed state is based on hyperactive " emotional reactivity " (Henry et al., 2007) and a study that reported that depressive mixed-state patients have prominent symptoms of " activation " such as anger, irritability , aggressiveness, hostility, and psychomotor activation (Biondi et al., 2005). These manic symptoms are associated with the serious clinical outcomes of bipolar mixed states, such as longer affective episodes and exacerbation of manic symptoms of syndromal mania (Judd et al., 2012). "
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ABSTRACT: We compared the time to achieve remission and the clinical characteristics of patients with bipolar depressive mixed state and those with bipolar depressive non-mixed state.
The subjects (N=131) were inpatients diagnosed between 2006 and 2012 with bipolar I or II disorder, depression and were classified into the following three groups: "pure depressive state" (PD, n=70), "sub-threshold mixed state" (SMX, n=38), and "depressive mixed state" (DMX, n=23). Diagnosis of a DMX was in accordance with Benazzi's definition: three or more manic symptoms in a depressive episode. The subjects' charts were retrospectively reviewed to ascertain the time to achieve remission from the index episode and to identify other factors, such as demographic and clinical characteristics, specific manic symptoms, and pharmacological treatment, that may have contributed to remission.
The time to achieve remission was significantly longer in the DMX (p=0.022) and SMX (p=0.035) groups than in the PD group. Adjustment for covariates using a Cox proportional hazards model did not change these results. Clinically, subjects with a DMX were more likely to have manic symptoms in the index episode, especially inflated self-esteem and psychomotor agitation than those in the PD.
We investigated only inpatients and therefore could not comment on outpatients.
These findings showed that sub-syndromal manic symptoms in bipolar depression had different clinical characteristics and a more severe illness course, including a longer time to achieve remission, than did a pure depressive state.
Available from: Christophe Lançon
- "Furthermore, three clusters of activation/inhibition levels identified with the MAThyS scale were associated with bipolar depression, manic states, and mixed states correspondingly . The scale also permitted the identification of two types of depression according to the level of activation/inhibition displayed: pure depression, characterized by global inhibition and emotional hyporeactivity, and depression with mixed features, characterized by mild activation and emotional hyperreactivity . "
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ABSTRACT: One of the major issues in clinical practice is the accurate differential diagnosis between mixed states and depression, often leading to inappropriate prescriptions of antidepressants in mixed states, and as a consequence, increasing the risk of manic switch and suicide. In order to better define the spectrum of mixed states, it may be useful to develop a dimensional approach. In this context, the MAThyS (Multidimensional Assessment of Thymic States) scale was built to assess activation/inhibition levels in all bipolar mood episodes, and to determine whether a clinical description in terms of activation/inhibition can help better define bipolar states with which both manic and depressive symptoms are associated. The aim of this paper is the validation of the MAThyS scale in 141 bipolar patients in acute states (manic, hypomanic, mixed, or depressive).
The validation of the MAThyS scale was the primary outcome of this 24-week, phase III, open-label, olanzapine single-arm clinical trial. Principal component, factorial analysis, and Cronbach's coefficient calculation (internal consistency) were performed. Concurrent validity (correlations with 17-item Hamilton Depression Rating Scale [HAMD-17], Hamilton Anxiety Rating Scale [HAMA], and Young Mania Rating Scale [YMRS]) and responsiveness to the clinical intervention were assessed (change in MAThyS scale and effect size) at 6 and 24 weeks.
Scree plot of eigenvalues identified a 2-dimension structure ("activation/inhibition level" and "emotional component"). Psychometric properties were good: Cronbach's coefficient was >0.9. Concurrent validity was good with low correlation (-0.19) with the HAMA scale and a higher correlation at baseline with the YMRS (0.72) and HAMD-17(-0.43). As expected, the activation state was predominant in manic, hypomanic, and mixed states while inhibition was predominant in depressive states. MAThyS score improvement was observed (effect size: -0.3 at 6 and 24 weeks).
The MAThyS demonstrated good psychometric properties. The MAThyS scale may help clinicians to better discriminate and follow bipolar episodes, especially the broad spectrum of mixed episodes.
ClinicalTrials.gov registration identification number: NCT#002592722.
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