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A clinical study on recurrent ma

A clinical study on recurrent mania: relation with body built and family history of mood disorder

Soumitra Ghosh*, Shyamanta Das,**  Maheshwar Nath Tripathi***, Jai Singh Yadav, ****.

*Associate Professor, Department of Psychiatry, Silchar Medical College Hospital, Silchar

**Assistant Professor, Department of Psychiatry, Fakhruddin Ali Ahmed Medical College Hospital, Barpeta

***Senior Resident, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi

****Assistant Professor, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi


Abstract


Background: Although recurrent manic episodes is rare, but in our clinical practice we have found that recurrent mania is much more common. And it was our observation that those who come with recurrent mania are more asthenic or ectomorphic body built whereas bipolar patients are more of pyknic or endomorphic in their body built. Bipolar group and/or endomorphic body built patients has more positive family history of mood disorder whereas recurrent manic group and/or ectomorphic body built patients has less positive family history of mood disorder.

Aims: With the above background we aimed to study on recurrent mania and its relation with body built and family history of mood disorder.

Method: This study was conducted at the Psychiatry Departments of a tertiary care centre. A diagnosis of manic-depressive psychosis (MDP)-manic and bipolar disorder was arrived at using the DSM-III-R9 criteria as DSM-IV was not published by that time. Body built was noted clinically as per Sheldon’s10 classification into ectomorphic, mesomorphic and endomorphic. Apart from descriptive statistics, Fisher’s exact and chi-squared tests were used to analyze the data.

Results: Fifty recurrent mania patients and equal number of bipolar disorder patients were taken for the study. Mean age for recurrent mania was 36.4 years and for bipolar patients was 41.1 years. Amongst the recurrent mania group, 8% (n=4) had endomorphic built, 28% (n=14) mesomorphic built and 64% (n=32) ectomorphic built. Whereas in bipolar group of patients, 78% (n=39) had endomorphic built, 10% (n=5) mesomorphic built and 12% (n=6) ectomorphic built. This difference in body built was found to be statistically significant (P<0.0001). When family history of mood disorder was compared between the groups, amongst recurrent mania group, 10% (n=5) had positive family history whereas in bipolar disorder group, 14 (28%) had family history of mood disorder. An attempt has made to compare different body built of both groups with family history. This finding was statistically considered to be very significant (P=0.0061).

Conclusion: In our present study, we found 64% (n=32) with ectomorphic body built amongst 50 cases of recurrent mania group and 78% (n=39) had endomorphic body built amongst 50 cases of bipolar disorder group. Next, family history was found more in bipolar disorder group than recurrent mania group.


Introduction


Unipolar mania is still a subject of debate for which the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 1 has not given any separate category but put them under bipolar mood disorder (bipolar I & II) not otherwise specified (NOS). Although the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD 10)2 has classified recurrent mania under other bipolar affective disorder (F31.8), there is reports3-5 of patients who seem to suffer from only recurrent manic episodes. According to Perris6 this type is rare and having occurred in only seventeen cases (1.1%) in total of 1539 patients. Venkoba Rao et al.7 noted that three (2.7%) out of 108 lithium clinic patients had recurrent manic episodes. Similar observations have been recorded by other investigators in India also.8

But in our clinical practice we have found that recurrent mania is much more common than that stated above. And it was our observation that those who come with recurrent mania are more asthenic or ectomorphic body built whereas bipolar patients (i.e. having both mania and depression) are more of pyknic or endomorphic in their body built. Bipolar group and/or endomorphic body built patients has more positive family history of mood disorder whereas recurrent manic group and/or ectomorphic body built patients has less positive family history of mood disorder.

So with this observation a prospective study was undertaken for a period of three years, because if this is true then we can predict beforehand over true unipolar mania and thus the treatment strategy would be different for them than the bipolar group.

Method:

This study was conducted at the Psychiatry Departments of Assam Medical College and V.G. Hospital, Dibrugarh. For this study sample were taken from inpatients and outpatients during October 1993 to August 1996. A diagnosis of manic-depressive psychosis (MDP)-manic and bipolar disorder was arrived at using the DSM-III-R9 criteria as DSM-IV was not published by that time. Diagnosis was confirmed by two psychiatrists in order to be included for the study. A thorough scrutiny was made in each case individually both from the patient during their recovery period and the reliable attendant in order to determine the exact nature of illness, family history and socio-demographic variables.

Diagnostic criteria: Recurrent mania was diagnosed when the patient had three or more episodes of mania with no history or evidence of depression in between. Bipolar disorder patients were those who had history or evidence of one or more episodes of mania and depression fulfilling DSM-III-R9 criteria.

Exclusion criteria: Patients with history of organic brain disease or substance abuse as primary diagnosis were not included in the study. Rapid cyclers and cyclothymia were also excluded from the study. Every precaution was taken to diagnose recurrent mania and in cases of doubtful depressive episodes in those patients, they were not included in the study. Family history of mood disorders was noted from the family members as well as patient. In cases of doubtful diagnosis of psychosis it was noted as negative.

Body built was ascertained clinically by two psychiatrists and commonalities of both were taken into consideration. Body built was noted clinically as per Sheldon’s10 classification into ectomorphic, mesomorphic and endomorphic.

Apart from descriptive statistics, Fisher’s exact and chi-squared tests were used to analyze the data.

Result

Fifty recurrent mania patients and equal number of bipolar disorder patients were taken for the study. Their socio-demographic variables were given in table 1. Mean age for recurrent mania was 36.4 years and for bipolar patients was 41.1 years.

Table1. Socio demographic variables

Variables

Recurrent mania
N (%)

Bipolar disorder
N (%)

Fisher’s exact*/
Chi-squared tests

Gender

     Male

     Female

 

35 (70)

15 (30)

 

34 (68)

16 (32)

 

P=1.000*

Age (in years)

     10—20

     21—30

     31—40

     41—50

     51—60

     61—70

 

3 (6)

14 (28)

16 (32)

13 (26)

3 (6)

1 (2)

 

1 (2)

8 (16)

16 (32)

14 (28)

8 (16)

3 (6)

P=0.3115

Community

     Assamese

     Bengali

     Nepali

     Bihari

     Marwari

     Others    

 

25 (50)

10 (20)

5 (10)

6 (12)

3 (6)

1 (2)

 

20 (40)

10 (20)

3 (6)

5 (10)

9 (18)

3 (6)

P=0.3983

 

Amongst the recurrent mania group, four (8%) had endomorphic built, 14 (28%) mesomorphic built and 32 (64%) ectomorphic built. Whereas in bipolar group of patients, 39 (78%) had endomorphic built, five (10%) mesomorphic built and six (12%) ectomorphic built. This difference in body built i.e. recurrent mania group were more ectomorphic and bipolar disorder group were more endomorphic, was found to be statistically significant (P<0.0001) (Table 2).

Table 2. Type of body built

Type of body built

Endomorphic (pyknic)

Mesomorphic (athletic)

Ectomorphic (asthenic)

 

Chi-square: 50.541

Degrees of Freedom: 2

P<0.0001

N

%

N

%

N

%

Recurrent mania

N=50

4

8

14

28

32

64

Bipolar disorder

N=50

39

78

5

10

6

12

 

When family history of mood disorder was compared between the groups, amongst recurrent mania group, five (10%) had positive family history whereas in bipolar disorder group, 14 (28%) had family history of mood disorder (Figure). Although percentage wise bipolar group had more positive family history of mood disorder but when compared with family history of other psychosis, it was not found to be statistically significant (P=0.3442) (table 2).

Figure Presence of family history.

Table 2.1. Presence of family history

 

Family history of mood disorder

Family history of other psychosis

Fisher’s exact test: two-sided P value is 0.3442

Positive

%

Positive

%

Recurrent mania

N=50

5

10

3

6

Bipolar disorder

N=50

14*

28

3

6

*second degree relatives

An attempt has made to compare different body built of both groups with family history. It was found that recurrent mania-endomorphic group had one positive family history whereas bipolar disorder-endomorphic group had 13 and recurrent mania-ectomorphic group had four positive family histories whereas in bipolar disorder-ectomorphic group had one positive family history of mood disorder. Amongst the mesomorphic group, neither recurrent mania nor bipolar disorder patients had positive family history. This finding was statistically considered to be very significant (P=0.0061) (Table 3).

Discussion

Previous study on unipolar mania are many and almost all the studies could not find much differences in the phenomenology, demographic variables amongst unipolar mania and bipolar cases.11,12 Shulman and Tehan13 found earlier age of onset and longer course of illness for unipolar mania than bipolar cases although it was a retrospective cohort study of 50 elderly manic patients. Kubacki14 found unipolar mania more in men than women and men tended to be younger than women in their study of 74 manic or hypomanic patients. But in our present study, we started with an observation that unipolar manic patients are mostly ectomorphic in body built and bipolar patients are mostly endomorphic in body built. And we found 32 (64%) with ectomorphic body built amongst 50 cases of recurrent mania group and 39 (78%) had endomorphic body built amongst 50 cases of bipolar disorder group.

To our best of knowledge, no such studies have been conducted regarding body built with recurrent mania (or unipolar mania) and/or bipolar disorder. It was Ernst Kretschmer15 who found that pyknic physique were more than normally common amongst manic-depressive patients while asthenic, athletic and dysplastic physique were usual amongst patients with schizophrenia. Sheldon’s10 work on body built was with temperament and personality trait and named them according to relative development of tissue derived from each of the three embryonic layers. Sheldon10 named these three primary components endomorphy, mesomorphy and ectomorphy which resembles Kretschmer’s15 pyknic, athletic and asthenic respectively. We failed to collect any other literature on this respect.


Table 3. Type of body built and family history of mood disorder in recurrent mania and bipolar disorder

 

Endomorphic (pyknic)

 

Mesomorphic (athletic)

 

Ectomorphic (asthenic)

Family  history

 

Family history

Family history

+ve

%

-ve

%

Total

+ve

%

-ve

%

Total

+ve

%

-ve

%

Total

Recurrent mania

(N=50)

1

25

3

75

4

0

0

14

100

14

4

12.5

28

87.5

32

Bipolar disorder

(N=50)

13

33.3

26

66.7

39

0

0

5

100

5

1

16.6

5

83.4

6

Fischer’s exact test: two-sided P value is 0.0061, considered very significant


Next, family history of mood disorder was compared between both the groups and family history was found more in bipolar disorder group than recurrent mania group. Abrams et al.5 reported increased morbid risk of unipolar depression in first degree relatives of patients with unipolar mania.  Srinivasan et al.12 found one (8.4%) case with positive family history of bipolar affective illness amongst 17 bipolar cases.  Although their sample size was too small but percentage wise it resembles our result. In our study purposely we had named recurrent mania instead of unipolar mania since validity of the concept of unipolar mania might be questioned in the absence of long term follow up studies of those patients.

Mania occurs in over half of the initial attacks in bipolar patients.16 Perries6 in his study found that in majority of the cases changes in polarity from mania to depression had occurred by the third episode after the onset of illness. Ten out of his 45 cases had their first episodes of depression after the third episode, rarely it may occur even after the eighth episode.  Many of our patients might have got classified as recurrent mania simply because they had not had an occasion to have depressive episode as yet although our inclusion criteria for recurrent mania was three consecutive episodes of mania.

Another methodological problem could be that mild depressive episodes might be unreported and unnoticed by the patients as well as family members and they got classified as recurrent mania. Nurnberger et al.11 in their study on unipolar mania found that on detailed enquiry patients originally classified as unipolar mania had suffered from depressive episodes.  Although we took precaution in order not to overlook depressive episodes in our recurrent manic sample group but longitudinal study was necessary to overcome this problem.

In our clinical practice recurrent mania was found to be much more common than that reported in the literature.  It might be because manic phase being more distressing to the family members and so the reporting was more whereas depressive phase used to be more distressing to the patient than the family members until and unless the patient became incapacitated and jobless, due to which reporting was less.

There were some limitations in our study. First, body built was determined clinically by mere appearance of the patients and opinion of two psychiatrists was taken for granted and no other anthropometric tools were used. Second, mean number of episodes could not be ascertained accurately. Hailing from rural lower middle class, most of the subjects could not recall more than four episodes and sometime they said ‘many’, ‘lot of time’, etc. instead of exact number of episodes.

References

1.        American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Washington DC: American Psychiatric Association; 1994.

2.        World Health Organization. ICD-10 Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO; 1992.

3.        Winoker G, Clayton PJ, Reich T. Manic depressive illness. St. Louis: C.V. Mosby; 1969.

4.        Abrams R, Taylor MA. Unipolar mania: a preliminary report. Arch Gen Psychiatry 1974; 30:441-3.

5.        Abrams R, Taylor MA, Hayman MA, Krishna NR. Unipolar mania revisited. J Affect Disord 1979; 1:59-68.

6.        Perris C. The distinction between bipolar and unipolar affective disorders. In: Paykel ES, editor. Handbook of affective disorders. London: Churchill Livingstone; 1982. p. 45-68.

7.        Venkoba Rao A, Hariharasubramanian N, Pravathi Devi S, Sugumar A, Srinivasan V. Lithium prophylaxis in affective disorder. Indian J Psychiatry 1982; 23:22-30.

8.        Tandon AK, Asare R, Saxena VC. Lithium treatment in affective disorders. Indian J Psychiatry 1981; 23:58-61.

9.        American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third edition. Revised. Washington DC: American Psychiatric Association; 1987.

10.     Sheldon WH, Stevens SS, Tucker WB. The varieties of human physique. Oxford, England: Harper; 1940.

11.     Nurnberger J, Roose SP, Dunner DL, Fieve RR. Unipolar mania: a distinct clinical entity? Am J Psychiatry 1979; 136:1420-3.

12.     Srinivasan K, Ray R, Gopinath PS. Unipolar mania – a separate entity? Indian J Psychiatry 1985; 27:321-4.

13.     Shulman KT, Tohen M. Unipolar mania reconsidered: evidence from an elderly cohort. Br J Psychiatry 1994; 164:547-9.

14.     Kubacki A. Male and female mania. Can J Psychiatry 1986; 31:70-2.

15.     Kretschmer E. Physique and character: an investigation of the nature of constitution and of the theory of temperament. Sprott WJH, translator. New York: Harcourt Brace; 1925.

16.     Coryell W, Winokur G. (1982) Course and outcome. In: Paykel ES, editor. Handbook of affective disorders. Edinburgh: Churchill Livingstone; 1982.