Behavioural addictions in bipolar disorder patients Role of impulsivity and personality dimensions

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JournalofAffectiveDisorders

journalhomepage:www.elsevier.com/locate/jad

Researchreport

Behaviouraladdictionsinbipolardisorderpatients:Roleofimpulsivityandpersonalitydimensions

MarcoDiNicola⁎,DanielaTedeschi,MariannaMazza,GiovanniMartinotti,DesireeHarnic,ValeriaCatalano,AngeloBruschi,GinoPozzi,PietroBria,LuigiJaniri

InstituteofPsychiatry,BipolarDisorderUnit,CatholicUniversityMedicalSchool,Rome,Italy

articleinfoabstract

Background:Behaviouraladdictions(BAs)canbeunderstoodasdisorderscharacterizedbyrepetitiveoccurrenceofimpulsiveanduncontrolledbehaviours.Veryfewstudieshaveinvestigatedtheirassociationwithmooddisorders.Thepresentstudywasundertakentodeterminetheprevalenceofthemainbehaviouraladdictionsinasampleofbipolaroutpatientsineuthymicphaseorstabilisedbymedicationsandtoinvestigatetheroleofimpulsivityandtemperamentalandcharacterdimensions.

Methods:One-hundred-fifty-eightBipolarDisorder(BD)(DSM-IV)outpatientswereassessedwithtestsdesignedtoscreenthemainbehaviouraladdictions:pathologicalgambling(SOGS),compulsiveshopping(CBS),sexual(SAST),Internet(IAD),work(WART)andphysicalexercise(EAI)addictions.TCI-RandBIS-11wereadministeredtoinvestigateimpulsivityandpersonalitydimensionsmainlyassociatedwithBAs.Theclinicalsamplehasbeencomparedwith200matchedhealthycontrolsubjects.

Results:Inbipolarpatients,33%presentedatleastoneBArespecttothe13%ofcontrols.Significantlyhigherscoresatthescalesforpathologicalgambling(pb.001),compulsivebuying(pb.05),sexual(pb.001)andworkaddictions(pb.05)havebeenfound.Self-Directness(p=.007)andCooperativeness(p=.014)scoresweresignificantlylowerwhileimpulsivitylevelwassignificantlyhigher(p=.007)inbipolarpatientswithBAthanthosewithoutBA.Conclusions:Toourknowledge,thisisthefirststudyinvestigatingtheprevalenceofbehaviouraladdictionsinBDshowingasignificantassociationofthesedisorders.BAsaremorefrequentinbipolarpatientsthaninhealthycontrolsandarerelatedtohigherimpulsivitylevelsandcharacterimmaturity.

©2010ElsevierB.V.Allrightsreserved.

Articlehistory:

Received12August2009

Receivedinrevisedform19December2009Accepted20December2009

Availableonline18January2010Keywords:

Bipolardisorder

BehaviouraladdictionsImpulsivity

Personalitydimensions

1.Introduction

Behaviouraladdictions(BAs)canbeunderstoodasdisorderscharacterizedbyrepetitiveoccurrenceofimpulsiveanduncontrolledbehavioursthatcausepsychological,socialandworkingproblems,sometimesalsolegalandeconomicconsequences.Corefeaturesofthesedisordersarefailuretoresistanimpulse,driveortemptationtoperformsomeact

⁎Correspondingauthor.InstituteofPsychiatry,BipolarDisorderUnit,CatholicUniversityMedicalSchool,LargoAgostinoGemelli,8,Rome00168,Italy.Tel.:+393406860419;fax:+390697276550.

E-mailaddress:mdnicola@libero.it(M.DiNicola).0165-0327/$–seefrontmatter©2010ElsevierB.V.Allrightsreserved.doi:10.1016/j.jad.2009.12.016

harmfultooneselfand/orothers,anincreasingsenseoftensionorexcitementbeforeactingout,asenseofpleasure,andgratificationorreleaseatthetimeofthebehaviourorshortlythereafter(Leioyeuxetal.,2000).

Behaviouraladdictionsincludeindulgenceingambling,shopping,sex,Internet,affectiverelationships,work,physicalactivityorevenfood.Alltheseactivitiesarepartoflifeanddonothaveanynegativeimpactinthenormalcourse;infact,itisnottheobjectthatdeterminetheaddictionbutaparticularlyintenseandrigidrelationshipbetweentheaddictandtheactivityofchoice(Keane,2004).

DSM-IVdoesnotcontemplateanycategoryneitherdiagnosticcriteriaforBAswiththeexceptionofpathological

M.DiNicolaetal./JournalofAffectiveDisorders125(2010)82–8883

gamblingwhichiscodedasanImpulseControlDisorder(ICD)(APA,2000).OtherBAssuchascompulsivecomputeruse,compulsivesexualbehaviour,andcompulsivebuyinghavebeenproposedtobeincludedinICDnototherwisespecified(NOS)(KuzmaandBlack,2005).However,thediscussionisstillopenwhetherBAsarerelatedtomooddisorders(WiseandTierney,1994),substanceusedisorders(Marks,1990),orimpulsecontroldisorders(Christensonetal.,1994)orwhethertheyfallwithinanobsessive–compulsivedisorderspectrum(Blacketal.,1998;LeeandMysyk,2004).

ComorbidityratesbetweenBAsandmooddisordershavenotbeensystematicallyinvestigatedandresultsaredebated.Studieshavereportedhighratesofmajordepressionanddysthymiaamongpathologicalgamblers(Blandetal.,1993;Cunningham-Williamsetal.,1998;Petryetal.,2005).Anepidemiologicalstudyfromel-Guebalyetal.(2006)underlinedthattheriskofmoderate/highseveritygamblingwas1.7timeshigherinsubjectswithmooddisordersandthatthosewithaffectivedisorderswere5timesmorelikelytobemoderate/highseveritygamblers.In24compulsivebuyers,Christensonetal.(1994)reportedthat50%wasaffectedbymajordepres-sion.Lejoyeuxetal.(1997)foundaprevalenceofcompulsivebuyingdisorderof31.9%inasampleof119depressedsubjects.Inamorerecentstudy,Lejoyeuxetal.(2002)reportedthatcompulsivebuyingindepressedpatientswassignificantlyassociatedwithcomorbidImpulseControlDisorders(ICDs).A39%comorbidityformajordepressionordysthymiawasfoundinthirty-sixsubjectsaffectedbycompulsivesexualbehaviour(Blacketal.,1997).AlsoforInternetaddictiontheassociationwithdepressivedisordersseemstobefrequent(Mihajlovićetal.,2008;ShawandBlack,2008).

Withregardtobipolardisordersveryfewstudieshavebeenconducted.Zimmermanetal.(2006)foundthatsubjectswithpathologicalgambling(PG)hadsignificantlymoreaxisIdisordersthansubjectswithoutPG,withhigherratesofbipo-lardisorder.ResultsfromtheCanadianCommunityHealthSurvey(McIntyreetal.,2007)reportedasignificantlyhigherprevalenceofPGamongthepopulationwithbipolardisorderascomparedtothegeneralpopulationandthosewithmajordepressivedisorder.Shapiraetal.(2000)intwentysubjectswithproblematicInternetusefoundalifetimediagnosisofbipolardisorder(with12havingbipolarIdisorder)in14ofthem.

Lejoyeuxetal.(1997)showedthatinasampleofdepressedpatients,compulsivebuyingwassignificantlyassociatedwithahighlevelofimpulsivity.Inmostcasesofbehaviouraldependencedisorders,ahighlevelofimpulsivityandsensation-seekingornoveltyseekingcoulddetermineanincreasedrisk(Leioyeuxetal.,2000).

Thepresentstudywasundertakentodeterminetheprevalenceofthemainbehaviouraladdictionsinasampleofbipolaroutpatients,andwhetherbehaviouraldependenceshaveclinicalspecificities.Inparticularweaimed:(i)toestimatetheprevalenceofBAs(pathologicalgambling,compulsivebuying,Internetaddictiondisorder,sexual,workandphysicalexerciseaddictions)inasampleofbipolarpatientsineuthymicphaseorstabilisedbymedicationsincomparisonwithmatchedhealthycontrolsubjects;(ii)tounderlineanypossiblecorrelationamongtheBAsscalesandbetweenBAs,impulsivityandpersonalitydimensions;(iii)tocomparebipolardisorderpatientswithandwithoutBAfor

socio-demography,prevalenceofbipolardisorderstypes,onsetanddurationofillness,associationwithcomorbidaxisIandIIdisorders,impulsivitylevelandtemperamentalandcharacterdimensions.2.Methods

ParticipantswererecruitedfromSeptember2006toOctober2008amongoutpatientsreferringtotheBipolarDisorderUnitTreatmentoftheDay-HospitalofClinicalPsychiatryoftheUniversityGeneralHospital“A.Gemelli”inRome.

Two-hundred-fifty-twosubjectswereconsecutivelyscreened.Inclusioncriteriawere:1)currentlymeetingDSM-IVcriteriaforBipolarDisorderI(BP-I),BipolarDisorderII(BP-II)orCyclothymicDisorder(CtD);2)age18to75years;3)thepropertyofspokenandwrittenItalianlanguage.

Subjectswereexcludedifanyofthefollowingconditionswaspresent:1)adiagnosisofmentalretardationordocu-mentedIQb70;2)comorbiditywithschizophrenicdisordersorsevereneurologicaldiseases;3)activesuicidalideation;4)currentmania;5)unstablegeneralmedicalconditions;6)clinicallysignificantpre-studyphysicalexam,electrocardio-gram,haematologicalandbiochemicalanalysesofbloodsamples,hormonalevaluationincludingthyroidhormones,orurinalysisabnormalitiesindicatingseriousmedicaldiseaseimpairingevaluation;7)alcohol/substanceintoxicationatthemomentoftheassessmentastotoxicologicalanalysis.

BPdiagnosiswaspreliminaryestablishedbytrainedpsychiatristsusingtheStructuredClinicalInterviewforDSM-IVAxisIDisorders(SCID-I)(Firstetal.,1995).PersonalitydisorderswerediagnosedthroughtheStructuredClinicalInterviewforDSM-IVAxisIIDisorders(SCID-II)(Firstetal.,1990).

Atthesametime,healthycontrolsubjects(HC)havebeenenrolled.HCsubjectswerefreeofanyAxisIpsychopathologyasdeterminedbytheSCID-I,NonPatientedition(SCID-I/NP)(Firstetal.,2002).2.1.Procedure

AftertheestablishmentoftheBipolarDisorderdiagnosis,ananamnesticinterviewwasadministeredtoobtainsocio-demographicinformation,medicalandpsychiatrichistory,andpsychiatricfamiliarhistory.

Eachpatienthasbeenevaluatedafteraperiodofatleasttwomonthsfromthelastacutephaseofdisease.Accordingtotheclinicalandtestingevaluation[ClinicalGlobalImpres-sion-Severity3–4(Guy,1976);HamiltonDepressionRatingScaleb8(Hamilton,1960);YoungManiaRatingScaleb6(Youngetal.,1978)]recruitedsubjectsweremildlyormoderatelyillandoutofanyhypomanic/manicordepressedstate.

Raters(MDNandMM)werespecificallytrainedandshowedagoodinter-ratereliabilityonallinstruments(kN0.80).

Attheevaluationsession,patientsfollowedanaturalisticmaintenancetreatment,withatypicalantipsychotics(olanza-pine,quetiapine,andaripiprazole),establishedmoodstabilisersandnewantiepilepticdrugs(lithium,valproate,carbamazepine,topiramate,andoxcarbazepine),antidepressants(SSRI,SNRI,NaSSA,andunspecificantidepressants).

84M.DiNicolaetal./JournalofAffectiveDisorders125(2010)82–88

Eachpatientwasadministeredabatteryofself-reportquestionnairestoscreenthemainbehaviouraladdictions,theItalianversionofboththeTemperamentandCharacterInventory—Revisedversion(TCI-R)(Cloninger,1999;Martinottietal.,2008)andtheBarrattImpulsivenessScaleversion11(BIS-11)(BarrattandStanford,1995;Fossatietal.,2001).TheSCIDIandIIwereadministeredfirstly(day1),thebehaviouraladdiction'squestionnairesandtheBIS-11wereadministeredduringafollowingmorningsessionnotex-ceeding1h,andwerealwayscompletedinthesameorderofsequence(day2).TheTCI-Rwasfilledoutinanothermorningsession(day3).

2.2.Assessmentinstruments

1)TheSouthOaksGamblingScreen(SOGS)(Lesieurand

Blume,1987).A20-itemquestionnairebasedonDSM-IIIcriteriausedasascreeningdevicetoidentifypathologicalgambling.

2)CompulsiveBuyingScale(CBS)(FaberandO'Guinn,1992a,

b).Itcontains13itemsderivedfrompreviousresearchandtheoreticalmodelsofcompulsivebuying.Subjectswereaskedtoratehowtrueeachitemwasforthemonascalerangingfrom1(notatall)to7(verymuch).Thescalehasanegativecut-offsothatthemorenegativearethescoresthemoresevereisthecompulsivebuyingbehaviour.3)SexualAddictionScreeningTest(SAST)(Carnes,1991),

designedtoassistintheassessmentofsexuallycompul-sivebehaviourswhichmayindicatethepresenceofsexaddiction.Developedincooperationwithhospitals,treatmentprograms,privatetherapistsandcommunitygroups,theSASTprovidesaprofileofresponseswhichhelptodiscriminatebetweenaddictiveandnon-addictivebehaviour.Itconsistsof25dichotomousyes/noitems.4)InternetAddictionDisordertest(IAD)(Young,1996).A20-itemInternetAddictionTest.WidyantoandMcMurran(2004)reportthatitemsreflectsixunderlyingdimensionsofInternetaddiction:salience,excessiveuse,neglectofwork,anticipation,lackofcontrolandneglectofsociallife.Itemsareratedona5-pointscale,where1=veryrarelyand5=veryfrequently.

5)WorkAddictionRiskTest(WART)(RobinsonandPost,

1994).This25itemssurveymorerecentlyspecifyingfiveunderlyingdimensionsofcompulsivetendencies,control,impairedcommunications/self-absorption,inabilitytodelegate,andself-worth(FlowersandRobinson,2002).6)ExerciseAddictionInventory—ShortForm(EAI)(Griffiths

etal.,2005).Itconsistsofsixstatementsbasedonamodifiedversionofthecomponentsofbehaviouraladdiction(Griffiths,1996).EachstatementhadafivepointLikertresponseoptioncodedsothathighscoresreflectedattributesofaddictiveexercisebehaviour:11/4“Stronglydisagree”,21/4“Disagree”,31/4“NeitheragreenorDisagree”,41/4“Agree”,51/4“StronglyAgree”.

7)TemperamentandCharacterInventory—Revisedversion

(TCI-R)(Cloninger,1999;Martinottietal.,2008).Itisatrue/falsequestionnairemeasuringtemperament(4dimensions:NoveltySeeking/NS,HarmAvoidance/HA,RewardDependence/RD,andPersistence/PE)andcharac-ter(3dimensions:SelfDirectness/SD,Cooperativeness/COandSelfTrascendence/ST).

8)BarrattImpulsivenessScale—11(BIS-11)(Barrattand

Stanford,1995;Fossatietal.,2001).Itisa30itemsself-reportedquestionnairethatinvestigateimpulsivitydi-mension;itincludesthreesubscales:Attentional(pro-blemsrelatedtoconcentrating/payingattention),Motor(fastreactionsand/orrestlessness),andNon-planning(orientationtowardthepresentratherthantothefuture).TothecontrolsampleonlythescalesforBAsassessmentwereadministered.

Anonymityhasbeenguaranteedtoalltheparticipants;thestudyprotocolcompliedfullywiththeguidelinesoftheEthicsCommitteeoftheCatholicUniversityofRome,andwasapprovedbytheInstitutionalReviewBoardsinaccordancewithlocalrequirements.ItwasconductedinaccordancewithGoodClinicalPracticeguidelinesandtheDeclarationofHelsinki(19)andsubsequentrevisions.Writteninformedconsentwasaskedafteracompletedescriptionofthestudywasprovidedtoeachsubject.Eachpatientatthepresenceofafamilymemberoracaregiverwasinformedthatnon-compliance,ortheinabilitytofillinthequestionnaireswouldleadtotheirexclusionfromthestudy.However,patientswerefreetoleavethestudyatanytime.Allsubjectsparticipatewithoutreceivinganyformofpayment.2.3.Statisticalanalysis

SincealltheBAscalesexceptofWART,checkedusingtheKolmogorov–Smirnovone-sampletest,werenotnormallydistributedbothinbipolarsubjects(SOGS:Z=4.272,pb.001;CBS:Z=1.577,p=.014;SAST:Z=1.422,p=.035;IAD:Z=3.326,pb.001;WART:Z=.424,p=.994;EAI:Z=1.952,p=.001)andhealthycontrols(SOGS:Z=6.366,pb.001;CBS:Z=1.437,p=.032;SAST:Z=3.565,pb.001;IAD:Z=3.363,pb.001;WART:Z=1.0,p=.187;EAI:Z=1.797,p=.003),theprincipaloutcomeanalysisconsistedofnonparametricMann–WhitneyUtestforcomparisonbetweenthetwogroups.

Spearman'scoefficientofrankcorrelationwascalculatedtoexaminetherelationshipbetweenBAscales,TCI-RdimensionsandBIS-11score.

ComparisonbetweenbipolarpatientspresentingwithandwithoutBAswasmadeforcontinuousvariablesbyusingtheindependentStudent'sttest,andfordiscretevariablesbytheChi-squaretest.

Finally,todeterminewhatfactors,ifany,wereassociatedwithBAs,weenteredvariablesthatweresignificantatpb.10inthebivariateanalysesintoamultivariablemodelusinglogisticregression.Weexaminedallvariablesformulti-collinearity.TheHosmer–Lemeshowgoodness-of-fitstatisticwasusedtocheckthefitofthemodel.FindingswerereportedasOddsRatios(ORs)andpvalues.

Statisticalsignificancewasdeterminedatthe.05levelofconfidence.3.Results

Eighty-onepatientswereexcludedbecausetheyfailedinthefulfilmentofinclusioncriteria;171weretestedonday1.Thirteenweredropped-out(4atday2and9atday3)becauseoflackofcomplianceandwerenotconsideredinthe

M.DiNicolaetal./JournalofAffectiveDisorders125(2010)82–8885

study.One-hundred-fifty-eightbipolarpatientswerefinallyincludedinthestudy.Two-hundredHCsubjectspairedtopatientsforgender,ageandeducationhavebeenconsideredfortheanalysis.

Socio-demographiccharacteristicsandclinicaldataofthesamplesareillustratedinTable1.AllsubjectsenrolledforthestudywereCaucasians.

Intheclinicalsample,comorbidAxisIdisorderswereintheareaofanxiety(n=16).TheadditionalAxisIIdiagnosiswere:borderline(n=8),avoidant(n=9),histrionic(n=14),passive–aggressive(n=8),schizoid(n=7)andNonOtherwiseSpecified(NOS)(n=8)personalitydisorders.Substancemisusewaspresentin30%oftheBPsubjects(n=47),twelvesubjects(7.6%)reportedprevioussuicideattempts.

3.1.Patientsvs.controls

InFig.1percentagesofsubjectsthatreachthecut-offatthequestionnairesforthescreeningofbehaviouraladdictionsaredescribed.

Inbipolarpatients,33%(n=52)reachedthecut-offforatleastoneBAwhileamonghealthycontrolsubjectsonlythe13%(n=16)didit.

BipolarpatientsweresignificantlymorelikelytoreporthighermeanscorestotheBAsscreeninginstrumentswiththeexceptionofthephysicalexerciseandInternetones,thanthecontrolgroup(Table2).Interestingly,themeanscoretotheIADforthescreeningofInternetaddictionwassignificantly

Table1

Socio-demographicandclinicaldataofbipolardisordersubjectsandhealthycontrols.Percentagesaregiveninbrackets.

Bipolarpatients

HealthycontrolsN

158200Gender(males)65(41)80(40)Age(M±SD)48.7±12.7

46.2±13.8

MaritalstatusSingle52(33)72(36)Married

76(48)100(50)Separated/divorced21(13)20(10)Widowed

9(6)8(4)

LevelofeducationElementaryschool

3(2)0

Lowersecondaryschool32(20)24(12)Highschooleducation88(56)120(60)Degree

35(22)56(28)

EmploymentconditionRegularjob

68(43)104(52)Occasionallyemployed11(7)30(15)Unemployed44(28)30(15)Student8(5)14(7)Retired

27(17)22(11)

BipolardiagnosisBP-I71(45)–BP-II44(28)–CtD

43(27)–Onsetofillness(age)(M±SD)30.1±8.4–Durationofillness(M±SD)

19.7±13.7–

BP-I,BipolarDisorderI;BP-II,BipolarDisorderII,CtD,CyclothymicDisorder.

Fig.1.Percentagesofsubjectsthatreachthecut-offatthequestionnairesforthescreeningofbehaviouraladdictions.Legend:SOGS:TheSouthOaksGamblingScreen;CBS:CompulsiveBuyingScale;SAST:SexualAddictionScreeningTest;IAD:InternetAddictionDisordertest;WART:WartAddictionRiskTest;EAI:ExerciseAddictionInventory.

higher(pb.001)inthehealthycontrolgroupthanintheclinicalsample,althoughnobodyreachedthecut-offforInternetAddictiondiagnosis(Table2,Fig.1).3.2.CorrelationsinBDpatientsgroup

Spearman'scorrelationsbetweenBAsscoresaredescribedinTable3whilecorrelationsbetweenBAs,TCI-RandBIS-11scoresareshowninTable4.

3.3.Bipolarpatientswith(BA+group;n=52)andwithoutbehaviouraladdictions(BA−group;n=106)

BA+groupweremorelikelytobeunemployed(χ2=5.368,p=.021)andcomorbidforanAxisIIpersonalitydisorder(χ2=5.162,p=.023)thantheBA−group.

Student'sttestrevealedthatSelf-Directness(t=2.760,p=.007)andCooperativeness(t=2.520,pb.014)scoresweresignificantlylowerandimpulsivitylevelwassignificantlyhigher(t=−2.737,p=.007)inpatientsBA+thanthoseBA−.

Table2

Mann–WhitneyUtestforcomparisonofBAsmeanscoresbetweenbipolardisorderpatients(BD)andhealthycontrols(HC).Legend:SOGS:TheSouthOaksGamblingScreen;CBS:CompulsiveBuyingScale;SAST:SexualAddictionScreeningTest;IAD:InternetAddictionDisordertest;WART:WartAddictionRiskTest;EAI:ExerciseAddictionInventory.

SubjectsMann–WhitneyUBD(n=158)HC(n=200)TestM±SD

M±SDZpvalueSOGS.87±2.3.23±1.29−3.7b.001⁎CBS.56±2.581.33±1.8−2.032.042⁎SAST4.17±3.2.32±4.06−5.349b.001⁎IAD25.6±11.728.14±10.52−3.950b.001⁎WART52.66±13.9148.47±11.14−2.794.005⁎EAI

11.22±5.96

11.11±4.91

−.566

.571n.s.

n.s.:notsignificant.

⁎Differenceisstatisticallysignificant.

86M.DiNicolaetal./JournalofAffectiveDisorders125(2010)82–88

Table3

Spearman'scorrelationsbetweenmeanscoresattheBAscalesinbipolardisorderpatients(n=158);**=pb.01;*=pb.05.Legend:SOGS:TheSouthOaksGamblingScreen;CBS:CompulsiveBuyingScale;SAST:SexualAddictionScreeningTest;IAD:InternetAddictionDisordertest;WART:WartAddictionRiskTest;EAI:ExerciseAddictionInventory.

SOGS

CBSSASTIADWARTEAISOGS–

−.255*.346**.311**.181.151CBS−.255*–

−.388**−.229*−.145−1.145SAST.346**−.388**–

.322**.143.301**IAD.311**−.229*.322**–

.268**.312**WART.181−.145.143.268**–.198*EAI

.151

−.145

.301**

.312**

.198*

–

TherewasnostatisticaldifferencebetweenBA+andBA−bipolarpatientsintermsofgender,age,levelofeducation,bipolarspectrumdiagnosis,onsetanddurationofillness,comorbidAxisIdisorders,substancemisuseandthepresenceofprevioussuicideattempts.

Consideringallbipolarsubjects,logisticregressionanal-ysisshowedthatthosewithahigherCooperativeness(OR=0.9;p=.042)andwithoutacomorbidAxisIIdiagnosis(OR=0.15;p=.003)havealowerrisktodevelopabeha-viouraladdiction.

Finally,weanalysedthedifferencesbetweensubjectswitheachbehaviouraladdictionandthosewithoutco-occurringBA.Becauseofthesmallsizeofthepopulationenrolled,statisticaldifferencescouldnotbedetermined.

Compulsivebuyersbipolarpatients(CB+;n=27)weremorefrequentlycomorbidforanAxisIIpersonalitydisorder(χ2=7.27,p=.007)andreportedsignificantlylowerscores(t=2.090,p=.041)atthecharacterdimensionof“Cooper-ativeness”(C)astotheTCI-R,thanpatientswithoutbehaviouraldependence(BA−;n=106)(CB+vs.BA−,mean±SD:118.77±17.53vs.128.75±14.91).

Alsobipolarpatientswithco-occurringsexualaddiction(n=5)reportedsignificantlyhigherratesofcomorbiditywithapersonalitydisorderastotheDSM-IVcomparedtopatientswithoutbehaviouraladdiction(BA−;n=106)(χ2=4.035,p=.045).

Workaholicbipolarpatients(WO+;n=21)showedsignificantlowerlevel(t=2.015,p=.048)of“Reward

Table4

Spearman'scorrelationsbetweenTCI-Rdimensions,BIS-11totalscoreandmeanscoresattheBAscalesinbipolardisorderpatients(n=158);**=pb.01;*=pb.05.Legend:SOGS:TheSouthOaksGamblingScreen;CBS:CompulsiveBuyingScale;SAST:SexualAddictionScreeningTest;IAD:InternetAddictionDisordertest;WART:WartAddictionRiskTest;EAI:ExerciseAddictionInventory;NS:NoveltySeeking;HA:HarmAvoidance;RD:RewardDependence;P:Persistence;SD:SelfDirectness;C:Coopera-tiveness;ST:SelfTrascendence;BIS-11:BarrattImpulsivenessScale-11.

SOGS

CBS

SAST

IAD

WART

EAI

NS.305**−.298**.220.135−.050.048

HA−.004.009.083.023−.002.078RD−.047−.157.184−.061−.090.094P−.032−.047−.026.059.436**.044SD−.398**.279*−.405**−.300**−.141−.109C−.220.299**−.210−.144−.108−.063ST

.018−.248*.086.086.175.168BIS-11total

.333**

−.347**.253*.278*.083.270*

Dependence”(RD)andsignificantlyelevatedtraits(t=−4.288,pb.001)of“Persistence+”(P)thansubjectswithoutbehaviouraldependence(WOvs.BA−,RDmean±SD:90.10±14.26vs.100.58±14.23;Pmean±SD:134.20±16.65vs.105.02±20.23).

RegardingimpulsivityassessedwithBIS-11,higherlevelsrespecttobipolarpatientswithoutBA(n=106;mean±SD:58.37±10.43)werefoundforpathologicalgamblers(n=11;mean±SD:73.5±7.09;t=−3.45,p=.001)andcompulsivebuyers(n=27;mean±SD:67.31±12.06;t=−2.68,p=.009);atrendtowardsignificancewasobservedinexerciseaddictedbipolarpatients(n=6;mean±SD:70.33±11.85;t=−1.922,p=.060).4.Discussion

Lifetimeprevalencerateofbipolarspectrumdisordersisupto6.5%inthegeneralpopulation(VornikandBrown,2006).Studiesreportedthatbipolardisorderpatientstendtobeimpulsiveandengagebothinriskybehavioursandpleasurableactivitieswithpotentialfornegativeconse-quences(APA,2000;KathleenHolmesetal.,2009).Further,BDisstronglyassociatedwithalcohol/substanceusedis-orderswithratessignificantlyhigherthaninthegeneralpopulation(e.g.:VornikandBrown,2006;Regieretal.,1990;FryeandSalloum,2006).

Theextensionofthedefinitionof“dependence”leadstotheconsiderationofsomeimpulsivebehavioursasaformofaddictivedisorder(Leioyeuxetal.,2000).Accordingtosomeresearchers,addictions,whetherinducedbypsychoactivesubstancesorbehaviours,sharecommonneurobiologicalmechanisms,throughtheactivationoftherewardpathwaysandtheinvolvementofmultipleneurotransmittersystems,thedopaminergicfirstly,theendogenousopioidsandtheserotoninergicsecondly(Keane,2004)andclinicalmanifes-tationssuchasmoodmodifications,tolerance,withdrawalandrelapsesothattheaddictionprocesscouldbeconsideredasunitary(Goodman,1993;Shaffer,1999;Gossop,2001;Baioccoetal.,2005).

Severalstudieshaveinvestigatedtheprevalenceofsubstanceusedisordersinbipolarpatientsdocumentingthestrongassociationbetweenthesetwosyndromes(e.g.:Regieretal.,1990;Brooneretal.,1997;Kessleretal.,1997;SonneandBrady,1999;Grantetal.,2004;Merikangasetal.,2007)whileveryfewstudieshaveexploredtheoccurrenceofBAsinthesepatients.

Toourknowledgethisisthefirststudyinvestigatingtheprevalenceofbehaviouraladdictionsinbipolaroutpatientsineuthymicphaseofdiseaseorstabilisedbymedicationsandexaminingtheassociationofthesedisorderswithimpulsivitylevelandpersonalitydimensions.Wefocusedonpathologicalgambling,compulsiveshopping,sexual,Internet,workandphysicalexerciseaddictions.

Inbipolardisordersample33%ofsubjectsreportedatleastoneBA,accordingtotheestablishedcut-offofthescales,whileinhealthycontrolsgrouponlythe13%didit;bipolarpatientsreportedalsosignificantlyhigherscoresatthescalesforpathologicalgambling,compulsivebuying,sexualaddic-tionandworkaddictionthancontrols.

CompulsivebuyingwastheBAmostrepresentedinoursample:ithasresultedinacomorbiddisorderforthe17%of

M.DiNicolaetal./JournalofAffectiveDisorders125(2010)82–8887

bipolarsubjectsandstronglyassociatedwithotherBAs,inparticularwithpathologicalgambling,sexualandInternetaddictions.

Ourfindingsshowedthatinbipolarpatientsallbeha-viouraladdictions,withtheexceptionoftheworkone,wereassociatedwithhighlevelsofimpulsivity.Wecouldhypoth-esizethatthesepatientsuseBAsaswellasabusersusesubstances:toreducetheactivationgivenbytheimpulsivityandmoregenerallybytheimmaturityofcharacter.

Infact,comparingbipolarpatientswithandwithoutBAwehavefoundthatbipolarpatientswithatleastoneBAreportedhigherimpulsivity,lowerself-directnessandcoop-erativeness,underliningthepresenceofageneralimmaturityofpersonality,thatcouldbecompensatedwithinadequatebehaviours.Further,BA+patientsweresignificantlymoreunemployedandcomorbidforapersonalitydisorderastotheDSM-IVthanBA−patients.

ConcerningtheassociationbetweenBAsscoresandtemperamentalandcharacterdimensions,highNoveltySeeking(NS)wasfoundtobecorrelatedwiththepresenceofbehavioursreferabletopathologicalgambling(SOGS)andcompulsivebuying(CBS).Thesedataconfirmwhathasalreadybeenreportedinpreviousstudies(Leioyeuxetal.,2000).Furthermore,noveltyseekingandimpulsivityhavebeensuggestedtobebehaviouralmarkersofthepropensitytotakeaddictivedrugs(Willsetal.,1994;Chakrounetal.,2004;Kreeketal.,2005):itseemsthatthesetraitsfavourtheengagealsoinbehaviouraldependences.Additionally,com-parabletosubstanceusedisorders,itispossiblethatexcessivereward-seekingbehaviourscanalleviatenegativemoodstates(Grüsseretal.,2007)sothatbehaviouraladdictionsmaybecomeanavailableresourcetocopewithstressfactorsassociatedwiththebipolarillness.

ThetemperamentaldimensionofPersistence(P)thatcharacterizesindustriousandhardworkingdespitefrustra-tionandfatigueindividuals(Martinottietal.,2008)andscoresatWART,screeningtheworkaddiction,wereinasignificantpositivecorrelation.Furthermore,bipolarpatientswithcomorbidworkaddictionreportedsignificantlyhigherscoresatthisdimensionandsignificantlylowertraitsofRewardDependence(RD)thanpatientswithoutbehaviouraladdictions.Infact,‘workaholics’showaninabilitytoselfregulatetheiremotionalstates.Inspiteofseriousnegativeconsequencesandasidefromreward,theywillcontinuetoactoutthenegativepatternaffectingtheirlife.

Highscoresatthescalesindicatingthepresenceofbehavioursreferabletocompulsivebuying,pathologicalgam-bling,sexualandInternetaddictionwereassociatedwithlowSelfDirectness(SD)expressingtheindividual'scompetencetowardautonomy,reliability,andmaturity(Martinottietal.,2008).Cooperativeness(C)wasinasignificantpositivecorrelationwithcompulsivebuying;further,compulsivebuyersbipolarpatientsreportedsignificantlylowerscoresatthisdi-mensionrespecttopatientswithoutbehaviouraldependences,suggestingthatanimprovementinsocialskillssuchassupport,collaborationandpartnership(Martinottietal.,2008)isaprotectivefactorforthedevelopmentofcompulsiveshopping.

Ourstudypresentssomelimitations:thepsychometricscalesadministeredareallscreeninginstruments,andtheymayhaveoverestimatedtheprevalenceratesofthedisorders;someresultscouldnothavebeendetectedbecausetherelative

smallnumberofpatientsenrolled.Besides,resultscouldhavebeeninfluencedbytheconcurrentpharmacologicaltreatment.Werecruitedpatientsineuthymicphaseofdiseasefromatleasttwomonths:therelativeshorttimeframeconsideredcouldhaveaffectedtheprevalencerateofbehaviouraladdictionsbutcomparingthoseeuthymicfrom2to5months(n=71)withthosefrommorethan5months(n=87)wedidnotfindanysignificantdifference(datanotshown).Therefore,itispossibleforustostatethatdetectedaddictivebehavioursinoursamplearenottracedbacktodepressiveormanic/hypomanicstateofdisease.

Summarizing,ourdataemphasizesthehigherfrequencyofassociationbetweenbipolardisorderandbehaviouraladdictionscomparedtononclinicalpopulation.Astoourresults,webelievethatbehaviouraladdictionscouldrepre-sentcomorbidconditionsofbipolardisordersthatneedtobeinvestigatedandassessed.Abetterunderstandingofthesedimensionscouldhelptoreduceharmfulbehavioursandtheriskofrelapsesandmayhaveadirectimpactonpsycho-educativeinterventions.

ThepresenceofBAsinoursampleresultstobeassociatedwithhighlevelofimpulsivityandwithtemperamentalandcharacterdimensions.Besides,thesubgroupofbipolarpatientswithco-occurringBAwasmorefrequentlyunem-ployedandcomorbidwithapersonalitydisorder,moreimpulsiveandwithageneralcharacterimmaturity.Finally,bipolarsubjectswithahighercooperativenessandwithoutacomorbidAxisIIdiagnosishavealowerrisktodevelopabehaviouraladdiction.

TodatethereisnoconsistentconceptfordiagnosisofBAsinDSM-IVortreatmentguidelinesforthesedisorders,andtheirclassificationisuncertain.However,theelevatednumberofsubjectsseekingtreatmentandthehighfrequencyofcomor-biditywithotherpsychiatricdisordersemphasizetheimpor-tanceofaclearconceptualisationoftheso-calledbehaviouraladdictionsandtheirsuccessfultreatment.

Theseobservationsneedtobereplicatedinalargerpopu-lation;furtherstudiesarealsonecessarytounderstandthebiologicalsubstratesthatcontributetotheoverlapbetweenbipolardisorderandbehaviouraldependencesandtoassesstheroleofBAsintermsofrelapsesandseverityofillness.

Roleoffundingsource

Nopharmaceuticalandindustrysupportwasemployedinthisstudy.Conflictofinterest

Allauthorsdeclaretherearenoconflictsofinterest.

Acknowledgments

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