THE EVOLVING BIPOLAR SPECTRUM: Prototypes I, II, III, and IV

doi:10.1016/S0193-953X(05)70093-9

Psychiatric Clinics of North America

Volume 22, Issue 3, 1 September 1999, Pages 517-534

https://doi.org/10.1016/S0193-953X(05)70093-9 Get rights and content

This article describes the bipolar spectrum in a historical³² and conceptual context,² then provides clinical descriptions for subtypes within this spectrum. Through case material, the authors illustrate how phenomenologic nuances can be used in support for diagnostic subtyping within this spectrum and how such subtyping could provide a more rational approach to mood stabilization in these patients. The prototypes provided should be seen as an attempt to map this vast clinical territory, rather than as definitive subclassification of bipolar spectrum disorders. For fuller description—and for much of the evidence supporting the concept of a bipolar spectrum—the reader is referred to earlier work by the authors.2, 4, 5, 6

Section snippets

FROM KRAEPELIN TO DSM-V

Kraepelin³² envisaged a continuum between manic and depressive states. His grand vision, developed at the turn of the nineteenth century, was based on clinical observation, longitudinal course, and family history. Many patients who began with depression ended up with mania and vice versa; other depressives went as far as hypomania but not beyond; there were also patients who had a cyclical course without discernible excited episodes but who were temperamentally similar to manic-depressive

BIPOLAR I: FULL-BLOWN MANIA

Manic-depressive illness often has an explosive manic onset with psychosis (mania means psychosis in Greek). Other patients begin with a mixture of depression and mania (dubbed dysphoric mania in the literature). Because the emphasis in this article is on the depressive aspects of the bipolar spectrum, the case provided next—with a long latency between the first depression and the first clear-cut manic episode—illustrates the never-ending risk for bipolarity in recurrent depression.

BIPOLAR I½: DEPRESSION WITH PROTRACTED HYPOMANIA

Where hypomania ends and mania begins is not clearly demarcated. Individuals with hypomania do not experience significant impairment, whereas mania is unmistakably disabling. Patients exist between these extremes, with protracted hypomanic periods, which cause some trouble to the patient and significant others without reaching the destructive potential that is almost always the case with the extreme excitement of full-blown manic psychosis.

This 45-year-old never-married man presented because of

BIPOLAR II: DEPRESSION WITH HYPOMANIA

Bipolar II patients by definition have moderately to severely impairing major depressions, interspersed with hypomanic periods of at least 4 days' duration without marked impairment. Signs and symptoms of a hypomanic episode represent a departure from the patient's habitual baseline and are summarized in Table 1.⁸

Although behavior is colored by the elated mood, confidence, and optimism, judgment is relatively preserved compared with mania. Nonetheless, the cyclic course of the disease may

BIPOLAR II½: CYCLOTHYMIC DEPRESSIONS

According to the DSM-IV schema, bipolar II patients must have clinical depression with hypomania of 4 days' duration or longer. Current research indicates that the more modal distribution for hypomania is 1 to 3 days.⁴ This means that a great many soft bipolar patients do not meet the strict DSM-IV criteria for bipolar II disorder. Patients with short hypomania often have a recurrent pattern of periods of excitement, which are followed by minidepressions, thereby fulfilling the criteria for

BIPOLAR III: ANTIDEPRESSANT-ASSOCIATED HYPOMANIA

Many patients with spontaneous hypomanic and manic episodes also often develop these episodes during antidepressant treatment. This process is often mediated by cyclothymic temperamental tendencies,⁸ of which hypomania is a natural expectation. This process appears quite different from clinically depressed patients, who experience hypomania only during antidepressant treatment. Clinical observations suggest that many of these patients have a depressive temperament or, to use DSM-IV language,

BIPOLAR III½: BIPOLARITY MASKED—AND UNMASKED—BY STIMULANT ABUSE

In bipolar disorder types I and II, there are discrete episodes of excitement of manic and hypomanic intensity; in type III, the occurrence of these episodes is in association with antidepressant use as well as other somatic treatment. There are also patients whose periods of excitement are so closely linked with substance or alcohol use and abuse that it is not always easy to decide whether these periods would have occurred in the absence of such use and abuse. In these cases that the authors

BIPOLAR IV: HYPERTHYMIC DEPRESSION

For this category, we propose patients with clinical depression that occurs later in life and superimposed on a lifelong hyperthymic temperament.³ The attributes of a hyperthymic temperament are not episode-bound and constitute part of the habitual long-term functioning of the individual (Table 4). Patients are typically men in their 50s whose lifelong drive, ambition, high energy, confidence, and extroverted interpersonal skills helped them to advance in life, to achieve successes in a variety

CONCLUSIONS

This article has emphasized the depressive manifestations of a range of bipolar conditions, which are best regarded as pseudo-unipolar.2, 5 We have not considered the severe psychotic end of bipolar disorder¹¹ nor have we presented the emerging fascinating data about the offspring of bipolar parents.⁷ The main thesis of this article has been that many major depressions in the DSM-IV schema are, in reality, part of the bipolar spectrum. Skeptics should examine a classic NIMH study by Gershon et

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Reward sensitivity and social rhythms during goal-striving: An ecological momentary assessment investigation of bipolar spectrum disorders
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The reward/circadian rhythm model of bipolar spectrum disorders (BSDs) posits that when individuals with hypersensitive reward systems encounter reward-relevant events, they experience social and circadian rhythm disruption, leading to mood symptoms. The aim of the current study is to test an element of this theoretical model by investigating changes in social rhythms during and after an ecologically-valid reward-relevant event and evaluating whether the strength of these associations differ by trait reward sensitivity and BSD diagnostic group.
Young adults from three groups (low BSD risk with moderate reward sensitivity [MRew], high BSD risk with high reward sensitivity [HRew], and high reward sensitivity with BSD [HRew+BSD]) completed a reward responsiveness task and 20-day ecological momentary assessment study structured around a participant-specific goal occurring on day 15. Social rhythm disruption (SRD) and social rhythm regularity (SRR) were assessed daily. Multilevel models examined whether reward sensitivity and group moderated associations between study phase (baseline [days 1–5], goal-striving [days 16–20], or outcome [days 16–20]) and social rhythms.
Participants experienced greater SRD after the goal-striving event during the outcome phase, compared to the baseline phase. The HRew+BSD group had significant decreases in SRR during the outcome phase, and this pattern differed significantly from the low-risk and high-risk groups. Greater task reward responsiveness also was associated with significant decreases in SRR during the outcome phase.
This study did not test whether social rhythm irregularity was associated with subsequent mood change.
Participants exhibited social rhythm changes over the course of this ecologically valid goal-striving period, providing evidence for the interplay between reward-activating events and social rhythms. The HRew+BSD group showed a distinct pattern in which their social rhythms were more irregular after completing reward-relevant goal-striving that was not observed for the low-BSD risk or high-BSD risk groups. These findings provide additional support for Interpersonal and Social Rhythms Therapy.
Eveningness chronotype and depressive affective temperament associated with higher high-sensitivity C-reactive protein in unipolar and bipolar depression
2023, Journal of Affective Disorders
Several studies investigated the role of inflammation in the etiopathogenesis of mood disorders. The aim of our cross-sectional study is evaluating baseline high-sensitivity C-reactive-protein (hsCRP) levels in a cohort of unipolar and bipolar depressive inpatients, in relation with psychopathological, temperamental and chronotype features.
Among 313 screened inpatients, we retrospectively recruited 133 moderate-to-severe depressive patients who were assessed for hsCRP levels, chronotype with Morningness-Eveningness Questionnaire (MEQ) and affective temperament with Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS).
The cross-sectional and retrospective design of the study, the small sample size, the exclusion of hypomanic, maniac and euthymic bipolar patients.
hsCRP levels were significantly higher among those with previous suicide attempt (p = 0.05), death (p = 0.018) and self-harm/self-injury thoughts (p = 0.011). Linear regression analyses, adjusted for all covariates, demonstrated that higher scores at the TEMPS-M depressive, while lower scores at the hyperthymic and irritable affective temperaments [F = 88.955, R² = 0.710, p < 0.001] and lower MEQ scores [F = 75.456, R² = 0.405, p < 0.001] statistically significantly predicted higher hsCRP.
Eveningness chronotype and a depressive affective temperament appeared to be associated with higher hsCRP levels during moderate-to-severe unipolar and bipolar depression. Further longitudinal and larger studies should better characterise patients with mood disorders by investigating the influence of chronotype and temperament.
The assessment of cyclothymic-hypersensitive temperament in youth with mood disorders and attention deficit hyperactivity disorder
2022, Journal of Affective Disorders
Cyclothymic-hypersensitive temperament (CHT) has been related to both depression and bipolarity, as well as to suicidality. Recently, a psychometrically sound way of assessment has been validated in youth (Cyclothymic-Hypersensitive Temperament Questionnaire, CHTQ), but data on clinical populations are still scant. Aim of our study is to further explore the structure and other psychometric properties of the revised version of CHTQ and its clinical implications in clinical samples.
The study is based on a dataset of patients with unipolar depression, bipolar disorder and attention deficit and hyperactivity disorder (ADHD) (243 patients, 135 males, mean age 14.22 ± 2.16 years, age range 9–18 years), compared to a community sample of adolescents (398 subjects, 95 boys, mean age 15.47 ± 1.96 years, age range 10–18 years)
The two-correlated factor structure of CHT has been confirmed, with a moodiness/hypersensitiveness factor, correlated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, correlated with externalizing symptoms. All CHTQ scores correlate with global functioning. CHTQ total scores discriminate patients from healthy controls. Only CHTQ impulsiveness/emotional dysregulation subscale score is higher in bipolar patients, compared to unipolar depression and ADHD, whereas neither CHTQ moodiness/hypersensitiveness subscale score nor CHTQ total score discriminate between clinical groups.
Data on current mood states are unavailable. Patients were recruited in a third level clinic. The unipolar depression group is relatively small.
CHT may be a rapid and reliable screening and diagnostic tool in the clinical practice with youth, exploring the cyclothymic dimension in different psychiatric disorders.
A piece of the puzzle: Does bipolarity partly explain the high prevalence of treatment resistance in depression?
2022, Psychiatry Research
In this cross-sectional study we examined whether the prevalence of treatment resistant depression (TRD) can be partly attributed to level of bipolarity. We included data of 201 patients with either episodic depression or TRD, who received treatment for their depression at either an outpatient or 2nd opinion/daytime setting, within a specialised mental healthcare department in the Netherlands. Whether level of TRD, assessed by the ‘Dutch Measure for quantification of Treatment Resistance in Depression’, can be partly explained by level of bipolarity, assessed by ‘the Bipolarity Index’, was examined using linear regression.
We found no direct association between level of TRD and level of bipolarity, nor did comorbid anxiety disorders obscure an existing association.
In this study we found no evidence for overlooked bipolarity contributing to the high prevalence of TRD. If replicated, we could state that additional screening on bipolarity with an instrument such as the ‘Bipolarity Index’ in the specialised mental health care is unnecessary.
Transitions: Hagop Souren Akiskal
2021, Journal of Affective Disorders
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: Address reprint requests to Hagop S. Akiskal, MD, Department of Psychiatry, University of California at San Diego, 9500 Gilman Drive, La Jolla, CA 92093–0603, e-mail: [email protected]

^*: International Mood Center, Department of Psychiatry, University of California at San Diego, La Jolla, California

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THE EVOLVING BIPOLAR SPECTRUM: Prototypes I, II, III, and IV

Section snippets

FROM KRAEPELIN TO DSM-V

BIPOLAR I: FULL-BLOWN MANIA

BIPOLAR I½: DEPRESSION WITH PROTRACTED HYPOMANIA

BIPOLAR II: DEPRESSION WITH HYPOMANIA

BIPOLAR II½: CYCLOTHYMIC DEPRESSIONS

BIPOLAR III: ANTIDEPRESSANT-ASSOCIATED HYPOMANIA

BIPOLAR III½: BIPOLARITY MASKED—AND UNMASKED—BY STIMULANT ABUSE

BIPOLAR IV: HYPERTHYMIC DEPRESSION

CONCLUSIONS

Psychiatr Clin North Am

Psychiatr Clin North Am

J Affect Disord

J Affect Disord

J Affect Disord

J Affect Disord

Compr Psychiatry

J Affect Diord

J Affect Disord

Compr Psychiatry

J Am Acad Child Adolesc Psychiatry

Compr Psychiatry

Psychiatry Res

J Affect Disord

J Affect Disord

The bipolar spectrum: New concepts in classification and diagnosis

Delineating irritable-choleric and hyperthymic temperaments as variants of cyclothymia

J Pers Disord

The prevalent clinical spectrum of bipolar disorders: Beyond DSM-IV

J Clin Psychopharmacol

Re-assessing the prevalence of bipolar disorders: Clinical significance and artistic creativity

Psychiatr Psychobiol

Affective disorders in referred children and younger siblings of manic depressives: Mode of onset and prospective course

Arch Gen Psychiatry

Criteria for the “soft” bipolar spectrum: Treatment implications

Psychopharmacol Bull

Switching from “unipolar” to “bipolar II”: An 11-year prospective study of clinical and temperamental predictors in 559 patients

Arch Gen Psychiatry

Psychotic forms of depression and mania

Psychiatr Clin North Am

Differentiation of primary affective illness from situational, symptomatic, and secondary depressions

Arch Gen Psychiatry