Akiskal Hagop S, Akiskal Kareen K, Perugi Giulio, Toni Cristina, Ruffolo Giuseppe, Tusini Giuseppe
Department of Psychiatry at the University of California at San Diego, and Veterans Administration Medical Center, La Jolla, CA,USA.
J Affect Disord. 2006 Dec;96(3):239-47. doi: 10.1016/j.jad.2006.08.010. Epub 2006 Sep 14.
In DSM-IV, bipolar II (BP-II) disorder is defined by depression and hypomania. There is little appreciation of affective instability, often associated with anxiety-particularly panic disorder and agoraphobia (PDA)-comorbidity. This association has genetic-familial implications, which we believe must be incorporated in refining the BP-II phenotype suitable for genotyping purposes.
We examined in a semi-structured format 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features and separated them into two subgroups according to the co-occurring criteria for PDA. They were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL 90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features, as well as Axis I and II comorbidity and temperamental dispositions, particularly cyclothymic instability.
Fifty (46.7%) of our patients met the DSM-IV criteria for PDA. In terms of significant results, PDA+ was more frequently female, had higher number of hypomanic episodes, and stressors; they were also more often BP-II, and cyclothymic. Ratings of reactivity, somatization, OCD and phobic anxiety too were significantly higher among the PDA+. In related analyses, most AD (75.7%) met criteria for BP-II; the BP-II subgroup was characterized by PDA, as well as borderline personality features and cyclothymic and hyperthymic temperaments.
Correlational clinical study in which clinicians could not be kept entirely blind to the variables under investigation.
In line with the description by the French psychiatrist Pierre Kahn a century earlier, cyclothymic reactivity and neurotic features (i.e., atypicality and panic attacks) appear relevant to the definition of what today we consider BP-II disorder. These data, which are in line with current familial-genetic models of this disorder, suggest that the DSM-IV characterization of BP-II must be enriched by greater emphasis on temperamentally based mood and anxious reactivity. Such phenotypic characterization is likely to assist in better genotyping. Previous work by us further suggests the relevance of bulimic and addictive tendencies, as well as "borderline personality" diagnosis in the proband and/or the family. We submit that these conditions, rather than being "comorbid," constitute, along with BP-II, a spectrum of overlapping underlying genetic diatheses.
在《精神疾病诊断与统计手册》第四版（DSM-IV）中，双相II型（BP-II）障碍由抑郁和轻躁狂定义。人们对情感不稳定的认识不足，情感不稳定常与焦虑相关，尤其是惊恐障碍和广场恐惧症（PDA）共病。这种关联具有遗传-家族意义，我们认为在完善适用于基因分型的BP-II表型时必须纳入这一点。
我们以半结构化形式检查了107例符合DSM-IV标准的具有非典型特征的重度抑郁发作患者，并根据PDA的共病标准将他们分为两个亚组。根据非典型抑郁诊断量表（ADDS）、霍普金斯症状清单（HSCL 90）和汉密尔顿抑郁评定量表（HRSD）及其针对反向植物神经特征的修订版，以及轴I和轴II共病情况和气质倾向，尤其是环性心境不稳定，对他们进行了进一步评估。
我们的患者中有50例（46.7%）符合PDA的DSM-IV标准。在显著结果方面，PDA+组女性更为常见，轻躁狂发作次数更多，应激源更多；他们也更常为BP-II型，且具有环性心境特征。PDA+组在反应性、躯体化、强迫症和恐惧焦虑方面的评分也显著更高。在相关分析中，大多数AD（75.7%）符合BP-II标准；BP-II亚组的特征是PDA，以及边缘型人格特征和环性心境及情感高涨气质。
相关性临床研究，临床医生无法对所研究的变量完全保持盲态。
与一个世纪前法国精神病学家皮埃尔·卡恩的描述一致，环性心境反应性和神经症特征（即非典型性和惊恐发作）似乎与我们今天所认为的BP-II障碍的定义相关。这些数据与该障碍当前的家族-遗传模型一致，表明DSM-IV对BP-II的特征描述必须通过更加强调基于气质的情绪和焦虑反应性来加以丰富。这种表型特征描述可能有助于更好地进行基因分型。我们之前的工作进一步表明了贪食和成瘾倾向以及先证者和/或家族中“边缘型人格”诊断的相关性。我们认为这些情况与BP-II一起，并非“共病”，而是构成了一系列重叠的潜在遗传素质。
