This article is more than 5 years old. Information may no longer be current.

Review supports activation as DSM-5 criterion A for bipolar disorder

A systematic review supported the elevation of activation to a criterion A symptom for bipolar disorder in DSM-5.

“Despite the reassertion of the importance of psychomotor function in [bipolar disorder], no current consensus definition or operationalization of terms such as activity/energy exists, to our knowledge,” Jan Scott, PhD, FRCPsych, of Newcastle University, England, and colleagues wrote. “For example, the DSM-5 does not explicate whether the increase in activity and/or energy refers to mean level, timing, or overall pattern. Also, the DSM-5 recognizes motor changes only in relation to (hypo) manic episodes, despite ample evidence that such abnormalities are common in bipolar depression.”

To determine if activation is statistically abnormal in bipolar disorder and thus an appropriate criterion, researchers conducted a systematic review of 56 longitudinal studies of mania and bipolar depression and data-driven analyses in bipolar disorder. Analysis included 29 studies of the factor structure of bipolar disorder, three of activity data from experimental sampling or ecological momentary assessment, 20 actigraphy and four laboratory-based studies.

Synthesis of study findings indicated mean levels of activity are lower during euthymia and depression in participants with bipolar disorder, compared with healthy controls and other comparison groups. This association was the most robust, according to researchers.

Ecological and laboratory studies showed less organized or predictable patterns of behavior and a lack of habituation among participants with bipolar disorders.

Factor analytic studies indicated fairly consistent evidence that mood and activation were distinct dimensions of bipolar disorder.

Studies evaluating interindividual and intraindividual patterns of activity indicated mania may be better characterized by differences in robustness, variability, predictability, or complexity of activation rather than mean activity levels.

“By aggregating findings across the three set questions, the present review of relevant literatures suggests that activation is disturbed in [bipolar disorder] (relative to a range of comparators), that activation differences in [bipolar disorder] are not merely epiphenomena of mood abnormalities, and indeed that activation may supersede mood as a cardinal, defining feature of mania and depression in [bipolar disorder]. Therefore, inclusion of activation as one of the core features of [bipolar disorder] in the DSM-5 is empirically based,” the researchers wrote. “However, this review strongly suggests the need for more systematic empirical programs of research, such as the collaborative network for research on activation called mMARCH (Motor Activity Research Consortium for Health) coordinated by a workgroup of NIMH.” – by Amanda Oldt

Disclosure: Scott reports being a visiting professor at Diderot University, the Norwegian University of Science and Technology, and The University of Sydney; receiving grant funding from the UK Medical Research Council (including for projects on a cohort of bipolar II disorders, randomized trials of cognitive behavioral therapy, and actigraphic monitoring in bipolar disorders) and from the UK Research for Patient Benefit program (PB-PG-0609-16166: Early identification and intervention in young people at risk of mood disorders); and receiving a personal fee from Janssen-Cilag for a nonpromotional talk on sleep problem. Please see the study for a full list of relevant financial disclosures.