Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

132 F. BenazziAkiskal, 2001; Akiskal and Benazzi, 2003;) was found to be a link between pure UPand BP. In the American Psychiatric Association, DSM-IV (1994) bipolar disordersare divided into:(1) BP-I disorder(2) BP-II disorder(3) cyclothymic disorder(4) bipolar disorder not otherwise specified(5) manic or hypomanic episodes due to a general medical disorder or substanceinduced.DSM-IV BP-II criteria for hypomania require elevated or irritable mood, lastingat least 4 days, plus at least three (four, if mood is irritable) hypomanic symptoms,an observable change in functioning, a mild episode not due to substances,antidepressants, or medical disorders, and not superimposed on psychotic disorders.DSM-IV BP-II criteria have some problems:(1) No data support the cut-off of 4 days (Dunner, 1998), while a cut-off of 2 daysis supported by data (Akiskal et al., 2000)(2) There are no clear boundaries between mania and hypomania(3) Antidepressant-associated hypomania is not classified as BP-II, while followupstudies found that antidepressant-associated hypomania will have spontaneoushypomania in many cases (Akiskal and Pinto, 1999)(4) Hypomanic mood is the first criterion, while recent studies (Akiskal et al.,2001; Angst et al., 2003; Benazzi and Akiskal, 2003a, b) found that overactivebehavior is at least as important as hypomanic mood(5) The Structured Clinical Interview for DSM-IV Axis I Disorders–Clinician Version(SCID-CV; First et al., 1997) skip-out stem question on mood does not allow theassessment of the other hypomanic symptoms if it is negative, while Dunner andTay (1993) and Benazzi and Akiskal (2003a) found that systematic assessment ofall past hypomanic symptoms increased the frequency of BP-II diagnoses.Recent literature reviewA comprehensive review of the literature on AD until the early 1990s can be foundin Rabkin et al. (1996), and an updated review in Angst et al. (2002). Thediagnostic validity of AD is mainly based on its better response to monoamineoxidase inhibitors (MAOI) rather than to tricyclic antidepressants (TCA) (Rabkinet al., 1996), and on latent class analysis (Kendler et al., 1996; Sullivan et al., 1998).An important limitation of these studies is the inclusion of mainly UP samples.The current definition of AD is mostly based on the Columbia group definition ofAD (Rabkin et al., 1996).