The Border between Bipolar Disorder and Personality Disorders / 신경정신의학

The concept of bipolar spectrum disorder (BSD) has developed to include affective temperaments such as cyclothymia and hyperthymia. This has greatly helped clinicians to differentiate depressed patients, who would potentially benefit from mood stabilizing treatment, from those with unipolar depression. Cyclothymia, however, has significant similarities with personality disorders, especially with borderline personality disorder (BPD). All the diagnostic items for BPD are frequently found in patients with BSD as well, which presents diagnostic challenges. There are no clear guidelines on how to differentiate BSD from BPD. Featuring borderline pathology for clinical purposes, it may be useful to rely on psychodynamic approaches to identify primitive defense mechanisms of splitting and projective identification suggesting borderline personality organization. Based on new findings on common features between BSD and BPD, some authors have proposed a renewal of the classification system of mental disorders. The dichotomy of bipolar and unipolar depression has gestated a new concept of BSD. Currently, the BSD concept forced us to formulate the border of BSD and personality disorders.

Chronotype in Relation to Bipolarity, Suicidal Ideation, and Auditory Evoked Potentials in Patients with Major Depressive Disorder : Preliminary Study

OBJECTIVES: The current study investigated the putative relationship between chronotype and suicidality or bipolarity in patients with major depressive disorder (MDD). METHOD: Nineteen outpatients who met the criteria for MDD according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders-text revision were recruited for the current study. The subjects were divided into two subgroups based on their Basic Language Morningness (BALM) scores (dichotomized according to the median BALM score). The Loudness Dependence of Auditory Evoked Potentials (LDAEP) was evaluated by measuring the auditory event-related potentials before beginning medication with serotonergic agents. In addition, K-Mood Disorder Questionaire (K-MDQ), Beck Scale for Suicidal Ideation (BSS), Beck Hopelessness Scale (BHS), Barratt Impulsiveness Scale (BIS) were applied. RESULTS: The K-MDQ, BSS, BHS, BIS score was higher for the eveningness group than for the morningness group. However, the LDAEP, Hamilton Depression Rating Scale, Hamilton Anxiety Scale scores did not differ significantly between them. There were negative correlations between the total BALM score and the total K-MDQ, BSS, and BHS scores (r = -0.64 and p = 0.0033, r = -0.61 and p = 0.0055, and r = -0.72 and p = 0.00056, respectively). CONCLUSIONS: Depressed patients with eveningness are more vulnerable to the suicidality than those with morningness. Eveningness is also associated with bipolarity.

Bipolar Spectrum: A Review of the Concept and a Vision for the Future

This paper reviews the bipolar spectrum concept historically and empirically. It describes how the concept derives from Kraepelin, but was lost with DSM-III, which divided the broad manic-depressive illness concept, based on recurrent mood episodes of either polarity, to the bipolar versus unipolar dichotomy, based on allowing non-recurrent mood episodes of only one polarity. This approach followed the views of Karl Leonhard and other critics of Kraepelin. Thus post DSM-III American psychiatry is not neo-Kraepelinian, as many claim, but neo-Leonhardian. The bipolar spectrum approach, as advocated by Akiskal and Koukopoulos first, harkens back to the original broad Kraepelinian view of manic-depressive illness. The evidence for and against this approach is discussed, and common misconceptions, including mistaken claims that borderline personality is similar, are revealed and critiqued.

Can the Loudness Dependence of Auditory Evoked Potentials and Suicidality Be Used to Differentiate between Depressive Patients with and without Bipolarity

OBJECTIVE: This study aimed to test the hypothesis that the loudness dependence of auditory evoked potentials (LDAEP) can be used to predict the presence of bipolarity in patients with major depressive episodes. METHODS: A cohort of 61 patients who met the criteria for major depressive disorder (MDD) following diagnosis using Axis I of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders-text revision, and who had no history of hypomanic or manic episodes was included in this study. The patients were stratified into two subgroups based on whether or not they achieved a positive score for the Korean versions of the Mood Disorder Questionnaire (K-MDQ). The LDAEP was evaluated by measuring the auditory event-related potentials before beginning medication with serotonergic agents. RESULTS: The Barratt Impulsiveness Scale (BIS) score was also higher for the positive screening group (81.24+/-11.87) than for the negative screening group (73.30+/-14.92; p=0.039, independent t-test). However, the LDAEP, Beck Depression Inventory, Hamilton Depression Rating Scale, Beck Hopelessness Scale (BHS), and Hamilton Anxiety Scale scores did not differ significantly between them. When binary logistic regression analysis was carried, the relationship between the positive or negative subgroups for K-MDQ and BIS or Beck Scale for Suicidal Ideation (BSS) score was also significant (respectively, p=0.017, p=0.038). CONCLUSION: We found that LDAEP was not significantly different between depressive patients with and without bipolarity. However, our study has revealed the difference between two subgroups based on whether or not they achieved a positive score for the K-MDQ in BIS or BSS score.

The Association Study between Mood Disorder Questionnaire and Bipolar Spectrum Disorder in Major Depressive Disorder / 신경정신의학

OBJECTIVES: This study was performed to evaluate the frequency of bipolar spectrum disorder (BSD) among patients who have been diagnosed with major depressive disorder. In addition, authors assessed the practical usefulness of the Mood Disorder Questionnaire (MDQ) to investigate the frequency of bipolar spectrum disorder in major depressive disorder. METHODS: The participants were 70 depressive patients who have never been diagnosed with bipolar disorders. The subjects were interviewed for diagnosis using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision criteria and the Mini-International Neuropsychiatric Interview to exclude bipolar disorders from the subjects. BSD criteria (as defined by Ghaemi, et al. 2002), and Korean version of the Mood Disorder Questionnaire (K-MDQ) was used to investigate their bipolarity. Data were collected including family history of affective disorder, number of previous depressive episode, age of onset, history of suicide attempt, comorbid psychiatric illness, and drug and alcohol use. RESULTS: Among 70 subjects, 25 patients (35.7%) were classified as having bipolar spectrum disorder on BSD criteria, while other 45 patients (64.3%) as unipolar depression. Among the 25 patients who meet the BSD criteria, 24 patients (34.3%) scored more than 7 and only 1 patient (1.4%) scored less than 6 on K-MDQ. Among the 45 patients who don't meet BSD criteria, 40 patients (57.1%) scored less than 6 and only 5 patients (7.1%) scored more than 7 on K-MDQ. Early age of onset, recurrent depressive episode, brief depressive episode, bipolar family history, history of suicide attempt, antidepressant induced hypomania, hyperthymic temperament, atypical depressive symptom, psychotic depressive symptom, and antidepressant "wear off" were found to be highly related with MDQ positive subjects and BSD subjects among the depressive subjects. CONCLUSION: The result of this study demonstrates the high frequency of BSD in depressive patients who have never been diagnosed with bipolar disorders. Some BSD criteria can be used to differentiate BSD subjects from the subjects with major depressive disorder. Also these results indicate that K-MDQ is useful for screening of bipolar spectrum disorder.

Validity of the Brazilian Portuguese version of the bipolar spectrum diagnostic scale / Validade da versão brasileira em português da escala diagnóstica do espectro bipolar

OBJECTIVE: Bipolar spectrum disorders (BSDs) are prevalent and frequently unrecognized and undertreated. This report describes the development and validation of the Brazilian version of the bipolar spectrum diagnostic scale (B-BSDS), a screening instrument for bipolar disorders, in an adult psychiatric population. METHOD: 114 consecutive patients attending an outpatient psychiatric clinic completed the B-BSDS. A research psychiatrist, blind to the B-BSDS scores, interviewed patients by means of a modified version of the mood module of the Structured Clinical Interview for DSM-IV ("gold standard"). Subthreshold bipolar disorders were defined as recurrent hypomania without a major depressive episode or with fewer symptoms than those required for threshold hypomania. RESULTS: The internal consistency of the B-BSDS evaluated with Cronbach's alpha coefficient was 0.89 (95 percent CI; 0.86-0.91). On the basis of the modified SCID, 70 patients (61.4 percent) of the sample received a diagnosis of BSDs. A B-BSDS screening score of 16 or more items yielded: sensitivity of 0.79 (95 percent CI; 0.72-0.85), specificity of 0.77 (95 percent CI; 0.70-0.83), a positive predictive value of 0.85 (95 percent CI; 0.78-0.91) and a negative predictive value of 0.70 (95 percent CI; 0.63-0.75). CONCLUSION: The present data demonstrate that the B-BSDS is a valid instrument for the screening of BSDs.

OBJETIVO: Transtornos do espectro bipolar (TEB) são prevalentes e comumente subdiagnosticados e subtratados. O presente trabalho descreve o desenvolvimento e a validação da versão brasileira da escala diagnóstica do espectro bipolar (B-EDEB), um instrumento de rastreio para transtornos bipolares, em uma população psiquiátrica adulta. MÉTODO: 114 pacientes consecutivos de um ambulatório psiquiátrico completaram a versão brasileira da B-EDEB. Um psiquiatra pesquisador, cego para os escores do B-EDEB, entrevistou os participantes por meio de uma versão modificada do módulo de transtornos do humor da entrevista clínica estruturada para o DSM-IV ("padrão-ouro"). RESULTADOS: A consistência interna da B-EDEB, avaliada mediante o coeficiente alfa de Cronbach, foi de 0,89 (IC 95 por cento; 0,86-0,91). De acordo com o padrão-ouro, 70 (61,4 por cento) participantes tiveram diagnóstico de TEB. Um escore da B-EDEB de 16 ou mais itens apresentou sensibilidade de 0,79 (IC 95 por cento; 0,72-0,85), especificidade de 0,77 (IC 95 por cento; 0,70-0,83), valor preditivo positivo de 0,85 (IC 95 por cento; 0,78-0,91) e valor preditivo negativo de 0,70 (IC 95 por cento; 0,63-0,75). CONCLUSÃO: Os resultados do presente estudo demonstram que a B-EDEB é um instrumento válido para o rastreio de TEB.

Screening of Bipolar Disorders in High School Students / 신경정신의학

OBJECTIVES: This study aimed to assess the prevalence of bipolar spectrum disorders among Korean high school students (individuals in late adolescence) using the Korean version of the Mood Disorder Questionnaire (K-MDQ). METHODS: Two thousand male and female participants were proportionately selected from among high school students nationwide. From November 2007 through February 2008, we conducted an epidemiological survey of, and administered the K-MDQ to, these participants, assessed their psychometric properties, and compared characteristics between K-MDQ-positive and K-MDQ-negative participants. RESULTS: The K-MDQ's internal consistency (Cronbach's alpha) was 0.74. The item-total score correlations ranged from 0.35 to 0.57, and all were statistically significant (p<.001). Factor analysis with varimax rotation revealed 3 factors that explained 42.6% of total variance. We found the cutoff endorsement of the K-MDQ score (7 or more in criteria 1) in 1207 students (60.4%) and found 104 (5.2%) subjects were K-MDQ-positive, meeting all 3 K-MDQ criteria. The mean K-MDQ total score was 7.2+/-2.9 and total scores of K-MDQ-positives and K-MDQ-negatives were 9.9+/-1.7 and 7.0+/-2.9, respectively. K-MDQ-positives and K-MDQ-negatives showed no differences in the sociodemographic variables we assessed. Endorsement of items in total subject ranged from 15.7% to 77.7%. All items except item 8 (more energy) differed significantly in endorsement between K-MDQ-positives and K-MDQ-negatives. Items accounting for over 30% of the endorsement differences between K-MDQ-positives and K-MDQ-negatives were"feel so good," "so irritable," and"excessive, foolish, risky behavior." CONCLUSION: The K-MDQ was a relatively valid screening tool for Korean high school students. Per the result of the K-MDQ survey, suspected lifetime prevalence of bipolar spectrum disorders for those in late adolescence (high school students) seems to be 5.2%, suggesting that systemic screening for bipolar spectrum disorder should be required for this age group.

Bipolar Diathesis in Patients with Treatment-Resistant Depression / 대한정신약물학회지

Despite the availability of numerous options for the treatment of depression, treatment-resistant depression remains common. Several patient-related and treatment-related risk factors have been identified as increasing the likelihood of nonresponsiveness to antidepressant treatment including psychiatric and physical comorbidity, the chronic subtype of depression, and treatment nonadherence. Evidence linking many cases of treatment-resistant depression with a diathesis to bipolar disorder has also emerged. This article reviews the current literature regarding the relevance of bipolarity to treatment-resistant depression, with particular attention to the prevalence of bipolarity in treatment-resistant depression.

Relaciones entre el trastorno límite de personalidad y el espectro bipolar: [revisión] / Relationship between borderline personality disorder and bipolar spectrum: [review]

Existe una controversia respecto a la independencia nosológica del trastorno límite de personalidad. Algunos autores sostienen que es parte del trastorno bipolar, mientras otros afirman que es una entidad independiente. En este trabajo se analiza la evolución histórica de los conceptos de trastorno límite y trastorno bipolar. Se discuten los argumentos a favor y en contra de incluir el trastorno límite dentro del trastorno bipolar. Por último se proponen nuevas estrategias para abordar este problema.

The independent nosological status of borderline personality disorder is a controversial issue. Some authors consider borderline as part of bipolar spectrum, but other sustain that is a independent entity. The historical evolution of borderline personality disorder and bipolar disorder is analyzed in this work. The arguments for include, or not include, borderline personality disorder in bipolar disorder is discussed. Finally, new strategies for study this problem are proposed.

The Validation Study of the Korean Version of the Bipolar Spectrum Diagnostic Scale / 신경정신의학

OBJECTIVES: Because bipolar spectrum disorders frequently go unrecognized in clinical practice, sensitive screening tools for bipolar spectrum disorders are much needed. This study was conducted to confirm the validity of the Korean version of the Bipolar Spectrum Diagnostic Scale (BSDS), which was originally designed by Ronald Pies. METHODS: The BSDS, which was translated into Korean by the authors, was administered to patients with known bipolar disorders (N=60) and unipolar depressive disorders (N=27). Using various cut-off scores, we calculated the sensitivities and specificities of the Korean version of the BSDS in order to determine the optimal cut-off score. RESULTS: In this study, a cut-off score of 10 was shown to be optimal, with a sensitivity of 0.73 and a specificity of 0.85, although a cut-off score of 13 was proposed to be optimal by the original authors of the BSDS. CONCLUSION: These results indicate that the Korean version of the BSDS is a valid screening tool for bipolar spectrum disorder.

La detección de casos de trastorno bipolar por medio de un instrumento de tamizaje: el Cuestionario de Trastornos del Animo versión en español

resumen está disponible en el texto completo

Summary Bipolar spectrum disorder which includes bipolar I, bipolar II, ciclothymia and bipolar disorder, not otherwise specified often goes unidentyfied, underdiagnosed, or confounded with major depressive disorder. There are several considerations that try to explain this frequent omission. One crucial aspect is that, the first mood episode at onset is often a depressive one, and some bipolar patients present multiple depressive episodes prior to their first episode of mania. Additionally, long-term evaluation of patients with bipolar I or II disorders, reveal that depressive symptoms occur more common than manic or hypomanic symptoms. Another plausible explanation is that bipolar patients frequently underreport symptoms of mania. Thus it is not surprising to find that in many patients, may elapse about 10 years from the first time for they seek treatment until a clinician finally makes the correct diagnosis. As a consequence, such patients may suffer poorer outcomes, subsyndromal symptoms and a course of illness marked by more sever symptoms, chronic mood episodes, increased recurrence and more impaired psychosocial functioning. The correct diagnosis of bipolar disorder becomes an important and crucial issue, if it is considered that there is a current trend to understand better this affective illness as a spectral disorder. This concept helps to identify different subtle subtypes of bipolarity which often are unrecognized, by means of the actual diagnostic criteria. This diagnostic reformulation is based on the phenomenological manifestations of the entities, as well as in other specific clinical aspects, such as comorbidity, predominant episodes, genetic information and treatment response to among others. Thus, correct recognition of bipolar disorder will bring an important benefit to patients and may reduce erratic treatments and improve outcome. Several epidemiological studies report that the global prevalence of bipolar I disorder is around 1%, in the general population, but when considering all subtypes included in the bipolar spectrum, this lifetime prevalence increases up to 5%. As a consequence of an incorrect diagnosis, patients are often undertreated or receive an erroneous pharmacological treatment, mainly with antidepressants, which complicate outcome by promoting manic or hypomanic reactions and may have devastating consequences in the further clinical intents to stabilize the disorder. In order to increase the recognition of an illness, the correct utilization of a clinical screening procedure is mandatory. Several screening instruments exist for a variety of psychiatric disorders. However, only until recently, some of them have been developed specifically to identify bipolar disorders. The Mood Disorder Questionnaire, was the first screening instrument specifically developed to detect bipolar cases in clinical settings. It is a self-report, single-page, paper and pencil inventory than can be quickly and easily scored by a physician, a nurse or by trained medical staff assistance. It is composed of 13 questions which are answered with a positive or negative fashion, elaborated from the bipolar diagnostic criteria and clinical experience and inquires about possible manic symptoms. In the original report of its development and validation, it was concluded that it is a useful screening instrument for bipolar spectrum disorders, with a good sensitivity (0.73) and a very good specificity (0.90). Method: The questionnaire has been translated to other languages and has been used in non-clinical settings, with very good standards of performance. Since there is not a Spanish version of it, we decided to translate this instrument and to design a trial for the following purposes: 1) to obtain a validated and understandable Spanish version of the questionnaire. 2) To determine its sensibility and specificity in a sample of patients with affective disorders. 3) To identify its optimal cutoff score for screening purposes. The first step in our study consisted in the development of a translated version of the instrument. For that purpose a translation- retranslation procedure was utilized, in which four clinical psychiatrists with experience in treating bipolar patients made each one a separate translation. Then, all the versions were discussed until a consensus was reached in a final version. This version was retranslated to English and, after making some adjustments, the final version in Spanish was concluded. The study aimed to determine the clinimetric parameters of the Mood Disorder Questionnaire in its Spanish version, was conducted at the outpatient affective disorders clinic in the National Institute of Psychiatry Ramón de la Fuente, in México City. Patients with an age of 18 years and over who looked for psychiatric consultation, due to the presence of affective disorder were invited to participate. After explaining the procedure and the purposes of the study, all those who accepted to participate, signed 51 an informed consent document. This study was approved by the Ethical Committee of our institution. All patients completed the Mood Disorder Questionnaire. Two experienced clinical psychiatrists, blind to the questionnaire results, applied the Structural Clinical Interview for DSM-IV (SCID) to obtain the specific affective diagnosis in all the patients. Clinical and demographic data, as well as results from the clinical interview and questionnaire's scores, were obtained and then analyzed. Sensitivity and specificity for each Mood Disorder Questionnaire score, were plotted by using results from the SCID interview as a standard. Sensitivity (percent of criterion standard diagnosis correctly diagnosed by the questionnaire) and specificity (percent of criterion standard noncases correctly identified as noncases by the questionnaire) were obtained by using different symptoms, threshold that ranged from 5 to 10 points in order to determine the optimal screen threshold. Results: A total of 100 patients were included in the study. Mean age for the complete group was 35.3 years and 64% were female. According to the SCID results, 49 patients had a diagnosis within the bipolar spectrum disorder and 51 had a unipolar affective diagnosis. Each group included patients with both first and recurrent episodes, and with and without comorbidities. The questionnaire was completed by the total sample of patients covering the total range of answer's possibilities, from non-positive responses (1% of the sample) to 13 positive responses (15% of the sample). Mean score (± SD) was 8.06 (3.5) with a significant difference between patients in the bipolar group (10.3 ± 2.7) and patients in the unipolar group (5.8 ± 2.7); t = -8.2, 98 gl, p<0.001. Using different cutoff scores sensitivity and specificity were calculated, observing that with a 10 point cutoff score, equilibrated sensitivity (0.71) and specificity (0.92) levels were obtained. Conclusions: The study was aimed to obtain an adequate translated version into Spanish of the Mood Disorder Questionnaire, and to determine its sensitivity and specificity, according to an optimal cutoff score, for correctly detecting bipolarity from a sample of affective disorder patients. With a reliable procedure of translation process, we obtained a satisfactory, understandable and easy to use version for patients. Similar to other reports, a structured clinical interview was utilized to obtain the patients diagnoses. After evaluating with different cutoff scores, we found that a score of 10, gives an adequate distribution for levels of sensitivity and specificity. However, lower scores (between 7 and 9), also give adequate levels of sensitivity and specificity. It is important to consider, that our study was done in a very specific sample of patients who had only affective disorders. With these type patients it is necessary to raise the bar sufficiently to obtain adequate results. In other studies that included non-affective patients the questionnaire worked well with lower cutoff points. The operating characteristics of the Mood Disorder Questionnaire in its Spanish version are sufficiently good to consider its application as a reliable screening instrument for detecting bipolar spectrum disorders at least, in an affective disorders clinical setting. Further studies are needed to evaluate whether the instrument would be useful in other psychiatric settings as well as in community or primary care samples, and also to determine the best cutoff point depending in the characteristics of the population in which it is being used.

Bipolar Disorder

Bipolar disorder is one of the most distinct syndromes in psychiatry. Bipolar I disorder affects approximately 1 percent of the population worldwide. About 50 percent of patients with bipolar illness have a family history of the disorder. Studies of twins suggest that the concordance rate of bipolar illness is between 40 percent and 80 percent in monozygotic twins. Although researchers have proposed myriad subtypes of depression, there are two major subtypes of disorder according to DSM-IV-TR: bipolar I and bipolar II. Bipolar I disorder is diagnosed on the basis of a single lifetime manic or mixed episode. Indeed, in one follow-up survey of tertiary care patients, depressive symptoms were more than three times as frequent as manic symptoms. Antidepressant monotherapy in an undiagnosed bipolar disorder patient can have devastating effects. So, clinical evaluation of a patient presenting with depression should always include the assessment for bipolar disorder. In addition to major episodes, it is important to pay attention to the course of subsyndromal and prodromal symptoms. Treatment options for bipolar disorder have rapidly expanded over the last decade. The literature supports the efficacy of a list of agents for the management of bipolar disorder, including lithium, valproate, lamotrigine, and carbamazepine, as well as the atypical antipsychotics olnazapine, risperidone, quetiapine, ziprasidone, and aripiprazole.

The Bipolar Diathesis in Patients with Treatment Resistant Depression / 대한정신약물학회지

OBJECTIVE: In this study, we determined the prevalence of bipolarity in patients with treatment resistant depression (TRD) by investigating demographic and clinical characteristics, diagnostic subtypes, and illness outcome. METHOD: A medical record review of patients admitted to a university hospital with the diagnosis of major depressive disorder (MDD) was conducted. DSM-IV diagnoses at index hospitalization and six months after discharge and detailed clinical information were obtained. We categorized subjects into a TRD group or a non-TRD group and re-evaluated the patients using the recently proposed criteria for bipolar spectrum disorder (BSD). Patients in the TRD group were compared with patients in the non-TRD group with regard to the prevalence rate of BSD at the index hospitalization and at the end of the follow up period. RESULTS: There were 281 patients diagnosed as MDD. At discharge, the number of patients who fulfilled the criteria for BSD was higher (p<.001) in the TRD group (32/68, 47.1%) than in the non-TRD group (8/213, 3.8%). At the end of six-month follow-up period, the diagnoses of 38 patients changed ; 18 (26.5%) in the TRD group were subsequently classified as having bipolar disorder, and seven (3.3%) in the non-TRD group (p<0.001). There was no difference between these two groups in other clinical and demographic variables. CONCLUSION: The findings suggest that a large number of patients with TRD have a bipolar diathesis.

Bipolar Spectrum Disorder / 대한정신약물학회지

The concept of bipolar disorder is an ongoing process, still in evolution, although its roots can be found from ancient Greek. Until recently, it was believed that no more than 1% of the general population has bipolar disorder. But literature on the lifetime prevalence of the bipolar spectrum disorder suggests rates of 4-5%. Bipolar spectrum disorder is a longitudinal diagnosis characterized by abnormal mood swings comprising some of the following cross-sectional clinical states: mania, hypomania, mixed states, hyperthymic temperament, major depressive episode, and depressive mixed state. Failure to recognize subthreshold expressions of mania, such as hypomania, cyclothymia, and hyperthymia, contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive one. These include the lack of subjective suffering, enhanced productivity, egosyntonicity, diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' difficulty in differentiating with personality disorders. In addition, most patients with bipolar spectrum disorder seek treatment for depression, rather than mania or hypomania. Therefore clinicians often miss the diagnosis of bipolar spectrum disorder. The recent 10 years of researches have suggested that 30-55% of patients with major depressive disorder are actually identified with broader spectrum of bipolar disorders. However, 48% of patients of bipolar disorder consulted 3 or more professionals before receiving a correct diagnosis, and 10% consulted 7 or more for their first diagnosis of bipolar disorder. Several studies have documented that patients often wait as long as 10 years for the correct diagnosis of bipolar spectrum disorder. This delay in diagnosis often has substantial adverse results. Patients do not get the appropriate treatment to alleviate their symptoms. They may even get treatments that exacerbate their symptoms, such as prescription of antidepressants precipitating mania and producing rapid cycling. The concepts of hypomania, cyclothymia, mixed state, depressive mixed states, hyperthymic temperament are the new areas of studying mood disorders in recent 20 years. The authors will review the studies on various subtypes of bipolar spectrum disorder with their historic aspects, and introduce the suggested screening tests for bipolar spectrum disorder in clinical practice.