Racing thoughts revisited: A key dimension of activation in bipolar disorder

Abstract

Background: Racing and crowded thoughts are frequently reported respectively in manic and mixed episodes of bipolar disorder (BD). However, questionnaires assessing this symptom are lacking. Here we aimed to investigate racing thoughts across different mood episodes of BD through a self-report questionnaire that we developed, the 34-item Racing and Crowded Thoughts Questionnaire (RCTQ). In addition to assessing its factor structure and validity, we were interested in the RCTQ's ability to discriminate mixed and non-mixed depression. Methods: 221 BD patients and 120 controls were clinically assessed via the YMRS (mania) and the QIDS-C16 (depression), then fulfilled the RCTQ, rumination, worry, and anxiety measures. Three depression groups were operationalized according to YMRS scores: YMRS scores 2 > 6 and YMRS scores = 1 or 2, for respectively mixed and non-pure depression, and YMRS = 0 for pure-depression. Results: Confirmatory factor analysis showed that the three-factor model of the RCTQ yielded the best fit indices, which improved after the removal of redundant items, resulting in a 13-item questionnaire. Hypomanic and anxiety symptoms were the main predictors of scores; rumination was not a significant predictor. RCTQ results were similar between mixed groups and non-pure depression, and both were higher than in pure-depression. Limitations: Patients' pharmacological treatment might have influenced the results. Conclusions: The 13-item RCTQ captures different facets of racing thoughts heightened in hypomanic and mixed states, but also in depression with subclinical hypomanic/activation symptoms (e.g. non-pure depression characterized by enhanced subjective irritability), suggesting that it is particularly sensitive to activation symptoms in BD, and could become a valuable tool in the follow-up of patients.

Racing and crowded thoughts in mood disorders: A data-oriented theoretical reappraisal

“…Concerning the question of anxiety, our own studies have confirmed the view developed in the 2010 review [13] that there was a link between racing thoughts and anxiety both in the general population [20] and in mood disorders patients [19,24]. This link could rely on a common dimension of hyperarousal in anxiety states and in hypomanic or mixed bipolar states.…”

“…Our recent studies confirmed the independence of the concept of racing/crowded thought and the concept of rumination by showing no relationship between the RCTQ score and the two subscales scores of the Ruminative Response Scale State version [60] neither in a general population sample [20] nor in a clinical sample [24]. Besides, a French study [61] showed that the level of depression in subjects initially admitted as emergencies for acute anxiety depressive disorders and/or suicide attempts was correlated with increased 'flow of thoughts', but not number of thoughts; these two dimensions were elegantly assessed by filling a drawing of an aquarium to reflect the number of thoughts (by drawing fish) and cognitive turmoil (by drawing wavy lines).…”

“…The "thought overexcitability" subscale included items conveying the notion of distractibility, and, in contrast with the first two factors, was associated with both elated and low mood. Subsequently, in a large clinical study including French, Italian and Belgian bipolar patients led by our group [24], the three-factor solution of the RCTQ yielded the best fit indices when compared with a single factor model proposed by our initial work [19] or an hypothetical two-factor model based on the racing versus crowded thought distinction. The short 13-item RCTQ, resulting from the removal of redundant and less discriminant items within the three factors, had the strongest psychometric properties [24].…”

Thought and language disturbance in bipolar disorder quantified via process-oriented verbal fluency measures

“…This makes the process-oriented VFT results all the more useful, as they provide a quantification of this clinical symptom, and improve the phenomenological models and scales aimed at evidencing enhanced spontaneous flexibility potentially involved in racing thoughts 14 . Importantly, clustering and switching abnormalities differentiated patients with manic symptoms, including the mixed depression group with few subthreshold – overlapping or not – hypomanic symptoms, from typical depression, suggesting that very few activation symptoms concurrent with depression might give rise to speech and thought abnormalities similar to those found in mania 25,37 .…”

Vocal features obtained through automated methods in verbal fluency tasks can aid the identification of mixed episodes in bipolar disorder

“…In our study, instead of applying the DSM-5 criteria [ 9 ], we used a data-driven approach based on Miller et al [ 11 ] and Suppes et al [ 28 ] to determine whether patients were in a mixed episode or not. This approach has been favored in a number of recent studies which argue for the use of a less-restrictive diagnostic algorithm for the diagnosis of mixed states, including overlapping symptoms (distractibility, irritability, and psychomotor agitation) [ 7 , 11 , 45 , 47 ]. While the algorithms we used were less restrictive than the ones proposed by the DSM-5, there is an ongoing debate whether even less restrictive approaches focusing on specific features should be favored [ 7 ].…”