Diagnosis of bipolar disorder: who is in a mixed state?

Mapping prodromal symptoms in patients with bipolar disorder: A network perspective

Bipolar disorder (BD) is a major mental disorder that significantly impairs behavior and social functioning. This study assessed the network structure of prodromal symptoms in patients with BD prior to their index mood episode. Semi-structured interviews were conducted with the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R) to examine patients' prodromal symptoms. Network analysis was conducted to elucidate inter-relations between prodromal symptoms. A total of 120 eligible patients participated in this study. Network analysis indicated that the observed model was stable. The edge Mania3-Depression9 ('Racing thoughts' - 'Thinking about suicide', edge weight = 14.919) showed the strongest positive connection in the model, followed by the edge Mania1-depression1 ('Extremely energetic/active' - 'Depressed mood', edge weight = 14.643). The only negative correlation in the model was for Mania7-depression2 ('Overly self-confident' - 'Tiredness or lack of energy', edge weight = -1.068). Nodes Mania3 ('Racing thoughts'), Depression9 ('Thinking about suicide'), Mania1 ('Extremely energetic/active'), and Depression1 ('Depressed mood') were the most central symptoms. Both depressive and manic or hypomanic symptoms appeared in the prodromal phase. Symptoms reflecting 'Racing thoughts', 'Thinking about suicide', 'Extremely energetic/active', and 'Depressed mood' should be thoroughly assessed and targeted as crucial prodromal symptoms in interventions to reduce the risk of BD episodes.

Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features

Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Clinical correlates of DSM-5 mixed features in bipolar disorder: A meta-analysis

BACKGROUND

Systematic data on clinical correlates of mixed features in bipolar disorder are not available, so far. We conducted a systematic review and meta-analysis estimating the association between DSM-5 mixed features and candidate characteristics in depressive and manic/hypomanic episodes.

METHODS

We included observational studies indexed in the main electronic databases. The association between DSM-5 mixed features and relevant correlates was estimated using odds ratio (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs), for categorical and continuous variables, respectively. Analyses were based on random effects models.

RESULTS

Eight studies were included, involving 3070 individuals (1495 with a major depressive episode and 1575 with hypo/manic episode). No clinical characteristics were associated with mixed features in subjects with a depressive episode. Among subjects with a manic/hypomanic episode, those with mixed features were more likely to have a history of suicide attempts (OR: 2.37; 95%CI: 1.42 to 3.94; I²=39.7%), co-occurring anxiety disorders (OR: 2.67; 95%CI: 1.28 to 5.57; I²=0%), and a rapid cycling course (OR=4.23; 95%CI: 1.29 to 13.81; I²=0%), with less severe manic symptoms (SMD=-0.40; 95%CI: -0.65 to -0.16; I²=0%).

LIMITATIONS

(1) the heterogeneity of methods across studies and the inconsistency of findings; (2) the limited amount of data on correlates of DSM-5 mixed features; (3) the possible influence of publication bias.

CONCLUSIONS

Findings of this meta-analysis show that mixed features among individuals with a manic/hypomanic episode may identify a special clinical population, characterized not only by depressive symptoms, but also by anxiety, rapid cycling, and suicidality.

Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach

OBJECTIVE

Remitted bipolar disorder (BD) patients frequently present with chronic mood instability and emotional hyper-reactivity, associated with poor psychosocial functioning and low-grade inflammation. We investigated emotional hyper-reactivity as a dimension for characterization of remitted BD patients, and clinical and biological factors for identifying those with and without emotional hyper-reactivity.

METHOD

A total of 635 adult remitted BD patients, evaluated in the French Network of Bipolar Expert Centers from 2010-2015, were assessed for emotional reactivity using the Multidimensional Assessment of Thymic States. Machine learning algorithms were used on clinical and biological variables to enhance characterization of patients.

RESULTS

After adjustment, patients with emotional hyper-reactivity (n = 306) had significantly higher levels of systolic and diastolic blood pressure (P < 1.0 × 10^-8 ), high-sensitivity C-reactive protein (P < 1.0 × 10^-8 ), fasting glucose (P < 2.23 × 10^-6 ), glycated hemoglobin (P = 0.0008) and suicide attempts (P = 1.4 × 10^-8 ). Using models of combined clinical and biological factors for distinguishing BD patients with and without emotional hyper-reactivity, the strongest predictors were: systolic and diastolic blood pressure, fasting glucose, C-reactive protein and number of suicide attempts. This predictive model identified patients with emotional hyper-reactivity with 84.9% accuracy.

CONCLUSION

The assessment of emotional hyper-reactivity in remitted BD patients is clinically relevant, particularly for identifying those at higher risk of cardiometabolic dysfunction, chronic inflammation, and suicide.

Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines

OBJECTIVE

This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states.

METHOD

The MEDLINE/PubMed and EMBASE databases were systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II.

RESULTS

The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood-stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines.

CONCLUSION

The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.

Is "early intervention" in bipolar disorder what it claims to be?

BACKGROUND

The notion of early intervention is understandably appealing for conditions such as bipolar disorder (BD), a chronic life-long illness that increases risk of suicide and diminishes quality of life. It is purported that intervening early in the course of the illness with suitable interventions could substantially alter the trajectory of BD and improve outcomes. However, while there are obvious benefits to the prompt commencement of treatment, it is important to consider the gaps in our understanding regarding the aetiopathogenesis of bipolar disorder-upon which the paradigm of early intervention is predicated.

METHODS

A literature search was undertaken using recognized search engines: PubMed, PsycINFO Medline, and Scopus, along with auxiliary manual searches.

RESULTS

This review first examines how the unpredictable nature of BD creates substantial difficulties when determining an optimal therapeutic target for early intervention. Second, the challenges with identifying appropriate populations and apposite times for early intervention strategies is discussed. Finally, the risks associated with intervening early are examined, highlighting the potential harmful effects of initiating medication.

CONCLUSION

Early intervention for BD is a potentially useful strategy that warrants investigation, but until the emergence and trajectory of the illness are definitive, and a clear view of key targets is achieved, a more conservative approach to treating nascent BD and its antecedent symptoms is needed.

Dysphoric mania, mixed states, and mania with mixed features specifier: are we mixing things up?

Various terms have been used to describe mania when it is accompanied by depressive symptoms. In this article, we attempt to define and discuss 3 of these terms: dysphoric mania, mixed state, and mania with mixed features specifier. We conclude that whatever term is used, it is important to be aware that mania is more often unpleasant than pleasant, and that the unpleasantness is not limited to depression.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Trends in diagnosis of bipolar disorder: Have the boundaries changed?

OBJECTIVE

There are concerns that the diagnostic boundaries of bipolar disorder have expanded. This study seeks evidence of change in diagnostic practice at three boundaries: the 'lower' boundary with subclinical mood conditions, the 'lateral' boundary with other mental health conditions (psychotic, anxiety, substance and personality disorders) and the 'internal' boundary within affective disorders.

METHODS

Diagnoses recorded in health system administrative data collections were used as a measure of clinician diagnostic behaviour. We examined all diagnoses made by public (state operated) inpatient and community mental health services in New South Wales, Australia, from 2003 to 2014.

RESULTS

A total of 31,746 people had at least one recorded diagnosis of bipolar disorder in the period. There was a significant upward trend in the age-standardised population rate of diagnosis of bipolar disorder. Bipolar disorders made up an increasing proportion of psychosis diagnoses. There was no increase in the rate of comorbid diagnosis of bipolar disorders with non-psychotic disorders or in the likelihood of diagnosis of bipolar disorder at first or subsequent episodes of depression. There were significant reductions in diagnoses of schizophrenia, particularly in younger people.

CONCLUSION

There may be some increase in diagnoses of bipolar disorder in New South Wales public mental health services. However, some changes in diagnosis, particularly in younger adults, may reflect movement away from diagnoses of schizophrenia towards a range of other diagnoses, rather than specific movement towards bipolar disorder. Expansion of bipolar disorder may have been more marked in private practice settings and may have involved the poorly defined bipolar II subtype.

[Mixed depression and DSM-5: A critical review]

BACKGROUND

Mixed depression is a depressive syndrome characterized by the presence, along with the typical depressive symptoms of depression, of those of over activation and excitation. If sometimes this activation is expressed by classical hypomanic symptoms, it is often observed by means of more subtle expression: inner tension, crowded thoughts, dramatic expression suffering, and unproductive agitation. It is important to identify mixed depression because such patients are particularly at risk of suicidal behaviors, substance abuse and therapeutic resistance. Even if therapeutic strategies continue to be discussed, treatments should rely on mood stabilizers and antipsychotics instead of antidepressants as in pure depression. Even though the concept of mixed depression has been described for more than twenty years, first by Koukopoulos and then by other authors, it had been little studied, especially because it did not appear in international psychiatric classifications. The DSM-IV supported a very narrow conception of the mixed states because the criteria required simultaneous full manic and full depressive syndromes, corresponding only to some dysphoric manias. The recently published DSM-5 proposes modifications in mood and bipolar disorder classifications, and especially introduces the possibility to specify depressive and manic episodes with "mixed features". To diagnose depression with mixed features, a full depressive syndrome has to be present together most of time with three hypomanic symptoms, except symptoms that are considered as overlapping (that can be observed either in mania or in depression), i.e. agitation, irritability and distractibility.

METHODS

Critical analysis of DSM criteria and review of literature.

RESULTS

We first analyzed the clinical relevance of the definition of depression with mixed features which could correspond to mixed depression. The problem is that the hypomanic symptoms allowed by the manual lead to symptom associations that are rather illogical (as euphoria with depression) or improbable (as increased or excessive involvement in activities that have a high potential for painful consequences). Also, some more specific symptoms that can be observed in mixed depression are not mentioned (such as hypersensitivity to light or noise, absence of motor retardation, dramatic expressivity of suffering). The DSM-5, as did DSM-IV, refers to an understanding of mixed depression as a simple addition of depressive and manic symptoms. The classification does not take into account that the symptoms could be rather different from hypomania, as the expression of an overactive thought in a depressed mind. Secondly, we reviewed cohort studies using the DSM-5 criteria (or similar criteria with the exclusion of overlapping symptoms), and as a consequence of the poorly defined symptoms, we found that the diagnosis of mixed depression according to DSM-5 is almost impossible, either in unipolar or in bipolar depression.

CONCLUSIONS

We think, with others, that the definition of the mixed depression by the DSM-5 is not clinically relevant and misses important information about the concept. Clinicians can be attentive to the identification of mixed character in depression, even if DSM-5 criteria are not fully met. Unfortunately, the DSM-5 definition could undermine research efforts for a better understanding of epidemiology, phenomenology and therapeutics of mixed depression. We propose and discuss alternative solutions for defining mixed depression, such as the absence of exclusion of "overlapping" symptoms, a more insighted phenomenology, or a dimensional approach.

Antidepressants in bipolar depression: yes, no, maybe?

Antidepressants are widely used in the treatment of bipolar depression despite relatively meagre evidence for their efficacy and significant concerns that their prescription can precipitate an acute affective switch into mania/hypomania and that long-term administration can lead to mood instability. Therefore, the use of antidepressants to treat bipolar depression is an important but contentious issue that two recent studies, which provide important new evidence, attempt to inform. One study suggests that long-term continuation of antidepressants in patients with rapid-cycling bipolar disorder leads to a threefold increase in mood episodes during the first year of follow-up-supporting the notion that antidepressants can cause more harm than good, and that they should be used sparingly. However, this is countered by findings from the other study, which suggests that continuation antidepressant monotherapy provides patients with bipolar II disorder reasonable prophylaxis, and that the risk of switching into mania/hypomania is actually quite low. In addition to contrary findings both studies are modest in sample sizes and have significant design limitations and hence the debate remains unresolved. This brief perspective presents both views in the context of evidence and provides some key insights into the complexity of this challenging but common clinical issue.

Diagnosis, Epidemiology and Management of Mixed States in Bipolar Disorder

Approximately 40% of patients with bipolar disorder experience mixed episodes, defined as a manic state with depressive features, or manic symptoms in a patient with bipolar depression. Compared with bipolar patients without mixed features, patients with bipolar mixed states generally have more severe symptomatology, more lifetime episodes of illness, worse clinical outcomes and higher rates of comorbidities, and thus present a significant clinical challenge. Most clinical trials have investigated second-generation neuroleptic monotherapy, monotherapy with anticonvulsants or lithium, combination therapy, and electroconvulsive therapy (ECT). Neuroleptic drugs are often used alone or in combination with anticonvulsants or lithium for preventive treatment, and ECT is an effective treatment for mixed manic episodes in situations where medication fails or cannot be used. Common antidepressants have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms; thus, they are not recommended during mixed episodes. A greater understanding of pathophysiological processes in bipolar disorder is now required to provide a more accurate diagnosis and new personalised treatment approaches. Targeted, specific treatments developed through a greater understanding of bipolar disorder pathophysiology, capable of affecting the underlying disease processes, could well prove to be more effective, faster acting, and better tolerated than existing therapies, therefore providing better outcomes for individuals affected by bipolar disorder. Until such time as targeted agents are available, second-generation neuroleptics are emerging as the treatment of choice in the management of mixed states in bipolar disorder.

DSM-5-defined 'mixed features' and Benazzi's mixed depression: which is practically useful to discriminate bipolar disorder from unipolar depression in patients with depression?

AIMS

Irritability, psychomotor agitation, and distractibility in a major depressive episode (MDE) should not be counted as manic/hypomanic symptoms of DSM-5-defined mixed features; however, this remains controversial. The practical usefulness of this definition in discriminating bipolar disorder (BP) from major depressive disorder (MDD) in patients with depression was compared with that of Benazzi's mixed depression, which includes these symptoms.

METHODS

The prevalence of both definitions of mixed depression in 217 patients with MDE (57 bipolar II disorder, 35 BP not otherwise specified, and 125 MDD cases), and their operating characteristics regarding BP diagnosis were compared.

RESULTS

The prevalence of both Benazzi's mixed depression and DSM-5-defined mixed features was significantly higher in patients with BP than it was in patients with MDD, with the latter being quite low (62.0% vs 12.8% [P < 0.0001], and 7.6% vs 0% [P < 0.0021], respectively). The area under the receiver operating curve for BP diagnosis according to the number of all manic/hypomanic symptoms was numerically larger than that according to the number of manic/hypomanic symptoms excluding the above-mentioned three symptoms (0.798; 95% confidence interval, 0.736-0.859 vs 0.722; 95% confidence interval, 0.654-0.790). The sensitivity/specificity of DSM-5-defined mixed features and Benazzi's mixed depression for BP diagnosis were 5.1%/100% and 55.1%/87.2%, respectively.

CONCLUSIONS

DSM-5-defined mixed features were too restrictive to discriminate BP from MDD in patients with depression compared with Benazzi's definition. To confirm this finding, studies that include patients with BP-I and using tools to assess manic/hypomanic symptoms during MDE are necessary.

DSM-5 reviewed from different angles: goal attainment, rationality, use of evidence, consequences--part 1: general aspects and paradigmatic discussion of depressive disorders

DSM-5 was published in 2013 after about 10 years of preparation. Part 1 of this paper discusses several more general aspects of DSM-5 and offers a detailed, paradigmatic analysis of changes made to the chapter on depressive disorders. The background for the changes is analysed on the basis of a PubMed search and review papers on the classification of mental disorders in general and on empirical knowledge about individual disorders. Contrary to the original plans, DSM-5 has not introduced a primarily dimensional diagnostic system but has widely preserved the categorical system of disorders. Also, it has not adopted a more neurobiological approach to disorders by including biological markers to increase the objectivity of psychiatric diagnoses but has maintained the primarily symptom-based, descriptive approach. The criteria for some disorders have been changed, including affective, schizophrenic and addiction disorders, and a few new disorders have been added. A minimal version of the dimensional approach was realised through the introduction of several transnosological specifiers and the option to make symptom- or syndrome-related severity and dimensional assessments. These specifiers and assessments might allow a more individualised description of a patient's psychopathological state and more personalised treatment. However, most of the symptom- and syndrome-related assessments are not mandatory and therefore may not be used in clinical practice.

Carving bipolarity using a lithium sword

The classification of mood disorders lacks precision and consequently there has been no recent meaningful advance in their treatment. By virtue of its therapeutic specificity, lithium responsivity offers an opportunity to diagnose a definitive subtype of mood disorders that may provide a platform for the development of targeted therapy.

The bipolar spectrum: conceptions and misconceptions

OBJECTIVE

This review aims to address concerns about the potential overinclusiveness and vagueness of bipolar spectrum concepts, and also, concerns about the overlap between bipolar illness and borderline personality.

METHOD

Narrative review based on historical and empirical studies.

RESULTS

Bipolar disorder (BD) and major depressive disorder (MDD) came to be separate entities with the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), in contrast to the Kraepelinian manic-depressive insanity (MDI) concept, which included both. The bipolar spectrum concept is a return to this earlier Kraepelinian perspective. Further, very different features differentiate the disease of bipolar illness (family history of bipolar illness, severe recurrent mood episodes with psychomotor activation) from the clinical picture of borderline personality (dissociative symptoms, sexual trauma, parasuicidal self-harm). The term 'disorder' obfuscates an ontological difference between diseases, such as manic-depressive illness, and clinical pictures, such as hysteria/post-traumatic stress disorder/dissociation/borderline personality.

CONCLUSIONS

Bipolar spectrum concepts are historically rooted in Kraepelin's manic-depressive illness concept, are scientifically testable, and can be clearly formulated. Further, they differ in kind from traumatic/dissociative conditions in ways that can be both historically and scientifically established.