The prevalent clinical spectrum of bipolar disorders: Beyond DSM-IV

International Mood Clinic, University of California at San Diego, La Jolla, USA.
Journal of Clinical Psychopharmacology (Impact Factor: 3.76). 05/1996; 16(2 Suppl 1):4S-14S. DOI: 10.1097/00004714-199604001-00002
Source: PubMed

ABSTRACT Based on the author's work and that of collaborators, as well as other contemporaneous research, this article reaffirms the existence of a broad bipolar spectrum between the extremes of psychotic manic-depressive illness and strictly defined unipolar depression. The alternation of mania and melancholia beginning in the juvenile years is one of the most classic descriptions in clinical medicine that has come to us from Greco-Roman times. French alienists in the middle of the nineteenth century and Kraepelin at the turn of that century formalized it into manic-depressive psychosis. In the pre-DSM-III era during the 1960s and 1970s, North American psychiatrists rarely diagnosed the psychotic forms of the disease; now, there is greater recognition that most excited psychoses with a biphasic course, including many with schizo-affective features, belong to the bipolar spectrum. Current data also support Kraepelin's delineation of mixed states, which frequently take on psychotic proportions. However, full syndromal intertwining of depressive and manic states into dysphoric or mixed mania--as emphasized in DSM-IV--is relatively uncommon; depressive symptoms in the midst of mania are more representative of mixed states. DSM-IV also does not formally recognize hypomanic symptomatology that intrudes into major depressive episodes and gives rise to agitated depressive and/or anxious, dysphoric, restless depressions with flight of ideas. Many of these mixed depressive states arise within the setting of an attenuated bipolar spectrum characterized by major depressive episodes and soft signs of bipolarity. DSM-IV conventions are most explicit for the bipolar II subtype with major depressive and clear-cut spontaneous hypomanic episodes; temperamental cyclothymia and hyperthymia receive insufficient recognition as potential factors that could lead to switching from depression to bipolar I disorder and, in vulnerable subjects, to predominantly depressive cycling. In the main, rapid-cycling and mixed states are distinct. Nonetheless, there exist ultrarapid-cycling forms where morose, labile moods with irritable, mixed features constitute patients' habitual self and, for that reason, are often mistaken for "borderline" personality disorder. Clearly, more formal research needs to be conducted in this temperamental interface between more classic bipolar and unipolar disorders. The clinical stakes, however, are such that a narrow concept of bipolar disorder would deprive many patients with lifelong temperamental dysregulation and depressive episodes of the benefits of mood-regulating agents.

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    • "Ces données épidémiologiques ont permis d'éclairer et de décrire une réalité clinique qui était ignorée par le manuel diagnostique et statistique des troubles mentaux dans sa 4 e édition (DSM-IV TR) [13] [14] [15] [24]. Le DSM-IV TR déÀ nissait un « épisode mixte » suivant une perspective catégorielle. "
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    ABSTRACT: Epidemiological studies of major depressive episodes (MDE) highlighted the frequent association of symptoms or signs of mania or hypomania with depressive syndrome. Beyond the strict definition of DSM-IV, epidemiological recognition of a subset of MDE characterized by the presence of symptoms or signs of the opposite polarity is clinically important because it is associated with pejorative prognosis and therapeutic response compared to the subgroup of "typical MDE". The development of DSM-5 took into account the epidemiological data. DSM-5 opted for a more dimensional perspective in implementing the concept of "mixed features" from an "episode" to a "specification" of mood disorder. As outlined in the DSM-5: "Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I and II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to therapeutic". However, the mixed features are sometimes difficult to identify, and neurophysiological biomarkers would be useful to make a more specific diagnosis. Two neurophysiological models make it possible to better understand MDE with mixed features : i) the emotional regulation model that highlights a tendency to hyper-reactive and unstable emotion response, and ii) the vigilance regulation model that highlights, through EEG recording, a tendency to unstable vigilance. Further research is required to better understand relationships between these two models. These models provide the opportunity of a neurophysiological framework to better understand the mixed features associated with MDE and to identify potential neurophysiological biomarkers to guide therapeutic strategies.
    L Encéphale 12/2013; 39 Suppl 3:149-56. · 0.60 Impact Factor
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    • "This concept was first introduced by Gerald Klerman in 1981 (Young & Klerman, 1992). Akiskal (Akistal, 1995), enlarged the concept by Gerald Klerman and defined six different types of bipolar disorders based on clinical features. However, in the current classification systems, these subtypes are not included. "
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    ABSTRACT: The represented case report demonstrates that interpersonal and behaviour-related CBASP strategies that include the disciplined personal involvement of the therapist were successful in reducing acute symptoms and maladjusted interpersonal behaviour, increasing over the long run the compliance and reducing disease risk and fall-back into maladapted depressive behaviour in this initially diagnosed "Double Depression" patient who switched into Bipolarity during the course of out-patient treatment. The main change in the core belief system of the patient was, in our opinion, connected to her belief of SOs. The restructuring of helplessness memories in antecedent-consequent way during the early treatment phase on the one hand, and the addressing, training, and thereby repairing of developmental trauma memories through IDE work in the SA/IDE treatment phase on the other hand, resulted in a high safety impact of the therapist on the hypothesized core content of the patient`s in-sessions fear that later generalized outside the therapy room. The resulting change in maladjusted interpersonal behaviour was clearly marked in (1) a change of the personal style from hostile-submissive into friendly-dominant, (2) and a positive adaptation of beliefs and predictions concerning self-efficacy and action-outcome learning. In addition, (3) the carefully timed self-disclosures during CPR interventions inhibited maladjusted rule-guided behaviour and counteracted the patient’s maladaptive interpersonal assumptions in both hypomanic episodes and the inter-episodic phase, which was characterized by on-going symptom fluctuations in both the depressive and the hypomanic pole.
    Psychiatric Disorders-New Frontiers in Affective Disorders, Edited by Dieter Schoepf, 05/2013: chapter 8: pages 183-202; INTECH OPEN ACCESS PUBLISHER., ISBN: ISBN 978-953-51-1147-4
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    • "Kraepelin posited that mood episodes arose from underlying affective temperaments in a cyclical nature. Specifically, Kraepelin suggested that affective temperaments occupy the intervals between mood episodes (Akiskal, 1996), but may also be present among individuals without full-blown mood disorders. Building on the historical foundation of Greek and German predecessors, Akiskal and Mallya (1987) operationalized, modified, and enriched Kraepelin's formulations and specifically identified cyclothymic, dysthymic, and hyperthymic temperaments. "
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    ABSTRACT: BACKGROUND: Numerous validation studies have examined the TEMPS-A in both clinical and nonclinical samples. However, the majority of these studies utilized cross-sectional assessments in laboratory or clinical settings. The present study is the first to examine the expression of affective temperaments in daily life using experience sampling methodology (ESM). METHODS: 138 participants completed the TEMPS-A and received a personalized digital assistant that signaled them eight times daily for one week to complete questionnaires that assessed affect, cognition, behavior, sense of self, and social interaction. RESULTS: As expected, cyclothymic/irritable temperament was positively associated with negative affect, risky behavior, and restlessness, and was negatively associated with positive affect and preference to be with others in daily life. In contrast, hyperthymic temperament was associated with positive affect, fullness of thought, doing many and exciting things, grandiosity, and preference to be with others in daily life. Dysthymic temperament was modestly associated with worry, and was positively associated with trouble concentrating, fullness of thought, and a preference for social contact. Cross-level interactions indicated that cyclothymic/irritable temperament was associated with elevated stress reactivity in daily life. LIMITATIONS: ESM data collection was limited to one week. Longer assessment periods might better capture the cyclical nature of affective temperaments. CONCLUSIONS: This was the first study to examine affective temperaments in daily life. The findings offer further validation of the TEMPS-A, as well as the maladaptive nature of the cyclothymic/irritable temperament.
    Journal of Affective Disorders 08/2012; 145(2). DOI:10.1016/j.jad.2012.07.026 · 3.71 Impact Factor
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