Hostname: page-component-848d4c4894-nmvwc Total loading time: 0 Render date: 2024-07-04T09:29:38.416Z Has data issue: false hasContentIssue false
  • English
  • Français

Challenging DSM-IV criteria for hypomania: Diagnosing based on number of no-priority symptoms

Published online by Cambridge University Press:  16 April 2020

Franco Benazzi
Franco Benazzi*
Affiliation:
Hecker Psychiatry Research Center at Forli, Forli, Italy University of California at San Diego (USA) collaborating center, San Diego, 9500 Gilman Dr., La Jolla, CA92093, USA Department of Psychiatry, University of Szeged, Szeged, Hungary Department of Psychiatry, National Health Service of Forli, Via Pozzetto 17, 48015Castiglione di CerviaRA, Italy
*
*Corresponding author. Department of Psychiatry, National Health Service of Forli, Via Pozzetto 17, 48015 Castiglione di Cervia RA, Italy. Tel.: +39 335 6191 852; fax: +39 054 330 069. E-mail address: francobenazzi@fbenazzi.it
Get access

Abstract

Background

DSM-IV definition of hypomania of bipolar-II disorder (BP-II), which includes elevated/irritable mood change as core feature (i.e., it must always be present), is not based on sound evidence.

Study aim

Following classic descriptions of hypomania, was to test if hypomania could be diagnosed on the basis of its number (9) of DSM-IV symptoms, setting no-priority symptom.

Methods

Consecutive 422 depression-remitted outpatients were re-interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version [a semi-structured interview modified by Benazzi and Akiskal (J Affect Disord, 2003; J Clin Psychiatry, 2005) to improve the probing for BP-II] in a private practice. History of episodes of subthreshold (i.e., 2 or more symptoms) and threshold (i.e., meeting DSM-IV criteria of elevated mood plus at least 3 symptoms, or irritable mood plus at least 4) hypomania, lasting at least 2 days, and which were the most common symptoms during the episodes, were systematically assessed.

Results

Bipolar-II disorder (BP-II) patients (according to DSM-IV criteria, apart from hypomania duration) were 260, and major depressive disorder (MDD) patients were 162. Mood change was present in all BP-II by definition. The most common symptoms were overactivity, which was present in almost all BP-II, followed by elevated mood and racing thoughts. ROC analysis of the number of hypomanic symptoms predicting BP-II found that a cut point of 5 or more symptoms over 9 had the best combination of sensitivity (90%) and specificity (84%), and the highest figure of correctly classified (87%) BP-II. History of episodes of 5 or more hypomanic symptoms was met by almost all BP-II.

Limitations

Single interviewer.

Conclusions

Following classic descriptions of hypomania, not setting any priority among the three basic domains of hypomania (mood, thinking, behavior), results suggest that a cutoff number of 5 symptoms over 9 (of those listed by DSM-IV) could be used to diagnose hypomania of BP-II. Diagnosing hypomania by counting a checklist of symptoms should make it easier to diagnose BP-II, and should reduce the current high misdiagnosis of BP-II as MDD, significantly impacting the treatment of depression.

Keywords

Bipolar II disorderHypomaniaDiagnostic criteriaDiagnosis
Type
Original article
Information
European Psychiatry , Volume 22 , Issue 2 , March 2007 , pp. 99 - 103
Copyright
Copyright © Elsevier Masson SAS 2006

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Akiskal, H.S., Benazzi, F.Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry 2005;66:914–921.CrossRefGoogle Scholar
Akiskal, H.S., Djenderedjian, A.M., Rosenthal, R.H., Khani, M.K.Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am J Psychiatry 1977;134:1227–1233.Google ScholarPubMed
Akiskal, H.S., Mallya, G.Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 1987;23:68–73.Google ScholarPubMed
Akiskal, H.S., Pinto, O.The evolving bipolar spectrum: prototypes I, II, III, and IV. Psychiatr Clin North Am 1999;22:517–534.CrossRefGoogle ScholarPubMed
American Psychiatric Association Diagnostic and statistical manual of mental disorders. Text revision (DSM-IV-TR). 4th ed.Washington, DC: American Psychiatric Association; 2000.Google Scholar
American Psychiatric Association Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002;159(Suppl):1–50.Google Scholar
Angst, J., Adolfsson, R., Benazzi, F., Gamma, A., Hantouche, E., Meyer, T.D.et al.The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 2005;88:217–233.CrossRefGoogle ScholarPubMed
Angst, J., Gamma, A., Benazzi, F., Ajdacic, V., Eich, D., Rossler, W.Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003;73:133–146.CrossRefGoogle Scholar
Benazzi, F., Akiskal, H.S.Refining the evaluation of bipolar II: beyond the strict SCID-CV guidelines for hypomania. J Affect Disord 2003;73:33–38.CrossRefGoogle ScholarPubMed
Benazzi, F., Akiskal, H.S.The dual factor structure of self-assessed MDQ hypomania: energized-activity versus irritable-thought racing. J Affect Disord 2003;73:56–64.CrossRefGoogle Scholar
Benazzi, F., Akiskal, H.S. The duration of hypomania in bipolar-II disorder in private practice: methodology and validation. J Affect Disord 2006 Jan 18 [Epub ahead of print].CrossRefGoogle Scholar
Benazzi, F.Borderline personality disorder and bipolar II disorder in private practice depressed outpatients. Compr Psychiatry 2000;41:106–110.CrossRefGoogle ScholarPubMed
Benazzi, F.Depression with racing thoughts. Psychiatry Res 2003;120:273–282.CrossRefGoogle ScholarPubMed
Benazzi, F.Diagnosis of bipolar II disorder: a comparison of structured versus semistructured interviews. Prog Neuropsychopharmacol Biol Psychiatry 2003;27:985–991.CrossRefGoogle ScholarPubMed
Benazzi, F.Factor structure of recalled DSM-IV hypomanic symptoms of bipolar II disorder. Compr Psychiatry 2004;45:441–446.CrossRefGoogle ScholarPubMed
Benazzi, F.Family history validation of a definition of mixed depression. Compr Psychiatry 2005;46:159–166.CrossRefGoogle ScholarPubMed
Benazzi, F.Is 4 days the minimum duration of hypomania in bipolar II disorder?. Eur Arch Psychiatry Clin Neurosci 2001;251:32–34.CrossRefGoogle ScholarPubMed
Benazzi, F.Level of functioning in hypomania of bipolar II disorder. Can J Psychiatry 2004;49:159–160.CrossRefGoogle ScholarPubMed
Benazzi, F.Suicidal ideation and depressive mixed states. Psychother Psychosom 2005;74:61–62.CrossRefGoogle ScholarPubMed
Benazzi, F.The problem of the treatment of bipolar-II depression. Bipolar Disord 2004;6:440–441.CrossRefGoogle ScholarPubMed
Cassano, G.B., Frank, E., Miniati, M., Rucci, P., Fagiolini, A., Pini, S.et al.Conceptual underpinnings and empirical support for the mood spectrum. Psychiatr Clin North Am 2002;25:699–712.CrossRefGoogle ScholarPubMed
Dunner, D.L.Bipolar depression with hypomania (Bipolar II). In: Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B., Davis, W.W.DSM-IV Sourcebook, volume 2 Washington, DC: American Psychiatric Association; 1996. p. 53–63.Google Scholar
Dunner, D.L.Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disord 2003;5:456–464.CrossRefGoogle ScholarPubMed
Dunner, D.L., Tay, K.L.Diagnostic reliability of the history of hypomania in bipolar II patients and patients with major depression. Compr Psychiatry 1993;34:303–307.CrossRefGoogle ScholarPubMed
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W.Structured clinical interview for DSM-IV axis I disorders-clinician version (SCID-CV). Washington, DC: American Psychiatric Press; 1997.Google Scholar
Goodwin, F.K., Jamison, K.R.Manic-depressive illness. New York: Oxford University Press; 1990.Google Scholar
Hantouche, E.G., Akiskal, H.S., Lencrenon, S., Allilaire, J.-F., Sechter, D., Azorin, J.-M.et al.Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 1998;50:163–173.CrossRefGoogle Scholar
Hantouche, E.G., Angst, J., Akiskal, H.S.Factor structure of hypomania: interrelationships with cyclothymia and the soft bipolar spectrum. J Affect Disord 2003;73:39–47.CrossRefGoogle ScholarPubMed
Judd, L.L., Akiskal, H.S., Schettler, P.J., Coryell, W., Endicott, J., Maser, J.D.et al.A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003;60:261–269.CrossRefGoogle ScholarPubMed
Koukopoulos, A.Ewald Hecker's description of cyclothymia as a cyclical mood disorder: its relevance to the modern concept of bipolar II. J Affect Disord 2003;73:199–205.CrossRefGoogle ScholarPubMed
Kraepelin, E.Manic-depressive insanity and paranoia. Edinburgh: Livingstone E & S; 1921.CrossRefGoogle Scholar
Manning, J.S., Haykal, R.F., Akiskal, H.S.The role of bipolarity in depression in the family practice setting. Psychiatr Clin North Am 1999;22:689–703.CrossRefGoogle ScholarPubMed
Rihmer, Z., Pestality, P.Bipolar II disorder and suicidal behavior. Psychiatr Clin North Am 1999;22:667–673.CrossRefGoogle ScholarPubMed
Rybakowski, J.K., Suwalska, A., Lojko, D., Rymaszewska, J., Kiejna, A.Bipolar mood disorders among Polish psychiatric outpatients treated for major depression. J Affect Disord 2005;84:141–147.CrossRefGoogle ScholarPubMed
Sedler, M.J.Falret's discovery: the origin of the concept of bipolar affective illness. Am J Psychiatry 1983;140:1127–1133.Google ScholarPubMed
Simpson, S.G., McMahon, F.J., McInnis, M.G., MacKinnon, D.F., Edwin, D., Folstein, S.E.et al.Diagnostic reliability of bipolar II diagnosis. Arch Gen Psychiatry 2002;59:736–740.CrossRefGoogle Scholar
Smith, D.J., Harrison, N., Muir, W., Blackwood, D.H.R.The high prevalence of bipolar spectrum disorders in young adults with recurrent depression: toward an innovative diagnostic framework. J Affect Disord 2005;84:167–178.CrossRefGoogle ScholarPubMed
Westen, D., Shedler, J., Bradley, R.A prototype approach to personality disorder diagnosis. Am J Psychiatry 2006;163:846–856.CrossRefGoogle ScholarPubMed
Zimmerman, M., McGlinchey, J.B., Young, D.D., Chelminski, I.Diagnosing MDD: relationship between number of symptoms and the diagnosis of disorder. Presented as a poster (NR305) at the American Psychiatric Association annual meeting, Toronto; 2006.Google Scholar
Submit a response

Comments

No Comments have been published for this article.