equilibriometric movement pattern analysis system that allows differentiation between psychomotor activity ..... and Manic-depressive Association 2000 survey of.
medica MEDICAL UNIVERSITY - Plovdiv, Bulgaria VOLUME 56
4/2014 O ct - D ec
P u b lish e d quarterly ISSN 0204-8043 (print) ISSN 1314-2143 (online)
ED ITO R IA L BOARD
Editor-in-chief Correspondent Member of Bulgarian Academy of Science Professor Stefan kostianev
Deputy/Managing Editor Professor Victoria Saratian Professor Todorka Tsvetkova
Editorial Advisory Board
Statistical Advisors Assoc. Professor Nonka Mateva, Kiri 1Simidchiev Assoc. Professor Maria Semerdjieva Technical Editors Vanya Gjulina, N ina Atanasova
Professor Blagovest Pehlivanov Professor Damianka Getova-Spasova Assoc. Professor Beniamin Anavi Members Professor Bernard Amour Paris. France Professor George Anastassov ЛУГ. I SA Professor Nikolai Boyadjiev Plovdiv. Bulgaria Professor Patrick Dhellemmes Lille. France Professor Christo Dobrev Plovdiv. Bulgaria Professor Ben Zion Garty Tel Aviv. Israel Professor Stefan Goranov Plovdiv. Bulgaria Professor Ivan Ivanov Plovdiv. Bulgaria Professor Margarita Kasarova Plovdiv. Bulgaria Professor Konstantinos Ka/akos . Uexandroupolis, Greece Professor Konstantinos Kouskoukis Alexandroitpolis. (ireece Professor Atanas Krastev Plovdiv. Bulgaria Professor Ingrid Kreissig Munheim. (iermany Professor Maria Kukleva Plovdiv. Bulgaria Professor John Kyriopoulos Athens. Greece Professor Jukka Meurman Helsinki. Finland Professor Mikhail Mikhailovsky Novosibirsk. Russia Professor Andrew Miles London. UK Acad. Professor Vanyo Mitev Sofia, Bulgaria
Professor Mariana Murdjeva Plovdiv. Bulgaria Professor Fedia Nikolov Plovdiv Bulgaria Professor Michael Oellerich Gbit ingen, German)' Professor Philippe Pellerin Lille. France Professor Yves Poumay Namur. Belgique Professor Emanuela Signori Roma. Italy Professor Constantines Simopoulos Alexandroitpolis. Greece Professor Stefan Sivkov Plovdiv. Bulgaria Professor Francisco Soriano Madrid. Spain Professor Chavdar Stefanov Plovdiv, Bulgaria Professor Rumen Stefanov Plovdiv, Bulgaria Professor Yordanka Stoilova Plovdiv, Bulgaria Professor Drozdstoy Stoyanov Plovdiv, Bulgaria Professor Mariana Stoycheva Plovdiv, Bulgaria Professor Dobrin Svinarov Sofia. Bulgaria Professor Georgi Todorov Plovdiv. Bulgaria Professor Angel Uchikov Plovdiv. Bulgaria Professor Kichka Velkova Plovdiv. Bulgaria Professor Fberhard Wieland Stuttgart. Germany
Language Editors (English): Assoc. Prof. 0. Obretenov (Plovdiv. Bulgaria) Language Editor (Russian): P. Kancheva(Plovdiv. Bulgaria). B. Philipov (Plovdiv. Bulgaria) Typeset by Medical University - Plov div. Scientific Department. Dipl. Eng. N. Atanasova Printed in Bulgaria. Plovdiv. Avtoprint I I I ) ISSN 0204-8043 (print) ISSN 1314-2143 (online) Number of copies: 1500
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56,4- 2 0 1 4 Oct - Dec C O N T E N T S Review Valeria T. Tananska Salivary a-Amylase and Chromogranin A in Anxiety-related Research ..................................................................................233 Yannis Dionyssiotis. Andreas Mavrogenis. Georgias Trovas, Grigories Skarantavos, .Jamlis Papathanasiou. Panayiotis Papagelopoulos Bone and Soft Tissue Changes in Patients with Spinal Cord Injury and Multiple Sclerosis................................................237
Original Articles Clinical in vestigations Maria E. Tsanyan, Sergey K. Soloviev, Stejka O'. Radenska-Lopovok. Anna Torgashina, Ekaterina V. Nikolaeva, Yaroslav B. Khrennikov, Evgeniy L. Nasonov Clinical and Morphological Improvement of Lupus Nephritis Treated with Rituximab ........................................................245 Ronit Friling. Ben-Zion Garty. Liora Kornreich. Oded Scheurman. Mural Hasanreisoglu, bit Taler. Jacob Amir, Gilal I.ivni and Moshe Snir Medical and Surgical Management of Orbital Cellulitis in Children ......................................................................................253 Leonardo Fisichella. Domenico Eenga, Michele Anilio Rosa Surgical Site Infection in Orthopaedic Surgery: Correlation between Age. Diabetes. Smoke and Surgical Risk.................................................................................................................................................................................... 259
Dental investigations i\ laria P. Shindova, Ani B. Belcheva Behaviour Evaluation Scales for Pediatric Dental Patients - Review and Clinical Experience................................:.......... 264
Case Report I.папа l.icata. Domenico Eenga, Giuseppe Speciale. Michele Attilio Rosa Clear Cell Sarcoma of Metatarsus: a Case Report......................................................................................................................271
Original Articles Experimental in vestigations Denitsa D. Kiradzhivska, Rositsa D. Mantcheva, Detelina L. Mileva. Krasimira I. Draganova. Yana N. Feodorova. Victoria S. Sarafian. Marian M Draganov Investigation of Chromium-Cobalt Coated Scaffolds on Cell Cultures In Vitro......................................................................275
Selected proceedings XVI International Conference for Philosophy, Psychiatry and Psychology Petya D. Teriiivanova, Svetlozar U. Haralanov Latent Bipolarity in Unipolar Depression: Experimental Findings, Conceptual Analysis and Implications for Treatment Strategies......................................................................................................................................................................... 282 Jakob Korf Emergence of Consciousness and Qualia from a Complex Brain.............................................................................................289 Francesca Brenda World. Time and Anxiety. Heidegger's Existential Analytic and Psychiatry .............................................................................297 Jeffrey D. Bedrick Mental Illness and Brain Disease................................................................................................................................................... 305 Erratum............................................................................................................................................................................................................ 309
Folia Medica 2014; 56(4): 282-288 Copyright © 2014 Medical University, Plovdiv doi: 10.1515/folmed-2015-0009
DE G R U Y T E R
S
OPEN
( SELECTED PROCEEDINGS^
XVI International Conference for Philosophy, Psychiatry and Psychology 26 - 29 June 2014, Golden Sands Resort, Bulgaria LATENT BIPOLARITY IN UNIPOLAR DEPRESSION: EXPERIMENTAL FINDINGS, CONCEPTUAL ANALYSIS AND IMPLICATIONS FOR TREATMENT STRATEGIES
Petya D. Terziivanova*, Svetlozar H. Haralanov First Psychiatric Clinic, St Naum University Hospital o f Neurology and Psychiatry, M edical University, Sofia, Bulgaria СКРМТАЯ БИПОЛЯРНОСТЬ В УНИПОЛЯРНОЙ ДЕПРЕССИИ: ЗКСПЕРИМЕНТАЛЬНЬШ ДАННБ1Е, КОНЦЕПТУАЛЬНЬШ АНАЛИЗ И ПОСЛЕДСТВИЯ ДЛЯ СТРАТЕГИИ ЛЕЧЕНИЯ Петя Д. Терзииванова*, Светлозар X. Хараланов Первая психиатрическая клиника Университетской больницьг неврологии и психиатрии имени Св. Наума, Медицинский университет, София, Болгария ABSTRACT I ntroduction: Previous studies have suggested that the two opposite poles of psychomotor disturbances in unipolar depression (UD) - retardation and agitation - require different treatment strategies as the psychomo tor overactivation requires an augmentation of the antidepressant therapy with mood stabilizers and/or atypical antipsychotics. O bjective : The aim of the present study was to objectively identify and measure the psycho motor disturbances in UD using differentiation between activity and reactivity. M aterial and methods: An equilibriometric movement pattern analysis system that allows differentiation between psychomotor activity and reactivity was applied in 58 unipolar depressive patients and 76 healthy controls. R esults: Compared to con trols, the patients as a group were significantly slower in their psychomotor reactivity. However, the subsequent subgrouping according to the direction of deviation of their objective psychomotor parameters revealed a disinhibition of psychomotor activity and/or reactivity in about one half of them. Such a contradictory combination of clinically manifested depressive mood and subclinically detected manic-like psychomotor overactivation might be regarded as belonging to the bipolar spectrum, since it was admitted that manic psychomotor disinhibition in unipolar depressive patients uncovers a latent bipolarity. C onclusion: Not only prototypical depressive inhibi tion, but also prototypical manic-like disinhibition may underlie clinically manifested UD. Since the combination between depressive mood and psychomotor overactivation multiplies the suicidal risk, we may presume that the timely detection of this combination at a subclinical level would contribute to an earlier and more effective sui cidal prevention by an objectively-guided optimization of pharmacological treatment. Key words: unipolar depression, cranio-corpo-graphy, psychomotor disturbances, bipolarity, suicidal prevention
Folia Medica 2014; 56(4): 282-288 Copyright © 2014 Medical University, Plovdiv РЕЗЮМЕ В ведение: Предндущие исследования показали, что два противоположнмх полюса психомоторнмх
нарушении в униполярной депрессии (УД) - замедление и перемешивание - требуют разнмх стратегий лечения, так как психомоторная сверхактивация требует добавления стабилизаторов настроения и/или атипичнмх нейролептиков к антидепрессивной терапии. Ц ел ь : Целью настоящето исследования является объективная регистрация и измерение психомоторной активности и реактивности при УД. М атериал и методн : Кранио-корпография как система, позволяющая дифференцировать психомоторную активность и реактивность, бнла применена в отношении 58 униполярнмх депрессивнмх пациентов и 76 здоровмх людей. Р езультати и обсуждение: По сравнению с контрольной группой, пациенти как группа бмли значительно медленнее в их психомоторной реактивности. Однако последующее субгруппирование в соответствии с направлением отклонения их объективнмх психомоторнмх параметров показали растормаживание психомоторной активности и/или реактивности примерно у половини из них. Такое противоречивое сочетание клинически проявленного депрессивного настроения и субклинически Article’s history: Received: 5 Dec 2014; Received in a revised form: 10 Dec 2014; Accepted: 18 Dec 2014 ■"Correspondence and reprint request to: P. Terziivanova, St. Naum University Hospital of Neurology and Psychiatry,
282
Medical University, Sofia, Bulgaria l "•Acad. Evstati Geshov" Blvd., 1113 Sofia, Bulgaria; Dr. Ljuben Rusev St., 1113 Sofia, Bulgaria
Latent Bipolarity in Unipolar Depression: Experimental Findings. Conceptual Analysis and Implications for Treatment Strategies
обнаруженная маниакально психомоторная сверхактивация может рассматриваться как принадлежащее к биполярному спектру, так как бьшо признано, что маниакальная психомоторная расторможенность среди униполярннх депрессивнмх пациентов указивает на скритую биполярность. З аключение: Не только прототипное депрессивное торможение, но и прототипная маниакальная расторможенность могут лежать в основе клинически проявляющейся УД. Посколько сочетание депрессивного настроения с психомоторной сверхактивацией увеличивает суицидальнмй риск, можно предположить, что своевременное субклиническое обнаружение зтой комбинации будет способствовать более ранней и более зффективной суицидальной профилактике путем объективно-управляемой оптимизации фармакологического лечения. Ключевме слова:униполярная депрессия, кранио-корпография, психомоторньгенарушения, биполярность, суицидальная профтакт ика Folia Medica 2014; 56(4): 282-288 © 2014 Все права защищенн. Медицинский университет, Пловдив INTRODUCTION
The lifetime prevalence of major depressive dis order is approximately 16%.' In Europe nine out o f a thousand people suffer from depression.2 Re current by nature, depression is associated with a great number o f years o f life lost due to disability and premature death. It is not surprising that the world-spread difficulties in clinical identification o f depressive syndrome, the delays o f psychiatric consultation and treatm ent initiation, as well as the poor management o f patients are all expected to make depression the second leading cause of disability by the year 2020.3 Clinical depression is a multidimensional psychi atric illness. It includes 4 main domains: negative affectivity (depressive mood), changes in cognitive functions (cognitive deficits), poor neurovegetative control (autonomic dysregulation) and psychomotor disturbances. Psychomotor disturbances are regarded as cardinal symptoms o f depression.410 The lat ter encompass two opposite deviations from the norm - retardation and over-activation or agitation. In psychomotor retardation, the depressive mood corresponds to an overall reduction and slowness
in volitional activity and emotional reactivity of the patient. Conversely, in psychomotor agitation, the depressive mood is associated with a raise in volitional activity and/or emotional reactivity. According to its longitudinal course, the en dogenous depression could be unipolar or bipolar. Recently, it was revealed that the treatm ent o f unipolar and bipolar depression is very different if not conflicting. Hence, it is important to make distinction between these two types o f depressive illness. The main problem is that the detection of bipolarity is complicated by the fact that in a half o f cases the bipolar disorder manifests itself with a series of depressive episodes before the onset o f the first manic, hypomanic or mixed episode.11 Therefore, a bipolar depression is often seen as "unipolar" and is incorrectly treated with antide pressant monotherapy. Such a m edication could worsen the course of the illness.12' 14 The presence of manic symptoms accompanying the current de pressive episode tends to be associated with rapid cycling, increased suicidality and a greater incidence of substance abuse.1516 It is well-known that the
Table 1. Descriptive statistics of unipolar depressive patients and healthy controls Unipolar Depression (n = 58)
Healthy Controls (n = 76)
Statistical results
Age Gender male female Height (cm)
45.69 ± 10.66
41.12 ± 10.42
P = 0.19; t = -2.49; df = 132
13 45 166.53 ± 7.94
12 64 167.80 ± 8.88
Weight (kg)
69.07 ± 14.50
67.79 ± 13.62
P = 0.39; t = 0.56; df = 132; P = 0.60; t = -0.52; df = 132
24.89 ± 5.01
24.04 ± 4.28
P = 0.29; t = -1.06; df - 132
BMI
p - level of significance; t - Student's coefficient; df - degree of freedom.
Folia Medica 2014; 56(4): 282-288 © 2014 Medical University, Plovdiv
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P. Terziivanova et al
¥
combination o f depressive mood and psychomotor over-activation multiplies the suicidal risk. So, early detection o f subthreshold bipolarity in unipolar depression would lead not only to the correct treatment with mood stabilizers and/or antipsychotics, but also would help to take more effective measures for prevention o f suicidal behav ior.17'20 We expected that the study of psychomo tor disturbances through quantitative measurement and objective recording o f stepping locomotion (differentiating between psychomotor activity and reactivity) would detect a latent bipolarity in a proportion o f patients presented clinically with unipolar depression. MATERIAL AND METHODS P a r t ic ip a n t s
A group o f 58 unipolar depressed inpatients was ex amined and compared to 76 matched healthy controls (Table 1). All participants signed informed consent forms. Excluded from the sample were patients with clinical evidence o f orthopedic, neurological and endocrine diseases, head injuries, substance abuse and comorbidity with other psychiatric disorders as well as patients with clinical features o f sedation and/or extrapyramidal symptoms. C
l in ic a l e v a l u a t io n a n d a s s e s s m e n t s
All patients met the ICD-10 diagnostic criteria for recurrent depressive disorder. Our unipolar depres sive patients and healthy controls were age, height, weight and BMI matched (Table 1). In str u m en ta l
a ssessm en t of th e psy ch o m o to r fun c
t io n
Em otional disturbances are closely related to disturbances in m otility (including locomotion), which is supported by the fact that the origin of the word “em otion” comes from the Latin verb for movement - „movere” . The strong correlation between emotion and locomotion is often reflected in everyday language. In English for example, we speak o f “spring in one’s step” when someone is in a bright mood and o f “heavy steps” when someone is in a sad mood. Having in mind these relations between emo tion and locomotion our team used computerized ultrasonographic cranio-corpo-graphy (www.zebris. de) in order to monitor psychomotor disturbances in depressive patients .This is a non-invasive method for objective recording and m easurem ent o f the head and body movements during the performance o f motor and equilibriometric tests. It was intro-
284
Figure 1. Computerized ultrasonographic cranio-corpography - Test o f Unterberger-Fukuda. duced in psychiatric practice by our team.21'26 The participants performed the locom otor "stepping test” o f Unterberger-Fukuda (Fig. 1). They stepped in place with outstretched hands and closed eyes for 1 minute. C
r a n io - c o r p o - g r a p h ic in d ic a t o r s
Our studies have found that this equilibriometric test allows a precise subclinical measurement o f two basic components o f psychomotor performance: conscious (volitional) activity and unconscious (automatic) reactivity.21'23 Psychomotor activity is measured by the indicator “number of steps per minute”, which directly reflects the speed o f loco motion and is determined by the internal rate of spontaneous mental activity. If it is lower than the normal values, it can be regarded as a manifesta tion o f reduced (inhibited) psychomotor activity or hypo-activity. Conversely, if it is higher than the normal values, it can be regarded as a manifestation o f increased (disinhibited) psychomotor activity or hyper-activity. Psychomotor reactivity is measured by the indicator “ lateral sway” . If it is higher than the normal values, it can be regarded as a delay (retar dation) in psychomotor reactivity (brady-reactivity). Conversely, if it is lower than the normal values, it can be regarded as acceleration o f psychomotor reactivity (tachy-reactivity). It is worth noting that prototypical depressive pattern involves higher values o f lateral sway (brady-reactivity) but lower values o f number o f steps per minute (hypo-activity). In contrast, prototypical manic pattern involves lower values o f lateral sway (tachy-reactivity) but higher
Folia Medica 2014; 56(4): 282-288 © 2014 Medical University, Plovdiv
Latent Bipolarity in Unipolar Depression: Experimental Findings, Conceptual Analysis and Implications for Treatment Strategies
Table 2. Psychomotor subgroups Subgroups Unipolar patients
Hyporeactive
Hyperreactive
38 ((65.5%)
20 ((34.5%)
Number ((%) Lateral sway ((cm)
TotalH 58 ((100%)
Hyperactive
Hypoactive
25 ((43.1 %)3
33 (56.9%)
12.50 ± 2.97
17.01 ± 5.51
Healthy controls 17.66 ± 4.37
Number © f steps per minute6 64.45 ± 16.73
10.14 ± 1.26
12.11 ± 3.14
76.59 ± 17.577
71.38 ± 13.20
□ UD (N=58) □ Healthy controls (N=76)
84.78 ± 11.015 56.41 ± 10.89
□ UD (N=58) □ Healthy controls (N=76)
***p
