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ORIGINAL ARTICLE  
Year : 2019  |  Volume : 61  |  Issue : 2  |  Page : 156-160
Impulsivity differences between bipolar and unipolar depression


Department of Psychiatry, Faculty of Medicine, Sakarya University, Sakarya, Turkey

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Date of Web Publication11-Mar-2019
 

   Abstract 


Background: Even though particularly bipolar depression and unipolar depression seem to be similar, they show differences in terms of the etiology, phenomenology, course, and treatment process. Bipolar depression is associated with mood lability, motor retardation, and hypersomnia to a larger extent. Early age of onset, a high frequency of depressive episodes, and history of bipolar disease in the family are suggestive of bipolar disorder (BD) rather than major depression. Bipolar and unipolar disorders are also associated with increased impulsivity during illness episodes. However, there is little information about impulsivity during euthymia in these mood disorders. The aim of this study was to illustrate the difference in impulsivity in euthymic bipolar and unipolar patients.
Materials and Methods: Impulsivity was evaluated by the Barratt Impulsiveness Scale (BIS-11A), in 78 interepisode BD patients, 72 interepisode unipolar disorder patients, and 70 healthy controls. The diagnosis was established by severe combined immunodeficiency. One-way between-groups ANOVA was used to compare the BIS-11A mean scores for all three groups.
Results: Impulsivity scores of the bipolar and unipolar disorder patients were significantly higher than controls on total and all subscales measures. There was no difference between the bipolar and unipolar disorder groups on total, attentional, and nonplanning impulsivity measures. However, BD patients scored significantly higher than the unipolar patients on motor impulsivity measures.
Conclusions: Both interepisode bipolar and unipolar disorder patients had increased impulsivity compared to healthy individuals. There was no significant difference on attention and nonplanning impulsivity subscales; however, on the motor subscale, bipolar patients were more impulsive than unipolar disorder patients.

Keywords: Bipolar disorder, impulsivity, mood disorder, remission, unipolar disorder

How to cite this article:
Ozten M, Erol A. Impulsivity differences between bipolar and unipolar depression. Indian J Psychiatry 2019;61:156-60

How to cite this URL:
Ozten M, Erol A. Impulsivity differences between bipolar and unipolar depression. Indian J Psychiatry [serial online] 2019 [cited 2019 Oct 14];61:156-60. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/2/156/253822





   Introduction Top


Among the mood disorders, bipolar depression and unipolar depression seem to be similar; however, they differ in terms of course, severity, symptom distribution, and treatment process. It is important to identify distinctive features and predictors of these two disorders.

There is no pathognomonic feature or biomarker that can reliably differentiate bipolar depression from other psychiatric disorders, particularly unipolar major depressive disorder (MDD).[1],[2] Consequently, several studies have been reported about sociodemographic and clinical features that can help clinicians in the diagnostic process.[3],[4],[5],[6]

The distinction between unipolar and bipolar diseases was established in the studies of Pierre Falret (1851) and Jules Baillarger (1854) and then Angst (1966), Peris (1966), and Winokur et al., (1969) who showed nosological differences between bipolar and unipolar disorders in terms of their clinical, genetic, and course features. In addition, there were many corresponding areas between the two disease groups, which raised the question of the presence of possible clinical subtypes between depressive and manic edges of affective diseases.

Bipolar disorder (BD), which may be difficult to diagnose, is often misdiagnosed as recurrent MDD. While diagnosing major depressive episode, clinicians should check if there is a history of mania or hypomania, which is indicative of BD rather than MDD. Bipolar depression is associated with mood lability, motor retardation, and hypersomnia to a larger extent.[7],[8],[9] Early age of onset, a high frequency of depressive episodes, family history of bipolar disease are suggestive of BD rather than major depression.[10],[11] Compared to unipolar depression, the clinical course of bipolar depression is more severe and suicide is more common.

Impulsivity has been defined as a predisposition toward rapid, unplanned reactions to internal or external stimuli, without regard to the negative consequences.[12] Although impulsivity itself is not a psychiatric diagnosis, it is more likely to be present in individuals with certain psychiatric disorders, such as BDs, attention deficit hyperactivity disorder, personality disorders, and substance abuse and dependence.

BD is commonly associated with increased impulsivity, particularly during manic and depressed episodes,[13],[14] and unipolar depressive disorder (UD) is also associated with increased impulsivity during depressive episodes.[15]

Increased impulsivity adversely affects the course of BD and UD by increasing suicide risk[13],[15],[16],[17] and mood instability.[18] In BD, elevated impulsivity during euthymic periods contributes to disruptive behaviors such as reckless driving,[19] substance abuse disorder,[20] and poor adherence to treatment.[21] However, there is a lack of studies evaluating impulsivity in euthymic UD patients, so it is not known whether impulsivity is associated with poor disease course and substance abuse risk as with BD.

Increased impulsivity in BD and UD during the disease episodes as well as in euthymic states supports that impulsivity is related to mood disorders in general.[18],[22] If this is confirmed, then therapies targeting impulsivity could represent novel interventions for mental disorders with impulsivity at their core, as suggested by Pattij and Vanderschuren.[23]

Therefore, in this study, we compared questionnaire-measured impulsivity in euthymic BD, UD patients, and healthy controls (HCs). BD and UD, which are not the same disorder, have similarities and differences, and their impulsivity characteristics and differences have not been demonstrated yet.

Our hypothesis is that these two disorders differ in terms of clinic, genetics, treatment, and prognosis, therefore have different impulsivity rates and profiles.

We compared the impulsivity differences of BD, UD and controls.


   Materials and Methods Top


Participants

Seventy-eight euthymic (interepisode) BD patients, 72 euthymic (interepisode) UD patients, and 70 HC were recruited from the Outpatient Psychiatry Clinic of Sakarya University Faculty of Medicine. BD and UD diagnoses were confirmed using the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-IV diagnoses.[24] Mood state defined according to Hamilton Rating Scale for Depression (HAM-D),[25] 21 items, and the young mania rating scale (YMRS).[26] Inclusion criteria consisted of being in remission for 2 months (YMRS score <6 and HAM-D score <8).

The inclusion criteria were as follows:

  1. 18 years of age or older
  2. Diagnosis of euthymic BD and UD
  3. No history of axis I disorders for HC.


The exclusion criteria for all groups were as follows:

  1. Presence of chronic illness (e.g., hypertension, diabetes, liver disease, kidney diseases, current thyroid dysfunction, or neurological disease)
  2. Current comorbid axis I disorders.


All procedures were performed after the participants had demonstrated adequate understanding and provided written informed consent.

Methods

The participants completed the BIS version 11A (BIS-11A)[27] to assess impulsivity. The BIS-11A is a 21-item self-report inventory that measures impulsivity as a trait encompassing three domains: attentional impulsivity (intolerance for complexity and persistence), motor impulsivity (tendency to act without forethought), and nonplanning impulsivity (lack of a sense of the future). Items were rated from 1 (absent) to 4 (most extreme).

Statistical analysis

All analyses were performed using the Statistical Package for the Social Sciences, Version 16 for (SPSS, Inc., Chicago, IL, USA). The two groups were compared using one-way between-groups ANOVA. The level of statistical significance was set at P = 0.05. We ran additional subgroup analyses comparing impulsivity in BD and UP with and without suicide attempts and a history of substance use.


   Results Top


Demographic data

Mean ages of BD and UD patients and HC were 35.42 ± 11.15, 39.31 ± 10.92, and 37.19 ± 11.54, respectively. Number of male and female patients in BD, UD, and HC groups were as follows: BD group (M: 36, F: 42), UD group (M: 22, F: 50), and HC group (M: 34, F: 36). Mean years of education of BD, UD, and HC groups were 9.21 ± 3.63, 8.69 ± 4.17, and 10.09 ± 4.06, respectively. The patients did not differ from controls in terms of age, gender, or education. Demographic characteristics of these three groups are shown in [Table 1].
Table 1: Demographic characteristics of the groups

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Group comparisons

Age of onset of BD was 27.71 ± 10.06 and age of onset of UD was 35.18 ± 10.24 years. The BD mean HAM-D score was 2.33 ± 1.87, and the mean YMRS score was 2.29 ± 1.79. The UD mean HAM-D score was 3.17 ± 1.73, and the mean YMRS score was 1.78 ± 1.46. Among the BD patients, 11 (14.1%) had attempted suicide versus 12 (16.7%) in the UD sample. Among the BD patients, 8 (10.2%) had past substance use disorders versus 3 (4.2%) in the UD sample. Clinical characteristics of BD and UD groups are shown in [Table 2].
Table 2: Clinical characteristics of BD and UD groups

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The BD and UD groups scored similarly on total impulsivity measures [Table 3]. However, the BD and UD groups scored significantly higher than the HC (P < 0.001).
Table 3: Comparisons of BIS 11-A scores of groups

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On the nonplanning subscale, the BD and UD groups scored similarly, and both scored higher than the HC (P < 0.001).

On the attentional subscale, the BD and UD groups scored similarly and both scored higher than the HC (P < 0.001).

On motor impulsivity, there were differences between the BD and UD groups. BD group scored significantly higher than UD group (P = 0.029) [Table 4] and both of these groups scored significantly higher than the HC group (P < 0.001).
Table 4: Post hoc Tukey analysis of groups

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   Discussion Top


Impulsivity is associated with the mechanisms and consequences of affective symptoms.[12],[28] The impulsivity, which is considered to be inherent in mania, is a prominent part of the diagnostic criteria.[24],[29] There is evidence supporting the presence of a relationship between impulsivity and depression as well as mania. Impulsivity can also be a component of the depressive state itself. Impulsivity appears to be differentially related to depressive and manic episodes. Swann et al. demonstrated that both depression and mania are significantly associated with total and attentional impulsivity.

Mania is associated with motor impulsivity, whereas depression is associated with nonplanning impulsivity. Impulsivity is increased in BD even when patients are euthymic.[13],[14] Euthymic bipolar patients express impulsivity at higher levels than healthy individuals;[29] however, they do not differ from manic bipolar patients.[30] These findings suggest that the impulsivity found among bipolar patients may be independent of mood state. Our findings confirm previous results of increased levels of impulsivity, even if patients are euthymic.[19],[31],[32],[33] Euthymic bipolar patients express higher total and subscale impulsivity scores.

This study specifically investigated impulsivity and its correlations in patients with MDD in an euthymic state and mainly demonstrated that impulsivity, measured using the BIS-11, was substantially higher in participants with MDD compared with healthy participants. In contrast to our findings, Westheide et al.[34] found that patients with major depression did not report increased impulsive behavior compared with healthy individuals. Two previous studies reported that euthymic unipolar patients scored significantly higher than HC only on motor impulsiveness, and they suggested that motor impulsivity may be a trait that differentiates unipolar individuals from healthy ones.[13],[35] The results of one review by Saddichha and Schuetz found no consistency in the association between depression and impulsivity.[36] They selected studies involving participants with MDD only in remission. A total of five studies reported an association while four studies did not. The results may also be indicative of a contribution of impulsivity in depression too, as the neutral results also showed significant differences in impulsivity, all indicating a higher impulsivity in the groups of individuals suffering from MDD. Hence, our results are important due to the association of impulsivity and MDD.

An association between impulsivity and mood disorders that extend across mood states is important because it would imply that impulsivity is more than the direct expression of mood symptoms in affected individuals. Therefore, the relatively high level of impulsivity found in mood disorders can only be a stable component that is not merely a manifestation of mood state. This association could have different origins: it could be a consequence of repeated mood episodes, a risk factor for the disorder, or a manifestation of an independent factor linked with the biological causes of the disorder. Elevated levels of impulsivity are thought to be core and pervasive feature of both BD and UD. Each of these possibilities could have important implications for a better understanding of bipolar and unipolar disorders.

Henna et al.[32] evaluated impulsivity by the BIS-11A in 54 BD patients, 25 unipolar disorder patients, 136 healthy volunteers, and 14 unaffected relatives. Bipolar and unipolar disorder patients scored significantly higher than the HC and unaffected relatives on all measures of the BIS-11A. In our study, bipolar and unipolar disorder patients scored similarly on total and all three subscales.

In our study, we demonstrated that both interepisode BD and UD had increased total impulsivity. Subscale attention and nonplanning impulsivity were not different; however, on the motor subscale, BD patients were more impulsive than unipolar disorder patients. Motor impulsivity was higher in BD group than UD group. This refers to BD patients who have special feature when they are compared with UD about impulsivity: a tendency to act impetuously. To the best of our knowledge, the current study is the first study which investigated the motor impulsivity difference between BD and UD.

This study has several limitations. We only used one clinical measurement of impulsiveness and did not carry out cognitive assessment. This is a cross-sectional study of baseline parameters; hence, the long-term associations between impulsivity and clinical properties were not addressed. There is a need to examine the longitudinal course of illness in these participants and evaluate the complex interrelationships among impulsivity and sociodemographic and clinical properties as well as the impact of psychopharmacological and psychosocial interventions. There were no controls for anxiety and personality disorders, which have been shown to be associated with high impulsivity.[12] Another limitation is that BD and UD participants in this study were all receiving psychotropic medicines despite being remission because of ethical issues. It is known that lithium, valproate antipsychotics, and antidepressants have anti-impulsive and anti-aggressive effects.[37],[38],[39],[40],[41],[42],[43],[44] In our study, it is important to note that despite the use of mood stabilizers, antidepressants, and antipsychotics that reduce impulsivity, the BD patients were more impulsive on the motor impulsivity than UD patients.


   Conclusions Top


Trait impulsivity was elevated in patients with isolated interepisode BD and UD, confirming that impulsivity is relatively independent of mood state and is higher in BD and UD patients. Interepisode BD and UD patients had increased total impulsivity. On the motor subscale, BD patients were more impulsive than UD patients. Motor impulsivity appeared to be related to BD rather than UD. Hence, these findings should be explored and replicated in larger samples.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4-12.  Back to cited text no. 1
    
2.
Lenox RH, Gould TD, Manji HK. Endophenotypes in bipolar disorder. Am J Med Genet 2002;114:391-406.  Back to cited text no. 2
    
3.
Akiskal HS, Hantouche EG, Bourgeois ML, Azorin JM, Sechter D, Allilaire JF, et al. Gender, temperament, and the clinical picture in dysphoric mixed mania: Findings from a French national study (EPIMAN). J Affect Disord 1998;50:175-86.  Back to cited text no. 3
    
4.
Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry 2001;158:1265-70.  Back to cited text no. 4
    
5.
Hantouche EG, Angst J, Akiskal HS. Factor structure of hypomania: Interrelationships with cyclothymia and the soft bipolar spectrum. J Affect Disord 2003;73:39-47.  Back to cited text no. 5
    
6.
Perlis RH, Brown E, Baker RW, Nierenberg AA. Clinical features of bipolar depression versus major depressive disorder in large multicenter trials. Am J Psychiatry 2006;163:225-31.  Back to cited text no. 6
    
7.
Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: A probabilistic approach. Bipolar Disord 2008;10:144-52.  Back to cited text no. 7
    
8.
Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, Keller M, et al. Switching from 'unipolar' to bipolar II. An 11-year prospective study of clinical and temperamental predictors in 559 patients. Arch Gen Psychiatry 1995;52:114-23.  Back to cited text no. 8
    
9.
Brockington IF, Altman E, Hillier V, Meltzer HY, Nand S. The clinical picture of bipolar affective disorder in its depressed phase. A report from London and Chicago. Br J Psychiatry 1982;141:558-62.  Back to cited text no. 9
    
10.
Bowden CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv 2001;52:51-5.  Back to cited text no. 10
    
11.
Mitchell PB, Malhi GS. Bipolar depression: Phenomenological overview and clinical characteristics. Bipolar Disord 2004;6:530-9.  Back to cited text no. 11
    
12.
Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. Psychiatric aspects of impulsivity. Am J Psychiatry 2001;158:1783-93.  Back to cited text no. 12
    
13.
Peluso MA, Hatch JP, Glahn DC, Monkul ES, Sanches M, Najt P, et al. Trait impulsivity in patients with mood disorders. J Affect Disord 2007;100:227-31.  Back to cited text no. 13
    
14.
Swann AC, Steinberg JL, Lijffijt M, Moeller FG. Impulsivity: Differential relationship to depression and mania in bipolar disorder. J Affect Disord 2008;106:241-8.  Back to cited text no. 14
    
15.
Corruble E, Benyamina A, Bayle F, Falissard B, Hardy P. Understanding impulsivity in severe depression? A psychometrical contribution. Prog Neuropsychopharmacol Biol Psychiatry 2003;27:829-33.  Back to cited text no. 15
    
16.
Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Steinberg JL, Moeller FG. Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder. Am J Psychiatry 2005;162:1680-7.  Back to cited text no. 16
    
17.
Perroud N, Baud P, Mouthon D, Courtet P, Malafosse A. Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders. J Affect Disord 2011;134:112-8.  Back to cited text no. 17
    
18.
Najt P, Perez J, Sanches M, Peluso MA, Glahn D, Soares JC. Impulsivity and bipolar disorder. Eur Neuropsychopharmacol 2007;17:313-20.  Back to cited text no. 18
    
19.
Smith AR, Witte TK, Teale NE, King SL, Bender TW, Joiner TE. Revisiting impulsivity in suicide: Implications for civil liability of third parties. Behav Sci Law 2008;26:779-97.  Back to cited text no. 19
    
20.
Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Moeller FG. Impulsivity: A link between bipolar disorder and substance abuse. Bipolar Disord 2004;6:204-12.  Back to cited text no. 20
    
21.
Elizabeth Sublette M, Carballo JJ, Moreno C, Galfalvy HC, Brent DA, Birmaher B, et al. Substance use disorders and suicide attempts in bipolar subtypes. J Psychiatr Res 2009;43:230-8.  Back to cited text no. 21
    
22.
Swann AC, Lijffijt M, Lane SD, Steinberg JL, Moeller FG. Increased trait-like impulsivity and course of illness in bipolar disorder. Bipolar Disord 2009;11:280-8.  Back to cited text no. 22
    
23.
Pattij T, Vanderschuren LJ. The neuropharmacology of impulsive behaviour. Trends Pharmacol Sci 2008;29:192-9.  Back to cited text no. 23
    
24.
First MB, Spitzer RL, Gibbon M, Williams JB. Structured Clinical Interview for DSM-IV Axis I Disorders. Patient Edition. New York: Biometrics Research Institute, New York State Psychiatric Institute; 1996.  Back to cited text no. 24
    
25.
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 25
    
26.
Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: Reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35.  Back to cited text no. 26
    
27.
Barratt ES. Impulsiveness and aggression. In: Monahan J, Steadman HJ, editors. Violence and Mental Disorder: Developments in Risk Assessment. Chicago: University of Chicago Press; 1994. p. 61-79.  Back to cited text no. 27
    
28.
Barratt ES, Patton JH. Impulsivity: Cognitive, behavioral, and psychophysiological correlates, In: Zuckerman M, editor). Biological Basis of Sensation-Seeking, Impulsivity, and Anxiety. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1983. p. 77-116.  Back to cited text no. 28
    
29.
Swann AC, Anderson JC, Dougherty DM, Moeller FG. Measurement of inter-episode impulsivity in bipolar disorder. Psychiatry Res 2001;101:195-7.  Back to cited text no. 29
    
30.
Swann AC, Pazzaglia P, Nicholls A, Dougherty DM, Moeller FG. Impulsivity and phase of illness in bipolar disorder. J Affect Disord 2003;73:105-11.  Back to cited text no. 30
    
31.
Strakowski SM, Fleck DE, DelBello MP, Adler CM, Shear PK, Kotwal R, et al. Impulsivity across the course of bipolar disorder. Bipolar Disord 2010;12:285-97.  Back to cited text no. 31
    
32.
Henna E, Hatch JP, Nicoletti M, Swann AC, Zunta-Soares G, Soares JC. Is impulsivity a common trait in bipolar and unipolar disorders? Bipolar Disord 2013;15:223-7.  Back to cited text no. 32
    
33.
Ekinci O, Albayrak Y, Ekinci AE, Caykoylu A. Relationship of trait impulsivity with clinical presentation in euthymic bipolar disorder patients. Psychiatry Res 2011;190:259-64.  Back to cited text no. 33
    
34.
Westheide J, Wagner M, Quednow BB, Hoppe C, Cooper-Mahkorn D, Strater B, et al. Neuropsychological performance in partly remitted unipolar depressive patients: Focus on executive functioning. Eur Arch Psychiatry Clin Neurosci 2007;257:389-95.  Back to cited text no. 34
    
35.
Hur JW, Kim YK. Comparison of clinical features and personality dimensions between patients with major depressive disorder and normal control. Psychiatry Investig 2009;6:150-5.  Back to cited text no. 35
    
36.
Saddichha S, Schuetz C. Impulsivity in remitted depression: A meta-analytical review. Asian J Psychiatr 2014;9:13-6.  Back to cited text no. 36
    
37.
Bierbrauer J, Nilsson A, Müller-Oerlinghausen B, Bauer M. Therapeutic and prophylatic effects of lithium on pathological aggression. In: Bauer M. Grog P, Müller-Oerlinghausen B, editors. Lithium in Neuropsychiatry. Abingdon: Informa; 2006. p. 227-36.  Back to cited text no. 37
    
38.
Dorrego MF, Canevaro L, Kuzis G, Sabe L, Starkstein SE. A randomized, double-blind, crossover study of methylphenidate and lithium in adults with attention-deficit/hyperactivity disorder: Preliminary findings. J Neuropsychiatry Clin Neurosci 2002;14:289-95.  Back to cited text no. 38
    
39.
Gobbi G, Gaudreau PO, Leblanc N. Efficacy of topiramate, valproate, and their combination on aggression/agitation behavior in patients with psychosis. J Clin Psychopharmacol 2006;26:467-73.  Back to cited text no. 39
    
40.
Hollander E, Swann AC, Coccaro EF, Jiang P, Smith TB. Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. Am J Psychiatry 2005;162:621-4.  Back to cited text no. 40
    
41.
Swann AC, Bowden CL, Calabrese JR, Dilsaver SC, Morris DD. Pattern of response to divalproex, lithium, or placebo in four naturalistic subtypes of mania. Neuropsychopharmacology 2002;26:530-6.  Back to cited text no. 41
    
42.
Schulz SC, Camlin KL, Berry SA, Jesberger JA. Olanzapine safety and efficacy in patients with borderline personality disorder and comorbid dysthymia. Biol Psychiatry 1999;46:1429-35.  Back to cited text no. 42
    
43.
Soler J, Pascual JC, Campins J, Barrachina J, Puigdemont D, Alvarez E, et al. Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am J Psychiatry 2005;162:1221-4.  Back to cited text no. 43
    
44.
Knutson B, Wolkowitz OM, Cole SW, Chan T, Moore EA, Johnson RC, et al. Selective alteration of personality and social behavior by serotonergic intervention. Am J Psychiatry 1998;155:373-9.  Back to cited text no. 44
    

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Correspondence Address:
Dr. Mustafa Ozten
Faculty of Medicine Psychiatry, Sakarya University, Sakarya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_166_18

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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