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Mood Weight Leaden
reactivity gain Overeating Hypersomnia paralysis

Weight gain 3.9
Overeating 5.3* 69.6**
Hypersomnia 5.2** 6.2** 6.5**
Leaden paralysis 1.3 3.1** 3.4** 2.0**
Interpersonal rejection
sensitivity 3.2** 1.1 1.0 1.4 2.2**



Table 6.8 Associations among atypical depression symptoms in the unipolar subsample
(n ¼ 164), by univariate logistic regression (odds ratio, *P < 0.05; **P < 0.01)

Mood Weight Leaden
reactivity gain Overeating Hypersomnia paralysis

Weight gain 1.4
Overeating nc 98.3**
Hypersomnia 3.1 18.5** 18.5**
Leaden paralysis 1.4 1.5 2.4 3.4**
Interpersonal rejection
sensitivity 1.2 4.4* 2.9* 4.1** 2.0*




Table 6.9 Comparison of atypical depression symptoms between mood-reactive (MR) and
non-mood-reactive (N-MR) major depressive episode patients

MR ¼ 344 N-MR ¼ 61
Atypical symptoms Z P

Weight gain 18.0% 6.5% 2.2 0.0249
Overeating 24.1% 3.2% 3.6 0.0002
Hypersomnia 33.4% 9.8% 3.7 0.0002
Leaden paralysis 40.9% 31.1% 1.4 0.1489
Interpersonal sensitivity 62.5% 42.6% 2.9 0.0035



et al., 2002, 2003; Benazzi studies in this paper), but not in others (McGrath et al.,
1992; Robertson et al., 1996; Posternak and Zimmerman, 2002). Different findings
may be related to diagnostic criteria, careful and systematic probing for past
hypomania, diagnostic interviews (fully structured versus semistructured),
149 Atypical depression and bipolar spectrum


clinician™s training, and to different study settings. Lower age of onset and more
females in AD versus non-AD were reported (American Psychiatric Association,
2000; Angst et al., 2002). More DMX in AD versus non-AD is a relatively new
finding (Benazzi, 2001g; Benazzi and Akiskal, 2001). However, more irritability (a
hypomanic symptom) was also reported by Posternak and Zimmerman (2002),
Akiskal (1996, 2000) reported that BP-II depression frequently had a combination
of AD and hypomanic symptoms, and DSM-IV-TR (American Psychiatric
Association, 2000) stated that BP-II females were more likely to have mixed
episodes. Much more BP family history in AD versus non-AD is an important
finding, as family history is an important variable, validating a diagnosis (Robins
and Guze, 1970). The review of Rabkin et al. (1996) concluded that, if AD was
related to BP, family history should show more BP. To test if the associations of
AD and female gender, early onset, DMX, and BP family history were specific
features of AD, or were instead due to its association with BP-II (which was closely
related to all these variables), multivariate logistic regression was used. Results
showed that the associations between AD and female gender, AD and early onset,
and AD and DMX were specific features of AD and were not related to the
association between AD and BP-II, but that the association between AD and BP
family history was related to the association between AD and BP-II.
It was found that the association between AD and axis I comorbidity was not
specific for AD, but could instead be related to a common early age of onset. It was
found that the association between AD and BP-II was specific for AD and not
related to a common age of onset. Two-way ANOVA was also used to find if the
lower age of onset in AD versus non-AD was related to an interaction between AD
and BP-II, showing such an interaction. Discriminant analysis of BP-II, female
gender, early onset, DMX, and BP family history for predicting AD found that AD
was significantly associated only with female gender, early onset, and DMX,
supporting the previous multivariate logistic regressions, and suggesting that AD
may not be so strongly related to BP-II when compared to these predictor vari-
ables. BP-II AD, versus UP AD had a significantly lower age of onset, more
recurrences, more depression chronicity, more DMX, more BP family history,
and more irritability, while AD symptoms were not significantly different. Results
suggest that BP-II AD may be distinct from UP AD, supporting a DSM-IV
classification, where AD is not a distinct mood disorder. AD had a high specificity
for predicting BP-II, second only to BP family history, when compared to BP
family history, early onset, many MDE recurrences, and DMX (which are typical
bipolar signs: Benazzi and Akiskal, 2001; Ghaemi et al., 2002). Discriminant
analysis of AD, BP family history, early onset, many MDE recurrences, and
DMX for predicting BP-II diagnosis found that AD was a near-significant pre-
dictor of BP-II compared to the other variables.
150 F. Benazzi


The results of these analyses suggest that AD is related to BP-II, and that there
are other indicators of bipolarity that are more strongly related to BP-II than AD.
However, AD is a cross-sectional sign of BP-II which is more reliable and easy to
assess during MDE assessment than onset, family history, and number of recur-
rences (all variables dependent on memory). AD and DMX can be useful cross-
sectional markers of BP-II for the clinician (Benazzi, 2001d), leading to careful
probing for past hypomania, and to the search for collateral information from
family, close friends, medical records, and previous clinicians. AD may have some
specific features, like more females, low age of onset, and DMX, which may be
independent of its association with BP-II. The strong association between DMX
and BP-II (Benazzi, 2001d; Benazzi and Akiskal, 2001; Akiskal and Benazzi, 2003)
and AD and DMX strengthen the link of AD with BP-II.
Mood reactivity was significantly associated with all DSM-IV AD symptoms,
apart from leaden paralysis (4/5), in the whole sample. All the other AD symptoms
were significantly associated with each other (10/10) in the whole sample.
However, when the analysis was made separately in the BP-II and UP subsamples,
results were partly different. In the BP-II subsample, mood reactivity was signifi-
cantly associated with 3/5 AD symptoms, while in the UP subsample it was
significantly associated with no AD symptom (0/5). In the two subsamples the
other AD symptoms were often, but not always, significantly associated with each
other (7/10, 8/10). Given the strong association between BP-II and AD found in
the present study and in previous studies (Angst, 1998; Perugi et al., 1998; Agosti
and Stewart, 2001; Angst et al., 2002, 2003; Benazzi studies in this paper), the
association between BP-II and mood reactivity was tested by logistic regression,
finding a strong association. The results of the present study in the BP-II sub-
sample are in line with the finding of Angst et al. (2002) of a significant association
between mood reactivity and the other DSM-IV AD symptoms. The results of the
present study in the UP subsample are also in line with Posternak and Zimmerman
(2002), who found a lack of correlation between mood reactivity and the other AD
symptoms. In these two studies UP and BP-II patients were combined in the
analysis, as shown in Table 6.6. An important difference between these two studies
is the number of BP-II patients included, which was very small in the study by
Posternak and Zimmerman (2002). In the present study, a large number of BP-II
patients were included, making it more comparable to the study by Angst et al.
(2002). However, in contrast to these two studies, UP and BP-II subsamples were
also studied separately (Tables 6.7 and 6.8), leading to findings which could
explain the opposite findings of the above two studies.
The results of the present study seem to suggest that the inclusion of mood
reactivity among the symptoms of AD may be different in BP-II versus UP. In BP-II,
mood reactivity could be included in AD, while in UP it could not be included.
151 Atypical depression and bipolar spectrum


This conclusion is also supported by differences found between BP-II AD and UP
AD (Benazzi, 1999a, b, 2000c, e).


REFERENCES
Agosti, V. and Stewart, J. W. (2001). Atypical and non-atypical subtypes of depression: compar-
ison of social functioning, symptoms, course of illness, co-morbidity and demographic
features. J. Affect. Disord., 65, 75“9.
Akiskal, H. S. (1996). The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV.
J. Clin. Psychopharmacol., 16 (suppl. 1), 4S“14S.
Akiskal, H. S. (2000). Mood disorders: clinical features. In Kaplan & Sadock™s Comprehensive
Textbook of Psychiatry, ed. B. J. Sadock and V. A. Sadock, 7th edn on CD-ROM,
pp. 28294“9391. Philadelphia: Lippincott Williams & Wilkins.
Akiskal, H. S. and Benazzi, F. (2003). Family history validation of the bipolar nature of
depressive mixed states. J. Affect. Disord., 73, 113“22.
Akiskal, H. S. and Pinto, O. (1999). The evolving bipolar spectrum: prototypes I, II, III, and IV.
Psychiatr. Clin. North Am., 22, 517“34.
Akiskal, H. S., Djenderedjian, A. H., Rosenthal, R. H., and Khani, M. K. (1977). Cyclothymic
disorder: validating criteria for inclusion in the bipolar affective group. Am. J. Psychiatry,
134, 1227“33.
Akiskal, H. S., Maser, J. D., Zeller, P. J., et al. (1995). Switching from ˜˜unipolar™™ to bipolar II. An
11-year prospective study of clinical and temperamental predictors in 559 patients. Arch. Gen.
Psychiatry, 52, 114“23.
Akiskal, H. S., Bourgeois, M. L., Angst, J., et al. (2000). Re-evaluating the prevalence and
diagnostic composition within the broad clinical spectrum of bipolar disorders. J. Affect.
Disord., 59 (suppl. 1), S5“30.
Akiskal, H. S., Hantouche, E. G., Bourgeois, M. L., et al. (2001). Toward a refined phenomeno-
logy of mania: combining clinician-assessment and self-report in the French EPIMAN study.
J. Affect. Disord., 67, 89“96.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders,
4th edn. Washington, DC: American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders,
Text Revision (DSM-IV-TR), 4th edn. Washington, DC: American Psychiatric Association.
Angst, J. (1996). Comorbidity of mood disorders: a longitudinal prospective study. Br. J. Psychiatry,
168 (suppl. 30), 31“7.
Angst, J. (1998). The emerging epidemiology of hypomania and bipolar II disorder. J. Affect.
Disord., 50, 143“51.
Angst, J., Sellaro, R., and Merikangas, K. R. (2000). Depressive spectrum diagnoses. Compr.
Psychiatry, 41 (suppl. 2), 39“47.
Angst, J., Gamma, A., Sellaro, R., Zhang, H., and Merikangas, K. (2002). The validity of
atypical depression in the community: results of the Zurich cohort study. J. Affect. Disord.,
72, 125“38.
152 F. Benazzi


Angst, J., Gamma, A., Benazzi, F., et al. (2003). Toward a re-definition of subthreshold
bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and
hypomania. J. Affect. Disord., 73, 133“46.
Baldessarini, R. J. (2000). A plea for integrity of the bipolar disorder concept. Bipolar Disord., 2, 3“7.
Benazzi, F. (1997a). Prevalence of bipolar II disorder in outpatient depression: a 203-case study
in private practice. J. Affect. Disord., 43, 163“6.
Benazzi, F. (1997b). Antidepressant-associated hypomania in outpatient depression: a 203-case
study in private practice. J. Affect. Disord., 46, 73“6.
Benazzi, F. (1999a). Prevalence of bipolar II disorder in atypical depression. Eur. Arch. Psychiatry
Clin. Neurosci., 249, 62“5.
Benazzi, F. (1999b) Prevalence and clinical features of atypical depression in depressed out-
patients: a 467-case study. Psychiatry Res., 86, 259“65.
Benazzi, F. (1999c). Chronic atypical major depressive episode in private practice: unipolar and
bipolar II. Acta Psychiatr. Scand., 100, 418“23.
Benazzi, F. (1999d). Bipolar II versus unipolar chronic depression: a 312-case study. Compr.
Psychiatry., 40, 418“21.
Benazzi, F. (1999e). Gender differences in bipolar II and unipolar depressed outpatients: a 557-
case study. Ann. Clin. Psychiatry, 11, 55“9.
Benazzi, F. (1999f). Is atypical depression a moderate severity depression? A 536-case study.
J. Psychiatry Neurosci., 24, 244“7.
Benazzi, F. (1999g). Bipolar versus unipolar psychotic outpatient depression. J. Affect. Disord.,
55, 63“9.
Benazzi, F. (1999h). Psychotic late-life depression: a 376-case study. Int. Psychogeriatr., 11,
325“32.
Benazzi, F. (2000a). Depression with DSM-IV atypical features: a marker for bipolar II disorder.
Eur. Arch. Psychiatry Clin. Neurosci., 250, 53“5.
Benazzi, F. (2000b). Early- versus late-onset bipolar II disorder. J. Psychiatry Neurosci., 25, 53“7.
Benazzi, F. (2000c). Atypical bipolar II depression compared with atypical unipolar depression
and non-atypical bipolar II depression. Psychopathology, 33, 100“2.
Benazzi, F. (2000d). Late-life atypical major depressive episode: a 358-case study in outpatients.
Am. J. Geriatr. Psychiatry, 8, 117“22.
Benazzi, F. (2000e). Early-onset versus late-onset atypical depression: unipolar and bipolar II.
J. Affect. Disord., 61, 95“9.
Benazzi, F. (2000f). Late-life chronic depression: a 399-case study in private practice. Int.
J. Geriatr. Psychiatry, 15, 1“6.
Benazzi, F. (2000g). Bipolar II depression with melancholic features. Ann. Clin. Psychiatry, 12,
29“33.
Benazzi, F. (2000h). Female depression before and after menopause. Psychother. Psychosom., 69,
280“3.
Benazzi, F. (2000i). Borderline personality disorder and bipolar II disorder in private practice
depressed outpatients. Compr. Psychiatry, 41, 106“10.
Benazzi, F. (2001a). Bipolar II depression in late life: prevalence and clinical features in 525
depressed outpatients. J. Affect. Disord., 66, 13“18.
153 Atypical depression and bipolar spectrum


Benazzi, F. (2001b). Factor analysis of the Montgomery Asberg Depression Rating Scale in 251
bipolar II and 306 unipolar depressed outpatients. Progr. Neuro-Psychopharmacol. Biol.
Psychiatry, 25, 1369“76.
Benazzi, F. (2001c). Is 4 days the minimum duration of hypomania in bipolar II disorder? Eur.
Arch. Psychiatry Clin. Neurosci., 251, 32“4.
Benazzi, F. (2001d). Sensitivity and specificity of clinical markers for the diagnosis of bipolar II
disorder. Compr. Psychiatry, 42, 461“5.
Benazzi, F. (2001e). High prevalence of bipolar spectrum disorders. J. Clin. Psychiatry, 62, 735“6.
Benazzi, F. (2001f). Early-onset versus late-onset bipolar II chronic depression. Depression
Anxiety, 13, 45“9.
Benazzi, F. (2001g). Atypical depression with hypomanic symptoms. J. Affect. Disord., 65,
179“83.
Benazzi, F. (2002a). Should mood reactivity be included in the DSM-IV atypical features
specifier? Eur. Arch. Psychiatry Clin. Neurosci., 252, 135“40.
Benazzi, F. (2002b). Bipolar depression and melancholia. Comments on Parker et al. The nature of
bipolar depression: implications for the definition of melancholia. J. Affect. Disord., 59, 217“24.
Benazzi, F. (2002c). Psychomotor changes in melancholic and atypical depression: unipolar and
bipolar II subtypes. Psychiatry Res., 112, 211“20.
Benazzi, F. (2002d). Highly recurrent unipolar may be related to bipolar II. Compr. Psychiatry,
43, 263“8.
Benazzi, F. (2002e). Which could be a clinically useful definition of depressive mixed state?
Progr. Neuropsychopharmacol. Biol. Psychiatry, 26, 1105“11.
Benazzi, F. (2002f). Can only reversed vegetative symptoms define atypical depression? Eur.
Arch. Psychiatry Clin. Neurosci., 252, 288“93.
Benazzi, F. (2003a). Is there a link between atypical and early onset ˜˜unipolar™™ depression and
bipolar II disorder? Compr. Psychiatry., 44, 102“9.
Benazzi, F. (2003b). Bipolar II depressive mixed state: finding a useful definition. Compr.
Psychiatry, 44, 21“7.
Benazzi, F. (2003c). Bipolar II disorder and major depressive disorder: continuity or disconti-
nuity? World J. Biol. Psychiatry, 4, 166“71.
Benazzi, F. (2003d). Testing DSM-IV definition of atypical depression. Ann. Clin. Psychiatry, 15, 9“6.
Benazzi, F. (2003e). Clinical and family history markers of bipolar II disorder. Can. J. Psychiatry,
48, 208“9.
Benazzi, F. (2004a). The problem of the treatment of bipolar-II depression. Bipolar Disord., 6,
440“1.
Benazzi, F. (2004b). Testing early-onset chronic atypical depression subtype.
Neuropsychopharmacology, 29, 440“1.
Benazzi, F. (2004c). Clinical differences between bipolar II depression and unipolar major
depressive disorder: lack of an effect of age. J. Affect. Disord., 75, 191“5.
Benazzi, F. (2004d). The role of gender in depressive mixed state. Psychopathology, 36, 213“17.
Benazzi, F. and Akiskal, H. S. (2001). Delineating bipolar II mixed states in the Ravenna“San
Diego collaborative study: the relative prevalence and diagnostic significance of hypomanic
features during major depressive episodes. J. Affect. Disord., 67, 115“22.
154 F. Benazzi

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