Current Psychiatry Reports

, Volume 12, Issue 6, pp 505–511 | Cite as

New Ways to Classify Bipolar Disorders: Going from Categorical Groups to Symptom Clusters or Dimensions

Article

Abstract

Current psychiatric disorder classifications are based exclusively on categorical models, which were designed to increase the reliability of diagnoses. However, this system has some limitations, and various psychiatric disorders may be classified using a dimensional approach, which is more appropriate when no clear boundaries exist between entities or when examining various features on a continuum. Thus, the forthcoming DSM-5 appears to be undertaking a hybrid approach by including categorical models associated with dimensions. We aim to review examples of dimensions or symptom clusters associated with a categorical approach that could be useful in refining bipolar disorder classification. We selected predominant polarity, psychotic symptoms, inhibition/activation behavioral level, and emotional reactivity to define mood episodes, impulsivity/suicidality/substance misuse, and cognitive impairment. The selection was based on the fact that these dimensions or symptom clusters are currently being discussed to be implemented in the DSM-5 and/or may orientate toward the choice of specific treatments and represent more homogeneous and thus more appropriate subgroups for research purposes. In the future, there will be a need to identify biomarkers that can definitively validate the use of these criteria.

Keywords

Bipolar disorder Dimension Category Polarity Impulsivity Emotion 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 4. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  2. 2.
    World Health Organization: The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1993.Google Scholar
  3. 3.
    Muzina DJ: Pharmacologic treatment of rapid cycling and mixed states in bipolar disorder: an argument for the use of lithium. Bipolar Disord 2009, 11(Suppl 2):84–91.CrossRefPubMedGoogle Scholar
  4. 4.
    Bauer M, Beaulieu S, Dunner DL, et al.: Rapid cycling bipolar disorder—diagnostic concepts. Bipolar Disord 2008, 10:153–162.CrossRefPubMedGoogle Scholar
  5. 5.
    Colom F, Vieta E, Daban C, et al.: Clinical and therapeutic implications of predominant polarity in bipolar disorder. J Affect Disord 2006, 93:13–17.CrossRefPubMedGoogle Scholar
  6. 6.
    •• Tohen M, Frank E, Bowden CL, et al.: The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders. Bipolar Disord 2009, 11:453–473. The International Society for Bipolar Disorders Task Force reported its consensus on the definition of predominant polarity and other nomenclature (response, remission, recovery, relapse, recurrence, subsyndromal states, switch, and functional outcome) to stimulate research on the validity of proposed concepts.CrossRefPubMedGoogle Scholar
  7. 7.
    Vieta E, Berk M, Wang W, et al.: Predominant previous polarity as an outcome predictor in a controlled treatment trial for depression in bipolar I disorder patients. J Affect Disord 2009, 119:22–27.CrossRefPubMedGoogle Scholar
  8. 8.
    Gonzalez-Pinto A, Alberich S, Barbeito S, et al.: Different profile of substance abuse in relation to predominant polarity in bipolar disorder: the Vitoria long-term follow-up study. J Affect Disord 2010, 124:250–255.CrossRefPubMedGoogle Scholar
  9. 9.
    •• Colom F, Vieta E: The road to DSM-V. Bipolar disorder episode and course specifiers. Psychopathology 2009, 42:209–218. This review presents arguments to remove, reconceptualize, modify, and add bipolar episode and course specifiers in the DSM-5, in particular psychosis and predominant polarity.CrossRefPubMedGoogle Scholar
  10. 10.
    Beynon S, Soares-Weiser K, Woolacott N, et al.: Pharmacological interventions for the prevention of relapse in bipolar disorder: a systematic review of controlled trials. J Psychopharmacol 2009, 23:574–591.CrossRefPubMedGoogle Scholar
  11. 11.
    Kleindienst N, Severus WE, Greil W: Are serum lithium levels related to the polarity of recurrence in bipolar disorders? Evidence from a multicenter trial. Int Clin Psychopharmacol 2007, 22:125–131.CrossRefPubMedGoogle Scholar
  12. 12.
    Severus WE, Kleindienst N, Evoniuk G, et al.: Is the polarity of relapse/recurrence in bipolar-I disorder patients related to serum lithium levels? Results from an empirical study. J Affect Disord 2009, 115:466–470.CrossRefPubMedGoogle Scholar
  13. 13.
    Goodwin F, Jamison K: Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, edn 2. Oxford: Oxford University Press; 2007.Google Scholar
  14. 14.
    Coryell W, Leon AC, Turvey C, et al.: The significance of psychotic features in manic episodes: a report from the NIMH collaborative study. J Affect Disord 2001, 67:79–88.CrossRefPubMedGoogle Scholar
  15. 15.
    Schurhoff F, Szoke A, Meary A, et al.: Familial aggregation of delusional proneness in schizophrenia and bipolar pedigrees. Am J Psychiatry 2003, 160:1313–1319.CrossRefPubMedGoogle Scholar
  16. 16.
    Meyer F, Meyer TD: The misdiagnosis of bipolar disorder as a psychotic disorder: some of its causes and their influence on therapy. J Affect Disord 2009, 112:174–183.CrossRefPubMedGoogle Scholar
  17. 17.
    Ivleva EI, Morris DW, Moates AF, et al.: Genetics and intermediate phenotypes of the schizophrenia—bipolar disorder boundary. Neurosci Biobehav Rev 2010, 34:897–921.CrossRefPubMedGoogle Scholar
  18. 18.
    Goes FS, Sanders LL, Potash JB: The genetics of psychotic bipolar disorder. Curr Psychiatry Rep 2008, 10:178–189.CrossRefPubMedGoogle Scholar
  19. 19.
    Kraepelin E: Manic Depressive Insanity and Paranoia. Edinburgh, Scotland: E. & S. Livingstone; 1899.Google Scholar
  20. 20.
    Koukopoulos A, Koukopoulos A: Agitated depression as a mixed state and the problem of melancholia. Psychiatr Clin North Am 1999, 22:547–564.CrossRefPubMedGoogle Scholar
  21. 21.
    Benazzi F: Depressive mixed state frequency: age/gender effects. Psychiatry Clin Neurosci 2002, 56:537–543.PubMedGoogle Scholar
  22. 22.
    Goldberg JF, Perlis RH, Bowden CL, et al.: Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 2009, 166:173–181.CrossRefPubMedGoogle Scholar
  23. 23.
    Suppes T, Mintz J, McElroy SL, et al.: Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Network: a sex-specific phenomenon. Arch Gen Psychiatry 2005, 62:1089–1096.CrossRefPubMedGoogle Scholar
  24. 24.
    Kraemer HC, Noda A, O’Hara R: Categorical versus dimensional approaches to diagnosis: methodological challenges. J Psychiatr Res 2004, 38:17–25.CrossRefPubMedGoogle Scholar
  25. 25.
    • Henry C, M’Bailara K, Mathieu F, et al.: Construction and validation of a dimensional scale exploring mood disorders: MATHYS (Multidimensional Assessment of Thymic States). BMC Psychiatry 2008, 8:82. This clinical study validates the MATHYS as a useful quantitative tool to distinguish bipolar patients presenting with various mood states.CrossRefPubMedGoogle Scholar
  26. 26.
    Henry C, M’Bailara K, Lépine JP, et al.: Defining bipolar mood states with quantitative measurement of inhibition/activation and emotional reactivity. J Affect Disord 2010 Jun 7 (Epub ahead of print).Google Scholar
  27. 27.
    Malhi GS, Adams D, Lampe L, et al.: Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand Suppl 2009, May:27–46.Google Scholar
  28. 28.
    Yatham LN, Kennedy SH, Schaffer A, et al.: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. Bipolar Disord 2009, 11:225–255.CrossRefPubMedGoogle Scholar
  29. 29.
    Henry C, Mitropoulou V, New AS, et al.: Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res 2001, 35:307–312.CrossRefPubMedGoogle Scholar
  30. 30.
    • Najt P, Perez J, Sanches M, et al.: Impulsivity and bipolar disorder. Eur Neuropsychopharmacol 2007, 17:313–320. This review suggests that impulsivity is not only state related but is also a trait component of bipolar disorder, which could represent a core feature of the illness.CrossRefPubMedGoogle Scholar
  31. 31.
    Swann AC, Anderson JC, Dougherty DM, Moeller FG: Measurement of inter-episode impulsivity in bipolar disorder. Psychiatry Res 2001, 101:195–197.CrossRefPubMedGoogle Scholar
  32. 32.
    Moeller FG, Barratt ES, Dougherty DM, et al.: Psychiatric aspects of impulsivity. Am J Psychiatry 2001, 158:1783–1793.CrossRefPubMedGoogle Scholar
  33. 33.
    Swann AC, Pazzaglia P, Nicholls A, et al.: Impulsivity and phase of illness in bipolar disorder. J Affect Disord 2003, 73:105–111.CrossRefPubMedGoogle Scholar
  34. 34.
    Michaelis BH, Goldberg JF, Singer TM, et al.: Characteristics of first suicide attempts in single versus multiple suicide attempters with bipolar disorder. Compr Psychiatry 2003, 44:15–20.CrossRefPubMedGoogle Scholar
  35. 35.
    Swann AC, Dougherty DM, Pazzaglia PJ, et al.: Impulsivity: a link between bipolar disorder and substance abuse. Bipolar Disord 2004, 6:204–212.CrossRefPubMedGoogle Scholar
  36. 36.
    Swann AC: The strong relationship between bipolar and substance-use disorder. Ann N Y Acad Sci 2010, 1187:276–293.CrossRefPubMedGoogle Scholar
  37. 37.
    Tondo L, Baldessarini RJ: Long-term lithium treatment in the prevention of suicidal behavior in bipolar disorder patients. Epidemiol Psichiatr Soc 2009, 18:179–183.PubMedGoogle Scholar
  38. 38.
    Kovacsics CE, Gottesman II, Gould TD: Lithium’s antisuicidal efficacy: elucidation of neurobiological targets using endophenotype strategies. Annu Rev Pharmacol Toxicol 2009, 49:175–198.CrossRefPubMedGoogle Scholar
  39. 39.
    • Balanza-Martinez V, Selva G, Martinez-Aran A, et al.: Neurocognition in bipolar disorders—a closer look at comorbidities and medications. Eur J Pharmacol 2010, 626:87–96. This review provides an overview of selected aspects of neurocognition in bipolar disorder with a focus on the relative contributions of medication, as well as medical and psychiatric comorbid conditions to cognitive dysfunction, and provides recommendations for future research in this field.CrossRefPubMedGoogle Scholar
  40. 40.
    Sanchez-Moreno J, Martinez-Aran A, Tabares-Seisdedos R, et al.: Functioning and disability in bipolar disorder: an extensive review. Psychother Psychosom 2009, 78:285–297.CrossRefPubMedGoogle Scholar
  41. 41.
    Ng B, Camacho A, Lara DR, et al.: A case series on the hypothesized connection between dementia and bipolar spectrum disorders: bipolar type VI? J Affect Disord 2008, 107:307–315.CrossRefPubMedGoogle Scholar
  42. 42.
    Pachet AK, Wisniewski AM: The effects of lithium on cognition: an updated review. Psychopharmacology (Berl) 2003, 170:225–234.CrossRefGoogle Scholar
  43. 43.
    Wingo AP, Wingo TS, Harvey PD, Baldessarini RJ: Effects of lithium on cognitive performance: a meta-analysis. J Clin Psychiatry 2009, 70:1588–1597.CrossRefPubMedGoogle Scholar
  44. 44.
    Kessing LV, Forman JL, Andersen PK: Does lithium protect against dementia? Bipolar Disord 2010, 12:87–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Deckersbach T, Nierenberg AA, Kessler R, et al.: Cognitive rehabilitation for bipolar disorder: an open trial for employed patients with residual depressive symptoms. CNS Neurosci Ther 2009 Nov 6 (Epub ahead of print).Google Scholar
  46. 46.
    Burdick KE, Braga RJ, Goldberg JF, Malhotra AK: Cognitive dysfunction in bipolar disorder: future place of pharmacotherapy. CNS Drugs 2007, 21:971–981.CrossRefPubMedGoogle Scholar
  47. 47.
    Patten SB, Paris J: The bipolar spectrum—a bridge too far? Can J Psychiatry 2008, 53:762–768.PubMedGoogle Scholar
  48. 48.
    Regier DA, Narrow WE, Kuhl EA, Kupfer DJ: The conceptual development of DSM-V. Am J Psychiatry 2009, 166:645–650.CrossRefPubMedGoogle Scholar
  49. 49.
    •• American Psychiatric Association DSM-5 Development: Mood disorders. Available at http://www.dsm5.org/ProposedRevisions/Pages/MoodDisorders.aspx. Accessed July 2010. The DSM-5 development website of the American Psychiatric Association proposes preliminary draft revisions of the current diagnostic criteria for psychiatric disorders.
  50. 50.
    Linscott RJ, van Os J: Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annu Rev Clin Psychol 2010, 6:391–419.CrossRefPubMedGoogle Scholar
  51. 51.
    Mondimore FM: Unipolar depression/bipolar depression: connections and controversies. Int Rev Psychiatry 2005, 17:39–47.CrossRefPubMedGoogle Scholar
  52. 52.
    • Benazzi F: Is there a continuity between bipolar and depressive disorders? Psychother Psychosom 2007, 76:70–76. This article reviews 86 studies from the literature evaluating outcomes resulting from the expansion of the bipolar disorder diagnostic categories and fails to identify any randomized controlled trials or prospective cohort studies evaluating modified diagnostic or therapeutic practices.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.INSERM, Unité U955CréteilFrance
  2. 2.Université Paris-Est, Faculté de Médecine, UMR-S 955fondation FondaMentalCréteilFrance
  3. 3.AP-HP, Groupe Henri-Mondor Albert-Chenevier, Pôle de PsychiatrieCréteilFrance

Personalised recommendations