Skip to main content
    • Aa
    • Aa
  • Get access
    Check if you have access via personal or institutional login
  • Cited by 22
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Betts, Kim S. Williams, Gail M. Najman, Jacob M. and Alati, Rosa 2016. Predicting spectrums of adult mania, psychosis and depression by prospectively ascertained childhood neurodevelopment. Journal of Psychiatric Research, Vol. 72, p. 22.

    Klimes-Dougan, Bonnie Kennedy, Kevin P. and Cullen, Kathryn R. 2016. Developmental Psychopathology.

    Lee, Sungkyu and Matejkowski, Jason 2016. Associations between comorbid health conditions and the use of mental health services among adults with bipolar disorder. Social Work in Health Care, Vol. 55, Issue. 1, p. 28.

    Baldeweg, Torsten and Hirsch, Steven R. 2015. Mismatch negativity indexes illness-specific impairments of cortical plasticity in schizophrenia: A comparison with bipolar disorder and Alzheimer's disease. International Journal of Psychophysiology, Vol. 95, Issue. 2, p. 145.

    Kotov, R. Perlman, G. Gámez, W. and Watson, D. 2015. The structure and short-term stability of the emotional disorders: a dimensional approach. Psychological Medicine, Vol. 45, Issue. 08, p. 1687.

    Dölitzsch, Claudia Fegert, Jörg M. Künster, Anne Kölch, Michael Schmeck, Klaus and Schmid, Marc 2014. Mehrfachdiagnosen bei Schweizer Heimjugendlichen. Kindheit und Entwicklung, Vol. 23, Issue. 3, p. 140.

    Hickie, I B 2014. Evidence for separate inheritance of mania and depression challenges current concepts of bipolar mood disorder. Molecular Psychiatry, Vol. 19, Issue. 2, p. 153.

    Merikangas, K R Cui, L Heaton, L Nakamura, E Roca, C Ding, J Qin, H Guo, W Yao-Shugart, Y Zarate, C and Angst, J 2014. Independence of familial transmission of mania and depression: results of the NIMH family study of affective spectrum disorders. Molecular Psychiatry, Vol. 19, Issue. 2, p. 214.

    Taylor, Matthew 2014. Magnetic Resonance Spectroscopy.

    Hickie, Ian B Scott, Jan Hermens, Daniel F Scott, Elizabeth M Naismith, Sharon L Guastella, Adam J Glozier, Nick and McGorry, Patrick D 2013. Clinical classification in mental health at the cross-roads: which direction next?. BMC Medicine, Vol. 11, Issue. 1,

    Hickie, Ian B Hermens, Daniel F Naismith, Sharon L Guastella, Adam J Glozier, Nick Scott, Jan and Scott, Elizabeth M 2013. Evaluating differential developmental trajectories to adolescent-onset mood and psychotic disorders. BMC Psychiatry, Vol. 13, Issue. 1,

    Keyes, K. M. Eaton, N. R. Krueger, R. F. Skodol, A. E. Wall, M. M. Grant, B. Siever, L. J. and Hasin, D. S. 2013. Thought disorder in the meta-structure of psychopathology. Psychological Medicine, Vol. 43, Issue. 08, p. 1673.

    Regier, Darrel A. Kuhl, Emily A. and Kupfer, David J. 2013. The DSM-5: Classification and criteria changes. World Psychiatry, Vol. 12, Issue. 2, p. 92.

    Scott, Elizabeth M. Hermens, Daniel F. Naismith, Sharon L. Guastella, Adam J. De Regt, Tamara White, Django Lagopoulos, Jim and Hickie, Ian B. 2013. Distinguishing young people with emerging bipolar disorders from those with unipolar depression. Journal of Affective Disorders, Vol. 144, Issue. 3, p. 208.

    Vaidyanathan, Uma Patrick, Christopher J. and Iacono, William G. 2012. Examining the Overlap between Bipolar Disorder, Nonaffective Psychosis, and Common Mental Disorders Using Latent Class Analysis. Psychopathology, Vol. 45, Issue. 6, p. 361.

    Hermens, Daniel F. Redoblado Hodge, M. Antoinette Naismith, Sharon L. Kaur, Manreena Scott, Elizabeth and Hickie, Ian B. 2011. Neuropsychological Clustering Highlights Cognitive Differences In Young People Presenting With Depressive Symptoms. Journal of the International Neuropsychological Society, Vol. 17, Issue. 02, p. 267.

    STRAKOWSKI, STEPHEN M. FLECK, DAVID E. and MAJ, MARIO 2011. Broadening the diagnosis of bipolar disorder: benefits vs. risks. World Psychiatry, Vol. 10, Issue. 3, p. 181.

    Vaidyanathan, Uma Patrick, Christopher J. and Iacono, William G. 2011. Patterns of comorbidity among mental disorders: a person-centered approach. Comprehensive Psychiatry, Vol. 52, Issue. 5, p. 527.

    Goldberg, D. 2010. Should our major classifications of mental disorders be revised?. The British Journal of Psychiatry, Vol. 196, Issue. 4, p. 255.

    Goldberg, D. 2010. Author's reply:. The British Journal of Psychiatry, Vol. 197, Issue. 2, p. 158.


Where should bipolar disorder appear in the meta-structure?: Paper 7 of 7 of the thematic section: ‘A proposal for a meta-structure for DSM-V and ICD-11’

  • D. P. Goldberg (a1), G. Andrews (a2) and M. J. Hobbs (a2)
  • DOI:
  • Published online: 01 October 2009

The extant major psychiatric classifications, DSM-IV and ICD-10, are purportedly atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis is greatly enhanced by an understanding of both risk factors and clinical history. In an effort to group mental disorders on the basis of risk factors and clinical manifestations, five clusters have been proposed. The purpose of this paper is to consider the position of bipolar disorder (BPD), which could be either with the psychoses, or with emotional disorders, or in a separate cluster.


We reviewed the literature on BPD, unipolar depression (UPD) and schizophrenia in relation to 11 validating criteria proposed by the DSM-V Task Force Study Group, and then summarized similarities and differences between BPD and schizophrenia on the one hand, and UPD on the other.


There are differences, often substantial and never trivial, for 10 of the 11 validators between BPD and UPD. There are also important differences between BPD and schizophrenia.


BPD has previously been classified together with UPD, but this is the least justifiable place for it. If it is to be recruited to a ‘psychotic cluster’, there are several important respects in which it differs from schizophrenia, so the cluster would have a division within it. The alternative would be to allow it to be in an intermediate position in a cluster of its own.

Corresponding author
*Address for correspondence: Professor Sir David Goldberg, Institute of Psychiatry, de Crespigny Park, London SE5 8AF, UK. (Email:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

O Agid , B Shapira , J Zislin , M Ritsner , B Hanin , H Murad , T Troudart , M Bloch , U Heresco-Levy , B Lerer (1999). Environment and vulnerability to major psychiatric illness: a case control study of early parental loss in major depression, bipolar disorder and schizophrenia. Molecular Psychiatry 4, 163172.

HS Akiskal , N Kilzieh , JD Maser , PJ Clayton , PJ Schettler , M Traci Shea , J Endicott , W Scheftner , RMA Hirschfeld , MB Keller (2006). The distinct temperament profiles of bipolar I, bipolar II and unipolar patients. Journal of Affective Disorders 92, 1933.

NC Andreasen , J Rice , J Endicott (1987). Familial rates of affective disorder. A report from the National Institute of Mental Health Collaborative Study. Archives of General Psychiatry 44, 461469.

G Andrews , DP Goldberg , RF Krueger , WT Carpenter Jr., SE Hyman , P Sachdev , DS Pine (2009 a). Exploring the feasibility of a meta-structure for DSM-V and ICD-11: could it improve utility and validity? Psychological Medicine. doi:10.1017/S0033291709990250.

G Andrews , DS Pine , MJ Hobbs , TM Anderson , M Sunderland (2009 b). Neurodevelopmental disorders: Cluster 2 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine. doi:10.1017/S0033291709990274.

LR Baxter Jr., ME Phelps , JC Mazziotta , JM Schwarz , RH Gerner , CE Selin , RM Sumida (1985). Cerebral metabolic rate for glucose in mood disorders. Archives of General Psychiatry 42, 441447.

A Bertelsen , B Harvald , M Hague (1977). A Danish twin study of manic depressive disorders. British Journal of Psychiatry 130, 330351.

D Blacker , MT Tsuang (1993). Unipolar relatives in bipolar pedigrees: are they bipolar? Psychiatric Genetics 3, 516.

A Borkowska , JK Rybakowski (2001). Neuropsychological frontal lobe tests indicate that bipolar depressed patients are more impaired than unipolar. Bipolar Disorders 3, 8894.

WE Bunney , BG Bunney (2000). Molecular clock genes in man and lower animals: possible implications for circadian abnormalities in depression. Neurophyschopharmacology 22, 335345.

DM Cannon , M Ichise , D Rollis , JM Klaver , SK Gandhi , DS Charney , HK Manji , WC Drevets (2007). Elevated serotonin transporter binding in major depressive disorder assessed using positron emission tomography and [11C]DASB: comparison with bipolar disorder. Biological Psychiatry 62, 870877.

TD Cannon , IM Rosso , JM Hollister , CE Bearden , LE Sanchez , T Hadley (2000). A prospective cohort study of genetic and perinatal influences in the etiology of schizophrenia. Schizophrenia Bulletin 26, 351366.

AG Cardno , F Rijsdijk , PC Sham , RM Murray , P McGuffin (2002). A twin study of genetic relationships between psychotic symptoms. American Journal of Psychiatry 159, 539545.

WT Carpenter Jr., JR Bustillo , GK Thaker , J van Os , RF Krueger , MJ Green (2009). Psychoses: Cluster 3 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine. doi:10.1017/S0033291709990286.

BJ Chun , DL Dunner (2004). A review of antidepressant-induced hypomania in major depression: suggestions for DSM-V. Bipolar Disorders 6, 3242.

PJ Clayton , C Ernst , J Angst (1994). Premorbid personality traits of men who develop unipolar or bipolar disorders. European Archives of Psychiatry and Clinical Neuroscience 243, 340346.

TJ Crow (2007). How and why genetic linkage has not solved the problem of psychosis: review and hypothesis. American Journal of Psychiatry 164, 1321.

AK Cuellar , SL Johnson , R Winters (2005). Distinctions between bipolar and unipolar depression. Clinical Psychology Review 25, 307339.

L Forty , D Smith , I Jones , S Caesar , C Cooper , C Fraser , K Gordon-Smith , S Hyde , A Farmer , P McGuffin , N Craddock (2008). Clinical differences between bipolar and unipolar depression. British Journal of Psychiatry 192, 388389.

TA Furukawa , W Konno , S Morinobu , H Harai , T Kitamura , K Takahashi (2000). Course and outcome of depressive episodes: comparison between bipolar, unipolar and subthreshold depression. Psychiatry Research 96, 211220.

TA Furukawa , A Ogura , T Hirai , S Fujihara , T Kitamura , K Takahashi (1999). Early parental separation experiences among patients with bipolar disorder and major depression: a case–control study. Journal of Affective Disorders 52, 8591.

JR Geddes , H Verdoux , N Takei , SM Lawrie , P Bovet , JM Eagles , R Heun , RG McCreadie , TF McNeil , E O'Callaghan , G Stober , U Willinger , RM Murray (1999). Schizophrenia and complications of pregnancy and labor: an individual patient data meta-analysis. Schizophrenia Bulletin 25, 413423.

DP Goldberg , RF Krueger , G Andrews , MJ Hobbs (2009). Emotional disorders: Cluster 4 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine. doi:10.1017/S0033291709990298.

JM Hettema (2008). What is the genetic relationship between anxiety and depression? American Journal of Medical Genetics. Part C, Seminars in Medical Genetics 148C, 140146.

SR Jaffee , TE Moffitt , A Capsi , E Fombonne , R Poulton , J Martin (2002). Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Archives of General Psychiatry 59, 215222.

KS Kendler , LM Karkowski , D Walsh (1998). The structure of psychosis: latent class analysis of probands from the Roscommon family study. Archives of General Psychiatry 55, 492499.

KS Kendler , MC Neale , RC Kessler , AC Heath , LJ Eaves (1993). A longitudinal twin study of personality and major depression in women. Archives of General Psychiatry 50, 853862.

KS Kendler , NL Pedersen , MC Neale , AA Mathe (1995). A pilot twin study of affective illness including hospital- and population-ascertained subsamples: results of model fitting. Behavior Genetics 25, 217232.

KS Kendler , CA Prescott , J Myers , MC Neale (2003). The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry 60, 929937.

R Kessler , WT Chiu , O Demler , EF Walters (2005). Prevalence severity and co-morbidity of 12 month DSM-4 disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 617627.

JZ Konarski , RS McIntyre , SH Kennedy , S Rafi-Tari , JK Soczynska , TA Ketter (2008). Volumetric neuroimaging investigations in mood disorders: bipolar disorder versus major depressive disorder. Bipolar Disorders 10, 137.

RF Krueger , SC South (2009). Externalizing disorders: Cluster 5 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine. doi:10.1017/S0033291709990328.

S Krüger , RG Cooke , GM Hasey , T Jorna , E Persad (1995). Comorbidity of obsessive–compulsive disorder in bipolar disorder. Journal of Affective Disorders 34, 117120.

S Krüger , D Seminowicz , K Goldapple , SH Kennedy , HS Mayberg (2003). State and trait influences on mood regulation in bipolar disorder: blood flow differences with an acute mood challenge. Biological Psychiatry 54, 12741283.

TM Laursen , T Munk-Olsen , M Nordentoft , PB Mortensen (2007). A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a Danish population-based cohort. Journal of Clinical Psychiatry 68, 16731681.

NS Lawrence , AM Williams , S Surguladze , V Giampietro , MJ Brammer , C Andrew , S Frangou , C Ecker , ML Phillips (2004). Subcortical and ventral prefrontal cortical neural responses to facial expressions distinguish patients with bipolar disorder and major depression. Biological Psychiatry 55, 578587.

P Lichtenstein , BH Yip , C Bjork , Y Pawitan , TD Cannon , PF Sullivan , CM Hultman (2009). Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet 373, 234239.

M Liotti , HS Mayberg , S McGinnis , SL Brannan , P Jerabek (2002). Unmasking disease-specific cerebral blood flow abnormalities: mood challenge in patients with remitted unipolar depression. American Journal of Psychiatry 159, 18301840.

W Maier , D Lichterman , J Minges , J Hallmayer , R Heun , O Benkert , DF Levinson (1993). Continuity and discontinuity of affective disorders and schizophrenia. Archives of General Psychiatry 50, 871873.

GS Malhi , MJ Green , A Fagiolini , ED Peselow , V Kumari (2008). Schizoaffective disorder: diagnostic issues and future recommendations. Bipolar Disorders 10, 215230.

P McGuffin , R Katz , P Bebbington (1987). Hazard, heredity and depression. A family study. Journal of Psychiatric Research 21, 365375.

P McGuffin , F Rijsdijk , M Andrew , P Sham , R Katz , A Cardno (2003). The heritability of bipolar disorder and its relationship to unipolar depression. Archives of General Psychiatry 60, 499502.

K Merikangas , R Herrell , J Swendsen , W Rössler , V Ajdacic-Gross , J Angst (2008). Specificity of bipolar spectrum conditions in the comorbidity of mood and substance use disorders. Archives of General Psychiatry 65, 4752.

KR Merikangas , HS Akiskal , J Angst , PE Greenberg , RMA Hirschfeld , M Petukhova , RC Kessler (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry 64, 543552.

PB Mitchell , GM Goodwin , GF Johnson , RMA Hirschfeld (2008). Diagnostic guidelines for bipolar depression: a probabilistic approach. Bipolar Disorders 10, 144152.

PB Mortensen , CB Pedersen , M Melbye , O Mors , H Ewald (2003). Individual and familial risk factors for bipolar affective disorders in Denmark. Archives of General Psychiatry 60, 12091215.

RM Murray , P Sham , J Van Os , J Zanelli , M Cannon , C McDonald (2004). A developmental model for similarities and dissimilarities between schizophrenia and bipolar disorder. Schizophrenia Research 71, 405416.

MJ Owen , N Craddock , A Jablensky (2007). The genetic deconstruction of psychosis. Schizophrenia Bulletin 33, 905911.

ML Phillips , WC Drevets , SL Rauch , R Lane (2003). Neurobiology of emotion perception. II: Implications for major psychiatric disorders. Biological Psychiatry 54, 515528.

ML Phillips , E Vieta (2007). Identifying functional neuroimaging biomarkers of bipolar disorder: toward DSM-V. Schizophrenia Bulletin 33, 893904.

MM Rea , DJ Miklowitz , MC Tompson , MJ Goldstein , S Hwang , J Mintz (2003). Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. Journal of Consulting and Clinical Psychology 71, 482492.

J Roschke , P Wagner , K Mann , J Fell , M Grozinger , C Frank (1996). Single trial analysis of event related potentials: a comparison between schizophrenics and depressives. Biological Psychiatry 40, 844852.

P Roy-Byrne , RM Post , TW Uhde , T Porcu , D Davis (1985). The longitudinal course of recurrent affective illness: life chart data from research patients at the NIMH. Acta Psychiatrica Scandinavica (Suppl.) 71, 134.

P Sachdev , G Andrews , MJ Hobbs , M Sunderland , TM Anderson (2009). Neurocognitive disorders: Cluster 1 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine. doi:10.1017/S0033291709990262.

GS Sachs , AA Nierenberg , JR Calabrese , LB Marangell , LR Wisniewski , L Gyulai , ES Friedman , CL Bowden , MD Fossey , MJ Ostacher , TA Ketter , J Patel , P Hauser (2007). Effectiveness of adjunctive antidepressant treatment for bipolar depression. New England Journal of Medicine 356, 17111722.

DA Solomon , AC Leon , W Coryell , TI Mueller , MA Posternak (2003). Unipolar mania: a 20-year follow-up study. American Journal of Psychiatry 160, 20492050.

I Soreca , E Frank , DJ Kupfer (2009). The phenomenology of bipolar disorder: what drives the high rate of medical burden and determines long-term prognosis? Depression and Anxiety 26, 7382.

SM Strakowski , SL McElroy , PW Keck Jr., SA West (1994). The co-occurrence of mania with medical and other psychiatric disorders. International Journal of Psychiatry in Medicine 24, 305328.

JL Tackett , LC Quilty , M Sellbom , M Rector , NA Bagby (2008). Internalizing disorders and personality structure. Journal of Abnormal Psychology 117, 454459.

J Van Os , P Jones , P Sham , P Bebbington , RM Murray (1998). Risk factors for onset and persistence of psychosis. Social Psychiatry and Psychiatric Epidemiology 33, 596605.

MM Weissman , RC Bland , GJ Canino , C Fravelli , S Greenwald , H-G Hwu , PR Joyce , EG Karam , C-K Lee , J Lellouch , J-P Lepine , SC Newman , M Rubio-Stipec , JE Wells , PJ Wickamaratne , H-U Wittchen , E-K Yeh (1996). Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association 276, 293299.

JE Wildes , MD Marcus , A Fagiolini (2008). Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder. Psychiatry Research 161, 5158.

G Winokur , W Coryell , M Keller , J Endicott , A Leon (1995). A family study of manic-depressive (bipolar I) disease: is it a distinct illness separable from primary unipolar depression. Archives of General Psychiatry 52, 367373.

J Wolfe , E Granholm , EN Butters , E Saunders , D Janowsky (1987). Verbal memory deficits associated with major affective disorders: a comparison of unipolar and bipolar patients. Journal of Affective Disorders 13, 8392.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *