Camacho Alvaro, Akiskal Hagop S
International Mood Center, Department of Psychiatry, University of California, San Diego (UCSD), 9500 Gilman Drive, La Jolla, CA 92093-0603R, USA.
J Affect Disord. 2005 Mar;85(1-2):217-30. doi: 10.1016/j.jad.2003.10.014.
Stimulant abuse and dependence in confusing admixtures with features of bipolar disorder has been variously conceptualized. DSM-IV-TR rules tend to be liberal in permitting the diagnosis of substance-induced disorder, and rather strict for a bipolar diagnosis in such cases. Accordingly, if bipolarity is ever considered in this interface, it usually pertains to syndromal bipolar I disorder.
We therefore focused on the more prevalent but relatively neglected admixture of stimulant abuse with bipolar II and lesser degrees of bipolarity. We examined in our dual diagnosis program the longitudinal progression of the dual pathology in 10 patients who had proven refractory to past efforts to treat the stimulant component. In doing so, we wished to better delineate the nature of the clinical interface of the stimulant bipolar spectrum and its response to anticonvulsant mood stabilizers.
In nearly all cases cyclothymic and hyperthymic traits preceded the use of stimulants by years, which seemed to serve the purpose of controlling or maintaining the subthreshold rewarding mood condition. Eventually clinically more ominous and socially destructive pathology evolved, with contributions from both the bipolar diathesis and the addictive process. Seven of 10 cases had bipolar familial indicators. Nearly all evidenced hypomanic and/or irritable depressive states with mixed features during protracted sobriety from the stimulant. Except for two of the 10 patients, substantial (30-45 point) gains were made on DSM-IV-TR axis V general assessment of functioning (GAF) scores with the use of largely "mood-stabilizing" anticonvulsants. This was paralleled with the reduction of craving. These data highlight the human dimensions of the bipolar-stimulant abuse interface, and document functional outcomes (rather than mere changes in rating scales which may not necessarily reflect clinically relevant improvement).
Open case series of 10 patients.
We propose a bipolar-stimulant spectrum-what the senior author has elsewhere labeled bipolar III-1/2-where subthreshold bipolar traits are complicated by stimulant abuse, eventually leading to pathology characteristic of both disorders. The contribution of bipolarity to this spectrum is supported by: (1) premorbid cyclothymic and hyperthymic traits; (2) familial bipolarity; (3) presence of subthreshold bipolar signs and symptoms during protracted sobriety. We further submit that anticonvulsants in this spectrum not only treat the acute escalation of activated and mixed depressive states, withdrawal phenomena, and craving for the stimulant, but also the craving for activation and mood enhancement of the underlying temperament. We submit that the latter might be crucial for the successful attenuation of the underlying diathesis for stimulant seeking behavior, abuse and dependence.
兴奋剂滥用及依赖与双相情感障碍特征相混淆的情况，其概念化方式多种多样。《精神疾病诊断与统计手册》第四版修订版（DSM-IV-TR）规则在允许诊断物质所致障碍方面往往较为宽松，而在此类情况下对双相情感障碍的诊断则较为严格。因此，如果在此类情况中考虑双相情感障碍，通常指的是双相I型综合征。
因此，我们聚焦于兴奋剂滥用与双相II型及较轻程度双相情感障碍更为常见但相对被忽视的混合情况。我们在双诊断项目中研究了10例对过去治疗兴奋剂成分的努力已证明无效的患者中双病理的纵向进展。在此过程中，我们希望更好地描绘兴奋剂双相谱系的临床界面性质及其对抗惊厥心境稳定剂的反应。
几乎在所有病例中，环性心境障碍和情感高涨特质在使用兴奋剂数年前就已存在，这似乎起到了控制或维持阈下愉悦心境状态的作用。最终，临床上更严重且具有社会破坏性的病理状况逐渐发展，这是由双相素质和成瘾过程共同导致的。10例中有7例有双相情感障碍家族指标。几乎所有患者在长时间停用兴奋剂期间都表现出具有混合特征的轻躁狂和/或易激惹抑郁状态。除10例中的2例患者外，使用主要为“心境稳定”的抗惊厥药物后，《精神疾病诊断与统计手册》第四版修订版轴V功能总体评估（GAF）分数有显著提高（30 - 45分）。这与渴望程度的降低相平行。这些数据突出了双相情感障碍 - 兴奋剂滥用界面的人文维度，并记录了功能结果（而非仅仅是评分量表上的变化，评分量表变化不一定反映临床相关改善）。
10例患者的开放性病例系列。
我们提出一个双相 - 兴奋剂谱系——资深作者在其他地方将其标记为双相III - 1/2——其中阈下双相特质因兴奋剂滥用而变得复杂，最终导致两种障碍的特征性病理状况。双相情感障碍对该谱系的影响得到以下因素支持：（1）病前环性心境障碍和情感高涨特质；（2）家族性双相情感障碍；（3）长时间戒断兴奋剂期间存在阈下双相体征和症状。我们进一步认为，该谱系中的抗惊厥药物不仅能治疗激活和混合抑郁状态的急性加重、戒断现象以及对兴奋剂的渴望，还能治疗对潜在气质的激活和心境增强的渴望。我们认为，后者对于成功减轻寻求兴奋剂行为、滥用和依赖的潜在素质可能至关重要。
