The affective spectrum

The variations of mood disorders can be conceived along one broad spectrum of affective illness ( Fig.„2), with bipolar disorder type I and a single major depressive episode at the extremes. Type II bipolar disorder and cyclothymia display less severe manic symptoms. The area between cyclothymia and recurrent unipolar depression is controversial, corresponding to the DSM-IV diagnosis of 'bipolar disorder, not otherwise specified'. We would suggest that it should include mid-spectrum cases; these might include those who only experience hypomanic or manic episodes with antidepressant medications but not spontaneously, and those with recurrent unipolar major depressive episodes and a first-degree relative with type I bipolar disorder. Some would add those with hyperthymic personality at baseline (i.e. when not depressed) who also experience recurrent unipolar major depressive episodes. Recurrent, psychotic, and atypical unipolar depression may also be closer to the bipolar end of the spectrum, with similarities in underlying pathophysiology and treatment response. At the extreme of the bipolar end of the spectrum, schizoaffective disorder, bipolar type might be viewed as a more severe psychotic form of bipolar illness (for a review of the data underlying these views, see Goodwin and Jamison(1>).

Fig. 2 The affective spectrum: MDD, major depressive disorder; MDE, major depressive episode; BP, NOS, bipolar disorder, not otherwise specified (this could include mania or hypomania only on antidepressants, recurrent MDD with underlying hyperthermia, or recurrent MDD with a first-degree relative with bipolar disorder); SA, schizoaffective disorder, bipolar type, which can be seen as a more severe version of manic-depressive illness.

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