What lies between hypomania and bipolar disorder? A qualitative analysis of 12 non‐treatment‐seeking people with a history of hypomanic experiences and no history of major depression

This study presents the thoughts of a group of 12 individuals over 30 years of age with a history of hypomanic experiences using the qualitative method: Interpretative Phenomenological Analysis. These individuals were specifically selected on the basis of a self‐reported history of hypomanic experiences (according to the mood disorder questionnaire, MDQ), and screened to rule out a history of mania or major depression, and therefore not fulfilling the criteria for bipolar I or II disorders. Thus, the current participants represent a unique sample of individuals, previously underreported in the literature. The aim of the interview was to determine the protective factors or characteristics which may prevent such individuals from experiencing hypomanic experiences that significantly disrupt their level of functioning. Three clusters of emergent themes emerged in the interviews: ‘positive qualities of hypomanic experiences’, ‘the social meaning of hypomanic experiences’, and ‘having hypomanic experiences is not a problem’. The responses to several interview questions are also provided, which highlight the situations preceding hypomanic experiences, possible explanations for their experiences not going out of control, and typical responses of other people to the participants' behaviour. Findings are discussed in relation to a recent cognitive model of bipolar disorder and mood swings.     

Combined Psychotherapy and Pharmacotherapy for Mood and Anxiety Disorders in Adults: Review and Analysis

Studies suggest a complex relationship between cognitive-behavior therapy (CBT) and pharmacotherapy for the combined treatment of mood disorders and anxiety disorders. Combined treatment for depression may have beneficial effects when applied to patients with chronic depression and in cases to prevent relapse. In bipolar disorder there is evidence for a strong effect of psychosocial treatment on the course of the disorder. In the anxiety disorders, there are some benefits in the short term, but combined treatment may limit the maintenance of treatment gains offered by CBT alone. Combined treatment should not be considered the default treatment for mood and anxiety disorders, with the possible exception of bipolar disorder. Instead, decisions whether combined treatment is worth the added cost and effort should be made in relation to the disorder under treatment, the level of severity or chronicity, and the stage of treatment (e.g., acute vs. relapse prevention).     

Cyclothymic disorder: a critical review

Cyclothymic disorder is a subtype of bipolar disorder included in the Diagnostic and Statistical Manual of Mental Disorders since 1980, but largely neglected in research. Additionally, it is rarely diagnosed clinically, in spite of evidence that it may be the most prevalent form of bipolar disorder. Neglect has contributed to confusion about the diagnosis and clinical presentation of cyclothymic disorder. Its status as a mood disorder is also ambiguous due to overlap in terminology and symptoms with temperament and personality disorders. Subthreshold bipolar disorder appears more prevalent among young people than previously thought, and follows a range of trajectories from remission to escalation-raising questions about risk factors and traits associated with the varied course. Cyclothymic disorder may be an important diathesis for major mood disorders. Constructs such as cyclothymic disorder link major mood disorder and peri-clinical fluctuations of mood, thus warranting a prominent role in dimensional models of mood and psychopathology. Current evidence indicates that cyclothymic disorder is a prevalent and highly impairing disorder on the bipolar spectrum, with the potential to make unique contributions to our understanding of the risk factors and outcomes associated with bipolar disorder. The inclusion of cyclothymic disorder in future research studies is essential to accurate diagnosis and effective treatment for the full spectrum of bipolar disorder, as well as understanding the developmental trajectory of bipolar spectrum disorders.     

Bipolar depression: diagnostic and treatment considerations

Bipolar affective disorder is a recurrent, disabling, and potentially lethal illness that typically begins early in life. Although the disorder is defined by the manic and hypomanic episodes, for most people the depression episodes are the more virulent aspect of the illness. Specifically, the depressive episodes are more numerous, last longer, and are more difficult to treat than the manias, and depression is the principal cause of the illness's increased mortality due to suicide. For people with early-onset depression, predictors of subsequent bipolarity include a family history, psychotic features, and reverse neurovegetative features. Initial episodes of depression are commonly misdiagnosed, which often delays initiation of appropriate therapy and increases the likelihood of treatment with antidepressants alone. Unfortunately, the correct diagnosis is often not made until there has been a treatment-emergent affective switch. There are no treatments specifically approved for bipolar disorder in youth and, among antidepressants, only fluoxetine has received approved. When bipolarity is suspected, treatment with mood stabilizers, both conventional (i.e., lithium, valproate, and carbamazapine) and more recently classified (lamotrigine) and atypical antipsychotics should be prioritized. When antidepressants are indicated in combination with mood stabilizers, first choice options include bupropion and the selective serotonin reuptake inhibitors. Studies of adults indicate that several forms of focused psychotherapy may improve longer term outcomes.     

The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder

BACKGROUND: The relationship between anxiety and depressive disorders has been conventionally limited to unipolar depression. Recent studies from both clinical and epidemiologic samples have revealed intriguing associations between anxiety and bipolar (mainly bipolar II) disorders. The present report examines the temporal sequence of hypomania to panic (PD), obsessive-compulsive (OCD) and social phobic (SP) disorders. METHODS: Specialty-trained clinicians retrospectively evaluated the foregoing relationships in 63 patients meeting the DSM-III-R diagnosis for PD, OCD and SP with lifetime comorbidity with bipolar disorders (87% bipolar II). Structured interviews were used. RESULTS: In nearly all cases, SP chronologically preceded hypomanic episodes and disappeared when the latter episodes supervened. By contrast, PD and OCD symptomatology, even when preceding hypomanic episodes, often persisted during such episodes; more provocatively, nearly a third of all onsets of panic attacks were during hypomania. LIMITATIONS: Assessing temporal relationships between hypomania and specific anxiety disorders on a retrospective basis is, at best, of unknown reliability. The related difficulty of ascertaining the extent to which past antidepressant treatment of anxiety disorders could explain the anxiety-bipolar II comorbidity represents another major limitation. CONCLUSIONS: Different temporal relationships characterized the occurrence of hypomania in individual anxiety disorder subtypes. Some anxiety disorders (notably SP, and to some extent OCD) seem to lie on a broad affective continuum of inhibitory restraint vs. disinhibited hypomania. By contrast, and more tentatively, PD in the context of bipolar disorder, might be a reflection of a dysphoric manic or mixed hypomanic symptomatology. The foregoing suggestions do not even begin to exhaust the realm of possibilities. The pattern of complex relationships among these disorders would certainly require better designed prospective observations.     

Bipolar mood disorders among Polish psychiatric outpatients treated for major depression

BACKGROUND: Significant proportion of patients treated for depression may have various types of bipolar mood disorders. The aim of the study was to assess the frequency of bipolar disorders among outpatients having at least one major depressive episode, treated by 96 psychiatrists, representing all regions of Poland. METHODS: The study included 880 patients (237 male, 643 female), identified to following diagnostic categories: bipolar I, bipolar II, bipolar spectrum disorder and major depressive disorder. RESULTS: Bipolar mood disorders were found in 61.2% of patients studied, bipolar I more frequent in men and bipolar II in women, and bipolar spectrum in 12% of patients. Patients with age ranges 19-49 and 50-65 years did not differ as to the percentage of diagnostic categories. Patients with bipolar mood disorders compared to major depressive disorder had significantly more frequent family history of bipolar disorder, premorbid hyper- or cyclothymic personality, early onset of depression, symptoms of hypersomnia and hyperphagia, psychotic depression, post-partum depression, and treatment-resistant depression. Bipolar spectrum patients had most clinical features similar to classic types of bipolar disorders. LIMITATIONS: Neither structured interview for family history, nor formal criteria for a number of clinical manifestations were used. The population treated by psychiatrists may not be representative and present a subgroup with more severe mood disorders. CONCLUSIONS: Bipolar mood disorders may be very prevalent among depressive outpatients treated by psychiatrists in Poland, which is confirmed by the results of recent studies. Bipolar patients (including bipolar spectrum) significantly differ from major depressive disorder as to numerous clinical features related mostly to depressive episode.     

The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology.

Failure to recognize subthreshold expressions of mania contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive ones. These include the lack of subjective suffering, enhanced productivity, ego-syntonicity, and diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' tendency to subsume persistent or even alternating symptoms among personality disorders. Furthermore, the central diagnostic importance placed on alterations in mood distracts clinicians from paying attention to other more subtle but clinically meaningful symptoms, such as changes in energy, neurovegetative symptoms and distorted cognitions. Although officially accepted in both ICD-10 and DSM-IV, we believe bipolar II disorder is underdiagnosed because of inattention to symptoms of hypomania. Moreover, by requiring the presence of both full-blown hypomanic and major depressive episodes, current nosology fails to include symptoms or signs which are mild and do not meet threshold criteria. There is already agreement in the field that such symptoms are important for depression. We now propose that attention should also be devoted to mild symptomatic manifestations of a manic diathesis, even if such manifestations may sometimes enhance quality of life. The term 'spectrum' is used to refer to the broad range of such manifestations of a disorder from core symptoms to temperamental traits. Spectrum manifestations may be present during, between, or even in the absence of, an episode of full-blown disorder. We have developed a structured clinical interview to assess the mood spectrum (SCI-MOODS) to evaluate the whole range of depressive and manic symptoms. This instrument is currently undergoing psychometric testing procedures. Similar to the SCID interview, the SCI-MOODS interview provides a separate rating for each of the major DSM-IV symptoms, but the latter also identifies and rates subthreshold and atypical manifestations. This paper presents the concept of a subthreshold bipolar disorder and discusses the potential epidemiological, diagnostic and therapeutic relevance of such a spectrum conditions. We also describe the SCI-MOODS interview used reliably to identify the occurrence of a bipolar spectrum condition. Obviously a great deal of systematic research needs to be conducted to ascertain the reliability and validity of subthreshold bipolarity as summarized in this paper and embodied in our instrument.     

Is there a continuity between bipolar and depressive disorders?

BACKGROUND: Recent studies questioned the current categorical split of mood disorders into bipolar disorders (BP) and depressive disorders (MDD). METHODS: Medline database search of papers from the last 10 years on the categorical-dimensional classification of mood disorders. Various combinations of the following key words were used: mood disorders, bipolar, unipolar, major depressive disorder, spectrum, category/categorical, classification, continuity. Only English language clinical papers were included, review papers were excluded, similar papers selected by quality. The number of papers found was 1,141. The number of papers selected was 109. RESULTS: The continuity/spectrum between BP (mainly BP-II) and MDD was supported by the following findings:(1) high frequency of mixed states (mixed mania, mixed hypomania, mixed depression, i.e. co-occurring depression and noneuphoric manic/hypomanic symptoms) because opposite polarity symptoms in the same episode do not support a hypomania/mania-depression splitting; (2) MDD was the most common mood disorder in BP probands' relatives; (3) no bimodal distribution of distinguishing symptoms between BP and MDD; (4) bipolar signs not uncommon in MDD; (5) many MDD shifting to BP; (6) many lifetime manic/hypomanic symptoms in MDD; (7) correlation between lifetime manic/hypomanic symptoms and MDD symptoms; (8) hypomania factors in MDD; (9) MDD often recurrent; (10) similar cognitive style.The categorical distinction between BP (mainly BP-I) and MDD was supported by the following findings: (1) BP more common in BP probands' relatives; (2) lower age at BP onset; (3) females as common as males in BP-I, more common than males in MDD; (4) BP-I depression more atypical and retarded, MDD depression more sleepless and agitated; (5) BP more recurrent. CONCLUSIONS: Focusing on mood spectrum's extremes (BP-I vs. MDD), a categorical distinction seems supported. Focusing on midway disorders (BP-II and MDD plus bipolar signs), a continuity/spectrum seems supported. Results seem to support both a categorical and a dimensional view of mood disorders.     

Treatment resistance in unipolar depression: Is it an iatrogenic phenomenon caused by antidepressant treatment of patients with a bipolar diathesis?

Major depressive disorder is a common psychiatric illness that is considered generally treatable; however, there are some patients who fail to respond in spite of adequate trials of antidepressants. Clinical factors known to contribute to treatment resistance include psychiatric and physical comorbidity, undiagnosed bipolarity, and treatment non-adherence. There is also emerging evidence that the use of antidepressants in some 'unipolar' patients may lead to a pattern of progressive diminution of therapeutic response and ultimately treatment resistance. A large number of these patients may have a bipolar diathesis even though there are no symptoms of hypomanic, manic or mixed episodes. It is hypothesized that the widespread and injudicious use of antidepressants in patients with a bipolar diathesis might result in treatment-induced resistant depression. Furthermore, attempts to manage the antidepressant-led mood instability might cause increased utilisation of other psychotropic drugs including sedative/hypnotics, neuroleptics and mood stabilisers and contribute to polypharmacotherapy.     

Bipolar spectrum disorders in severely obese patients seeking surgical treatment

BACKGROUND: Much of the literature investigating the link between mood disorders and obesity has focused on depression whereas historic polarity of mood has not been previously carefully assessed. The aim of the present study has been to evaluate the prevalence of the entire bipolar spectrum, by including subsyndromal hypomania, and its related demographic and clinical correlates, in severely obese patients seeking surgical treatment. METHODS: Eighty-three consecutive bariatric patients who presented for presurgical psychiatric consultation were systematically interviewed with both the SCID-CV questionnaire and, as a self-assessment instrument, with the Hypomania Symptom Checklist (HCL-32) on all past hypomanic behaviours (focusing more on prior overactivity than on mood changes) regardless of duration and initial negative response to the screening question on mood. RESULTS: A bipolar spectrum disorder was found in 89% of severely obese patients, with the highest prevalence rates for bipolar II disorder. Comorbidity with panic disorder was observed in 30% of bipolar spectrum patients. LIMITATIONS: The lack of normal-weight or general medical control groups and the reliance on self-report, retrospective assessment for the collection of some parameters warrant some caution in the interpretation of substantive findings. CONCLUSIONS: These findings suggest that bipolar spectrum illness, in particular a hypomanic condition characterized by overactivity, is very common in severely obese subjects, thus contradicting previous evidence of low levels of physical activity in this population. Given the high prevalence rates of bipolar spectrum in morbid obesity, this study encourages further research on the causal association.     

Core beliefs and narcissistic characteristics among eating‐disordered and non‐clinical women

Objectives . Narcissism is a personality trait that can interfere with the application of evidence‐based therapies for the eating disorders, influencing collaboration and the patient's willingness to take responsibility for participating in change. In order to understand and work with this personality characteristic, it is important to understand the cognitions that underpin the traits concerned. Design . This study examined the associations between schema‐level core beliefs and narcissism in eating disorders. Narcissism was conceptualized in terms of both its core element (entitlement and grandiosity) and the narcissistic defences (‘bad you’ and ‘poor me’ attitudes). Methods . Validated measures of the different elements of narcissism and of core beliefs were completed by 80 eating‐disordered patients and 70 non‐clinical comparison women. Multiple regression analyses were used to determine the core beliefs associated with each aspect of narcissism. Results . The pattern of association differed across the two groups. Among the eating‐disordered women, different core beliefs were associated with core narcissism and with each of the two defences. Conclusions . Unconditional schema‐level beliefs are associated with narcissistic personality traits in the eating disorders suggesting that these therapy‐interfering personality characteristics might be addressed by modifying the relevant core beliefs, thus making it possible to work more directly with the eating disorder itself.     

Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders

Until recently it was believed that no more than 1% of the general population has bipolar disorder. Emerging transatlantic data are beginning to provide converging evidence for a higher prevalence of up to at least 5%. Manic states, even those with mood-incongruent features, as well as mixed (dysphoric) mania, are now formally included in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of bipolar patients over a lifetime; current evidence supports a broader definition of mixed states consisting of full-blown mania with two or more concomitant depressive symptoms. The largest increase in prevalence rates, however, is accounted for by 'softer' clinical expressions of bipolarity situated between the extremes of full-blown bipolar disorder where the person has at least one manic episode (bipolar I) and strictly defined unipolar major depressive disorder without personal or family history for excited periods. Bipolar II is the prototype for these intermediary conditions with major depressions and history of spontaneous hypomanic episodes; current evidence indicates that most hypomanias pursue a recurrent course and that their usual duration is 1-3 days, falling below the arbitrary 4-day cutoff required in DSM-IV. Depressions with antidepressant-associated hypomania (sometimes referred to as bipolar III) also appear, on the basis of extensive international research neglected by both ICD-10 and DSM-IV, to belong to the clinical spectrum of bipolar disorders. Broadly defined, the bipolar spectrum in studies conducted during the last decade accounts for 30-55% of all major depressions. Rapid-cycling, defined as alternation of depressive and excited (at least four per year), more often arise from a bipolar II than a bipolar I baseline; such cycling does not in the main appear to be a distinct clinical subtype - but rather a transient complication in 20% in the long-term course of bipolar disorder. Major depressions superimposed on cyclothymic oscillations represent a more severe variant of bipolar II, often mistaken for borderline or other personality disorders in the dramatic cluster. Moreover, atypical depressive features with reversed vegetative signs, anxiety states, as well as alcohol and substance abuse comorbidity, is common in these and other bipolar patients. The proper recognition of the entire clinical spectrum of bipolarity behind such 'masks' has important implications for psychiatric research and practice. Conditions which require further investigation include: (1) major depressive episodes where hyperthymic traits - lifelong hypomanic features without discrete hypomanic episodes - dominate the intermorbid or premorbid phases; and (2) depressive mixed states consisting of few hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-blown major depressive episodes - included in Kraepelin's schema of mixed states, but excluded by DSM-IV. These do not exhaust all potential diagnostic entities for possible inclusion in the clinical spectrum of bipolar disorders: the present review did not consider cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden, intermittently explosive or agitated psychiatric conditions for which the bipolar connection is less established. The concept of bipolar spectrum as used herein denotes overlapping clinical expressions, without necessarily implying underlying genetic homogeneity. In the course of the illness of the same patient, one often observes the varied manifestations described above - whether they be formal diagnostic categories or those which have remained outside the official nosology. Some form of life charting of illness with colored graphic representation of episodes, stressors, and treatments received can be used to document the uniquely varied course characteristic of each patient, thereby greatly enhancing clinical evaluation.     

Trait impulsivity in patients with mood disorders

BACKGROUND: Impulsivity is a key component of the manic behavior of bipolar disorder and is reported to occur in bipolar patients as a stable characteristic, i.e. a trait. Nevertheless, impulsivity has not been widely studied in depressed bipolar patients. We assessed impulsivity in depressed and euthymic bipolar and unipolar patients and healthy controls. We hypothesized that bipolar subjects would have higher levels of trait impulsivity than the comparison groups. METHODS: Twenty-four depressed bipolar, 24 depressed unipolar, 12 euthymic bipolar, and 10 euthymic unipolar patients, as well as 51 healthy subjects were evaluated with the Barratt Impulsiveness Scale (BIS). Analysis of covariance with age and sex as covariates was used to compare mean group differences. RESULTS: Depressed bipolar, euthymic bipolar, and depressed unipolar patients did not differ, and showed greater impulsivity than healthy controls on all of the BIS scales. Euthymic unipolar patients scored higher than healthy controls only on motor impulsivity. LIMITATIONS: Higher number of past substance abusers in the bipolar groups, and no control for anxiety and personality disorders, as well as small sample sizes, limit the reach of this study. CONCLUSIONS: This study replicates prior findings of stable trait impulsivity in bipolar disorder patients, and extends them, confirming that this trait can be demonstrated in depressed patients, as well as manic and euthymic ones. Trait impulsivity may be the result of repeated mood episodes or be present prior to their onset, either way it would influence the clinical presentation of bipolar disorder.     

A Commentary on "Sleep Disturbance in Bipolar Disorder"

Sleep disturbances are among the most common clinical features of bipolar affective disorder and are typically present in manic, hypomanic, mixed, and depressive episodes. The processes that regulate sleep are relevant to the pathophysiology of bipolar illness and further study of these processes may help to elucidate fundamental associations with central nervous system arousal and cerebral metabolism. Among the various therapeutic interventions that are used to treat insomnia associated with bipolar affective disorder, the strategies and approaches of behavioral sleep medicine warrant greater attention.     

Self-reported data from patients with bipolar disorder: impact on minimum episode length for hypomania

OBJECTIVE: Some investigators have suggested decreasing the minimum hypomania episode length criterion from 4 days, as in the DSM-IV, to 2 days. Using daily self-reported mood ratings, we studied the impact of changing the length requirement on the number of hypomanic episodes in patients with bipolar disorder. METHOD: 203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software (30,348 total days, mean 150 days). Episodes of hypomania and days of hypomania outside of episodes were determined. RESULTS: Decreasing the minimum duration criterion for an episode of hypomania from 4 to 2 days doubled the mean percent of days in a hypomanic episode for each patient (4% to 8%), doubled the number of patients with a hypomanic episode (44 to 96) and increased the number of hypomanic episodes for all patients about three-fold (129 to 404). With a minimum episode length of 4 days, bipolar I patients were more likely to report hypomania outside episodes than bipolar II patients (p=0.010), but with a length of 2 or 3 days there was no significant difference in the distribution of hypomania outside of episodes by diagnosis. With a 2-day length, about one-third (36%) of hypomania remained outside of an episode. LIMITATIONS: Self-reported data, computer access, relatively short length, fewer bipolar II than bipolar I patients. CONCLUSION: As the minimum length for an episode of hypomania decreases, there was a large increase in both the number of episodes and number of patients with episodes. One-day hypomania outside of episodes occurs frequently in both bipolar I and bipolar II disorder.     

The high prevalence of bipolar spectrum disorders in young adults with recurrent depression: toward an innovative diagnostic framework

BACKGROUND: Young adults with early-onset major depressive disorder (MDD) may be at high risk of progression to bipolar disorder. Although hypomanic symptoms are common in young people with depression, many do not reach the strict DSM-IV and ICD-10 criteria for hypomania. We used an emerging innovative framework for bipolar spectrum to evaluate this question. METHODS: Consecutive referrals to a psychiatric outpatient clinic at a university health service were assessed for recurrent episodes of depression. DSM-IV diagnoses were based on a SCID-1 interview. We used two approaches to delineate bipolar spectrum. The first focused on bipolar spectrum disorder (BSD, as defined by Ghaemi et al. [Can. J. Psychiatry 47 (2002) 125]), and the second on a symptoms perspective based on MDD with a history of hypomanic symptoms, using a 15-point hypomanic symptoms checklist with a cut-off > or =8 or more symptoms (modified from J. Affect. Disord. 73 (2003) 39 and J. Affect. Disord. 73 (2003) 73). Data were also obtained on family history of affective disorder, course and number of episodes of depression, symptom severity, psychosocial functioning, suicidality and deliberate self-harm, and drug and alcohol use. RESULTS: High rates of bipolar and bipolar spectrum disorder were identified. Under DSM-IV, 14 subjects (16.1%) had bipolar affective disorder and 73 subjects (83.9%) had recurrent MDD. Depending on the method used to diagnose bipolar spectrum, between 47.1% and 77.0% of the total cohort could be so diagnosed. Hypomanic symptom counts, irrespective of duration, yielded the highest estimates for bipolar spectrum. High rates of pharmacological hypomania were also identified: 12 subjects (16.4%) with recurrent MDD group reported this, and all could be diagnosed with bipolar spectrum. LIMITATIONS: The reliability of using the 15-point hypomanic scale for the diagnostic assignments was not tested. All subjects were recruited from a university health service and, given the affluence of their parents, findings may not generalise to other populations. Most importantly, because bipolar family history and pharmacological hypomania were part of the diagnostic criteria of the BSD group, they could not be used as external validators for Ghaemi's BSD construct. CONCLUSIONS: Bipolar disorders emerge as extremely common in this cohort of young adults with recurrent depression. Antidepressant-induced hypomania and high scores on a hypomanic symptoms checklist help to identify patients who are likely to have a bipolar spectrum illness, but who do not meet DSM-IV criteria for bipolar disorder. This is a preliminary study, and further evidence from external validating strategies are needed to verify the bipolar status of these patients in a larger and unselected cohort representing a broader socio-economic demographic profile.     

Atypical depression with hypomanic symptoms

BACKGROUND: Depressive mixed states (major depressive episodes with some hypomanic symptoms) (DMS) are not classified in DSM-IV and are understudied. The aims of this study were to find the prevalence and clinical features of DMS in atypical depression. METHODS: A total of 87 bipolar II and unipolar depressed outpatients were interviewed within the DSM-IV Structured Clinical Interview. RESULTS: More than two hypomanic symptoms were present in 50.0% of the atypical and 20.3% of the non-atypical depression cases (P=0.006). DMS mainly included irritable mood, distractibility, racing thoughts, and increased talking. LIMITATIONS: There was a single interviewer, and it was a non-blind, cross-sectional assessment, with bipolar II reliability. CONCLUSIONS: Findings have treatment implications, as antidepressants may worsen DMS, and mood stabilizers may improve it.     

Affective temperaments: Unique constructs or dimensions of normal personality by another name?

Background

Current models theorize that affective temperaments underlie the development and expression of mood psychopathology. Recent studies support the construct validity of affective temperaments in clinical and non-clinical samples. However, one concern is that affective temperaments may be describing characteristics that are better captured by models of normal personality. We conducted two studies examining: (a) the association of affective temperaments with domains and facets of normal personality, and (b) whether affective temperaments accounted for variance in mood symptoms and disorders, impairment, and daily-life experiences over-and-above variance accounted for by normal personality.

Methods

Study 1 included 522 young adults who completed the TEMPS-A and the NEO-PI-3. Study 2 included 145 participants who were administered the TEMPS-A, NEO-FFI, interviews assessing psychopathology and impairment, and an assessment of daily life experiences.

Results

Study 1 revealed that personality domains and facets accounted for one-third to one-half of the variance in affective temperaments. However, study 2 demonstrated that affective temperaments accounted for unique variance in measures of psychopathology, impairment, and daily-life experiences after partialling variance associated with personality domains. Specifically, cyclothymic/irritable temperament predicted bipolar disorders, impairment, borderline personality traits, urgency, and anger in daily life. Hyperthymic temperament predicted hypomanic episodes, grandiosity, sensation seeking, and increased activity in daily life.

Limitations

The study was limited by the fact that only domain, not facet-level, measures of FFM were available in study 2.

Conclusions

The findings support the validity of hyperthymic and cyclothymic/irritable temperaments as indicators of clinical psychopathology and indicate that they provide information beyond normal personality.