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The bipolar spectrum: A clinical reality in search of diagnostic criteria and an assessment methodology
Abstract
Failure to recognize subthreshold expressions of mania contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive ones. These include the lack of subjective suffering, enhanced productivity, ego-syntonicity, and diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' tendency to subsume persistent or even alternating symptoms among personality disorders. Furthermore, the central diagnostic importance placed on alterations in mood distracts clinicians from paying attention to other more subtle but clinically meaningful symptoms, such as changes in energy, neurovegetative symptoms and distorted cognitions. Although officially accepted in both ICD-10 and DSM-IV, we believe bipolar II disorder is underdiagnosed because of inattention to symptoms of hypomania. Moreover, by requiring the presence of both full-blown hypomanic and major depressive episodes, current nosology fails to include symptoms or signs which are mild and do not meet threshold criteria. There is already agreement in the field that such symptoms are important for depression. We now propose that attention should also be devoted to mild symptomatic manifestations of a manic diathesis, even if such manifestations may sometimes enhance quality of life. The term 'spectrum' is used to refer to the broad range of such manifestations of a disorder from core symptoms to temperamental traits. Spectrum manifestations may be present during, between, or even in the absence of, an episode of full-blown disorder. We have developed a structured clinical interview to assess the mood spectrum (SCI-MOODS) to evaluate the whole range of depressive and manic symptoms. This instrument is currently undergoing psychometric testing procedures. Similar to the SCID interview, the SCI-MOODS interview provides a separate rating for each of the major DSM-IV symptoms, but the latter also identifies and rates subthreshold and atypical manifestations. This paper presents the concept of a subthreshold bipolar disorder and discusses the potential epidemiological, diagnostic and therapeutic relevance of such a spectrum conditions. We also describe the SCI-MOODS interview used reliably to identify the occurrence of a bipolar spectrum condition. Obviously a great deal of systematic research needs to be conducted to ascertain the reliability and validity of subthreshold bipolarity as summarized in this paper and embodied in our instrument.
... Traditionally, in this framework the word "spectrum" has been employed to emphasize the connection between different symptomatic clusters or between different levels of severity of a same disorder (Akiskal and Akiskal, 1992) or different disorders (Hollander and Wong, 1995). Starting from these considerations, at the beginning of the current century was developed the "Collaborative Spectrum Project" with the aim to describe and better characterize the subtle and atypical signs linked to numerous DSM disorders (Cassano et al., 1997(Cassano et al., , 1999Dell'Osso et al., 2003, 2016a,b, 2017Carmassi et al., 2023). According to the spectrum project conceptualization (Cassano et al., 1997(Cassano et al., , 1999Dell'Osso et al., 2003, 2016b, Carmassi et al., 2023, the spectrum of a disorder encompasses both full-blown and prototypical presentations along with sub-clinical and non-typical ones. ...
... Starting from these considerations, at the beginning of the current century was developed the "Collaborative Spectrum Project" with the aim to describe and better characterize the subtle and atypical signs linked to numerous DSM disorders (Cassano et al., 1997(Cassano et al., , 1999Dell'Osso et al., 2003, 2016a,b, 2017Carmassi et al., 2023). According to the spectrum project conceptualization (Cassano et al., 1997(Cassano et al., , 1999Dell'Osso et al., 2003, 2016b, Carmassi et al., 2023, the spectrum of a disorder encompasses both full-blown and prototypical presentations along with sub-clinical and non-typical ones. It also comprises discrete signs and symptoms, symptom clusters, behavioral patterns, temperamental and/or personality qualities, and symptoms that are assumed to be related to the primary symptoms of the disorder. ...
... The goal of this work was to introduce the OBS-SV, a clinical tool inspired by a dimensional approach to psychopathology, in light of the spectrum model (Cassano et al., 1997(Cassano et al., , 1999Dell'Osso et al., 2003, 2016a,b, 2017. The OBS-SV investigates not only the prototypic symptoms of OCD but also unusual manifestations, temperamental traits, and other noteworthy clinical aspects linked to the main symptoms. ...
Aim:
In the recent years, a rising amount of research has stressed the importance of a dimensional perspective on mental disorders. In particular, the conceptualization of an obsessive-compulsive spectrum appears to be in line with the very first descriptions of Obsessive-Compulsive Disorder and has been partially acknowledged by the inclusion of the "OCD-spectrum related syndromes and disorders" section in the DSM-5. The goal of the current study is to ascertain the psychometric characteristics of the Obsessive-Compulsive Spectrum-Short Version (OBS-SV), a novel questionnaire designed to measure the complete range of obsessive-compulsive symptoms, from severe full blown to subthreshold ones.
Methods:
Forty three subjects with a clinical diagnosis of OCD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5); 42 subjects with a clinical diagnosis of social anxiety disorder (SAD), and 60 individuals without current or lifetime mental disorders (HC) were recruited from the Psychiatric Clinic of the University of Pisa. Subjects were assessed with the SCID-5, the Yale Brown Obsessive Compulsive Scale (Y-BOCS) and the OBS-SV.
Results:
OBS-SV showed strong test-retest reliability for both the total and the domains scores, as well as a high level of internal consistency. The Pearson's coefficients for the OBS-SV domain scores ranged from 0.771 to 0.943, and they were positively and strongly linked with one another (p < 0.001). The OBS-SV total score had a strong correlation with each of the OBS-SV domain scores. All correlation coefficients between OBS-SV and additional measures of OCS were observed to be strong, significant and positive. Both OBS-SV domain and overall score differences between diagnostic groups were found to be statistically significant. From HCs, to the SAD, up to the OC group, which had the highest values, the OBS-SV total score grew dramatically and progressively.
Conclusion:
The OBS-SV demonstrated significant convergent validity with other dimensional OCD measures, excellent internal consistency, and test-retest reliability. Across the three diagnostic categories, the questionnaire functioned differently, with a rising score gradient from healthy controls through SAD patients to OCD subjects.
... A significant body of studies has been drawing attention to the importance of spectrum approaches for the purpose of optimization of diagnosis and treatment of mental disorders [30][31][32][33][34][35][36][37][38][39][40][41][42]. In the framework of the so-called Spectrum Project, an Italian-American collaboration research project (www.spectrumproject.org), a spectrum approach has been proposed, encompassing not only core features associated with DSM mental disorders, but also isolated and atypical symptoms, as well as subthreshold symptom clusters, personality traits and behavioral manifestations that may precede, follow or be manifested in concurrence with DSM mental disorders [30,39]. ...
... In the framework of the so-called Spectrum Project, an Italian-American collaboration research project (www.spectrumproject.org), a spectrum approach has been proposed, encompassing not only core features associated with DSM mental disorders, but also isolated and atypical symptoms, as well as subthreshold symptom clusters, personality traits and behavioral manifestations that may precede, follow or be manifested in concurrence with DSM mental disorders [30,39]. The application of this model of spectrum provides a more accurate representation of clinical syndromes, including the recognition of subthreshold prodromal symptoms that can lead to early diagnosis and prevention [32][33][34][40][41][42]. ...
... The AdAS Spectrum was developed by a group of researchers from the University of Pisa, within the framework of the Spectrum Project, an international Italy-USA research network started in 1995 [32][33][34][39][40][41][42]. In line with all the spectrum assessment instruments, the AdAS Spectrum was developed simultaneously in Italian and English, by researchers that are essentially bilingual and some also studied in the United States (CC and CG), and revised by an Italian/ English bilingual translator that is trained in the field of psychiatry; all questions were discussed extensively, always with an eye toward deciding precisely how the concept was expressed in both languages and revised for inconsistencies between the two languages. ...
Aim:
Increasing literature has shown the usefulness of a dimensional approach to autism. The present study aimed to determine the psychometric properties of the Adult Autism Subthreshold Spectrum (AdAS Spectrum), a new questionnaire specifically tailored to assess subthreshold forms of autism spectrum disorder (ASD) in adulthood.
Methods:
102 adults endorsing at least one DSM-5 symptom criterion for ASD (ASDc), 143 adults diagnosed with a feeding and eating disorder (FED), and 160 subjects with no mental disorders (CTL), were recruited from 7 Italian University Departments of Psychiatry and administered the following: SCID-5, Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale 14-item version (RAADS-14), and AdAS Spectrum.
Results:
The AdAS Spectrum demonstrated excellent internal consistency for the total score (Kuder-Richardson's coefficient=.964) as well as for five out of seven domains (all coefficients>.80) and sound test-retest reliability (ICC=.976). The total and domain AdAS Spectrum scores showed a moderate to strong (>.50) positive correlation with one another and with the AQ and RAADS-14 total scores. ASDc subjects reported significantly higher AdAS Spectrum total scores than both FED (p<.001) and CTL (p<.001), and significantly higher scores on the Childhood/adolescence, Verbal communication, Empathy, Inflexibility and adherence to routine, and Restricted interests and rumination domains (all p<.001) than FED, while on all domains compared to CTL. CTL displayed significantly lower total and domain scores than FED (all p<.001). A significant effect of gender emerged for the Hyper- and hyporeactivity to sensory input domain, with women showing higher scores than men (p=.003). A Diagnosis* Gender interaction was also found for the Verbal communication (p=.019) and Empathy (p=.023) domains. When splitting the ASDc in subjects with one symptom criterion (ASD1) and those with a ASD, and the FED in subjects with no ASD symptom criteria (FED0) and those with one ASD symptom criterion (FED1), a gradient of severity in AdAS Spectrum scores from CTL subjects to ASD patients, across FED0, ASD1, FED1 was shown.
Conclusions:
The AdAS Spectrum showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of ASD. The questionnaire performed differently among the three diagnostic groups and enlightened some significant effects of gender in the expression of autistic traits.
... Bipolar disorders are heterogeneous affective disorders characterized by periods of extreme mood, including depression, mania or hypomania, as well as mixed episodes (American Psychiatric Association, 2000). Within this diagnostic category, there is a continuum or spectrum of severity from the milder subsyndromal cyclothymia to bipolar II disorder to full-blown bipolar I disorder (Cassano et al., 1999). The illnesses have a lifetime prevalence in about 3.9 % of the adult population , and account for the highest suicide rate of all mental health conditions (Proudfoot, Doran, Manicavasagar, & Parker, 2010). ...
... Bipolar disorders are regarded as severe mental disorders, with a lifetime prevalence of about 3.9 % of the adult population . Within this diagnostic category, there is a continuum or spectrum of severity, from the milder subsyndromal cyclothymia to bipolar II disorder to full-blown bipolar I disorder (Cassano et al., 1999). Even though the disorders are defined by the history of manic or hypomanic episodes, depressive episodes are seen more frequently and tend to last longer. ...
... According to diagnostic criteria, bipolar I disorder is characterized by at least one lifetime manic or mixed episode; bipolar II disorder by at least one lifetime hypomanic episode along with at least one episode of major depression; and cyclothymia by two or more years of alterations between hypomanic and depressive symptoms that do not meet criteria for hypomania or a major depressive episode (American Psychiatric Association, 2000). The disorders are accordingly often described as a continuum of severity (Cassano et al., 1999). Bipolar disorders have frequent co-morbidity and hold the highest suicide rates of all mental health conditions (Proudfoot, Doran, Manicavasagar & Parker, 2011). ...
... It is well known that bipolar disorders frequently go unrecognized in psychiatric and non-psychiatric settings (Benvenuti et al., 2008). The under-diagnosis of hypomania and mania may delay the recognition of illness and the start of an appropriate treatment, therefore worsening the prognosis of Bipolar Disorders, especially when severe comorbid physical conditions occur (Cassano et al., 1999). Part of the delay is due to the fact that patients usually do not present for treatment of the milder forms of mania, such as hypomania, which are rarely perceived as a source of distress (Cassano et al., 2002). ...
... Again, no bipolar disorders were detected. However, It is well known from psychiatric and epidemiological samples, that a relevant percentage of patients cross-sectionally diagnosed with 'unipolar depression' (Major Depressive Episodes, MDE) in psychiatric and non psychiatric settings, might actually have an underlying bipolar diathesis or sub-threshold manifestations of bipolarity that complicates clinical course and treatment response, especially when a longitudinal assessment is performed (Cassano et al., 1999;Cassano et al., 2002;Cassano et al., 2009;Cassano et al., 2012;Nielsen, Kugathasan, Straszek, Jensen, & Licht, 2019). ...
Objective:
We reviewed literature on drugs for bipolar disorders (BD), utilized in ovarian cancer (OC).
Method:
We adhered to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines in completion of this systematic review.
Results:
We identified 73 papers. Thirty-two studies were finally included. BD is rarely diagnosed in OC patients. Limited finding from case reports is available. Drugs used to treat BD (mainly lithium and valproic acid) have been extensively studied in add-on to chemotherapy for treatment-resistant OC cells or in animal models, with promising results in vitro but not in vivo.
Conclusions:
The clinical underestimation of BD in OC has leaded to the almost complete absence of evidences for a soundly based clinical guidance in this field. There is a urgent need for a systematic multi-disciplinary approach to OC.
... According to this model, eating spectrum symptoms may occur as prodromals to a fully developed disorder, as precursors of a not-yet-fully expressed disorder, as a mix of well-defined diagnostic categories, or as sequalae of a previously experienced full-fledged condition. The eating spectrum concept is intended to ascertain also whether symptoms and phenomena, that are usually considered 'soft' or 'clinically irrelevant', might, conversely, produce a subjective sufferance and an objective impairment (Cassano et al., 1997(Cassano et al., , 1999. In order to evaluate eating spectrum features using a standardized assessment, researchers of the Spectrum Project (1993-2019) developed and validated the self-report Anorexia-Bulimia Questionnaire (ABS-SR) designed to collect signs and symptoms of both AN and BN, together with social aspects of EDs, which could affect the development and course of the disease or interfere with treatment response. ...
... Conversely, the proposed 'eating spectrum model' by Mauri et al. (2000Mauri et al. ( , 2002 refers to an integrated view, with the assessment of a number of psychopathological/psychological dimensions (domains) within the DSM diagnostic categories. This approach has prompted research mainly in other two fields than eating disorders, namely panic-agoraphobic and mood disorders spectra (Cassano et al., 1997;Cassano et al., 1999; the spectrum instruments are all available for download at the Spectrum Website: http://www.spectrumproject.org/intro.html). For example, data emerging from the studies with the mood spectrum approach suggested the existence of a continuum from 'pure mania' to 'pure depression', without a clear cut-off between the two realms, confirming the need for a probabilistic approach towards mood disorders (Angst & Cassano, 2005;Phelps et al., 2008;Mitchell et al., 2008). ...
Eating and Feeding Disorders are heterogeneous clinical conditions characterized by cognitive, interpersonal, and behavioural features. They might spread across a spectrum of severity, from mild or sub-threshold conditions, belonging to the realm of altered eating habits or body dysmorphic features, to severe disorders. The Anorexia-Bulimia Spectrum (ABS) aims at exploring and describing in a systematic manner this psychological/psychopathological area. The ABS model has been proposed to detect, in a lifetime perspective, signs and symptoms that might be considered as clinically relevant or not, but evenly associated with different levels of subjective impairment. To detect the eating disorder spectrum phenomenology, a structured clinical interview has been built and validated, the Anorexic-Bulimic Spectrum Clinical Interview (SCI-ABS). The paper describes its clinical significance and potential implications.
... In the framework of a spectrum approach to psychopathology, proposed by the Italian-American research project named Spectrum-project (www.spectrumproject.org) [76][77][78][79][80][81][82][83][84][85][86], we recently developed and validated the Adult Autism Subthreshold Spectrum (AdAS Spectrum), which aims to assess both typical and atypical symptoms, but also attenuated manifestations, personality traits, and behavioural features that may be associated with ASD but which may also be present in subthreshold or partial forms [55]. Compared to other available instruments, the AdAS Spectrum, besides assessing more subtle manifestations of autism spectrum, investigates features that have been suggested as the female phenotype of ASD [62][63][64][65][66][67]. ...
... The AdAS Spectrum is a questionnaire developed by Dell'Osso et al. [55], within the framework of the international research network called Spectrum Project [47,48,[76][77][78][79][80][89][90][91]. The instrument was devised to assess the lifetime presence of the wide spectrum of manifestations associated with ASD, but which could be found even in individuals who do not fulfill diagnostic criteria for a formal disorder: in this regard, it was not developed to be a diagnostic instrument. ...
Aim:
Increasingly data suggest a possible overlap between psychopathological manifestations of eating disorders (EDs) and autism spectrum disorders (ASD). The aim of the present study was to assess the presence of subthreshold autism spectrum symptoms, by means of a recently validated instrument, in a sample of participants with EDs, particularly comparing participants with or without binge eating behaviours.
Methods:
138 participants meeting DSM-5 criteria for EDs and 160 healthy control participants (HCs), were recruited at 3 Italian University Departments of Psychiatry and assessed by the SCID-5, the Adult Autism Subthreshold Spectrum (AdAS Spectrum) and the Eating Disorders Inventory, version 2 (EDI-2). ED participants included: 46 with restrictive anorexia (AN-R); 24 with binge-purging type of Anorexia Nervosa (AN-BP); 34 with Bulimia Nervosa (BN) and 34 with Binge Eating Disorder (BED). The sample was split in two groups: participants with binge eating behaviours (BEB), in which were included participants with AN-BP, BN and BED, and participants with restrictive behaviours (AN-R).
Results:
participants with EDs showed significantly higher AdAS Spectrum total scores than HCs. Moreover, EDs participants showed significantly higher scores on all AdAS Spectrum domains with the exception of Non verbal communication and Hyper-Hypo reactivity to sensory input for AN-BP participants, and Childhood/Adolescence domain for AN-BP and BED participants. Participants with AN-R scored significantly higher than participants with BEB on the AdAS Spectrum total score, and on the Inflexibility and adherence to routine and Restricted interest/rumination AdAS Spectrum domain scores. Significant correlations emerged between the Interpersonal distrust EDI-2 sub-scale and the Non verbal communication and the Restricted interest and rumination AdAS Spectrum domains; as well as between the Social insecurity EDI-2 sub-scale and the Inflexibility and adherence to routine and Restricted interest and rumination domains in participants with EDs.
Conclusions:
Our data corroborate the presence of higher subthreshold autism spectrum symptoms among ED participants with respect to HCs, with particularly higher levels among restrictive participants. Relevant correlations between subthreshold autism spectrum symptoms and EDI-2 Subscale also emerged.
... T h e s p e c t r u m i s a t e r m borrowed from physics, where the visible light after passing through the prism appears as a rainbow spectrum of colors. From a medical/psychiatric perspective, the spectrum concept includes the broad areas of psychiatric phenomenology relating to a given 'classical' form of disorder , but in addition, also goes on to include: 6 • Core, subthreshold and subclinical symptoms of the classically described disorder • T e m p e r a m e n t a l a n d / o r personality traits Spectra of symptoms may be prodromal, precursors of a full disorder or sequelae of a previous full disorder. From a medical perspective, there is a need to pay attention to these spectrum conditions, as this approach for bipolar spectrum disorders may h e l p u s i n i d e n t i f y i n g a t -r i s k population, lessen morbidity and providing a rationale for the use of a single group of drugs for a continuum/spectrum of disorders. ...
... From a medical perspective, there is a need to pay attention to these spectrum conditions, as this approach for bipolar spectrum disorders may h e l p u s i n i d e n t i f y i n g a t -r i s k population, lessen morbidity and providing a rationale for the use of a single group of drugs for a continuum/spectrum of disorders. 6,7 T h e b i p o l a r s p e c t r u m i s a broader concept, and questions the strict categorical division of erstwhile manic-depressive illness by the third edition of DSM-III into two discrete categories viz. bipolar disorder and major depressive disorder. ...
The bipolar spectrum is a broader concept, which questions the strict dichotomous categorical division of erstwhile manic-depressive illness into two discrete categories viz. bipolar disorder and major depressive disorder, thereby overlooking a wide ‘spectrum’ of patients which lie ‘in between’ the two extremes. The presence of underlying bipolar ‘spectrum’ or ‘soft bipolarity’ often goes undetected in patients presenting with major depression. This sub-group of patients may not stabilize with indiscriminate use of anti-depressant drugs, and without proper management, it may be associated with continued nonresponsive symptoms, increased suicidality and poorer prognosis. There is a need to suspect and identify such cases of soft bipolarity/spectrum by early screening of patients with major depression presenting to medical settings. The review paper covers the current concepts and understanding of bipolar spectrum disorders which is aimed to facilitate early identification, management and referral of cases detected to have soft bipolarity in the general medical settings. © 2017, Journal of Association of Physicians of India. All rights reserved.
... The wide range of comorbidity percentages between the two psychopathological areas (from 20 to 90 %) can be only partially explained with the heterogeneity of clinical assessment adopted across the different studies, raising questions about the usefulness of the categorical approach. A dimensional approach, overcoming the unipolar/bipolar dichotomy, has been proposed to improve the phenotypic definition of mood disorders, and to enhance the validity and reliability of comorbidity assessment [9,10]. ...
... A dimensional approach should allow us to discriminate clinical phenotypes of patients with AN, and BN and comorbid mood spectrum signs and symptoms, with a greater level of specificity than that provided by the stereotypic descriptions of Axis I categories. According to the 'mood spectrum model' as originally conceived by Cassano and Colleagues, threshold-level manifestations of unipolar and bipolar mood psychopathology, atypical symptoms and behavioral traits are parts of the same continuum [9]. The 'mood spectrum' considers as clinically meaningful both manic/hypomanic and depressive features that may occur throughout the lifetime. ...
Purpose:
To investigate the presence of mood spectrum signs and symptoms in patients with anorexia nervosa, restricting subtype (AN-R) or bulimia nervosa (BN).
Method:
55 consecutive female patients meeting DSM-IV criteria for eating disorders (EDs) not satisfying DSM-IV criteria for Axis I mood disorders were evaluated with the Lifetime Mood Spectrum Self-Report (MOODS-SR) and the Mini-International Neuropsychiatric Interview (MINI). The MOODS-SR explored the subthreshold comorbidity for mood spectrum symptoms in patients not reaching the threshold for a mood disorder Axis I diagnosis. MOODS-SR included 161 items. Separate factor analyses of MOODS-SR identified 6 'depressive factors' and 9 'manic-hypomanic factors'.
Results:
The mean total score of MOODS-SR was significantly higher in BN than in AN-R patients (97.5 ± 25.4 vs 61.1 ± 38.5, respectively; p = 0.0001). 63.6 % of the sample (n = 35) endorsed the threshold of ≥61 items, with a statistically significant difference between AN-R and BN (39.3 % vs 88.9 %; χ (2) = 14.6; df = 1; p = 0.0001). Patients with BN scored significantly higher than AN-R patients on several MOODS-SR factors: (a) MOODS-SR depressive component: 'depressive mood' (11.2 ± 7.4 vs 16.0 ± 5.8; p < 0.05), 'psychomotor retardation' (5.4 ± 5.6 vs 8.9 ± 3.8; p = 0.003), 'psychotic features' (2.0 ± 1.8 vs 4.1 ± 1.6; p = 0.001), 'neurovegetative symptoms' (5.0 ± 2.6 vs 7.7 ± 1.7; p = 0.001); (b) MOODS-SR manic/hypomanic component: 'psychomotor activation' (4.3 ± 3.6 vs 7.4 ± 3.1; p = 0.002), 'mixed instability' (1.0 ± 1.5 vs 2.0 ± 1.6; p < 0.05), 'mixed irritability' (2.5 ± 1.8 vs 3.7 ± 1.6; p < 0.05), 'inflated self-esteem' (1.1 ± 1.4 vs 2.1 ± 1.6; p < 0.05), and 'wastefulness/recklessness' (1.0 ± 1.4 vs 2.0 ± 1.2; p = 0.009).
Conclusions:
MOODS-SR identifies subthreshold mood signs/symptoms among patients with AN-R, and BN and with no Axis I comorbidity for mood disorders, and provides a better definition of clinical phenotypes.
... Bipolar disorder is a heterogeneous condition, characterized by symptoms that span from mild cyclothymia to severe depression or full-blown mania, sometimes accompanied by psychotic features (5)(6)(7). Due to the wide variety of illness presentation and progression of the bipolar spectrum disorders, clinical staging, alongside conventional diagnostic models, greatly contributes to the prognostic validity in BPD (8). A staging model in BPD would be useful in order to specify where an individual is positioned on the continuum from 'at risk' but asymptomatic to 'end-stage' illness and to provide the necessary information to the clinician for selecting stagespecific strategies for treatment (8,9). ...
Introduction: Bipolar disorder (BPD) is the sixth leading cause of disability worldwide. A staging model in BPD would be useful in order to provide the necessary information to the clinician for selecting stage-specific strategies for treatment. Multiple studies emphasize the view that the behavioral approach system (BAS) may be a relevant marker of illness onset and progression in BPD. Objective: The aim of this research study was to further explore the roles of self-reported BAS Drive, Fun Seeking and Reward Responsiveness levels in a sample of Romanian bipolar I disorder patients compared with a control group. Materials and methods: Our sample consisted of 93 subjects, divided in to 58 BPD I patients and 35 healthy controls. Consequently the BPD I group was subdivided, according to specific psychopathological clinical states such as mania, hypomania, depressive and mixed episodes, by using the Romanian version of the MINI International Neuropsychiatric Interview. The BIS/BAS self-report scale was used in order to assess the behavioral approach system. Results: Our study showed higher mean rank values of BAS score for the participants suffering from BPD I compared with healthy controls. Our data revealed increased mean rank values of BAS scores only for the participants who presented in a manic episode when compared with the depression, remission and the healthy control subgroups. High BAS Drive and BAS Reward Responsiveness scores were directly correlated with a greater number of past manic episodes, while a high BAS Fun Seeking score was indirectly correlated with the number of past episodes of depression. Conclusion: Our results contribute the current research findings regarding the BAS dysregulation theory in BPD and subscribe to the importance of measuring BAS hypersensitivity as a reliable behavioral marker for attaining a theoretically driven model for disease progression in BSD and improving therapeutic strategies for our patients.
... In particular, regarding PD and AG, some researchers observed that patients with PD actually manifest a "spectrum" of associated clinical features not included in the DSM criteria, while patients with other mental disorders, such as Separation anxiety disorder or mood disorders, may sometimes show these clinically significant features without satisfying the criteria for PD (Pini et al., 2005;Manicavasagar e al., 2010;Cassano et al., 1997). In order to make measurable the panicagoraphobic spectrum model, a Structured Clinical Interview for PanicAgoraphobic Spectrum (SCI-PAS) and the corresponding self-report form (PAS-SR) were developed in the context of the Spectrum Project (Cassano et al., 1999). The questionnaire showed a good internal consistency and a excellent inter-rater reliability along with a good discriminant validity; however, its use in the daily clinical practice remained quite difficult due to the long time needed to fill out it, which is around 50 minutes. ...
Objective:
a spectrum model of psychopathology has allowed, in recent years, to recognize the subclinical or sub-threshold symptomatology that may be associated with full-blown mental disorders. The conceptualization of a panic - agoraphobic spectrum was developed in consideration of the substantial clinical heterogeneity revealed by studies on panic disorder with or without agoraphobia. The current study aims to determine the psychometric properties of the Panic Agoraphobic Spectrum - Short Version (PAS-SV), a new questionnaire designed to identify the spectrum of panic - agoraphobic symptoms.
Method:
42 subjects with panic disorder or agoraphobia (PAD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 41 subjects with autism spectrum disorder (ASD), and 60 healthy controls (HC) were recruited from the Psychiatric Clinic of the University of Pisa and assessed with the SCID-5, the Panic Disorder Severity Scale (PDSS) and the PAS-SV.
Results:
PAS-SV demonstrated a high level of internal consistency and the test-retest reliability for total and domain scores was excellent. PAS-SV domain scores were positively and significantly correlated with each other (p < 0.001), with Pearson's coefficients ranging from 0.771 to 0.943. All the PAS-SV domain scores were highly correlated with the PAS-SV total score. The correlation coefficients between PAS-SV and alternative measures of panic - agoraphobic symptoms appeared all significant and positive. Significant differences among diagnostic groups on both PAS-SV domains and total scores were found. PAS-SV total score increased significantly and progressively from HC, to the ASD up to the PA group.
Conclusions:
The PAS-SV showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of PA. The questionnaire performed differently among the three diagnostic groups, with an increasing score gradient from HC to patients with ASD to the PA group.
... The basic rationale for this diagnostic grouping is the clinical experience and scientific evidence that many patients with severe recurrent depression do not meet classic DSM-III-5 criteria for bipolar disorders type I or type II, nor the classic definition of major depressive disorder (MDD). In other words, this concept captures the extensive discussion Akiskal and Pinto 1999;Angst and Cassano 2005;Angst and Gamma 2002;Cassano et al. 1999) and notable literature Angst 2007Angst , 1998Angst et al. 1990;Cassano et al. 2004), not only in the past two decades but continuing into current research Mazzarini et al. 2018;Mesman and Hillegers 2017), supporting a dimensional spectrum to bipolar illness. For instance, many patients have severe recurrent depressive episodes, but not spontaneous hypomanic or manic episodes, but have parents with bipolar illness, or multiple family members diagnosed with bipolar illness ). ...
Background
In the 1970 s, scientific research on psychiatric nosology was summarized in Research Diagnostic Criteria (RDC), based solely on empirical data, an important source for the third revision of the official nomenclature of the American Psychiatric Association in 1980, the Diagnostic and Statistical Manual, Third Edition (DSM-III). The intervening years, especially with the fourth edition in 1994, saw a shift to a more overtly “pragmatic” approach to diagnostic definitions, which were constructed for many purposes, with research evidence being only one consideration. The latest editions have been criticized as failing to be useful for research. Biological and clinical research rests on the validity of diagnostic definitions that are supported by firm empirical foundations, but critics note that DSM criteria have failed to prioritize research data in favor of “pragmatic” considerations.
Results
Based on prior work of the International Society for Bipolar Diagnostic Guidelines Task Force, we propose here Clinical Research Diagnostic Criteria for Bipolar Illness (CRDC–BP) for use in research studies, with the hope that these criteria may lead to further refinement of diagnostic definitions for other major mental illnesses in the future. New proposals are provided for mixed states, mood temperaments, and duration of episodes.
Conclusions
A new CRDC could provide guidance toward an empirically-based, scientific psychiatric nosology, and provide an alternative clinical diagnostic approach to the DSM system.
... Bipolar Spectrum Disorders (BSDs) include several disorders (i.e., cyclothymia, bipolar II, and bipolar I disorder) that tend to progress in severity over time (Alloy, Urošević, et al., 2012;Birmaher et al., 2009;Kochman et al., 2005). This tendency to progress in severity highlights the importance of identifying corollaries of risk that can facilitate early detection, clarify pathophysiology, and generate targets for early intervention (Angst et al., 2002;Cassano et al., 1999). ...
Objective:
Elevated sensitivity to rewards prospectively predicts Bipolar Spectrum Disorder (BSD) onset; however, it is unclear whether volumetric abnormalities also reflect BSD risk. BSDs emerge when critical neurodevelopment in frontal and striatal regions occurs in sex-specific ways. The current paper examined the volume of frontal and striatal brain regions in both individuals with and at risk for a BSD with exploratory analyses examining sex-specificity.
Methods:
One hundred fourteen medication-free individuals ages 18-27 at low-risk for BSD (moderate-reward sensitivity; N = 37), at high-risk without a BSD (high-reward sensitivity; N = 47), or with a BSD (N = 30) completed a structural MRI scan of the brain. We examined group differences in gray matter volume in a priori medial orbitofrontal cortex (mOFC) and nucleus accumbens (NAcc) regions-of-interest.
Results:
The BSD group had enlarged frontostriatal volumes (mOFC, NAcc) compared to low individuals (d = 1.01). The mOFC volume in BSD was larger than low-risk (d = 1.01) and the high-risk groups (d = 0.74). This effect was driven by males with a BSD, who showed an enlarged mOFC compared to low (d = 1.01) and high-risk males (d = 0.74). Males with a BSD also showed a greater NAcc volume compared to males at low-risk (d = 0.49), but not high-risk males.
Conclusions:
An enlarged frontostriatal volume (averaged mOFC, NAcc) is associated with the presence of a BSD, while subvolumes (mOFC vs. NAcc) showed unique patterning in relation to risk. We report preliminary evidence that sex moderates frontostriatal volume in BSD, highlighting the need for larger longitudinal risk studies examining the role of sex-specific neurodevelopmental trajectories in emerging BSDs.
... It is therefore often that, when presenting for treatment, patients with BD are not in the manic or hypomanic phases of the illness. This suggests that manic phases, especially when brief or not characterized by impulse dyscontrol, need to be elicited with retrospective assessment, despite the substantial risk for spontaneous recall bias, especially due to the frequent lack of subjective suffering, enhanced productivity, ego-syntonicity and diurnal or seasonal rhythmicity associated with several manic/hypomanic symptoms [17]. To date, several factors have been proposed as possible predictors of the diagnosis of BD, essentially by comparing early clinical characteristics of patients and eventually meeting diagnostic criteria for a bipolar versus unipolar depressive disorder worldwide [3,18,19], including Egypt [20]. ...
Objective:To assess the psychometric properties of the Arabic adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) inpatients suffering a current major depressive episode (MDE).Method:The“Bipolar Disorders: Improving Diagnosis, Guidance, and Education”Arabic module of the HCL-32-R2 was administered tomother-tongue Arabic MDE inpatients between March 2013 and October 2014. Diagnostic and Statistical Manual Fourth edition (DSM-IV)diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls.Results:In our sample (n = 500, of whom, BD-I = 329; BD-II = 70; MDD = 101), using a cut-off of 17 allowed the HCL-32-R2 todiscriminate DSM-IV-defined MDD patients between“true unipolar”(HCL-32-R2−) and“sub-threshold bipolar depression”(HCL-32-R2+)with sensitivity = 82% and specificity = 77%. Area under the curve was .883; positive and negative predictive values were 93.44% and73.23% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factorsolution (F1=”hyperactive/elated”vs. F2=”irritable/distractible/impulsive”) was preferred using exploratory and confirmatory factorsanalyses. Item n.33 (“I gamble more”) and n.34 (“I eat more”) introduced in the R2 version of the HCL-32 loaded onto F1, though veryslightly. Cronbach’s alphas were F1 = .86 and F2 = .60.Limitations:No cross-validation with any additional validated screening tool. Inpatients only sample; recall bias; no systematic evaluation ofeventual medical/psychiatric comorbidities, current/lifetime pharmacological history, or record of severity of current MDE.Conclusions:In our sample, the HCL-32 fairly discriminated between MDD and BD-I but not BD-II, therefore soliciting for replicationstudies for use in Arabic-speaking depressed inpatients.
(PDF) Factor structure and reliability of the Arabic adaptation of the Hypomania Check List-32, second revision (HCL-32-R2). Available from: https://www.researchgate.net/publication/346645251_Factor_structure_and_reliability_of_the_Arabic_adaptation_of_the_Hypomania_Check_List-32_second_revision_HCL-32-R2 [accessed Dec 15 2020].
... Survivors were assessed by means of a specific instrument developed to assess posttraumatic stress spectrum symptoms: the Trauma and Loss Spectrum-Self Report (TALS-SR) 18 , referred to the earthquake exposure. The TALS-SR is an instrument developed in the framework of an international collaborative research project called Spectrum Project going on since 1995, exploring common clinical features that accompany each disorder, as it is classified through DSM diagnostic criteria 19,20 . According to this view, the spectrum approach refers to a dimensional view of psychopathology that takes into account, besides the core and most severe DSM symptoms, a wide number of atypical and sub-threshold manifestations, as well as temperamental traits, that might be prodromals, precursors or sequelae of the target disorder. ...
Objectives Several studies have shown that survivors of natural disasters present high PTSD rates. On 6th April 2009, L'Aquila (Central Italy) was jolted by a 6.3 Richter scale magnitude earthquake causing a massive destruction of the town. More than 300 individuals died, 1,600 were injured and about 65,000 displaced. The aim of this paper is to review the researches conducted on survivors to this earthquake in the context of the Pisa-L'Aquila Collaboration Project which is going on since 2009, in order to assess post-traumatic stress spectrum psychopathology and its correlates. Methods An overall sample of more than 2000 earthquake survivors was assessed by means of the Trauma and Loss Spectrum-Self Report (TALS-SR), a questionnaire exploring post-traumatic stress spectrum symptoms. The TALS-SR offers a multidimensional approach that considers three major dimensions: potentially traumatic events, including losses and the so-called low magnitude events; symptoms of the acute/peri-traumatic reaction; post-traumatic spectrum symptoms. Survivors were also assessed by means of Mood Spectrum-Self Report (MOODS-SR), to detect correlations between post-traumatic stress spectrum and mood spectrum symptoms. Results High prevalence rates of both full and partial PTSD were found, as well as several factors (e.g. younger age, female gender, degree of exposure, bereavement experiences) associated with an increased likelihood of post-traumatic stress symptoms. Survivors with PTSD also reported significantly higher prevalence rates of specific symptoms, such as maladaptive behaviors including suicidality, and impairment in eating behaviors and somatic symptoms. Conclusions These studies highlighted the heavy burden of PTSD in the aftermath of the earthquake, even months after exposure, and a close relationship between post-traumatic stress spectrum and mood spectrum symptoms, suggesting the need of additional research.
... In addition to the Structured Clinical Interview for DSM-5 (First et al., 2015), in this study we employed a set of instruments (namely the AdAS Spectrum, the MOODS-SR and the TALS-SR) developed and validated in the framework of the international research network called Spectrum Project (Carmassi et al., 2013;Cassano et al., 1999;Dell' Osso et al., 2016a, b, d;Dell'Osso et al., 2014, 2002bFagiolini et al., 1999;Frank et al., 1998). Applying a spectrum approach to psychopathology, the spectrum instruments are devised to assess not only the presence of a disorder according to standard psychiatric classification systems, but also the broader spectrum of symptoms, behavioral characteristics and associated features, that may occur to subjects who do not conform to the formal diagnosis. ...
An increasing number of studies highlighted significant correlations between autistic traits (AT) and mood spectrum symptoms. Moreover, recent data showed that individuals with high AT are likely to develop trauma and stressor-related disorders. This study aims to investigate the relationship between AT and mood symptoms among university students, focusing in particular on how AT interact with ruminations and trauma-related symptomatology in predicting mood symptoms. 178 students from three Italian Universities of excellence were assessed with The Structured Clinical Interview for DSM-5 (SCID-5), the Adult Autism Subthreshold Spectrum (AdAS Spectrum), the Ruminative Response Scale (RRS), the Trauma and Loss Spectrum (TALS) and the Moods Spectrum (MOODS). Considering the AdAS Spectrum total scores, 133 subjects (74.7%) were categorized as “low scorers” and 45 subjects (25.3%) as “high scorers”. Students in the high scorer group showed significantly higher scores on RRS, TALS-SR and MOOD-SR total scores. Total and direct effects of AdAS Spectrum total score on MOODS-SR total score were both statistically significant. AdAS Spectrum total score also showed a significant indirect effect on MOODS-SR total score through TALS and RRS total scores. Results showed a significant relationship between AT and mood spectrum, which is partially mediated by ruminations and trauma/stressor-related symptomatology.
... The MASS has been shown to have substantial clinical utility, displaying associations with treatment outcome in unipolar depression (40), with functional impairment (37), and with treatment outcome in bipolar disorder (32,41) that persist after traditional DSM diagnostic comorbidity is controlled for (32,(42)(43)(44). Thus the aim of the study reported here was to expand on this research by applying item response theory to test the scale's dimensionality and to investigate the utility of MASS scores derived in a CAT environment on the basis of the scale's empirical factor structure. ...
Objective:
This study investigated the combination of item response theory and computerized adaptive testing (CAT) for psychiatric measurement as a means of reducing the burden of research and clinical assessments.
Methods:
Data were from 800 participants in outpatient treatment for a mood or anxiety disorder; they completed 616 items of the 626-item Mood and Anxiety Spectrum Scales (MASS) at two times. The first administration was used to design and evaluate a CAT version of the MASS by using post hoc simulation. The second confirmed the functioning of CAT in live testing.
Results:
Tests of competing models based on item response theory supported the scale's bifactor structure, consisting of a primary dimension and four group factors (mood, panic-agoraphobia, obsessive-compulsive, and social phobia). Both simulated and live CAT showed a 95% average reduction (585 items) in items administered (24 and 30 items, respectively) compared with administration of the full MASS. The correlation between scores on the full MASS and the CAT version was .93. For the mood disorder subscale, differences in scores between two groups of depressed patients--one with bipolar disorder and one without--on the full scale and on the CAT showed effect sizes of .63 (p<.003) and 1.19 (p<.001) standard deviation units, respectively, indicating better discriminant validity for CAT.
Conclusions:
Instead of using small fixed-length tests, clinicians can create item banks with a large item pool, and a small set of the items most relevant for a given individual can be administered with no loss of information, yielding a dramatic reduction in administration time and patient and clinician burden.
... While some argue for a separate diagnostic status for BD-II based on true genetic breeding, others point out the significant minority who eventually convert to more disabling BD-I to argue against giving BD-II a separate diagnostic status. [1,2] Early age of onset has been one of the most consistently replicated risk factors for progression from BD-II to BD-I. [3] We report the case of an elderly lady who converted from a baseline diagnosis of BD-II to BD-I after two decades of illness. ...
... The AdAS Spectrum is a questionnaire developed within the framework of the international research network called Spectrum Project [22]. The instrument assesses the lifetime presence of the wide spectrum of manifestations associated with ASD, but which could be founded even in individuals who do not fulfill diagnostic criteria for a formal disease: in this regard, it was not developed to be a diagnostic instrument. ...
This case report draws attention to the potential relevance of undetected autism spectrum symptoms in a bipolar patient with high work functioning showing a peculiar addictive profile with impulsive and antisocial behaviors. A 23-year-old man with a diagnosis of Bipolar Disorder (BD) and Substance Use Disorder (SUD) was hospitalized at the Psychiatric Clinic of the University of Pisa for diuretics and β -2 adrenergic agonist abuse in a remission phase of benzodiazepines and substance abuse. He reported a history of behavioral addictions in the framework of a global high work functioning with particular skills in computer science. When assessed for adult autism spectrum symptoms, despite not fulfilling a DSM-5 diagnosis of Autism Spectrum Disorder (ASD), he reported a score of 93/240 at the Ritvo Autism and Asperger Diagnostic Scale (RAADS-r) and of 88/160 at the Adult Autism Subthreshold Spectrum (AdAS Spectrum), both indicative of ASD. We argue the possible role of adult subthreshold autism spectrum features, generally disregarded in adult psychiatry, in the peculiar addictive profile developed by this patient with BD that may deserve appropriate treatment.
... There are some reasons why BDs were underdiagnosed, this include stigma, lack of insight from communities: lack of subjective suffering, perceived as variation of personality, not a disorder. They enjoy their 'high' so prefer not to seek help or treatment; lack of insight of the clinicians mild cases which resemble other mental disorders; bipolar disorders does not always present in a consistent pattern, lack of systematic assessment of mania; the symptoms of 'highs' also occur in people who do not have BDs (Cassano et al., 1999;Smith & Ghaemi, 2010). For these reasons, it is important to screen for BDs either in population or in the clinics. ...
Although Bipolar Disorder (BD) is a common mental illness worldwide (1-3%), there was no data about the prevalence of BD or bipolar spectrum disorder in Indonesia. This study aimed to screen bipolar disorders in various communities Surabaya and its variations of symptoms characteristics. Through a cross-sectional design and non-random sampling survey (N = 1,104) was conducted using the Mood Disorder Questionnaire (MDQ), a screening tool for BDs, and validated self-report instrument. The SPSS 17.0 and chi square was used for analysis. Results showed the lifetime proportion of MDQ positive was 10.7% (n = 118). The proportions of MDQ positive by gender were 4.8% males and 5.9% females, no gender (p = .444) and educational background differences (p = .470). The highest proportions of MDQ positive were 4.4% in the 25-60 year group, 4% having an education level of senior high school and 6.7% having unmarried status. Among participants who had MDQ positive, 22% had an awareness of having psychological problems, unfortunately only 5.9% had visited a medical professional. Overall, the lifetime proportion of suspected bipolar disorder spectrum in Surabaya was higher than that reported in other studies. Conducting a periodic research regarding other psychosocial-cultural backgrounds will help clinicians and government identify the exact prevalence of bipolar disorder in the society and their risk factors. Furthermore, it will help to prevent the increased rate of bipolar disorders.
... The Romanian translated version 6.0.0 of the Mini-International Neuropsychiatric Interview (M.I.N.I.), a structured diagnostic interview based on the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), (30) was administered in order to confirm the positive diagnosis of BPD I for the participants included in the study (31). ...
Context:
Hypothalamic-pituitary-adrenal (HPA) axis irregularities have been described both in bipolar disorder and suicidal behaviour, but few studies have examined the relationship between suicidal behaviours and cortisol levels in bipolar disorder.
Objective:
We compared HPA axis activity in bipolar I (BPD I) individuals with and without suicidal ideation and behaviour through multiple measurement of serum and salivary cortisol.
Design:
Cross-sectional, observational study.
Subjects and methods:
75 BPD I patients were assigned into 3 groups (no history of suicidal behaviour, history of suicidal ideation, history of suicide attempt), according to the C-SSRS. Socio-demographical and clinical data was obtained by using MINI 6.0 and a semi-structured questionnaire. Salivary samples were collected using Sarstedt Cortisol Salivette synthetic swab system for two consecutive days at 08:00, 16:00, 23:00 and salivary cortisol concentrations were determined by ELISA technique. A unique 1mg dose of dexamethasone was administered on the first day, at 23:00, after the collection of the saliva sample. Blood was collected on the first day at 8:00 AM and basal morning serum cortisol levels were determined by immunoassay with fluorescence detection.
Results:
Cortisol parameters in our BPD I sample did not vary significantly in respect to suicidal history. However, patients with a history of suicidal ideation have significantly higher total cortisol outputs than patients with no history of suicidal behaviour in the 18 to 40 age category compared with the above 40 age category.
Conclusions:
Total cortisol daily output varies significantly in an age-dependent manner in respect to suicidal thoughts in BPD I individuals.
... The spectrum model proposed highlights the significance of isolated symptoms and subthreshold symptom clusters that accompany each disorder classified in the DSM, and may follow, or be manifested, in concurrence with the main disorder. 23 Accordingly, the Trauma and Loss Spectrum Self-Report (TALS-SR) 24,25 explores the spectrum related to PTSD upon a multidimensional approach across three major dimensions: that of the traumatic event, including the socalled low-magnitude events; that of the acute reaction; and that of the symptomatological clusters including maladaptive behaviors. Most recently, data on the PTSD symptomatological prevalence data according to DSM-5 criteria among survivors to natural and human-made disasters have been reported by some of researchers. ...
Introduction
PTSD is extremely common in patients with fibromyalgia (FM) with rates up to 57%, and it often correlates with increased severity of the disease.
Objectives
The aim of this study was to investigate the presence of PTSD, diagnosed according to DSM-5 criteria, and of Post-Traumatic Stress Spectrum symptoms in a sample of patients with FM.
Methods
Sixty-one patients, 7 males and 54 females, with FM, diagnosed according to American College of Rheumatology (ACR) at the Unit of Rheumatology of A.O.U.P clinics, were assessed by: SCID-5; Trauma and Loss Spectrum Self-Report (TALS-SR); Adult Autism Subthreshold Spectrum (AdAS Spectrum).
Results
Patients with FM with full and partial PTSD reported a significantly higher number of losses and potentially traumatic events in the TALS-SR than patients without PTSD. Significantly, higher AdAS Spectrum scores in almost all domains were reported in patients with PTSD with respect to those with partial or without PTSD. Moderate to good correlations were highlighted amongst most of the TALS-SR and ADAS-Spectrum domains.
Conclusions
Significant DSM-5 PTSD rates emerged in our sample of patients with FM. Significant correlations were found between Adult Subthreshold Autism Spectrum and Post-Traumatic Stress Spectrum, corroborating recent hypotheses that indicate autism spectrum symptoms as vulnerability factors for PTSD.
... The spectrum model proposed highlights the significance of isolated symptoms and subthreshold symptom clusters that accompany each disorder classified in the DSM, and may follow, or be manifested, in concurrence with the main disorder. 23 Accordingly, the Trauma and Loss Spectrum Self-Report (TALS-SR) 24,25 explores the spectrum related to PTSD upon a multidimensional approach across three major dimensions: that of the traumatic event, including the socalled low-magnitude events; that of the acute reaction; and that of the symptomatological clusters including maladaptive behaviors. Most recently, data on the PTSD symptomatological prevalence data according to DSM-5 criteria among survivors to natural and human-made disasters have been reported by some of researchers. ...
Increasing literature suggests the need to explore for post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in parents and caregivers of children with acute and chronic illnesses but scant data are available on epilepsy. The aim of the present study was to estimate full and partial PTSD rates among parents of children with epilepsy comparing DSM-5 and DSM-IV-TR criteria. Further, the aim of the present study was to examine possible gender differences between mothers and fathers. Results showed 9.1% and 12.1% PTSD rates in the total sample, according to DSM-5 or DSM-IV-TR criteria, respectively, with an overall consistency of 92.9% (Kohen's K = 0.628, p = .453). Significant gender differences emerged for Avoidance/Numbing and Hyperarousal symptoms diagnosed by means of DSM-IV-TR criteria, as well as for Negative alterations in cognitions/mood and Hyperarousal symptoms, when adopting DSM-5 criteria. This study underscores the relevance of detecting PTSD in parents of children with a chronic illness such as epilepsy.
... The initial treatment recommendation might include a mood stabilizer alone or in combination with an antidepressant. Some patients, however, may feel that their hypomanic symptoms do not require treatment (4). They may thus be averse to taking a mood stabilizer and may inquire about being treated solely with an antidepressant. ...
Objective:
The authors compared medication-induced mood switch risk (primary outcome), as well as treatment response and side effects (secondary outcomes) with three acute-phase treatments for bipolar II depression.
Method:
In a 16-week, double-blind, multisite comparison study, 142 participants with bipolar II depression were randomly assigned to receive lithium monotherapy (N=49), sertraline monotherapy (N=45), or combination treatment with lithium and sertraline (N=48). At each visit, mood was assessed using standardized rating scales. Rates of switch were compared, as were rates of treatment response and the presence and severity of treatment-emergent side effects.
Results:
Twenty participants (14%) experienced a switch during the study period (hypomania, N=17; severe hypomania, N=3). Switch rates did not differ among the three treatment groups, even after accounting for dropout. No patient had a manic switch or was hospitalized for a switch. Most switches occurred within the first 5 weeks of treatment. The treatment response rate for the overall sample was 62.7% (N=89), without significant differences between groups after accounting for dropout. The lithium/sertraline combination group had a significantly higher overall dropout rate than the monotherapy groups but did not have an accelerated time to response.
Conclusions:
Lithium monotherapy, sertraline monotherapy, and lithium/sertraline combination therapy were associated with similar switch and treatment response rates in participants with bipolar II depression. The dropout rate was higher in the lithium/sertraline combination treatment group, without any treatment acceleration advantage.
... It is generally used when a clinician determines that a mental illness is present, although the patient fails to meet the criteria for one of the existing diagnostic category. Although this category should be given rarely, studies show that the NOS category is used as often as any of the specific diagnostic categories of the DSM (Cassano, 1999, Fairburn, 2007, Wilberg, 2008). Second, although a categorical diagnostic approach considers that patients suffering for a given mental illness display similar symptoms, we now know that there is a lot of overlap of symptoms in psychiatric populations, and this explains the high level of comorbidities observed in patients. ...
In 2008, the National Institute of Mental Health (NIMH) announced that in the next few decades, it will be essential to study the various biological, psychological and social ‘signatures’ of mental disorders. Along with this new ‘signature’ approach to mental health disorders, modifications of DSM were introduced. One major modification consisted of incorporating a dimensional approach to mental disorders, which involved analyzing, using a transnosological approach, various factors that are commonly observed across different types of mental disorders. Although this new methodology led to interesting discussions of the DSM5 working groups, it has not been incorportated in the last version of the DSM5. Consequently, the NIMH launched the ‘Research Domain Criteria’ (RDoC) Framework in order to provide new ways of classifying mental illnesses based on dimensions of observable behavioral and neurobiological measures. The NIMH emphasizes that it is important to consider the benefits of dimensional measures from the perspective of psychopathology and environmental influences, and it is also important to build these dimensions on neurobiological data. The goal of this paper is to present the perspectives of DSM5 and RDoC to the science of mental health disorders and the impact of this debate on the future of human stress research. The second goal is to present the ‘Signature Bank’ developed by the Institut Universitaire en Santé Mentale de Montréal (IUSMM) that has been developed in line with a dimensional and transnosological approach to mental illness.
... Within the framework of an international Italy-USA research project (Spectrum Project), started in 1995 and involving the Department of Psychiatry of the University of Pisa along with the Universities of Pittsburgh, Columbia New York and California San Diego, a Spectrum Model approach to mental disorders has been developed [7,8]. Such model has been shown to be particularly appropriate for understanding the clinical features, course and comorbidity of most mental disorders, as well as the continuity between the general and the clinical population. ...
Growing interest has recently been devoted to partial forms of autism, lying at the diagnostic boundaries of those conditions previously diagnosed as Asperger’s Disorder. This latter includes an important retrieval of the European classical psychopathological concepts of adult autism to which Hans Asperger referred in his work. Based on the review of Asperger's Autistische Psychopathie, from first descriptions through the DSM-IV Asperger’s Disorder and up to the recent DSM-5 Autism Spectrum Disorder, the paper aims to propose a Subthreshold Autism Spectrum Model that encompasses not only threshold-level manifestations but also mild/atypical symptoms, gender-specific features, behavioral manifestations and personality traits associated with Autism Spectrum Disorder. This model includes, but is not limited to, the so-called broad autism phenotype spanning across the general population that does not fully meet Autism Spectrum Disorder criteria. From this perspective, we propose a subthreshold autism as a unique psychological/behavioral model for research that could help to understand the neurodevelopmental trajectories leading from autistic traits to a broad range of mental disorders.
... By means of the scores on the Trauma and Loss Spectrum Self-Report (TALS-SR) (Dell'Osso et al. 2008), rates as high as Comprehensive Guide to Post-Traumatic Stress Disorder DOI 10.1007/978-3-319-08613-2_127-2 # Springer International Publishing Switzerland 2016 37.5 % of PTSD were found, with significantly higher rates among females (51.7 %) than males (25.7 %), despite no significant gender differences in partial PTSD rates, consistently with previous literature (Lai et al. 2004;Bal and Jensen 2007). The TALS explores post-traumatic stress reactions according to a spectrum model that highlights the significance of isolated symptoms and subthreshold symptom clusters that accompany each disorder classified in the DSM and may follow or be manifested in concurrence with the main disorder (Cassano et al. 1999): it includes 116 items, organized into 9 domains ( Fig. 1, Table 1). ...
A growing body of literature has explored Post-Traumatic Stress Disorder (PTSD) since its first introduction in DSM-III, up to the last DSM-5 edition that acknowledged the nosographic independence of post-traumatic stress conditions with respect to other mental disorders. In the past decades, increasing research has focused on the mental health impact of mass trauma such as earthquake on the general populations exposed, highlighting PTSD as being the most frequently occurring mental disorder affecting up to as much as even 80 % of the victims involved, particularly women. Women have been consistently demonstrated to be the most affected, as well as more symptomatic with respect to men, and with a substantially more chronic and disabling disorder. Interestingly, maladaptive behaviors that have been acknowledged by the DSM-5 among criterion symptoms, such as reckless driving, promiscuous sex, alcohol and drug addiction, self-injuring behaviors, and suicidal behaviors, show a different trend with men being the most affected, particularly in the younger age ranges. All these data support the need for specific interventions in the aftermath of such disasters, with particular attention to female gender.
... By means of the scores on the Trauma and Loss Spectrum Self-Report (TALS-SR) (Dell'Osso et al. 2008), rates as high as Comprehensive Guide to Post-Traumatic Stress Disorder DOI 10.1007/978-3-319-08613-2_127-2 # Springer International Publishing Switzerland 2016 37.5 % of PTSD were found, with significantly higher rates among females (51.7 %) than males (25.7 %), despite no significant gender differences in partial PTSD rates, consistently with previous literature (Lai et al. 2004;Bal and Jensen 2007). The TALS explores post-traumatic stress reactions according to a spectrum model that highlights the significance of isolated symptoms and subthreshold symptom clusters that accompany each disorder classified in the DSM and may follow or be manifested in concurrence with the main disorder (Cassano et al. 1999): it includes 116 items, organized into 9 domains ( Fig. 1, Table 1). ...
A growing body of literature has explored Post-Traumatic Stress Disorder (PTSD) since its first introduction in DSM-III, up to the last DSM-5 edition that acknowledged the nosographic independence of post-traumatic stress conditions with respect to other mental disorders. In the past decades, increasing research has focused on the mental health impact of mass trauma, such as earthquakes, on the general populations exposed, highlighting PTSD as being the most frequently occurring mental disorder affecting up to as much as even 80 % of the victims involved, particularly women. Women have been consistently demonstrated to be the most affected, as well as more symptomatic with respect to men, and with a substantially more chronic and disabling disorder. Interestingly, maladaptive behaviors that have been acknowledged by the DSM-5 among criterion symptoms, such as reckless driving, promiscuous sex, alcohol and drug addiction, self-injuring behaviors, and suicidal behaviors, show a different trend with men being the most affected, particularly in the younger age ranges. All these data support the need for specific interventions in the aftermath of such disasters, with particular attention to female gender.
... 93,115 That is, the different clinical presentations of affective episodes (depressive, manic, mixed states, atypical and subthreshold symptoms, or comorbidity patterns) are a possible source of the inconsistency of the literature, as is the use of questionnaires that are not specific for bipolar disorder but that are mainly derived from research on schizophrenia. 116,117 Obsessive-Compulsive Disorder Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts (obsessions) or by repetitive behaviors (compulsions) that are aimed at reducing the anxiety generated by obsessions, that are excessive and time-consuming, and that interfere with a person's global functioning. ...
In spite of the increasing number of studies on insight in psychiatry and also in neurology and psychology, its nature is still elusive. It encompasses at least three fundamental characteristics: the awareness of suffering from an illness, an understanding of the cause and source of this suffering, and an acknowledgment of the need for treatment. As such, insight is fundamental for patients' management, prognosis, and treatment. Not surprisingly, the majority of available data, which have been gathered on schizophrenia, show a relationship between low insight and poorer outcomes. For mood disorders, however, insight is associated with less positive results. For other psychiatric disorders, insight has rarely been investigated. In neurology, the impaired ability to recognize the presence of sensory, perceptual, motor, affective, or cognitive functioning-referred to as anosognosia-has been related to damage of specific brain regions. This article provides a comprehensive review of insight in different psychiatric and neurological disorders, with a special focus on brain areas and neurotransmitters that serve as the substrate for this complex phenomenon.
... Major depression with family history of bipolar disorder Hypomania and depressive symptoms Cassano (56) Major depression with hyperthymic temperament Chronic presence of manic traits that do not meet criteria for hypomanic or manic episode (the opposite of dysthymic disorder in DSM-IV) The presence of hypomanic symptoms superimposed on an episode of major depression Dysthymic mood states with superimposed hypomanic symptoms Hypomania that occurs oniy in association with antidepressant use Bipolar disorders separated on the basis of severity of manic/ hypomanic symptoms Hypomanic symptoms lasting for 1 day or more, at least monthiy for 1 year Hypomanic symptoms iasting at ieast 1 day, iess frequentiy than monthiy Any manic symptoms not meeting criteria for a hypomanic syndrome One or more episodes meeting DSM-IV criteria for mania, with no history of depression An episode of major depression in a patient with a family history of bipoiar disorder Discrete hypomanic episodes with interepisode depressive symptoms An episode of major depression in a patient with hyperthymic temperament (see Akiskal above) ...
... The lifetime version (MOODS-LT) was designed to assess lifetime occurrence of the typical mood symptoms as well as a range of clinical features associated with mood psychopathology. The objective of MOODS-LT is to screen for symptoms which resemble the DSM criteria and, at the same time, considering subthreshold manifestations and temperamental features which may not reach a diagnostic threshold but have diagnostic and therapeutic significance [15]. The lifetime version has been validated in English, Italian and Spanish [16]. ...
Background:
Mood Spectrum Self Report (MOODS-SR) is an instrument that assesses mood spectrum symptomatology including subthreshold manifestations and temperamental features. There are different versions of the MOODS-SR for different time frames of symptom assessment: lifetime (MOODS-LT), last-month and last-week (MOODS-LW) versions.
Objective:
To evaluate the psychometric properties of the MOODS-LT the MOODS-LW.
Methods:
The reliability of the MOODS-LT and MOODS-LW was evaluated in terms of internal consistency and partial correlations among domains and subdomains. The known-group validity was tested by comparing out-patients with bipolar disorder (n=27), unipolar depression (n=8) healthy controls (n=68). The convergent and divergent validity of MOODS-LW were evaluated using the Montgomery Åsberg Depression Rating Scale (MADRS), the Young-Ziegler Mania Rating Scale (YMRS) in outpatients as well the General Health Questionnaire (GHQ-12) in healthy controls.
Results:
Both MOODS-LT and MOOODS-LW showed high internal consistency with the Kuder-Richardson coefficient ranging from 0.823 to 0.985 as well as consistent correlations for all domains and subdomains. The last-week version correlated significantly with MADRS (r= 0.79) and YMRS (r=0.46) in outpatients and with GHQ-12 (r= 0.50 for depression domain, r= 0.29 for rhythmicity) in healthy controls.
Conclusion:
The Swedish version of the MOODS-LT showed similar psychometric properties to other translated versions. Regarding MOODS-LW, this first published psychometric evaluation of the scale showed promising psychometric properties including good correlation to established symptom assessment scales. In healthy controls, the depression and rhythmicity domain scores of the last-week version correlated significantly with the occurrence of mild psychological distress.
... These chronic conditions more often mimic the symptoms of hypomania and often, atypical episode of MDD, similar to those in bipolar II but of milder degree and without obvious dysfunction. In some cases, they can be productive or functionally enhancing (626). ...
Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar 11 disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.
BACKGROUND: Post-traumatic stress diseases have been recently applied to understand the impact of work-related stress, but the frequent symptoms overlap and comorbidity with mood disorders induced authors to better investigate the relationship between these disorders with particular attention to gender differences. METHODS: Authors collected socio-demographic, occupational, and clinical data of 345 subjects who presented at the Occupational Health Department of a university hospital over a 3-year-period (2016-2018). Study sample fulfilled the Trauma and Loss Spectrum-Self Report (TALS-SR) and the Mood Spectrum-Self Report (MOODS-SR), lifetime version. RESULTS: Women reported significant higher rates in the following TALS-SR domains: loss events (P=0.000), grief reactions (P=0.018), emotional, physical and cognitive responses to traumas (P=0.011) and in the following MOODS-SR domain: rhythmicity and vegetative functions (P=0.000). A multiple linear regression model identified the following TALS-SR domains: emotional, physical and cognitive responses to traumas and maladaptive coping as significant predictors of MOOD-SR total score. In the end were evidenced strong positive correlations between TALS-SR total score and the depressive mood (R=0.561), depressive cognition (R=0.582) and rhythmicity and vegetative functions (R=0.500) domains of the MOOD-SR. CONCLUSIONS: Noteworthy correlations between the two psychopathological dimensions emerged and this could bring to a better understanding of the mutual impact of both mood and post-traumatic stress symptoms on physical health in the contest of occupational stress.
Background: The clinical presentation of Eating Disorders (EDs) is often characterized by a great phenotypic variability and by a substantial instability over time of diagnostic categories. For these reasons, it has been proposed a different approach to EDs, encompassing both their dimensional and categorical descriptions, in a lifetime perspective, namely the ‘Anorexic-Bulimic Spectrum’ (ABS). Here we report a retrospective study with the interview built and validated for the assessment of ABS signs and symptoms, the ‘Structured Clinical Interview for Anorexic-Bulimic Spectrum’ (SCI-ABS), administered together with the ‘Mood Spectrum Self Report’ (MOODS-SR), a questionnaire able to assess sub-threshold mood spectrum dysregulations often comorbid with EDs signs and symptoms.
The main aim of the study was twofold: to assess and better characterize clinical phenotypes of EDs; to highlight potential lifetime sub-threshold mood dysregulations that might occur comorbid with EDs, and that patients might consider relevant to their ‘subjective experience of illness’. In order to obtain these goals, we decided to utilize a machine learning analysis.
Methods: two groups were recruited and compared, namely patients with EDs (n=53) and healthy controls (HC) (n=54). Both groups underwent psychological testing with MOODS-SR and SCI-ABS.
Results: in discriminating and classifying EDs individuals from HC, machine learning classifiers obtained an accuracy higher than 70%. Based on all variables considered, the analysis revealed that SCI-ABS ‘Phobias’ domain (more in detail, ‘Weight Gain Phobia’ total score), the ‘Impairment and Insight’ item 5, (‘…your relationship with food was all you could think about?’) and the MOODS-SR item 154 (‘you were less sexually active than is typical for you?’) were the best psychological elements in discriminating EDs patients from HC (accuracy range: 72.90-86.92%). Given the large number of predictors, we run a supervised attributes selection procedure. The procedure yielded an accuracy of 90.65% in classifying EDs patients from HC.
Conclusions: the very high overall accuracy is indicative that the selected combinations of features capture the most important determinants in the discrimination of EDs patient’s vs HC. The items selected by the machine learning analysis confirmed that an extreme polarization of ideas on weight and food control characterize the cognitive asset of EDs patients.
Objective.:
Work-related stress presents a significant impact on work performance and physical health. It has been associated with the onset of a multitude of symptoms. The main aim of this investigation is to better understand the impact of post-traumatic stress symptomatology, using a specific self-assessment questionnaire, in subjects experiencing occupational stress with the rationale to address the variegated symptoms expressed by this particular population in a post-traumatic dimensional perspective.
Methods.:
Authors collected socio-demographic, occupational, and clinical data. They utilized Trauma and Loss Spectrum Self Report (TALS-SR), a questionnaire investigating post-traumatic stress symptoms. The population size was 345 subjects who presented at the Occupational Health Department of a university hospital over a 3 years period (2016-2018).
Results.:
Data analysis revealed 33.9% of subjects who met post-traumatic stress disorder (PTSD) criteria. Gender distribution of this set was (36.4% female, 31% male). A family history or personal history of mental disorders were related to higher scores in almost all TALS-SR domains and were related, respectively, to higher scores of criterion B "intrusion symptoms" (P = .014), criterion D "negative alterations in cognitions and mood" (P = .023), and criterion E "arousal" (P = .033) of PTSD. Differences in TALS-SR scores also emerged based on age and gender.
Conclusions.:
PTSD symptoms manifest at a significant level in those who experience work-related stress. Personal background of individuals, both in terms of family and personal history for mental disorders, seems to increase their vulnerability to develop post-traumatic stress symptoms. This study suggests the importance of evaluating occupational stress from a post-traumatic stress perspective also at an early stage.
Background. To explore relationships among post-traumatic stress disorder (PTSD), depres- sive spectrum symptoms, and intrusiveness in subjects who survived the crash of a train derailed carrying liquefied petroleum gas and exploded causing a fire.
Methods. A sample of 111 subjects was enrolled in Viareggio, Italy. AMOS version 21 (IBM Corp, 2012) was utilized for a structural equation model-path analysis to model the direct and indirect links between the exposure to the traumatic event, the occurrence of depressive symptoms, and intrusiveness. Subjects were administered with the SCID-IV (Structured Clin- ical Interview for DSM-IV), the Questionnaire for Mood Spectrum (MOODS-SR)-Last Month version, the Trauma and Loss Spectrum Questionnaire (TALS-SR), and the Impact of Event Scale-Revised version (IES-R).
Results. Sixty-six (66/111; 59.4%) subjects met SCID-IV criteria for PTSD. Indices of goodness of fit were as followed: χ2/df = 0.2 P = .6; comparative fit index = 1 and root mean square error of approximation = 0.0001. A significant path coefficient for direct effect of potential traumatic events on depressive symptoms (β = 0.25; P < .04) and from depressive symptoms to intrusive- ness (β = 0.34; P < .003) was found. An indirect effect was also observed: standardized value of potential traumatic events on intrusiveness was 0.86. The mediating factor of this indirect effect path was represented by depressive symptoms. Potential traumatic events explained 6.2% of the variance of depressive symptoms; 11.8% of the variance of intrusiveness was accounted for traumatic event and depressive symptoms.
Conclusions. Path analysis led us to speculate that depression symptoms might have mediated the relationship between the exposure to potential traumatic events and intrusiveness for the onset of PTSD.
In the process of refining our understanding of separation anxiety disorder (SEPAD) as a mental disorder, it is vital to examine the extent to which the category overlaps with other common mental disorders and behavioural patterns. Unravelling the commonalities and interactions with other response patterns in psychiatry may cast new light on the nature of SEPAD both in terms of its aetiology and the boundaries that divide that diagnosis from others. In the process of examining these issues, it is important to keep in mind the complexities that still remain to be clarified regarding the boundary between normative and pathological forms of separation anxiety (SA) and the variation in patterns and course of symptoms. For example, SA is likely to be a normal response amongst women in the vulnerable time of pregnancy and the perinatal period and the upper boundary of what his normative during that phase still requires clarification. Moreover, there are various pathways that SEPAD follow during the course of maturation. Children can manifest SEPAD for a period of time but not experience any further episodes throughout their lives; conversely, in some, SEPAD can be lifelong pattern either as a persisting problem or fluctuating according to exposure to external stressors; and for others, SEPAD may have its first onset in adulthood.
Background:
Increasing evidence suggests Bipolar Disorder (BD) to be frequently associated to a history of traumatic experiences and Post-traumatic Stress Disorder (PTSD), with consequent greater symptoms severity, number of hospitalizations and worsening in quality of life. The aim of the present study was to investigate the lifetime exposure to traumatic events and PTSD rates in-patients with BD and to analyze the relationships between PTSD symptoms, clinical characteristics and severity of the mood disorder.
Methods:
A consecutive sample of 212 in-patients with a DSM-5 diagnosis of BD was enrolled at the psychiatric unit of a major University hospital in Italy and assessed by the SCID-5 and MOOD Spectrum-Self Report lifetime version (MOODS-SR). Socio-demographic characteristics, clinical features, substance or alcohol abuse, history of suicide related behaviors were also collected.
Results:
Lifetime trauma exposure emerged in 72.3% subjects, with a DSM-5 PTSD diagnosis reported by 35.6%. Patients with PTSD showed more frequently a (hypo)manic episode at onset, alcohol or substance abuse, psychotic features, suicide behaviors, higher scores in almost all the MOODS-SR domains, compared to those without PTSD.
Limitations:
Cross sectional study. Lack of data about the time since trauma exposure or PTSD onset.
Conclusions:
Our findings show a history of multiple traumatic experiences in hospitalized patients with BD besides high rates of PTSD, with the co-occurrence of these conditions appearing to be related to a more severe BD. Detailed investigation of post-traumatic stress symptoms is recommended for the relevant implications on the choice of a tailored treatment and the prognosis assessment.
Objective
To investigate if sleep disturbances may affect treatment outcomes of patients with panic disorder (PD).
Methods
Eighty-five PD outpatients with no Axis I comorbidity for mood disorders completed a baseline assessment (T1) and were evaluated after 3 (T2), 6 (T3) and 12 months (T4), with the Panic Disorder Severity Scale (PDSS) total score as outcome measure during a 12-month naturalistic follow-up. Patients were assessed with the Mood Spectrum Self-Report (MOODS-SR, Lifetime Version), and the PDSS.
Results
Forty-three patients (50.5%) met criteria for remission (PDSS<5) and 42 (49.5%) for no remission. In a logistic regression model with remission as the dependent variable, MOODS-SR sleep disturbances was the only determinant for a lower likelihood of PD remission. The items accounting for this result were the following: Repeated difficulty falling asleep (chi-square = 4.4; df = 1; p = 0.036), and Repeatedly waking up in the middle of the night (chi-square = 5.2; df = 1; p = 0.022).
Conclusion
Lifetime sleep disturbances would represent a cue of mood spectrum (in absence of overt affective comorbidity) that may impair remission in PD.
Anorexia nervosa (AN) is an eating disorder characterized by severe food restriction resulting in low body weight and an intense fear of gaining weight. This disorder has one of the highest suicide rates of any psychiatric illness; however, few studies have investigated prospective predictors of suicide ideation (SI) in this population. Quality‐of‐life impairment may be particularly relevant for understanding suicide risk in AN, given associations with SI in other psychiatric disorders and associations with chronicity and severity in AN. This study explored associations between eating disorder‐related impairment and SI in individuals with AN (n = 113) who completed assessments at treatment discharge and 3, 6, and 12 months after discharge. Greater psychological impairment predicted future occurrence of SI controlling for age, depression, history of SI, and eating disorder variables. Associations were specific to psychological impairment as other domains of impairment did not predict SI over time. Findings highlight the potential importance of targeting interpersonal–psychological consequences of AN to decrease future suicide risk.
Aims and background
To summarize current knowledge on psychopharmacological and psychotherapeutic options for patients with breast cancer and comorbid depression, starting from the psychiatric viewpoint. Issues on diagnostic boundaries of depression and outcome measures are raised.
Methods
We completed a literature review from the last 30 years (until March 2012) using PubMed by pairing the key words: ‘breast cancer and depression treatment’ (about 1431 works, including 207 reviews), ‘breast cancer and antidepressants’ (about 305 works, including 66 reviews), and in particular ‘selective serotonin reuptake inhibitors and breast cancer’ (38 works, including 10 reviews) and ‘breast cancer and psychotherapy’ (603 works, including 84 reviews). Papers in the English language were selected, including recent reviews.
Results
There is little evidence for the superiority of any one specific intervention with pharmacological options or psychotherapy. The heterogeneity of assessment criteria, the small number of subjects collected in systematic studies, the difficulty in adopting standardized outcome measures, and the limited numbers of available drugs with a favorable side effect profile are the main limitations that emerge from the literature. No conclusive findings are available on mid-term/long-term treatment strategies, or when depression is part of a bipolar disorder.
Conclusions
Further research is necessary to define the most appropriate approach to depression when it occurs in comorbidity with breast cancer. A more accurate definition of the clinical phenotypes of depression in the special population of patients with breast cancer is suggested as a key issue.
Şizofreni, günümüzde pozitif özellikli şizofreni olarak tanımlanan halüsinasyon,
hezeyan ve dezorganize davranışın hakim olduğu klinik tablosu ile bipolar affektif
bozukluğun manik epizodu arasında semptomolojik olarak benzerlik bulunmaktadır.
İki hastalık grubunun exitasyon tablosunda düşünce, duygulanım ve davranış
özellikleri benzerdir ve bu durum klinisyenin ayırt edici tanı koymasını
güçleştirmektedir. Bu araştırmada iki hastalık grubu Rorschach testi ile
karşılaştırılarak testin ayırıcı tanı için diagnostik özelliğinin incelenmesi
amaçlanmıştır. 200 hasta ile yapılan araştırma sonucunda bulgular; hastaların bilişsel
ve affektif süreçleri, ego fonksiyonları, kişilerarası ve sosyal uyum düzeyleri, nesne
ilişkileri, immaturite, impulsivite ve anksiyete düzeyleri arasında istatistiksel olarak
anlamlılık göstermiştir. Regresyon düzeylerinde ise bir farklılık saptanmamıştır.
Sonuçlar, Rorschach testinin şizofreni ve bipolar affektif bozukluk manik epizod
hastalarının protokollerini birbirinden belirgin olarak ayırabildiğini ve Rorschach
testinin ayırıcı tanı yapabildiğini göstermektedir.
It is the goal of diagnostic classification in child and adolescent psychiatry to organize information about the problems of a child or adolescent, and his or her family, so that their future course can be predicted and reasonable interventions can be chosen. The underlying conception is that the current state and past history of a disorder may be used to predict its further development.
Background:
Individuals diagnosed with bipolar 1 disorder (BP1), bipolar 2 disorder (BP2), or major depressive disorder (MDD) experience varying levels of depressive and (hypo)manic symptoms. Clarifying symptom heterogeneity is meaningful, as even subthreshold symptoms may impact quality of life and treatment outcome. The MOODS Lifetime self-report instrument was designed to capture the full range of depressive and (hypo)manic characteristics.
Methods:
This study applied clustering methods to 347 currently depressed adults with MDD, BP2, or BP1 to reveal naturally occurring MOODS subgroups. Subgroups were then compared on baseline clinical and demographic characteristics and as well as depressive and (hypo)manic symptoms over twenty weeks of treatment.
Results:
Four subgroups were identified: (1) high depressive and (hypo)manic symptoms (N=77, 22%), (2) moderate depressive and (hypo)manic symptoms (N=115, 33%), (3) low depressive and moderate (hypo)manic symptoms (N=82, 24%), and (4) low depressive and (hypo)manic symptoms (N=73, 21%). Individuals in the low depressive/moderate (hypo)manic subgroup had poorer quality of life and greater depressive symptoms over the course of treatment. Individuals in the high and moderate severity subgroups had greater substance use, longer duration of illness, and greater (hypo)manic symptoms throughout treatment. Treatment outcomes were primarily driven by individuals diagnosed with MDD.
Limitations:
The sample was drawn from three randomized clinical trials. Validation is required for this exploratory study.
Conclusions:
After validation, these subgroups may inform classification and personalized treatment beyond categorical diagnosis.
Background:
Patients with subthreshold bipolar disorder (Sub-BP) experience severe clinical courses and functional impairments which are comparable to those with bipolar I and II disorders (BP-I and -II). Nevertheless, lifetime prevalence, socioeconomic correlates and diagnostic overlaps of bipolar spectrum disorder (BPS) have not yet been estimated in the general population of South Korean adults.
Methods:
A total of 3013 adults among the 2011 Korean Epidemiologic Catchment Area survey (KECA-2011) completed face-to-face interviews using the Korean versions of the Composite International Diagnostic Interview 2.1 and Mood Disorder Questionnaire (K-CIDI and K-MDQ).
Results:
The lifetime prevalence of BPS in the South Korean adults was measured to be 4.3% (95% CI 2.6-6.9). Nearly 80% of the subjects with BPS were co-diagnosed with other DSM-IV non-psychotic mental disorders: 35.4% (95% CI 24.2-48.5) for major depression and dysthymic disorder, 35.1% (95% CI 27.7-43.3) for anxiety disorders, and 51.9% (95% CI 40.5-63.1) for alcohol and nicotine use disorders. Younger age (18-34 years) was the only sociodemographic predictor of BPS positivity (P=0.014), and the diagnostic overlap patterns were different between men and women.
Limitations:
The prevalence of BPS and other mental disorders could have been influenced by recall bias due to the retrospective nature of this study.
Conclusions:
Positivity for BPS was estimated to be much greater than the prevalence of DSM-IV BP in South Korea. Most of the respondents with BPS were diagnosed with other major mental disorders and this might be related with mis- and/or under-diagnosis of clinically relevant Sub-BP.
p>The terms melancholia and mania have their etymologies in classical Greek. Melancholia is derived from ‘melas’ (black) and ‘chole’ (bile), highlighting the term’s origins in pre-Hippocratic humoral theories [ 1 ]. Where depression/melancholia was viewed as an excess of black bile, the humoral perspective saw mania as arising from an excess of yellow bile [ 2 ], or a mixture of excessive black and yellow bile [ 3 ]. The exact origins of the term mania however, are not as clear-cut as those outlined for melancholia. The Roman physician, Caelius Aurelianus, proposes several origins for the word mania, including the Greek word ‘ania’, meaning to produce great mental anguish. He also suggests ‘manos’, meaning relaxed or loose, which would approximate to an excessive relaxing of the mind or soul [ 4 ]. There are at least five other etymological candidates proposed by Aurelianus for the word mania and the confusion surrounding the exact etymology is attributed to its varied usage in the pre-Hippocratic poetry and mythologies [ 4 ]. </p
Objective: Recent research on the epidemiology, clinical course, diagnosis, and treatment of bipolar II disorder (BD II) stands to have a considerable impact on clinical practice. This paper reviews these developments. Method: We conducted a Pubmed search, focusing on the period from January 1, 1994, to August 31, 2004. Articles deemed directly relevant to the epidemiology, course, diagnosis, and management of BD II were considered. Results: The prevalence of BD II is likely higher than previously suggested. Systematic probing for particular clinical features and use of screening tools allow for a more timely and accurate detection of the disorder. There is a paucity of good quality data to guide clinicians treating BD II. Conclusion: Significant progress has been made in clarifying diagnostic and treatment issues in BD II. Neither strong nor broad treatment recommendations can be made; a cautious interpretation of available data suggests that lithium or lamotrigine are fairly reasonable first-line choices. More well-designed studies with larger samples are needed to improve the evidence base for managing this disorder.
Secondary analyses in a subsample (N = 9160) of the National Institute of Mental Health Epidemiologic Catchment Area Program data base revealed that 19.6% of the general population reported one or more depressive symptoms in the previous month. One-year prevalence of two or more depressive symptoms in the general population was 11.8%, a prevalence figure exceeding the 9.5% 1-year prevalence for all the DSM-III mood disorders combined. We have labeled this potential clinical condition as subsyndromal symptomatic depression (SSD), defining it as any two or more simultaneous symptoms of depression, present for most or all of the time, at least 2 weeks in duration, associated with evidence of social dysfunction, occurring in individuals who do not meet criteria for diagnoses of minor depression, major depression, and/or dysthymia. SSD has a 1-year prevalence in the general population of 8.4%, two thirds of whom are women (63.4%). The most common SSD symptoms reported are insomnia (44.7%), feeling tired out all the time (42.1%), recurrent thoughts of death (31.0%), trouble concentrating (22.7%), significant weight gain (18.5%), slowed thinking (15.1%), and hypersomnia (15.1%). Increased prevalence of disability and welfare benefits was found in SSD as compared with respondents with no depressive symptoms. SSD represents a significant clinical population not covered by any DSM-III, DSM-III-R, or DSM-IV mood disorder diagnosis. Since SSD is also associated with significant increases in social dysfunction and disability, we feel there is good evidence to conclude that SSD is an unrecognized clinical condition of considerable public health importance that is deserving of further characterization and study.
This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States.
The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview.
Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status.
The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.
Affective psychoses have distinctive phenomenology which is different from that for schizophrenia. The delusional and hallucinatory experiences in a 'pure' affective psychosis can usually be explained by the pathological mood and associated disturbances. Psychotic affective disorder is severe affective disorder, not schizophrenia, and in the authors' experience should be preferentially treated with antidepressant drugs or lithium salts; because of the severity of the disorder, higher than usual doses of these drugs and a longer than usual period of trial are recommended. In addition to affectively based delusional and hallucinatory experiences, patients suffering from affective illness also have what on cursory mental status examination may mimic 'schizophrenic' symptoms. The authors presented evidence to the effect that such situations are often caused by underlying or superimposed conditions that give rise to transient and epiphenomenal psychotic experiences of a nonaffective nature. Finally, even when such concurrent conditions cannot be demonstrated, the occasional and fleeting presence of Schneiderian symptoms or Bleulerian signs does not necessarily mean that an otherwise 'classical' affective psychosis should be reclassified under a 'schizoaffective' or 'schizophrenic' disorder; the overall clinical course of the psychotic episode-rather than cross-sectional mental status findings - should dictate the episode - rather diagnosis in such cases (along with the nature of past and future episodes, family history, and response to treatment). There are few, if any, pathognomonic diagnosis signs and symptoms in psychiatry. Therefore, the differential diagnosis of schizophrenic and affective psychoses cannot, and should not, be based on an occasional Bleurian sign or a Schneiderian symptom.
Background:
The authors define 6 groups of subthreshold psychiatric symptoms that do not meet the full criteria for a DSM-IV Axis I disorder and examine the clinical significance of these symptoms in an outpatient primary care sample.
Methods:
The subjects were 1001 adult primary care patients in a large health maintenance organization. Data on sociodemographic characteristics and functional impairment, including scores on the Sheehan Disability Scale, were collected at the time of the medical visit, and a structured diagnostic interview for DSM-IV disorders was completed by telephone within 4 days of the visit. Subthreshold symptoms were defined for depressive, anxiety, panic, obsessive-compulsive, drug, and alcohol symptoms.
Results:
Subthreshold symptoms were as or more common than their respective Axis I disorders: panic (10.5% vs 4.8%), depression (9.1% vs 7.3%), anxiety (6.6% vs 3.7%), obsessive-compulsive (5.8% vs 1.4%), and alcohol (5.3% vs 5.2%) and other drug (3.7% vs 2.4%) cases. Patients with each of the subthreshold symptoms had significantly higher Sheehan Disability Scale scores (greater impairment) than did patients with no psychiatric symptoms. Many patients (22.6%-53.4%) with subthreshold symptoms also met the full criteria for other Axis I disorders. After adjusting for the confounding effects of other Axis I disorders, other subthreshold symptoms, age, sex, race, marital status, and perceived physical health status, only depressive symptoms, major depressive disorder, and, to a lesser extent, panic symptoms were significantly correlated with the impairment measures.
Conclusions:
In these primary care patients, the morbidity of subthreshold symptoms was often explained by confounding mental, physical, or demographic factors. However, depressive symptoms and, to a lesser extent, panic symptoms were disabling even after controlling for these factors. Primary care clinicians who detect subthreshold psychiatric symptoms should consider a broad psychiatric assessment.
Rates based on clinical and recent epidemiologic studies suggest that cyclothymia uncomplicated by major affective episodes occurs in 3-4% of young adults. Although this rubric is included in the diagnostic manual of the American Psychiatric Association (DSM-III) and the International Classification of Diseases (ICD-10), its classic temperamental variants consisting of irritable and hyperthymic types are not widely recognized. Instead, patients suffering from recurrent mood disorders - especially those with the bipolar II subtype - are often characterized as 'passive-aggressive,' 'borderline,' 'antisocial,' 'histrionic,' or 'narcissistic.' Other terms unofficially applied to these patients include 'emotionally unstable,' 'explosive,' 'impulsive,' and 'sensation seeking.' Building on classical German treatises and more recent European and American research, the present review argues for the greater cogency and validity of describing the intermorbid and premorbid functioning of these disorders in the more classic affective language of temperaments rather than employing Axis II characterologic terminology.
Objective: To validate and clinically characterize mixed bipolar states derived from the concepts of Kraepelin and the Vienna School and defined as sustained instability of affective manifestations of opposite polarity — that usually fluctuate independently of one another — in the setting of marked emotional perplexity. Method: Our criteria for mixed states represent a modified “user-friendly” operationalization of these classical concepts. We compared 143 mixed state patients, so defined, with 118 DSM III-R manic patients, systematically evaluated with the Semistructured Interview for Depression (SID) in our in-patient and day-hospital facilities. Results: The two groups were comparable from demographic and familial standpoints (including family history for bipolar disorder). Mixed states were predominant in the past history of index mixed patients who were more likely to have experienced stressors and to have attempted suicide; manic and hypomanic episodes were more common in the past history of the index manic patients who, in addition, had more episodes and hospitalizations. Although rates of chronicity and rapid cycling were not significantly different in the two groups, the modal episodes in the mixed states were 3–6 months, and in mania they were less than 3 months. Two thirds of both groups arose from a dysregulated baseline temperamental dysregulation, which, in manics, was largely hyperthymic, and in mixed patients, was both hyperthymic and depressive. Of our 143 mixed states, only 54% met the DSM III-R criteria for mixed states (which conformed to “dysphoric mixed mania”); of the remaining, 17.5% could be described as “mixed agitated psychotic depressive states” with irritable mood and flight of ideas, and 26% as “unproductive–inhibited manic” with fatigue and indecisiveness. The family history and course of these “non-DSM III-R” mixed states were essentially similar to DSM III-R mixed states. Limitation: Family history could not be obtained blind to clinical status in patients with severe psychotic mood states. Clinical Relevance: These data favor the classical European approach to mixed states over the grossly under-inclusive current official diagnostic systems. Conclusion: The phenomenology of mixed states is more than the mere superposition of opposite affective symptoms and, in many instances, it represents an expansive–excited phase intruding into a depressive temperament, and a melancholic episode intruding into a hyperthymic temperament.
Data on 108 hospitalized bipolar I women were analyzed to characterize those whose course was marked with at least one mixed episode (i.e. an episode with concomitant manic and depressed features) on the basis of various anamnestic and cross-sectional clinical features in comparison with those without mixed episodes. Our data revealed a later age of appearance of the first mixed episode in the course of bipolar illness with a tendency to recur true to type; greater prevalence of mood incongruent psychotic features; lower frequency of hyperthymic temperament; and familial depressive, rather than bipolar, disorders. These characteristics tend to identify the mixed state as a distinct longitudinal pattern of manic-depressive illness.
Dr. Tyrer describes what will be for the next decade or so the two most influential and widely used classifications of neurotic disorders—the forthcoming (10th) revision of the International Classification of Disease (ICD-10) and the American Psychiatric Association's classifications DSM-III [Diagnostic and Statistical Manual of Mental Disorders-III] and DSM-III-R [Revised]. He focuses on the differences between them and the novel concepts, like Panic Disorder, which are common to both. He also discusses the implications of these differences and the relevant empirical evidence—the clinical trials, family studies and follow-up studies—that help to establish or to undermine the validity of the diagnostic concepts concerned. He therefore not only describes the phenomena of neurotic illness and contemporary classifications of these phenomena; he also raises important practical and theoretical questions that might otherwise have remained unasked. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Synopsis
A five year semi-annual follow-up of patients with non-bipolar (N = 442), bipolar II (N = 64) and bipolar I (N = 53) major depression tracked the courses of prospectively observed major depressive, hypomanic and manic syndromes. In all three groups, depression was much more likely in any given week than was hypomania or mania. However, during the majority of weeks, no full syndrome was present and none of the groups exhibited evidence of continuing psychosocial deterioration. Though all three groups exhibited similar times to recovery from index and subsequent major depressive episodes, both bipolar groups had substantially higher relapse rates and developed more episodes of major depression, hypomania and mania. The two bipolar groups, in turn, differed by the severity of manic-like syndromes and thus remained diagnostically stable; the bipolar II patients were much less likely to develop full manic syndromes or to be hospitalized during follow-up. In conjunction with family study data showing that bipolar II disorder breeds true, these data support the separation of bipolar I and bipolar II affective disorder.
A representative sample of 95 hospitalized bipolar manic-depressive patients was followed up from 1959 to 1975. The mean age of the group at the time of this study was 61 years. It was observed that female bipolar patients demonstrate depression much more frequently than mania, while male patients show a symmetric distribution of both manic and depressive syndromes. The longitudinal occurrence of syndromes remains more or less constant; for instance, individual patients do not tend to go into depression with increasing age. The study shows that even after three episodes 29% of all bipolar patients would still have been misdiagnosed as unipolar depression.
An attempt is made to classify bipolar patients into three subtypes, ‘preponderantly manic,’ ‘preponderantly depressed,’ and a ‘nuclear’ type. Male patients belong mainly to the latter with an equal proportion of the first and third subtype. In contrast, female patients belong mainly to the depressed subtype.
The findings are discussed assuming either a heterogeneity of bipolar disorders or a threshold model of affective disorders suggested by Gershon et al. (1976).
The aim of this study was to examine the relationship between mixed and pure mania using both narrow (DSM-III-R) and broad (Cincinnati) operational diagnostic criteria to define mixed mania regarding the degree of associated depression. Hospitalized patients aged ≥12 years and meeting DSM-III-R criteria for bipolar disorder, manic or mixed, were compared regarding demographics, phenomenology, course of illness, comorbidity, family history, and short-term outcome. Seventy-one patients were recruited during a 1-year period. Twenty-four patients (34%) met DSM-III-R criteria for mixed bipolar disorder; 28 (40%) met the broader definition (which required three associated depressive symptoms rather than full syndromal DSM-III-R depression). Compared with pure manic patients, DSM-III-R mixed patients had significantly more depressive symptoms, were more likely to be female, experienced more prior mixed episodes, displayed higher rates of comorbid obsessive-compulsive disorder, and had longer hospitalizations. However, when mixed mania was defined more broadly, differences in gender and hospitalization length were lost. Also, regardless of the definition used, mixed and pure manic patients were similar on most other variables assessed. We conclude that mixed and pure mania differ in some respects but have many similarities, especially when mixed mania is defined by lesser degrees of depression. The use of dimensional rather than categoric systems to describe the degree of associated depression may be a more meaningful method of classifying mania.
A proposal made for DSM-IV was to include a means with which to provide a dimensional profile of a patient in terms of the diagnostic categories. However, a suggestion of the DSM-V Research Planning Conference on personality disorders was to develop a more fundamental revision through an integration of alternative dimensional models of personality disorder and general personality structure. A purpose of the current article is to provide this proposal. Also discussed is a primary concern with respect to the implementation of any such dimensional model: clinical utility. Discussed in particular are concerns regarding feasibility and treatment implications.
Both depressive (unipolar) and manic (bipolar) disorders have a strong familial component, like many other psychiatric illnesses, and the weight of the evidence indicates that the component is largely if not entirely genetic. Knowledge about the exact mechanisms of inheritance is still incomplete, but practical conclusions based on available data may be useful to the physician who comes into contact with such patients.
The authors attempted to assess the extent to which bipolar patients are misdiagnosed as unipolar by evaluating the development of mania in patients who had recognized bipolar illness and by means of follow-up data on patients who had recurrent depressions. Mania occurred early in the course of bipolar illness: almost 80% of the bipolar patients were initially hospitalized for mania. Follow-up data and theoretically based calculations suggest that the chance of a patient with recurrent depressions becoming bipolar is about 5%. Based on these findings, the authors make suggestions for the classification of unipolar patients.
In an attempt to improve the classification of Bipolar II disorders, we have examined a consecutive series of 687 primary major depressives: 5.1% gave a past history of mania (Bipolar I), 13.7% met our operational criteria for hypomania (Bipolar II), and the remaining 81.2% were provisionally categorized as 'unipolar.' Although Bipolar II was in some respects intermediate between Bipolar I and Unipolar, gender, familial bipolar history, age at onset and course characteristics generally supported its closer kinship to bipolar illness. Seventy one of the unipolars (10.3% of the total series) further met our operational criteria for hyperthymic temperament (U-HT), leaving behind a purer unipolar group of 487 major depressives. With respect to the proportion having male gender and bipolar family history, U-HT was similar to Bipolar I and II, and all three differed significantly from pure unipolar; as for age at onset, number of episodes and related indices of course, BI and BII were similar, and U-HT was closer to pure unipolar. These findings suggest that major depressive episodes arising from a hyperthymic temperament (constituting 12.4% of the 'unipolar' universe by conventional definition) are 'genotypically' closer to Bipolar II defined by hypomania, and course-wise similar to other unipolars.
The Lifetime and 6 month DSM-III prevalence rates of mental disorders from an adult general population sample of former West Germany are reported. The most frequent mental disorders (lifetime) from the Munich Follow-up Study were anxiety disorders (13.87%), followed by substance (13.51%) and affective (12.90%) disorders. Within anxiety disorders, simple and social phobia (8.01%) were the most common, followed by agoraphobia (5.47%) and panic disorder (2.39%). Females had about twice the rates of males for affective (18.68% versus 6.42%), anxiety (18.13% versus 9.07%), and somatization disorders (1.60% versus 0.00%); males had about three times the rates of substance disorders (21.23% versus 6.11%) of females. Being widowed and separated/divorced was associated with high rates of major depression. Most disordered subjects had at least two diagnoses (69%). The most frequent comorbidity pattern was anxiety and affective disorders. Simple and social phobia began mostly in childhood or early adolescence, whereas agoraphobia and panic disorder had a later average age of onset. The majority of the cases with both anxiety and depression had depression clearly after the occurrence of anxiety. The DIS-DSM-III findings of our study have been compared with both ICD-9 diagnoses assigned by clinicians independently as well as other epidemiological studies conducted with a comparable methodology.
For a period of six months (april to october 1990) 361 manic-depressive in-patients or out-patients were examined and treated. 178 patients (119 females and 69 males) were suffering from depression at examination time. Among them, 34 women and 11 men had mixed mood disorders with a symptomatology near that of typical depression (major depression, according to the DSM III-R criteria) but not of mixed bipolar disorder. The main symptoms were: dysphoric mood with irritability; internal tension, psychic and sometimes physical agitation; emotional lability; head crowded with thoughouts or thoughts that vanish too quickly; sleep disorders with initial insomnia or with frequent night awakenings; suicidal thoughts or attempted suicide with impulsiveness. These patients sustained severe suffering. They were in no way slow-minded but rather talkative and expressive. Antidepressant drugs increased agitation and insomnia, and in some cases, suicidal impulses. BZDs had limited efficacy but neuroleptics given in small doses, anticonvulsants and lithium gave very effective results. A limited number of electroshocks provided rapid improvement. In many respects, depression with delirium seems a more severe form of the above-described combined depressive syndrome and responds to the same treatments. We think that this mood disorder includes excitement as an important component, although this was not clearly evident. However, it is not easy to conceive this syndrome as a mixture of depressive and manic symptoms; it should rather be regarded as another specific mood condition, either permanent or transient, situated between the two other conditions.
Major Depressive Episod (MDE) delimits a wide range of heterogeneous disorders. Nowadays, both for research and for therapeutic aims, precise characteristization of MDE subtypes are needed, different subtypes of MDE requiring individualized short, long-term and preventive treatments. As patients mainly seek for physician help during the full-blown depressive phase, we focused our study on patients presenting a major depression as the index episode. In order to attempt to isolate subtypes of the disorder relatively to the mood spectrum disease and to obtain a better clinical characterization of each, we have considered the role of soft indicators of bipolarity or of milder mood disregulations in distinguishing among subtypes of MDE; special attention was devoted to detect spontaneous or drug-induced hypomania, as well as to assess the hyperthymic or cyclothymic temperament, and family history for mood disorders. Data on prior course, characteristics of index episode, and familial aggregation of patients with Bipolar II Disorder support the autonomy of this condition. Differently from our previous analyses we considered Bipolar II with hypomanic episodes separately from U-HT unipolar with only hyperthymic temperament. The comparison between these two subgroups showed a higher percentage of males in the hyperthymics, longer duration of illness and a greater number of depressive episodes and hospitalizations in bipolar II with hypomania. Data from our analyses are exposed and discussed.
Systematic and detailed psychopathological examination of 400 consecutive primary major depressives failed to confirm common clinical stereotypes which ascribe greater somatisation, hypochondriasis, agitation, psychotic tendencies, and chronicity to old age. Those above 65 were more likely to suffer from single episodes of depression that were often precipitated, whereas subjects whose illness began earlier were more likely to express depression as part of a recurrent unipolar or bipolar disorder, with higher rates of affective temperamental pathology and familial affective illness. The acute clinical picture was relatively uniform in older and younger depressives and, taken together with the other findings, tends to favour a spectrum model of primary mood disorders.
In reviewing recent findings on affective conditions in the interface of unipolar and bipolar disorders, we find evidence favoring a partial return to Kraepelin's broad concept of manic-depressive illness, which included many recurrent depressives and temperamental variants. This review addresses methodologic, clinical, and familial considerations in the definition and characterization of a proposed spectrum of bipolar disorders which subsumes episodic and chronic forms. Episodic bipolar disorders are subclassified into bipolar schizoaffective, and bipolar I and II, and bipolar III or pseudo-unipolar forms. Chronic bipolar disorders could be either intermittent or persistent, and are subclassified into chronic mania, protracted mixed states, and rapid-cycling forms, as well as the classical temperaments (cyclothymic, hyperthymic, irritable and dysthymic).
Data on prior course, characteristics of index episode, and familial aggregation of patients with bipolar II disorder is discussed. The data supports the separation of this condition from both bipolar I and recurrent unipolar disorder.
Onset, course, and outcome of affective disorders were studied prospectively--at 5-year intervals, until 1980--in 406 patients admitted to the Psychiatric University Hospital, Zurich, between 1959 and 1963. A few results are summarized. Bipolar I and bipolar II disorders take a very similar course. The distinction between unipolar depression and bipolar affective disorder, and the separation by presence or absence of psychotic features (delusions and hallucinations), and then again by mood congruence, are of high prognostic value.
This paper has drawn attention to a large and neglected universe of a soft bipolar spectrum characterized by abrupt biphasic shifts in mood, cognition, behavior, and circadian rhythms. The ease with which tricyclic anti-depressants induced changes in the cyclic nature of the illness is a special instance of these patients' vulnerability to abrupt shifts from depression to hypomania and vice versa or from euthymia to one of the affective phases and vice versa. Such shifts can also be brought about by influences possibly involving catecholaminergic excess, e.g., object loss, rapid eye movement sleep deprivation, and seasonal variation in daylight. Such vulnerability has important implications in the treatment of mood disorders and suggests caution in the overzealous use of tricyclic antidepressants in instances where subtle indicators of bipolarity can be demonstrated. Criteria for the precise clinical delineation of these elusive bipolar categories are presented.
Patients with primary major depression (N = 372) were followed for 2 years to determine the prognostic importance of past manic or hypomanic episodes. While bipolar I and bipolar II patients were more likely to relapse and bipolar I patients were more likely to attempt suicide, these patients resembled nonbipolar depressed patients in likelihood of recovery and psychosocial impairment in various areas. Compared to nonbipolar patients, those with bipolar I depression were much more likely to develop mania, while bipolar II patients were more likely to develop hypomania. Cycling during the index episode predicted a relatively low likelihood of recovery for bipolar I patients but had no apparent prognostic significance for patients with bipolar II illness.
Outpatients diagnosed as borderline (N = 100) were prospectively followed for 6-36 months and examined from phenomenologic developmental, and family history perspectives. At index evaluation, 66 met criteria for recurrent depressive, dysthymic, cyclothymic, or bipolar II disorders, and 16 for those of schizotypal personality. Other subgroups included sociopathic, somatization, panic-agoraphobic, attention deficit, epileptic, and identify disorders. Compared with nonborderline personality controls, borderlines had a significantly elevated risk for major affective but not for schizophrenic breakdowns during follow-up. Prominent substance abuse history, tempestuous biographies, and unstable early home environment were common to all diagnostic subgroups. In family history, borderlines were most like bipolar controls, and differed significantly from schizophrenic, unipolar, and personality controls. It is concluded that, despite considerable overlap with subaffective disorders, the current adjectival use of this rubric does not identify a specific psychopathologic syndrome.
The course of 434 bipolar patients (256 women, 178 men) was studied longitudinally. The prevailing patterns of the manic-depressive cycles at the end of the observation time were: mania followed by depression (usually mild), 28%; depression followed by mania (usually hypomania), 25%; and continuous circular course, with long cycles, 19%, or with short (rapid) cycles, 20%. The cycles followed an irregular pattern in 8% of the patients.
As to the intensity of the episodes, 52% of the patients had severe depressions and hypomanias; 26% had severe manias and mild depressions; and 22% had severe depressions and severe manias. No significant sex differences was found regarding the patterns of the cycles or the intensity of the episodes, except among the rapid cyclers, where women (61) outnumbered men (26).
With time the course tended to change from monopolar to bipolar, and the frequency of recurrence increased. Concurrent treatments, especially antidepressants, contributed to these changes, while female sex, middle age and menopause, along with antidepressant drugs, contributed to the establishment of rapid cyclicity. The depression-hypomania course was the one which was most prone to rapid cyclicity.
Response to lithium prophylaxis was good in the maniadepression-free interval course, in the continuous circular course with long cycles, and in the irregular course. It was less good in the depression-mania-free interval course, where it increased the frequency of recurrences, although these were shorter and milder. Response was very poor in the rapid cycling course. But rapid cyclers and patients with the depressionmania-free interval course responded well to lithium when antidepressant drugs were not administered during the depressions.
Structured interviews were used to study rates of past suicide attempts among 123 outpatients treated for affective disorders. Subjects met the Feighner criteria for major affective illness, and bipolar and unipolar groups were identified in accordance with the Fieve-Dunner criteria. Although a small group (N = 6), the women with a history of hospitalization for depression and outpatient treatment for hypomania (BP II) had the highest rate of past suicide attempts. (66 percent). This confirms previous findings. Women showed higher rates overall (39 percent vs. 28 percent for men). Suicide attempters were found to be significantly younger than nonattempters, which is in line with previous reports that suicide risk is high early in the course of bipolar illness. A trend for attempters to have received their first treatment at a younger age suggests that early onset may be a risk factor. No differences in marital status were found between attempters and nonattempters. Males and females did not differ in number, seriousness, or lethality of attempts.