The Clinical Spectrum of Mania

In his authoritative review, Akiskal has used the spectrum of mania as the royal road to the field of bipolar disorders. When mapping the manic spectrum Akiskal, the trialblazer, has seen boundaries both in the current classification systems (DSM-IV and ICD-10) and in various rating scales and questionnaires 1 . Thus, the manic symptomatology goes from schizomania at the top to hyperthymia at the bottom. Between these extremes are the other categories from mania to hypomania. The description of...

Aetiopathogenesis for Bipolar Disorder

Roy Chengappa1, 2 Lokaranjit Chalasani1, 2 and Joseph Levine1, 3 Charles Bowden's comprehensive and thoughtful review of the pharmacological treatment of bipolar illness articulates succinctly several fundamental issues and controversies. Not unexpectedly, the issue of What is a mood stabilizer is a central theme. This concept was shaped by lithium and its reported effects for the different phases (acute antimanic, acute antidepressant, and prophylactic against recurrences of mania or...

And Management of Bipolar Disorder A Review 359

Shulman, Ayal Schaffet, Anthony Levitt and Nathan Herrmann 5.1 Heterogeneity of Bipolar Disorder Does Childhood Onset Make a Difference 398 5.2 Bipolar Disorders in Children and Adolescents Critical Diagnostic Issues for Clinicians 5.3 Emotion, Mood and Bipolar Disorder in Children 408 5.4 Childhood Mania Is it Bipolar Disorder 412 5.5 Bipolar Disorder in Children Some Issues of Concern 414 Y.C. Janardhan Reddy and Shoba Srinath 5.6 Bipolar Disorder The Need for Treatment 5.7...

What is Disordered in Bipolar Disorders

Mania (euphoric or irritable), the clinical hallmark of bipolar disorder, is usually easy to recognize, whereas the limits of hypomania (the criterion for bipolar type II) with normality and mania proper are much more difficult to ascertain. But what is specific of bipolar disorder is still debated. It is not the symptoms according to Kraepelin 1 , all symptoms can be seen in all mental disorders Pope and Lipinski 2 and Brockington et al 3 found schizophrenic symptoms as frequent in mania as in...

Borderline Personality Disorder

There is a great deal of confusion in clinical psychiatry today concerning the boundaries between bipolar II disorder, cyclothymic disorder and borderline personality disorder. Such individuals also often use various substances, which further complicates their diagnostic status. Although much has been written from either personality disorder 220 or mood disorder perspectives 221 , definitive studies to convince the opposite groups are lacking or what has been published is conflicting. In the...

References

Goodwin F.K., Jamison K.R. (1990) Manic-Depressive Illness. Oxford University Press, New York. 2. Marneros A., Angst J. (Eds) (2000) Bipolar Disorders 100 Years after Manic Depressive Insanity. Kluwer, Dordrecht. 3. Akiskal H.S. (Ed.) (1999) Bipolarity Beyond Classic Mania. Saunders, Philadelphia. 4. Goodnick P.J. (Ed.) (1998) Mania Clinical and Research Perspectives. American Psychiatric Press, Washington. 5. Young L.T., Joffe R.T. (Eds) (1997) Bipolar Disorder Biological Models and their...

Drugs Principally Affecting Depression Lamotrigine

Lamotrigine was significantly superior to placebo in a double-blind, randomized, placebo-controlled, seven-week study of bipolar I depressed patients (level I). Significant improvement was noted from the point at which lamo-trigine-treated patients received 50mg day for one week 38 . The study is the only high quality designed monotherapy study conducted for bipolar depression. The planned primary test of efficacy yielded only trends for superiority of lamotrigine over placebo. The primary...

Bipolar Disorder across the Reproductive Life Cycle

Pregnancy, the postpartum period, and menopause are each stages of the reproductive life cycle that may impact bipolar illness. Some have suggested that pregnancy may be a time in which women with BD experience a relief from their mood symptoms. However, this opinion has not been conclusively supported by the available evidence. Most notably, Blehar et al. 7 closely examined the timing of pregnancy and emotional problems in 51 women with BD type I, and found that 19 51 (37 ) reported...

The Importance of Natural Course and Depression in Bipolar I Disorder

Marneros and Brieger's comprehensive review of the prognosis of bipolar I disorder offers considerable evidence that the most consistent and powerful predictor of long-term course is prior morbidity. Marneros and Brieger summarize several studies that fail to find baseline variables that predict long-term course. Candidate subtypes such as rapid cycling and mixed episodes show poor stability over time and support for their prognostic value is equivocal. Furthermore, evidence comparing...

Bipolar II Disorder

These patients typically present with a major depressive episode, and upon further inquiry, history for hypomanic episodes is elicited 21 . Accurate diagnosis then depends on the vagaries of the patient's memory and how rigorously the clinician pursues queries about hypomania and, most importantly, whether relatives are available to respond to such queries. Otherwise, unless noted in the patient's past psychiatric record, the examining psychiatrist may have little clue from the patient's...

Culture Matters Too in Bipolar Disorder

The biological component of bipolar disorder is unquestionable, as it is the case in most, if not all, mental disorders. Psychosocial aspects are, however, important, although usually neglected, especially in their cultural component. This component is clearly missing in the excellent review of Mark Bauer. It is true that very few studies exist in this field, and this is difficult to understand. As a matter of fact, bipolar disorder is a frequently encountered condition, with a rich behavioural...

Mood Stabilizers in Bipolar Depression

Although eight of nine placebo-controlled, crossover-designed studies of lithium were reported as supporting superiority to placebo in treatment of bipolar depression, the study designs were consistently flawed, with abrupt discontinuation contributing in part to apparent lithium advantage. A systematic review of these studies, utilizing more realistic criteria of response, reported the response rate to be 36 (level II) 24 . This evidence of, at best, modest antidepressant effects in bipolar...

Introduction Definition of mood stabilizers

As the array of pharmacological treatments for bipolar disorder has expanded, implementation of treatment has become more complex, as have notions of the concept of mood stabilization. The first efforts at definition of mood stabilizers referred to drugs that benefited at least one primary aspect of bipolar illness (mania, depression, cycling frequency, number of episodes, subthreshold symptoms) without worsening any other aspect of the illness 1 . This definition focused on the developing...

Why We Care About the Economic and Social Burden of Bipolar Disorder

Our interest in the economic and social burden of bipolar disorder is not primarily motivated by scientific curiosity. Instead, we hope to use data on the burden of illness to influence public policy and identify priority areas for clinical and quality improvement. 1 Center for Health Studies, Group Health Cooperative, 1730 Minor Ave. 1600, Seattle, WA, USA Continued discrimination against those with mental disorders depends on a series of prejudicial assumptions. The first is that mental...

Disputed Boundaries Of Bipolarity

Until recently, compared to the UK, bipolar disorder was often misdiagnosed as schizophrenia in the US 15, 16, 37 . We are aware of at least one data-based paper on this subject from another country 205 . Current data from the US 206 indicate that schizophrenia no longer tops the list in missed bipolar diagnoses. A national survey of the US Depressive and Manic-Depressive Association 207 recently revealed that disorders within the broader affective range major depressive and comorbid anxiety...

Biochemical Changes Elicited by Mood Stabilizers

It is estimated that the lifetime prevalence of bipolar disorder is 0.6 in the United States and similar figures have been quoted for Europe and Australasia. It is also known that the risk of acquiring the disorder is increased in first-degree relatives of affected individuals. Genetic linkage analyses have led to the identification of several regions in the human genome that may contain genes conferring susceptibility to the disorder. Nevertheless, specific genes that are highly associated...

Novel Mood Stabilizing Strategies and 50 Years of Lithium

Compared to 30 years ago, it has become more difficult to make rational treatment decisions in the management of bipolar disorder. Nowadays, we have many more treatment options and a substantially larger group of patients are diagnosed as bipolar. The review presented by Charles Bowden gives an outstanding orientation for clinical practice by critically discussing the current evidence regarding the available treatment strategies. For lithium, the classic treatment of choice in bipolar illness,...

The Diagnosis of Bipolar Disorder Some Open Issues

The thorough and comprehensive review on the diagnosis of bipolar disorders by Hagop Akiskal, one of the leading clinical investigators in the field, leaves no room for new information. Nevertheless it warrants some comments on the main issues he has raised. Since the diagnosis of bipolar disorders is still lacking a solid validation, derived from either an identifiable cause or from objectively measured neurobiological markers, the clinical insightful observation remains the only tool for...

Antidepressant Induced Mood Instability

The paucity of studies allows at best tentative statements on the subject of induction of mania hypomania, increase in cycling frequency, or symptom-atically milder mood instability. The one randomized, prospective, on-off design of antidepressants in bipolar disorder indicated a marked increase in cycling frequency while taking the antidepressant (level II) 124 . The thoughtful study of Altshuler et a indicates a direct link between switching and increased frequency of cycling 128 . The only...

Stress Relapse and Disability in Bipolar Disorder

The extent of disability, family disruption and fatality associated with bipolar disorder truly makes it one of the most financially impacting 1 145 East 26th Street, Suite 3C, New York, NY 10010, USA illnesses affecting mankind. Goldberg and Ernst describe the economic impact of bipolar illness not only in direct costs, but also in the hard to define indirect costs of social impact. As they report, there is a large body of research suggesting psychosocial disability may be profound among...

Classification Diagnosis and Boundaries of Bipolar Disorders A Review Hagop S Akiskal

1.1 Terminology, History and Definition of Bipolar Spectrum 1.2 Toward an Expansion of Bipolar Disorders in DSM-V 1.3 Narrowing and Broadening Diagnostic Criteria for Bipolar Disorder Competing Demands of Research and Clinical Practice 1.4 Is Phenomenological Dissection for Bipolar Disorders Spectrum Possible 1.5 In Search for a Definition for Bipolar Disorder 1.6 What is Disordered in Bipolar Disorders 1.7 How Prevalent is the Bipolar Spectrum 1.8 Broadening the Definition of Bipolar Disorder...

Rapid Cycling

Rapid cycling bipolar patients, as defined in DSM-IV, experience a minimum of four episodes (mania hypomania and major depression) per year 196, 197 . They most frequently arise from a bipolar II terrain 198 , and thus present with at least four alternating depressive-hypomanic cycles per year. As a result, these patients rarely have freedom from affective episodes during the rapid-cycling phase of their illness, which is usually dominated by depression. Rapid cycling lies along a continuum...

Cyclothymia

Both Kraepelin 36 and Kretschmer 115 described cyclothymic individuals in whom low-grade affective manifestations of a subdepressive and mild hypomanic nature oscillated over long periods of the life span. While in the classical, and especially German, literature 116 cyclothymia refers to the entire range of manic-depressive manifestations, in its current usage 117 the term cyclothymic disorder is restricted to a subthreshold bipolar trait or temperament. In most cyclothymes presenting...

Mania

Classic euphoric mania is unmistakable the elated mood is accompanied by grandiosity, psychomotor acceleration, a rush of ideas, distractibility, and decreased need for sleep 36 . The manic patient is witty, his behaviour expansive, jesting, and dramatic. The patient lifts the clinician's spirits, but can be irritating as well. Although this mode of emotional communication is highly characteristic of mania 88 , as contrasted with schizophrenia, it is not specifically mentioned in the diagnostic...

Suicide Homicide And Forensic Issues

Suicide accounts for a significant proportion of premature death among individuals with bipolar disorder 36 . It has been estimated that, on average, a 25-year-old woman with untreated bipolar disorder will lose nine years of life expectancy (due largely to suicide), although with appropriate treatment a 6.5-year increase in life expectancy may be recaptured 37 . Because suicide risk historically has been described as being particularly high during the first few years after the onset of...

Interpersonal Interventions

Related to intra-family stress as a potential modulator of bipolar disorder, several investigators have focused more broadly on interpersonal interactions in bipolar disorder from one of two perspectives. Frank and co-workers (e.g., 43 ) have written extensively on interpersonal interactions as a key stressor and or remediating factor in bipolar disorder. Accordingly, they took the approach of adapting Interpersonal Therapy (IPT 44 ) for depression to bipolar disorder and adding elements to...

Chronicity Milder Forms and Cognitive Impairment in Bipolar Disorder

Eduard Vieta, Francesc Colom and Anabel Martinez-Aran1 Bipolar disorders are severe illnesses, chronic and lifelong. This could be, in their own words, the summary of the excellent review by Marneros and Brieger on the course and prognosis of manic-depressive illness. However, if we look at the way we treat our patients (or the way they accept to be treated), it does not look like we really assume that. In Europe, many psychiatrists would wait until the second or even the third episode before...

Psychoanalysis and Psychodynamic Psychotherapy

Bipolar disorder attracted the attention of psychoanalysts since the early days of that treatment. Perhaps the most comprehensive review of psychoanalytic thought on bipolar disorder is summarized by Frieda Fromm-Reichmann's group, which undertook extensive study of several cases in an ongoing case supervision seminar 34, 35 , and by the more recent work of Jackson 36 . The common threads through much of psychoanalytic thought about bipolar disorder are the contrast of bipolar disorder with...

Bipolar Unipolar Dichotomy

Based on epidemiological and family studies and clinical intuition, Akiskal estimated that 4-5 of the general population belongs to a broad bipolar spectrum with predominantly depressive phenomenology and muted bipolar features. These figures contrast the classical figure of 1-1.6 for bipolar disorder. This widening of bipolarity to the detriment of unipolar forms was corroborated by Angst 1 , who demonstrated through epidemiological data that more than 5 of the general population might be...

Special Aspects Onset

The exact definition of age at onset is difficult, because the age when symptoms first appear does not correspond to the age at first medical consultation or at first admission to hospital. Symptoms generally appear some time before medical consultation is first sought 5, 14, 95 . Bipolar affective patients usually become ill at a younger age than unipolar patients. There is good agreement in the literature that the peak onset occurs in the 20s (between 25 and 30) for bipolar disorders and in...

For Clinicians Across the World

Due to the lack of pathognomonic biological markers for most of psycho-pathology, and with the current emphasis on facts rather than theory in defining psychiatric syndromes, phenomenology is of critical importance for the scientific development of psychiatry. The international success of the most visible current diagnostic systems in psychiatry (the DSM-IV and the ICD-10), both based on phenomenology, attest to the great importance researchers and clinicians ascribe to the symptomatic...

Pregnant Girls Dlavori

Weissman M.M., Bland R., Joyce P.R., Newman S., Wells J.E., Wittchen H.-U. (1993) Sex differences in rates of depression cross-national perspectives. J. Affect. Disord., 29 77-84. 2. Kessler R.C., Rubinow D.R., Holmes C., Abelson J.M., Zhao S. (1997) The epidemiology of DSM-III-R bipolar I disorder in a general population survey. Psychol. Med., 27 1079-1089. 3. Hendrick V., Altshuler L.L., Gitlin M.J., Delrahim S., Hammen C. (2000) Gender and bipolar illness. J. Clin. Psychiatry, 61 393-396. 4....

Developing Countries

We are indebted to Goldberg and Ernst for their seminal review about the economic and social burden of bipolar disorder in spite of the scarcity of the literature on this subject. The economics of mental disorders is rarely estimated in developing countries, because the resources needed for such studies are unavailable in low-income countries. The studies done on bipolar disorder are scarce even in developed countries. However, they can be a paradigm for cost estimates of mental disorders in...

Atypical Psychosis The Other Boundary of Bipolar Disorder

The concept of bipolarity presented by Hagop Akiskal is a good clue for all psychiatrists to find an alternative and effective treatment strategy in patients who might have received a diagnosis of unipolar depression according to classical diagnostic systems. Since nothing should be added to his thorough and well-organized review, I would like to comment on one topic, the other boundary of bipolar disorder, which may be specific to Japan. Although DSM-IV is generally used in research and...

Fiction or Future

Despite all advances and a recent rapid increase of confirmatory controlled trials, the pharmacotherapy of bipolar disorder has still a long way to go to achieve similar success rates as many nonpsychiatric drug treatments. Part of it is due to the fact that bipolar disorder was a long-time neglected orphan in the development of new drugs. Comparing the number of patients in randomized trials between 1988 and 1995, 10 times as many patients had been in controlled trials for atypical...

Narrowing and Broadening Diagnostic Criteria for Bipolar Disorder Competing Demands of Research and Clinical Practice

Like most psychiatric, and many medical disorders, the diagnosis of a bipolar disorder remains fixed to clinical evaluation, symptom recognition and syndrome definition. Hagop Akiskal provides a comprehensive review of the evolution of this diagnosis during the previous two millennia, particularly the most recent 100 years. Additionally, he proposes a spectrum of bipolar disorders that incorporates broader coverage into primarily depressive states that have typically been included under the...

Terminology History and Definition of Bipolar Spectrum

Hagop Akiskal has written a masterly review on bipolar disorder, which amply illustrates Heracleitus' view that all things are in a state of flux. This volume of the World Psychiatric Association is devoted to bipolar disorders, making the history of the term and concept of central interest. The terms unipolar and bipolar disorder were coined by Karl Kleist 1 and were taken over by his pupils Neele 2 and Leonhard 3 . Apart from manic-depressive (circular) disorders, Kleist and Leonhard's...

What is the True Cost of Bipolar Disorder

Much has been and should be made of the findings of The Global Burden of Disease project which revealed that major psychiatric disorders accounted for five of the 10 most common causes of disability worldwide in 1990 1 . Without improved treatment access, adherence and advances, these disorders were projected to remain causes of profound disability well into this century. Among these illnesses, bipolar disorder was ranked as the sixth leading cause. This clearly is bad news. Goldberg and Ernst...

The Bipolar Spectrum Focus on Core Personality Characteristics

Hagop Akiskal's review is both informative and provocative. He coherently supports the position that various manifestations of bipolar disorders exist on a spectrum ranging from temperament or personality to affectively loaded psychotic illness (i.e. schizobipolar or schizoaffective disorder). The glue holding this spectrum together appears to be the existence of and or the potential for manic, hypomanic or sub-hypomanic phenomena, the tendency for antidepressants to cause hypomanic episodes in...

Prognosis and Manic Depressive Cycle

Manic-depressive illness is essentially a cyclic phenomenon. Its cyclicity is not simply a type of course such as can be observed, for instance, in malarial fevers or epileptic attacks, but is probably its fundamental component, 1 Centro Lucio Bini, Via Crescenzio 42, 00193 Roma, Italy because the disorder in its core manifestations appears closely related to cyclic biological rhythms like sleep, and to environmental, circadian and seasonal variations. From a clinical point of view, it is the...

Treatment of Bipolar Disorder

Short-term treatment of manic and depressive episodes may prove a cumbersome task, but eventually the majority of patients will experience a full or partial response. Long-term prophylactic treatment presents both patients and doctors with additional problems which I shall deal with briefly. In his review, Charles Bowden competently and in great detail examines the evidence for treatment efficacy of various drugs and drug combinations, and it is quite clear that long-term treatment efficacy is...

Pharmacoeconomics And Pharmacotherapies

Financial costs relating to treatment include not only the direct expense of medications and individual institutional provider services but also expenses associated with treatment, including the need for adjunctive pharmacotherapies or antidotes to primary medication side effects, laboratory monitoring of medication blood levels and end-organ functioning, additional health service utilization (such as emergency department visits or medical intensive care unit admissions due to medication...

Depressive Mixed State

5-10 of depressed patients switch to the opposite pole upon antidepressant treatment 139-141 . Other destabilizing factors, uncovered in pioneering studies conducted by Himmelhoch et a 142 , include cerebral factors and alcohol and drug abuse or withdrawal. The process can be acute or subacute and many patients develop a driven depression with psychomotor restlessness they may be stuck for many months in a depressive phase with severe anxiety and hypomanic admixtures such as marked...

Future Directions

Shulman et al, in their review of age and gender issues on phenomenology and management of bipolar disorder, have given the reader a most comprehensive view of the literature. The recurrent themes of discussion and debate about child and adolescent bipolar disorder include Does bipolar disorder really onset in this age group How common is it How can one recognize bipolar disorder before there is threshold level mania What are the overlaps and interfaces with attention deficit hyperactivity...

Modern Studies

The NIMH Collaborative Program on the Psychobiology of Depression The NIMH Collaborative Program on the Psychobiology of Depression observed bipolar patients prospectively up to 15 years in a large naturalistic study, One 10-year follow-up report of 165 patients with bipolar I disorder drop-out rate 29 focused on comparison of poor-prognosis and non-poor-prognosis control bipolar subjects 33 , Poor prognosis was defined as belonging to the highest quartile of a morbidity index for the last...

Review Methodology

This review sought to locate all studies on psychotherapy for bipolar disorder that filled the following criteria a published in peer-reviewed journals b investigated an intervention in a sample of patients with bipolar disorder, or reported separately results for bipolar subsamples from a diagnostically heterogeneous group c specified quantitative outcome variables d written in English an unfortunate, but recognized, limitation of the author . Literature databases including MedLine, PsychLit...