Prodromal symptoms and temperamental characteristics in first episode psychotic mania: re-looking the cynosure

Background: Prodrome has recently been proposed as target for early intervention but their phenomenology remains obscure and often certain temperamental characteristics are confused with prodromal symptoms leading to the possibility of over-reporting. Methods: Fifty-one consecutively admitted patients, between the age group of 18-60 years, fulfilling the ICD-10 criteria for mania with psychotic symptoms were included. They were rated on Young Mania Rating Scale (YMRS) and were started on appropriate medications. After they attained remission (YMRS<12), they were interviewed on the Bipolar Prodrome Symptom Scale- Retrospective version (BPSS-R) and the General Behaviour Inventory (GBI). Twenty-five normal controls were assessed using the same tools. Results: Prodromal symptoms were reported by 58.8% of the patients, as compared to eight per cent of controls. Irritability (28.33%) was the most commonly reported prodromal symptom followed by anxiety (13.33%) and sleep disturbance (ten per cent). All the three frequently reported prodromal symptoms were of moderate severity and recurrent in frequency in three-fourth of the patients. The mean number of prodromal symptoms among the patients was 1.14 (SD 1.44), which was significantly higher than the normal controls (p<0.001). Hypomanic/ depressive temperaments were significantly higher in the patients with prodrome as compared to normal controls (p<0.01) as well as patients without prodrome (p<0.01). Discussion: Significantly higher number of prodromal symptoms was present in the patients and these symptoms were mostly moderate in severity and recurrent in nature. Also, the number of patients who reported prodromal symptoms was much higher than the number of controls. However, when a comparison was made between the reported prodromal symptoms in the patient and control group, a significant difference was noted only in ‘irritability'. Further, the proportion of prodromal symptoms reported in our study was lower when compared to previous studies. This could be because most of these studies had looked for these symptoms over the lifetime leading to likelihood of over-reporting. Individually, these symptoms may not have predictive significance but the occurrence of these clinical characteristics in patients who have hypomanic or depressive temperament could be a sign of impending first episode mania.