Trastorno Bipolar. Hipomania Disfórica

HACIA LA DELINEACION CLINICA DE LA HIPOMANIA DISFORICA.
DILEMAS OPERACIONALES Y CONCEPTUALES.

Original Article

Toward a clinical delineation of dysphoric hypomania – operational and conceptual dilemmas

Akiskal HS, Benazzi F.

Bipolar Disord 2005: 7: 456–464. ©
Blackwell Munksgaard, 2005

Objective: Unlike dysphoric mania, we are unaware of any formal studies of dysphoric hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states.

Methods: In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (>2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric hypomania had to last at least 1 week.

Results: Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) “pure” BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH.

Conclusions: The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as
hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.

Hagop S Akiskal a,b and Franco Benazzi c

a International Mood Center, University of California
at San Diego, La Jolla,
b VA Medical Center, San Diego, CA, USA,
c Outpatient Psychiatry Private Center (Ewald Hecker Center), Ravenna, Italy

Key words: bipolar II disorder – dysphoric
hypomania – major depression – mixed state

Received 16 June 2004, revised and accepted for publication 19 June 2005

Corresponding author: Hagop S Akiskal, MD,
International Mood Center, University of California
at San Diego, 3350 La Jolla Village Dr (116-A), San
Diego, CA 92161, USA. Fax: 858 534 8598;
e-mail: hakiskal@ucsd.edu

Trastorno Bipolar y Tabaco

Original Article

Tobacco smoking behaviors in bipolar disorder: a comparison of the general population, schizophrenia, and major depression

Diaz FJ, James D, Botts S, Maw L, Susce MT, de Leon J.


Objectives: This study compared the prevalence of tobacco smoking behaviors in patients with bipolar disorder with normal and psychiatric (schizophrenia and major depression) controls. The main goal was to establish that bipolar patients smoke more than normal controls. Differences with psychiatric controls were explored.

Methods: Samples of 424 patients (99 bipolar, 258 schizophrenia and 67 major depression) and 402 volunteer controls were collected in Central Kentucky. Smoking data for Kentucky_s general population were available. Odds ratios (ORs) and their 95% confidence intervals (CIs) were used to establish the strength of associations. Logistic regression was used to adjust ORs for confounding variables.

Results: Using epidemiological definitions of smoking behaviors and the general population as controls provided bipolar disorder unadjusted ORs of 5.0 (95% CI: 3.3–7.8) for current cigarette smoking, 2.6 (95% CI: 1.7–4.4) for ever cigarette smoking, and 0.13 (95% CI: 0.03–0.24) for smoking cessation. Using a clinical definition and volunteers as controls provided respective bipolar disorder adjusted ORs of 7.3 (95% CI: 4.3–12.4), 4.0 (95% CI: 2.4–6.7), and 0.15 (95% CI: 0.06–0.36). Prevalences of current daily smoking for patients with major depression, bipolar disorder, and schizophrenia were 57%, 66%, and 74%, respectively.

Conclusions: Bipolar disorder was associated with significantly higher prevalences of tobacco smoking behaviors compared with the general population or volunteer controls, independently of the definition used. It is possible that smoking behaviors in bipolar disorder may have intermediate prevalences between major depression and schizophrenia,
but larger samples or a combination of multiple studies (meta-analysis) will be needed to establish whether this hypothesis is correct.



Francisco J Diaz 1, Danielle James 2, Sheila Botts 2, Lorraine Maw 2,
Margaret T Susce 2 and Jose de Leon 2,3

1 Department of Statistics, Universidad Nacional, Medellin, Colombia,
2 University of Kentucky, Mental Health Research Center at Eastern State Hospital,
Lexington, KY, USA,
3 Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences,
University of Granada, Granada, Spain


Corresponding author: Jose de Leon, MD, Mental Health Research Center at Eastern State Hospital, 627 West Fourth Street, Lexington, KY 40508, USA.
Fax: 859-246-7019;
e-mail: jdeleon@uky.edu

Received 7 April 2008, revised and accepted for publication 20 June 2008

Bipolar Disord 2009: 11: 154–165. © 2009
The Authors Journal compilation © 2009
Blackwell Munksgaard