XI Congresso della Società Italiana di Psicopatologia Psichiatria ...

Introduction
SIMPOSI TEMATICI
22 FEBBRAIO 2005 - ORE 16.00-17.30
SALA CAVALIERI 1
S13 - Disturbi Bipolari e Disturbi Depressivi:
continuità o discontinuità?
F. Benazzi
University of California, San Diego and Hecker Psychiatry
Research Center, Forlì
Background: recent studies have questioned DSM-IV-TR
and ICD-10 categorical split of mood disorders into Bipolar
disorders and Depressive disorders.
Findings supporting a continuity/spectrum between Bipolar
disorders and Depressive disorders: a continuity/spectrum
between Bipolar disorders (mainly bipolar II disorder—
BP-II) and major depressive disorder (MDD) could be supported
by the following findings: 1) mixed depression (depressive
mixed states, the combination of depression and
manic/hypomanic symptoms), as co-occurring opposite polarity
symptoms do not support the splitting between mania/hypomania
and depression; 2) MDD is the most common
mood disorder in the relatives of bipolar probands; 3) no bimodality
in the distribution of distinguishing symptoms between
BP-II and MDD depression; 4) bipolar features present
in MDD; 5) a high proportion of MDD shifting to bipolar disorders
in the long-run; 6) lifetime manic/hypomanic symptoms
in MDD; 7) correlation between lifetime and current
manic/hypomanic symptoms and MDD depressive symptoms;
8) dimensions of hypomania present in MDD depression;
9) course of MDD often recurrent.
Findings supporting a categorical distinction between
Bipolar disorders and Depressive disorders: by mainly
comparing bipolar I disorder (BP-I) and MDD (the extremes
of the mood spectrum), several differences were found on diagnostic
validators: 1) family history: Bipolar disorders more
common in relatives of bipolar probands compared to MDD
probands, and MDD more common in relatives of MDD
probands vs. bipolar probands; 2) age at onset: lower age at
onset in Bipolar disorders vs. Depressive disorders; 3) gender
differences: females as common as males in BP-I, females
more common than males in MDD; 4) treatment response:
long-term antidepressants preventing recurrences in MDD,
and negatively impacting the course of Bipolar disorders; 5)
clinical picture of depression: BP-I depression more likely to
have atypical symptoms (e.g., hypersomnia) and psychomotor
retardation, MDD depression more likely to have insomnia
and psychomotor agitation; 6) course of illness: more recurrences
in Bipolar disorders vs. MDD.
Summary: by focusing on the extremes of the mood spectrum
(i.e., BP-I vs. MDD), a categorical distinction could be
supported by differences on diagnostic validators. By focusing
on disorders which are in the middle between BP-I and
MDD, such as BP-II and subtypes of MDD plus bipolar features,
a continuity/spectrum of mood disorders could be
supported. Which one of these approaches is the best has yet
to be shown. However, the evidence reviewed, especially
MODERATORI
F. Benazzi, M. Biondi
that on mixed depression, seems to be moving the pendulum
toward a continuity approach. Much research is needed in
the area, also because of its possible important treatment impact.
The gradient of bipolarity between DSM-IV
bipolar-II and major depressive disorder
J. Angst, F. Benazzi * , A. Gamma, V. Ajdacic, D. Eich,
W. Rössler
Zurich University, Psychiatric Hospital, Zurich; * University
of California, San Diego and Hecker Psychiatry Research
Center, Forlì
Background: there is growing international consensus that
major depressive disorder is over-diagnosed and bipolar disorder
under-diagnosed. In addition there is evidence for two
continua: a) continuum of severity of depression or mania
from psychotic to normal mood changes, b) continuum of
bipolarity from bipolar-I via bipolar-II to major depressive
disorder (MDD).
Method: in the Zurich cohort study of a longitudinal sample
of young adults, investigated from age 20/21 to 40/41
we defined four sub-groups of bipolar-II disorders by successively
broadening the criteria: 1) DSM-IV bipolar-II disorder;
2) DSM BP-II without restriction of the duration; 3)
strict Zurich criteria (increased activity plus 3 of 7 symptoms
of hypomania, plus personal or social consequences);
4) broad Zurich criteria (increased activity plus 2 of 7 symptoms).
Temperament was assessed by the General Behavior
Inventory (GBI) of Depue et al. 1 .
Results: there was a gradient of hypomania between DSM-
IV BP-II via the tentatively broader definitions of BP-II to
MDD in terms of a family history of mania, presence of
manic symptoms across 22 years and temperamental traits.
Alcohol use disorders were systematically associated with
the bipolar gradient and about twice as common among BP-
II than MDD disorder (MDD did not differ significantly
from controls).
Conclusion: there is a continuum of bipolarity between
DSM-IV bipolar-II disorder and MDD. We propose the introduction
of a clinically validated diagnostic specifier of
bipolarity in order to reduce the common under-diagnosis of
BP-II disorder. This diagnostic classification can also help
to clarify the association of alcohol use disorders with mood
disorders and might help to prevent alcohol use disorders.
Reference
1 Depue RA, Slater JF, et al. A behavioral paradigm for identifying
persons at risk for bipolar depressive disorder: A conceptual
framework and five validation studies. J Abnorm Psychol
1981;90:381-437.
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