Putative clinical subtypes of social phobia: a factor-analytical study.

OBJECTIVE: To examine symptomatological subtypes of social phobia (SP) and their relationships with a number of feared situations and avoidant personality disorder (APD). METHOD: In 153 out-patients with SP according to DSM-III-R criteria, clinical subtypes were investigated by means of principal component factor analysis of the Liebowitz Social Anxiety Scale (LSAS). We compared the various SP subtypes on the basis of the highest Z-scores obtained on each LSAS factor. RESULTS: Five factors (interpersonal anxiety, formal speaking anxiety, stranger-authority anxiety, eating and drinking while being observed, anxiety of doing something while being observed) emerged, accounting for 64.7% of the total variance. When the dominant LSAS factor groups were compared, the highest values in the numbers of feared situations and the presence of APD were observed in the "interpersonal anxiety" dominant group and the lowest in the "anxiety of doing something while being observed". The "interpersonal anxiety" dominant group was the most likely to present a positive family history for SP and a lifetime comorbidity with mood disorders. CONCLUSION: The emerging multidimensional structure of phobia is congruent with, and further enriches, the existing literature.

Is mood-incongruent manic psychosis a distinct subtype?

BACKGROUND: Despite several research reports on incongruent psychotic features in mania, whether such features define a distinct disorder is unsettled. METHOD: One hundred and fifty-five inpatients with mania according to DSM-III-R were systematically evaluated in order to collect demographic and clinical information. The symptomatological evaluation was conducted by means of the Comprehensive Psychopathological Rating Scale (CPRS) and the Scale for the Assessment of Positive Symptoms (SAPS). The presence/absence of incongruent psychotic symptoms at the index episode defined two subgroups of patients, whose familial, symptomatological, clinical and course characteristics were compared. RESULTS: Eighty-six (55.5%) patients presented mood-incongruent psychotic features (MIP+). When this group was compared with the remainder of manic patients without such features (MIP-), we found substantial similarities in most demographic, familial and clinical characteristics. Despite these fundamental similarities, 4% of MIP+ vs 0% of MIP- had family history for schizophrenia (p < 0.05). We also observed a longer duration of the current episode, a higher percentage of chronic course, more suicide attempts and hospitalisations in MIP+. Moreover, other than psychotic symptoms, MIP+ showed more frequently depressive features and hostility. They also reported higher scores in social disability, especially in family and social settings. CONCLUSION: Although our findings suggest that incongruent psychotic features in the main do not distinguish two separate entities--and can be considered as hallmarks of overall severity of mania--in a small minority of cases such features appear linked to familial schizophrenia. The numerous overlapping clinical characteristics in MIP+ and MIP- raise questions about the general nosographic utility of this categorisation.

The contrasting influence of depressive and hyperthymic temperaments on psychometrically derived manic subtypes.

The present investigation focused on symptomatological subtypes of mania and their relationships with affective temperaments and other clinical features of bipolar disorder. In 153 inpatients with mania diagnosed according to DSM-III-R, symptomatological subtypes have been investigated by means of principal component factor analysis of 18 selected items of the Comprehensive Psychopathological Rating Scale (CPRS). We compared other clinical features, depressive and hyperthymic temperamental attributes, and first degree-family history for mood disorders among the various manic subtypes on the basis of the highest z-scores obtained on each CPRS factor (dominant CPRS factor groups). Five factors--Depressive, Irritable-Agitated, Euphoric-Grandiose, Accelerated-Sleepless, Paranoid-Anxious--emerged, accounting for 59.8% of the total variance. When the factor-based groups were compared, significant differences emerged in terms of the duration of the current episodes, rates of chronicity and incongruent psychotic features--being highest in the 'Depressive' and 'Paranoid-Anxious' dominant groups. The patients with highest z-scores for the 'Euphoric-Grandiose', 'Paranoid-Anxious' and 'Accelerated-Sleepless' factors were those most likely to belong to the hyperthymic temperament, while the 'Depressive' dominant group had the highest rate of depressive temperament. Finally, it is noteworthy that the 'Irritable-Agitated' group was high for both temperaments. The foregoing multidimensional structure of mania--revealing five factors--is generally concordant with the emerging literature. Consistently with our original hypothesis, a hyperthymic temperament seems to underlie the most extreme manic excitement with euphoric-accelerated-paranoid phenomenology. By contrast, the depressive temperament seemed to mute the expression of mania into a depressive-manic phenomenology.

Clinical characterization of depressive mixed state in bipolar-I patients: Pisa-San Diego collaboration.

BACKGROUND: Although mixed states were classically described as various concomitant admixtures of depression and mania, the official current definitions in both DSM-IV and ICD-10 tend to restrict the concept to manic patients with full syndromal depression. Recent research has actually shown that mania with few depressive symptoms constitutes the most prevalent clinical presentation of mixed or dysphoric mania. Major depressive patients with few concomitant manic symptoms are not officially recognized within the current nosology. In this paper we attempt to delineate the clinical profile of such depressive mixed states in the context of bipolar I disorder. METHODS: In the Pisa day center, we studied 195 bipolar I patients who either met Pisa criteria for bipolar mixed state (n=159) or DSM-III-R criteria for major depressive episode (bipolar major depression or B-MD, n=36). Of the 159 patients identified by Pisa criteria as mixed state, 86 also met the criteria of the DSM-III-R for mixed episode (core mixed state or MS group), while 32 met the DSM III-R criteria for major depressive episode (provisionally defined as depressive mixed states, D-MS); the remaining patients (n=41, 25.7%) with predominatly manic picture were not included in the present comparisons. RESULTS: The three groups (B-MD, MS and D-MS) had close similarities in clinical and sociodemographic characteristics such as age, sex distribution, marital status, schooling, residence, age at onset, age of first treatment, age of first hospitalization, degree of chronicity of the index episode, stressor within the 6 months before the index episode, lifetime suicide attempts and premorbid temperament. First degree family history for bipolar illness and that for other mental disorders was also similar, except for major depression that was more common among the relatives of D-MS. MS and D-MS were further distinguished from B-MD by the fact that the latter followed a more 'cyclic' course with shorter yet greater number of episodes, and which began with a pure depressive episode; by contrast, MS and D-MS had fewer episodes of longer duration, less interepisodic remission, and tended to begin with a mixed episode. Incongruous psychotic features were more common in the two mixed groups compared to B-MD, and the most common features of the D-MS group were agitation, psychotic depression with irritable mood, pressured speech and/or flight of ideas. LIMITATION: It was not feasible to collect information blind to clinical status in patients with severe psychotic mood states. CONCLUSION: These data confirm the existence of psychotic agitated depressive mixed states with flight of ideas, distinct from cyclic retarded pure bipolar depressive states. The recognition of these affective states is clinically important to protect patients from the potentially harmful indiscriminate use of antidepressants and to provide them with the benefits of an anticonvulsant, a short-term neuroleptic, or ECT.

Polarity of the first episode, clinical characteristics, and course of manic depressive illness: a systematic retrospective investigation of 320 bipolar I patients.

In 320 patients with established bipolar I disorder, we examined the past course on the basis of polarity at onset (depressive, mixed, and manic). Despite the obvious limitations of retrospective methodology, information on course parameters in a large sample of affective disorders is most practically obtained by such methodology. We believe that our systematic interview of patients and their relatives--as well as the systematic study of their records--minimized potential biases. Depressive onsets were the most common, accounting for 50%, followed by mixed and manic onsets in about equal proportion. In general, the polarity of episodes over time reflected polarity at onset. Those with depressive onset had significantly higher levels of rapid cycling, as well as suicide attempts, but were significantly less likely to develop psychotic symptoms. Mixed onsets, too, had high rates of suicide attempts, but differed from depressive onsets in having significantly more chronicity yet negligible rates of rapid cycling at follow-up evaluation. Because cases with depressive onset had received significantly higher rates of psychopharmacologic treatment, our data are compatible with the hypothesis that antidepressants may play a role in the induction of rapid cycling. Overall, our data support the existence of distinct longitudinal patterns within bipolar I disorder, which in turn appear correlated with the polarity at onset. In particular, rapid cycling and mixed states emerge as distinct psychopathologic processes.

Chronic mania. Family history, prior course, clinical picture and social consequences.

BACKGROUND: Mania with chronic course has been overlooked in the recent literature. Our aim was clinically to characterise and validate this form of mania. METHOD: We evaluated 155 people with DSM-III-R mania and assessed their family history, temperament, symptomatology and course. We used a semi-structured interview for mood disorders, as well as the Comprehensive Psychopathological Rating Scale and the Scale for the Assessment of Positive Symptoms. RESULTS: Twenty (13%) had a chronic course arising from a background of hyperthymic temperament and recurrent mania, with a deteriorative pattern. Clinically, they were characterised by a significantly high rate of almost constant euphoria, grandiose delusions and related delusions, but had relatively low rates of sleep disturbance, psychomotor agitation and hypersexuality. CONCLUSION: Even with current therapies a significant number of people with bipolar disorders have a deteriorative outcome associated with the gradual disappearance of acute mania with an increase in megalomanic delusions, alienation from loved ones and decreased likelihood of medical and psychiatric care.