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Bipolar disorder is a severe psychiatric disorder, characterized by depressive, manic and mixed episodes. The illness affects about 1-2 % of the population. Bipolar I disorders affect both genders equally, whereas bipolar II disorders seem to occur more frequently in women. The classification of the different subtypes of bipolar disorders is done depending on the severity and frequency of the episodes. Other subtypes beside bipolar I and bipolar II disorder are rapid cycling (more than 4 episodes of mania, depression, hypomania or mixed state in one year) and cyclothymia (hypomanic and subdepressive symptoms over a two year period). Besides a thorough psychiatric and neurological examination, further clinical tests should be performed in order to exclude differential diagnosis (psychiatric as well as neurological and somatic diseases). The course of the illness is often negatively affected by the high frequency of psychiatric and somatic comorbidities. After all the prognosis of bipolar disorder is depending on the individual course of the illness. Notably comorbidities and psychotic symptoms seem to have a negative influence on the prognosis.

Objective: Considerable debate exists as to whether the bipolar disorders are best classified according to a categorical or dimensional model. This study explored whether there is evidence for a single or multiple subpopulations and the degree to which differing diagnostic criteria correspond to bipolar subpopulations., Method: A mixture analysis was performed on 1081 clinically diagnosed (and a reduced sample of 497 DSM-IV diagnosed) bipolar I and II disorder patients, using scores on hypomanic severity (as measured by the Mood Swings Questionnaire). Mixture analyses were conducted using two differing diagnostic criteria and two DSM markers to ascertain the most differentiating and their associated clinical features., Results: The two subpopulation solution was most supported although the entropy statistic indicated limited separation and there was no distinctive point of rarity. Quantification by the odds ratio statistic indicated that the clinical diagnosis (respecting DSM-IV criteria, but ignoring 'high' duration) was somewhat superior to DSM-IV diagnosis in allocating patients to the putative mixture analysis groups. The most differentiating correlate was the presence or absence of psychotic features., Conclusion: Findings favour the categorical distinction of bipolar I and II disorders and argue for the centrality of the presence or absence of psychotic features to subgroup differentiation., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Bipolar disorders are a group of psychiatric disorders with profound negative impact on affected patients. Even if their symptomatology has long been recognized, diagnostic criteria have changed over time and diagnosis often remains difficult. The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), issued in May 2013, comprises several changes regarding the diagnosis of bipolar disorders compared to the previous edition. Diagnostic categories and criteria for bipolar disorders show some concordance with the internationally also widely used Tenth Edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). However, there are also major differences that are worth highlighting. The aim of the following text is to depict and discuss those.

Objective: Research on adults with cyclothymic disorder (CycD) suggests that irritability and impulsive aggression (IA) are highly prevalent among this population. Less is known about whether these behaviors might also distinguish youth with CycD from youth without CycD. Additionally, little is known about how irritability and IA relate to one another, and whether they are associated with different outcomes. This study aimed to compare irritability and IA across diagnostic subtypes to determine whether CycD is uniquely associated with these behaviors, and to assess how irritability and IA relate to youth social and general functioning., Methods: Participants (n = 459), 11-18 years of age, were recruited from an urban community mental health center and an academic outpatient clinic; 25 had a diagnosis of CycD. Youth and caregivers completed measures of IA and irritability. Youth and caregivers also completed an assessment of youth friendship quality. Clinical interviewers assessed youth social, family, and school functioning., Results: Youth with CycD had higher scores on measures of irritability and IA than youth with nonbipolar disorders, but scores were not different from other youth with bipolar spectrum disorders. Measures of irritability and IA were correlated, but represented distinct constructs. Regression analyses indicated that irritability was related to friendship quality (p < 0.005). Both IA and irritability were related to social impairment (ps < 0.05-0.0005) and Child Global Assessment Scale (C-GAS) scores (ps = 0.05-0.005). CycD diagnosis was associated with poorer caregiver-rated friendship quality and social functioning (ps < 0.05)., Conclusions: We found that irritability and aggression were more severe among youth with CycD than among youth with nonbipolar diagnoses, but did not differ across bipolar disorder subtypes. Among youth seeking treatment for mental illness, irritability and IA are prevalent and nonspecific. Irritability and IA were uniquely related to our outcomes of social and general functioning, suggesting that it is worthwhile to assess each separately, in order to broaden our understanding of the characteristics and correlates of each.

DSM-IV-TR defines four subtypes of bipolar disorder (BP): bipolar I, bipolar II, cyclothymic disorder and bipolar not otherwise specified (NOS). However, cyclothymic disorder in children is rarely researched, or often subsumed in an "NOS" category. The present study tests the replicability of findings from an earlier study, and expands on the criterion validity of cyclothymic disorder in youth. Using the Robins and Guze (1970) framework we examined the validity of cyclothymic disorder as a subtype of BP. Using a youth (ages 5-17) outpatient clinical sample (N = 894), participants with cyclothymic disorder (n = 53) were compared to participants with other BP spectrum disorders (n = 399) and to participants with non-bipolar disorders (n = 442). Analyses tested differences in youth with cyclothymic disorder and bipolar disorder not otherwise specified who do, and those who do not, have a parent with BP. Compared to youth with non-bipolar disorders, youth with cyclothymic disorder had higher irritability (p < 0.001), more comorbidity (p < 0.001), greater sleep disturbance (p < 0.005), and were more likely to have a family history of BP (p < 0.001). Cyclothymic disorder was associated with a younger age of onset compared to depression (p < 0.001) and bipolar II (p = 0.05). Parental BP status was not significantly associated with any variables. Results support that cyclothymic disorder belongs on the bipolar spectrum. Epidemiological studies indicate that cyclothymic disorder is not uncommon and involves significant impairment. Failing to differentiate between cyclothymic disorder and bipolar NOS limits our knowledge about a significant proportion of cases of bipolarity.

Objective: Episodes of bipolar disorder are defined as depressive or manic, but depressive and manic symptoms can combine in the same episode. Coexistence or rapid alternation of depressive and manic symptoms in the same episode may indicate a more severe form of bipolar disorder and may pose diagnostic and treatment challenges. However, definitions of mixed states, especially those with prominent depression, are not well established., Method: The authors performed literature searches for bipolar disorder, multivariate analyses, and the appearance of the terms "mixed" in any field; references selected from the articles found after the search were combined after a series of conferences among the authors., Results: The authors reviewed the evolution of the concept of mixed states and examined the symptom structure of mixed states studied as predominantly manic, predominantly depressive, and across both manic and depressive episodes, showing essentially parallel structures of mixed states based on manic or depressive episodes. The authors analyzed the relationships between mixed states and a severely recurrent course of illness in bipolar disorder, with early onset and increased co-occurring anxiety-, stress-, and substance-related disorders, and they used this information to derive proposed diagnostic criteria for research or clinical use., Conclusions: The definitions and properties of mixed states have generated controversy, but the stability of their characteristics over a range of clinical definitions and diagnostic methods shows that the concept of mixed states is robust. Distinct characteristics related to the course of illness emerge at relatively modest opposite polarity symptom levels in depressive or manic episodes.

The issue of mixed states has an important place in the debate on psychiatric nosography since the end of 19th century. The current definition of mixed states according to the DSM- IV, as a thymic episode of bipolar disorder type I, is probably somewhat too restrictive in clinical practice. Due to the clinical heterogeneity of bipolar disorder, the mixed states will define within a dimensional approach, likely in the next DSM- V. As the evolution, the prognosis or the therapeutic strategies differ from what is applied in other thymic episodes, this transition from "mixed state" to manic or depressive episodes "with mixed features" may be relevant in practice., (Copyright © 2012 L’Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

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., (Copyright © 2011 Elsevier B.V. All rights reserved.)

In the history of the nosographies in psychiatry, the affective disorders were gradually distinguished from the other categories of mental disorders, until being considered as separate illness entities, such as what Kraepelin named manic-depressive insanity at the end of the 19th century. The latter will be subsequently divided in two main categories, the bipolar disorder on the one hand and recurrent depression on the other hand, this separation being still current, and extensively diffused by the mean of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, whose revisions largely determine the evolution of the contemporary nosographic models, mainly relies on a categorical approach of the mental disorders. The next revision will probably continue to follow this kind of approach, even if the use of dimensional components could also be developed. In the future, true nosographic advances can be waited from clinical epidemiology studies, as those which recently made it possible to highlight various sub-types of affective disorders on the basis of clinical, biographical or temperamental characteristics. Etiological approaches, centered on the pathophysiology of the affective disorders, could also contribute to build nosographic models on the basis of an objective knowledge on these diseases., (Copyright © 2010 L'Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

Background: The aim of this study was to investigate the role of hyperthymic temperament in suicidal ideation between a sample of patients with affective disorders (unipolar and bipolar)., Method: We investigated affective disorders outpatients (unipolar, bipolar I, II and NOS) treated in eleven participating centres during at least a six-month period. DSM-IV diagnosis was made by psychiatrists experienced in mood disorders, using the corresponding modules of the Mini International Neuropsychiatric Interview (MINI). In addition, bipolar NOS diagnoses were extended by guidelines for bipolar spectrum symptoms as proposed by Akiskal and Pinto in 1999. Thereby we also identified NOS III (switch by antidepressants) and NOS IV (hyperthymic temperament) bipolar subtypes. All patients completed the Beck Depression Inventory (BDI). We screened a total sample of 411 patients (69% bipolar), 352 completed all the clinical scales without missing any item., Results: No statistical significant difference in suicidal ideation (measure by BDI item 9 responses) was found between bipolar and unipolar patients (4.5% vs. 9.1%, respectively). On the group of bipolar patients, suicidal ideation was slightly more frequent among bipolar NOS compared with bipolar I and II (p value 0.094 and 0.086, respectively), interestingly we found a statistical significant less common suicidal ideation among bipolar subtype IV (with hyperthymic temperament) compared with bipolar NOS patients (p value 0.048)., Conclusions: Our results indicate that those subjects with hyperthymic temperament displayed less suicidal ideation. This finding supports the hypothesis that this particular affective temperament could be a protective factor against suicide among affective patients., Limitation: The original objective of the national study was the cross validation between MDQ and BSDS in patients with affective disorders in our country. This report arises from a secondary analysis of the original data., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Dementia is a neuropsychiatric disorder characterized by cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. Management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature. A better understanding of BPSD etiology could lead to better management strategies. We submit that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder, or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia. The existence of such a relationship is based on clinical observation, as far as the high frequency of bipolar spectrum disorders in the general population, with a prevalence estimated to be between 5.4% and 8.3%, and the psychopathological similarities between BPSD and mood disorder episodes in bipolar illness. We will review the concept of the bipolar spectrum and explain BPSD before proposing clinical pointers of a possible bipolar spectrum contaminating the phenomenology of dementia, which could lead to the targeted prescription of mood-stabilizing agents in lieu of antidepressant monotherapy. These considerations are of heuristic interest in reconceptualizing the origin of the behavioral manifestations of dementia, with important implications for geriatric practice.

Introduction: Despite numerous explanatory hypotheses, few studies have involved a large national clinical sample examining risk factors in the occurrence of rapid cycling during the course of bipolar illness., Methods: From 1,090 manic bipolar I disorder inpatients included in a multicenter national study in France, 958 could be classified as rapid or nonrapid cyclers and assessed for demographic, illness course, clinical, psychometric, temperament, comorbidity, and treatment characteristics., Results: Rapid cycling bipolar disorder occurred in 9% (n=86) of the study group. Compared to nonrapid cyclers (n=872), patients with rapid cycling experienced the onset of their illness at a younger age, a higher number of prior episodes, more depression during the first episode, and more suicide attempts. At study entry, they also experienced manic episodes with more depressive and anxious symptoms, but less psychotic features. The following independent variables were associated with rapid cycling: longer duration of illness, antidepressant treatment, episodes with no free intervals, cyclothymic temperament, lower scores on the Scale for Assessment of Positive Symptoms and presence of thyroid disorder. Retrospective study limited to bipolar I disorder inpatients; several factors previously associated with rapid cycling were not assessed., Conclusion: Our findings may confirm previous descriptions, according to which rapid cycling develops later in the course of illness following a sensitization process triggered by antidepressant use or thyroid dysfunction, in patients with a depression-mania-free interval course, and cyclothymic temperament.

Objective: Rapid cycling (RC) affects 13-30% of bipolar patients. Most of the data regarding RC have been obtained in tertiary care research centers. Generalizability of these findings to primary care populations is thus questionable. We examined clinical and demographic factors associated with RC in both primary and tertiary care treated populations., Method: Clinical data were obtained by interview from 240 bipolar I disorder (BDI) or bipolar II disorder (BDII) community-treated patients and by chart reviews from 119 bipolar patients treated at an outpatient clinic of a teaching hospital., Results: Lifetime history of rapid cycling was present in 33.3% and 26.9% of patients from the primary and tertiary care samples, respectively. Among community-treated patients, lifetime history of RC was significantly associated with history of suicidal behavior and higher body mass index. There was a trend for association between RC and BDII, psychiatric comorbidity, diabetes mellitus, as well as lower age of onset of mania/hypomania. In the tertiary care treated sample there was a trend for association between lifetime history of RC and suicidal behavior. Tertiary versus primary care treated subjects with lifetime history of RC demonstrated markedly lower response to mood stabilizers., Conclusions: Lifetime history of RC is highly prevalent in both primary and tertiary settings. Even primary care treated subjects with lifetime history of RC seem to suffer from a more complicated and less treatment-responsive variant of bipolar disorder. Our findings further suggest relatively good generalizability of data from tertiary to primary care settings.

Objectives: This paper reviews the literature to examine the DSM-IV diagnostic criteria for rapid cycling in bipolar disorder., Methods: Studies on the clinical characteristics of rapid cycling bipolar disorder were reviewed. To identify relevant papers, literature searches using PubMed and MEDLINE were undertaken., Results: First observed in the prepharmacologic era, rapid cycling subsequently has been associated with a relatively poor response to pharmacologic treatment. Rapid cycling can be conceptualized as either a high frequency of episodes of any polarity or as a temporal sequence of episodes of opposite polarity. The DSM-IV defines rapid cycling as a course specifier, signifying at least four episodes of major depression, mania, mixed mania, or hypomania in the past year, occurring in any combination or order. It is estimated that rapid cycling is present in about 12-24% of patients at specialized mood disorder clinics. However, apart from episode frequency, studies over the past 30 years have been unable to determine clinical characteristics that define patients with rapid cycling as a specific subgroup. Furthermore, rapid cycling is a transient phenomenon in many patients., Conclusions: While a dimensional approach to episode frequency as a continuum between the extremes of no cycling and continuous cycling may be more appropriate and provide a framework to include ultra-rapid and ultradian cycling, the evidence does not exist today to refine the DSM-IV definition in a less arbitrary manner. Continued use of the DSM-IV definition also enables comparisons between past and future studies, and it should be included in the next release of the ICD. Further scientific investigation into rapid cycling is needed. In addition to improving the diagnostic criteria, insight into neurophysiologic mechanisms of mood switching and episode frequency may have important implications for clinical care.

An audit of the diagnosis of 300 consecutive new cases presenting in a private practice over the period of the last four years (from January 2003 to December 2006) is presented. The main observation is the high percentage of patients who fall within the bipolar spectrum who are diagnosed and reported. In particular, there is a large proportion of patients who suffer from Bipolar II illness. The consequences of this in the diagnosis and management of patients is discussed.

Aims: Worldwide criminal statistics show a disproportionately high incidence of violent offences committed under the influence of alcohol. A psychopathological subtyping of alcohol dependence in offenders who committed homicide has mainly been related to impulsive and dissocial personalities up to now., Methods: In an investigation on 48 alcohol-dependent offenders who committed homicide, a subtyping according to the multidimensional classification systems of Lesch and Cloninger has now been conducted for the first time., Results: In Lesch's classification, there was a high incidence of homicides committed by type II and type III subjects with the comorbidity anxiety and cyclothymia. While type III offenders were more often repeat offenders, there was a remarkably high rate of first offenders among type II subjects (Chi-squared test; chi(2) = 30.0, df = 3, P < 0.001). With respect to Lesch's typology, the blood alcohol concentrations did differ significantly in the group of offenders (Kruskal-Wallis, chi(2) = 18.3, df = 3, P < 0.001), whereas the blood alcohol concentration of type II offenders at the time of offence was significantly lower than in type III offenders (Mann-Whitney-U, Z = -3.47; P = 0.001). Regarding to the Cloninger's typology, no significant differences in the aforementioned parameters could be found., Discussion: An excessive noradrenergic reaction of anxiety offenders with initial withdrawal is discussed as a possible explanatory model.

Background: Although the cyclothymic temperament appears to be related to the familial diathesis of bipolar disorder, exhibiting high sensitivity for bipolar II (BP-II) disorder, it is presently uncertain which of its constituent traits are specific for this disorder., Methods: In a sample of 446 major depressive patients (BP-II and unipolar), in the French National EPIDEP study, the cyclothymic temperament was assessed by using clinician- and self-rated scales. We computed the frequency of individual traits and relative risk for family history of bipolarity., Results: From both clinician- and self-rated scales, four items related to mood reactivity, energy, psychomotor and mental activity were significantly highly represented in the subgroup with positive family history of bipolarity. The item "rapid shifts in mood and energy" obtained the highest relative risk (OR=3.42) for positive family history of bipolarity., Conclusion: These findings delineate those cyclothymic traits which are most likely to tap a familial-genetic diathesis for BP-II, thereby identifying traits which can best serve as a behavioral endophenotype for this bipolar subtype. Such an endophenotype might underlie the cyclic course of bipolar disorder first described in France 150 years ago by Falret and Baillarger.

Background: Current data indicate a strong association between Cyclothymic temperament (and its more ultradian counterpart of mood lability) and Bipolar II (BPII). Administration of elaborate measures of temperament are cumbersome in routine practice. Accordingly, the aim of the present analyses was to test if a practical measure of mood lability was unique to BPII, in comparison with major depressive disorder (MDD)., Methods: Using the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version as modified by us [J. Affect. Disord. 73 (2003) 33; Curr. Opin. Psychiatry 16 (2003) S71], we interviewed 62 consecutive BPII outpatients, as well as their 59 MDD counterparts during a major depressive episode (MDE). Hypomanic symptoms during MDE were systematically assessed: three or more such symptoms defined depressive mixed state (DMX3) on the basis of previous work by us [J. Affect. Disord. 73 (2003) 113]. A downscaled definition of trait mood lability was adapted from Akiskal et al. [Arch. Gen. Psychiatry 52 (1995) 114] and Angst et al. [J. Affect. Disord. 73 (2003) 133], requiring a positive response to one of two queries on whether one is a person with frequent "ups and downs" in mood, and whether such mood swings occur for no reason. The patients selected for inclusion had not received neuroleptics and antidepressants for at least 2 weeks prior to the index episode, they were free of substance and alcohol abuse, and did not meet the DSM-IV criteria for borderline personality disorder (BPD). Associations between mood swings and clinical variables were tested by logistic regression (STATA 7)., Results: Mood swings were endorsed by 50.4% of the entire sample: 62.9% of BPII and 37.2% of MDD (p = 0.0047). This practical measure of mood lability was significantly associated with BPII, lower age at onset, high depressive recurrences, atypical features, and DMX3. When controlled for number of major affective episodes, mood swings were still significantly associated with BP-II. Sensitivity and specificity of mood swings for predicting BPII were 62.9% and 62.7%, respectively., Limitation: The low specificity of trait mood lability for BPII diagnosis is probably due to the fact that we used a downscaled simplified measure of this trait., Conclusions: On the other hand, the relatively high sensitivity of our downscaled measure of mood lability for predicting BPII supports its usefulness as a screening tool for this diagnosis. The lack of association between self-reported mood lability and number of major mood episodes indicates that such lability does not reflect the perception of history of frequent episodes, and that it has some validity as a trait indicator. Given that our sample excluded patients meeting the DSM-IV criteria for BPD, contradicts the opinion of the latter manual that such mood lability represents its pathognomonic characteristic that distinguishes it from BPII. The bipolar nature of mood lability is further supported by significant associations with external validating criteria for bipolarity. Overall, these data indicate that in the differential diagnosis between MDD and BPII, trait mood lability favors the latter at a significant statistical level.

Objective: To examine differences in temperament profiles between patients with recurrent unipolar and bipolar depression., Method: Depressed individuals with recurrent major depressive disorder (MDD) (n = 94) and those with bipolar (n = 59) disorders (about equally divided between types I and II) were recruited by newspaper advertisement, radio and television announcements, flyers and newsletters, and word of mouth. All patients were interviewed using the Structured Clinical Interview for DSM III-R (SCID) and had the severity of their depressive episode assessed by means of the 17-item Hamilton Rating Scale for Depression. All patients filled out the TEMPS-A, a validated instrument., Results: Temperament differences between bipolar and MDD patients were examined using MANCOVA. Overall significant effect of the fixed factor (bipolar vs. unipolar) was noted for the temperament scores [Hotelling's F((5,142)) = 2.47, p < 0.05]. Overall effects were found for age [F((5,142)) = 2.40, p < 0.05], but not for gender and severity of depression [F((5,142)) = 1.65, p = 0.15 and F((5,142)) = 0.66, p = 0.66, respectively]. Dependent variables included the five subscales of the TEMPS-A, but only the cyclothymic temperament scores showed significant between-group differences., Limitation: Small bipolar subsample cell sizes did not permit to test the specificity of the findings for bipolar II vs. bipolar I patients., Conclusion: The finding that the clyclothymic subscale is significantly elevated in the bipolar vs. the unipolar depressive group supports the theoretical assumptions upon which the scale is based, and suggests that it might become a useful tool for clinical and research purposes.

Background: Since 1977, the work of the author has shown the primacy of behavioral activation, flamboyance, and extravagance in detecting hypomania, the historical hallmark of cyclothymic and the broader spectrum of bipolar II (BP-II) disorders. In other words, the soft spectrum is more likely to declare itself in behavioral rather than mood disturbances. The obligatory search for elation and related mood changes a la DSM-IV (and its interview form, the SCID) during the clinical interview is often doomed to failure, thereby "condemning" the patient to a unipolar diagnosis, and hence to sequential and often tragic failures with antidepressants or combinations thereof., Methods: To characterize behavioral signs of good specificity, though individually of low sensitivity for BP-II in patents presenting with major depression, the author undertook a chart review of over 1000 depressive patients he had examined extending over a period of nearly three decades. The Mood Clinic Data Questionnaire (MCDQ) used in the author's Memphis mood clinic permitted systematization of unstructured observations. BP-II had been independently confirmed by hypomania of > or =2 days and/or cyclothymia over the course of the index illness (both of which were validated by family history for bipolarity in earlier research in our clinic)., Results: Triads of behavior or traits in the patients' biographical history-as well as in the biologic kin-involving polyglottism, eminence, creative achievement, professional instability, multiple substance/alcohol use, multiple comorbidity (axis I and axis II), multiple marriages, a broad repertoire of sexual behavior (including brief interludes of homosexuality), impulse control disorders, as well as ornamentation and flamboyance (with red and other bright colors dominating) were specific for BP-II. Temperamentally, many of these individuals thrive on activity-they are indeed "activity junkies.", Limitation: The reported findings pertain primarily to the differential diagnosis between BP-II and unipolar depression. Replication of the approach espoused herein will require quantification of the operational definitions of the observed phenomenology., Conclusion: The findings, which make sense in an evolutionary model of the advantage that "dilute" bipolar traits confer to human biography and erotic life, suggest that such behavioral traits can be useful provisionally in assigning a depressive episode to the realm of the bipolar II spectrum. Overall, the perspective espoused in this paper indicates that temperamental excesses and, more generally, a biographical approach, represent a more coherent approach than hypomanic episodes in the diagnosis of BP-II patients. Finally, such a diagnostic approach underscores the importance of incorporating evolutionary considerations and principles in understanding the origin of affective disorders.

Relatively absent from previous studies of the pharmacotherapy for bipolar disorder is examination of the impact of comorbidity on treatment choices. This has occurred despite the presence of high levels of comorbid anxiety and substance use disorders, and the association of these disorders with severity and course markers of bipolar disorder. In this study, we examined comorbid disorders, identified by structured interviews, and the pharmacotherapy reported at study entry by the first 1000 patients entered into a large, multicenter study of bipolar disorder (Systematic Treatment Enhancement Program for Bipolar Disorder). Our study focused on the degree to which comorbid conditions are linked to the reported use of mood stabilizers deemed "minimally adequate" and the association between specific comorbidities and pharmacotherapy treatment, such as the use of anxiolytics in patients with anxiety disorders. Despite the presence of high levels of comorbidity, the presence of these disorders was only minimally associated with pharmacotherapy. Of the sample of bipolar outpatients, only 59% reported pharmacotherapy use meeting criteria for "minimally adequate" mood stabilizer, regardless of comorbid diagnoses, rapid cycling, or bipolar I or II status. Moreover, the cross-sectional use of "comorbidity-specific" pharmacotherapy for anxiety disorders, substance use disorders, and attention deficit disorder in this outpatient sample of patients with bipolar disorders was limited, suggesting that comorbid conditions in patients with bipolar disorder may be undertreated. Our findings highlight the need for greater clinical guidance and treatment options for patients with bipolar disorder and comorbidity.

Background: Despite its clinical relevance, the diagnosis of cycloid psychosis has been relatively neglected in the psychiatric literature and in the current nosological systems. This study examined the clinical validity and nosological status of the cycloid psychosis concept., Method: Six-hundred and sixty psychotic in-patients were assessed for psychosis-related variables and diagnosed according to DSM-III-R, DSM-IV, ICD-10 and the Perris & Brockington criteria forcycloid psychosis. The cycloid psychosis diagnosis (N = 68, 10.3%) was examined in regard to its discriminant validity, concordance with other psychotic disorders, and predictive validity in relation to schizophrenia and psychotic mood disorders. To address putative heterogeneity within cycloid psychosis, affective (N = 38) and non-affective (N = 30) subgroups were examined., Results: Cycloid psychosis had good discriminant validity regarding other psychoses (95% of correctly classified cases) and poor concordance with individual diagnoses from the formal diagnostic systems (K < 0.22). Cycloid patients had levels of psychotic, disorganization and first-rank symptoms comparable to schizophrenia, and levels of affective symptoms in-between schizophrenia and mood disorders. Regarding most clinical variables and morbidity risk of mood disorders, cycloid psychosis was closer to mood disorders. Cycloid psychosis had higher psychosocial stressors than schizophrenia and mood disorders. Affective and non-affective groups of cycloid psychosis differed in a number of variables indicating an overall better outcome for the non-affective group., Conclusions: Cycloid psychosis does not correspond closely to any DSM-III-R, DSM-IV or ICD-10 category of psychosis, and more specifically this nosological concept is not well represented by the different formal definitions of remitting psychotic disorders. Cycloid psychosis seems to be an heterogeneous condition in that affective and non-affective subgroups can be differentiated.

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., 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 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=74) versus those without CT (n=120), were differentiated as follows: (1). younger age at onset (P=0.005) and age at seeking help (P=0.05); (2). higher scores on HAM-D (P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3). longer delay between onset of illness and recognition of bipolarity (P=0.0002); (4). higher rate of psychiatric comorbidity (P=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 characterized as the "darker" expression of the more prototypical "sunny" BP-II phenotype. Coupled with the data from our companion paper (Hantouche et al., 2003, this issue), the present findings indicate that screening for cyclothymia in major depressive patients represents a viable approach for detecting a bipolar subtype that could otherwise be mistaken for an erratic personality disorder. Overall, our findings support recent international consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over erratic and borderline personality disorders when criteria for both sets of disorders are concurrently met.

On the basis of epidemiology, neurobiology and clinical observation, the classification of bipolar disorders has shown considerable development and expansion in recent years. In particular, the recognition of mixed states, the introduction of bipolar II disorders, increasing awareness of the diagnosis of hypomania, as well as the interest in cyclothymic disorders and temperament have led to a shift in diagnostic attitudes in the USA, as well as in European countries. In this article, the possible clinical and scientific benefits of such tendencies are discussed, as are the risks of broadening bipolar disorders beyond DSM-IV. Also demonstrated is how several "modern" concepts of bipolarity have deep roots in the history of German psychiatry; a mixity scale based on Kraepelin's classification of affective mixed states is presented.

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.

Background: No systematic data exists on the phenomenology and psychometric aspects of hypomania. In this report we focus on the factor structure of hypomania and its relationships with cyclothymic temperament in unipolar (UP) and bipolar II (BP-II) spectrum (soft bipolar) patients., Method: The combined sample of UP and BP-II spectrum patients (n=427) derives from the French National multi-center study (EPIDEP). The study involved training 48 psychiatrists at 15 sites in France in a protocol based on DSM-IV phenomenological criteria for major depressive disorder, hypomania, and BP-II, as well as a broadened definition of soft bipolarity. Psychometric measures included Angst's Hypomania Checklist (HCA) and Akiskal's Cyclothymic Temperament (CT) Questionnaires., Results: In the combined sample of the UP and BP-II spectrum, the factor pattern based on the HCA was characterized by the presence of one hypomanic component. In the soft bipolar group (n=191), two components were identified before and after varimax rotation. The first factor (F-1) identified hypomania with positive (driven-euphoric) features, and the second factor (F-2) hypomania with greater irritability and risk-taking. In exploratory analyses, both factors of hypomania tentatively distinguished most soft BP subtypes from UP. However, F-1 was generic across the soft spectrum, whereas F-2 was rather specific for II-1/2 (i.e., BP-II arising from CT). CT, which was found to conform to a single factor among the soft bipolar patients, was significantly correlated only with irritable risk-taking hypomania (F-2)., Limitation: In a study conducted in a clinical setting, psychiatrists cannot be kept blind of the data revealed in the various clinical evaluations and instruments. However, the systematic collection of all data tended to minimize biases., Conclusion: EPIDEP data revealed a dual structure of hypomania with 'classic' driven-euphoric contrasted with irritable risk-taking expressions distributed differentially across the soft bipolar spectrum. Only the latter correlated significantly with cyclothymic temperament, suggesting the hypothesis that repeated brief swings into hypomania tend to destabilize soft bipolar conditions.

A unidimensional model of the relationships between normal temperament, psychopathic variants of it and the two main forms of so-called endogenous psychoses (major affective disorders and schizophrenia) was derived from Kretschmer's constitutional typology. It was, however, not confirmed by means of a biometric approach nor was Kretschmer's broad concept of cyclothymia as a correlate of physical stoutness on the one hand and major affective disorders on the other supported by empirical data. Yet the concept of the 'melancholic type' of personality of patients with severe unipolar major depression (melancholia) which resembles descriptions by psychoanalysts could be corroborated. This was also true for the 'manic type' of personality as a (premorbid) correlate of predominantly manic forms of a bipolar I disorder. As predicted from a spectrum concept of major affective disorders, the ratio of traits of either type co-varied with the ratio of the depressive and the manic components in the long-term course of such a disorder. The two types of premorbid personality and a rare variant of the 'manic type', named 'relaxed, easy-going type', were conceived as 'affective types' dominating in major affective disorders. They are opposed to three 'neurotoid types' prevailing in so-called neurotic disorders as well as in schizophrenic psychoses. The similarity among the types can be visualized as spatial relationships in a circular, i.e. a two-dimensional, model (circumplex). Personality disorders as maladapted extreme variants of personality are, by definition, located outside the circle, mainly along its 'neurotoid' side. However, due to their transitional nature, axis I disorders cannot be represented adequately within the plane which represents (adapted as well as maladapted) forms of habitual behaviour (personality types and disorders, respectively). To integrate them into the spatial model of similarity interrelations, a dimension of actual psychopathology has to be added to the two-dimensional plane as a third (orthogonal) axis. The distance of a case from the 'ground level' of habitual behaviour corresponds with the severity of the actual psychopathological state. The specific form of that state (e.g. manic or depressive), however, varies along one the axes which define the circumplex of habitual behaviour. This three-dimensional model is, by its very nature, more complex than the unidimensional one derived from Kretschmer's typological concept, but it is clearly more in accordance with empirical data.

Objective: We prospectively investigated a sample of 42 patients with acute and transient psychotic disorder (ATPD) as defined by the 10th revision of the International Classification of Diseases (ICD-10; F23) to determine the clinical and demographic features of this entity and its relationship to cycloid psychoses., Methods: During a 5-year period, all in-patients with ATPD were identified. We systematically evaluated demographic and clinical features and carried out follow-up investigations on average 2 years after the index episode, using standardised instruments., Results: We found 42 cases of ATPD (4.1%) among 1,036 patients treated for psychotic disorders or a major affective episode. There was a marked female preponderance in ATPD (79%). Fifty-five percent of cases concurrently met the criteria of cycloid psychosis according to Perris and Brockington [in Perris C, Struwe G, Jansson B (eds): Biological Psychiatry. Amsterdam, Elsevier, 1981, pp 447-450]. There was no difference in gender distribution between cycloid and non-cycloid ATPD. As expected, abrupt onset and polymorphic features were significantly more common in cycloid than in non- cycloid ATPD. At follow-up, patients with cycloid ATPD showed less persistent alterations and better social functioning., Conclusion: ATPD as defined by ICD-10 is a heterogeneous category. A diagnosis of cycloid psychosis is made in half of the cases of ATPD, and in these cases, the prognosis is more favourable., (Copyright 2002 S. Karger AG, Basel)

The concept of bipolar disorder is an ongoing process. Its roots can be found in the work of the ancient Greek physician Aretaeus of Cappadocia, who assumed that melancholia and mania are two forms of one and the same disease; he actually believed that mania was a more severe form of melancholia. Falret [Bull. Acad. Natl. Med., Paris (1851)] and Baillarger [Ann. Méd-psychol. 6 (1854) 369] from France are the fathers of the modern understanding of bipolar disorders. But the definitive distinction of bipolar from unipolar disorders occurred in 1966 by Jules Angst and Carlo Perris in Europe, and later supported by Winokur and colleagues in the United States. Schizoaffective disorders should also be dichotomized into unipolar and bipolar forms. Another extension of the group of bipolar disorders is the contemporaneous rebirth of cyclothymia, originally described in the work of Kahlbaum (1882) and Hecker (1898) [Z. Prakt. Arzte 7 (1898) 6]; the main importance of cyclothymia today is its relevance for what Akiskal [Clin. Neuropharm. 15(1) (1992) 632] considers the realm of the 'soft bipolar spectrum.' A further interesting development is the renewed research in the field of 'mixed states' which originated in the classic Handbook of Kraepelin a century ago (1899).

Kraepelin had a modern vision of affective illness. He hypothesized that affective recurrences arose from enduring dispositions of depressive, cyclothymic, irritable, or 'manic' types. These dispositions appeared as 'temperaments' in English translations of his work. In the extreme, such temperamental gloominess or moodiness is today officially diagnosed as 'dysthymic' or 'cyclothymic'; irritable and hyperthymic (or manic) dispositions have not received official sanction in the contemporary psychiatric nomenclature. This paper reviews recent research which supports Kraepelin's theoretical framework regarding dysthymic and cyclothymic dispositions both as clinically relevant extreme forms of temperament and as precursors of major affective episodes. Compelling lines of evidence along epidemiologic, clinical-descriptive, familial-genetic, therapeutic, and follow-up perspectives are summarized for each disposition. Much of what in contemporary psychiatry is considered to be in the realm of subthreshold affective conditions, overlaps considerably with Kraepelin's concepts of the trait affective dispositions described herein. Most importantly, although Kraepelin's observations were based primarily on hospitalized, severely ill affective patients, his broad vision still guides us today for understanding etiology and instituting public health and preventive measures in major affective episodes.

This article argues for the necessity of a partial return to Kraepelin's broad concept of manic-depressive illness, and proposes definitions--and provides prototypical cases--to illustrate the rich clinical phenomenology of bipolar subtypes I through IV. Although considerable evidence supports such extensions of bipolarity encroaching upon the territory of major depressive disorder, further research is needed in this area. From a practice standpoint, the compelling reason for broadening the bipolar spectrum lies in the utility of mood stabilizers as augmentation or monotherapy in the treatment of major depressive disorders with soft bipolar features falling short of the current strict standards for the diagnosis of bipolar II and hypomania in DSM-IV and ICD-10.

The two major subtypes of manic-depressive illness are bipolar disorder and recurrent major depressive disorder. Biological data strongly indicate that a significant genetic factor is involved in the development of manic-depressive illness. But, stressful life events, environmental stress and premorbid personality factors may also be involved in other important etiologic factors. Some research data indicate that cyclothymic disorder and temperamental disorders may be considered as mild forms of bipolar disorders so called "subaffective disorders". The identification of clinical or biological features reflecting the severity of the major depressive episode is very important in regard of the high potential for suicide of the illness.

The concept of cycloid psychoses means a certain species as part of the group of schizophrenias. From our clinical point of view, the subtypes of Leonard and their poles are axial syndromes. They can occur simultaneously or intermingle during one phase. In the present phenomenological study the inner connections of these axial syndromes are shown. Apart from these connections, cycloid psychoses can be differentiated from core schizophrenia by three conditions: (1) the lack of deformation of affect and affect expression; (2) the lack of deformaton of thought structure; and (3) the lack of certain movement deformations, e.g., parakinesis. Our concept of phenomenon is explained to criticize the current operational definitions of cycloid psychoses. A different approach is suggested.

Seventy-two percent of 86 major depressive patients with atypical features as defined by the DSM-IV and evaluated systematically were found to meet our criteria for bipolar II and related "soft" bipolar disorders; nearly 60% had antecedent cyclothymic or hyperthymic temperaments. The family history for bipolar disorder validated these clinical findings. Even if we limit the diagnosis of bipolar II to the official DSM-IV threshold of 4 days of hypomania, 32.6% of atypical depressives in our sample would meet this conservative threshold, a rate that is three times higher than the estimates of bipolarity among atypical depressives in the literature. By definition, mood reactivity was present in all patients, while interpersonal sensitivity occurred in 94%. Lifetime comorbidity rates were as follows: social phobia 30%, body dysmorphic disorder 42%, obsessive-compulsive disorder 20%, and panic disorder (agoraphobia) 64%. Both cluster A (anxious personality) and cluster B (e.g., borderline and histrionic) personality disorders were highly prevalent. These data suggest that the "atypicality" of depression is favored by affective temperamental dysregulation and anxiety comorbidity, clinically manifesting in a mood disorder subtype that is preponderantly in the realm of bipolar II. In the present sample, only 28% were strictly unipolar and characterized by avoidant and social phobic features, without histrionic traits.

Background: The purpose of this study was to evaluate the reliability and psychometric properties of the Semistructured Affective Temperament Interview, and determine cut-offs for each temperament., Method: 1010 Italian students aged between 14 and 26 were evaluated by means of the Akiskal and Mallya criteria in a Semistructured Interview for depressive, cyclothymic, hyperthymic, and irritable temperaments., Results: This instrument has very good reliability and internal consistency. The percentage of subjects with a z-score higher than the second positive standard deviation ( + 2 SD) on the scales of depressive and cyclothymic temperaments are 3.6% and 6.3% (reaching scores of 7/7 and 9/10), respectively. Hyperthymic traits, on the other hand, are widespread in our sample: most subjects are included within the second positive standard deviation ( + 2 SD), and 8.2% of these reach a 7/7 score; therefore, the problem of defining a cut-off for this temperament is still open. By contrast, the irritable temperament is rare, conforming to a non-gaussian distribution, with 2.2% of cases above the second positive standard deviation ( + 2 SD)., Limitation: The data are based on subject report without collateral information and external validation., Conclusion: This study contributes to more accurate definition of cut-offs for individual temperament scales. The standardization of the interview thus makes it possible to compare three out of four temperamental scales, showing the dominant temperamental characteristics for each subject. Prospective studies are needed to demonstrate the stability of these traits over time.

The aim of this article is to review and put in their historical context today's data, methodologies and concepts concerning subaffective disorders. The historic roots of dysthymic and cyclothymic disorders--part of the subaffective spectrum--are essentially Greek, but the first use of the word 'dysthymia' in psychiatry was by C.F. Flemming in 1844. E. Hecker introduced the term 'cyclothymia' in 1877. K.L. Kahlbaum (1882) further developed the concepts of hyperthymia, cyclothymia and dysthymia--with possible subthreshold symptomatology--in 1882. After Kraepelin's rubric of 'manic-depressive insanity', the term 'dysthymia' was widely forgotten, and 'cyclothymia' became ill defined. Nowadays the latter term is used in three, partially contradictory, senses: (1) a synonym for bipolar disorder (K. Schneider), (2) a temperament (E. Kretschmer) and (3) a subaffective disorder (DSM-IV, ICD-10). A renaissance of subaffective disorders began with the development of DSM-III. Therapeutically important research has focused on dysthymic disorder and its relationship to major depressive disorder, while cyclothymic disorder is relatively neglected; nonetheless, operationalized as a subaffective dimension or temperament, cyclothymia appears to be a likely precursor or ingredient of the construct of bipolar II disorder.

The term "cyclothymia" is being used with different meanings. DSM-IV and ICD-10 define "cyclothymia" or "cyclothymic disorder" as a long lasting, subeffective disorder with frequent shifts between hypomanic and (sub)depressive states. In the tradition of Kurt Schneider cyclothymia was understood as a synonym for manic-depressive illness exclusively, while different personality typologies speak of a "cyclothymic" typus. Historically, the term was first used by the German psychiatrist Ewald Hecker in 1877. The definitions of DSM-IV and ICD-10 seem to be satisfactory in respect to reliability, but the nosological position of "cyclothymic disorder" is unclear. We review results concerning clinical symptomatology, comorbidity, biological parameters, personality (including the question of creativity), psycho- and pharmacotherapy as well as clinical course, which leave many questions open. Nevertheless, results in family studies support the idea that at least a fraction of "cyclothymia" is a mild or subclinical form of bipolar disorders. Until further research, which is urgently needed, we suggest that the term "cyclothymia" should be only used according to the guidelines of DSM-IV and ICD-10.

Based on the author's work and that of collaborators, as well as other contemporaneous research, this article reaffirms the existence of a broad bipolar spectrum between the extremes of psychotic manic-depressive illness and strictly defined unipolar depression. The alternation of mania and melancholia beginning in the juvenile years is one of the most classic descriptions in clinical medicine that has come to us from Greco-Roman times. French alienists in the middle of the nineteenth century and Kraepelin at the turn of that century formalized it into manic-depressive psychosis. In the pre-DSM-III era during the 1960s and 1970s, North American psychiatrists rarely diagnosed the psychotic forms of the disease; now, there is greater recognition that most excited psychoses with a biphasic course, including many with schizo-affective features, belong to the bipolar spectrum. Current data also support Kraepelin's delineation of mixed states, which frequently take on psychotic proportions. However, full syndromal intertwining of depressive and manic states into dysphoric or mixed mania--as emphasized in DSM-IV--is relatively uncommon; depressive symptoms in the midst of mania are more representative of mixed states. DSM-IV also does not formally recognize hypomanic symptomatology that intrudes into major depressive episodes and gives rise to agitated depressive and/or anxious, dysphoric, restless depressions with flight of ideas. Many of these mixed depressive states arise within the setting of an attenuated bipolar spectrum characterized by major depressive episodes and soft signs of bipolarity. DSM-IV conventions are most explicit for the bipolar II subtype with major depressive and clear-cut spontaneous hypomanic episodes; temperamental cyclothymia and hyperthymia receive insufficient recognition as potential factors that could lead to switching from depression to bipolar I disorder and, in vulnerable subjects, to predominantly depressive cycling. In the main, rapid-cycling and mixed states are distinct. Nonetheless, there exist ultrarapid-cycling forms where morose, labile moods with irritable, mixed features constitute patients' habitual self and, for that reason, are often mistaken for "borderline" personality disorder. Clearly, more formal research needs to be conducted in this temperamental interface between more classic bipolar and unipolar disorders. The clinical stakes, however, are such that a narrow concept of bipolar disorder would deprive many patients with lifelong temperamental dysregulation and depressive episodes of the benefits of mood-regulating agents.

Symptom patterns in women with childbearing-related onset illnesses (CBROI) and nonchildbearing-related onset illnesses (NCBROI) were compared. Women with diagnoses of Affective Disorders and Psychoses (n = 762) were divided into four groups: CBROI with psychosis, CBROI with non-psychotic affective illnesses, NCBROI with psychosis, and NCBROI with non-psychotic affective illness. Principal components analysis of 64 symptoms revealed 9 factors. The most dramatic result was the high score for psychotic women with CBROI on the factor cognitive disorganization/psychosis. Psychotic women with CBROI also reported homicidal ideation more frequently. Symptoms of non-psychotic women with CBROI and NCBROI did not differ.

Depending on the population studied, anywhere from half to two-thirds of DSM-III borderline disorders seem to represent subaffective expressions, principally on the border of bipolar disorder. "Borderland" may actually be a better characterization of this large temperamentally unstable terrain with a population prevalence of 4-6% (as compared with 1% for classical bipolar disorder). The temperaments include the dysthymic, irritable, and cyclothymic types which, respectively, coexist with "double depressive", mixed bipolar, and bipolar II disorders; others conform to an anxious-sensitive temperament in continuum with hysteroid dysphoric and atypical depressive disorders. Borderline "stable instability" in these patients appears secondary to affective temperamental dysregulation, which has exacerbated into a protracted emotional storm during a difficult maturational phase in the biography of a given patient.

The concept of hypomanic personality has historically been viewed with ambivalence. However, by replacing cyclothymic personality with cyclothymic disorder, DSM III doomed this entity into oblivion. The author examines the Dickensian portrayal of Mr. Micawber in light of existing descriptions of hypomanic personality in order to justify its inclusion in future psychiatric classifications.

Based on the reported data and the authors' findings 40 cases of larvate cyclothymia are described. The pivotal symptomatology of the disease involved masked hypochondriac subdepressions that imitated pathology of the bones and joints. In view of this fact the mental disease could not be recognized by the physicians and was diagnosed erroneously as a pathology of the bones and joints. The author provides a 3-component structure of the given hypochondriac depressions and differential diagnostic criteria for their separation from genuine pathology of the bones and joints.

The author develops a nosologic framework for understanding the psychopathology of low-grade chronic depressions: 1) late-onset primary depressions with residual chronicity, 2) chronic secondary dysphorias, having a variable onset age and considered part of the symptomatic picture of nonaffective "neurotic" disorders or reactions to longstanding incapacitating medical diseases, and 3) early-onset characterologic depressions, which include a) character-spectrum disorders developing in the setting of tempestuous early object relationships and b) subaffective dysthymic disorders, conceptualized as genetically attenuated forms of primary affective illnesses. Differences in family history, REM latency, and pharmacologic responsiveness are presented in support of these distinctions. The author also proposes operational criteria to identify a thymoleptic-responsive subaffective dysthymic group.

The authors identified 46 cyclothymic probands from a random pool of 500 psychiatric outpatients and prospectively followed them over a 2-3 year period. They used 50 bipolar patients with a definite history of mania and 50 patients with personality disorders as control groups. Although 66% of the cyclothymic outpatients had previously received the diagnosis of hysteria or sociopathy, their pedigrees were similar to those seen in classical bipolar manic-depressive illness; furthermore, 44% of the cyclothymic group experienced brief hypomanic episodes while taking tricyclic drugs, and 35% developed full-blown hypomanic, manic, or depressive episodes during drug-free follow-up. The authors conclude that these findings provide evidence for a cyclothymic-bipolar spectrum.

We report on the utility of a new instrument to identify subtypes of major depressive episodes with special reference to pseudo-unipolar conditions. By incorporating reliable measures of depressive and hyperthymic temperamental characteristics in subtype definitions, we achieve the sharpest possible demarcation between unipolar and bipolar disorders. The new procedures also reveal that 1 out of 3 primary depressives in a consecutive series of 405 patients belong to the bipolar spectrum. Furthermore, among bipolars, bipolar II disorder (redefined as major depressions with hypomania or hyperthymic temperament) represents the most common variant. We discuss the nosologic, therapeutic, methodologic and theoretical implications of these considerations on the unipolar-bipolar dichotomy. Given that major depression emerges as the final common clinical expression of a heterogeneous group of disorders, it underscores the importance of focusing on temperament and course of illness in subclassification efforts such as attempted here.