553954 research-article2014
ANP0010.1177/0004867414553954Australian & New Zealand Journal of PsychiatryWatson and Porter
Editorial Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 975–976 DOI: 10.1177/0004867414553954
Childhood adversity in bipolar disorder
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Stuart Watson1 and Richard J Porter2
In this issue, Daglas and colleagues (2014) present a study examining the impact of early adversity on the 12-month outcome of patients managed in Melbourne who presented with first-episode psychotic mania. The data shows that patients who have reported early adversity fare worse and have higher scores on symptom rating scales and worse psychosocial functioning at 12-month follow-up. This study is unique because of the specificity of the population and the authors are to be congratulated for recruiting 65 participants. The study adds significantly to the literature in this area. Over the past few years it has become increasingly evident that childhood adversity is a major risk factor for bipolar disorder (indeed for all mood disorders) and is associated with a greater symptom burden and a worse prognosis. There are a number of implications of this. First, it is incumbent upon us, as clinicians, to give our patients the opportunity to discuss childhood experiences – and here we need to be aware that the relevant experiences are not confined to intrusive and frightening incidents but include also factors such as the persistent absence of a loving and supportive parental relationship (Watson et al., 2013). We also need to reconsider our use of psychological therapies. Psychological treatment for bipolar disorder has tended to focus on psychoeducation, often with the intended outcome being increased compliance with medication (Crowe et al., 2012), and on ‘Social Rhythms’ focusing on regularising activity and sleep.
Psychoeducation and Interpersonal Social Rhythms Therapy have proven benefit in clinical trials (Crowe et al., 2012). Daglas’ paper, however, and others in the field, in demonstrating the importance of early experiences raise the question of the extent to which it may also be helpful to develop therapeutic interventions which address the psychological consequences of upbringing and early experience. The potential value of this is highlighted by a study which demonstrated a greater benefit from psychotherapy compared with drug treatment in depressed patients who had experienced childhood abuse (Nemeroff et al., 2003). The natural tendency is for the intensity of therapeutic input to reduce when bipolar patients recover from acute episodes and are ‘stabilised’. This is the very time, we would argue, that bipolar patients are most able to make use of psychological therapies which may serve to improve prognosis by reducing the persistent burden of low mood or the likelihood, severity or duration of future relapse. Daglas’ study also causes us to reflect on the biological substrates of mania and depression and on the mechanism by which events in childhood, or indeed in utero, can alter developmental trajectories and ultimately manifest such diverse psychopathology in adulthood. Exciting developments in the field of epigenetics shows us that genes relevant to the aetiology and maintenance of bipolar disorder can be persistently rendered more or less active by experiences during critical developmental
periods. Such epigenetic scars, which are moderated by genetic factors (single nuclear polymorphisms, etc.) to determine the risk of developing a host of psychiatric disorders, including bipolar disorder, can be transmitted from generation to generation but, importantly, are reversible and thus may give a biological substrate for the beneficial effect of mindfulness and other therapies. The impact of epigenetic changes is likely mediated by an interacting network of structural and functional parameters. Hippocampal structure and function, the immune system and the hypothalamic-pituitary-adrenal axis appear particularly relevant at this stage; certainly the relationship of childhood adversity on the expression and function of the glucocorticoid receptor has been the focus of much scientific endeavour (Klengel et al., 2014). In short, the paper by Daglas and colleagues in this month’s issue provides further support to the notion that upbringing affects the risk of developing psychosis and mania and engenders a poor prognosis. This
1The
Wolfson Research Unit, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom 2Department of Psychological Medicine, University of Otago, Christchurch, New Zealand Corresponding author: Stuart Watson, University of Newcastle, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE41 8EP, United Kingdom. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(11)
Downloaded from anp.sagepub.com at FUDAN UNIV LIB on May 15, 2015
976 finding reminds us of the value of seeking information about early experiences so that we can better advise about their expected health trajectories and optimise the use of, unfortunately scarce, psychotherapeutic resources. It raises questions about the biological and psychological mediation of the impact of early adversity. The emerging understanding of the epigenetic scars imposed by childhood stress and the knowledge that these scars are reversible is relevant here and, when considered alongside the Daglas study, will help us to better understand both the way that our earliest experiences alter developmental trajectories and also the biological
Editorial underpinnings of bipolar disorder. It will also give hope that psychotherapeutic endeavours will make a real difference to our patients. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Crowe M, Porter R, Inder M, et al. (2012) Effectiveness of interventions to improve
medication adherence in bipolar disorder. Australian and New Zealand Journal of Psychiatry 46: 317–326. Daglas R, Conus P, Cotton SM, et al. (2014) The impact of past direct-personal traumatic events on 12-month outcome in first episode psychotic mania: Trauma and early psychotic mania. Australian and New Zealand Journal of Psychiatry 48: 1017-1024. Klengel T, Pape J, Binder EB, et al. (2014) The role of DNA methylation in stress-related psychiatric disorders. Neuropharmacology 80: 115–132. Nemeroff CB, Heim CM, Thase ME, et al. (2003) Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proceedings of the National Academy of Sciences of the United States of America 100: 14,293–14,296. Watson S, Gallagher P, Dougall D, et al. (2013) Childhood trauma in bipolar disorder. Australian and New Zealand Journal of Psychiatry 48: 564–570.
Australian & New Zealand Journal of Psychiatry, 48(11) Downloaded from anp.sagepub.com at FUDAN UNIV LIB on May 15, 2015
ANP0010.1177/0004867414553954Australian & New Zealand Journal of PsychiatryWatson and Porter
Editorial Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 975–976 DOI: 10.1177/0004867414553954
Childhood adversity in bipolar disorder
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Stuart Watson1 and Richard J Porter2
In this issue, Daglas and colleagues (2014) present a study examining the impact of early adversity on the 12-month outcome of patients managed in Melbourne who presented with first-episode psychotic mania. The data shows that patients who have reported early adversity fare worse and have higher scores on symptom rating scales and worse psychosocial functioning at 12-month follow-up. This study is unique because of the specificity of the population and the authors are to be congratulated for recruiting 65 participants. The study adds significantly to the literature in this area. Over the past few years it has become increasingly evident that childhood adversity is a major risk factor for bipolar disorder (indeed for all mood disorders) and is associated with a greater symptom burden and a worse prognosis. There are a number of implications of this. First, it is incumbent upon us, as clinicians, to give our patients the opportunity to discuss childhood experiences – and here we need to be aware that the relevant experiences are not confined to intrusive and frightening incidents but include also factors such as the persistent absence of a loving and supportive parental relationship (Watson et al., 2013). We also need to reconsider our use of psychological therapies. Psychological treatment for bipolar disorder has tended to focus on psychoeducation, often with the intended outcome being increased compliance with medication (Crowe et al., 2012), and on ‘Social Rhythms’ focusing on regularising activity and sleep.
Psychoeducation and Interpersonal Social Rhythms Therapy have proven benefit in clinical trials (Crowe et al., 2012). Daglas’ paper, however, and others in the field, in demonstrating the importance of early experiences raise the question of the extent to which it may also be helpful to develop therapeutic interventions which address the psychological consequences of upbringing and early experience. The potential value of this is highlighted by a study which demonstrated a greater benefit from psychotherapy compared with drug treatment in depressed patients who had experienced childhood abuse (Nemeroff et al., 2003). The natural tendency is for the intensity of therapeutic input to reduce when bipolar patients recover from acute episodes and are ‘stabilised’. This is the very time, we would argue, that bipolar patients are most able to make use of psychological therapies which may serve to improve prognosis by reducing the persistent burden of low mood or the likelihood, severity or duration of future relapse. Daglas’ study also causes us to reflect on the biological substrates of mania and depression and on the mechanism by which events in childhood, or indeed in utero, can alter developmental trajectories and ultimately manifest such diverse psychopathology in adulthood. Exciting developments in the field of epigenetics shows us that genes relevant to the aetiology and maintenance of bipolar disorder can be persistently rendered more or less active by experiences during critical developmental
periods. Such epigenetic scars, which are moderated by genetic factors (single nuclear polymorphisms, etc.) to determine the risk of developing a host of psychiatric disorders, including bipolar disorder, can be transmitted from generation to generation but, importantly, are reversible and thus may give a biological substrate for the beneficial effect of mindfulness and other therapies. The impact of epigenetic changes is likely mediated by an interacting network of structural and functional parameters. Hippocampal structure and function, the immune system and the hypothalamic-pituitary-adrenal axis appear particularly relevant at this stage; certainly the relationship of childhood adversity on the expression and function of the glucocorticoid receptor has been the focus of much scientific endeavour (Klengel et al., 2014). In short, the paper by Daglas and colleagues in this month’s issue provides further support to the notion that upbringing affects the risk of developing psychosis and mania and engenders a poor prognosis. This
1The
Wolfson Research Unit, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom 2Department of Psychological Medicine, University of Otago, Christchurch, New Zealand Corresponding author: Stuart Watson, University of Newcastle, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE41 8EP, United Kingdom. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(11)
Downloaded from anp.sagepub.com at FUDAN UNIV LIB on May 15, 2015
976 finding reminds us of the value of seeking information about early experiences so that we can better advise about their expected health trajectories and optimise the use of, unfortunately scarce, psychotherapeutic resources. It raises questions about the biological and psychological mediation of the impact of early adversity. The emerging understanding of the epigenetic scars imposed by childhood stress and the knowledge that these scars are reversible is relevant here and, when considered alongside the Daglas study, will help us to better understand both the way that our earliest experiences alter developmental trajectories and also the biological
Editorial underpinnings of bipolar disorder. It will also give hope that psychotherapeutic endeavours will make a real difference to our patients. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Crowe M, Porter R, Inder M, et al. (2012) Effectiveness of interventions to improve
medication adherence in bipolar disorder. Australian and New Zealand Journal of Psychiatry 46: 317–326. Daglas R, Conus P, Cotton SM, et al. (2014) The impact of past direct-personal traumatic events on 12-month outcome in first episode psychotic mania: Trauma and early psychotic mania. Australian and New Zealand Journal of Psychiatry 48: 1017-1024. Klengel T, Pape J, Binder EB, et al. (2014) The role of DNA methylation in stress-related psychiatric disorders. Neuropharmacology 80: 115–132. Nemeroff CB, Heim CM, Thase ME, et al. (2003) Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proceedings of the National Academy of Sciences of the United States of America 100: 14,293–14,296. Watson S, Gallagher P, Dougall D, et al. (2013) Childhood trauma in bipolar disorder. Australian and New Zealand Journal of Psychiatry 48: 564–570.
Australian & New Zealand Journal of Psychiatry, 48(11) Downloaded from anp.sagepub.com at FUDAN UNIV LIB on May 15, 2015
