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The bipolar spectrum

  • Jules Angst (a1)
Summary

The two-dimensional bipolar spectrum described here comprises a continuum of severity from normal to psychotic and a continuum from depression, via three bipolar subgroups to mania. This combination of dimensional and categorical principles for classifying mood disorders may help alleviate the problems of underdiagnosis and undertreatment of bipolar disorders.

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References
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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The bipolar spectrum

  • Jules Angst (a1)
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eLetters

Response to Dr. Prakash S. Gangdev and Dr. Ryan O'Neill

Jules Angst, Prof. Dr. med.
01 August 2007

Over- and under-diagnosis of bipolar disorder

Although the under-diagnosis of bipolar disorder remains a fact, Dr Gangdev makes the valid point that there are very few advocates for those misdiagnosed as BP patients and mentions that temperament and vegetative lability should not be considered pathological.This is in full agreement with the spectrum concept presented in my editorial: temperament and hypomanic symptoms per se are variations withinnormality. It would therefore be wrong to diagnose bipolar-II disorder in a patient suffering from major depression and having a cyclothymic temperament. Although a cyclothymic temperament is a correlate of bipolar disorder, many subjects with such a temperament may develop only depression and not bipolar disorder. However, this is again a hypothesis, which has to be tested by prospective data from community studies. Kretschmer (1921) distinguished clearly between cyclothymic temperament asa normal trait and cycloid personality, which was a pathological state of mood swings corresponding to a personality disorder in the current terminology.Dr. Gangdev puts hopes in phenomenology to bring the necessary progress. Our Zurich Study interview, including 30 symptoms of depression, unfortunately was unable to find any qualitative differences between the symptom profiles of bipolar-II depression and. unipolar major depression. Phenomenology may not be able to solve the diagnostic problem of bipolar-II disorder. Moreover, both the interview (including 20 symptoms of hypomania) and the self-assessment hypomania checklist of 32 symptoms demonstrated only a continuum between normal highs and pathological hypomania.

The Dr O’Neill’s comment, urging closer attention to mixed affective states as a means of reducing under- and misdiagnosis, raises the interesting problem of mixed states as an important expression of bipolar disorders. Mixed states are not integrated into the current diagnostic manuals probably because there is not enough sound, modern, prospective data available. Kraepelin (1914: pp. 1223-1224) was aware of the fact, for instance, that agitated depression, currently considered by many colleagues as a classical mixed state, often occurs in melancholic states in association with anxiety in the elderly, and he warned explicitly against considering all agitated depressive states as bipolar disorder. Our community data show that both agitated and retarded depressive syndromes are associated with validators of bipolarity without being specific or pathognomonic for bipolar disorder (Angst, Gamma, Benazzi, et al, submitted).

I agree with Dr O’Neill that the presence of manic mixed states allows the diagnosis of bipolar disorder; it is probably also correct thatdepression with at least two manic symptoms represent mixed states of bipolar disorder. The problem is that mixed states are most often a temporary syndrome in the transition from a depressive to a manic episode or vice versa. We are far from conceptualising mixed states as a specific diagnostic subgroup of mood disorders in order to qualify as an element ofthe spectrum concept. A first goal would be to create well-defined subtypes of mixed states as diagnostic specifiers of mood disorders.

Jules Angst

Angst, J., Gamma, A., Benazzi, F., et al (submitted) Do agitation andretardation in major depressive episodes indicate bipolarity? Evidence from the Zurich Study. Eur Arch Psychiatry Clin Neurosci.Kraepelin, E. (1914) Psychiatrie: ein Lehrbuch für Studierende und Ärzte(Vol. III). Leipzig: Barth.Kretschmer, E. (1921) Körperbau und Charakter. Untersuchungen zum Konstitutionsproblem und zur Lehre von den Temperamenten. Berlin: Springer.
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Conflict of interest: None Declared

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Mixed states and Bipolarity.

Ryan O'Neill, Consultant Psychiatrist
18 April 2007

I read a recent editorial by Jules Angst on the bipolar spectrum in the February edition of the British Journal of Psychiatry. Certainly thiscombination of dimensional and categorical principles for classifying mooddisorders may help alleviate problems with underdiagnosis and under treatment of bipolar disorders. I did however feel that any editorial discussing the bipolar spectrum could also have had some commentary on mixed affective states.

As outlined in this editorial underdiagnosis is a major problem, as is misdiagnosis. Misdiagnosis is highlighted in a recent study of the National Depressive and Manic Depressive association 2000 (Hirschfeld et al 2003). This study revealed that more than two thirds (69%) of respondents with bipolar disorder were misdiagnosed as suffering from a major depressive disorder with substantial numbers of the misdiagnosed having anxiety disorder (26%), schizophrenia (18%) and personality disorder (17%). One third of respondents revealed a time period of 10 years or more from the first consultation to accurate diagnosis. There are many implications with misdiagnosis, particularly with the use of psychotropic medications, which may prolong or exacerbate current symptoms,induce rapid cycling states. Mixed affective states have been described by Emil Kraepelin (1921). (Marneros 2001) .DSM IV does not allowfor the coding of mixed affective states subtypes, ICD 10 criteria are less restrictive and allow for the diagnosis of a depressive mixed type, ICD 10 states “the diagnosis of a mixed bipolar disorder should be made only if the two sets of symptoms are both prominent for the greater part of the current episode” .

Therefore mixed states are difficult to diagnose within these two coding systems, as a result this leads to further mis and underdiagnosis. Mixed state sub types can be defined according to the presence of euphoriaor depressed mood, flight of ideas or inhibition of thought, and hyperactivity or avolution. Subtypes include depressive- anxious mania, excited or agitated depression, mania with thought poverty, manic stupor, depression with flight of ideas, inhibited mania.

Mixed affective states are a risk factor for bipolarity, and also indicate a poor response to treatment and an increased risk of suicide.

The author suggests the proportional model being fruitful in differentiating major mood disorders, the proportional mood spectrum couldbe taken further to include mixed affective states. Overall it is very welcoming to see an UK editorial discussing the iceberg that is bipolarity.

References:

Hirschfeld RM,Lewis L, Vornik LA.Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003 Feb;64(2):161-74

Marneros A.Origin and development of concepts of bipolar mixed statesJournal of Affective Disorders, Volume 67, Number 1, December 2001, pp. 229-240(12)
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Conflict of interest: None Declared

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Over- and under-diagnosis of bipolar disorder

Jules Angst, Professor of Psychiatry
18 April 2007

Although the under-diagnosis of bipolar disorder remains a fact, Dr Gangdevmakes the valid point that there are very few advocates for those wronglydiagnosed as BP patients and mentions that temperament and vegetative labilityshould not be considered pathological.

This is in full agreement with the spectrum concept presented in my editorial: temperament and hypomanic symptoms per se are variations withinnormality. It would therefore be wrong to diagnose bipolar-II disorder in a patient suffering from major depression and having a cyclothymic temperament. Although a cyclothymic temperament is a correlate of bipolar disorder, many subjects with such a temperament may develop only depression and not bipolar disorder. However, this is again a hypothesis, which has to be tested by prospective data from community studies. Kretschmer (1921-16557) distinguished clearly between cyclothymic temperament as a normal trait and cycloid personality, which was a pathological state of mood swings corresponding to a personality disorder in the current terminology.

Dr: Gangdev puts hopes in phenomenology to bring the necessary progress. Our Zurich Study interview, including 30 symptoms of depression,unfortunately was unable to find any qualitative differences between the symptom profiles of bipolar-II depression and. unipolar major depression. Phenomenology may not be able to solve the diagnostic problem of bipolar-II disorder. Moreover, both the interview (including 20 symptoms of hypomania) and the self-assessment hypomania checklist of 32 symptoms demonstrated only a continuum between normal highs and pathological hypomania.
... More

Conflict of interest: None Declared

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How does the evidence for treatments correspond with the proposed classification?

Marcus Hughes, Consultant Psychiatrist
11 April 2007

I found the editorial by Angst informative, and I'm sure that the twodimensional model he proposes will be helpful to doctors and patients in understanding how mood symptoms vary between individuals.

However, for me to change my practice as Dr Angst advocates, in favour of diagnosing and treating bipolar disorders more frequently, I would need more information. Specifically, I would like to know if and how the evidence for treatment changes across the two dimensions of the model. If experts are proposing a modification in the diagnostic criteriafor bipolar disorder, we may need to acknowledge that some of the treatment evidence was generated in studies using the old definitions, andmay not be applicable to all the patient groups that fall within the new definitions. ... More

Conflict of interest: None Declared

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Need to Improve Diagnosis and Treatment For Bipolar Disorder

Mark Agius, Associate Specialist
28 March 2007

We welcome Angst’s editorial on the Bipolar Spectrum. The understanding of mental health conditions in a dimensional way, enables a better understanding of how and why mental illness develops, in particularallowing correlations with possible genetic aetiology. However, the concept of the bipolar spectrum also has major implications for how we diagnose and treat mental illness. Angst is right in pointing out that there is frequent under diagnosis of bipolar disorder, particularly the type II form. The long durations of untreated illness in Bipolar Affectivedisorder have given rise to concern. The length of time between onset of symptoms and accurate diagnosis has been quoted as 5-10 years. [Morselli, 2002] The spectrum may continue from Bipolar disorder through to unipolar depression; Angst has shown that if a series of patients with unipolar depression are followed up over time, some, at a constant rate, gradually change to cases of Bipolar Affective disorder. One of us [Tavormina 2006] has presented a study in which 300 new patientspresenting to a private psychiatric clinic were assessed according to the methodology described by Akiskal, [1996] . Of these patients, while only one suffered from Bipolar I disorder, 26% suffered from Bipolar II disorder, while only 4% suffered a major depressive episode. Nine% had brief recurrent depressive disorder, while 28% suffered ‘agitated Depression’, or Depression with Anxiety. Thus, a surprisingly large numberappear to suffer from Bipolar II disorder.If this is shown to be the case in British primary care, there are important consequences for the management of Depressive illness in terms of both clinical guidelines and policy.

In the past, there has been concern in the UK and elsewhere that depression used to be inadequately treated in General Practice. As a consequence, guidelines have been been drafted for the treatment of depression in Primary Care. However, the advent of the concept of the bipolar spectrum, all such guidelines will need to be re-written in order to ensure that patients with Bipolar illness, including type II are identified before treatment is commenced.

Angst has rightly pointed to the higher mortality, including mortality from suicide, [Rimmer 2006] in Bipolar Illness, and the greater complexity of treating Bipolar Illness, therefore one would expect more ofsuch patients to be referred to secondary care.The inappropriate use of anti-depressants in bipolar illness may lead to complications such as the induction of mania.[Smith 2007] The caution thatantidepressant monotherapy for bipolar disorder may precipitate hypomanic or mixed states, which are strongly associated with self harm and completed suicide, should then lead to a policy that, once Bipolar depression is identified earlier, mood stabilisers, including Lithium, could be used to treat the illness , rather than anti-depessants alone.We are intending to audit our own secondary care caseload in order to establish whether many Bipolar II patients are present among the group of our patients presently having a diagnosis of Depression or recurrent depressive disorder, keeping in mind the possible short duration [1-3days]of hypomania in such patients.

Mark Agius[1], Giuseppe Tavormina[2], Catherine Louise Murphy[1], Alpha Win[1], Rashid Zaman[1] [1] Bedfordshire Centre for Mental Health Research in Association with the University of Cambridge[2]President of "Psychiatric Studies Centre" - Piazza Portici, 11 - 25050 Provaglio d'Iseo (BS) - Italy References

1.Akiskal HS. [1996]The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV. J Clin Psychopharmacol 16 (suppl 1): 4-14.2.Morselli P, Elgie R [2002]The Gamian-Europe Beam Survey; Preliminary findings of a patient questionnaire circulated to 3450 members of EuropeanAdvocacy groups.Third European Stanley Foundation Conference on Bipolar Disorder September 2002.3.Rihmer Z, Gonda X. [2006] Prediction and prevention of suicide in bipolar illness. The second dual congress on Psychiatry and the Neurosciences, 1st European Congress of the International NeuropsychiatricAssociation ; 2nd Mediterranean congress of the World Federation of Societies of Biological Psychiatry Athens 2006 Book of Abstracts p 304.Smith D, Walters J.[2007] Bipolarity is important during treatment withantidepressants. BMJ 2007; 334: 327. 5.Tavormina G.[2006] The approach to Bipolar Spectrum Diagnosis. ”The 2ndDual Congress on Psychiatry and the Neurosciences, 1st European Congress of the INA”, ”2nd Mediterranean congress of the WFSBP”, Athens 2006, Bookof Abstracts p 48.
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