Cassano G B, Dell'Osso L, Frank E, Miniati M, Fagiolini A, Shear K, Pini S, Maser J
Department of Psychiatry, University of Pisa, Italy.
J Affect Disord. 1999 Aug;54(3):319-28. doi: 10.1016/s0165-0327(98)00158-x.
Failure to recognize subthreshold expressions of mania contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive ones. These include the lack of subjective suffering, enhanced productivity, ego-syntonicity, and diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' tendency to subsume persistent or even alternating symptoms among personality disorders. Furthermore, the central diagnostic importance placed on alterations in mood distracts clinicians from paying attention to other more subtle but clinically meaningful symptoms, such as changes in energy, neurovegetative symptoms and distorted cognitions. Although officially accepted in both ICD-10 and DSM-IV, we believe bipolar II disorder is underdiagnosed because of inattention to symptoms of hypomania. Moreover, by requiring the presence of both full-blown hypomanic and major depressive episodes, current nosology fails to include symptoms or signs which are mild and do not meet threshold criteria. There is already agreement in the field that such symptoms are important for depression. We now propose that attention should also be devoted to mild symptomatic manifestations of a manic diathesis, even if such manifestations may sometimes enhance quality of life. The term 'spectrum' is used to refer to the broad range of such manifestations of a disorder from core symptoms to temperamental traits. Spectrum manifestations may be present during, between, or even in the absence of, an episode of full-blown disorder. We have developed a structured clinical interview to assess the mood spectrum (SCI-MOODS) to evaluate the whole range of depressive and manic symptoms. This instrument is currently undergoing psychometric testing procedures. Similar to the SCID interview, the SCI-MOODS interview provides a separate rating for each of the major DSM-IV symptoms, but the latter also identifies and rates subthreshold and atypical manifestations. This paper presents the concept of a subthreshold bipolar disorder and discusses the potential epidemiological, diagnostic and therapeutic relevance of such a spectrum conditions. We also describe the SCI-MOODS interview used reliably to identify the occurrence of a bipolar spectrum condition. Obviously a great deal of systematic research needs to be conducted to ascertain the reliability and validity of subthreshold bipolarity as summarized in this paper and embodied in our instrument.
未能识别躁狂的阈下表现导致双相情感障碍经常被漏诊。与类似的单纯抑郁症状相比，阈下躁狂症状的识别率较低有几个原因。这些原因包括缺乏主观痛苦、生产力提高、自我和谐，以及许多躁狂和轻躁狂症状相关的昼夜和季节性节律，还有精神科医生倾向于将持续甚至交替出现的症状归为人格障碍。此外，对情绪改变的核心诊断重要性使临床医生忽略了其他更细微但具有临床意义的症状，如精力变化、植物神经症状和认知扭曲。尽管国际疾病分类第10版（ICD - 10）和精神疾病诊断与统计手册第4版（DSM - IV）都正式认可，但我们认为双相II型障碍因未关注轻躁狂症状而被漏诊。此外，由于要求同时存在典型的轻躁狂发作和重度抑郁发作，当前的疾病分类学未能纳入那些轻微且未达到阈标准的症状或体征。该领域已经达成共识，即这些症状对抑郁症很重要。我们现在提议，即使这些轻微症状有时可能提高生活质量，也应关注躁狂素质的轻微症状表现。术语“谱系”用于指代从核心症状到气质特征的一系列广泛的疾病表现。谱系表现可能在典型疾病发作期间、发作之间甚至在无典型发作时出现。我们开发了一种结构化临床访谈来评估情绪谱系（SCI - MOODS），以评估抑郁和躁狂症状的全范围。该工具目前正在进行心理测量测试程序。与精神障碍诊断访谈问卷（SCID）访谈类似，SCI - MOODS访谈对DSM - IV的每个主要症状都进行单独评分，但后者还识别并评估阈下和非典型表现。本文介绍了阈下双相情感障碍的概念，并讨论了这种谱系状况在流行病学、诊断和治疗方面的潜在相关性。我们还描述了可靠地用于识别双相谱系状况的SCI - MOODS访谈。显然，需要进行大量系统研究，以确定本文总结并体现在我们工具中的阈下双相性的可靠性和有效性。
