Diagnostic Criteria For Bipolar Disorder Research Articles

COVID-19 pandemic amplified mortality rates among adolescents with bipolar disorder through family-related factors.

Recently, a growing number of adolescents have been afflicted with mental disorders, with annual morbidity rates on the rise. This trend has been exacerbated by the global coronavirus disease 2019 (COVID-19) pandemic, leading to a surge in suicide and self-harm rates among this demographic. To investigate the impact of the COVID-19 pandemic on adolescent bipolar disorder (BD), along with the underlying factors contributing to heightened rates of suicide and self-harm among adolescents. A comprehensive statistical analysis was conducted utilizing clinical interviews and self-reports obtained from patients or their guardians. Diagnostic criteria for BDs were based on the Diagnostic and statistical manual of mental disorders, international classification of diseases-11, and the National institute of mental health research domain criteria. Statistical analyses were performed using SPSS 26.0 software, with significance set at P < 0.05. A cohort of 171 adolescents diagnosed with BD between January 1, 2018, and December 31, 2022, was included in the analysis. The gender distribution was 2.8:1 (female to male), with ages ranging from 11 to 18 years old. Major factors contributing to adolescent BDs included familial influences, academic stress, genetic predisposition and exposure to school-related violence. Notably, a significant increase in suicide attempts and self-harm incidents was observed among adolescents with BD during the COVID-19 pandemic. Statistical analysis indicated that the pandemic exacerbated familial discord and heightened academic stress, thereby amplifying the prevalence of suicidal behavior and self-harm among adolescents. The COVID-19 pandemic has exacerbated familial tensions and intensified the incidence of suicide and self-harm among adolescents diagnosed with BD. This study underscores the urgent need for societal, familial and educational support systems to prioritize the well-being of adolescents and offers valuable insights and guidelines for the prevention, diagnosis and treatment of adolescent BDs.

MALADAPTIVE PARENTING AND PEER GROUP BULLYING AS PATHOLOGICAL PATHWAYS TO BORDERLINE PERSONALITY DISORDER SYMPTOMS IN EARLY ADULT: CASE REPORT

Introduction – Maladaptive experiences during adolescene have been consistently linked with borderline personality disorder. BPD is a serious mental illness characterized by pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. Tthere was an interrelated relationship between parenting experiences and the development of BPD symptoms. Children who reported chronic bullying had a fivefold increase in the likelihood of developing BPD symptoms. Methods – Presented the case of patient, 20 years old young male with symptoms of borderline personality disorder turned out to have maladaptive parenting and history of became victim by peer group bullying since childhood. Data were taken from interviews and mental status examinations in psychiatric clinics, then a literature review was carried out. Results – The development of borderline personality disorder in adult linked with report of low care parenting, involves coldness, indifference, and rejection. BPD is also inevitable from hereditary risk factors. Discuss – There is a direct significant association between being victim of bullying and development of BPD. Empathy is one important aspect of social behavior that may not function in BPD. Atypical depressed patients with affective dysregulation first diagnosed with borderline personality disorder if do not meet the diagnostic criteria for bipolar disorder. Conclusion – Borderline personality disorder (BPD) is very prone to occur in young adults. Starting from affect dysregulation, inability to impulse control, unstable interpersonal relationships, and unstable self-image that begin to develop in children and adolescents when exposed to environmental risk factors. Risk factors that are very often influencing are family and peer group relationships. BPD is also an entry point for developing into bipolar disorder. Therefore, effective interventions should be targeted, early preventing the development of affect dysregulation in the development of the borderline personality disorder by reducing exposure to environmental risk factors. Keywords: borderline personality disorder, maladaptive parenting, bullying.

Psychosocial Traumatic Environments: A Clinical Case of Childhood Abuse

Traumatic psychosocial environments directly impact adult life. Compromised self-esteem, emotional self-regulation, and interpersonal relationships are observed, and a predisposition to the presence of mental and personality disorders is exacerbated in cases of sexual abuse. Science has presented quantitative and statistical studies on child abuse and a limited number of studies that have investigated the consequences and long-term impacts on the lives of individuals who suffered maltreatment in childhood and did not have access to forms of protection or social support after the identification of child abuse, especially in Brazil. Therefore, this case report is a qualitative study of an ideographic nature which aims to evaluate the “particular” form of abuse repercussions in the life of a 60-year-old woman, giving voice to the victim of child abuse through the process of the investigation and complex analysis of her life history and family relationships. The psychological assessment protocol included a semi-structured interview, active listening, a genogram, and a mental status examination. The results reveal the coexistence of a rigid and violent environment with the presence of physical punishment and child sexual abuse. Self-injurious episodes and suicide attempts began in adolescence. Changes in mood, changes in remote memory, negative thoughts, self-injurious behavior, suicidal ideation and attempts, clinical comorbidities, a lack of interest in romantic relationships, and the repetition of behaviors that perpetuate the cycle of abuse and violence (physical, psychological, and patrimonial) were identified. The diagnostic criteria for bipolar disorder with dependent and borderline personality traits have been established. The case requires a multi-disciplinary follow-up with the use of medication to control and remit the symptoms.

The significance of sleep quality in euthymic bipolar patients from Nigeria.

BackgroundBipolar disorder is highly under-researched in Africa. Existing studies show that racial/ethnic disparities exist for sleep quality. Poor sleep quality in bipolar disorder causes significant morbidity and mortality even during periods of euthymia.AimThis study aimed to assess sleep quality and its correlates amongst euthymic patients with bipolar I disorder from Nigeria.SettingThe study was carried out in a teaching hospital, and state hospital, in Ibadan, Nigeria.MethodThis cross-sectional study was conducted amongst 76 euthymic bipolar patients aged between 18 and 60 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for bipolar disorder. Euthymia was defined as having a score of ≤ 5 on the Young Mania Rating Scale and < 8 on the Hamilton Depression Rating Scale. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI).ResultsA total of 37 (48.7%) participants had poor quality sleep. Sleep quality was associated with marital status (p = 0.013) and suicide plan (p = 0.047). Participants with good sleep quality had higher total sleep duration, lower time to fall asleep (sleep latency), better subjective quality of sleep, were less likely to use sleep medications and had less daytime dysfunction than participants with poor sleep quality. All p-values were < 0.05. Subjective quality of sleep, ongoing use of sleep medication, daytime dysfunction were independently associated with poor sleep quality.ConclusionPoor sleep quality frequently persists during euthymic periods in patients with bipolar disorder. The correlates identified can be targeted for intervention during treatment.

The Greater Houston Area Bipolar Registry-Clinical and Neurobiological Trajectories of Children and Adolescents With Bipolar Disorders and High-Risk Unaffected Offspring.

The aims of this article are to discuss the rationale, design, and procedures of the Greater Houston Area Bipolar Registry (HBR), which aims at contributing to the effort involved in the investigation of neurobiological mechanisms underlying bipolar disorder (BD) as well as to identify clinical and neurobiological markers able to predict BD clinical course. The article will also briefly discuss examples of other initiatives that have made fundamental contributions to the field. This will be a longitudinal study with participants aged 6–17 at the time of enrollment. Participants will be required to meet diagnostic criteria for BD, or to be offspring of a parent with BD. We will also enroll healthy controls. Besides clinical information, which includes neurocognitive performance, participants will be asked to provide blood and saliva samples as well as to perform neuroimaging exams at baseline and follow-ups. Several studies point to the existence of genetic, inflammatory, and brain imaging alterations between individuals at higher genetic risk for BD compared with healthy controls. Longitudinal designs have shown high conversion rates to BD among high-risk offspring, with attempts to identify clinical predictors of disease onset, as well as clarifying the burden associated with environmental stressors. The HBR will help in the worldwide effort investigating the clinical course and neurobiological mechanisms of affected and high-risk children and adolescents with BD.

Childhood maltreatment, prefrontal-paralimbic gray matter volume, and substance use in young adults and interactions with risk for bipolar disorder

Childhood maltreatment is associated with adverse effects on the brain, and an increased risk for psychopathology, including mood and substance use disorders. Individuals vary on the degree to which they exhibit neurobiological and clinical differences following maltreatment. Individuals with bipolar disorder exhibit greater magnitude of maltreatment-related prefrontal-paralimbic gray matter volume (GMV) deficits compared to typically developing individuals. It is unclear if greater structural differences stem from greater neural vulnerability to maltreatment in bipolar disorder, or if they relate to presence of other clinical features associated with childhood maltreatment, e.g., elevated prevalence of comorbid substance use disorders. To investigate this, we compared young adults with a family history of bipolar disorder (n = 21), but who did not fulfill diagnostic criteria for bipolar disorder, with typically developing young adults without a family history of bipolar disorder (n = 26). Participants completed structural neuroimaging, clinical and family history interviews, and assessment of childhood maltreatment and recent alcohol and cannabis use patterns. We examined relations between childhood maltreatment and prefrontal-paralimbic GMV by modeling main effects of maltreatment and family history group by maltreatment interactions on prefrontal-paralimbic GMV. We also examined relations between maltreatment and associated GMV changes with recent alcohol and cannabis use. Childhood maltreatment correlated with lower ventral, rostral and dorsolateral prefrontal and insular cortical GMV across all participants regardless of the presence or absence of familial history of bipolar disorder. However, exploratory analyses did reveal greater maltreatment-related GMV differences in individuals with prodromal symptoms of depression. Lower insula GMV was associated with greater frequency of cannabis use across all participants and greater quantity of alcohol use only in those with familial risk for bipolar disorder. Results suggest familial risk for bipolar disorder, and presumably genetic risk, may relate to outcomes following childhood maltreatment and should be considered in prevention/early intervention strategies.

Aristotle and DSM on ‘Bipolar’ Melancholy: Symptoms, Medication, Link to Creativity.

That Aristotle connected excellence, creativity to (bipolar) melancholy is known. This article adds depth and detail by distilling from his work characteristics of hot and cold melancholy, placing them in pairs of opposites, and comparing them with the diagnostic criteria for bipolar disorder in DSM. The Greek warned against extreme mood. He named two examples of mythical persons who suffered the tragic consequences; Ajax’ suicide and Hercules’ manic destruction of his wife and children. More recent examples are Vincent van Gogh, who committed suicide and his brother Theo who attacked his wife and child, was interned and finally succumbed from the consequences of extreme mania. Aristotle urged melancholics to temper their mood. For it was only from mild melancholy that sustained creativity could be expected. He advocated hellebore as medicine. His general ethical advice to strive towards the opposite extreme is especially relevant for melancholics. Aristotle’s work on excellence and bipolar melancholy can inspire those confronted with bipolar disorder today to temper their mood. The examples of famous melancholics throughout the ages bring comfort and a sense of belonging. The author, who is stabilized on lithium, holds up the example of the van Gogh family who, lacking the effective the medicine available today, communicated openly with each other about their disorder. With the new 20th century medication, perfected in our own time, it is from increased openness that the major advances in mental health are now to be expected.

A case of mania presenting with hypersexual behavior and gender dysphoria thatresolved with valproic acid

Hypersexuality and gender dysphoria have both been described in the literature as symptoms of mania. Hypersexuality is listed in the Diagnostic and Statistical Manual of Mental Disorders 5 as part of the diagnostic criteria for bipolar disorder. Gender dysphoria is less often described and its relation to mania remains unclear. This case report describes a young homosexual man presenting in a manic episode with co-morbid amphetamine abuse whose mania was marked by hypersexuality and the new onset desire to be a woman. Both of these symptoms resolved with the addition of valproic acid to antipsychotics. This case report presents the existing literature on hypersexuality and gender dysphoria in mania and describes a treatment option that has not been previously reported.

Bipolar disorders following initial depression: Modeling predictive clinical factors

ObjectiveMost first lifetime episodes among persons eventually diagnosed with bipolar disorder are depressive, often with years of delay to a final differentiation from unipolar major depression. To support early differentiation, we tested several predictive factors for association with later diagnoses of bipolar disorder. MethodWith data from mood-disorder patients with first-lifetime episodes of major depression, we used multivariate, logistic modeling and Bayesian methods including Receiver Operating Characteristic curves to evaluate ability of one or more selected factors to differentiate patients who later met DSM-IV-TR diagnostic criteria for bipolar disorder and not unipolar major depressive disorder. ResultsWe analyzed data from 2146 patients (642 bipolar, 1504 unipolar) at risk for 13 years following initial depressive episodes. In multivariate modeling for 812 subjects with information on all clinical factors considered, seven significantly and independently differentiated bipolar from unipolar disorders, ranking (by significance): (a) ≥4 previous depressive episodes, (b) suicidal acts, (c) cyclothymic temperament, (d) family history of bipolar disorder, (e) substance-abuse, (f) younger-at-onset, or onset-age <25, and (g) male sex; four of these (c, d, f, g) can be identified at illness-onset. Bayesian analysis indicated optimal sensitivity and specificity at 2–4 factors/person and correct classification of 64–67% of cases, and ROC analysis of factors/person yielded a significant area-under-the-curve of 0.72 [CI: 0.68–0.75]. ConclusionsIn multivariate modeling, 7 factors were significantly and independently associated with bipolar disorder diagnosed up to 13 years after initial depression.

Problematic Boundaries in the Diagnosis of Bipolar Disorder: The Interface with Borderline Personality Disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. The most studied question on the relationship between BPD and bipolar disorder is their diagnostic concordance. Across studies approximately 10 % of patients with BPD had bipolar I disorder and another 10 % had bipolar II disorder. Likewise, approximately 20 % of bipolar II patients were diagnosed with BPD, though only 10 % of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is, nonetheless, diagnosed in the absence of the other in the vast majority of cases (80-90 %). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are more commonly diagnosed in patients with BPD than is bipolar disorder. Studies comparing patients with BPD and bipolar disorder find significant differences on a range of variables. These findings challenge the notion that BPD is part of the bipolar spectrum. While a substantial literature has documented problems with the under-recognition and under-diagnosis of bipolar disorder, more recent studies have found evidence of bipolar disorder over-diagnosis and that BPD is a significant contributor to over-diagnosis. Re-conceptualizing the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, diagnostic criteria for bipolar disorder as a type of test, rather than the final word on diagnosis, shifts the diagnostician from thinking solely whether a patient does or does not have a disorder to considering the risks of false-positive and false-negative diagnoses, and the ease by which each type of diagnostic error can be corrected by longitudinal observation.

Diagnosing bipolar disorders in DSM-5.

Editorial A few weeks ago, after many years of intensive work, the much-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published. It is still the case today that psychiatric diagnoses seem to be more consensus-based than validity-based (Cuthbert and Insel 2013; Bschor et al. 2012; Berk 2013) something that DSM-5 will also be unable to change. In spite of this, DSM-5 introduces several important changes with regard to diagnostic criteria for bipolar disorders. The International Journal of Bipolar Disorders is honored that Jules Angst, whose work has made an outstanding contribution to the modifications regarding bipolar disorders in DSM-5 (Angst et al. 2011, 2012), has agreed to comment on the strengths, problems and perspectives relating to these changes in the paper that accompanies this editorial (Angst 2013). An essential topic thankfully addressed by Jules Angst in the accompanying paper (Angst 2013) has been hotly debated within the psychiatric scientific community throughout the last few years namely whether bipolar disorders are much more frequent than previously assumed. If this is the case, one may conclude that the hitherto existing diagnostic criteria have falsely prevented the proper diagnosis of all cases of bipolar disorders on account of their being overly restrictive. In DSM-5, bipolar and related disorders, as they are now called, are given a chapter on their own, between depressive disorders and schizophrenia spectrum disorders, that includes bipolar I disorder (which represents, according to DSM-5, classic manic depressive disorder, with the exception that neither a depressive episode nor psychosis has to be present for diagnosis), bipolar II disorder and cyclothymic disorder. Furthermore, in this chapter, there are now separate diagnostic criteria for

Post-Acute Effectiveness of Lithium in Pediatric Bipolar I Disorder

This study examined the long-term effectiveness of lithium for the treatment of pediatric bipolar disorder within the context of combination mood stabilizer therapy for refractory mania and pharmacological treatment of comorbid psychiatric conditions. Outpatients, ages 7-17 years, meeting American Psychiatric Association, diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) diagnostic criteria for bipolar disorder I (BP-I) (manic or mixed) who demonstrated at least a partial response to 8 weeks of open-label treatment with lithium (phase I) were eligible to receive open-label lithium for an additional 16 weeks (phase II). Up to two adjunctive medications could be prescribed to patients experiencing residual symptoms of mania or comorbid psychiatric conditions, following a standardized algorithm. Forty-one patients received continued open-label long-term treatment with lithium for a mean of 14.9 (3.0) weeks during phase II. The mean weight-adjusted total daily dose at end of phase II was 27.8 (6.7) mg/kg/day, with an average lithium concentration of 1.0 (0.3) mEq/L. Twenty-five of the 41 patients (60.9%) were prescribed adjunctive psychotropic medications for residual symptoms. The most frequent indications for adjunctive medications were refractory mania (n=13; 31.7%) and attention-deficit/hyperactivity disorder (ADHD) (n=15; 36.6%). At the end of this phase 28 (68.3%) patients met a priori criteria for response (≥50% reduction from phase I baseline in young mania rating scale [YMRS] summary score and a clinical global impressions-improvement [CGI-I] score of 1 or 2), with 22 (53.7%) considered to be in remission (YMRS summary score≤12 and CGI-severity score of 1 or 2). These data suggest that patients who initially responded to lithium maintained mood stabilization during continuation treatment, but partial responders did not experience further improvement during Phase II, despite the opportunity to receive adjunctive medications. The most commonly reported (≥20%) adverse events associated with lithium treatment were vomiting, headache, abdominal pain, and tremor. Lithium may be a safe and effective longer-term treatment for patients with pediatric bipolar disorder who respond to acute treatment with lithium. Partial responders to acute lithium did not appear to experience substantial symptom improvement during the continuation phase, despite the possibility that adjunctive medications could be prescribed.

Cumulative morbidity and prognostic staging of illness in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

Staging models may provide heuristic utility for intervention selection in psychiatry. Although a few proposals have been put forth, there is a need for empirical validation if they are to be adopted. Using data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), we tested a previously elaborated hypothesis on the utility of using the number of previous episodes as a relevant prognostic variable for staging in bipolar disorder. This report utilizes data from the multisite, prospective, open-label study 'Standard Care Pathways' and the subset of patients with acute depressive episodes who participated in the randomized trial of adjunctive antidepressant treatment. Outpatients meeting DSM-IV diagnostic criteria for bipolar disorder (n = 3345) were included. For the randomized pathway, patients met criteria for an acute depressive episode (n = 376). The number of previous episodes was categorized as less than 5, 5-10 and more than 10. We used disability at baseline, number of days well in the first year and longitudinal scores of depressive and manic symptoms, quality of life and functioning as validators of models constructed a priori. Patients with multiple previous episodes had consistently poorer cross-sectional and prospective outcomes. Functioning and quality of life were worse, disability more common, and symptoms more chronic and severe. There was no significant effect for staging with regard to antidepressant response in the randomized trial. These findings confirm that bipolar disorder can be staged with prognostic validity. Stages can be used to stratify subjects in clinical trials and develop specific treatments.

Screening for bipolar disorder in adolescents with the Mood Disorder Questionnaire – Adolescent version (MDQ‐A) and the Child Bipolar Questionnaire (CBQ)

Screening instruments for bipolar disorders (BDs) in children and adolescents have been developed recently. The present study examined performances of the French versions of the mood disorder questionnaire-adolescent version (MDQ-A) and child bipolar questionnaire (CBQ) in a sample of in- and outpatients. Seventy-six adolescents (age 13-18) and parents first completed the MDQ-A (adolescent and parent versions) and CBQ screening instruments. About 3 weeks later, they had a diagnostic interview with the Kiddie-schedule for affective disorders and schizophrenia-present and lifetime (K-SADS-PL), and the adolescent MDQ-A self-report was completed a second time. Eight of 76 patients (10.5%) met K-SADS-PL diagnostic criteria for BD. Test-retest reliability of the adolescent MDQ-A self-report was moderate (kappa = 0.66), whereas agreement between adolescent and parent reports was poor (kappa = 0.07). Sensitivity and specificity of the MDQ-A with respect to K-SADS-PL were 75.0% and 57.4% for the adolescent version, and 87.5% and 63.2% for the parent version. Corresponding figures were 50.0% and 73.5% for the CBQ. All three screening instruments had low positive predictive values (17.1% for the MDQ-A adolescent version; 21.9% for the MDQ-A parent version; 18.2% for the CBQ), whereas negative predictive values were higher than 90%. The present study points to modest performances of the MDQ-A and CBQ to detect BDs in adolescents, with diagnostic criteria for BD being unmet for a majority of patients who screened positive.

Would Broadening the Diagnostic Criteria for Bipolar Disorder Do More Harm Than Good? Implications From Longitudinal Studies of Subthreshold Conditions

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), is a categorical system that provides descriptive diagnostic criteria for psychiatric syndromes. These syndrome descriptions are imperfect representations of an underlying behavioral, psychological, or biological dysfunction; thus, the criteria could be conceptualized as a type of test for the etiologically defined illnesses. Accordingly, as with any other diagnostic test, diagnoses based on DSM-IV criteria produce some false positive and some false negative results. That is, some patients who meet the criteria will not have the illness (ie, false positives), and some who do not meet the criteria because their symptoms fall below the diagnostic threshold will have the illness and incorrectly not receive the diagnosis (ie, false negatives). In this context, I consider the controversy over whether the diagnostic threshold for bipolar disorder should be lowered. Longitudinal studies of the prognostic significance of subthreshold bipolar disorder are considered. Subthreshold bipolarity is a risk factor for the future emergence of bipolar disorder, but the majority of individuals with subthreshold bipolarity do not develop a future manic or hypomanic episode. The diagnostic threshold for bipolar disorder should not be lowered for 4 reasons: (1) the results of longitudinal studies suggest that lowering the diagnostic threshold for bipolar disorder will result in a greater increase in false positive than true positive diagnoses; (2) there are no controlled studies demonstrating the efficacy of mood stabilizers in treating subthreshold bipolar disorder; (3) if a false negative diagnosis occurs and bipolar disorder is underdiagnosed, diagnosis and treatment can be changed when a manic/hypomanic episode emerges; and (4) if bipolar disorder is overdiagnosed and patients are inappropriately prescribed a mood stabilizer, the absence of a future manic/hypomanic episode would incorrectly be considered evidence of the efficacy of treatment, and the unnecessary medications that might cause medically significant side effects would not be discontinued.

Severe Mood Dysregulation, Irritability, and the Diagnostic Boundaries of Bipolar Disorder in Youths

In recent years, increasing numbers of children have been diagnosed with bipolar disorder. In some cases, children with unstable mood clearly meet current diagnostic criteria for bipolar disorder, and in others, the diagnosis is unclear. Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials. (Reprinted with permission from The American Journal of Psychiatry 2011; 168:129–142)

Subthreshold bipolarity: diagnostic issues and challenges

Research suggests that current diagnostic criteria for bipolar disorders may fail to include milder, but clinically significant, bipolar syndromes and that a substantial percentage of these conditions are diagnosed, by default, as unipolar major depression. Accordingly, a number of researchers have argued for the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to better account for subsyndromal hypomanic presentations. The present paper is a critical review of research on subthreshold bipolarity, and an assessment of some of the challenges that researchers and clinicians might face if the DSM-5 were designed to systematically document subsyndromal hypomanic presentations. Individuals with major depressive disorder (MDD) who display subsyndromal hypomanic features, not concurrent with a major depressive episode, have a more severe course compared to individuals with MDD and no hypomanic features, and more closely resemble individuals with bipolar disorder on a number of clinical validators. There are clinical and scientific reasons for systematically documenting subsyndromal hypomanic presentations in the assessment and diagnosis of mood disorders. However, these benefits are balanced with important challenges, including (i) the difficulty in reliably identifying subsyndromal hypomanic presentations, (ii) operationalizing subthreshold bipolarity, (iii) differentiating subthreshold bipolarity from borderline personality disorder, (iv) the risk of over-diagnosing bipolar spectrum disorders, and (v) uncertainties about optimal interventions for subthreshold bipolarity.

At the edge of the bipolar spectrum: primacy of affective over psychotic symptoms or vice versa?

Strakowski et al should be congratulated upon this very comprehensive and well balanced essay of pros and cons about a broadening of diagnostic criteria for bipolar disorder. They very well point out potential benefits for otherwise insufficiently treated patients, but also that, given our lack of a full understanding of the biological basis, such a broadening might be premature in treatment research. So far, we still have a long way to go if we want to define groups of mental disorder by shared genetic underpinnings or biological markers, and thus we rely on phenomenology and derived categorizations when we conduct treatment research. And, in my opinion, these categorizations still need to be strict, reliable and largely unaltered over time, until we find better (and tested) definitions. With rising placebo response rates in randomized clinical trials and subsequent narrowing of drug-placebo differences, it becomes increasingly difficult to identify specific benefits of a drug, e.g. against core manic symptoms. Allowing, for example, patients into trials whose “mania” manifests itself just by agitation and irritability may give rise to large numbers of subjects with maniform features which are in fact related to substance use or personality. As a consequence, we would not expect a drug to differentiate from placebo unless it probably has a strong sedative component, but would we consider this as a true and specific antimanic agent? Strakowski et al also make it quite clear that bipolar disorder has a huge overlap of symptoms and features with other major mental disorders. Besides the grey zone that does (or does not) divide bipolar disorder from other affective, or more generalized, emotional states, a fascinating question is the relationship of bipolar disorder and schizophrenia. As Strakowski et al point out, a future trend might be, “based on risk factor and clinical history considerations, that bipolar disorder may be better classified with schizophrenia in a psychotic cluster than with unipolar depression in an emotional cluster”. But, how valid is the clinical observation of psychotic symptoms to serve as a basis of categorical clustering, and are they not more likely subsidiary to emotional processes? Looking back, for many decades bipolar disorder has been an orphan of psychiatry, whereas schizophrenia was considered the most important challenge. At the beginning of last century, it was still well accepted that all psychotic symptoms arise from mood dysregulation 1. In the post-Kraepelinian area, diagnostic habits continuously shifted towards schizophrenia, putting much more weight on psychotic than affective symptoms. Kraepelin’s successor Schneider reports that the ratio of patients diagnosed with schizophrenia vs. cyclothymia at the Munich hospital between 1934 and 1936 was greater than 5:1, while in the same department 35 years earlier Kraepelin had stated that 10-15% of hospital admissions were suffering from manic-depressive illness 2. Whereas it was hard to neglect the obvious existence of (unipolar) depression, bipolar disorder was almost cut down to clinical (and research) insignificance. This tendency of overdiagnosing schizophrenia at the expense of bipolar disorder continued well into the 1970s 3. Now the pendulum seems to swing back the other way. Lake and Hurwitz 4 questioned the validity of the diagnosis of schizophrenia, postulating that a single disease, a mood disorder with a broad spectrum of severity, accounts for functional psychoses. Compared to schizophrenia, and despite all limitations, diagnostic criteria for bipolar disorder may still have a better validity 5. Schneiderian first-rank symptoms (FRS) are not exclusive to schizophrenia; they also occur in some bipolar patients 6, although they may be more frequent and more severe in patients with schizophrenia than bipolar disorder. Schizophrenia patients with FRS during the acute phase are more likely to have poorer long-term outcome than those who do not have these symptoms. However, the same is true also for bipolar patients exhibiting FRS 7. But what really matters in end is how we can improve our bipolar patient’s life. Strakowski et al make it clear that the categorical vs. spectrum discussion is not a academic one in an ivory tower, but has clinical significance: “People with bipolar disorder are identified from the general population in order to assign therapies that will alleviate their suffering (i.e., symptoms), ideally through evidence-based treatment guidelines developed from past studies of similar individuals”.

Broadening bipolar diagnostic criteria: why not start with hypomania?

Broadening bipolar diagnostic criteria: why not start with hypomania?

Severe Mood Dysregulation, Irritability, and the Diagnostic Boundaries of Bipolar Disorder in Youths

In recent years, increasing numbers of children have been diagnosed with bipolar disorder. In some cases, children with unstable mood clearly meet current diagnostic criteria for bipolar disorder, and in others, the diagnosis is unclear. Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials.