Dr. Grossi's Blog
The Bipolar Spectrum, Part II
This discussion will focus on the conditions between major depressive disorder and bipolar I (true manic depressive). In the prior blog I discussed bipolar II which is the most common intermediary disorder. They almost always present as being depressed and so deliberate effort should be exerted to uncover a hypomanic state. The characteristics of hypomania include cheerfulness, gregariousness, increased sexual drive, garrulousness, overconfident or overoptimnistic, racing thoughts, reduced need for sleep, vigor, overinvolved in relationships or projects. In order to qualify as hypomanic, one must have three or more of these characteristics. DSM-IV requires a duration of four days. I find that the duration is inversely correlated with the number of such episodes but should be at least one to two days. This is distinguished from happiness by its recurrent nature as well as its ability to be precipitated by antidepressant therapy. When precipitated by antidepressants, it is designated bipolar III. While hypomanic states can result in enormous productivity and creativity, often insight and judgment are lost so that these states can result in disastrous consequences similar to manic states.
Another intermediate form of bipolarity are those patients who are temperamentally cyclothymic and who experience a superimposed depression. Cyclothymia is a condition characterized by many of the following: 1) ability to think varies from sharp to dull, 2) sudden shifts in mood and energy, 3) constant shifts between being lively and sluggish, 4) see things as vivid or lifeless, 5) sudden mood changes without reason 6) frequent shifts between being outgoing and withdrawn, 7) moods and energy are either high or low, rarely in between, 8) feeling of overconfidence alternate with feeling unsure 9) need for sleep varies from just a couple of hours to nine hours or more, 10) sometimes go to bed feeling great and awaken feeling life is not worth living, 11) feeling about other varies from liking a lot to no interest at all, 12) can be happy and sad at the same time. An individual would need at least six of the above characteristics to meet criteria for cyclothymia. These patients are quite unstable and are often misdiagnosed with borderline personality disorder. These patients are variants of bipolar II and are designated bipolar II 1/2.
Another intermediate form of bipolar disorder is designated bipolar IV. In this condition, the individual has hyperthymia prior to a depressive episode and between depressive episodes. The characteristics of hyperthymia include feeling: 1) upbeat and exuberant 2) articulate and jocular, 3) overoptimistic and carefree, 4) overconfident and boastful 5) high energy level, lots of plans, 6) versatile with broad interests, 7) overinvolved and meddlesome, 8) uninhibited and risk-taking, 10) short sleeper i.e. less than 6 hours. One must have at least four of the foregoing characteristics and are habitual long-term functioning, not in episodes. So these individuals are energetic and active where as cychothymics are characterized by mood lability. The biphasic disturbance in bipolar illness often consists of the development of episodes that are opposite in polarity to the baseline temperament.
Soft bipolar conditions have many coexisting disorders. Among the most common are substance and alcohol abuse. Substances are often used to enhance the up periods especially with stimulants. Bulimia is comorbid as are other impulse disorders such as gambling and kleptomania. ADHD is another comorbidity which needs to be distinguished from emotional dysregulatory periods in the children of bipolar patients. Professional outstanding achievement is often overrepresented in healthy relatives of bipolar patients.
Part III will focus on other characteristics that can be used as clinical pointers to bipolar disorder.
Bipolar Spectrum Disorder, Part I
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies bipolar disorders into bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified. This categorization implies a bipolar spectrum. Scientific inquiry and clinical literature support bipolar I and II subtypes as well as softer expressions of bipolarity e.g., bipolar II with briefer hypomanias; bipolar II 1/2, depression superimposed on cyclothymia; bipolar III, depression with antidepressant induced hypomania; bipolar IV, depression superimposed on hyperthymic temperament.
Patients falling outside the DSM-IV descriptors but within this soft spectrum are extraordinarily prevalent in psychiatric practice. They often appear in the disguise of depression (about 50% of the patients I see who complain of depression fall within this group), panic disorder, addictions, bulimia and erratic personality disorders. I have found that I need to be compulsive in looking for hypomania because it is often lost in the shuffle of erratic and complex experience and sealed over outside of conscious recall. In some instances other family members need to be queried.
So I am implying that the historical view of bipolar disorder as a division between the extremes of mania and depression is too narrow a concept for bipolar spectrum disorder. Rather it should be seen as containing varying mixtures of depression, hypomania and temperamental instability. If the individual has spontaneous hypomania, they are designated in DSM-IV as bipolar II. However there are depressed patients who experience hypomanic symptoms during the depressive episode which then results in a "Mixed depressive state" which is not found in the DSM-IV. Depressions which are treated with antidepressants that result in the emergence of hypomania are probably related to bipolar II patients but are usually referred to as bipolar III patients. Then there are hyperthymic people, (overenergetic, overconfident, overcheerful) who experience depression. This is referred to as bipolar IV. These patients in the soft spectrum may present with anxiety, depression, panic, and moodiness often precipitated by antidepressants, alcohol or stimulants, or seasonal changes. "Firework-type" experiences like falling in and out of love often lead to sleep disruptions which contribute to instability.
The current classification in DSM-IV is couched in the unipolar-bipolar distinction. More recent thinking and studies and clinical experience supports the existence of a large spectrum of patients with soft or subtle signs of bipolarity. The best known is bipolar II disorder first described by David Dunner et.al. These patients usually present as a major depressive disorder but with a history of spontaneous activated behavior, explosive behavior, irritability, and mood instability. I see these as markers on a path between Kraepelin's conceptualization of manic depressive illness (bipolar I) and unipolar disorder.
Part II that follows will discuss the soft spectrum.
Autism
In the last year I have been asked questions about autism at an increasing frequency by parents, grandparents, aunts, uncles, and siblings who are troubled by the confusing presentation of their developmentally disabled relative. This has accompanied an increasing social awareness of autism by families seeking more research funding and insurance coverage. There has been an influx of researchers from many disciplines seeking to contribute to the research effort by the community of scholars that has been created during the last five or six years. This blog is meant to provide some basic information about this spectrum disorder.
Autism was first recognized as a separate disorder in the early 1940s when two researchers, Leo Kanner and Hans Asperger, working independently in different countries, described several individuals and gave them the name "autism" after the term used by Eugene Bleuler in describing the social isolation found in schizophrenia. They described an intense aloneness, a boy a bubble, and an insistence on sameness or repetition, blended with some areas of satisfactory functioning. Prior to their papers, these children were classified as mild to severe intellectual disability, or seizure disorder patients, or language disabled patients. Undoubtedly the syndrome was not obvious because it is a spectrum and blends with "normality" at one end and severe disability at the other.
The Modified Checklist for Autism in Toddlers (M-CHAT) is designed for use in children up to 18 months but can be used up to 36 months if there are developmental delays and up to 60 months if the child demonstrates impaired social skills. While there are 23 questions in the checklist, 6 can be used as a quick screen. If there are two negatives, then the child should be referred for a detailed evaluation and diagnosis. Remember, these questions are just a screen.
1) Does your child take an interest in other children?
2) Does your child ever use his/her index finger to point, to indicate interest in something?
3) Does your child ever bring objects over to you to show you something?
4) Does your child imitate you? If you were to make a face, would your child imitate it?
5) Does your child respond to his/her name when you call?
6) If you were to point to a toy across the room, does your child look at it?
Autism is diagnosed by abnormal social interactions, compromised communication and repetitive behaviors. This neurodevelopmental disorder has a genetic underpinning. Concordance in identical twins is greater than 90% but less that 10% in fraternal twins or siblings. The genetics have become more complicated recently due to new genetic discoveries. In the past genetic research was focused on single neucleotide polymorphisms (SNPs) in which a single base is substituted in a DNA sequence. However, recently other genetic abnormalities have been discovered in which extra copies of genes are present, e.g., three copies rather than two (copy number variations, CNV) or even long sections duplicated. In addition, spontaneous mutations have been found to be much more common that previously thought. So the child could have the mutation but it is not found in the parents' somatic cells but only in the parental cells that unite to make an offspring. This could account for 25% of all cases. There could be hundreds of loci that convey risk.
These genes encode the proteins that shape and determine the function, stability, and plasticity of the neurons and the connections between neurons called synapses. Neurons form circuits and the circuits and neurons can be either stimulative or inhibitory. The current theory is that there is an imbalance in these two activities resulting in an information overload in autistic individuals so that the world is experienced as overwhelming and impossible to process. There are candidate areas in the brain where this may take place,such as the temporal lobe in the region of the superior temporal gyrus. At the molecular level, adhesion molecules such as neurexin in axons and neuroligin in dendrites attract and bind with tremendous selectivity.
These connections regulate excitatory and inhibitory transmission of information in neural circuits. Were the Beatles on to something when they sang "there is something in the way you move that attracts me like no other"?
