Posted by Nickengland on November 3, 2005, at 12:01:18
In reply to Re: Hypomania-- a solution to TR Depression? » Girlnterrupted, posted by neuroman on November 3, 2005, at 10:57:00
This is interesting..
Examining the underdiagnosis of BD naturally leads to a discussion of how broad the spectrum of bipolar diagnosis should be. Clinical and genetic data suggest that nonclassic parts of the bipolar spectrum (that is, BD II, NOS, and cyclothymia) may be more common than classic type I manic-depressive illness (21). In fact, as Grof has suggested, classic type I manic depressive illness may differ in many respects from less typical forms of bipolar illness, especially in being more lithium-responsive. It is this classic syndrome that Ketter has called “Cade’s disease.” Figure 1 suggests a possible conceptualization of these conditions on the affective spectrum. Bipolar spectrum conditions exhibit less severe mania, but they are not less severe in terms of depressive symptoms. Apart from the major morbidity and substantial suicide risk that these depressive symptoms present (3), varieties of BD produce unstable lives, failed careers, high divorce rates, and stormy biographies. Hence, we believe that the entire bipolar spectrum needs to be aggressively diagnosed and treated.
The problem of BD underdiagnosis is partly (although not entirely) related to failure to recognize bipolar spectrum states such as hypomania, assuming a version of the spectrum beyond full mania is accepted. Because hypomania is the only major DSM-IV diagnosis in which the essential criterion of social and occupational dysfunction is not required (and in fact, one must rule out significant social and occupation dysfunction), many clinicians find hypomania to be a difficult condition to diagnose. Thus, hypomania is mainly distinguished from mania based on function, rather than symptoms. Because the term “significant” is deliberately vague, psychiatrist identification of hypomania is not reliable (24). Given this situation, hypomania may be underdiagnosed as “normality,” and mania may be underdiagnosed as hypomania.
Also, the complete focus on polarity found in the diagnostic schema of DSM-III/IV obscures the relation between bipolar and highly recurrent forms of unipolar depression. BD is diagnosed when mood elevation is present, and its place in the diagnostic schema implies a totally separate illness. However, phenomenologic studies dating back to Kraepelin put primary emphasis on illness course and considered cycling to be as important as polarity. Cases of recurrent depression may be more likely to have genetic characteristics and treatment responses similar to those encountered in BD (3). Patients presenting with mainly depressive symptoms may exhibit other clues to possible bipolarity, and these are outlined in Table 1.
Given the debate and confusion surrounding the bipolar spectrum, we propose here a heuristic definition based on these clues (Tables 1 and 2). We propose placing all versions of bipolar illness apart from BD I or II in a single category, labelled “bipolar spectrum disorder (BSD).” This is in contrast to others who have suggested types of bipolar illness (III-VI) beyond BD I and II (21,25). We envision that this BSD diagnosis might replace the current nonspecific DSM-IV diagnosis of BD NOS. We heuristically define BSD as a diagnostic category that possesses several of the potential signs of bipolarity listed in Table 1, with greater weight given to family history and antidepressant-induced manic symptoms (26). Even in patients that have not spontaneously experienced a manic or hypomanic episode, we suggest that BSD can be diagnosed if they have MDEs with several signs of bipolarity (Table 2).
http://www.cpa-apc.org/Publications/Archives/CJP/2002/march/inReviewCadesDisease2.asp
Kind regards
Nick
poster:Nickengland
thread:574432
URL: http://www.dr-bob.org/babble/20051031/msgs/574954.html