Identifying prodromal features that predate the onset of bipolar disorder (BD) may enable the prevention of BD and aid early intervention. This review addresses two key questions: Is there a bipolar prodrome? And, if there is, what are its characteristic features?

A comprehensive search of databases (PubMed, Medline, EMBASE and PsycINFO) supplemented by hand searches was used to identify studies of symptoms preceding the onset of BD.

Fifty-nine studies were identified, of which 14 met inclusion criteria. Symptoms can predate the onset of BD by months to years and can be categorized as attenuated forms of BD symptoms, general symptoms common to a range of mental disorders, and personality traits, particularly cyclothymia. Two studies provided sufficient data to enable sensitivity and specificity to be calculated. Specificity of several of the features was high (>90%) but sensitivity was generally low (all <60%). We propose a model based on the findings in the studies reviewed to illustrate the potential trajectory to BD and the points at which it may be possible to intervene.

Clinical features preceding the onset of BD can be identified. However, conclusions about whether there is a distinct prodrome to BD are restricted by the limitations of current evidence. The high specificity of some features suggests they may be useful in clinical practice. Large-scale longitudinal studies are needed to validate these features and characterize their specificity and sensitivity in independent samples.

Whether temperament and character differ between bipolar disorder (BD) and major depressive disorder (MDD) patients and general population subjects, or between BD I and BD II patients, remains unclear.

BD patients (n=191) from the Jorvi Bipolar Study and MDD patients (n=266) from the Vantaa Depression Study (VDS) and the Vantaa Primary Care Depression Study were interviewed at baseline, at 6 and 18 months, and in the VDS at 5 years. A general population comparison group (n=264) was surveyed by mail. BD patients' scores on the Temperament and Character Inventory-Revised were compared at an index interview, when levels of depression and mania were lowest, with scores of MDD patients and controls. BD I (n=99) and BD II (n=92) patients were compared.

Compared with controls, both BD and MDD patients had higher harm avoidance [odds ratio (OR) 1.027, p<0.001 and OR 1.047, p<0.001, respectively] and lower persistence (OR 0.983, p=0.006 and OR 0.968, p<0.001, respectively) scores. Moreover, BD patients had lower self-directedness (OR 0.979, p=0.003), MDD patients lower reward dependence (OR 0.976, p=0.002) and self-transcendence (OR 0.966, p<0.001) scores. BD patients scored lower in harm avoidance (OR 0.980, p=0.002) and higher in novelty seeking (OR 1.027, p<0.001) and self-transcendence (OR 1.028, p<0.001) than MDD patients. No differences existed between BD I and II patients.

The patterns of temperament and character dimensions differed less between BD and MDD patients, than patients from their controls. The most pronounced difference was higher novelty seeking in BD than MDD patients. The dimensions investigated are unlikely to differ between BD I and BD II patients.

Some personality characteristics have previously been associated with an increased risk for psychiatric disorder. Longitudinal studies are required in order to tease apart temporary (state) and enduring (trait) differences in personality among individuals with bipolar disorder (BD). This study aimed to determine whether there is a characteristic personality profile in BD, and whether associations between BD and personality are best explained by state or trait effects.

A total of 2247 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder study completed the NEO Five-Factor Inventory administered at study entry, and at 1 and 2 years.

Personality in BD was characterized by high neuroticism (N) and openness (O), and low agreeableness (A), conscientiousness (C) and extraversion (E). This profile was replicated in two independent samples, and openness was found to distinguish BD from major depressive disorder. Latent growth modeling demonstrated that manic symptoms were associated with increased E and decreased A, and depressed symptoms with higher N and lower E, A, C and O. During euthymic phases, high N and low E scores predicted a future depression-prone course.

While there are clear state effects of mood on self-reported personality, personality variables during euthymia predict future course of illness. Personality disturbances in extraversion, neuroticism and openness may be enduring characteristics of patients with BD.

Despite international concern about unregulated predictive genetic testing, there are surprisingly few data on both the determinants of community interest in such testing and its psychosocial impact.

A large population-based public survey with community-dwelling adults (n=1046) ascertained through random digit dialling. Attitudes were assessed by structured interviews.

The study found strong interest in predictive genetic testing for a reported susceptibility to depression. Once the benefits and disadvantages of such testing had been considered, there was significantly greater interest in seeking such a test through a doctor (63%) compared to direct-to-consumer (DTC; 40%) (p<0.001). Personal history of mental illness [odds ratio (OR) 2.58, p<0.001], self-estimation of being at higher than average risk for depression (OR 1.92, p<0.001), belief that a genetic component would increase rather than decrease stigma (OR 1.62, p<0.001), and endorsement of benefits of genetic testing (OR 3.47, p<0.001) significantly predicted interest in having such a test.

Despite finding attitudes that genetic links to mental illness would increase rather than decrease stigma, we found strong community acceptance of depression risk genotyping, even though a predisposition to depression may only manifest upon exposure to stressful life events. Our results suggest that there will be a strong demand for predictive genetic testing.

According to cognitive theories of depression, negative biases affect most cognitive processes including perception. Such depressive perception may result not only from biased cognitive appraisal but also from automatic processing biases that influence the access of sensory information to awareness.

Twenty patients with major depressive disorder (MDD) and 20 healthy control participants underwent behavioural testing with a variant of binocular rivalry, continuous flash suppression (CFS), to investigate the potency of emotional visual stimuli to gain access to awareness. While a neutral, fearful, happy or sad emotional face was presented to one eye, high-contrast dynamic patterns were presented to the other eye, resulting in initial suppression of the face from awareness. Participants indicated the location of the face with a key press as soon as it became visible. The modulation of suppression time by emotional expression was taken as an index of unconscious emotion processing.

We found a significant difference in the emotional modulation of suppression time between MDD patients and controls. This difference was due to relatively shorter suppression of sad faces and, to a lesser degree, to longer suppression of happy faces in MDD. Suppression time modulation by sad expression correlated with change in self-reported severity of depression after 4 weeks.

Our finding of preferential access to awareness for mood-congruent stimuli supports the notion that depressive perception may be related to altered sensory information processing even at automatic processing stages. Such perceptual biases towards mood-congruent information may reinforce depressed mood and contribute to negative cognitive biases.

There are no risk models for the prediction of anxiety that may help in prevention. We aimed to develop a risk algorithm for the onset of generalized anxiety and panic syndromes.

Family practice attendees were recruited between April 2003 and February 2005 and followed over 24 months in the UK, Spain, Portugal and Slovenia (Europe4 countries) and over 6 months in The Netherlands, Estonia and Chile. Our main outcome was generalized anxiety and panic syndromes as measured by the Patient Health Questionnaire. We entered 38 variables into a risk model using stepwise logistic regression in Europe4 data, corrected for over-fitting and tested it in The Netherlands, Estonia and Chile.

There were 4905 attendees in Europe4, 1094 in Estonia, 1221 in The Netherlands and 2825 in Chile. In the algorithm four variables were fixed characteristics (sex, age, lifetime depression screen, family history of psychological difficulties); three current status (Short Form 12 physical health subscale and mental health subscale scores, and unsupported difficulties in paid and/or unpaid work); one concerned country; and one time of follow-up. The overall C-index in Europe4 was 0.752 [95% confidence interval (CI) 0.724–0.780]. The effect size for difference in predicted log odds between developing and not developing anxiety was 0.972 (95% CI 0.837–1.107). The validation of predictA resulted in C-indices of 0.731 (95% CI 0.654–0.809) in Estonia, 0.811 (95% CI 0.736–0.886) in The Netherlands and 0.707 (95% CI 0.671–0.742) in Chile.

PredictA accurately predicts the risk of anxiety syndromes. The algorithm is strikingly similar to the predictD algorithm for major depression, suggesting considerable overlap in the concepts of anxiety and depression.

The concept of narcissism has been much researched in psychoanalysis and especially in self psychology. One of the hallmarks of narcissism is altered emotion, including decreased affective resonance (e.g. empathy) with others, the neural underpinnings of which remain unclear. The aim of our exploratory study was to investigate the psychological and neural correlates of empathy in two groups of healthy subjects with high and low narcissistic personality trait. We hypothesized that high narcissistic subjects would show a differential activity pattern in regions such as the anterior insula that are typically associated with empathy.

A sample of 34 non-clinical subjects was divided into high (n=11) and low (n=11) narcissistic groups according to the 66th and 33rd percentiles of their scores on the Narcissism Inventory (NI). Combining the psychological, behavioral and neuronal [i.e. functional magnetic resonance imaging (fMRI)] measurements of empathy, we compared the high and low narcissistic groups of subjects.

High narcissistic subjects showed higher scores on the Symptom Checklist-90 – Revised (SCL-90-R) and the 20-item Toronto Alexithymia Scale (TAS-20) when compared to low narcissistic subjects. High narcissistic subjects also showed significantly decreased deactivation during empathy, especially in the right anterior insula.

Psychological and neuroimaging data indicate respectively higher degrees of alexithymia and lower deactivation during empathy in the insula in high narcissistic subjects. Taken together, our preliminary findings demonstrate, for the first time, psychological and neuronal correlates of narcissism in non-clinical subjects. This might stipulate both novel psychodynamic conceptualization and future psychological–neuronal investigation of narcissism.

Previous neuroimaging studies have demonstrated abnormalities in visual body image processing in anorexia and bulimia nervosa, possibly underlying body image disturbance in these disorders. Although cognitive behavioural interventions have been shown to be successful in improving body image disturbance in eating disorders, no randomized controlled study has yet analysed treatment-induced changes in neuronal correlates of visual body image processing.

Altogether, 32 females with eating disorders were randomly assigned either to a manualized cognitive behavioural body image therapy consisting of 10 group sessions, or to a waiting list control condition. Using functional magnetic resonance imaging, brain responses to viewing photographs of one's own and another female's body taken from 16 standardized perspectives while participants were wearing a uniform bikini were acquired before and after the intervention and the waiting time, respectively.

Data indicate a general blood oxygen level dependent signal enhancement in response to looking at photographs of one's own body from pre- to post-treatment, whereas exclusively in the control group activation decreases from pre- to post-waiting time were observed. Focused activation increases from pre- to post-treatment were found in the left middle temporal gyrus covering the coordinates of the extrastriate body area and in bilateral frontal structures including the middle frontal gyrus.

Results point to a more intense neuronal processing of one's own body after the cognitive behavioural body image therapy in cortical regions that are responsible for the visual processing of the human body and for self-awareness.

The present study aimed to (a) characterize 10-year trajectory patterns of depressive symptoms and (b) investigate the association between depressive trajectory and subsequent obesity, metabolic function and cortisol level.

In a prospective study of Taiwanese adults aged ⩾60 years (n=3922) between 1989 and 1999, depression was assessed using a 10-item short-form of the Center for Epidemiologic Studies Depression Scale and information on body mass index (BMI) was collected by self-report. A subsample (n=445) of the original cohort in 1989 was drawn to assess metabolic variables and cortisol levels in a 2000 follow-up. After trajectory analyses were performed, multinomial logistic regression analyses were used to estimate the association estimates.

We identified four distinctive trajectories of depressive symptoms: class 1 (persistent low, 41.8%); class 2 (persistent mild, 46.8%); class 3 (late peak, 4.2%); and class 4 (high-chronic, 7.2%). The results from both complete cases and multiple imputation analyses indicated that the odds of obesity were lower in the class 2, 3 or 4 elderly, as compared with those in class 1, while the odds of underweight were higher. The classes of older adults with more and persistent depressive symptoms showed a trend toward having both a lower BMI (p=0.01) and a higher cortisol level (p=0.04) compared with those with low depressive symptoms.

Incremental increases in depressive symptoms over time were associated with reduced risk of obesity and higher cortisol levels.

Some neuroimaging studies have supported the hypothesis of progressive brain changes after a first episode of psychosis. We aimed to determine whether (i) first-episode psychosis patients would exhibit more pronounced brain volumetric changes than controls over time and (ii) illness course/treatment would relate to those changes.

Longitudinal regional grey matter volume and ventricle:brain ratio differences between 39 patients with first-episode psychosis (including schizophrenia and schizophreniform disorder) and 52 non-psychotic controls enrolled in a population-based case-control study.

While there was no longitudinal difference in ventricle:brain ratios between first-episode psychosis subjects and controls, patients exhibited grey matter volume changes, indicating a reversible course in the superior temporal cortex and hippocampus compared with controls. A remitting course was related to reversal of baseline temporal grey matter deficits.

Our findings do not support the hypothesis of brain changes indicating a progressive course in the initial phase of psychosis. Rather, some brain volume abnormalities may be reversible, possibly associated with a better illness course.

Abnormalities in the connectivity of white-matter (WM) tracts in schizophrenia are supported by evidence from post-mortem investigations, functional and structural magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). The aims of this study were to explore the microstructural changes in first-episode schizophrenia in a Han Chinese population and to investigate whether a family history of psychiatric disorder is related to the severity of WM tract integrity abnormalities in these patients.

T1-weighted MR and DT images were collected in 68 patients with first-episode schizophrenia [22 with a positive family history (PFH) and 46 with a negative family history (NFH)] and 100 healthy controls. Voxel-based analysis was performed and WM integrity was quantified by fractional anisotropy (FA). Cluster- and voxel-level analyses were performed by using two-sample t tests between patients and controls and/or using a full factorial model with one factor and three levels among the three sample groups (patients with PFH or NFH, and controls), as appropriate.

FA deficits were observed in the patient group, especially in the left temporal lobe and right corpus callosum. This effect was more severe in the non-familial schizophrenia than in the familial schizophrenia subgroup.

Overall, these findings support the hypothesis that loss of WM integrity may be an important pathophysiological feature of schizophrenia, with particular implications for brain dysmaturation in non-familial and familial schizophrenia.

An intrinsic cerebral network comprising the anterior cingulate and anterior insula (the salience network) is considered to play an important role in salience detection in healthy volunteers. Aberrant salience has been proposed as an important mechanism in the production of psychotic symptoms such as delusions and hallucinations (reality distortion). We investigated whether structural deficits in the salience network are associated with the reality distortion seen in schizophrenia.

A sample of 57 patients in a clinically stable state of schizophrenia and 41 controls were studied with high-resolution magnetic resonance imaging.

Bilateral volume reduction was seen in the anterior cingulate and anterior insula in patients with schizophrenia. Reduced volume in the two left-sided regions of the salience network was significantly correlated with the severity of reality distortion.

These findings suggest that a deficit of grey matter in the salience network leads to an impaired attribution of salience to stimuli that is associated with delusions and hallucinations in schizophrenia.

We investigated cerebral structural connectivity and its relationship to symptoms in never-medicated individuals with first-onset schizophrenia using diffusion tensor imaging (DTI).

We recruited subjects with first episode DSM-IV schizophrenia who had never been exposed to antipsychotic medication (n=34) and age-matched healthy volunteers (n=32). All subjects received DTI and structural magnetic resonance imaging scans. Patients' symptoms were assessed on the Positive and Negative Syndrome Scale. Voxel-based analysis was performed to investigate brain regions where fractional anisotropy (FA) values significantly correlated with symptom scores.

In patients with first-episode schizophrenia, positive symptoms correlated positively with FA scores in white matter associated with the right frontal lobe, left anterior cingulate gyrus, left superior temporal gyrus, right middle temporal gyrus, right middle cingulate gyrus, and left cuneus. Importantly, FA in each of these regions was lower in patients than controls, but patients with more positive symptoms had FA values closer to controls. We found no significant correlations between FA and negative symptoms.

The newly-diagnosed, neuroleptic-naive patients had lower FA scores in the brain compared with controls. There was positive correlation between FA scores and positive symptoms scores in frontotemporal tracts, including left fronto-occipital fasciculus and left inferior longitudinal fasciculus. This implies that white matter dysintegrity is already present in the pre-treatment phase and that FA is likely to decrease after clinical treatment or symptom remission.

Catechol-O-methyltransferase (COMT) Val158Met has been associated with activity of the mesial temporal lobe during episodic memory and it may weakly increase risk for schizophrenia. However, how this variant affects parahippocampal and hippocampal physiology when dopamine transmission is perturbed is unclear. The aim of the present study was to compare the effects of the COMT Val158Met genotype on parahippocampal and hippocampal physiology during encoding of recognition memory in patients with schizophrenia and in healthy subjects.

Using blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI), we studied 28 patients with schizophrenia and 33 healthy subjects matched for a series of sociodemographic and genetic variables while they performed a recognition memory task.

We found that healthy subjects had greater parahippocampal and hippocampal activity during memory encoding compared to patients with schizophrenia. We also found different activity of the parahippocampal region between healthy subjects and patients with schizophrenia as a function of the COMT genotype, in that the predicted COMT Met allele dose effect had an opposite direction in controls and patients.

Our results demonstrate a COMT Val158Met genotype by diagnosis interaction in parahippocampal activity during memory encoding and may suggest that modulation of dopamine signaling interacts with other disease-related processes in determining the phenotype of parahippocampal physiology in schizophrenia.

Military service can lead to profound changes in identity, both in servicemen's perception of themselves and in their relationship to the world, but the significance of these changes for psychopathology is unclear. We investigated whether the extent and valence of identity change was related to the degree of military trauma exposure or to post-traumatic stress disorder (PTSD) and suicide attempts. We further sought to describe the nature of such changes using qualitative analysis.

A total of 153 veterans in receipt of a war pension for PTSD or physical disability were identified. Interviews established retrospectively DSM-IV diagnoses of PTSD and reports of suicidal ideation or behaviour since enlistment were examined.

Trauma exposure alone was unrelated to any measure of identity change. By contrast, PTSD was associated with a relationship to the world that had changed in a negative direction. It was also associated with a changed perception of self, which could be either positive or negative. After controlling for trauma exposure and PTSD, suicidal behaviours were associated with more negative perceptions of the world. These perceptions of the world included disillusionment about human nature and a more specific rejection of civilian life.

PTSD and suicidal behaviours in veterans seem not to be associated with significantly more negative views of the self but rather with more alienation from civilian life. This has serious consequences for engaging veterans in National Health Service (NHS) mental health services and for the provision of effective treatment.

Pre-menstrual dysphoric disorder (PMDD) is commonly studied in white women; consequently, it is unclear whether the prevalence of PMDD varies by race. Although a substantial proportion of black women report symptoms of PMDD, the Biocultural Model of Women's Health and research on other psychiatric disorders suggest that black women may be less likely than white women to experience PMDD in their lifetimes.

Multivariate multinomial logistic regression modeling was used with a sample of 2590 English-speaking, pre-menopausal American women (aged 18–40 years) who participated in the Collaborative Psychiatric Epidemiology Surveys in 2001–2003. The sample consisted of 1672 black women and 918 white women. The measure of PMDD yields a provisional diagnosis of PMDD consistent with DSM-IV criteria.

Black women were significantly less likely than white women to experience PMDD [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.25–0.79] and pre-menstrual symptoms (OR 0.64, 95% CI 0.47–0.88) in their lifetimes, independently of marital status, employment status, educational attainment, smoking status, body mass index, history of oral contraceptive use, current age, income, history of past-month mood disorder, and a measure of social desirability. The prevalence of PMDD was 2.9% among black women and 4.4% among white women.

This study showed for the first time that black women were less likely than white women to experience PMDD and pre-menstrual symptoms, independently of relevant biological, social-contextual and psychological risk factors. This suggests that PMDD may be an exception to the usual direction of racial disparities in health. Further research is needed to determine the mechanisms that explain this health advantage.

The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population.

Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment.

Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions.

Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

Little is known about the long-term mental health of extremely low birth weight (ELBW) (<1000 g) survivors. We test whether young adults aged 22 to 26 years born at ELBW differ from normal birth weight (NBW) controls in self-reported levels of psychopathology.

Participants included 142 ELBW survivors (86% response) born between 1977 and 1982 to residents of central-west Ontario, Canada and 133 NBW control subjects (92% response). The Young Adult Self-Report measure was used to create five DSM-IV oriented scales aggregated to form internalizing (depressive problems, anxiety problems, avoidant personality problems) and externalizing (attention deficit-hyperactivity disorder problems and antisocial personality problems) scales.

After adjusting for family background characteristics, mean scores for ELBW survivors were 3.02 [95% confidence interval (CI) 0.78–5.26] points higher for internalizing problems and no different, i.e. 0.00 (95% CI −1.17 to 1.17), for externalizing problems. There was a sex×group statistical interaction such that being male muted the risk for externalizing problems among those born at ELBW: −2.11 (95% CI −4.21 to −0.01). Stratifying ELBW adults as born small for gestational age (SGA) versus appropriate weight for gestational age (AGA) revealed a significant gradient of risk for levels of internalizing problems that was largest for SGA, i.e. 4.75 (95% CI 1.24–8.26), and next largest for AGA, 2.49 (95% CI 0.11–4.87), compared with NBW controls.

Depression, anxiety and avoidant personality problems (internalizing problems) are elevated in young adulthood among ELBW survivors. This effect is relatively small overall but noticeably larger among ELBW survivors born SGA.

The current longitudinal study examined the developmental patterns of marijuana use and their relationship with subsequent psychological adjustment in a community-based sample of urban African American and Puerto Rican women.

Participants were interviewed five times over a period ranging from adolescence (mean age 14.0 years) to adulthood (mean age 32.5 years). Outcome measures included depressive symptoms, anger/hostility and the presence of a substance use disorder (abuse/dependence).

Three distinct trajectories of marijuana use were identified: non-users, increasers and quitters. Increasers reported higher levels of depressive symptoms and anger/hostility than did non-users and were more likely to meet criteria for a substance use disorder at age 32.5 years.

Our findings indicate that early-starting long-term use of marijuana is associated with psychological maladjustment among women. Prevention efforts should emphasize the long-term cost associated with marijuana use, and that the best psychological health is reported by those who abstain from the drug.