Posted by jrbecker on May 1, 2003, at 13:56:11
In reply to Re: bipolar, but misdiagnosed as unipolar?, posted by jrbecker on May 1, 2003, at 12:20:50
I pasted some interesting research abstracts on this topic to look at below. Once again, the diagnostic criteria for atypical MDD v. bipolar II dx is very debated. But it seems that many in the field believe the current DSM-IV bipolar standards lack the ability to encompass the symptoms that might express the full spectrum of bipolar II/III features. This mainly comes out of the definition of what exactly "hypomania" is defined as. More and more though, the notion of 'dysphoric' hypomania (e.g, irritability, anger outbursts, sleep disturbance, attention issues) are being flagged as possible indicators just as much as the more classic 'euphoric' hypomanic manifestations (e.g., increased talketiveness, racing and tangential thoughts, grandiosity, etc). Of course, any of these symptoms could point to any number of other comorbid diagnoses to consider. But it at least provides a more descriptive checklist to evaluate than the current rigid checklist that the DSM-IV endorses. Other important indicators that are being considered to be "tip-offs" are listed on the Tips search engine I mentioned previously. I thought I'd list a few of those here though: 1) hypersomnia when depressed, 2) winter intensification of depression, 3)family hx of bipolar spectrum disorders 4)profound lethargy when depressed 5)irritability as a response to antidepressants 6) "mini-hypomanias" -- seldom reported by the pt, but often by significant others, if asked (checklist offered by Ivan Goldberg of Depression Central). Others believe that a rapid response to ADs in the first few days which eventually lose efficacy might indicate possible bipolarity.
More diagnostic research on this issue listed below...
Perugi G, Akiskal HS, Lattanzi L, Cecconi D, Mastrocinque C, Patronelli A, Vignoli S, Bemi E.
The high prevalence of "soft" bipolar (II) features in atypical depression.
Compr Psychiatry 1998 Mar-Apr;39(2):63-71
"Seventy-two percent of 86 major depressive patients with atypical features as defined by the DSM-IV and evaluated systematically were found to meet our criteria for bipolar II and related "soft" bipolar disorders; nearly 60% had antecedent cyclothymic or hyperthymic temperaments. The family history for bipolar disorder validated these clinical findings. Even if we limit the diagnosis of bipolar II to the official DSM-IV threshold of 4 days of hypomania, 32.6% of atypical depressives in our sample would meet this conservative threshold, a rate that is three times higher than the estimates of bipolarity among atypical depressives in the literature. By definition, mood reactivity was present in all patients, while interpersonal sensitivity occurred in 94%. Lifetime comorbidity rates were as follows: social phobia 30%, body dysmorphic disorder 42%, obsessive-compulsive disorder 20%, and panic disorder (agoraphobia) 64%. Both cluster A (anxious personality) and cluster B (e.g., borderline and histrionic) personality disorders were highly prevalent. These data suggest that the "atypicality" of depression is favored by affective temperamental dysregulation and anxiety comorbidity, clinically manifesting in a mood disorder subtype that is preponderantly in the realm of bipolar II. In the present sample, only 28% were strictly unipolar and characterized by avoidant and social phobic features, without histrionic traits."Benazzi F.
Depression with DSM-IV atypical features: a marker for bipolar II disorder.
Eur Arch Psychiatry Clin Neurosci 2000;250(1):53-5
"The aim of the study was to find the prevalence of atypical features in bipolar II depression versus unipolar depression. Five hundred and fifty seven unipolar and bipolar II depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. DSM-IV atypical features were significantly more common in bipolar II patients than in unipolar patients (45.4% vs 25.4%, odds ratio 2.4). As the diagnosis of bipolar II disorder is often based on diagnosis of past hypomania, which may not be very reliable. depression with atypical features may point to bipolar II disorder diagnosis."Cassano GB, Dell'Osso L, Frank E, Miniati M, Fagiolini A, Shear K, Pini S, Maser J.
The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology.
J Affect Disord 1999 Aug;54(3):319-28
"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."Akiskal HS.
The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV.
J Clin Psychopharmacol 1996 Apr;16(2 Suppl 1):4S-14S
"Based on the author's work and that of collaborators, as well as other contemporaneous research, this article reaffirms the existence of a broad bipolar spectrum between the extremes of psychotic manic-depressive illness and strictly defined unipolar depression. The alternation of mania and melancholia beginning in the juvenile years is one of the most classic descriptions in clinical medicine that has come to us from Greco-Roman times. French alienists in the middle of the nineteenth century and Kraepelin at the turn of that century formalized it into manic-depressive psychosis. In the pre-DSM-III era during the 1960s and 1970s, North American psychiatrists rarely diagnosed the psychotic forms of the disease; now, there is greater recognition that most excited psychoses with a biphasic course, including many with schizo-affective features, belong to the bipolar spectrum. Current data also support Kraepelin's delineation of mixed states, which frequently take on psychotic proportions. However, full syndromal intertwining of depressive and manic states into dysphoric or mixed mania--as emphasized in DSM-IV--is relatively uncommon; depressive symptoms in the midst of mania are more representative of mixed states. DSM-IV also does not formally recognize hypomanic symptomatology that intrudes into major depressive episodes and gives rise to agitated depressive and/or anxious, dysphoric, restless depressions with flight of ideas. Many of these mixed depressive states arise within the setting of an attenuated bipolar spectrum characterized by major depressive episodes and soft signs of bipolarity. DSM-IV conventions are most explicit for the bipolar II subtype with major depressive and clear-cut spontaneous hypomanic episodes; temperamental cyclothymia and hyperthymia receive insufficient recognition as potential factors that could lead to switching from depression to bipolar I disorder and, in vulnerable subjects, to predominantly depressive cycling. In the main, rapid-cycling and mixed states are distinct. Nonetheless, there exist ultrarapid-cycling forms where morose, labile moods with irritable, mixed features constitute patients' habitual self and, for that reason, are often mistaken for "borderline" personality disorder. Clearly, more formal research needs to be conducted in this temperamental interface between more classic bipolar and unipolar disorders. The clinical stakes, however, are such that a narrow concept of bipolar disorder would deprive many patients with lifelong temperamental dysregulation and depressive episodes of the benefits of mood-regulating agents."Benazzi F, Rihmer Z.
Sensitivity and specificity of DSM-IV atypical features for bipolar II disorder diagnosis.
Psychiatry Res 2000 Apr 10;93(3):257-62
"The aim of the study was to find the sensitivity and the specificity of DSM-IV atypical features (mood reactivity, weight gain, appetite increase, hypersomnia, leaden paralysis, interpersonal rejection sensitivity) for the diagnosis of bipolar II disorder. Consecutive 557 unipolar (54.9%) and bipolar II (45.0%) major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV and the Global Assessment of Functioning Scale. Bipolar II was diagnosed broadly, with a minimum duration of hypomania of at least some days, instead of the 4 days required by DSM-IV. MDE with atypical features was significantly more common in bipolar II patients. For the diagnosis of bipolar II disorder, MDE with atypical features, sensitivity was 0.45, and specificity was 0. 74. Among individual atypical features, hypersomnia had the best combination of sensitivity (0.35) and specificity (0.81). Combinations of two and three features did not improve sensitivity and specificity. As the diagnosis of past hypomania may not be very reliable from a patient's interview, atypical features may be an important marker of bipolar II disorder."Benazzi F.
Atypical bipolar II depression compared with atypical unipolar depression and nonatypical bipolar II depression.
Psychopathology 2000 Mar-Apr;33(2):100-2
"Aim of the study was to find out whether atypical bipolar II depression was distinct from both atypical unipolar depression and nonatypical bipolar II depression. Seventy-nine consecutive atypical bipolar II depressed outpatients were compared with 42 consecutive atypical unipolar depressed outpatients and with 53 consecutive nonatypical bipolar II depressed outpatients. Among the variables studied (age at intake, age at onset, female gender, duration of illness, psychosis, comorbidity, chronicity, recurrences, severity), age at intake and onset were significantly lower in the atypical bipolar II group than in the other groups. The other variables, apart from psychosis, were not significantly different. Findings suggest that atypical bipolar II depression may have an age at onset different from that of atypical unipolar depression and nonatypical bipolar II depression. As different ages at onset may identify distinct subtypes of depression, this finding might suggest that atypical bipolar II depression may be distinct from both atypical unipolar depression and nonatypical bipolar II depression. Copyright 2000 S. Karger AG, Basel."
poster:jrbecker
thread:223635
URL: http://www.dr-bob.org/babble/20030429/msgs/223656.html