The spectrum of mania

doi:10.1016/0010-440X(81)90049-3

Comprehensive Psychiatry

Volume 22, Issue 1, January–February 1981, Pages 11-20

https://doi.org/10.1016/0010-440X(81)90049-3 Get rights and content

Abstract

The twentieth anniversary issue of Comprehensive Psychiatry spans a period in the history of psychiatry that is undisputedly the era of psychopharmacology. Although it is commonly believed that this era was initiated with the advent of chlorpromazine in the early 1950s, a revisionist's version of history would probably credit Cade¹ who reasoned his way from lethargy in guinea pigs to the control of manic excitement via lithium. Acknowledgment of the impact and applications of this discovery grew very slowly, and it was not until the mid 1960s that the importance of lithium in psychiatry gained wide recognition.

Two volumes^2,3 dealing comprehensively with the role of lithium in research and treatment were published in the 1970s. It has only been relatively recently that mania has emerged as a distinct entity worthy of independent study; an entire volume devoted exclusively to mania edited by Shopsin,⁴ was published in 1979.

During the past two decades, several major scientific advances have contributed to our understanding of mania, including: (1) the advent of psychotherapeutic agents; (2) a renaissance of interest in psychopathology and diagnosis; (3) emphasis on biological and genetic etiologic factors; and (4) the growth of psychiatric epidemiology.

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Cited by (102)

Categorical differentiation of the unipolar and bipolar disorders
2021, Psychiatry Research
Citation Excerpt :
For instance, DSM-5 lists ‘cyclothymic disorder’ as a diagnosis which encompasses hypomanic and depressive symptoms but does not meet the full criteria for a hypomanic or major depressive episode. Klerman (1981) also described a spectrum of ‘elations’ ranging from normal happiness, through to cyclothymic personality, non-psychotic mania and psychotic mania – defining a total of six bipolar sub-types. Additionally, Akiskal and Pinto (1999) proposed seven categories within a ‘bipolar spectrum’: BP-I (full-blown mania), BP-I ½ (depression with protracted hypomania), BP-II (depression with hypomania), BP-II ½ (cyclothymic depression), BP-III (antidepressant drug-associated hypomania), BP-III ½ (bipolar disorder masked and unmasked by stimulant use), and BP-IV (hyperthymic depression).
There has been a longstanding debate as to whether the bipolar disorders differ categorically or dimensionally, with some dimensional or spectrum models including unipolar depressive disorders within a bipolar spectrum model. We analysed manic/hypomanic symptom data in samples of clinically diagnosed bipolar I, bipolar II and unipolar patients, employing latent class analyses to determine if separate classes could be identified. Mixture analyses were also undertaken to determine if a unimodal, bimodal or a trimodal pattern was present. For both a refined 15-item set and an extended 30-item set of manic/hypomanic symptoms, our latent class analyses favoured three-class solutions, while mixture analyses identified trimodal distributions of scores. Findings argue for a categorical distinction between unipolar and bipolar disorders, as well as between bipolar I and bipolar II disorders. Future research should aim to consolidate these results in larger samples, particularly given that the size of the unipolar group in this study was a salient limitation.
The emergence of loss of efficacy during antidepressant drug treatment for major depressive disorder: An integrative review of evidence, mechanisms, and clinical implications
2019, Pharmacological Research
Citation Excerpt :
Please refer to Fig. 1 for a pictorial synthesis of the main mechanisms accounted for loss of response to antidepressants. In 2001, Ghaemi et al. adopted the label of “antidepressant view of the world”, referring to an increase in research interest and a sharp increase in the prescription of antidepressant drugs worldwide [73] as being the (by) product of what Ross Baldessarini conceptualized as the “pharmaco-centric view of the world” in the year 2000 [74], based on the historical contributions of Klerman [75,76]. According to their claims, these latter prominent researchers prompted-out for the risk of over-prescribing antidepressant drugs, especially since the early 1980s, often with poor attention to subsequent outcomes, especially iatrogenic switch into mania and also a potentially deleterious impact on the course of mood disorders in general.
The re-emergence (i.e. ‘breakthrough’) of depressive symptoms despite maintenance treatment of depression with antidepressant drugs is a complex clinical phenomenon referred to as tolerance. Herein we critically appraise evidence from both pre-clinical and clinical studies, focusing on putative mechanisms as well as clinical correlates and implications of the emergence tolerance during antidepressant treatment for major depressive disorder (MDD). It is firstly unclear to what extent this phenotype reflects a pharmacological effect of an antidepressant, is driven by non-adherence, is a marker of latent bipolarity or another comorbidity, a marker of neuroprogression of the underlying disorder or the intrusion of the impact of psychosocial variables into the clinical course. The operational definitions of tolerance and its related phenomena have also been largely inconsistent. Several protective clinical indicators have been proposed, including a rapid-cycling course and comorbid chronic anxiety, whilst poor treatment adherence, proneness to emotional blunting and sub-threshold bipolarity have been identified as possible correlates of tolerance to antidepressant treatment in MDD. Putative neurobiological underpinnings include adaptations in the hypothalamic–pituitary–adrenal (HPA) axis and the serotonergic system. Due to the clinical and diagnostic challenges imposed by the emergence of tolerance to antidepressants, there is an urgent need for upcoming international guidelines to reach a consensus on operational definitions for this complex clinical phenomenon, thus enabling a more precise appreciation of the incidence and correlates of tolerance to antidepressants. Taken together, the present review underscores the need to cautiously weight benefits and risks prior to considering long-term antidepressant treatment for patients with MDD as tolerance may emerge in a subset of patients.
Clinical and psychopathological features associated with treatment-emergent mania in bipolar-II depressed outpatients exposed to antidepressants
2018, Journal of Affective Disorders
Citation Excerpt :
Yet, abrupt changes in mood polarity were described well before the beginning of the psychopharmacological era: manic features observed after a depressive episode were reported as “post-melancholic reactive hyperthymia”, while mania that evolved into depression was referred to as “reactive depression” (Angst and Sellaro, 2000). Possibly, the use of mood-stabilizers (Malhi et al., 2009), second-generation antipsychotics (SGAs) (Fornaro et al., 2016d; Savas et al., 2007; Yatham et al., 2005), as well as development of novel pharmacological avenues (Fornaro et al., 2016b), has been hindered by the so-called “antidepressant view of the world” promoting jaunty prescriptions of antidepressant monotherapies among BD patients or complex polypharmacy which further hinders the understanding of the clinical epidemiology and neurobiology underpinning the TEM phenomena (Fornaro et al., 2011; Ghaemi et al., 2001; Klerman, 1971, 1981; Klerman and Weissman, 1989). The international guidelines for Bipolar Disorders (ISBD) either pose formal counter-recommendations or they either call for prudence concerning the use of antidepressants in BD, especially for long-term antidepressant-monotherapy (Anderson et al., 2008; Fornaro et al., 2012; Goodwin, 2009; Pacchiarotti et al., 2013; Parker et al., 2017; Tundo et al., 2015).
Treatment-emergent affective switch (TEAS), including treatment-emergent mania (TEM), carry significant burden in the clinical management of bipolar depression, whereas the use of antidepressants raises both efficacy, safety and tolerability concerns. The present study assesses the prevalence and clinical correlates of TEM in selected sample of Bipolar Disorder (BD) Type-II (BD-II) acute depression outpatients.
Post-hoc analysis of the clinical and psychopathological features associated with TEM among 91 BD-II depressed outpatients exposed to antidepressants.
Second-generation antipsychotics (SGA) (p = .005), lithium (≤ .001), cyclothymic/irritable/hyperthymic temperaments (p = ≤ .001; p = .001; p = .003, respectively), rapid-cycling (p = .005) and depressive mixed features (p = .003) differed between TEM⁺ cases vs. TEM⁻ controls. Upon multinomial logistic regression, the accounted psychopathological features correctly classified as much as 88.6% of TEM⁺ cases (35/91 overall sample, or 38.46% of the sample), yet not statistically significantly [Exp(B) = .032; p = ns]. Specifically, lithium [B = − 2.385; p = .001], SGAs [B = − 2.354; p = .002] predicted lower rates of TEM⁺ in contrast to the number of lifetime previous psychiatric hospitalizations [B = 2.380; p = .002], whereas mixed features did not [B = 1.267; p = ns].
Post-hoc analysis. Lack of systematic pharmacological history record; chance of recall bias and Berkson's biases. Permissive operational criterion for TEM. Relatively small sample size.
Cyclothymic temperament and mixed depression discriminated TEM⁺ between TEM⁻ cases, although only lithium and the SGAs reliably predicted TEM^+/− grouping. Larger-sampled/powered longitudinal replication studies are warranted to allow firm conclusions on the matter, ideally contributing to the identification of clear-cut sub-phenotypes of BD towards patient-tailored-pharmacotherapy.
A diagnosis of bipolar spectrum disorder predicts diagnostic conversion from unipolar depression to bipolar disorder: A 5-year retrospective study
2015, Journal of Affective Disorders
The major aims of this study were to identify factors that may predict the diagnostic conversion from major depressive disorder (MDD) to bipolar disorder (BP) and to evaluate the predictive performance of the bipolar spectrum disorder (BPSD) diagnostic criteria.
The medical records of 250 patients with a diagnosis of MDD for at least 5 years were retrospectively reviewed for this study.
The diagnostic conversion from MDD to BP was observed in 18.4% of 250 MDD patients, and the diagnostic criteria for BPSD predicted this conversion with high sensitivity (0.870) and specificity (0.917). A family history of BP, antidepressant-induced mania/hypomania, brief major depressive episodes, early age of onset, antidepressant wear-off, and antidepressant resistance were also independent predictors of this conversion.
This study was conducted using a retrospective design and did not include structured diagnostic interviews.
The diagnostic criteria for BPSD were highly predictive of the conversion from MDD to BP, and conversion was associated with several clinical features of BPSD. Thus, the BPSD diagnostic criteria may be useful for the prediction of bipolar diathesis in MDD patients.
The prestige model of spectrum bipolarity
2015, Medical Hypotheses
Citation Excerpt :
A spectrum is a system in which components are contiguously distributed according to rank – best exemplified by the spread of the wavelengths of light – as induced by refraction through a prism. A cyclothymic-bipolar spectrum was first proposed by Akiskal et al. [1], while Klerman [2] suggested a mania spectrum. Ghaemi et al. [3] incepted a model of bipolar spectrum disorder, which bridges the gulf between bipolar I disorder and major depressive disorder.
Because affective pathogenesis is a hard problem for psychiatry, it behoves researchers to develop and test novel models of causality. We examine the notion that the adaptive drive to social investment – prestige – provides clues to the bipolar spectrum. A seven node bipolar spectrum is proposed, based on a putative gradient of “bipolarity”. It is conceived that this gradient may correlate with the drive to social investment (prestige). In order to test this hypothesis with proof of concept data, a case control study categorised 228 subjects into a seven node bipolar spectrum. Whilst controlling for mood elevation and depression, differences in strategic prestige (leadership) motivation (MSPM) between spectrum groups were examined. The bipolar I (S1) node had a greater strategic prestige (leadership) motivation score than the controls (S7) by 21.17 points, 95% CI [8.16, 34.18], p < .001, d = 1.05, while the bipolar II (S2) node was higher than the control group by 16.73 points, 95% CI [0.92, 32.54], p = .030, d = 0.84. Whilst the pseudounipolar (S3) node (those with depression and bipolar family histories; n = 17) had only a marginally statistical difference in MSPM compared to controls (p = .051), the mean difference (16.98) and d value (0.86) indicated an elevated MSPM level. Prestige (leadership) motivation score positively correlated with dimensional lifetime bipolarity (Mood Disorder Questionnaire) score (r_p = 0.47), supporting the spectrum prestige motivation gradient notion. Evidence is presented for a genetic disposition to elevated strategic prestige (leadership) motivation. Sensitivity to Social Inclusion (MSIS), Contingency of Self-Worth (CSW.av) and tension significantly predicted strategic prestige (leadership) motivation (MSPM) score in a multiple regression. – suggesting that a vulnerability of the social self may be a feature of bipolar disorders. The prestige model of spectrum bipolarity offers a new conceptualisation of affective disorders and has received preliminary support.
A critical look at the widening of bipolarity, psychopathology of mood changes and morbid euphoria
2014, Annales Medico-Psychologiques
De la psychose maniaco-dépressive au spectre bipolaire, la psychiatrie actuelle assiste à un élargissement des critères de bipolarité. Pour certains auteurs, la conception d’un spectre élargi serait censée être plus proche de la réalité clinique et représenterait une opportunité pour mieux diagnostiquer cette maladie, d’instaurer en conséquence une prise en charge précoce et adaptée afin d’en limiter les complications. D’autres déplorent une dilution du trouble avec une inflation néfaste d’un diagnostic trop hétérogène pour être opérant, colonisant de manière excessive d’autres pathologies et relayant au second plan la psychopathologie. Nous proposons une réflexion critique sur l’extension actuelle du trouble bipolaire. Pour cela, nous aborderons les glissements nosographiques de la bipolarité à travers l’histoire de la psychiatrie. Ensuite, seront étudiées l’autonomie et les limites de la maladie avec de multiples pathologies mentales, la normalité voire avec le champ de l’avantage. Nous nous interrogerons sur la question d’une bipolarité possible à tous les âges de la vie, sur la réalité du rapport de la maladie avec certains personnages historiques ainsi que sur les facteurs propres à notre époque qui conditionnent ce mouvement d’extension. Enfin, nous proposerons une analyse psychopathologique de l’euphorie morbide et des différents mouvements de l’humeur. L’ensemble de nos considérations confrontent les données actuelles aux écrits de psychiatres classiques et d’auteurs inspirés par la psychanalyse et la phénoménologie.
From manic-depressive psychosis to bipolar spectrum, today's psychiatry allows us to observe a widening of bipolar criteria. This article aims at studying this evolution, its consequences with a critical look and the psychopathology of mood changes and morbid euphoria.
All of our considerations refer to current data on bipolar disorders (review with Medline and Science Direct) compared with studies from classical psychiatrists (Kraepelin, Ey) and various authors inspired by psychoanalysis (Freud, Racamier) and phenomenology (Binswanger, Tellenbach, Tatossian).
Many contemporary authors encourage clinicians to detect bipolar disorders from symptoms, early signs and attenuated or atypical expressions. The concept of a widened spectrum is supposed to be closer to clinical reality and it would be an opportunity to diagnose this disease and its deleterious consequences better and thus to set up an appropriate therapy at an early stage. Other authors, on the other hand, deplore a dilution of bipolar disorders together with harmful diagnostic inflation around a concept that has become too heterogeneous to be effective, that subjugates or interferes with other pathologic entities in an excessive manner and abandoning a psychopathological approach. In this view, we shall analyze the nosographic shifts of bipolar disorders throughout the history of psychiatry, from manic-depressive psychosis to bipolar disorder and spectrum. We shall then scrutinize the autonomy and limitations related to bipolar disorders as opposed to normality, confusing clinical presentations and other major mental diseases: Psychosis, depression, pathological personality, anxiety, impulse-control, attention deficit-hyperactivity, addiction and psycho-organic disorders. This work shall first introduce a discussion on the concept of bipolar disorders for children, and then through the case of some historical figures. Then we will deal with the contemporary social factors that are currently furthering the extension of this diagnosis. Last, this article sheds a light on psychopathological specificities of mania – the cornerstone in bipolar disorders – mood changes and morbid euphoria.
We think that classic psychiatry, phenomenology and psychoanalysis would act as a guiding light through this debate and could help the clinician in this daily practice. Mood variations require a careful clinical observation and a rigorous set of interpretation, before being specified too excessively or hastily as a symptom of a real bipolarity.

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¹: Gerald L. Klerman, M.D.: Administrator, Alcohol, Drug Abuse, and Mental Health Administration ( (ADAMHA). Publich Health Service, Department of Health and Human Services, Rockville, Md.

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The spectrum of mania

Abstract

Compr Psychiatry

Lithium salts in the treatment of psychotic excitement

Med J Australia

The affective disorders: Clinical and epidemiological aspects

Die temperamente in den familien der monopolaren und bipolaren phasischen psychosen

Psychiatr Neurol

Bipolar affective disorder-techniques and results of treatment

Am J Psychotherapy

Genetic forms of manic illness and the question of atypical mania