Complex clinical picture of mania: links among mixity, anxiety and instable temperament

"EPIMAN-II Thousand" is a national multi-site collaborative study dedicated to replicate and complete the previous EPIMAN study (Hantouche et al., 2003). It involved training 317 French psychiatrists working in different sites representative of all France. The study actually succeeded in recruiting 1090 cases admitted for acute mania (DSM-IV criteria). The MRS was used to assess the intensity of mania and MADRS + CLDS (checklist of depressive symptoms, 10 items) for co-existing depression. Lifetime comorbid anxiety disorders were assessed by using the DSM-IV criteria, and the AMDP Anxiety Scale of Bobon. The full TEPMS-A French version (84 items, Hantouche et al., 2001) was used to assess the Affective Temperaments.

Results

Mixed Mania, as defined by the presence of 2 items from CLDS was observed in 30% of the entire population. The PCA conducted on the combined items of "MRS + MADRS" showed, after varimax rotation, that the core factor was "Depression" (eigenvalue = 3,7). Rates of positive cases (score of 10 or more) with Cyclothymic, Depressive, and Irritable Temperaments were significantly (p = 0.0022) higher in Mixed Mania versus Pure Mania (respectively 75% vs 44%; 37% vs 22%; 30% vs 21%). In Mixed Mania, the rates of comorbid anxiety disorders were higher than in Pure Mania (especially GAD, 30,3% vs 14,3%; Panic Disorder 7,9% vs 2,7%; and PTSD 4,5% vs 0,9%). The PCA conducted on the AMDP scale revealed the presence of 3 major components: core factor "Dysphoric Inner Agitation" (9 items), "Psychic and Physical Anxiety" (7 items), and "Phobias" (2 items). The global score factor and factorial scores on AMDP were significantly higher in Mixed Mania versus Pure Mania (respectively 25,3 vs 17,1; 15,5 vs 11,0 on F1; 10,3 vs 6,6 on F2; and 1,2 vs 0.7 on F3, p < 0.0001). Moreover, the different scores on AMDP were mostly correlated with the scores on Cyclothymic and Irritable Temperaments (stronger than with Depressive Temperament).

Conclusion

Our data obtained on the largest population of manic patients ever conducted (n = 1090) confirmed the complex and atypical forms of acute mania could best explained by a significant relationship between Mixed Mania, anxiety and instable temperaments, such as cyclothymic and irritable.