Bordering on the bipolar: a review of criteria for ICD-11 and DSM-5 persistent mood disorders

[ICD-11: New revision and impact of this classification in psychiatry]

OBJECTIVES

After more than 20 years of work, the World Health Organization's efforts have culminated in the adoption of the 11th revision of the International Classification of Diseases (ICD-11). The process has been guided by the principles of global applicability, scientific validity, and clinical utility. The update of the chapter on mental, behavioral, and neurodevelopmental disorders (MBND) within the ICD-11 has generated widespread interest worldwide. This has raised various questions about the status of mental disorder nosology, changes to diagnostic guidelines, and the potential implications for clinical practice.

METHODS

We conducted a narrative analysis of the literature in four different languages to track the various stages of the ICD-11 revision and to highlight the major changes. We searched databases such as PubMed, EMBASE, MEDLINE, and Google Scholar, and consulted the official websites of the WHO, APA, and UNICEF. A total of 79 articles from 40 different editorials and websites were analyzed and included in this study.

RESULTS

The new chapters on mental disorders in the ICD-11 include 21 groups, as opposed to the 11 in the ICD-10. The changes aim to align the diagnoses with those of the DSM-5 and introduce a new chapter structure, new diagnostic categories, modifications to diagnostic criteria, and advancements in dimensionality. For the first time in the history of the ICD, sleep and wakefulness disorders, as well as disorders related to sexual health, have been addressed in separate chapters of the international classification. Four new diagnoses have been added: complex post-traumatic stress disorder (PTSD), gaming disorder, prolonged grief disorder, and compulsive sexual behavior which replaces "excessive sexual activity" in the ICD-10. Moreover, the ICD-11 revision has brought about a fundamental change in the clinical conceptualization of addictive behaviors, introducing a distinction between substance use disorders and addictive behaviors. The criteria for many existing conditions have been revised, particularly those related to bipolar disorders, eating disorders, and gender identity disorders.

CONCLUSIONS

The revision process for mental, behavioral, and neurodevelopmental disorders in the ICD-11 has witnessed unprecedented participation in the history of mental disorder classification. These changes could have a significant impact on clinical practice in psychiatry. However, it is crucial to examine the advantages and limitations of this new classification compared to previous versions.

Resting-state fMRI in depressive and (hypo)manic mood states in bipolar disorders: A systematic review

OBJECTIVE

Abnormalities in spontaneous brain activity, measured with resting-state functional magnetic resonance imaging (rs-fMRI), may be key biomarkers for bipolar disorders. This systematic review compares rs-fMRI findings in people experiencing a bipolar depressive or (hypo)manic episode to bipolar euthymia and/or healthy participants.

METHODS

Medline, Web of Science and Embase were searched up until April 2021. Studies without control group, or including minors, neurological co-morbidities or mixed episodes, were excluded. Qualitative synthesis was used to report results and risk of bias was assessed using the National Heart, Lung and Blood Institute tool for case-control studies.

RESULTS

Seventy-one studies were included (3167 bipolar depressed/706 (hypo)manic). In bipolar depression, studies demonstrated default-mode (DMN) and frontoparietal network (FPN) dysfunction, altered baseline activity in the precuneus, insula, striatum, cingulate, frontal and temporal cortex, and disturbed regional homogeneity in parietal, temporal and pericentral areas. Functional connectivity was altered in thalamocortical circuits and between the cingulate cortex and precuneus. In (hypo)mania, studies reported altered functional connectivity in the amygdala, frontal and cingulate cortex. Finally, rs-fMRI disturbances in the insula and putamen correlate with depressive symptoms, cerebellar resting-state alterations could evolve with disease progression and altered amygdala connectivity might mediate lithium effects.

CONCLUSIONS

Our results suggest DMN and FPN dysfunction in bipolar depression, whereas local rs-fMRI alterations might differentiate mood states. Future studies should consider controlling rs-fMRI findings for potential clinical confounding factors such as medication. Considerable heterogeneity of methodology between studies limits conclusions. Standardised clinical reporting and consistent analysis approaches would increase coherence in this promising field.

In light of the DSM-5 dimensional model of personality: Borderline personality disorder at the crossroads with the bipolar spectrum

BACKGROUND

State-of-the-art research highlights that borderline personality disorder (PD) and bipolar spectrum disorders have clinical characteristics in common, which imply uncertainty in differential diagnoses. Although there is a growing body of literature on the DSM-5 dimensional model of personality disorder, its discriminative features between these clinical samples are still understudied. In this study, we seek to identify the best set of predictors that differentiate between borderline PD and bipolar spectrum, based on pathological and normative personality traits and symptoms.

METHODS

A cross-sectional study of three clinical samples: 1) Borderline PD group of 63 participants; 2) Major depressive disorder group of 89 participants; 3) Bipolar disorder group of 65 participants. Self-reported assessment: Personality Inventory for DSM-5; Brief Symptom Inventory; FFM Inventory. A series of one-way ANOVAs and logistic regression analyses were computed.

RESULTS

The major set of data emerging as common discriminants of borderline PD across the bipolar spectrum are unusual beliefs & experiences, paranoid ideation, obsession-compulsion and extraversion. Depressivity (OR: 34.95) and impulsivity (OR: 22.35) pathological traits displayed the greatest predictive values in the differential diagnosis.

LIMITATIONS

The small size of the samples; a lack of data from participants' previous clinical history.

CONCLUSIONS

Findings support the DSM-5 pathological traits as differentiating borderline PD through bipolar spectrum, and reinforcing the joint use of symptom-related pathological functioning and normal-range personality traits. Alongside the bipolar spectrum, borderline pathology sheds light upon a hypothetical overlap along the depressive and schizoaffective/schizophrenia spectra, representing a borderland space at a crossroads with the psychopathology of a meta-spectrum.

Threading a pathway through the forest of mood and personality disorders

The classification of mood and personality disorders has become unnecessarily complicated. It has become bogged down by well-meaning but unhelpful subcategories that puzzle the will of clinicians to make useful judgements. The answer is to think of bipolar, depressive and personality disorders as each constituting a spectrum of severity and not to be too preoccupied with individual labels. It would also be useful to avoid the diagnostic chimera of borderline personality disorder, a condition that defies proper classification.