Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder

OBJECTIVE: To obtain a comprehensive view of differences in current comorbidity between bipolar I and II disorders (BD) and (unipolar) major depressive disorder (MDD), and Axis I and II comorbidity in BD in secondary-care psychiatric settings. METHOD: The psychiatric comorbidity of 90 bipolar I and 101 bipolar II patients from the Jorvi Bipolar Study and 269 MDD patients from the Vantaa Depression Study were compared. We used DSM-IV criteria assessed by semistructured interviews. Patients were inpatients and outpatients from secondary-care psychiatric units. Comparable information was collected on clinical history, index episode, symptom status, and patient characteristics. RESULTS: Bipolar disorder and MDD differed in prevalences of current comorbid disorders, MDD patients having significantly more Axis I comorbidity (69.1% vs. 57.1%), specifically anxiety disorders (56.5% vs. 44.5%) and cluster A (19.0% vs. 9.9%) and C (31.6% vs. 23.0%) personality disorders. In contrast, BD had more single cluster B personality disorders (30.9% vs. 24.6%). Bipolar I and bipolar II were similar in current overall comorbidity, but the prevalence of comorbidity was strongly associated with the current illness phase. CONCLUSIONS: Major depressive disorder and BD have somewhat different patterns in the prevalences of comorbid disorders at the time of an illness episode, with differences particularly in the prevalences of anxiety and personality disorders. Current illness phase explains differences in psychiatric comorbidity of BD patients better than type of disorder.     

Do mood instability symptoms in epilepsy represent formal bipolar disorder?

We aimed to assess rates of bipolar symptoms versus bipolar disorder in epilepsy, and the effect of bipolar symptoms on quality of life (QOL) in epilepsy. Bipolar, disability, and QOL instruments were administered to 99 tertiary epilepsy center patients. Patients who scored positive on the Mood Disorder Questionnaire (MDQ) also completed depression scales and a structured psychiatric interview. Results indicated MDQ+ patients (10.1%) had worse QOL and more work, social, and family life disruptions. Most MDQ+ patients did not have bipolar disorder. There was close overlap between depressive and bipolar symptomatology. Based on results of this study, bipolar symptom is not synonymous with bipolar disorder. Symptoms picked up by the MDQ may be epilepsy-related depressive symptoms. Bipolar symptoms are associated with more disability, worse QOL, and may have treatment implications.     

Revisiting depressive-prone bipolar disorder: polarity of initial mood episode and disease course among bipolar I systematic treatment enhancement program for bipolar disorder participants.

BACKGROUND: We examined the hypothesis that a first depressive rather than manic episode in bipolar disorder might herald a subsequent course notable for greater burden of depressive symptoms. METHODS: We analyzed retrospective data on the polarity of first mood episode obtained from 704 bipolar I subjects entering the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. Subjects with an initial manic or depressive episode and those in whom both poles occurred within the same year were compared. RESULTS: Depressive-onset bipolar disorder was more common in women and those with earlier onset of illness. Adjusting for these differences, it was significantly associated with more lifetime depressive episodes and a greater proportion of time with depression and anxiety in the year prior to study entry. CONCLUSIONS: Polarity of first mood episode may be useful in distinguishing subsets of bipolar patients at risk for a more chronic course.     

Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study

OBJECTIVES: To determine if bipolar disorder is accurately diagnosed in clinical practice and to assess the effects of antidepressants on the course of bipolar illness. METHOD: Charts of outpatients with affective disorder diagnoses seen in an outpatient clinic during 1 year (N = 85 with bipolar or unipolar disorders) were reviewed. Past diagnostic and treatment information was obtained by patient report and systematic psychiatric history. Bipolar diagnosis was based on DSM-IV criteria using a SCID-based interview. RESULTS: Bipolar disorder was found to be misdiagnosed as unipolar depression in 37% of patients who first see a mental health professional after their first manic/hypomanic episode. Antidepressants were used earlier and more frequently than mood stabilizers, and 23% of this unselected sample experienced a new or worsening rapid-cycling course attributable to antidepressant use. CONCLUSION: These results suggest that bipolar disorder tends be misdiagnosed as unipolar major depressive disorder and that antidepressants seem to be associated with a worsened course of bipolar illness. However, this naturalistic trial was uncontrolled, and more controlled research is required to confirm or refute these findings.     

Depressive symptomatology differentiates subgroups of patients with seasonal affective disorder

Patients with seasonal affective disorder (SAD) may vary in symptoms of their depressed winter mood state, as we showed previously for nondepressed (manic, hypomanic, hyperthymic, euthymic) springtime states [Goel et al., 1999]. Identification of such differences during depression may be useful in predicting differences in treatment efficacy or analyzing the pathogenesis of the disorder. In a cross-sectional analysis, we determined whether 165 patients with Bipolar Disorder (I, II) or Major Depressive Disorder (MDD), both with seasonal pattern, showed different symptom profiles while depressed. Assessment was by the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder Version (SIGH-SAD), which includes a set of items for atypical symptoms. We identified subgroup differences in SAD based on categories specified for nonseasonal depression, using multivariate analysis of variance and discriminant analysis. Patients with Bipolar Disorder (I and II) were more depressed (had higher SIGH-SAD scores) and showed more psychomotor agitation and social withdrawal than those with MDD. Bipolar I patients had more psychomotor retardation, late insomnia, and social withdrawal than bipolar II patients. Men showed more obsessions/compulsions and suicidality than women, while women showed more weight gain and early insomnia. Whites showed more guilt and fatigability than blacks, while blacks showed more hypochondriasis and social withdrawal. Darker-eyed patients were significantly more depressed and fatigued than blue-eyed patients. Single and divorced or separated patients showed more hypochondriasis and diurnal variation than married patients. Employed patients showed more atypical symptoms than unemployed patients, although most of the subgroup distinctions lay on the Hamilton Scale. These results comprise a set of biological and sociocultural factors-including race, gender, and marital and employment status-which contribute to depressive symptomatology in SAD. Significant mood and sociocultural factors, in contrast to biological factors of gender and eye color, were similar to those reported for nonseasonal depression. Lightly pigmented eyes, in particular, may serve to enhance photic input during winter and allay depressive symptoms in vulnerable populations.     

Insomnia symptoms predict emotional dysregulation,impulsivity and suicidality in depressive bipolar II patients with mixed features

IntroductionInsomnia symptoms are very common in Bipolar Disorder. Our aim was to assess the potential association between insomnia, emotion dysregulation and suicidality in subjects with Bipolar Disorder.MethodsSeventy-seven subjects with Bipolar Disorder type II with a depressive episode with mixed features were recruited. Patients were assessed with SCID-DSM-5, the Insomnia Severity Index (ISI), the Difficulties in Emotion Regulation Scale (DERS), the Scale for Suicide Ideation (SSI) while evaluating manic and depressive symptoms.ResultsSubjects with insomnia symptoms compared to those without showed higher scores in the DERS scale and subscales, including impulsivity, and in the SSI scale. Insomnia symptoms significantly predicted the severity of depressive symptoms, emotion dysregulation, and suicidality in subjects with bipolar disorder. In particular, insomnia was related to difficulties in some areas of emotion regulation including impulsivity. Emotion dysregulation significantly mediated the association between insomnia and depressive symptoms (Z = 2.9, p = 0.004). Furthermore, emotional impulsivity mediated the association between insomnia symptoms and suicidality (Z = 2.2, p = 0.03).ConclusionIn our study, subjects with bipolar disorder suffering from insomnia experienced a greater severity of depressive symptoms and suicidality compared to subjects without insomnia. Insomnia was associated with emotion dysregulation, impulsivity and suicidality. Further research is necessary to investigate if these latter features may benefit from early insomnia treatment in subjects with bipolar disorder.     

Depression in bipolar disorder versus major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

Moreno C, Hasin DS, Arango C, Oquendo MA, Vieta E, Liu S, Grant BF, Blanco C. Depression in bipolar disorder versus major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Bipolar Disord 2012: 14: 271–282. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: To compare the clinical features and course of major depressive episodes (MDEs) occurring in subjects with bipolar I disorder (BD‐I), bipolar II disorder (BD‐II), and major depressive disorder (MDD). Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (2001–2002), a nationally representative face‐to‐face survey of more than 43000 adults in the USA, including 5695 subjects with lifetime MDD, 935 with BD‐I and lifetime MDE, and 494 with BD‐II and lifetime MDE. Differences on sociodemographic characteristics and clinical features, course, and treatment patterns of MDE were analyzed. Results: Most depressive symptoms, family psychiatric history, anxiety disorders, alcohol and drug use disorders, and personality disorders were more frequent—and number of depressive symptoms per MDE was higher—among subjects with BD‐I, followed by BD‐II, and MDD. BD‐I individuals experienced a higher number of lifetime MDEs, had a poorer quality of life, and received significantly more treatment for MDE than BD‐II and MDD subjects. Individuals with BD‐I and BD‐II experienced their first mood episode about ten years earlier than those with MDD (21.2, 20.5, and 30.4 years, respectively). Conclusions: Our results support the existence of a spectrum of severity of MDE, with highest severity for BD‐I, followed by BD‐II and MDD, suggesting the utility of dimensional assessments in current categorical classifications.     

Health-related quality of life and functioning of middle-aged and elderly adults with bipolar disorder

OBJECTIVE: Data characterizing bipolar disorder in older people are scarce, particularly on functional status. We evaluated health-related quality of life and functioning (HRQoLF) among older outpatients with bipolar disorder as well as the relationship of HRQoLF to bipolar illness characteristics. METHOD: We compared community-dwelling middle-aged and older adults (age range, 45 to 85 years) with bipolar disorder (N=54; mean age=57.6 years), schizophrenia (N=55; mean age=58.5 years), or no psychiatric illnesses (N=38; mean age=64.7 years) on indicators of objective functioning (e.g., education, occupational attainment, medical comorbidity) and health status (e.g., Quality of Well-Being scale [QWB] and the Medical Outcomes Study-Short Form Health Survey [SF-36]). Within the group with bipolar disorder, we examined the relationship between HRQoLF and clinical variables (e.g., phase and duration of illness, psychotic symptoms, cognitive functioning). RESULTS: Patients with bipolar disorder were similar in educational and occupational attainment to the normal comparison group, but they obtained lower scores on the QWB and SF-36 (with large effect sizes). Compared with schizophrenia, bipolar disorder was associated with better educational and work histories but similar QWB and SF-36 scores and more medical comorbidity. Patients in remission from bipolar disorder had QWB scores that were worse than those of normal comparison subjects. Greater severity of psychotic and depressive symptoms and cognitive impairment were associated with lower HRQoLF. CONCLUSIONS: Bipolar disorder was associated with substantial disability in this sample of older adults, similar in severity to schizophrenia. Remission of bipolar disorder was associated with significant but incomplete improvement in functioning, whereas psychotic and depressive symptoms and cognitive impairment seemed to contribute to lower HRQoLF.     

抑郁症门诊患者中未识别出的双相障碍者的临床特征（英文）

背景双相障碍常未被识别或被误诊为单相抑郁。明确未被识别或被误诊的双相障碍者的临床特征有助于减少错误分类。目的调查门诊抑郁症患者中未被识别的双相障碍者的比例,并分析未被识别的双相障碍者的临床特征。方法使用32项轻躁狂症状清单（Hypomania Checklist-32,HCL-32）、心境障碍问卷（Mood Disorder Questionnaire,MDQ）和简明国际神经精神访谈（Mini International Neuropsychiatric Interview,MINI）对目前被诊断为抑郁症的100例门诊患者进行调查。对被重新诊断为双相障碍与仍然被诊断为抑郁症的患者的临床特征进行比较分析。结果共有29例（29%）抑郁症门诊患者被诊断为双相障碍;其中双相Ⅰ型6例,双相Ⅱ型23例。与未更改诊断的抑郁症者相比,被重新诊断为双相障碍者年龄轻、起病早、发病次数多、受教育程度高,多为复发性抑郁且多伴精神病性症状。多因素Logistic回归分析显示年龄（OR=0.55,95%CI=0.34~0.89）和精神病性症状（OR=9.12,95%CI=1.56~53.26）是双相障碍的独立危险因素。结论在门诊抑郁症患者中未被识别的双相障碍比例较高,尤其是双相Ⅱ型。与单相抑郁相比,诊断为抑郁症而为未被识别的双相障碍者年龄轻,更可能伴有精神病性症状。     

Functional impairment in the remission phase of bipolar disorder

OBJECTIVES: The purpose of this study was to evaluate functional impairment in a group of patients with bipolar disorder in remission and to determine the extent of relationships between overall functioning and current depressive, manic and panic spectrum symptoms. METHOD: A subset of the patient population at the Pittsburgh site of the Systematic Treatment Enhancement Program in Bipolar Disorder (STEP-BD) study was evaluated in this study. The subsample comprises 103 male and female subjects with bipolar I disorder (n = 70), bipolar II disorder (n = 24), schizoaffective disorder - bipolar type (n = 4), or bipolar disorder NOS (n = 5). Subjects were evaluated in a period of remission (at least 4 weeks with no more than two depressive or manic symptoms). Subjects were assessed for overall functional status using the Work and Social Adjustment Scale (WSAS) and for current bipolar and panic spectrum symptoms using the Mood Spectrum Self-Report questionnaire (MOODS-SR) and Panic-Agoraphobic Spectrum Self-Report questionnaire (PAS-SR). RESULTS: The median WSAS total score in these remitted subjects was 14, indicating significant functional impairment. Regressing WSAS on current depressive, manic, and panic spectrum total scores, we observed a highly significant depressive spectrum effect (t = 4.9, df = 94, p < 0.0001), but non-significant panic and manic spectrum effects (t = 1.3, df = 94, p = 0.19 and t = -1.8, df = 94, p = 0.07, respectively). CONCLUSION: Bipolar disorder is associated with functional deficits even during periods of sustained and substantial remission. The degree of functional impairment is correlated with the degree of depressive spectrum symptoms.     

Bipolar II disorder family history using the family history screen: findings and clinical implications

Psychiatric family history of bipolar II disorder is understudied. The aims of the current study were to find the psychiatric family history of bipolar II patients using a new structured interview, the Family History Screen by Weissman et al (2000), and to find bipolar disorders family history predicting power for the diagnosis of bipolar II. One hundred sixty-four consecutive unipolar major depressive disorder (MDD) and 241 consecutive bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The Family History Screen was used. Sensitivity and specificity of predictors of the diagnosis of bipolar II (bipolar [type I and II] family history, bipolar II family history, atypical depression, depressive mixed state, many MDE recurrences, early onset) were studied. Bipolar II subjects had significantly more bipolar I, more bipolar II (50.7%), more MDE, and more social phobia in first-degree relatives than did unipolar subjects. Bipolar II subjects had many more first-degree relatives with bipolar II than with bipolar I. Among the predictors of the diagnosis of bipolar II, bipolar II family history had the highest specificity (82.8%), while early onset had the highest sensitivity. Discriminant analysis of predictor variables found that bipolar II family history and early onset were highly significant predictors. In conclusion, bipolar II family history was common in bipolar II patients, and it had high specificity for predicting bipolar II. If detected, it could reduce bipolar II misdiagnosis by inducing careful probing for a history of hypomania.     

When do antidepressants worsen the course of bipolar disorder?

Bipolar disorder may be more prevalent than previously believed. Because a substantial number of patients with bipolar disorder present with an index depressive episode, it is likely that many are misdiagnosed with unipolar major depression. Even if a correct diagnosis is made, depressive symptoms in bipolar disorder are notoriously difficult to treat. Patients are often treated with antidepressants, which, if used improperly, are known to induce mania and provoke rapid cycling. This article explores diagnostic conundrums in bipolar depression and their possible solutions, based on current research evidence. It also elucidates current evidence regarding the risks and benefits associated with antidepressant use and evaluates alternative treatment regimens for the depressed bipolar population, including the use of traditional mood stabilizers such as lithium, novel anticonvulsants such as lamotrigine, and atypical antipsychotics.     

Cognition in older adults with bipolar disorder versus major depressive disorder

Gildengers AG, Butters MA, Chisholm D, Anderson SJ, Begley A, Holm M, Rogers JC, Reynolds CF III, Mulsant BH. Cognition in older adults with bipolar disorder versus major depressive disorder. Bipolar Disord 2012: 14: 198–205. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: Bipolar disorder (BD) and major depressive disorder (MDD) are associated with cognitive dysfunction in older age during both acute mood episodes and remitted states. The purpose of this study was to investigate for the first time the similarities and differences in the cognitive function of older adults with BD and MDD that may shed light on mechanisms of cognitive decline. Methods: A total of 165 subjects with BD (n = 43) or MDD (n = 122), ages ≥ 65 years [mean (SD) 74.2 (6.2)], were assessed when euthymic, using comprehensive measures of cognitive function and cognitive–instrumental activities of daily living (C‐IADLs). Test results were standardized using a group of mentally healthy individuals (n = 92) of comparable age and education level. Results: Subjects with BD and MDD were impaired across all cognitive domains compared with controls, most prominently in Information Processing Speed/Executive Function. Despite the protective effects of having higher education and lower vascular burden, BD subjects were more impaired across all cognitive domains compared with MDD subjects. Subjects with BD and MDD did not differ significantly in C‐IADLs. Conclusion: In older age, patients with BD have worse overall cognitive function than patients with MDD. Our findings suggest that factors intrinsic to BD appear to be related to cognitive deterioration and support the understanding that BD is associated with cognitive decline.     

Bipolar disorder not otherwise specified in relation to the bipolar spectrum

BACKGROUND: The purpose of this study was to determine the clinical characteristics of patients who are diagnosed with bipolar disorder not otherwise specified (BPD NOS) and who are considered to represent part of the bipolar spectrum. The lifetime prevalence of BPD in the general population may be as high as 6% when the full spectrum of bipolar disorders is accounted for. Correct identification of true bipolar patients in clinical settings may result in more appropriate treatment. Our hypothesis was that patients with BPD NOS would be more similar to other bipolar patients than major depressive disorder (MDD) patients in terms of age of onset, history of suicidal behavior and family history of BPD. METHODS: We conducted a retrospective chart review to extract and analyze data on the family history, disease course and clinical characteristics of 305 bipolar disorder I (BPD I), bipolar disorder II (BPD II), bipolar disorder not otherwise specified (BPD NOS) or major depressive disorder (MDD) patients who were then grouped by diagnosis for analysis. Nominal variables were compared between groups using chi-square tests and ANOVA was used to compare means between groups for continuous variables. Significant F values were followed by independent-samples t-tests. RESULTS: Patients with BPD I, BPD II and BPD NOS were all found to have a significantly earlier mean age of onset of depression than MDD patients. A significantly higher incidence of bipolar illness in a first-degree relative was found in all BPD groups (27-32%) compared with MDD patients (11%). Only the BPD I group had a significantly higher rate of suicide attempts (42%), compared with the BPD NOS (17%) and MDD recurrent (16%) groups. CONCLUSIONS: Our data support the conclusions of others that an early age of onset and a positive family history of bipolar illness are associated not only with BPD I and II but also with 'softer' forms of bipolar illness, which DSM-IV classifies as BPD NOS and the current literature refers to as a category of 'bipolar spectrum disorder', albeit with varying proposed definitions and diagnostic criteria. Suicide attempt history may be more useful in identifying the severity of illness than distinguishing the bipolar spectrum from depressive disorders. Further research is needed to clearly define the boundaries of the bipolar spectrum.     

Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

This study was designed to document eating disorder symptoms in a well-defined sample of patients with bipolar disorder and to evaluate the relationship of current loss of control over eating (LOC) to demographic and clinical features hypothesized to characterize bipolar patients at risk for disordered eating. Eighty-one patients enrolled in the Bipolar Disorder Center for Pennsylvanians provided demographic information and completed the Structured Clinical Interview for DSM-IV Axis I Disorders. The Eating Disorder Examination was administered by independent clinicians to evaluate current and lifetime eating disorder symptomatology. Twenty-one percent of participants met DSM-IV criteria for a lifetime eating disorder, and 44% reported a history of LOC. Patients who endorsed weekly LOC during the past six months (n=18) were heavier, had more atypical depressive symptoms, and were more likely to have a lifetime substance use disorder compared to patients in the rest of the sample (n=63). These findings indicate that eating disorder symptoms are prevalent in patients with bipolar disorder and are associated with obesity and other psychiatric morbidity. Screening for eating disorders in bipolar patients is warranted, as intervention may minimize distress and improve treatment outcome.     

Diagnosing major depressive disorder IV: relationship between number of symptoms and the diagnosis of disorder

The symptom inclusion criteria for DSM-IV major depressive disorder (MDD) consist of a list of nine characteristic features of depression, at least five of which must be present. Two of the criteria for MDD, low mood and loss of interest or pleasure, are accorded greater importance than the remaining seven criteria in that one of these two features is required for the diagnosis. The implicit assumption underlying this organization of the criteria is that some individuals might meet five of the nine criteria without experiencing low mood or loss of interest or pleasure and thus be inappropriately diagnosed with major depression. We are not aware of any studies that have examined this assumption. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how many psychiatric outpatients meet five of the nine DSM-IV criteria for MDD without simultaneously experiencing either low mood or loss of interest or pleasure. If this pattern is rare or does not exist, then the method of counting criteria to diagnose major depression could be simplified to a straightforward five out of nine. Twenty-seven (1.5%) patients reported five or more criteria in the absence of low mood or loss of interest or pleasure. More than half (N = 16) of these 27 patients were diagnosed with MDD or bipolar disorder, depressed type, in partial remission (N = 14), bipolar disorder mixed type (N = 1), or bipolar disorder not otherwise specified (N = 1). Six of the remaining 11 patients were diagnosed with depressive disorder not otherwise specified. Thus, few patients who met five or more of the MDD criteria were not diagnosed with a depressive disorder. This suggests that the diagnostic criteria for MDD can be simplified to a straightforward symptom count without reference to the necessity of low mood or loss of interest or pleasure.     

Bipolar mixed episodes and antidepressants: a cohort study of bipolar I disorder patients

Valentí M, Pacchiarotti I, Rosa AR, Bonnín CM, Popovic D, Nivoli AMA, Murru A, Grande Í, Colom F, Vieta E. Bipolar mixed episodes and antidepressants: a cohort study of bipolar I disorder patients.
Bipolar Disord 2011: 13: 145–154. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: The aim of this study was to elucidate the factors associated with the occurrence of mixed episodes, characterized by the presence of concomitant symptoms of both affective poles, during the course of illness in bipolar I disorder patients treated with an antidepressant, as well as the role of antidepressants in the course and outcome of the disorder. Method: We enrolled a sample of 144 patients followed for up to 20 years in the referral Barcelona Bipolar Disorder Program and compared subjects who had experienced at least one mixed episode during the follow‐up (n = 60) with subjects who had never experienced a mixed episode (n = 84) regarding clinical variables. Results: Nearly 40% of bipolar I disorder patients treated with antidepressants experienced at least one mixed episode during the course of their illness; no gender differences were found between two groups. Several differences regarding clinical variables were found between the two groups, but after performing logistic regression analysis, only suicide attempts (p < 0.001), the use of serotonin norepinephrine reuptake inhibitors (p = 0.041), switch rates (p = 0.010), and years spent ill (p = 0.022) were significantly associated with the occurrence of at least one mixed episode during follow‐up. Conclusions: The occurrence of mixed episodes is associated with a tendency to chronicity, with a poorer outcome, a higher number of depressive episodes, and greater use of antidepressants, especially serotonin norepinephrine reuptake inhibitors.     

非典型症状与双相障碍

概述：双相障碍（Bipolar Disorder,BD）临床症状多样,容易被误诊为抑郁症（Major depressive disorder, MDD）。非典型症状（Atypical Features,ATFs）是一个有用的指标,可以从抑郁状态中识别出双相障碍,有助于双相障碍与抑郁症的鉴别诊断。本文就非典型症状与双相障碍的相关性问题进行讨论。