Posts tagged ‘bipolar diagnosis’

Bipolar Spectrum Research

It is almost inevitable that when people attempt to categorize anything they make the initial categories too narrow. Psychiatrists have know for some time that the diagnostic categories for bipolar in DSM-IV TR continue to be inadequate, in spite of revisions. Inevitably, people fall through the cracks, usually into the dreaded NOS (not otherwise specified) category. I say “dreaded” because a nonspecific diagnosis often results in lower quality treatment, especially if the physician is inexperienced with bipolar patient.

A recent review of the literature looked at the 4 recognized types of bipolar (I, II, III, and IV) and compared their symptom criteria with what is actually seen in clinics and hospitals. The author (Hagop S. Akiskal, MD) found evidence for five additional categories, as follows:

Bipolar _ , or schizobipolar, falls under a separate DSM category, Schizoaffective disorders. These are diagnosed in patients who exhibit both psychotic symptoms and mood swings, satisfying most of the criteria for each type of disorder.

Bipolar I is a well-known type that represents what many people think of as “bipolar”. The patient’s mood episodes cover the entire range from depression to mania (which often has psychotic features). Akiskal suggests that an additional category, bipolar I_, includes those who have frequent depressive episodes interspersed with a few manic or near-manic but not psychotic periods.

Bipolar II was first identified in 1976 by researchers at the National Institutes of Mental Health. In a nutshell (no pun intended!), these individuals experience recurrent deep depressions along with hypomania, often at the end of the depression. Mood shifts can occur quickly, and the delineation between the two moods is more clear. These are “typical” bipolar II’s.

Bipolar II_ individuals, according to Akiskal, experience greater mood dysregulation and frequent occurence of depression and an irritable rather than euphoric hypomania. Even between episodes they are considered “moody” by those around them. In fact, the moody person who develops major depression is more likely to shift to bipolar I or II in the future than is the person who is not normally moody. This is an important clinical consideration (although I have not seen practical application of it). Panic disorder and/or social phobia are also classified by Akiskal as indicators of potential bipolar II_.

Bipolar III is diagnosed when anti-depressants prescribed for a major depression produce a shift into hypomania. It most often occurs in patients with a first-degree bipolar relative, which reinforces the genetic link for bipolar spectrum disorders. The hypomania does not generally last long, and recurrs infrequently.

In Bipolar III_, the bipolar episodes are inextricably linked with substance abuse, such that it is impossible to determine which came first, the chicken or the egg. (My experience here:) These individuals are now termed “Dual Diagnosis” in hospital settings, based on the belief that it is depression that caused the substance abuse in the first place. However, it could just as easily be bipolar disorder — one reason why it is often better to treat according to symptoms instead of diagnoses.

Bipolar IV, as described by Akiskal, is a category I have never encountered myself. Apparently, sometimes people (mostly men) who have led successful and seemingly happy lives develop depression in the latter part of middle age. This quickly leads to an agitated depression or “mixed state” in which the person fulfills criteria for both depression and hypomania. The author suggests that this disorder may be the cause of unexpected suicides — “but he was so successful, I don’t know what went wrong.” An agitated depression is highly dangerous for anyone no matter what their diagnosis is, because if they are suicidal that have enough energy to complete the act, unlike typical depression with complete lack of energy (personal experience again).

Of course, these categories can still be further refined, but I think this work is helpful in recognizing the various stops along the bipolar spectrum. In the end, though, I think the symptoms are what’s most important. It’s nice to have an “umbrella” designation to give the physician a place to start. On the other hand, the inadequacy of the categories in the DSM can fool them into a simplistic view of bipolar (“are you I or II?”) and likewise, a simplistic method of treatment.

Reference:
Akiskal HS. The Emergence of the bipolar spectrum: validation along clinical-epidemiologic lines and familial-genetic lines. Psychopharmoacol Bull. 2008; 40(4):99-115.

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October 12, 2008 at 5:30 am Leave a comment


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