Journal of Affective Disorders 64 (2001) 267–270www.elsevier.com/ locate / jad

Brief Report

A factor analysis of signs and symptoms of the manic episode withBech–Rafaelsen Mania and Melancholia Scales

a,b , a b a*Alessandro Rossi , Enrico Daneluzzo , Luca Arduini , Monia Di Domenico ,b aRocco Pollice , Concetta Petruzzi

a `Department of Clinical Psychology, ‘Villa Serena Medical Center’, Citta S. Angelo (Pescara), ItalybInstitute of Experimental Medicine, University of L’Aquila, L’Aquila, Italy

Received 15 November 1999; received in revised form 4 April 2000; accepted 10 April 2000

Abstract

Background: Several factor analyses of signs and symptoms of mania have been reported using different rating scales. Wepropose here that the use of two instruments well known in the European literature may be useful in detecting the structureof manic episodes. Method: We investigated the pattern of symptoms in a group of 124 bipolar inpatients hospitalised for amanic episode. We conducted a factor analysis of the broad range of psychiatric symptoms covered by the Bech–RafaelsenMania Scale (BRMaS) and Melancholia Scale (BRMeS). Results: Five eigen values were greater than unity, whichdetermined the number of factors computed. The five factors captured 66.7% of the total variance. Following rotation, fivefactors were clinically relevant. Conclusion: This suggests that both euphoric activation and depression are prominent in thissample. 2001 Elsevier Science B.V. All rights reserved.

Keywords: Factor analysis; Bipolar disorder; Bech–Rafaelsen Mania Scale; Bech–Rafaelsen Melancholia Scale

1. Introduction sion and euphoric mania, manic and depressed statesare often not mutually exclusive. Their combination

Even though the two phases of bipolar disorder in in mixed states has been repeatedly described sincetheir classical expression consist of retarded depres- Kraepelin (1921). However, a clear definition and

boundaries for mixed states is still lacking (Mc Elroyet al., 1995) so that their clinical presentationcontinues to be relevant not only within the diagnos-

`*Corresponding author. Unita Operativa di Psicologia Clinica, tic debate but also for treatment options (Dilsaver et`c /o ‘Casa di Cura Villa Serena’, Viale L. Petruzzi 19, 65013 Citta

al., 1993).S. Angelo (PE), Italy. Tel.: 139-085-959-0201; fax: 139-085-Factor analyses provide one way to examine the959-0400.

E-mail address: a.rossi@villaserena.it (A. Rossi). issue of homogeneity versus heterogeneity of manic

0165-0327/01/$ – see front matter 2001 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 00 )00228-7

268 A. Rossi et al. / Journal of Affective Disorders 64 (2001) 267 –270

episodes. Factor analysis could suggest possible 40 men and 84 women. The mean (6S.D.) age of theclinical subtypes of the disorder. Cassidy et al. patients was 45.24616.22 years.(1998a), in a population of 237 patients with bipolardisorder, found five independent factors with a 2.1. Measures, rating procedure and reliabilitybimodal distribution of the dysphoria factor. Dilsaveret al. (1999), in 105 acutely manic patients, found Symptom severity was assessed with the use of thefour factors corresponding to manic activation, de- Bech–Rafaelsen Mania and Melancholia Scale (Bechpressed state, sleep disturbance and irritability / et al., 1979; Bech, 1988). These are two 11-itemparanoia. Serretti et al. (1996), in a group of 523 scales with five scoring categories per item, giving abipolar I patients, found a three factor solution with range of total possible scores from 0 to 44. Allpsychic and motor excitement, psychosis and ir- patients were interviewed within 3 days of admissionritability factors explaining 52.4% of the rotated to hospital. Members of the research team performedvariance. These results are sensitive to the rating all ratings (all were experienced psychiatrists) afterscales used. The research question is whether or not informed consent to participate was obtained. Thedepressive symptoms are common during manic interviews were carried out independently by two ofepisodes or are confined to clinical subtypes. us (ED and MDD). The interrater reliability was

We approached this issue to determine if the evaluated on a sample of 30 patients and was highconcurrent administration of rating scales widely (Pearson r 5 0.92)applied in the assessment of manic depressive illnesssuch as the Bech–Rafaelsen Mania and Melancholia 2.2. Statistical analysisScales (Goodwin and Jamison, 1990), mainly usedseparately to assess manic patients and depressive The symptom intercorrelations were studied bypatients (Licht and Jensen, 1997; Smolka and Stieg- principal components factor analysis using a correla-litz, 1999), could add further knowledge about the tion matrix and a Varimax rotation. The number ofstructure of mania. We investigated the pattern of factors considered was taken as those with eigensymptoms in a group of 146 bipolar inpatients values greater than unity (Norusis, 1992). Thehospitalised for a manic episode. We conducted a Kolmogorov–Smirnov statistics demonstrated thatfactor analysis of the broad range of psychiatric the distributions of the factor scores were normalsymptoms covered by the Bech–Rafaelsen Mania (K–S Z values ranging from 0.54 to 1.30 for the fiveScale (BRMaS) and the Bech–Rafaelsen Melan- factors, NS).cholia Scale (BRMeS).

3. Results

2. Method Descriptive analyses showed a mean BRMeS totalscore of 14.376 5.70 (S.D.) and a mean BRMaS

The subjects were 146 patients consecutively total score of 28.0567.32 (S.D.). Table 1 shows theadmitted for the treatment of manic episodes at Villa factor analysis. Five eigen values were greater thanSerena Medical Center (VSMC), a psychiatry ter- unity, which determined the number of factorstiary referral center. With 150 beds for acute patients, computed. The five factors captured 66.7% of theVSMC is among the largest psychiatric departments total variance. Following rotation, the five factorsin Italy. Patients were diagnosed as affected by were clinically relevant. The first and strongest factorbipolar disorder (mania 124 or mixed 22) according could be labelled as activation-euphoric. The secondto DSM III R criteria (American Psychiatric Associa- factor includes depressive items and factor 3 repre-tion, 1987). In order to limit the study to a more sents psychomotor retardation. Factor 4 is mainlyhomogeneous sample, mixed patients were excluded due to hostility-destructiveness and factor 5 repre-from the subsequent analyses. The patients included sents sleep disturbances.

A. Rossi et al. / Journal of Affective Disorders 64 (2001) 267 –270 269

Table 1Factor analysis with Varimax rotation of the Bech–Rafaelsen Mania (Ma) and Melancholia (Me) Scale items (pts. No. 124)

Factor

1 2 3 4 5

Eigenvalue 6.47 4.16 1.66 1.33 1.07Variance proportion 29.4 18.9 7.5 6.0 4.9

aItem Factor loadingMa1 — Activity (motor) 0.83Ma2 — Activity (verbal) 0.82Ma3 — Flight of thought 0.82Ma4 — Noise level 0.88Ma5 — Hostility /destructiveness 0.64Ma6 — Mood level 0.59Ma7 — Self-esteem 0.59Ma8 — Contact 0.78Ma9 — Sleep 0.81Ma10 — Sexual interest 0.78Ma11 — Activity (work) 0.62Me1 — Retardation (motor) 0.84Me2 — Retardation (verbal) 0.85Me3 — Retardation (intellectual) 0.53Me4 — Anxiety (psychic) 0.67Me5 — Suicide 0.56Me6 — Depressed mood 0.71Me7 — Guilt 0.76Me8 — Retardation (emotional) 0.60Me9 — Insomnia (general) 0.81Me10 — Tiredness and pains 0.71Me11 — Activity(work and activities) 0.44 0.40

a Scores with high and relative non-overlapping loading on the factor.

4. Comment prompted several factor analysis studies to examinethe issue of possible psychopathological subtyping ofthe disorder (Double, 1990; Mc Elroy et al., 1992;The use of two well-validated instruments in theCassidy et al., 1998a). Even excluding mixed pa-assessment of mood disorders, such as the Bech–tients, our study confirms that the occurrence ofRafaelsen Mania and Melancholia Scales, is able to‘depression during mania’ is not confined to aadd further knowledge about the internal structure ofminority of cases, but it is relevant to the constructmanic episode presentation. These instruments haveof mania itself as recently suggested by Cassidy etmainly been used separately to assess manic oral. (1998b).depressive symptoms (Bech, 1988). Even though it

is difficult to compare our factor analysis with othersobtained with different instruments, our factors are

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