Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders
Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders
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DOI：
10.1016/s0165-0327(00)00203-2
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发表时间：
2000-09-01
影响因子：
6.6
通讯作者：
Hirschfeld, R
中科院分区：
文献类型：
--
作者：
Akiskal, HS;Bourgeois, ML;Hirschfeld, R
直到最近，人们还认为不超过1%的总人口患有双相情感障碍。新出现的跨大西洋数据开始提供一致的证据，证明至少高达5%的更高患病率。躁狂状态，即使是那些情绪不协调的特征，以及混合(烦躁)躁狂，现在都正式包括在ICD-10和DSM-IV中。混合状态平均出现在40%的双相患者的一生中；目前的证据支持对混合状态的更广泛的定义，包括全面的躁狂和两个或更多伴随的抑郁症状。然而，患病率增长最大的原因是，临床表现出的双相情感处于全面双相情感障碍的两极之间，即此人至少有一次躁狂发作(双相I相)，以及严格定义的单相严重抑郁障碍，在兴奋时期没有个人或家族病史。双相II是这些中间状态的原型，具有严重的抑郁和自发性低躁狂症发作的病史；目前的证据表明，大多数低躁狂症患者都会反复发作，其通常持续时间为1-3天，低于DSM-IV所要求的任意4天的截止时间。在ICD-IO和DSM-IV忽视的广泛国际研究的基础上，患有抗抑郁药相关的低躁狂症(有时称为双相III)的抑郁症似乎也属于双相情感障碍的临床谱系。广义地说，过去十年进行的研究中的双极频谱占所有主要萧条的30%-55%。快速循环，定义为抑郁和兴奋的交替(每年至少四次)，更多地来自双相II型而不是双相I型基线；这种循环基本上不是一个明显的临床亚型--而是双相障碍长期病程中20%的一过性并发症。叠加在环胸腺振荡上的严重抑郁代表了双相信息技术的一种更严重的变体，经常被误认为是戏剧性集群中的临界性或其他人格障碍。此外，在这些和其他双相患者中，具有反向植物体征、焦虑状态以及酒精和药物滥用共病的非典型抑郁特征是常见的。正确认识这种“面具”背后的整个临床两极光谱对于精神病学的研究和实践具有重要的意义。需要进一步研究的情况包括：(1)重大抑郁发作，其中高胸腺特征--终生低躁狂特征--主导发病间期或发病前阶段；(2)在全面的重大抑郁发作期间，由很少的低躁狂症状(即，竞速思考、性唤醒)组成的抑郁混合状态--包括在Kraepelin的混合状态模式中，但被DSM-IV排除。这些并没有穷尽所有可能包括在双相情感障碍临床谱系中的潜在诊断实体：本综述没有考虑周期性、季节性、易怒-烦躁或以其他方式冲动、间歇性易怒或躁动的精神疾病，而双相情感障碍的联系较少。这里使用的双极谱概念表示重叠的临床表现，而不一定暗示潜在的遗传同质性。在同一患者的疾病过程中，人们经常观察到上述各种不同的表现--无论是正式的诊断类别还是官方病因学之外的那些。某些形式的疾病生命图可以用来记录每个患者独特的不同的病程特征，从而极大地提高临床评估。(C)2000年爱思唯尔科学公司。版权所有。
Until recently it was believed that no more than 1% of the general population has bipolar disorder. Emerging transatlantic data are beginning to provide converging evidence for a higher prevalence of up to at least 5%. Manic states, even those with mood-incongruent features, as well as mixed (dysphoric) mania, are now formally included in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of bipolar patients over a lifetime; current evidence supports a broader definition of mixed states consisting of full-blown mania with two or more concomitant depressive symptoms. The largest increase in prevalence rates, however, is accounted for by 'softer' clinical expressions of bipolarity situated between the extremes of full-blown bipolar disorder where the person has at least one manic episode (bipolar I) and strictly defined unipolar major depressive disorder without personal or family history for excited periods. Bipolar II is the prototype for these intermediary conditions with major depressions and history of spontaneous hypomanic episodes; current evidence indicates that most hypomanias pursue a recurrent course and that their usual duration is 1-3 days, falling below the arbitrary 4-day cutoff required in DSM-IV. Depressions with antidepressant-associated hypomania (sometimes referred to as bipolar III) also appear, on the basis of extensive international research neglected by both ICD-IO and DSM-IV, to belong to the clinical spectrum of bipolar disorders. Broadly defined, the bipolar spectrum in studies conducted during the last decade accounts for 30-55% of all major depressions. Rapid-cycling, defined as alternation of depressive and excited (at least four per year), more often arise from a bipolar II than a bipolar I baseline; such cycling does not in the main appear to be a distinct clinical subtype - but rather a transient complication in 20% in the long-term course of bipolar disorder. Major depressions superimposed on cyclothymic oscillations represent a more severe variant of bipolar IT, often mistaken for borderline or other personality disorders in the dramatic cluster. Moreover, atypical depressive features with reversed vegetative signs, anxiety states, as well as alcohol and substance abuse comorbidity, is common in these and other bipolar patients. The proper recognition of the entire clinical spectrum of bipolarity behind such 'masks' has important implications for psychiatric research and practice. Conditions which require further investigation include: (1) major depressive episodes where hyperthymic traits - lifelong hypomanic features without discrete hypomanic episodes - dominate the intermorbid or premorbid phases; and (2) depressive mixed states consisting of few hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-blown major depressive episodes - included in Kraepelin's schema of mixed states, but excluded by DSM-IV. These do not exhaust all potential diagnostic entities for possible inclusion in the clinical spectrum of bipolar disorders: the present review did not consider cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden, intermittently explosive or agitated psychiatric conditions for which the bipolar connection is less established. The concept of bipolar spectrum as used herein denotes overlapping clinical expressions, without necessarily implying underlying genetic homogeneity. in the course of the illness of the same patient, one often observes the varied manifestations described above - whether they be formal diagnostic categories or those which have remained outside the official nosology.Some form of life charting of illness with colored graphic representation of episodes, stressors, and treatments received call be used to document the uniquely varied course characteristic of each patient, thereby greatly enhancing clinical evaluation. (C) 2000 Elsevier Science BN. All rights reserved.