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

258 K. I. ShulmanTable 11.1 Proposed criteria for vascular mania subtype specifierA. Mania occurring in the context of clinical and/or neuroimaging evidence ofcerebrovascular disease or neuropsychological impairmentB1. Clinical manifestations may include history of stroke or transient ischemic attacks, orfocal neurological signs or symptoms (e.g., exaggeration of deep tendon reflexes, extensorplantar response, pseudobulbar palsy, gait disturbance, weakness of an extremity)B2. Neuroimaging findings may include white- or gray-matter hyperintensities (Fazekas et al.,1998 criteria >2 ; or lesion >5 mm in diameter and irregular in shape), confluent whitematterlesions, or cortical or subcortical infarctsB3. Cognitive impairment manifested by disturbance of executive function (e.g., planning,organizing, sequencing, abstracting), memory, or speed of processing of informationThe diagnosis is supported by the following features:1. Mania onset after 50 years of age or change in the course of mood disorder after the onset ofvascular disease in patients with onset before 50 years of age2. Lack of family history of mood disorders3. Marked disability in instrumental or self-maintenance activities of daily livingReprinted with permission from Biological Psychiatry, 43, Steffens, D. C. and Krishnan, K. R. R.Structural neuroimaging and mood disorders. Recent findings, implications for classification,and future directions, 705–12, copyright 1990, with permission from Society of BiologicalPsychiatry.Specify vascular subtype (can be applied to the current or most recent manic episode in bipolardisorder) if A and B1 or B2 or B3.(2) Latent bipolar disorder: this subgroup is related to elderly bipolars whoseonset began in middle age as a first episode of depression but who ‘‘converted’’to mania much later in life, often after a prolonged latency and repeateddepressive episodes. In this subgroup, it is postulated that cerebral factors maybe responsible for the ‘‘conversion’’ from a unipolar depressive pattern to thatof bipolarity.(3) Secondary mania (disinhibition syndromes): this is largely a late-onset subtypewithout prior history of mood disorder and a lower but still significantfamilial predisposition. It is necessary to find a neurological or other systemicmedical disorder that is associated with the manic syndrome. The proposedvascular mania subtype would fall into this subgroup.(4) Unipolar mania: this is a much smaller but potentially heuristically valuablesubgroup who have a course of manic-only episodes, generally of early onsetand persisting over a prolonged period of time. Their similarity to patientswith chronic frontal disinhibition is of interest but requires furtherinvestigation.