Case-series Evaluating a Transdiagnostic Cognitive-behavioral Treatment For Co-occurring Anxiety Disorders.

Background. Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioral interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating cooccurring anxiety disorders. Aims. To evaluate the efficacy of a transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders. Methods. An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13 session modular transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD. Results. Five of the six participants completed treatment. At post-treatment assessment the five treatment completers achieved diagnostic and symptomatic change with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the three-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre- to post-intervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at three-month follow-up. Conclusions. Results suggest that transdiagnostic cognitive behavioral interventions can be of benefit to patients with co-occurring anxiety disorders.

Affective Instability, Childhood Trauma and Major Affective Disorders

BACKGROUND: Affective instability (AI), childhood trauma, and mental illness are linked, but evidence in affective disorders is limited, despite both AI and childhood trauma being associated with poorer outcomes. Aims were to compare AI levels in bipolar disorder I (BPI) and II (BPII), and major depressive disorder recurrent (MDDR), and to examine the association of AI and childhood trauma within each diagnostic group. METHODS: AI, measured using the Affective Lability Scale (ALS), was compared between people with DSM-IV BPI (n=923), BPII (n=363) and MDDR (n=207) accounting for confounders and current mood. Regression modelling was used to examine the association between AI and childhood traumas in each diagnostic group. RESULTS: ALS scores in descending order were BPII, BPI, MDDR, and differences between groups were significant (p<0.05). Within the BPI group any childhood abuse (p=0.021), childhood physical abuse (p=0.003) and the death of a close friend in childhood (p=0.002) were significantly associated with higher ALS score but no association was found between childhood trauma and AI in BPII and MDDR. LIMITATIONS: The ALS is a self-report scale and is subject to retrospective recall bias. CONCLUSIONS: AI is an important dimension in bipolar disorder independent of current mood state. There is a strong link between childhood traumatic events and AI levels in BPI and this may be one way in which exposure and disorder are linked. Clinical interventions targeting AI in people who have suffered significant childhood trauma could potentially change the clinical course of bipolar disorder.

Adverse Childhood Life Events and Postpartum Psychosis in Bipolar Disorder

Background Women with bipolar disorder are at increased risk of postpartum psychosis. Adverse childhood life events have been associated with depression in the postpartum period, but have been little studied in relation to postpartum psychosis. In this study we investigated whether adverse childhood life events are associated with postpartum psychosis in a large sample of women with bipolar I disorder. Methods Participants were 432 parous women with DSM-IV bipolar I disorder recruited into the Bipolar Disorder Research Network (www.BDRN.org). Diagnoses and lifetime psychopathology, including perinatal episodes, were obtained via a semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry; Wing et al., 1990) and case-notes. Adverse childhood life events were assessed via self-report and case-notes, and compared between women with postpartum psychosis (n=208) and those without a lifetime history of perinatal mood episodes (n=224). Results There was no significant difference in the rate of any adverse childhood life event, including childhood sexual abuse, or in the total number of adverse childhood life events between women who experienced postpartum psychosis and those without a lifetime history of perinatal mood episodes, even after controlling for demographic and clinical differences between the groups. Limitations Adverse childhood life events were assessed in adulthood and therefore may be subject to recall errors. Conclusions We found no evidence for an association between adverse childhood life events and the occurrence of postpartum psychosis. Our data suggest that, unlike postpartum depression, childhood adversity does not play a significant role in the triggering of postpartum psychosis in women with bipolar disorder.

Comorbid Migraine in Major Depressive Disorder Suggests a Subgroup Related to Bipolar Disorder

Aims: Previous small-scale studies suggest presence of migraine in major depressive disorder (MDD) is associated with specific clinical characteristics that may overlap with those of bipolar disorder. We aimed to compare a broad range of characteristics in participants who have MDD with and without migraine, and to explore possible similarities between those characteristics associated with the presence of migraine in MDD and those in bipolar disorder in a large UK sample. Methods: Lifetime and episodic clinical characteristics and affective temperaments in DSM-IV MDD with (n=134) and without (n=218) migraine were compared. Characteristics associated with the presence of migraine were then compared with a sample of participants with DSM-IV bipolar disorder (n=407). All participants were recruited into the Bipolar Disorder Research Network (www.bdrn.org). Results: The presence of migraine in MDD was associated with female gender (76.9% vs 56.9%, p<0.001), younger age of onset (23 vs 27 years, p=0.002), history of attempted suicide (38.3% vs 22.7%, p=0.002), and more panic/agoraphobia symptomatology (6 vs 4, p<0.001). Female gender (OR=2.44, p=0.006) and younger age of onset (OR=0.97, p=0.013) remained significant in a multivariate model. These clinical characteristics were not significantly different to those of our participants with bipolar disorder. Conclusions: The presence of migraine in MDD delineates a subgroup of individuals with a more severe illness course. The clinical presentation of this subgroup more closely resembles that of bipolar disorder than that of MDD without migraine. The presence of migraine in major depression may be a marker of a specific subgroup that could be useful in future research.

History of Premenstrual Mood Change and Postpartum Episodes are Associated with Perimenopausal Episodes in Women with Bipolar Disorder

Background and Aims: Reproductive life events are potential triggers of mood episodes in women with bipolar disorder. We aimed to establish whether a history of premenstrual mood change and postpartum episodes are associated with perimenopausal episodes in women who have bipolar disorder. Methods: Participants were 339 post-menopausal women with DSM-IV bipolar disorder recruited into the Bipolar Disorder Research Network (www.bdrn.org). Women self-reported presence (N = 200) or absence (N = 139) of an illness episode during the perimenopausal period. History of premenstrual mood change was measured using the self-report Premenstrual Symptoms Screening Tool (PSST), and history of postpartum episodes was measured via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry, SCAN) and inspection of case-notes. Results: History of a postpartum episode within 6 months of delivery (OR = 2.13, p = 0.03) and history of moderate/severe premenstrual syndrome (OR = 6.33, p < 0.001) were significant predictors of the presence of a perimenopausal episode, even after controlling for demographic factors. When we narrowed the definition of premenstrual mood change to premenstrual dysphoric disorder, it remained significant (OR = 2.68, p = 0.007). Conclusions: Some women who have bipolar disorder may be particularly sensitive to reproductive life events. Previous mood episodes in relation to the female reproductive lifecycle may help clinicians predict individual risk for women with bipolar disorder approaching the menopause. There is a need for prospective longitudinal studies of women with bipolar disorder providing frequent contemporaneous ratings of their mood to overcome the limitations of retrospective self-report data.

Identifying Risk Factors for Postpartum Mood Episodes in Bipolar Disorder – A UK Prospective Study

Background and Aims: Women with bipolar disorder are vulnerable to episodes postpartum, but risk factors are poorly understood. We are exploring risk factors for postpartum mood episodes in women with bipolar disorder using a prospective longitudinal design. Methods: Pregnant women with lifetime DSM-IV bipolar disorder are being recruited into the Bipolar Disorder Research Network (www.BDRN.org). Baseline assessments during late pregnancy include lifetime psychopathology and potential risk factors for perinatal episodes such as medication use, sleep, obstetric factors, and psychosocial factors. Blood samples are taken for genetic analysis. Perinatal psychopathology is assessed via follow-up interview at 12-weeks postpartum. Interview data are supplemented by clinician questionnaires and case-note review. Potential risk factors will be compared between women who experience perinatal episodes and those who remain well. Results: 80 participants have been recruited to date. 32/61 (52%) women had a perinatal recurrence by follow-up. 16 (26%) had onset in pregnancy. 21 (34%) had postpartum onset, 19 (90%) within 6-weeks of delivery: 11 (18%) postpartum psychosis, 5 (8%) postpartum hypomania, 5 (8%) postpartum depression. Postpartum relapse was more frequent in women with bipolar-I than bipolar-II disorder (45% vs 17%). 62% women with postpartum relapse took prophylactic medication peripartum and almost all received care from secondary psychiatric services (95%). Conclusions: Rate of postpartum relapse is high, despite most women receiving specialist care and medication perinatally. A larger sample size will allow us to examine potential risk factors for postpartum episodes, which will assist in providing accurate and personalised advice to women with bipolar disorder who are considering pregnancy.

Postpartum Psychosis in Bipolar Disorder: No Association with Personality, Cognitive Style and Temperament

Background and Aims: Bipolar disorder has been associated with a number of personality traits, cognitive styles and affective temperaments. Women who have bipolar disorder are at increased risk of experiencing postpartum psychosis, however no previous research has investigated these traits in relationship to postpartum episodes. Our aim was to establish whether aspects of personality, cognitive style and affective temperament, that have been associated with bipolar disorder, confer vulnerability to postpartum psychosis over and above their known association with bipolar disorder. Methods: Participants were 552 parous women with DSM-IV bipolar I disorder recruited into the Bipolar Disorder Research Network (www.bdrn.org). Postpartum psychosis group: lifetime episode of postpartum psychosis within 6 weeks of delivery (N = 284). Non-postpartum psychosis group: no history of any perinatal mood episodes (N = 268). Bipolar disorder-associated personality traits (neuroticism, extraversion, schizotypy and impulsivity), cognitive styles (low self-esteem and dysfunctional attitudes) and affective temperaments were measured using well validated self-report questionnaire measures. Results: After controlling for key demographic, clinical and pregnancy-related variables, and measures of current mood state, there were no statistically significant differences between the postpartum psychosis group and non-postpartum psychosis group on any of the personality, cognitive style or affective temperament measures. Conclusions: Personality traits, cognitive styles and affective temperaments associated with the bipolar disorder diathesis in general were not associated with the onset of postpartum psychosis specifically. We have found no evidence that these traits should play a key role when evaluating risk of postpartum psychosis in women with bipolar I disorder considering pregnancy.

The Influence of Borderline Personality Traits on the Course of Bipolar Disorder

Background and Aims: Bipolar disorder and borderline personality disorder are commonly comorbid. Borderline personality disorder is diagnosed categorically, but personality pathology may be better characterised dimensionally. The impact of borderline personality traits (not diagnosis) on the course of bipolar disorder is unknown. We examined the presence and severity of borderline personality traits in a large UK sample of bipolar disorder, and the impact of these traits on illness course. Methods: Borderline Evaluation of Severity over Time (BEST) was used to measure presence and severity of borderline traits in 1447 individuals with DSM-IV bipolar I disorder (n = 1008) and bipolar II disorder (n = 439) recruited into the Bipolar Disorder Research Network (www.bdrn.org). Clinical course was measured via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry) and case-notes. Results: BEST score was higher in bipolar II than bipolar I (36 v 27, p < 0.001) and 9/12 individual BEST traits were significantly more common in bipolar II than bipolar I. Within both bipolar I and bipolar II higher BEST score was associated with younger age of bipolar onset (p < 0.001), history of alcohol misuse (p < 0.010), and history of suicide attempt (p < 0.001). Conclusions: Borderline personality traits are common in bipolar disorder, and more severe in bipolar II than bipolar I disorder. Borderline trait severity was associated with more severe bipolar illness course; younger age of onset, alcohol misuse and suicidal behaviour. Clinicians should be vigilant for borderline personality traits irrespective of whether criteria for diagnosis are met, particularly in those with bipolar II disorder and younger age of bipolar onset.

Affective Instability, Childhood Trauma and Major Affective Disorders

Background and Aims Affective instability (AI), childhood trauma, and mental illness are linked, but evidence in affective disorders is limited, despite both AI and childhood trauma being associated with poorer outcomes. Aims were to compare AI levels in bipolar disorder I (BPI) and II (BPII), and major depressive disorder recurrent (MDDR), and to examine the association of AI and childhood trauma within each diagnostic group. Methods AI, measured using the Affective Lability Scale (ALS), was compared between people with DSM-IV BPI (n = 923), BPII (n = 363) and MDDR (n = 207) accounting for confounders and current mood. Regression modelling was used to examine the association between AI and childhood traumas in each diagnostic group. Results ALS scores in descending order were BPII, BPI, MDDR, and differences between groups were significant (p < 0.05). Within the BPI group any childhood abuse (p = 0.021), childhood physical abuse (p = 0.003) and the death of a close friend in childhood (p = 0.002) were significantly associated with higher ALS score but no association was found between childhood trauma and AI in BPII and MDDR. Conclusions AI is an important dimension in bipolar disorder independent of current mood state. There is a strong link between childhood traumatic events and AI levels in BPI and this may be one way in which exposure and disorder are linked. Clinical interventions targeting AI in people who have suffered significant childhood trauma could potentially change the clinical course of bipolar disorder.

Improving the Psychometric Utility of the Hypomania Checklist (HCL-32): a Rasch Analysis Approach

Background The HCL-32 is a widely-used screening questionnaire for hypomania. We aimed to use a Rasch analysis approach to (i) evaluate the measurement properties, principally unidimensionality, of the HCL-32, and (ii) generate a score table to allow researchers to convert raw HCL-32 scores into an interval-level measurement which will be more appropriate for statistical analyses. Methods Subjects were part of the Bipolar Disorder Research Network (BDRN) study with DSM-IV bipolar disorder (n=389). Multidimensionality was assessed using the Rasch fit statistics and principle components analysis of the residuals (PCA). Item invariance (differential item functioning, DIF) was tested for gender, bipolar diagnosis and current mental state. Item estimates and reliabilities were calculated. Results Three items (29, 30, 32) had unacceptable fit to the Rasch unidimensional model. Item 14 displayed significant DIF for gender and items 8 and 17 for current mental state. Item estimates confirmed that not all items measure hypomania equally. Limitations This sample was recruited as part of a large ongoing genetic epidemiology study of bipolar disorder and may not be fully representative of the broader clinical population of individuals with bipolar disorder. Conclusion The HCL-32 is unidimensional in practice, but measurements may be further strengthened by the removal of four items. Re-scored linear measurements may be more appropriate for clinical research.