ORIGINAL ARTICLES THE INTERFERENCE BETWEEN BIPOLAR PATHOLOGY AND PSYCHOSIS FROM ONSET AND ON THE LONG TERM - A COMPARATIVE STUDY 1 2 2 2 3 Miruna Milin, Anca Racolþa, Cristian Silvoºeanu, Radu Romoºan, Cristina Bredicean, 4 Mircea Lãzãrescu Abstract: Introduction: During the long term evolution of bipolar disorder, the interference of incongruent psychosis can manifest as a purely psychotic onset, sometimes followed by a few years of evolution with psychotic episodes, before the appearance of bipolar episodes or it can interfere constantly with affective episodes. Clinical practice shows that the frequency of this type of bipolar pathology is quite high compared to typical bipolar evolution. Objectives: The purpose of this research is to focus on how psychotic onset and constant interference of incongruent psychosis in the course of bipolar disorder, affects the long term prognosis of this pathology and the socioprofessional functioning of the patients. Methods: 42 patients were selected, currently diagnosed with bipolar disorder and with over 10 years of evolution. The cases were divided into three batches, with and without incongruent psychosis and retrospectively analysed from a clinical and socio-professional perspective. Results: The data analysis reveals that patients with psychotic onset have the earliest age at onset and the highest relapse rate, compared with bipolar patients with affective onset episode. Also, psychotic onset is more frequent in men. From the comparison of the present marital status of all the cases, we found a correlation between the earliest age at onset and the highest percent of single persons. Regarding the professional functioning, all patients with psychotic onset are presently unemployed, whereas approximately 1/3 of the bipolar patients with affective onset episode are still working. Conclusions: The results lead to the conclusion that there is a special category of bipolar patients, with psychotic onset, with or without a few years of evolution of this incongruent psychosis before the stability of bipolar affective episodes. These bipolar patients have an earlier onset, a worse long term prognosis and poorer social integration compared to patients with typical bipolar evolution. Keywords: Bipolar, onset, incongruent psychosis, prognosis, marital status, professional status. Rezumat: Introducere: În cadrul evoluþiei pe termen lung al patologiei bipolare, interferenþa cu simptomatologia psihotica se poate manifesta printr-un debut psihotic, care poate fi urmat de episoade psihotice câþiva ani pânã la apariþia episoadelor bipolare sau prin interferenþa constantã a delirului incongruent în cadrul episoadelor afective. Din experienþa clinicã remarcãm cã frecvenþa acestor cazuri este destul de mare faþã de cazurile cu o evoluþie tipic bipolarã. Obiective: Scopul acestei lucrãri este studierea mai amãnunþitã a modului în care debutul psihotic ºi interferenþa psihozei incongruente în cadrul patologiei bipolare, afecteazã prognosticul bolii pe termen lung ºi funcþionarea socio-profesionalã a pacienþilor. Metode: Au fost analizate retrospectiv 42 de cazuri, în prezent diagnosticate cu Tulburare Afectivã Bipolarã ºi cu minim 10 ani de evoluþie. Lotul a fost divizat în trei subloturi ºi s-au comparat parametrii clinico-evolutivi ºi statutul socio-profesional. Rezultate: Prelucrarea datelor aratã cã pacienþii cu debut psihotic au avut vârsta cea mai precoce de debut si numãrul cel mai mare de reinternãri pe termen lung, comparativ cu pacienþii cu evoluþie bipolarã de la debut. De asemenea, debutul cu psihozã este mai frecvent la bãrbaþi. Din analiza comparativã a statutului marital actual al pacienþilor, reiese cã în lotul cu cea mai precoce vârstã de debut existã numãrul cel mai mare de pacienþi necãsãtoriþi. Din perspectiva funcþionãrii profesionale, toþi pacienþii din lotul cu debut psihotic sunt în prezent pensionari de boalã, pe când aproximativ 1/3 dintre pacienþii cu evoluþie tipic bipolarã sunt încã în activitate. Concluzii: Rezultatele obþinute duc la concluzia cã existã o categorie aparte de pacienþi bipolari, cu debut psihotic, unii având o evoluþie de câþiva ani a psihozei pânã la stabilizarea simptomatologiei de tip bipolar. Aceºtia debuteazã mai precoce, au o evoluþie mai severã pe termen lung ºi o mai slabã funcþionare socio-profesionalã faþã de pacienþii cu evoluþie tipic bipolarã. Cuvinte cheie:. bipolar, debut, delir incongruent, evoluþie, statut marital, statut profesional 1 M.D. Psychiatry, Psychiatric Ambulatory, Timisoara, Romania. Correspondence: trandafirmiruna@yahoo.com, tel 0040745273551. 2 M.D. Psychiatry Resident, Psychiatric Clinic, Timisoara, Romania 3 M.D. Psychiatry, UMF Timisoara, Department of Psychiatry, Timisoara, Romania 4 Senior psychiatrist, MD, PhD, University Professor, UMF Timisoara, Department of Psychiatry, Timisoara, Romania Received July 23, 2011, Revised September 30, 2011, Accepted October 24, 2011. 185
Miruna Milin, Anca Racolþa, Cristian Silvoºeanu, Radu Romoºan, Cristina Bredicean, Mircea Lãzãrescu: The Interference Between Bipolar Pathology And Psychosis From Onset And On The Long Term - A Comparative Study INTRODUCTION A major topic of controversy nowadays is whether psychotic conditions should be classified as a few major conditions or as one continuous spectrum, challenging the Kraepelinian dichotomy. ( 1 ) Differentiating mania from schizophrenia or schizoaffective disorder is a diagnostic challenge often faced by clinicians. Acute symptoms like irritability, anger, paranoid delusions, thought disorder, and catatonic-like excitement cannot distinguish mania from schizophrenia. Because some symptoms can be similar in mania and schizophrenia, the clinician must pay equal attention to the clinical symptoms, level of premorbid functioning, family history, natural course and the character of prior episodes. ( 2 ) This differential diagnosis was partially clarified by the broadening of the criteria for mania to include a range of psychotic features. More than a quarter of patients with mania have classic Bleulerian symptoms of schizophrenia ( 3 ). In the past, some studies suggested that bipolar disorder was often misdiagnosed as schizophrenia, especially in The United States and in developing countries ( 4, 5 ). The introduction of DSM III brought more balance to this situation. The classification introduced by DSM IV and taken over by ICD-10 determined a more nuanced delimitation and interference, between the traditional endogenous psychoses. Thus, it is accepted that, in the long term evolution of bipolar disorder, psychotic features (congruent or incongruent) during manic or depressive episodes and sporadic schizoaffective episodes can appear, without changing the main diagnosis. Another topic of interest in international literature is the longitudinal study of acute and transient psychosis, which shows that they can evolve in multiple directions, including schizoaffective or purely affective episodes, taking the aspect of bipolar disorder. ( 6 ) Often, individuals initially placed in the category of brief psychotic disorder eventually present symptoms that allow a diagnosis of either bipolar illness or schizophrenia. ( 7 ) In particular, postpartum psychosis is highly associated with bipolar illness and may represent the first episode of the disorder (with manic episodes to follow) ( 8 ). The purpose of the present study is to assess how different patterns of onset and the interference of psychotic symptoms in bipolar disorder, affects the long term prognosis and the quality of life of these patients from a social and professional perspective. MATERIAL AND METHOD This research aims to study retrospectively the particularities of the onset and course of bipolar disorder which interferes with psychotic pathology, in patients with a long term evolution (over 10 years). The cases in this study have a stable diagnosis at present, because the diagnosis has a continuity of minimum 5 years. The bipolar patients who presented psychotic symptoms from the onsetor throughout their evolution were compared with bipolar patients without psychosis. The presence of first rank Schneiderian symptoms was accepted, as long as it did not change the diagnosis of bipolar disorder. The study included a number of 42 cases, who were selected from the Register of cases for endogenous psychosis which was started in 1985 in The Psychiatric Clinic of Timisoara and is still open as we speak. For the selection of these patients, no statistical methods were necessary. I took into consideration only the inclusion and exclusion criteria, referring exclusively to the cases which offered complete information. The data was collected from hospital charts and patient interviews carried during the year 2010. Inclusion criteria: 1.The patients are presently diagnosed with bipolar disorder according to ICD-10 criteria and the diagnosis has been stable for at least 5 years; 2.The onset age is between 18-65 years; 3.The patients have been under continuous observation, from onset until the present, in the psychiatric ambulatory system in Timisoara; 4.The subjects gave their consent to participate in this study Exclusion criteria: 1.The presence of organic pathology or mental retardation; 2.The presence of substance abuse. The cases were divided into three batches: -Batch A included 15 subjects who had a pure psychotic onset, with or without a few years of psychosis evolution, followed by affective episodes; -Batch B is made up of 14 subjects diagnosed with bipolar disorder from the first episode, but with the constant interference of incongruent psychotic features, during affective episodes; -Batch C comprises 13 bipolar patients without elements of psychosis. The analyzed parameters were: 1.Socio-demographic: gender, onset age, marital and professional status in the present; 2.Clinical and evolutional traits: clinical diagnosis at onset, at each relapse and in the present, the number of admittances in the hospital. The results were collected from hospital charts and the anamnesis of the patients in 2010 and processed in order to compare the age and type of onset, the long-term evolution and the socio-professional status of the three groups of patients. RESULTS The analyzed group is made up of 17 men and 25 women, with a period of evolution of the disease between 10 and 30 years. The average onset age in the subgroup A of bipolar patients with psychotic onset was 24, in comparison with the subgroup B of bipolar patients with mood-incongruent psychotic features, where the average onset age was 29, and with the subgroup C of bipolar patients without psychosis, where the average onset age was 3 (table 1). As type of onset episode (see fig. 1), in subgroup A of bipolar patients with psychotic onset, 2/3 of the cases had only one psychotic episode at onset, followed by a bipolar evolution and 1/3 of the cases presented a few years of evolution of this incongruent psychosis before the appearance of typical affective episodes. In the other two 186
Romanian Journal of Psychiatry, vol. XIII, No.4, 2011 interferences had a manic episode at onset and 83% of the bipolar patients without psychotic elements had a depressive episode at onset. Another interesting observation regarding the type of onset is that 76% of women in this study had an affective episode at onset and only a quarter of them had a psychotic onset, whereas, among men, more than a half of them (56%) had a psychotic episode at onset. Batch A B C Age at onset (years) 24 29 30 Men/Women 9> /6+ 3> /11+ 4> /8+ hallucinations in approximately half of the patients from subgroup A and B. Visual or kinaesthetic hallucinations during manic episodes were very rare. Regarding the pattern of evolution (see fig. 3), bipolar patients with incongruent psychotic symptoms had mostly manic episodes throughout their entire evolution, (73% in subgroup A and 58% in subgroup B), which leads me to the conclusion that incongruent psychosis appears more frequently in manic episodes. The pattern of evolution I took into consideration was predominantly manic or depressive, as long as more than a half of the episodes were of the same type. Table 1. Average age at onset and distribution by gender of the batches Figure 1. Type of onset episode After analyzing the long term evolution of all the cases, the results showed that patients with psychotic onset (subgroup A) had the most severe evolution, with an average of 1 hospital admittance /year, worse than patients from subgroup B, which had an average of 0.7 hospital admittances/year, and patients from subgroup C, with an average of 0.55 admittances/year (fig. 2). Figure 3. Pattern of evolution Figure 2. Average number of admissions per year The most frequent incongruent psychotic symptoms encountered were paranoid delusions, especially during manic episodes. The first rank Schneiderian symptoms appeared sporadically in approximately 1/3 of the patients from the entire batch, mostly during schizophrenic or brief psychotic episodes at the onset, or during manic or schizoaffective episodes. Among symptoms that are more common in schizophrenia, the most frequent occurrence is that of the thought control syndrome, in 2/3 of the cases from subgroup A and 1/3 of the patients in subgroup B. In addition, I noticed the occasional presence of auditory From the analysis of the present marital status of all the patients (see fig. 4), a correlation with the onset age can be noticed, meaning that the group of patients with the earliest onset age (24 years) contains the highest percentage of single persons (approximately 30% ). In comparison, in patients with a later onset (30 years), in subgroup B and C, the percentages of unmarried persons are lower (22% and 15%) From the occupational point of view (see fig. 5), all the patients in batch A with psychotic onset are currently unemployed due to their illness, unlike patients in subgroup B and C, where 30% and 39% are now professionally active. DISCUSSIONS Although it is unanimously accepted that the interference of incongruent psychotic symptoms is frequently encountered during the course of bipolar disorder, nowadays there are few studies that focus on 187
Miruna Milin, Anca Racolþa, Cristian Silvoºeanu, Radu Romoºan, Cristina Bredicean, Mircea Lãzãrescu: The Interference Between Bipolar Pathology And Psychosis From Onset And On The Long Term - A Comparative Study how the presence of these symptoms affects the longterm evolution of this pathology. Figure 4. Marital status Figure 5. Professional status The interference of incongruent psychosis with affective pathology can manifest itself from the onset, which can be a purely psychotic episode and sometimes with the continuity of this psychotic pathology (even with a diagnosis of schizophrenia), for a few years, until the appearance and continuity of affective episodes. More often, it manifests through a constant interference of incongruent psychotic symptoms during manic or depressive episodes. The average onset age of this disease is between 20 and 30 years and it is earlier in patients with a psychotic onset. In terms of the long-term evolution of the disease from a longitudinal perspective, the results that were obtained are very similar with the data from international literature, especially the fact that early onset age and the presence of incongruent psychotic symptoms represent risk factors for a worse prognosis, determining a higher relapse rate and a poorer social and professional functioning. ( 9 ) Also, a different clinical subclass of bipolar disorder is distinguished, that is characterized by a psychotic onset (acute or schizophrenia-like), which can be followed by a few years of evolution with only psychotic episodes, before the appearance of affective episodes. This type of pathology seems to have the earliest onset age and the worst prognosis in terms of clinical evolution and socio-professional status. Another subject of great interest is the social integration of mentally ill patients. A big component of social inclusion is given by the marital and professional status. Epidemiologic studies investigating marital status among bipolar patients have revealed that the disorder is slightly more common among single and divorced or separated persons ( 10 ). The early onset of the illness may be an important factor that contributes to the single status, negatively influencing personality development and thus causing difficulties in establishing and maintaining relationships. As Krauthammer and Klerman ( 11 ) pointed out, marital status may change as a result of the disorder, rather than leading to its onset. Still, it is likely that stressful marriages, as well as being single or divorced may be a risk factor for affective episodes. Currently, there is no evidence to support a causal relationship between the disorder and marital status. A correlation between the onset age and the professional status can be noticed, thus patients with the earliest onset (in subgroup A) are all inactive professionally, while in subgroups B and C patients had a later onset (around 30 years), one third of them are still professionally active. This correlation can be due to the stigma related to mental illnesses, the family's excessive protection, the more severe long-term evolution or the cognitive dysfunctions caused by the frequent relapses or to medication. The development of the concept of malady spectrum brought up discussions about the interference between schizophrenic spectrum and bipolar spectrum and not only between schizophrenia and bipolar disorder. In the end, all of these lead to the much debated hypothesis of the psychotic continuum and raises the necessity for a more detailed study of the interference between bipolar disorder and incongruent psychosis. CONCLUSIONS In the context of bipolar pathology stands out a clinical subclass that interferes with paranoid delusion. The interference between bipolar disorder and incongruent psychosis can manifest itself in two ways: with a purely psychotic onset and in some cases with the continuity of this pathology in the first years of evolution, or with a constant interference of this psychosis with affective pathology. The onset of the disorder is earlier in patients who have a first psychotic episode. As particular aspects of the onset, bipolar patients with constant psychotic interferences have 188
Romanian Journal of Psychiatry, vol. XIII, No.4, 2011 mostly manic episodes at onset and psychotic onset is more frequent in men. Bipolar patients with a psychotic onset have a more severe long-term evolution, with a higher rate of relapses and hospital admittances. From a clinical perspective in these patients, psychotic symptoms appear more frequently during manic episodes and seldom during depressive episodes. Also, thought control and auditory hallucinations appear especially during schizoaffective episodes and in brief or schizophrenia-like psychotic episodes at onset. Schizoaffective episodes are only sporadic in 1/3 of all cases, in-between typical bipolar episodes. Bipolar patients with psychotic onset have on the long term, a poorer social integration, regarding marital and professional status, which can be correlated with the earlier onset age and the more severe evolution of the illness. REFERNCES 1.Marneros A, Andreasen N C, Tsuang M T (Eds). Psychotic Continuum. Berlin: Springer Verlag, 1995, 243-246. 2.Frederick K Goodwin and Kay Redfield Jamison: Manic-Depressive Illness. Bipolar Disorder and Recurrent Depression. London: Oxford University Press, 2007, 102-103. 3.Pope H G Jr and Lipinski J S Jr. Diagnosis in schizophrenia and manicdepressive illness. A reassessment of the specificity of schizophrenic symptoms in light of current research. Arch Gen Psychiatry 1978; 46: 353-358. 4.Vieta E and Salva J. Diagnostico diferencial de los trastornos bipolares. In: Vieta E and Gasto C (eds). Trastornos bipolares. Barcelona:Springer- Verlag, 1997,175-193. 5.Ghaemi SN, Sachs GS, Chiou AM, Panduragi AK and Goodwin FK. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disorder 1999; 52:135-144. 6.Stoica I. Prodromul in primul episod de psihoza. Bucuresti: Info Medica, 2008, 34-35. 7.Marneros A, Akiskal HS. The overlap of affective and schizophrenic spectra. London: Cambridge University Press, 2007, 182-202. 8.Viguera AC, Cohen LS. The course and management of bipolar disorder during pregnancy. Psychopharmacologic Bull 1998; 34(3)339-346. 9.Yurgelun-Todd D. Psychosis in Bipolar Disorder. In: Fujii D, Ahmed I (Eds). The Spectrum of Psychotic Disorders. London: Cambridge Univ. Press, 2007, 137-155. 10.Szadoczky E, Papp ZS, Vitrai J, Rihmer Z and Furedi J. The prevalence of major depressive and bipolar disorders in Hungary: Results from a national epidemiologic survey. J Affect Disord 1998; 50:153-162. 11.Krauthammer C and Klerman GL. The epidemiology of mania. In: B Shopsin (Ed). Manic Illness. New York: Raven Press, 1979, 11-28. 189