Evidence that bipolar disorder is the poor outcome fraction of a common developmental phenotype: an 8-year cohort study in young people

Abstract

Background. Reported rates of bipolar syndromes are highly variable between studies because of age differences, differences in diagnostic criteria, or restriction of sampling to clinical contacts.Method. In 1395 adolescents aged 14-17 years, DSM-IV (hypo)manic episodes (manic and hypomanic episodes combined), use of mental health care, and five ordinal subcategories representing the underlying continuous score of (hypo)manic symptoms (' mania symptom scale ') were measured at baseline and approximately 1.5, 4 and 10 years later using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI).Results. Incidence rates (IRs) of both (hypo)manic episodes and (hypo)manic symptoms (at least one DSM-IV core symptom) were far higher (714/105 person-years and 1720/10 5 person-years respectively) than traditional estimates. In addition, the risk of developing (hypo)manic episodes was very low after the age of 21 years [hazard ratio (HR) 0.031, 95 % confidence interval (CI) 0.0050-0.19], independent of childhood disorders such as attention deficit hyperactivity disorder (ADHD). Most individuals with hypomanic and manic episodes were never in care (87 % and 62 % respectively) and not presenting co-morbid depressive episodes (69 % and 60 % respectively). The probability of mental health care increased linearly with the number of symptoms on the mania symptom scale. The incidence of the bipolar categories, in particular at the level of clinical morbidity, was strongly associated with previous childhood disorders and male sex.Conclusions. This study showed, for the first time, that experiencing (hypo)manic symptoms is a common adolescent phenomenon that infrequently predicts mental health care use. The findings suggest that the onset of bipolar disorder can be elucidated by studying the pathway from non-pathological behavioural expression to dysfunction and need for care.

Toward a Comprehensive Clinical Staging Model for Bipolar Disorder: Integrating the Evidence

“…Finally, clinical staging represents an important step toward reducing stigma by legitimizing these illnesses as heritable complex brain diseases and aligning the approach to treatment and research with the way we approach other medical disorders, while always being mindful of the importance to balance early identification against overdiagnosis of normative, transient, or self-resolving emotional symptoms in youth. 69,84 We are at a vital crossroads in our efforts to advance psychiatric research, particularly regarding understanding and recognizing the development of mood disorders. A major leap forward would come through integrating the evidence from various perspectives into a unified comprehensive staging model.…”

Affective Dysregulation and Reality Distortion: A 10-Year Prospective Study of Their Association and Clinical Relevance

“…Both binary and continuous affective variables were constructed as described previously [34][35][36] : i) ''Binary (hypo)mania'' and ''binary depression'': An a priori binary (hypo)mania variable was defined as at least 2 DIA-X/M-CIDI mania symptoms and a binary depression variable as at least 3 DIA-X/M-CIDI depression symptoms. ii) In addition, guided by previous work, 34-36 a continuous ''(Hypo)mania Score'' and a continuous ''Depression Score'' variable were constructed.…”

“…Multiple studies suggest that subclinical psychotic experiences increase the risk for nonaffective psychotic disorder, [19][20][21][22][23][24] and similarly subthreshold depression and/or (hypo)mania symptoms have been shown to increase the risk for bipolar disorder. 35,36 Overall, affective dysregulation and reality distortion have been shown to represent the behavioral expression of risk for more severe psychotic states including schizophrenia and bipolar disorder in the general population. In light of the accumulating evidence on overlap in genetic liability, [3][4][5] suggesting a broad underlying vulnerability that expresses across the different categories, our findings of associations between affective dysregulation and psychotic experiences in the general population may therefore simply reflect passive clustering of the behavioral expression of overlapping genetic risks.…”

The predictive value of childhood subthreshold manic symptoms for adolescent and adult psychiatric outcomes

“…However, in general population cohorts the relationship between subthreshold symptoms and clinical outcomes has modest contemporaneous specificity and predictive value. This is because childhood subthreshold manic symptoms in the general population are common (5-25%) (Shankman et al, 2009;Tijssen et al, 2010a), they are present in children with a variety of disruptive disorders and are associated with multiple adult diagnoses, most commonly BD, anxiety, depression and substance abuse disorders (Brietzke et al, 2012;Duffy, 2012;Faedda et al, 2015;Tijssen et al, 2010b;Tijssen et al, 2010c). …”