Bipolar Disorder: Krüger S

Krüger S, Bräunig P, Grunze H. · Klinik und Poliklinik für Psychiatrie und Psychotherapie der Universitätsklinik Carl-Gustav Carus, Dresden. · Psychiatr Prax. · Pubmed #16511724 No free full text.

Abstract: There are several national and international practice guidelines on the treatment of acute mania. Their purpose is to assess the available evidence of efficacy for medication used in the treatment of bipolar mania and to grade it according to the quality of studies available. The World Federation of Societies of Biological Psychiatry (WFSBP) has developed such guidelines in 2003. They categorize the scientific quality of the studies into four levels of evidence (A-D) and provide an algorithm based on the degree of severity of the acute manic episode.

Krüger S, Prager P. · Klinik und Poliklinik für Psychiatrie und Psychotherapie der Charité Berlin. · MMW Fortschr Med. · Pubmed #17724969 No free full text.

Abstract: Bipolar disorder is characterized by alternating phases of manic and depressive states that are separated by variably long and sometimes symptom-free intervals. Rapid changes in symptoms and mixed states during acute episodes can make diagnosis difficult. The risk of suicide is high. For diagnostic confirmation, the patient should be referred to a specialist as early as possible. The therapy should also be carried out in close collaboration with a neurologist or psychiatrist. The role of the family physician is to monitor the pharmaceutical phase prophylaxis and to attend to the patient's comorbidities.

Grunze H, Adli M, Bauer M, Berger M, Bergmann A, Bräunig P, Bschor T, Falkai P, Gastpar M, Greil W, Kasper S, Krüger S, Laux G, Müller WE, Naber D, Walden J. · Psychiatrische Klinik LMU, München. · Fortschr Neurol Psychiatr. · Pubmed #17427043 No free full text.

Abstract: During recent years valproate has been established as a cornerstone for the drug-treatment of bipolar disorder. In Germany, valproate was licensed both for the treatment of acute mania and for maintenance treatment in summer 2005. At this occasion, this review summarises the scientific evidence and clinical experience of well-known experts with valproate-treatment. It was concluded that valproate will continue to be of high clinical significance despite the recent increase of treatment alternatives, both in monotherapy and combination treatment of acute mania, mixed states and maintenance treatment.

Merkl A, Regen F, Schindler F, Krüger S, Anghelescu I. · Klinik und Hochschulambulanz für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin. · Fortschr Neurol Psychiatr. · Pubmed #17031775 No free full text.

Abstract: Affective mixed states in bipolar disorders are a current matter of scientific debate and represent a complex clinical picture with coexisting manic and depressive symptoms. Treatment of mixed states is regarded as an important challenge. As diagnostic uncertainties complicate systematic clinical evaluations of this patient group, generally accepted clinical treatment guidelines are lacking yet. In this review the significance as well as the problems and risks of new treatment options are discussed.

Schöttle D, Rode S, Krüger S, Bräunig P. · Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf. · Psychiatr Prax. · Pubmed #16511732 No free full text.

Abstract: The article provides an overview of clinical self-rating scales for manic symptoms, aiming to promote its use in clinical practice. Of the four identified scales available in German language, the Manie-Selbstbeurteilungs-Skala MSS by Bräunig et al., which is a translation of the Self-Rating Manic Inventory SRMI by Shugar et al., is the best validated instrument both for diagnostic purposes and for measuring symptom severity during the course of illness. This overview is followed by a brief discussion of newer developments in the bipolar spectrum, temperament and hypomania research. In addition, options of using mania scales for measuring hypomania according to DSM-IV and/or ICD-10 criteria for bipolar disorders are suggested.

Krüger S, Young T, Bräunig P. · Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl-Gustav Carus, Dresden. · Psychiatr Prax. · Pubmed #16511729 No free full text.

Abstract: OBJECTIVE: Mixed episodes comprise up to 40 % of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options. METHOD: Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state (s), mixed episode (s), treatment, therapy, study or trial. RESULTS: Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a subgroup of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms. CONCLUSIONS: More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target selected aspects of these episodes.

Krüger S. · Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl-Gustav Carus, Dresden. · Psychiatr Prax. · Pubmed #16511727 No free full text.

Abstract: Olanzapin is an atypical antipsychotic drug, which is approved for use in acute mania and in the prophylaxis of bipolar disorder. There are eight double-blind, placebo-controlled studies, which show its efficacy in the treatment of acute mania, five, which document its efficacy in the long-term treatment of bipolar disorder and one that shows its use in bipolar depression. The following overview presents and critically evaluates these studies. Quality of life aspects on olanzapine treatment and the safety profile of the drug will also be discussed.

Krüger S, Trevor Young L, Bräunig P. · Center for Addiction and Mental Health, Clarke Institute of Psychiatry, Mood and Anxiety Disorders Division, University of Toronto, Toronto, Canada. · Bipolar Disord. · Pubmed #15898959 No free full text.

Abstract: OBJECTIVE: Mixed episodes comprise up to 40% of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options. METHOD: Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state(s), mixed episode(s), treatment, therapy, study or trial. RESULTS: Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a sub-group of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms. CONCLUSIONS: More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target select aspects of these episodes.

Grunze H, Walden J, Dittmann S, Berger M, Bergmann A, Bräunig P, Dose M, Emrich HM, Gastpar M, Greil W, Krüger S, Möller HJ, Uebelhack R. · Psychiatrische Klinik der Universität München. · Nervenarzt. · Pubmed #11975062 No free full text.

Abstract: The broadening of the classification systems for manic-depressive illness towards a spectrum of bipolar disorders implicates a more differentiated use of pharmacotherapies. However, many questions still remain open. This implies that all consensus guidelines and recommendations have to be considered as preliminary. On the other hand, research in the last decade has developed many new treatment alternatives, both for mood stabilizers and antidepressants as well as antipsychotics. These recommendations, which have been developed in the process of two consensus meetings, try to consider the broadening of the concept of bipolar disorder by differentiating between subgroups according to acute symptomatology and characteristics of the long-term course, e.g., rapid cycling. In particular, the emerging role and new indications of mood stabilizing antiepileptic drugs, atypical antipsychotics, and new antidepressants will be discussed.

Krüger S, Frasnelli J, Bräunig P, Hummel T. · Department of Psychiatry, University of Dresden Medical School, 01307 Dresden, Germany. · J Psychiatry Neurosci. · Pubmed #16862244 links to  free full text

Abstract: OBJECTIVE: Some patients with bipolar disorder experience mood episodes following emotional life events, whereas others do not. There is evidence that orbitofrontal hypoactivity may be related to this, because the orbitofrontal cortex is involved in the regulation of emotional and behavioural responses to external events. The close anatomical and functional connection between the orbitofrontal cortex and olfactory processing suggests that patients with bipolar disorder and heightened emotional reactivity may exhibit altered olfactory function compared with patients with bipolar disorder who do not exhibit this sensitivity. METHODS: In this pilot study, olfactory function was assessed in patients with bipolar disorder and a history of event-triggered episodes (n = 7) and in patients with bipolar disorder without such a history (n = 9) at the Department of Psychiatry and the Taste and Smell Clinic of the University of Dresden, Germany. Each patient's bipolar disorder was in remission at study entry, and they were on monotherapy with mood stabilizers. Assessment included olfactory event-related potentials (ERP) and psychophysical tests for odour threshold, odour identification and olfactory quality discrimination. RESULTS: Odour thresholds were lower in patients with bipolar disorder and event-triggered episodes compared with the other patient group. In addition, patients with event-triggered episodes exhibited shorter N1 peak latencies of the olfactory ERP. CONCLUSIONS: Our findings indicate disinhibition of orbitofrontal areas involved in the processing of emotional events in a subset of patients with bipolar illness.

Bräunig P, Krüger S, Shugar G. · Klinik für Psychiatrie, Verhaltensmedizin und Psychosomatik, Klinikum Chemnitz, Akademisches Lehrkrankenhaus, Universität Leipzig. · Fortschr Neurol Psychiatr. · Pubmed #10443341 No free full text.

Abstract: OBJECTIVE: The study investigates the prevalence, clinical characteristics and implications of catatonic symptoms in mania. METHODS: Sixty-one in patients with DSM-III-R bipolar disorder, manic or mixed episode established by SCID were assessed for the presence of catatonia by a 21-item rating scale. Associated symptoms, comorbidity and severity of the manic episode were also systematically assessed. RESULTS: Nineteen patients fulfilled criteria for catatonic mania exhibiting between 5 and 16 catatonic symptoms. Catatonic manics had more mixed episodes, more severe manic symptoms, more general psychopathology, a higher prevalence of comorbidity, longer hospitalization and lower GAF-scores than the non-catatonics. CONCLUSIONS: The results indicate that catatonic symptoms are a marker of a more severe course and outcome in mania.

Krüger S. · Klinik und Poliklinik für Psychiatrie und Psychotherapie, Charité Campus Mitte, Universitätsmedizin Berlin, Berlin. · Ther Umsch. · Pubmed #19496044 No free full text.

Abstract: Pregnancy and the postpartum are times of increased risk for women with bipolar disorder to develop mood episodes, especially depressions that may require pharmacotherapy. If mood stabilizing agents are discontinued prior or due to pregnancy, the risk for relapse increases dramatically. On the other hand, there is no psychotropic drug that is completely risk-free for the unborn. Some mood stabilizing medications are teratogenic, others can cause severe perinatal complications. Thus, the decision whether to treat the pregnant women with psychotropic drugs is difficult to make. In this paper, the reproductive risks of mood stabilizing agents, antidepressants, neuroleptics and benzodiazepines for the fetus are reviewed. During the postpartum period severe mood disorders can occur. The signs and symptoms of these disorders are reviewed and therapeutic strategies are discussed.

Krüger S, Alda M, Young LT, Goldapple K, Parikh S, Mayberg HS. · Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada. · Am J Psychiatry. · Pubmed #16449479 links to  free full text

Abstract: OBJECTIVE: The authors previously identified depression-specific differences in brain responses to an emotional challenge in patients with bipolar and unipolar mood disorder. In this study, potential markers of bipolar risk and resilience were examined in a new cohort of lithium-responsive bipolar patients and their healthy siblings. METHOD: Changes in regional cerebral blood flow (rCBF) were measured with [(15)O]water positron emission tomography after induction of transient sadness in nine euthymic lithium responders and nine healthy siblings. The patterns of change in these groups were compared, and then they were contrasted with previous findings on bipolar responders to valproate. RESULTS: Common to all three groups with induced sadness were rCBF increases in the dorsal/rostral anterior cingulate and anterior insula and decreases in the orbitofrontal and inferior temporal cortices. Distinguishing the groups were decreases in the medial frontal cortex in the patients but an increase in this region in the siblings. DISCUSSION: Common changes with emotional challenge were identified in bipolar patients and their healthy siblings. These were not seen previously in healthy subjects without a family history of mood disorder, suggesting a potential marker of bipolar risk. The siblings' unique increases in the medial frontal cortex appear to identify a compensatory response in this at-risk group, as this pattern was not seen previously in healthy subjects without depression risk factors. This differential change pattern in patients and their siblings highlights the role of the anterior cingulate and medial frontal regions in mediating resiliency and vulnerability in bipolar disorder families.

Krüger S, Seminowicz D, Goldapple K, Kennedy SH, Mayberg HS. · Department of Psychiatry (SK), University of Dresden, Dresden, Germany. · Biol Psychiatry. · Pubmed #14643095 No free full text.

Abstract: BACKGROUND: Even in remission, patients with bipolar disorder (BD) remain sensitive to external stressors that can trigger new episodes. Imitating such stressors by the controlled transient exposure to an emotional stimulus may help to identify brain regions modulating this sensitivity. METHODS: Transient sadness was induced in 9 euthymic and in 11 depressed subjects with BD. Regional blood flow (rCBF) changes were measured using (15)O-water positron emission tomography. RESULTS: Common changes in both groups were increased rCBF in anterior insula and cerebellum and decreased rCBF in dorsal-ventral-medial frontal cortex, posterior cingulate, inferior parietal, and temporal cortices. Decreases in dorsal ventral medial frontal cortices occurred in both groups, but subjects in remission showed a greater magnitude of change. Unique to remitted subjects with BD were rCBF increases in dorsal anterior cingulate and in premotor cortex. Lateral prefrontal rCBF decreases were unique to depressed subjects with BD. At baseline, remitted subjects showed a unique increase in dorsal anterior cingulate and orbitofrontal cortex. CONCLUSIONS: Common rCBF changes in remitted and depressed subjects identifies potential sites of disease vulnerability. Unique cingulate and orbitofrontal changes both at baseline and with induced sadness seen in the absence of prefrontal rCBF decreases may identify regional interactions important to the euthymic state in this population.

Krüger S, Bagby RM, Höffler J, Bräunig P. · Klinik für Psychiatry, Verhaltensmedizin und Psychosomatik am Klinikum Chemnitz, University of Dresden, Germany. · Compr Psychiatry. · Pubmed #14610726 No free full text.

Abstract: Catatonia is a frequent psychomotor syndrome, which has received increasing recognition over the last decade. The assessment of the catatonic syndrome requires systematic rating scales that cover the complex spectrum of catatonic motor signs and behaviors. The Catatonia Rating Scale (CRS) is such an instrument, which has been validated and which has undergone extensive reliability testing. In the present study, to further validate the CRS, the items composing this scale were submitted to principal components factor extraction followed by a varimax rotation. An analysis of variance (ANOVA) was performed to assess group differences on the extracted factors in patients with schizophrenia, pure mania, mixed mania, and major depression (N=165). Four factors were extracted, which accounted for 71.5% of the variance. The factors corresponded to the clinical syndromes of (1) catatonic excitement, (2) abnormal involuntary movements/mannerisms, (3) disturbance of volition/catalepsy, and (4) catatonic inhibition. The ANOVA revealed that each of the groups showed a distinctive catatonic symptom pattern and that the overlap between diagnostic groups was minimal. We conclude that this four-factor symptom structure of catatonia challenges the current conceptualization, which proposes only two symptom subtypes.

Bräunig P, Krüger S. · Klinik für Psychiatrie, Verhaltensmedizin und Psychosomatik, Chemnitz, University of Dresden, Dresden, Germany. · J Psychopharmacol. · Pubmed #12870574 No free full text.

Abstract: Levetiracetam (LEV) is a novel anticonvulsant that is currently investigated in bipolar disorder. It may be useful in the treatment of refractory and complicated cases, in which conventional mood stabilizers are not effective. We report two cases of rapid cycling bipolar disorder in which the add-on of LEV to a conventional treatment regimen improved symptoms of depression, as well as those of mania/mixed mania, and disrupted the severe rapid cycling pattern.

Krüger S, Cooke RG, Spegg CC, Bräunig P. · Centre for Addiction and Mental Health, Clarke Institute of Psychiatry, Mood Disorders Program, University of Toronto, Toronto, Canada. · J Affect Disord. · Pubmed #12738047 No free full text.

Abstract: BACKGROUND: Catatonic symptoms have been associated with mixed mania in the older psychiatric literature, however, to date no systematic studies have been performed to assess their frequency in these patients. METHOD: Ninety-nine patients with bipolar disorder manic or mixed episode were assessed for the presence of catatonia. RESULTS: Thirty-nine patients fulfilled criteria for mixed mania of whom 24 were catatonic. Among the patients with pure mania, only three were catatonic. Eighteen catatonic patients with mixed mania required admission to the acute care unit (ACU). LIMITATIONS: Our findings only apply to severely ill patients with mixed mania who require ACU admission. Nevertheless, it is important to know, that the likelihood of overlooking catatonia in less severely ill patients with mixed mania is low and that it does not need to be routinely assessed on a general ward. CONCLUSIONS: Catatonia is frequent in mania and linked to the mixed episode. Catatonia in mixed mania is likely to be found among the severely ill group of patients with mixed mania, who require emergency treatment.

Krüger S, Bräunig P, Cooke RG. · Centre for Addiction and Mental Health, Clarke Institute of Psychiatry, Mood and Anxiety Disorders Division, University of Toronto, Ontario, Canada. · Bipolar Disord. · Pubmed #11254024 No free full text.

Abstract: OBJECTIVE: To determine the frequency of obsessive-compulsive disorder (OCD) in inpatient subjects with bipolar disorder (BD) and to examine the clinical characteristics of BD subjects with OCD. METHOD: The sample consisted of 143 inpatient subjects with DSM-III-R BD-I and BD-NOS (BD-II), recovered from a current episode of either depression or mania. Demographic and clinical variables were obtained on the day of admission. Current comorbid conditions including OCD were determined by the Structured Clinical Interview for DSM-III-R Ifollowing recovery from the acute affective episode. RESULTS: The frequency of current OCD was 7% (N = 10). All BD subjects with OCD were BD-II, were male, and had a diagnosis of current dysthymia. They had fewer episodes and a higher incidence of prior suicide attempts than bipolar subjects without OCD. None of the bipolar subjects with OCD fulfilled criteria for cyclothymia. CONCLUSIONS: Our findings suggest that BD-II, OCD, dysthymia, and suicidality cluster together in some subjects with BD. We discuss the clinical implications of our findings.

Krüger S, Sarkar R, Pietsch R, Hasenclever D, Bräunig P. · No affiliation provided · Psychopharmacology (Berl). · Pubmed #18369598 No free full text.

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