“Double bipolar disorder”: A separate entity? (original) (raw)
Journal of Affective Disorders, 2003
Objective: Recent data, including our own, indicate significant overlap between atypical depression and bipolar II. Furthermore, the affective fluctuations of patients with these disorders are difficult to separate, on clinical grounds, from cyclothymic temperamental and borderline personality disorders. The present analyses are part of an ongoing Pisa-San Diego investigation to examine whether interpersonal sensitivity, mood reactivity and cyclothymic mood swings constitute a common diathesis underlying the atypical depression-bipolar II-borderline personality constructs. Method: We examined in a semi-structured format 107 consecutive patients who met criteria for major depressive episode with DSM-IV atypical features. Patients were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL-90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features as well as Axis I and SCID-II evaluated Axis II comorbidity, and cyclothymic dispositions ('APA Review', American Psychiatric Press, Washington DC, 1992). Results: Seventy-eight percent of atypical depressives met criteria for bipolar spectrum-principally bipolar II-disorder. Forty-five patients who met the criteria for cyclothymic temperament, compared with the 62 who did not, were indistinguishable on demographic, familial and clinical features, but were significantly higher in lifetime comorbidity for panic disorder with agoraphobia, alcohol abuse, bulimia nervosa, as well as borderline and dependent personality disorders. Cyclothymic atypical depressives also scored higher on the ADDS items of maximum reactivity of mood, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the interpersonal sensitivity, phobic anxiety, paranoid ideation and psychoticism of the HSCL-90 factors. The total number of cyclothymic traits was significantly correlated with 'maximum' reactivity of mood and interpersonal sensitivity. A significant correlation was also found between interpersonal sensitivity and 'usual' and 'maximum' reactivity of mood. Limitation: Correlational study. Conclusions: Mood lability and interpersonal sensitivity traits appear to be related by a cyclothymic temperamental diathesis which, in turn, appears to underlie the complex pattern of anxiety, mood and impulsive disorders which atypical depressive, bipolar II and borderline patients display clinically. We submit that conceptualizing these constructs as being related will make patients in this realm more accessible to pharmacological and psychological interventions geared to their common temperamental attributes. More generally, we submit that the construct of borderline personality disorder is better covered by more conventional diagnostic entities.
Examining the Validity of Cyclothymic Disorder in a Youth Sample: Replication and Extension
Journal of Abnormal Child Psychology, 2013
Background-Four subtypes of bipolar disorder (BP) -bipolar I, bipolar II, cyclothymia and bipolar not otherwise specified (NOS) -are defined in DSM-IV-TR. Though the diagnostic criteria for each subtype are intended for both adults and children, research investigators and clinicians often stray from the DSM when diagnosing pediatric bipolar disorder (PBD) (Youngstrom, 2009), resulting in a lack of agreement and understanding regarding the PBD subtypes. Robins and Guze (1970) to systematically evaluate cyclothymic disorder as a distinct diagnostic subtype of BP. Using a youth (ages 5-17) outpatient clinical sample (n=827), participants with cyclothymic disorder (n=52) were compared to participants with other BP spectrum disorders and to participants with non-bipolar disorders.
Clinical configuration of cyclothymic disturbances
Journal of Affective Disorders, 2012
Objective: While there is an increasing recognition of the role of subthreshold symptomatology in bipolar disorder, little attention has been dedicated to its only formally acknowledged subtype, cyclothymic disorder. The aim of this investigation was to provide a controlled evaluation of DSM-IV cyclothymic disorder by using a broad assessment strategy geared to subclinical signs. Methods: Sixty-two patients who met the DSM-IV criteria for cyclothymic disorder and did not present comorbidity with other mood disorders, alcohol and drug abuse, and borderline personality disorder and 62 control subjects matched for sociodemographic variables were administered the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR), the Clinical Interview for Depression (CID) and the Mania Scale (MAS). Results: In DSM-IV terms, there was an overlap with anxiety disorders in more than half of the cases. About 3 patients out of 4 were found to present with at least one DCPR syndrome (particularly demoralization and irritable mood). Cyclothymic patients displayed significantly higher levels of depressive and anxiety disturbances on the CID, with particular reference to reactivity to social environment. They also had significantly higher scores on the MAS. Limitations: The study was cross-sectional and the sample, because of the exclusion criteria, may not be representative of the clinical populations in psychiatric settings. Conclusion: In our patients with cyclothymia, without comorbidity with major mood disorders, DSM-IV anxiety disorders, psychosomatic clinical syndromes (irritable mood, demoralization) and subclinical symptoms such as reactivity to social environment resulted to be more frequent than in controls. The use of a broad assessment strategy aimed at subclinical symptomatology may help identifying clinical phenomena that cut across the current definition of subthreshold forms of bipolar disorder.
Examining the validity of cyclothymic disorder in a youth sample
International Clinical Psychopharmacology, 2011
Background-Four subtypes of bipolar disorder (BP)-bipolar I, bipolar II, cyclothymia and bipolar not otherwise specified (NOS)-are defined in DSM-IV-TR. Though the diagnostic criteria for each subtype are intended for both adults and children, research investigators and clinicians often stray from the DSM when diagnosing pediatric bipolar disorder (PBD) (Youngstrom, 2009), resulting in a lack of agreement and understanding regarding the PBD subtypes. Methods-The present study uses the diagnostic validation method first proposed by Robins and Guze (1970) to systematically evaluate cyclothymic disorder as a distinct diagnostic subtype of BP. Using a youth (ages 5-17) outpatient clinical sample (n=827), participants with cyclothymic disorder (n=52) were compared to participants with other BP spectrum disorders and to participants with non-bipolar disorders. Results-Results indicate that cyclothymic disorder shares many characteristics with other bipolar subtypes, supporting its inclusion on the bipolar spectrum. Additionally, cyclothymia could be reliably differentiated from non-mood disorders based on irritability, sleep disturbance, age of symptom onset, comorbid diagnoses, and family history. Limitations-There is little supporting research on cyclothymia in young people; these analyses may be considered exploratory. Gaps in this and other studies are highlighted as areas in need of additional research. Conclusions-Cyclothymic disorder has serious implications for those affected. Though it is rarely diagnosed currently, it can be reliably differentiated from other disorders in young people. Failing to accurately diagnose cyclothymia, and other subthreshold forms of bipolar disorder, contributes to a significant delay in appropriate treatment and may have serious prognostic implications.
Journal of Affective Disorders, 2008
Background: Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders. Methods: The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya`s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour. Results: Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR) = 1.58 (95% CI 1.15-2.18) and DES-T OR = 1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n = 30) and without an affective temperament (n = 35): mean (95% CI), 13.5 vs. 10.5 (−7.8 to 1.9), p = 0.224. However the subgroup with a cyclothymic temperament (n = 18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p = 0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n = 35) or without (n = 28) a Type A behaviour pattern (JAS N 0): mean (95% CI) 12. 7 vs. 10.9 (−6.8 to 3.3), p = 0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p = 0.017), and this was still significant (p = 0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n = 9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p b 0.001); eating disorder (n = 13) (14.0 vs. 6.8 (1.8-12.6), p = 0.009), psychotic symptoms during depressions (n = 9) (16.6 vs. 6.9 (3.7-15.8), p = 0.002), and in those with a history of suicide attempt (n = 28) (11.9 vs. 5.4 (2.2-10.8), p = 0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p = 0.043). Limitations: The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status.
Bipolar II disorder and comorbidity
Comprehensive Psychiatry, 2000
The validity and reliability of the diagnosis of bipolar II disorder has been questioned by means of comorbidity with nonaffective disorders, including substance abuse, personality disorders, and anxiety disorders. This study examined the comorbid diagnosis of a sample of bipolar II patients, comparing patients with comorbidity and those with ''pure'' bipolar II disorder.
World psychiatry : official journal of the World Psychiatric Association (WPA), 2011
The constructs of atypical depression, bipolar II disorder and borderline personality disorder (BPD) overlap. We explored the relationships between these constructs and their temperamental underpinnings. We examined 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features. Those who also met the DSM-IV criteria for BPD (BPD+), compared with those who did not (BPD-), had a significantly higher lifetime comorbidity for body dysmorphic disorder, bulimia nervosa, narcissistic, dependent and avoidant personality disorders, and cyclothymia. BPD+ also scored higher on the Atypical Depression Diagnostic Scale items of mood reactivity, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the Hopkins Symptoms Check List obsessive-compulsive, interpersonal sensitivity, anxiety, anger-hostility, paranoid ideation and psychoticism factors. Logistic regression revealed that cyclothymic temperame...
Journal of Affective Disorders, 2003
Background: In the present report deriving from the French national multi-site EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on the basis of cyclothymic temperament (CT). In our companion article (Hantouche et al., 2003, this issue), we found that this temperament in its self-rated version correlated significantly with hypomanic behavior of a risk-taking nature. Our aim in the present analyses is to further test the hypothesis that such patients-assigned to CT on the basis of clinical interview-represent a more ''unstable'' variant of BP-II. Methods: From a total major depressive population of 537 psychiatric patients, 493 were re-examined on average a month later; after excluding 256 DSM-IV MDD and 41 with history of mania, the remaining 196 were placed in the BP-II spectrum. As mounting international evidence indicates that hypomania associated with antidepressants belongs to this spectrum, such association per se did not constitute a ground for exclusion. CT was assessed by clinicians using a semi-structured interview based on Akiskal and Mallya (1987) in its French version; as two files did not contain full interview data on CT, the critical clinical variable in the present analyses, this left us with an analysis sample of 194 BP-II. Socio-demographic, psychometric, clinical, familial and historical parameters were compared between BP-II subdivided by CT. Psychometric measures included self-rated CT and hypomania scales, as well as Hamilton and Rosenthal scales for depression. Results: BP-II cases categorically assigned to CT (n 5 74) versus those without CT (n 5 120), were differentiated as follows: (1) younger age at onset (P 5 0.005) and age at seeking help (P 5 0.05); (2) higher scores on HAM-D (P 5 0.03) and Rosenthal (atypical depressive) scale (P 5 0.007); (3) longer delay between onset of illness and recognition of bipolarity (P 5 0.0002); (4) higher rate of psychiatric comorbidity (P 5 0.04); (5) different profiles on axis II (i.e., more histrionic, passive-aggressive and less obsessive-compulsive personality disorders). Family history for depressive and bipolar disorders did not significantly distinguish the two groups; however, chronic affective syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II scored significantly much higher on irritable-risk-taking than ''classic'' driven-euphoric items of hypomania. Conclusion: Depressions arising from a cyclothymic temperament-even when meeting full criteria for hypomania-are likely to be misdiagnosed as personality disorders. Their high familial load for affective disorders (including that for bipolar disorder) validate the bipolar nature of these ''cyclothymic depressions.'' Our data support their inclusion as a more ''unstable'' variant of BP-II, which we have elsewhere termed ''BP-II 1 / 2.'' These patients can best be *Corresponding author. VA Psychiatry Service (116-A),
Psychotherapy and Psychosomatics, 2011
Background: There is a lack of controlled studies of psychological treatment of cyclothymic disorder. The aim of this investigation was to examine the benefits of the sequential combination of cognitive behavioral therapy (CBT) and well-being therapy (WBT) compared to clinical management (CM) in DSM-IV cyclothymic disorder. Methods: Sixty-two patients with DSM-IV cyclothymic disorder were randomly assigned to CBT/WBT (n = 31) or CM (n = 31). Both CBT/WBT and CM consisted of ten 45-min sessions every other week. An independent blind evaluator assessed the patients before treatment, after therapy, and at 1- and 2-year follow-ups. The outcomes included total score of the change version of the Clinical Interview for Depression, and the Mania Scale. All analyses were performed on an intent-to-treat basis. Results: Significant differences were found in all outcome measures, with greater improvements after treatment in the CBT/WBT group compared to the CM group. Therapeutic gains were main...
Restructuring mood in cyclothymia using cognitive behavior therapy: an intensive time‐sampling study
Journal of clinical psychology, 2008
Hypotheses predicting how cognitive behavioral therapy (CBT) would change the daily pattern of mood and sleep in a patient with cyclothymia were formulated based on circadian processes. Using a prospective single-case experimental design, the patient provided mood ratings every 4 hours and sleep reports daily for 49 weeks, including a 4-week baseline, a 20-session CBT intervention, and a follow-up period. Improvements in mood during and after therapy were accounted for by reduced daily mood variability and extended sleep. The patient's energy at different times of day was explained by adjusting the endogenous rhythm in a mathematical circadian model. Treatment of cyclothymia and related bipolar disorders may be enhanced by integrating understanding of circadian mood regulation into CBT treatment.
Affective temperament and attachment in adulthood in patients with Bipolar Disorder and Cyclothymia
Comprehensive Psychiatry, 2014
Objective: To examine attachment and affective temperament in patients who have been diagnosed with Bipolar Disorder and to investigate possible differences in both variables among Bipolar I Disorder (BD-I), Bipolar II Disorder (BD-II), and cyclothymic patients. Methods: Ninety (45 male and 45 female) outpatients with bipolar or cyclothymic disorder between the ages of 18 and 65 years were recruited consecutively between September 2010 and December 2011 at the Bipolar Disorder Unit of the Psychiatry Day Hospital affiliated with the University General Hospital "A. Gemelli" in Rome, Italy. Patients were assessed using the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Temperament Evaluation of Memphis, Pisa, and San Diegoauto-questionnaire version, and the Experiences in Close Relationships (ECR) questionnaire applied by trained interviewers. Results: The 3 groups of patients differed only on the ECR Anxiety scores with BD-I patients having the highest anxiety levels, followed by the BD-II patients, and the patients with cyclothymic disorder reporting the lowest level of anxiety. Conclusions: This finding suggests that bipolar disorder (type I, type II) and cyclothymic/dysthymic temperament are more strongly associated with insecure attachment style as compared to the general population.
A Study of Prevalence of Psychiatric Comorbidity in Bipolar Affective Disorder Patients
https://www.ijrrjournal.com/IJRR\_Vol.6\_Issue.12\_Dec2019/Abstract\_IJRR0029.html, 2019
Background and Aim: Many studies have explored prevalence of psychiatric comorbidity in bipolar affective disorder. However, Indian studies are lacking in this area. The present study was aimed to assess prevalence of psychiatric comorbidity in bipolar affective disorder patients. Material and Methods: 100 randomly selected patients with bipolar affective disorder as per ICD-10 criteria were cross-sectionally assessed. After taking written informed consent and recording socio-demographic details, Young’s Mania Rating Scale, Hamilton Rating Scale for Depression, Mini International Neuropsychiatric Interview, Global Assessment Scale and Brief Psychiatric Rating Scale were applied. Appropriate statistical methods were used. Results: Out of 100 patients, majority were males (71%), belongs to 21-30 years (36%) and 31-40 years (23%) age group, under matric (59%), married (66%). Majority of patients were unemployed (53%) and belonged (75%) to nuclear family, from rural areas (58%). A significantly higher number of male patients were found in both groups ( 87.87% & 62.68% respectively(x2 7.04, p < 0.05), had a family income of rupees 5001-1000093.94.% & and 33.33% respectively (x27.08, p <0.05 S),history of suicide attempts 27.27% & 10.45% respectively (x2 4.45, p < 0.05 S). A significantly higher number of patients with comorbidity than without comorbidity, had more than two admissions 21.21% & 5.97% respectively (x2 4.95, p < 0.05 S),treated in ward cases 45.45% & 23.88% respectively (x2 4.73, p < 0.05 S). Majority of patients belong to Other harmful use/dependence group (54.55%) and 24.24% to Anxiety disorder. Remaining 15.15% and 6.06% belong to Alcohol harmful use/dependence and Personality disorder respectively. Conclusion: Approximately 1/3rd patients with bipolar disorder have psychiatric comorbidity, most common being substance use & dependence followed by anxiety disorders. Comorbidity in bipolar disorder worsens the prognosis and future course of illness. Management of comorbidity along with the primary disorder should be an integral part of management of patients with bipolar affective disorder.
Aile Hekimliği ve Palyatif Bakım, 2016
Introduction: This study aims to compare sociodemographic characteristics of the patients with bipolar disorder (BD) with and without comorbid dissociative disorder (DD) and to investigate the eventual effect of the comorbidity on the treatment. Methods: We enrolled a total of 149 patients diagnosed with BD and treated as inpatients consecutively in Şişli Etfal Hospital, Psychiatry Clinic between 2010 and 2011. For the patients who were diagnosed with DD using SCID-D and with BD using SCID-I, sociodemographic characteristics, YMRS, HAM-D, BPRS, DES scores and duration and number of hospital stays were evaluated. Results: 23 patients (15.4%) had dissociative disorder not otherwise specified (DD-NOS), 4 patients (2.6%) had dissociative identity disorder (DID) and 1 patient (0.6%) had dissociative amnesia. BD patients with comorbid DD were found to be predominantly female (p=0.015) and younger (p=0.002) and to have significantly higher DES scores than BD patients without DD (p<0.001). The total score of DES was correlated with duration hospital stay (p=0.001, Spearman r=0.336) in the total sample. Total HAM-D score at the time of admission was significantly higher in the comorbidity group (p=0.027), and suicide item was found to be significantly higher both at admission and at discharge (p<0.001 and p=0.035). Among BPRS scores at admission, hallucinatory behavior item was found to be higher in the comorbidity group (p=0.019). Among YMRS scores both at admission and at discharge, velocity and amount of speech item (p=0.027) and insight item at admission (p=0.006) was found to be significantly higher in the pure bipolar group (p=0.018). Conclusion: In patients with BD, DD comorbidity should be investigated. The BD patients with DD comorbidity tend to be female and younger, and show higher depression scores, leading to a prolonged hospital stay. In the presence of dissociation comorbidity, attempts and number of suicides and hallucinatory behaviors seem to be increased.
Bipolar comorbidity: from diagnostic dilemmas to therapeutic challenge
The International …, 2003
Comorbidity in bipolar disorder is the rule rather than the exception-more than 60 % of bipolar patients have a comorbid diagnosis-and is associated with a mixed affective or dysphoric state; high rates of suicidality ; less favourable response to lithium and poorer overall outcome. There is convincing evidence that rates of substance use and anxiety disorders are higher among patients with bipolar disorder compared to their rates in the general population. The interaction between anxiety disorders and substance use goes both ways: patients with bipolar disorder have a higher rate of substance use and anxiety disorder, and vice versa. Bipolar disorder is also associated with borderline personality disorder and ADHD, and to a lesser extent with weight gain. As more than 40 % of bipolar patients have anxiety disorder, it is indicated that while diagnosing bipolar patients, systematic enquiry about different anxiety disorders is called for. This also presents a therapeutic challenge, since agents that effectively treat anxiety disorders are associated with the risk of induced mania. Therefore, the treating psychiatrist needs to carefully evaluate the potential benefit of treating the anxiety against the potential cost of inducing a manic episode. A possible solution would be to use, when possible, a non-pharmacological intervention, such as a cognitive-behavioural approach. Alternately, it is suggested that the clinician attempts to ensure that the patient receives adequate treatment with mood stabilizers before slowly and carefully attempting the addition of anti-anxiety compounds with a relatively lower risk of mania induction (e.g. SSRIs compared to TCAs).
Journal of Affective Disorders, 2005
Although several recent studies suggest that bipolar disorder most commonly begins during childhood or adolescence, the illness still remains under-recognized and under-diagnosed in this age group. As part of the French Bipolar network and in line with the hypothesis that juvenile depression is pre-bipolar (Akiskal, 1993), we evaluated the rate of onset of bipolar disorders in a naturalistic 2-year prospective study of consecutive, clinically depressed children and adolescents, and to test whether the cyclothymic temperament underlies such onset. Methods: Complete information was obtained from both parents and patients in 80 of 109 depressed children and adolescents assessed with Kiddie-SADS semi-structured interview, according to DSM IV criteria. They were also assessed with a new questionnaire on cyclothymic-hypersensitive temperament (CHT) from the TEMPS-A cyclothymic scale adapted for children (provided in Appendix A), and other assessment tools including the Child Depression Inventory (CDI), Young Mania Rating Scale, Clinical Global Assessment Scale (CGAS), and Overt Aggressive Scale (OAS). Results: Of the 80 subjects, 35 (43%) could be diagnosed as bipolar at the end of the prospective follow-up. This outcome was significantly more common in those with cyclothymic temperament measured at baseline. Most of these patients were suffering from a special form of bipolar disorder, characterized by rapid mood shifts with associated conduct disorders (CD), aggressiveness, psychotic symptoms and suicidality. Limitation: The primary investigator, who took care of the patients clinically, was not blind to the clinical and psychometric data collected. Since all information was collected in a systematic fashion, the likelihood of biasing the results was minimal. Conclusion: We submit that the CHT in depressed children and adolescents heralds bipolar transformation. Unlike hypomanic or manic symptoms, which are often difficult to establish in young patients examined in cross-section or by history, cyclothymic traits 0165-0327/$ -see front matter D Journal of Affective Disorders 85 are detectable in childhood. Our data underscore the need for greater effort to standardize the diagnosis and treatment of prebipolar depressions in juvenile patients. D
Background: The aim of the present study was to assess sociodemographic and clinical differences between inpatients with major mood disorders (bipolar disorder -BDand major depression -MDD) and the cyclothymic phenotype (CYC), and pure BDs or MDDs. Methods: Participants were 281 adult inpatients (134 men and 147 women) consecutively admitted to . The patients completed the Hamilton Scale for Depression (HAMD 17 ), the Young Mania Rating Scale, the TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego-Autoquestionnaire), and the Beck Hopelessness Scale. Results: 38.7% of the MDD patients and 48.3% of the BD patients satisfied criteria to be included in the cyclothymic groups. Above 92% of the patients with the cyclothymic phenotype reported suicidal ideation at the item #3 of the HAMD 17 . Furthermore, patients with the cyclothymic phenotype reported higher hopelessness than other patients. Limitations: Our results are potentially limited by the small number of MDD-CYC patients included in the sample. Conclusions: Our results support the clinical usefulness of the concept of soft bipolar spectrum. Patients with the cyclothymic phenotype differ from pure MDD patients and BD patients for temperamental profile and clinical variables.