Posted by jrbecker on February 11, 2005, at 12:24:38
In reply to Bipolar II Series -Antidepressnt-induced dysphoria, posted by jrbecker on February 11, 2005, at 12:14:46
Journal of Affective Disorders
Volume 84, Issues 2-3 , February 2005, Pages 279-290
Bipolar Depression: Focus on Phenomenology
doi:10.1016/j.jad.2004.06.002
Copyright © 2004 Elsevier B.V. All rights reserved.
Special article
Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: the “red sign,” the “rule of three” and other biographic signs of temperamental extravagance, activation and hypomania
Hagop S. Akiskal ,International Mood Center, University of California at San Diego, V.A. Hospital 3350, La Jolla Village Dr. (116-A), San Diego CA 92161, USA
Received 12 January 2004; accepted 3 June 2004. Available online 10 February 2005.
Abstract
Background
Since 1977, the work of the author has shown the primacy of behavioral activation, flamboyance, and extravagance in detecting hypomania, the historical hallmark of cyclothymic and the broader spectrum of bipolar II (BP-II) disorders. In other words, the soft spectrum is more likely to declare itself in behavioral rather than mood disturbances. The obligatory search for elation and related mood changes à la DSM-IV (and its interview form, the SCID) during the clinical interview is often doomed to failure, thereby “condemning” the patient to a unipolar diagnosis, and hence to sequential and often tragic failures with antidepressants or combinations thereof.
Methods
To characterize behavioral signs of good specificity, though individually of low sensitivity for BP-II in patents presenting with major depression, the author undertook a chart review of over 1000 depressive patients he had examined extending over a period of nearly three decades. The Mood Clinic Data Questionnaire (MCDQ) used in the author's Memphis mood clinic permitted systematization of unstructured observations. BP-II had been independently confirmed by hypomania of ≥2 days and/or cyclothymia over the course of the index illness (both of which were validated by family history for bipolarity in earlier research in our clinic).
Results
Triads of behavior or traits in the patients' biographical history—as well as in the biologic kin—involving polyglottism, eminence, creative achievement, professional instability, multiple substance/alcohol use, multiple comorbidity (axis I and axis II), multiple marriages, a broad repertoire of sexual behavior (including brief interludes of homosexuality), impulse control disorders, as well as ornamentation and flamboyance (with red and other bright colors dominating) were specific for BP-II. Temperamentally, many of these individuals thrive on activity—they are indeed “activity junkies.”
Limitation
The reported findings pertain primarily to the differential diagnosis between BP-II and unipolar depression. Replication of the approach espoused herein will require quantification of the operational definitions of the observed phenomenology.
Conclusion
The findings, which make sense in an evolutionary model of the advantage that “dilute” bipolar traits confer to human biography and erotic life, suggest that such behavioral traits can be useful provisionally in assigning a depressive episode to the realm of the bipolar II spectrum. Overall, the perspective espoused in this paper indicates that temperamental excesses and, more generally, a biographical approach, represent a more coherent approach than hypomanic episodes in the diagnosis of BP-II patients. Finally, such a diagnostic approach underscores the importance of incorporating evolutionary considerations and principles in understanding the origin of affective disorders.
Keywords: Bipolar II; Major depression; Bipolar spectrum; Temperament; Ethology
Article Outline
1. Introduction
2. Clinical rationale
2.1. Methodologic innovation
2.2. Prospective investigations
2.3. Structuring unstructured observations
2.4. Modifications of the diagnostic process
2.5. Emphasis on the social/behavioral phenotype
3. Results and interpretation
3.1. Polyglottism
3.2. Eminence
3.3. Creativity
3.4. Biographic instability and/or excesses
3.5. “Activity junkies”
3.6. Multiple substances of use
3.7. Multiple comorbidity
3.8. Multiple outrageous behaviors
3.9. Sexual excesses
3.10. Marital history
3.11. Flamboyance and ornamentation
4. Discussion
References
1. Introduction
Although bipolar I (BP-I) disorder may still pose diagnostic problems (Bowden, 2001)—especially in its differentiation from schizophrenia—there exists a rich literature about this classical boundary question (Taylor and Abrams, 1973, Carlson and Goodwin, 1973, Pope and Lipinski, 1978 and Akiskal and Puzantian, 1979; Andreasen and Akiskal, 1983; Berner et al., 1992). Nonetheless, recent data from the US (Ghaemi et al., 2002 and Hirschfeld et al., 2003) and France (Hantouche et al., 2003) indicate that BP-I disorder is still subject to misdiagnosis, but now as major depressive disorder (MDD), as well as anxiety and personality disorders. Diagnostic errors are even more formidable in bipolar II (BP-II) disorder (Hantouche et al., 1998). Current data indicate that the BP-II spectrum is much more prevalent than BP-I in the community (Szadoczky et al., 1998; Angst, 1998 and Judd and Akiskal, 2003), and may account for at least 50% of all depressions observed in clinical practice (Akiskal and Mallya, 1987, Benazzi, 1997, Manning et al., 1997, Hantouche et al., 1998 and Akiskal et al., 2000). This paper will focus on a new diagnostic approach to this prevalent bipolar subtype.
BP-II was first described by Dunner and Gershon (1976), as a bipolar patient who had had hospitalization for depression, but not for mania; this meant that hypomanic signs and symptoms were almost always to be obtained by history. Although finally sanctioned by DSM-IV (1994), clinical assessment of BP-II presents formidable problems, principally because of the low reliability of the diagnosis of hypomania by history (Rice et al., 1986), which in turn is due in part to the vagaries of the patient’s state-dependent memory (difficulty to remember hypomanic mood during clinical depression), as well as failure to obtain history from significant others (Akiskal et al., 2000). The diagnostic process is complicated by inter-episodic instability (Akiskal, 1981) and comorbidity (Perugi and Akiskal, 2002), both of which contribute to the failure of recognizing it as a bipolar disorder (Akiskal and Pinto, 1999 and Akiskal et al., 2000): Such patients are then diagnosed as major depressives arising from cluster B personality disorders and/or substance-induced mood disorders. There also exist unmistakable, even severe major depressions without marked personality pathology, apparently “unipolar,” who nonetheless exhibit intra-episodic signs of submanic activation, flight of ideas, irritability, hostibility and agitation (Akiskal and Mallya, 1987, Koukopoulos and Koukopoulos, 1999 and Benazzi and Akiskal, 2001). Although not so-classified in the official International Classification of Mental and Behavioral Disorders (ICD-10, 1992) and theAmerican Psychiatric Association (DSM-IV, 2000) nomenclature of mental disorders, there is increasing evidence that such patients belong to the bipolar spectrum (Akiskal and Benazzi, 2003 and Sato et al., 2003).
Clinical diagnosis of BP-I is relatively easy, because when patients do not provide history of mania, past records are often decisive in this regard (Hantouche et al., 1998). This is rarely the case for BP-II. The best documented ways to improve the diagnostic process in evaluating depressed patients for BP-II are semi-structured interviewing by clinicians experienced in the diagnosis of bipolar II (Dunner and Tay, 1993) specifically geared for the signs and symptoms of hypomania; the diagnostic process can be further enhanced by obtaining information from significant others, and re-interviewing the patient as he or she is recovering from depression (Hantouche et al., 1998). Re-interviewing the patient at this time is helpful because the lifting of depression—sometimes accompanied by sudden brightening of mood and/or antidepressant associated hypomania (Akiskal et al., 2003)—helps the patient in recalling past episodes of hypomania (Akiskal et al., 2000). However, undue emphasis on elated and/or labile moods may lead to false negative diagnoses; a more fruitful approach is to inquire about behaviors suggestive of hypomania which patients are more likely to endorse (Akiskal et al., 1977).
The foregoing considerations suggest that objective features of hypomania or its behavioral manifestations should be given greater diagnostic weight in the evaluation of BP-II disorder. The purpose of this paper is to propose such an observational clinical framework in the differential diagnosis of “unipolar” major depressive vs. BP-II disorder that the author has developed in his clinical practice over the past several decades.
2. Clinical rationale
2.1. Methodologic innovation
What will be proposed here is a list of discreet observational signs and features outside the officially sanctioned clinical picture of BP-II in DSM-IV (1994) and ICD-10 (1992), and which can be useful in detecting “cryptic” bipolarity. These have been observed by the author during systematic interviewing of a very large depressive patient population extending over the three decades of the 1970s, 1980s and the 1990s. These findings emerged from four methodologic features in our systematic diagnostic interview process which we have used as of our earliest studies in the Memphis Mood Clinic (Akiskal et al., 1978) and in subsequent private practice and/or consultations.
1. The development of operational criteria for temperaments, such as the cyclothymic, irritable and hyperthymic (Akiskal et al., 1979a and Akiskal and Mallya, 1987), permitted broad assessment of behavioral traits underlying bipolarity. These are quite distinct from personality disorders—particularly because, in addition to emotional reactivity patterns which make people vulnerable to affective disorders, they describe their positive attributes.
2. Our interview schedule itself, the Memphis Mood Clinic Data questionnaire (MCDQ), was liberally semi-structured in format, permitting the clinician to probe biographical domains of interest beyond specified operational criteria. The MCDQ is particularly well suited for clinicians, because it represents systematization of what they normally do in evaluating patients. The MCDQ was filled routinely by trainees, fellows and visiting clinical scientists to our clinic and was eventually exported overseas. This is one of the reasons there now exists a cadre of clinical researchers (e.g., Manning et al., 1997, Akiskal and Pinto, 1999, Hantouche et al., 1998, Perugi et al., 1999, Haykal and Akiskal, 1999 and Benazzi and Akiskal, 2003) who think differently than the DSM-IV (and SCID) fixated “majority” in our field.
3. In the main, the MCDQ does not adhere to hierarchical rules. This means for instance that a patient can be diagnosed as having both a depressive episode and simultaneously meet criteria for hypomania during that episode, or; a patient presenting with depressive disorder can also be diagnosed as having a lifelong cyclothymic temperament. More generally, multiple diagnoses can be made in depressive disorders, including, for instance, anxiety disorders, substance use and alcohol disorders. To the post-DSM-III-R reader, the latter may seem like nothing new. Yet it is important to understand that suspension of hierarchical rules (DSM-III-R, American Psychiatric Association, 1987) was not the practice during much of the 1970s and 1980s when we conducted the bulk of the studies in our Mood Clinic. It is also noteworthy that in the Washington University Schema (Feighner et al., 1972), patients meeting the criteria for multiple co-existing mental disorders were considered “undiagnosed.”
4. Our Mood Clinic was different from the Lithium clinics of the 1970s and the bipolar clinics of today in a fundamental respect. The latter clinics admit well known or perhaps, in some instances, suspected bipolar patients. Our mood clinic admitted all consecutive depressive as well as bipolar patients referred to our service. This meant that we had the opportunity to study predictors of switching from depressive to bipolar disorders on a prospective basis. In brief, the bipolar status of patients reported in this paper does not represent cross-sectional entities, but prospectively validated diagnoses. Such a system with prospective diagnostic rigor can only be accomplished in a large service of both public and private patients. They do not typically attract—at least in those days—research dollars. The modus operandi of such a clinical service are typically labeled by conventional research standards as a “fishing expedition”, yet it represents clinical reality of everyday practice. However, our procedures did differ from routine practice in one crucial respect: data both at baseline or entry and during follow-up were collected systematically and rigorously. Conventional research methodology has consistently failed to account for the most common types of depressed patients encountered in private and public practice settings. The present report is an attempt to correct the narrow scope of the former.
2.2. Prospective investigations
Several systematic investigations during this period conducted in the author's mood clinics in Memphis led to the “rule of three” regarding the differential diagnosis of BP vs. MDD. For instance, we had found that BP-II patients arising from a cyclothymic baseline (Akiskal et al., 1977) often had a triad of past diagnoses from the dramatic cluster of personality disorders, e.g., “psychopathic,” histrionic, and “borderline.” In a subsequent study (Akiskal et al., 1983), we found that switching of depressed patients to bipolar I disorder could be prospectively predicted, among others, on the basis of a familial triad involving bipolar family history, “loaded” family history for affective disorder (>3 affected members in a pedigree), and consecutive generation family history for affective disorder (typically ≥3 generations). In this study, we computed sensitivity (which ranged from 32–42%) and specificity (which ranged from 83% to 98%) for these familial features in predicting who would switch to bipolar. In still a third study, which derived from the NIMH depression database (Akiskal et al., 1995), a triad of trait “mood lability,” “energy activity,” and “daydreaming (mental activation)” emerged as the best predictors of switching of “unipolar” major depression to BP-II over a long prospective observational period. In this study, in some ways reminiscent of our work on cyclothymic disorder summarized earlier, we reported excellent sensitivity (91% for the triad); the single best diagnostic predictor for BP-II was mood lability (sensitivity of 42% and specificity of 86%).
2.3. Structuring unstructured observations
The foregoing systematic and psychometrically validated observations were further enhanced by sporadic clinical observations, originally made in Memphis in the author’s Mood Clinic. These are best described as systematization of unstructured observations. For instance, we noted that some patients who presented with depression exhibited a triad involving the color red, e.g., drove to the clinic in a red sports car, wore either a bright red hat or a colorful necktie, or used a red pen in signing their names. This led to the unofficial use of the “red sign” of (bipolar) melancholia in our mood clinic. But in reality, this was a “red flag” for bipolarity because nearly all of those patients either gave past history of hypomania or developed it subsequently. The clinical rationale for considering the “red sign” as an indicator of bipolarity was that such colorful flamboyance was incompatible with the dark or blue mood of melancholia.
2.4. Modifications of the diagnostic process
On the basis of what has been already summarized, during diagnostic assessments of clinically depressed patients, the author would specifically inquire about these and related features in search for soft bipolarity. For purposes of this report, based on retrospective chart review of over 1000 interviews of affectively ill patients, I have compiled a preliminary list of triads of signs and characteristics which, while having relatively low sensitivity values (rates of 5–30%), appeared to have high specificity for a BP-II diagnosis in the sense that they were rarely observed (5%) or encountered among (unipolar) major depressive disorder. The validating independent clinical diagnosis of unipolar vs. BP-II was made on the basis of hypomania, and/or cyclothymic disorder, which conforms to DSM-IV (2000) definitions with one exception: 2 days of hypomania was considered sufficient for a diagnosis of BP-II in line with old and new evidence validating this duration threshold (e.g., Akiskal et al., 1977, Akiskal et al., 1979b, Cassano et al., 1992, Manning et al., 1997, Akiskal et al., 2000 and Benazzi and Akiskal, 2003). It is important to emphasize that the patients were evaluated during a clinically depressed state, and observations and/or history for the triads were made at this time; hypomania and other required evidence documenting bipolar disorder were obtained subsequently, as they became available. This is the sequence of events that happens in clinical practice. In other words, I am proposing these signs as discreet features as a preliminary approach in the differential diagnosis of unipolar vs. BP-II disorders when a clear-cut history of hypomania is not available or has not yet been obtained.
2.5. Emphasis on the social/behavioral phenotype
It would be useful to recapitulate the methodology of obtaining information from patients based on our mood clinic data questionnaire more fully described elsewhere (Akiskal et al., 1978). It is derived from the Feighner et al. (1972) framework, enriched by subthreshold diagnoses such as BP-II (Dunner and Gershon, 1976), and depressive subtypes in the RDC or research diagnostic criteria (Spitzer and Endicott, 1979), as well as temperament traits along hyperthymic, irritable and cyclothymic lines (Akiskal et al., 1979a). Systematic data is also collected on psychopathologic, demographic, developmental, social, educational and professional aspects, and family pedigrees based on the Winokur approach as incorporated into the RDC (Andreasen et al., 1977).
The interview is semi-structured and permits open-ended questions about aspects that the clinician will find relevant—striking or unusual, and in need of further probing—which would be faithfully recorded in the present or past history. This is how observational and behavioral features beyond the conventional diagnostic criteria have been noted. Finally, our procedures permit the perusing of signs and symptoms of hypomania during an index depressive episode, even in the absence or uncertainty about history of hypomanic episodes. As noted, the latter was made possible because the MCDQ suspended diagnostic hierarchies both within and outside the boundary of mood disorders.
3. Results and interpretation
What is summarized here are observations that would aid clinical differential diagnosis between a unipolar major depressive and a BP-II patient and, whenever available, supporting evidence from the literature. The bipolar indicators to be described here broadly fall into two groups: Those which pertain to the depressed patient's social traits obtained by history, and those observed at the index depressive episode which brought the patient to clinical consultation.
3.1. Polyglottism
People with proficiency ≥3 languages are rare among the US-born: among the affectively ill, it is also uncommon, but when it occurs, it appears limited to BP-II disorder. This probably does not apply to most European patients, where the base rate of multilingualism is quite high. In brief, when a US-born depressed patient lists in his biography competence in three or more languages, bipolarity should be searched diligently.
It is of interest that Rihmer et al. (1982) reported that in Hungary, three languages were the threshold for bipolarity. This study was conducted at a time when Hungary was less open to the West and, unless somebody had a special reason to learn more than a few languages, such as belonging to the family of a diplomat, three languages were significantly associated with bipolarity.
Language is for communication between people, and it makes good sense that the extroverted traits of individuals with bipolar disorder would lead to special abilities to learn languages. Also, extroverted and novelty-seeking individuals travel more and are more likely to encounter the opportunity to learn other languages.
3.2. Eminence
Diplomats would also qualify for bipolar traits by virtue of their belonging to an extroverted profession. The latter include political or other leadership, journalism, media and/or entertainment. All require interpersonal charm and eloquence, well-known features of the hyperthymic temperament (Gardner, 1982 and Akiskal, 1992). All such individuals, when clinically depressed, should be examined for bipolarity. When examining a depressed individual, history of eminence in the family, especially that for extroverted professions, should also lead to the search for bipolarity. When members of the family meet criteria for eminence along these lines, the connection to bipolarity is strengthened.
It is of interest in this regard that Coryell et al. (1989), examining the large database of the NIMH collaborative study of depression, found that achievement was significantly higher in the families of bipolar, as opposed to unipolar, patients. Using different methodology, Verdoux and Bourgeois, 1995a and Verdoux and Bourgeois, 1995b have replicated this find in France with respect to social class.
3.3. Creativity
Although most BP-II are not extraordinarily creative, and many individuals who are accomplished in an artistic domain do not meet criteria for full-blown affective disorders, artists who do present with clinical depression are more often BP-II than unipolar (Akiskal and Akiskal, 1988 and Akiskal and Akiskal, 1992). Indeed, those rare artists who excel in three domains, e.g., poetry, painting, and music, when clinically depressed, are more likely to belong to BP-II. Also, depressed individuals with extensive family history for artistic creativity should be carefully examined for BP-II disorder. There is some support for this in the literature in a study by Richards et al., 1988, demonstrating that creativity scores were significantly higher among relatives of bipolars as opposed to unipolars. Finally, the work ofAndreasen (1987) and Jamison (1995) on the connection between artistic creativity and bipolarity can be cited in general support for the foregoing suggestions.
3.4. Biographic instability and/or excesses
Instabilities in three areas of life, such as going to three universities and not obtaining a degree, or changing line of work and/or city of residence frequently have all been reported as strong correlates of the cyclothymic temperament (Akiskal et al., 1977). Should a clinically depressed individual give such history, the diagnosis of BP-II has to be entertained. Those individuals who shift from one profession to another, and then yet to another, such as law, medicine, and music, should be considered to be in the bipolar spectrum, at least temperamentally. For instance, a professor of medicine who practices law, and regularly sings in the opera. The foregoing consideration is also true for those who are boarded in three or more distinct medical subspecialties. All such individuals when clinically depressed should be examined for other clinical hints for bipolarity. Athletes who excel in three distinct sports, from such a list as basketball, soccer, baseball, tennis or skiing, when presenting clinically with a depression, must be examined for possible bipolarity. Finally, although one may have sound economic reasons for maintaining three jobs on a daily basis, when such a person develops clinical depression (which is not uncommon among such individuals), bipolarity should be high on the list of differential diagnoses, especially since such individuals often sleep no more than a few hours per day, or use stimulants towards this purpose. Individuals who have such orientation to work that requires both energy and obsessoid traits are typically in the realm of hyperthymic temperament (Akiskal, 1992 and Sakai et al., 2005).
3.5. “Activity junkies”
Individuals who travel long distance more than three times a month for whatever reasons, scientists who write three papers per month, and novelists who write three books per year are typically individuals with great energy for their line of work. These are desirable characteristics and help in climbing the ladder of professional success; they do not constitute mental illness. However, if and when these people present clinically with altered sleep patterns and fatigue, one should search for signs of depressive illness and then proceed to elicit signs of hypomania, which should prove not difficult in most such instances. Again, the rationale here is that the boundless energy, characteristic of such individuals, and their obsessoid traits are features of the hyperthymic temperament (Akiskal, 1992 and von Zerssen et al., 1998). While hyperthymic traits per se do not represent pathology, the development of clinical depression in individuals with such traits would suggest a bipolar spectrum disorder (Akiskal and Pinto, 1999).
3.6. Multiple substances of use
Comorbidity with substance abuse at the polysubstance level (three or more major drugs, such as nicotine, stimulants, alcohol and/or opiates) should also raise suspicion of bipolarity in an individual presenting with depression beyond the period of detoxification (Akiskal et al., 1977 and Angst et al., 2005). This is a complex issue, which will require much better documentation, but it is useful to think along these lines, both for familial-genetic (Winokur, et al.,1998), clinical (Akiskal and Pinto, 1999), and therapeutic reasons (Brady and Sonne, 1995).
3.7. Multiple comorbidity
As far as comorbid diagnoses, depressed individuals with at least three anxiety disorder diagnoses (panic-agoraphobic, social phobic, and obsessive-compulsive) are commonly BP-II (Perugi et al., 1999). Those with the triad of bulimic, atypical, and seasonal depressions also seem to belong to the realm of BP-II (Perugi and Akiskal, 2002). Related to the latter are depressions with rapid onset, short duration, and rapid offset, almost always associated with BP-II (Strober and Carlson, 1982 and Akiskal et al., 1983).
3.8. Multiple outrageous behaviors
Depressed individuals who have in the past received controversial diagnoses with an impulsive component such as “borderline personality,” “compulsive gambling,” and “sexual addiction” are paramount among those who should be evaluated for bipolarity. The same applies to individuals who, with some regularity, take extreme risks for thrills such as gambling, car racing, sky diving, and wildlife safaris. Whether all impulse control disorders are bona fide bipolar disorders is an unsettled question, but association of a triad of such activities is reported by many (Akiskal et al., 1995, McElroy et al., 1996, Cassano et al., 2000 and Deltito et al., 2001).
The boundary between “psychopathic” behavior and bipolar temperaments is not always easy to draw (Pukrop et al., 1998). In a study of 559 depressives to predict those “unipolars” who switched to BP-II over prospective observation (Akiskal et al., 1995), we reported that certain “outrageous” behaviors, particularly occasional “anti-social” acts were significantly over-represented in the minority (8.6%) who switched. In this light, it would not be surprising that clinically depressed individuals who give history of three such “anti-social” acts—e.g., shoplifting, a paraphilia, and arrest for participation in a riot—might after all belong to the bipolar spectrum. If for nothing else, this would open therapeutic opportunities (Nelson et al., 2001), as discussed earlier in relation to controversial diagnostic categories involving impulsivity. We are neither arguing for decriminalizing certain behaviors, nor romanticizing them. The point is that prisons are full of people for “offenses” or felonies that can be perhaps one day understood in a broader humane perspective based on temperamental excesses—along hypomanic or cyclothymic lines—operating within a certain social context that did not provide the socialization and education to harness their energy and drive to socially desirable goals and achievement.
3.9. Sexual excesses
As far as erotic life, depressed individuals who give history of having engaged, with more than occasional frequency, in sexual behavior with the same sex and both sexes at the same time or different times, are in our clinical experience, over-represented among the BP-II. Brief homosexual liaison during hypomania—sometimes protracted beyond—underscores the disinhibition that BP-II brings to the lives of these individuals (Akiskal and Pinto, 1999); alcohol use is often contributory to such behaviors.
Moreover, those with excesses in sexual behavior such as simultaneously dating three or more individuals for extended periods of time, or on the same day (such as breakfast, lunch, and dinner), indeed those who actually repeatedly engage in sex with three different individuals on the same day, must all be suspect for bipolar traits. Along these lines, someone whose sexual desire is so excessive that they would regularly engage in sex with their own spouse as well as visiting prostitutes, in addition to repeated masturbation on a daily basis, should be evaluated for bipolarity. Finally I must mention individuals who date in three faraway cities in the same week (for instance, Memphis, Hawaii, and New York; or Chicago, London, and Bali); obviously this is confounded by one's financial resources, which, as discussed earlier, represents another factor in favor of bipolarity (Verdoux and Bourgeois, 1995b).
Sexual prowess and openness to different forms of expression of the sexual passion may, hypothetically, represent the evolutionary rationale for the emergence of genes which contribute to bipolarity (Gardner et al., 1982; Hamer and Copeland, 1998 and Akiskal, 2001). As such, they have an essential role in human biology, and obviously do not constitute pathology; from such a perspective, they may be regarded as an advantage, representing a greater repertoire of sexual behavior and responding. The clinical claim we make here is that in an individual presenting clinically with depressive illness, history of the type of sexual behaviors described herein should be taken as a hint of bipolarity. A perusal of the criteria for bipolar disorder in official classification systems (ICD-10, 1992; DSM-IV, 1994) leaves no doubt that excessive involvement in any activity with major potential for risk due to seeking of pleasure, including sexual hedonism, is in the realm of trait bipolarity.
3.10. Marital history
Related to the above considerations are individuals with three or more marriages and/or divorces (Akiskal et al., 1995). The same is true for family history for more than three divorces in one or both parents. Individuals—and these are usually men—who are legally married and have children, but maintain two or more families in other cities without having been married or in polygamous relationships (Akiskal, 2000). Again, such individuals may never suffer from affective illness, but if and when they present with clinical depression, bipolarity should be high on the list of differential diagnosis.
Individuals who dare into trans-ethnic marriages are bold and unconventional—and certainly a trend of the future in the rapidly shrinking travel distances between countries, and the expansion of diasporas. As discussed above for erotic life and openness to experience, this behavior probably has advantages from a cultural and evolutionary point of view. Thus, those who consummate three or more marriages, each to distinctly different ethnic groups from their own, are probably making a statement about their novelty-seeking temperament. This temperament is close to the hyperthymic and the cyclothymic (Maremmani et al., 2005). Therefore, we contend that when clinically depressed, their depressions are likely to belong to the soft bipolar realm.
3.11. Flamboyance and ornamentation
The “red sign” of bipolarity has already been mentioned. It goes along with the flamboyance of the cyclothymic temperament (Akiskal, 1992). At least in the Western world, women are more likely to wear colorful clothing; this is generally less so in men. Therefore, a depressed female must be observed to have a marked degree of flamboyance to be considered for BP-II; on the other hand, a pink watchband or pink socks or shoes would each alone probably suffice in raising ones diagnostic suspicion for bipolarity in a depressed male patient!
A particular development in certain youth subcultures in recent years are individuals who wear pierced rings in unusual parts of their body such as the tongue, nipples, navel and external genitalia. Other individuals have tattoos, both visible and discreet. Again, by themselves these are not necessarily indicators of any specific mental condition. However, when a depressed individual is examined in a clinical setting and is wearing three or more such rings, or three or more elaborate tattoos, bipolarity should be kept in mind.
Of all the observations made about discreet bipolarity, this is the most susceptible to cultural and subcultural influences and, hence, least secure from a diagnostic standpoint. The origin of such ornamentation might, hypothetically, by traced to an era in human evolution when their use conveyed a certain status in the territory of a tribe or a clan. Alternatively, their power status in the hierarchy might have lent to its bearer certain aphrodisiac or erotic qualities. Even today, the latter seems to represent the implicit, if not explicit, message of ornamentation, tattooing and piercing.
4. Discussion
The main findings are summarized in Table 1 in the form of a mnemonic of 3 to facilitate their didactic use, but also to emphasize the excessive nature of the listed behaviors as bipolar indications. I comment on selected aspects.
The clinical observations reported in this paper suggest that temperamental excesses or instabilities underlying or associated with the BP-II spectrum are more useful in the diagnostic assessment of these patients than attempts to elicit hypomania during the clinical interview (see Akiskal et al., 1995).
The findings further indicate that behavioral activation is more important than mood change per se in diagnosing BP-II hypomania. This has been verified in both clinical (Benazzi and Akiskal, 2003) and epidemiological studies (Angst et al., 2003). I would like to expand on this methodologic point, because it is contrary to the diagnostic algorhythms of research interviewing in the SCID (First et al., 1997). In a recent Ravenna-San Diego Collaboration (Benazzi and Akiskal, 2003), bypassing the stem question A on mood change in hypomania in SCID interviews, and first eliciting hypomanic behaviors (indicative of activation), yielded a significant increase in BP-II diagnoses; because once such behaviors were elicited, patients (and significant others) upon re-questioning could recall positive mood changes. This collaborative study also suggested that, rather than obtaining history for hypomanic signs and symptoms, the clinician could more profitably search for signs of hypomanic activation during the index depression, in effect supporting the diagnosis of a depressive mixed state (a diagnosis regrettably “forbidden” in the DSM-IV schema and its SCID derivative).
Phenomenologically, perhaps the most provocative of the findings reported, “the red sign,” finds partial validation in an NIMH study (Donnelly et al., 1975). These authors wrote: “The color-reactive style of the bipolar group on the Rorschach underscores the potential for manic (impulsive) behavior in the midst of depressive episode.”
The reported observations also suggest, but do not prove, a relationship between homosexual behavior and the bipolar spectrum. In a written personal communication (June 5, 2004), Richard C. Pillard, M.D. expressed the opinion that such a relationship could be formulated in terms of greater mood variability (at least among homosexual men) at the lower thresholds of the bipolar spectrum. Homosexuals are often of upper middle or upper class and flamboyant (Saghir, 1973), both of which accord with the proposed putative link with the BP-II spectrum (at least temperamentally). On the other hand, the proposed hypothetical link between homosexual behavior and the bipolar spectrum might be due to the confounding variables of higher education and higher class status; in addition, individuals with homosexual orientation from such socio-economic background are more likely to participate in interview research. Finally, homosexual behavior and bisexual behavior are not synonymous. For all these reasons, the relationship between homosexual behavior and the bipolar spectrum is still an open question that deserves further study. Nonetheless, the following conclusions appear warranted: (1) The bipolar spectrum appears associated with a greater repertoire of sexual behavior, including homosexual and bisexual behavior, and (2) among individuals with homosexual or bisexual orientation presenting clinically with a depressive episode, the differential diagnosis should include BP-II.
On a more theoretical note, bipolar II, associated with other forms of affective dysregulation, impulse control disorders, as well as alcohol and stimulant abuse might share genetic underpinnings. This is a challenge for the future.
The diagnostic approach itself illustrates the enriching of psychiatric formulation by evolutionary theory (Kramer and McKinney, 1979, McGuire et al., 1992, Nesse, 1998, Wilson, 1998 and Stevens and Price, 2004). This valuable perspective is regrettably omitted in psychiatric education (Abed, 2000).
Finally, this paper illustrates the intimate link between one’s temperament, biography and the form of depression one will suffer from (Possl and von Zerssen, 1990, Kraus, 1996 and Akiskal, 1996). This is a desirable feature for the interview process in modern psychiatry which, in its quest for “objectivity”, is distancing itself from the person who is ill. Psychiatry without a biographical perspective misses the richness of human experience and behavior in their positive and tragic expressions. It also may miss the opportunity to learn a great deal about the patient that can be uniquely useful in the diagnostic process. Patients presenting to psychiatrists are not just a constellation of signs and symptoms. These merely provide a systematic framework for a diagnosis, but unless understood in the context of the patient's life and experiences, they do not provide a coherent and adequate information for an optimum understanding of the individual patient. I will close in going as far as to submit that psychiatry without a biographical perspective is not psychiatry at all.
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