Successful treatment in a case of ultra‐rapid cycling bipolar disorder is reflected in brain arousal regulation

Abstract

Ultra-rapid cycling is a rare form of bipolar affective disorder with more than four mood episodes per month (ICD-10: F31.8). A dysregulation of brain arousal has been discussed as a potential pathogenetic mechanism underlying both affective disorders and attention deficit hyperactivity disorder (ADHD). 2 Brain arousal denotes a global functional state of the brain and corresponds behaviorally to different levels of wakefulness. In healthy individuals, brain arousal adapts flexibly to changing environmental requirements. For example, during the wake-sleep transition, brain arousal is gradually downregulated, whereas an external threat may result in a sudden upregulation of arousal. Brain arousal and its regulation can be reliably assessed using electroencephalography (EEG).A previous study provided first evidence that bipolar patients with depressive episodes differ in their arousal regulation from bipolar patients with manic episodes. Specifically, upregulated arousal was found during depressive episodes, whereas patients with manic episodes show an earlier decline to low arousal levels than healthy controls. 3 To date, such comparisons have not been conducted based on longitudinal studies of the same individuals. In addition, brain arousal regulation has not been previously studied in patients with ultra-rapid cycling. In this context, we examined the patterns of brain arousal regulation in a successfully treated patient with ultra-rapid cycling. Based on the arousal regulation model of affective disorders, 2 we expected to find upregulated (hyperstable) arousal in the depressive state and a faster onset of low EEG-vigilance stages (indicating states of arousal) and lower arousal level in the hypomanic state as compared to the remitted state. To objectively assess brain arousal and its regulation, we applied the Vigilance Algorithm Leipzig (VIGALL; version 2.1; manual and download at https://research.uni-leipzig.de/vigall/) in the current study. VIGALL is an EEG-and electrooculogram (EOG)-based algorithm, using low-resolution electromagnetic tomography, that allows an automatic classification of EEG-vigilance stages within multichannel EEG recordings (for a detailed description, see 1 ). Preprocessing and EEG-vigilance staging were conducted as previously described. 3 | CASE PRESENTATIONMr. J, a 46-year-old white male (body mass index [BMI] 33.6), was admitted to our inpatient psychiatric unit with rapidly switching mood states for adjustment of medication. Ten months prior to presentation, he first developed ultra-rapid cycling after antidepressant therapy with venlafaxine. Following this hospitalization, he was diagnosed with bipolar disorder as a patient of our outpatient clinic, and then stabilized with lithium. On current presentation, Mr. J was complaining about depressed mood, irritability and high inner tension, sleeplessness and feeling high. He reported cycling of affective states between 24 and 72 hours, with depressive states in the morning and switches to mania in the afternoon as well as mixed moo...

Impact of brain arousal and time-on-task on autonomic nervous system activity in the wake-sleep transition

“…For example, an unstable regulation of brain arousal was found in patients with bipolar disorder during manic episodes [18] and in patients with ADHD [19]. In contrast, a hyperstable pattern of arousal regulation was observed in patients with depression [20, 21] and bipolar patients during depressive episodes [18, 22]. …”

Fatigue and brain arousal in patients with major depressive disorder

“…VIGALL has been validated with simultaneous EEG-PET and EEG-fMRI studies (for review, see [34]) and by relating EEG vigilance stages to parameters of the autonomic nervous system [28,35,36]. Using this approach, arousal dysregulations have been found in patients with affective disorders and ADHD [10,[37][38][39][40]. In patients with MDD an upregulated arousal regulation, compared to healthy controls during a resting state EEG, is a robust finding [37,41,42].…”