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Of 71 adolescents assessed during their first hospitalization for a manic or mixed episode of bipolar disorder, 85% experienced "syndromic" recovery (i.e., ceased to meet the diagnostic criteria) in the following year. However, only 39% had substantial symptom resolution or regained full functioning. In the naturalistic study by DelBello et al. (CME, p. 582), syndromic recovery was less likely for adolescents who did not take prescribed medication, had co-occurring attention deficit hyperactivity disorder or alcohol use disorder, or had low family socioeconomic status. Symptomatic recovery was only half as likely for girls as for boys. During the 1-year follow-up, syndromic recurrence of bipolar disorder was more common among patients who took antidepressants and those who abused alcohol. Recurrence was less common among those who received psychotherapy. In an editorial on p. 537, Dr. Boris Birmaher discusses bipolar disorder in adolescents.

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FIGURE 1.

Accentuating the Negative in Depression

Excess activity in emotion-related brain regions has been linked to maladaptive emotional reactions and sensitivity to negative cues in people with depression. Fu et al. (CME, p. 599) previously demonstrated this relationship in depressed patients by presenting facial images with sad expressions and measuring brain responses with functional magnetic resonance imaging. Now these authors report the converse: an attenuated range of neural responses to happy faces. After 8 weeks of drug treatment, however, the capacity for processing happy faces increased. Moreover, patients with the greatest clinical improvement showed the largest brain responses to the happy faces. Using a different neuropsychological task and EEG event-related potentials, Chiu et al. (p. 608) found that depressed patients had exaggerated early neural responses to their own errors. The EEG error-related negativity component showed a higher amplitude in depressed patients than in nondepressed subjects. This difference increased when errors were associated with financial punishment, but not reward. The error-related negativity component is likely generated by the anterior cingulate gyrus, and it appears 50–100 msec after an incorrect response. Thus, this abnormality in depressed patients occurs early in the sequence of impaired neural processes. Dr. Maria Oquendo discusses these findings in an editorial on p. 540.

Uncovering Trichotillomania

An inappropriate head covering may signal that a patient is hiding trichotillomania, repetitive hair pulling that causes distress and functional impairment. Patients tend to be highly secretive about the condition and to regard it as shameful. Thus, clinicians should be sensitive as well as observant. While acknowledging the lack of reliable information on trichotillomania, Chamberlain et al. (CME, p. 568) review the existing findings on epidemiology, genetics, comorbidity, neurocognition, brain abnormalities, and treatment. Although trichotillomania is similar phenomenologically to obsessive-compulsive disorder (OCD), hair pulling is usually driven by increasing psychological tension rather than by obsessions. Its epidemiology, brain and neuropsychological dysfunction, and comorbidity also distinguish it from OCD. Treatment is likely to be largely determined by patient preference, as there have been few well-designed comparator trials. Clomipramine and behavior therapy have shown benefits in some comparisons, but fluoxetine has not. Dual therapy with both drug and behavior treatments may work best for some patients.

Related Articles:

Longitudinal Course of Pediatric Bipolar Disorder

Boris Birmaher
Am J Psychiatry 2007 164: 537-539. [Full Text] [PDF]

Full Text (PDF) April AJP Audio Practice Guideline for the Treatment of Patients With Substance Use Disorders, Second Edition Residents' Journal Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Search for Related Content Related Articles

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