- Email: [email protected]
Premorbid history and clinical manifestations at the onset of psychosis
FRIDAy, MAY 20
BIOL PSYCHIATRY 695 1994;35:615-747
288. LONGITUDINAL CLASSIFICATION IN SCHIZOPHRENIA: THE RELATIONSHIP BETWEEN KRAEPELINIAN AND DEFICIT SYNDROME SUBTYPOLOGIES
290. EMPIRICAL EVALUATION OF THE FACTORIAL STRUCTURE OF CLINICAL SYMPTOMS IN SCHIZOPHRENIA: IS THE PANSS A VALID SCALE?
S.H. Apter, R.S.E. Keefe, J. Hirschowitz, M. Davidson, J.M. Macaluso, R. Amato, & K.L. Davis
P.D. Harvey, L. White, M. Parrella, P. Powchik, & M. Davidson
Bronx Veterans Administration Hospital, Mount Sinai School of Medicine, New York, NY 10468
Mt. Sinai School of Medicine and Pilgrim Psychiatric Center
Kraepelinian schizophrenics are defined as a subgroup of schizophrenic patients who display at least five continuous years of complete dependence on others for food, shelter, and clothing. These patients have been empirically distinguished from nonkmepelinian schizophrenics in several areas of diagnostic validation. Kraepelinians demonstrate an absence of treatment response, greater CT vencicular abnormalities, more severe formal thought disorder and negative symptoms, less severe symptoms of mood disorder, and greater morbid risk for schizophrenia spectrum disorders in their first degree relatives. The deficit syndrome, as described by Carpenter et al (1987), is defined as the presence of enduring negative symptoms considered to be primary (ie., not secondary to such factors as depression, medication, etc.) and stable (i.e., present both during and between exacerbations of positive symptomatology for at least one year), it was the aim of the present study to assess the relationship between Kraepelinian status and the deficit syndrome, two longitudinal subtypologies of schizophrenia. The Schedule for the Deficit Syndrome was completed by 16 Kraepelinian and 31 nonkmepelinian schizophrenic patients, similar in terms of age, education, and duration of illness. Kraepelinian patients were significantly more likely to present with the deficit syndrome than were nonkraepelinian patients (chi-square 18.0, df- i, p -.0001). Every Kraepelinian patient met criteria for the deficit syndrome while only 35% of the nonkraepelinian patients (I I out of 31) exhibited the deficit syndrome. Of 27 total deficit patients, only 16 were Kraepelinian. Thus, there is substantial overlap between the Kraepelinian and the deficit syndrome subtypes, with the Kraepelinian subtype identifying a more restricted group of patients.
Recent approaches to conceptualizing the symptomatology of schizophrenia have gone beyond previous subtyping (e.g., paranoid vs. nonparanoid) or simple two-factor (e.g., positive-negative) models. Several recent studies using confirmatory factor analysis have demonstrated that schizophrenic symptoms have a complex multifactorial structure and that several aspects of symptomatology that have been seen as a single factor (e.g., thought disorder, negative symptoms) are actually multifactorial. In this study, we attempted use confirmatory factor analysis to develop and test muitifactorial models of schizophrenic symptomatology using the Positive and Negative Syndrome Scale (PANSS). Geriatric (n-308) and nongeriatric (n-240) schizophrenic patients were the subjects and we tested five-factor and three-factor models, previously derived on the basis of either previous exploratory factor analyses or the conceptual organization of the PANSS. There were no differences in the relative fit of the models across geriatric vs. nongeriatric samples. Although both the three. factor and five-factor models were a significant (X2 (i) - i 44; p<.001; X2 (8) - 199, p<.001) improvement over a simple unifactorial severity model, no model fit the data particularly well. l~n fact, a model derived on an exploratory basis using the PANSS data from the geriatric patients in this study fit the data very poorly (X2 (395)-!015,p<.001, Comparative Fit Index-.55). These data suggest that PANSS may have significant limitations in construct validity, compared to other clinical rating scales (e.g., the SANS, the TLC, and the SAPS) that have been successfully used in previous factor analytic studies. These results may also suggest that "comprehensive" psychiatric rating scales such as the PANSS ~nd the BPRS may be more useful for characterizing generalized severity of illness than for use in conceptual studies of symptomatology.
289. CONFIRMATORY FACTOR ANALYSIS TO TEST SCHIZOPHENIC MODELS
291. PREMORBID HISTORY AND CLINICAL MANIFESTATIONS AT THE ONSET OF PSYCHOSIS
V. Peralta, MJ. Cuesta, & J. de Leon Virgen del Camino" Hospital, Pamplona, Spain and the Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute Schizophrenia models postulate two syndromes, positive and negative, but exploratory factor analyses suggest also a disorganization syndrome. The sample included 253 DSM-lll-R schizophrenics who were consecutively hospitalized in acute psychiatric inpatient unit. Confirmatory factor analyses using LISREL were conducted to asses the latent structure of symptoms reflecting underlying pathological processes. The analyses included SAPS and SANS items and subscales and were performed to test 13 different models of schizophrenia with one, two or three syndromes. The three-syndrome models displayed the best fitness. All of three-syndrome models shared the positive and negative dimension. The other syndrome was the disorganization or Strauss' relational syndrome. A foursyndrome model comprised of positive, disorganization, negative and relational syndromes showed excellent fitness. Despite its limitations, this study suggests the need to explore the validity of a four-syndrome model, since the positive-negative model fits poorly with the data.
R. Scheffer l, E.E. Correntil, R.L. Borison 2, & S. Mukherjee2 tDepartmcnt of Psychiatry & Neurology, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905; and 2Department of Psychiatry, Medical College of Georgia, ! 515 Pope Avenue, Augusta, GA 30912 Data will be presented from an ongoing study of patients admitted to an Army Medical Center for their first episode of psychosis. History of premorbid functioning was recorded using the Premorbid Adjustment Scale (PAS; Cannon-Spoor et al 1982). Only subjects for whom a well relative was available are included. The sample comprised ! 3 patients, I I men and 2 women, with a mean age of 22.3 + 4.5 yrs. The sample was unique in that mean duration of psychosis was 4.5 + 2.5 days. Treatment was "doctor's choice." The clinical state was monitored using the Brief Psychiatric Rating Scale (BPRS). Poorer childhood school performance was associated with higher baseline BPRS positive symptom score (r-.6l; p<.05), while poor early adolescent school performance was associated with higher baseline negative symptom scores (r - .70; p<.02). Although there were trends for PAS scores predicting 6-wk response of both posi-
696
BIOLPSYCHIATRY 1994;35:615-747
tive and negative symptoms to neuroleptic treatment, none of these were significant after controlling for covafiance due to baseline severity of the respective symptom clusters, which were strongly predictive of 6-wk outcome. Data will also he presented on the relation of premorbid functioning to 6-month outcome. In summary, although a history of poor premorbid functioning appears to influence symptoms severity very early at the onset of psychosis, it does not seem to influence very short-term response to naturalistic treatment during this period.
292. CLINICAL STATUS OF EARLY-ONSET ADOLESCENT PSYCHOTIC IN-PATIENTS M. Reich, J. O'Brien, A. Smith, S. Smith, E. Aronoff, G. Osgood, E. Horwitz, M. Obuchowski, & B. Comblatt Mr. Sinai School of Medicine, New York, NY 10029 As part of the Elmhurst Adolescent Project (EAP), we are interested in clinically characterizing psychotic adolescents. In this report, we assess the effects of medication on early symptoms in the adolescents and compare these treatment effects with those of chronic adult schizophrenics. Fourteen adolescent patients (mean age 15) were rated on an adolescent version (A-PANSS) of the adult PANSS, a state measure divided into three scales: positive syndrome, negative syndrome and general psychopathology. Adolescent ratings were conducted first within a week of admission when medication free and a second time, approximately four weeks later, when stabilized on neuroleptics. Adolescents were compared with 20 multi-episode adult psychotics (mean age 30), who were rated ~,fter a four week drug washout and again after a four week chug stabilization period. No differences in clinical profiles were found between adolescents and chronic patients. With medication, subjects in both patient groups improved in positive symptoms and general psychopathology, but showed no change in negative symptoms. However, a difference between groups in medication dosage was detected, with negative symptoms significantly related to medication level for adolescents (r-.61, p-.04) but not for adult patients. This dosage pattern in adolescents may represent an attempt to aggressively treat young patients with high levels of negative symptoms. ~owever, the data reported here preliminui~y suggest that, as has been established in adults, increasing neuroleptic dose does not effectively reduce negative symptoms in adolescent patients,
293. TRAINING RATERS TO ASSESS NEUROLEPTIC-INDUCED AKATHISIA USING STANDARDIZED VIDEOTAPES L.A. Adler I, A.A. Nierenbera2, M. Fava2, J. Hannibal l, & J. Rotrosen ! tPsychiatry Service, New York DVAMC; Department of Psychiatry, NYU School of Medicine; 2Clinical Psychopharmacology Unit, Massachusetts General Hospital and Department of Psychiatry, Harvard University School of Medicine Neuroleptic-induced akathisia (NIA) is a troublesome side-effect of antipsycbotic medications. Patients with NIA complain of a sense of inner restlessness and often have concomitant motor movements including
FRIDAY, MAY 20
rocking from foot to foot, leg waggling, and pacing. The distress of NIA is often significant and can lead to exacerbation of underlying psychopathology, non-compliance with treatment, and occasionally results in violence and suicide. Therefore, the appropriate diagnosis of NIA of clinical significance. The importance of an accurate diagnosis of NIA is now further highlighted by the inclusion of NIA as one of the neurolepticinduced movement disorders in DSM-IV. In fact, Weiden et al. (1987) found that akathisia was commonly under diagnosed by residents on a university hospital teaching unit. We have developed a 16 session videotape to train raters in the diagnosis of NIA. The syndrome is clinically described and instructions are given as to the administration of the Barnes Akathisia Scale (BAS) (1989), which was used in all ratings. The BAS separately rates objective motor movements (0 - 3), subjective awareness of and distress from restlessness (each 0 - 3) and a global assessment of akathisia (0- 5). Subjective awareness and distress ratings are summed to form a single rating of subjective akathisia. The first 5 ratings are used as practice sessions and subsequent ratings are used for determining reliability ratings. Descriptions of standardized ratings are presented at the completion of practice (n - 5) and training (n - !!) sessions. We now present results on the use of this videotape to train physicians in rating NIA. Four physicians in the Clinical Psychopharmacology Unit at Massachusetts General Hospital participated in the ratings. Ratings are presented for the practice sessions and the mining sessions (n - 5 ) completed to date. These akathisia ratings improved from the practice to the training sessions. This was demonstrable in several ways. There was a decrease in the co-efficient of variation ($D/ mean) for all akathisia ratings (objective + subjective + global subsets) from 0.337 during practice ratings to 0.255 during training ratings. The mean difference from standardized ratings for all subsets (objective + subjective + global) significantly decreased from ! 1.2% during practice to 5.5% during training 0(28) - !.972, p<0.05). At the time of presentation we will also discuss: I) differences in mining among subjective, objective and global ratings, 2) data from physician mining on the full 16 session tape, 3) data from training of non-physician and resident physician raters and how training of these raters differed from the clinical investigators described above.
294. TESTING DEFINITIONS OF DYSPHORIC MANIA AND HYPOMANIA M. Bauer 1,2, L. Gyulai 3, & P. Whybrow 3 'Dept. of Psychiatry and Human Behavior, Brown University, ?rovidence, RI; 2Dept. of Veterans Affairs Medical C e n t er, Providence RI; 3Dept. of Psychiatry, University of Pennsylvania, Philadelphia, PA 37 outpatients with at least one prospectively observed manic or hypomanic episode comprised a sample for comparison of five definitions of dysphoric mania or hypomania. No differences in dysphoria were seen between manic and hypomanic subjects, and the groups were combined for further analyses. Dysphoric symptoms were continuously rather than bimodally distributed both for index episodes (n-37) and for all prospectively observed episodes (n-64). Prevalence varied from 5-73% depending on the definition used. No pair of definitions stood out as having high diagnostic concordance. Multivariate analysis indicated that among nine demographic, clinical, and treatment characteristics only female gender was associated with dysphoria, and this was so under two of the five definitions. Interepisode stability in patients with at least two prospectively observed episodes (n=!5) was not significantly different from chance by any definition. These data do not support a single definition, or set of highly concordant definitions, as optimal for dichotomizing (hypo)mania into dysphoric and non-dysphoric subtypes. Advantages and disadvantages of dimensional and categorical approaches to specifying mood in (hypo)mania are discussed.
BIOL PSYCHIATRY 695 1994;35:615-747
288. LONGITUDINAL CLASSIFICATION IN SCHIZOPHRENIA: THE RELATIONSHIP BETWEEN KRAEPELINIAN AND DEFICIT SYNDROME SUBTYPOLOGIES
290. EMPIRICAL EVALUATION OF THE FACTORIAL STRUCTURE OF CLINICAL SYMPTOMS IN SCHIZOPHRENIA: IS THE PANSS A VALID SCALE?
S.H. Apter, R.S.E. Keefe, J. Hirschowitz, M. Davidson, J.M. Macaluso, R. Amato, & K.L. Davis
P.D. Harvey, L. White, M. Parrella, P. Powchik, & M. Davidson
Bronx Veterans Administration Hospital, Mount Sinai School of Medicine, New York, NY 10468
Mt. Sinai School of Medicine and Pilgrim Psychiatric Center
Kraepelinian schizophrenics are defined as a subgroup of schizophrenic patients who display at least five continuous years of complete dependence on others for food, shelter, and clothing. These patients have been empirically distinguished from nonkmepelinian schizophrenics in several areas of diagnostic validation. Kraepelinians demonstrate an absence of treatment response, greater CT vencicular abnormalities, more severe formal thought disorder and negative symptoms, less severe symptoms of mood disorder, and greater morbid risk for schizophrenia spectrum disorders in their first degree relatives. The deficit syndrome, as described by Carpenter et al (1987), is defined as the presence of enduring negative symptoms considered to be primary (ie., not secondary to such factors as depression, medication, etc.) and stable (i.e., present both during and between exacerbations of positive symptomatology for at least one year), it was the aim of the present study to assess the relationship between Kraepelinian status and the deficit syndrome, two longitudinal subtypologies of schizophrenia. The Schedule for the Deficit Syndrome was completed by 16 Kraepelinian and 31 nonkmepelinian schizophrenic patients, similar in terms of age, education, and duration of illness. Kraepelinian patients were significantly more likely to present with the deficit syndrome than were nonkraepelinian patients (chi-square 18.0, df- i, p -.0001). Every Kraepelinian patient met criteria for the deficit syndrome while only 35% of the nonkraepelinian patients (I I out of 31) exhibited the deficit syndrome. Of 27 total deficit patients, only 16 were Kraepelinian. Thus, there is substantial overlap between the Kraepelinian and the deficit syndrome subtypes, with the Kraepelinian subtype identifying a more restricted group of patients.
Recent approaches to conceptualizing the symptomatology of schizophrenia have gone beyond previous subtyping (e.g., paranoid vs. nonparanoid) or simple two-factor (e.g., positive-negative) models. Several recent studies using confirmatory factor analysis have demonstrated that schizophrenic symptoms have a complex multifactorial structure and that several aspects of symptomatology that have been seen as a single factor (e.g., thought disorder, negative symptoms) are actually multifactorial. In this study, we attempted use confirmatory factor analysis to develop and test muitifactorial models of schizophrenic symptomatology using the Positive and Negative Syndrome Scale (PANSS). Geriatric (n-308) and nongeriatric (n-240) schizophrenic patients were the subjects and we tested five-factor and three-factor models, previously derived on the basis of either previous exploratory factor analyses or the conceptual organization of the PANSS. There were no differences in the relative fit of the models across geriatric vs. nongeriatric samples. Although both the three. factor and five-factor models were a significant (X2 (i) - i 44; p<.001; X2 (8) - 199, p<.001) improvement over a simple unifactorial severity model, no model fit the data particularly well. l~n fact, a model derived on an exploratory basis using the PANSS data from the geriatric patients in this study fit the data very poorly (X2 (395)-!015,p<.001, Comparative Fit Index-.55). These data suggest that PANSS may have significant limitations in construct validity, compared to other clinical rating scales (e.g., the SANS, the TLC, and the SAPS) that have been successfully used in previous factor analytic studies. These results may also suggest that "comprehensive" psychiatric rating scales such as the PANSS ~nd the BPRS may be more useful for characterizing generalized severity of illness than for use in conceptual studies of symptomatology.
289. CONFIRMATORY FACTOR ANALYSIS TO TEST SCHIZOPHENIC MODELS
291. PREMORBID HISTORY AND CLINICAL MANIFESTATIONS AT THE ONSET OF PSYCHOSIS
V. Peralta, MJ. Cuesta, & J. de Leon Virgen del Camino" Hospital, Pamplona, Spain and the Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute Schizophrenia models postulate two syndromes, positive and negative, but exploratory factor analyses suggest also a disorganization syndrome. The sample included 253 DSM-lll-R schizophrenics who were consecutively hospitalized in acute psychiatric inpatient unit. Confirmatory factor analyses using LISREL were conducted to asses the latent structure of symptoms reflecting underlying pathological processes. The analyses included SAPS and SANS items and subscales and were performed to test 13 different models of schizophrenia with one, two or three syndromes. The three-syndrome models displayed the best fitness. All of three-syndrome models shared the positive and negative dimension. The other syndrome was the disorganization or Strauss' relational syndrome. A foursyndrome model comprised of positive, disorganization, negative and relational syndromes showed excellent fitness. Despite its limitations, this study suggests the need to explore the validity of a four-syndrome model, since the positive-negative model fits poorly with the data.
R. Scheffer l, E.E. Correntil, R.L. Borison 2, & S. Mukherjee2 tDepartmcnt of Psychiatry & Neurology, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905; and 2Department of Psychiatry, Medical College of Georgia, ! 515 Pope Avenue, Augusta, GA 30912 Data will be presented from an ongoing study of patients admitted to an Army Medical Center for their first episode of psychosis. History of premorbid functioning was recorded using the Premorbid Adjustment Scale (PAS; Cannon-Spoor et al 1982). Only subjects for whom a well relative was available are included. The sample comprised ! 3 patients, I I men and 2 women, with a mean age of 22.3 + 4.5 yrs. The sample was unique in that mean duration of psychosis was 4.5 + 2.5 days. Treatment was "doctor's choice." The clinical state was monitored using the Brief Psychiatric Rating Scale (BPRS). Poorer childhood school performance was associated with higher baseline BPRS positive symptom score (r-.6l; p<.05), while poor early adolescent school performance was associated with higher baseline negative symptom scores (r - .70; p<.02). Although there were trends for PAS scores predicting 6-wk response of both posi-
696
BIOLPSYCHIATRY 1994;35:615-747
tive and negative symptoms to neuroleptic treatment, none of these were significant after controlling for covafiance due to baseline severity of the respective symptom clusters, which were strongly predictive of 6-wk outcome. Data will also he presented on the relation of premorbid functioning to 6-month outcome. In summary, although a history of poor premorbid functioning appears to influence symptoms severity very early at the onset of psychosis, it does not seem to influence very short-term response to naturalistic treatment during this period.
292. CLINICAL STATUS OF EARLY-ONSET ADOLESCENT PSYCHOTIC IN-PATIENTS M. Reich, J. O'Brien, A. Smith, S. Smith, E. Aronoff, G. Osgood, E. Horwitz, M. Obuchowski, & B. Comblatt Mr. Sinai School of Medicine, New York, NY 10029 As part of the Elmhurst Adolescent Project (EAP), we are interested in clinically characterizing psychotic adolescents. In this report, we assess the effects of medication on early symptoms in the adolescents and compare these treatment effects with those of chronic adult schizophrenics. Fourteen adolescent patients (mean age 15) were rated on an adolescent version (A-PANSS) of the adult PANSS, a state measure divided into three scales: positive syndrome, negative syndrome and general psychopathology. Adolescent ratings were conducted first within a week of admission when medication free and a second time, approximately four weeks later, when stabilized on neuroleptics. Adolescents were compared with 20 multi-episode adult psychotics (mean age 30), who were rated ~,fter a four week drug washout and again after a four week chug stabilization period. No differences in clinical profiles were found between adolescents and chronic patients. With medication, subjects in both patient groups improved in positive symptoms and general psychopathology, but showed no change in negative symptoms. However, a difference between groups in medication dosage was detected, with negative symptoms significantly related to medication level for adolescents (r-.61, p-.04) but not for adult patients. This dosage pattern in adolescents may represent an attempt to aggressively treat young patients with high levels of negative symptoms. ~owever, the data reported here preliminui~y suggest that, as has been established in adults, increasing neuroleptic dose does not effectively reduce negative symptoms in adolescent patients,
293. TRAINING RATERS TO ASSESS NEUROLEPTIC-INDUCED AKATHISIA USING STANDARDIZED VIDEOTAPES L.A. Adler I, A.A. Nierenbera2, M. Fava2, J. Hannibal l, & J. Rotrosen ! tPsychiatry Service, New York DVAMC; Department of Psychiatry, NYU School of Medicine; 2Clinical Psychopharmacology Unit, Massachusetts General Hospital and Department of Psychiatry, Harvard University School of Medicine Neuroleptic-induced akathisia (NIA) is a troublesome side-effect of antipsycbotic medications. Patients with NIA complain of a sense of inner restlessness and often have concomitant motor movements including
FRIDAY, MAY 20
rocking from foot to foot, leg waggling, and pacing. The distress of NIA is often significant and can lead to exacerbation of underlying psychopathology, non-compliance with treatment, and occasionally results in violence and suicide. Therefore, the appropriate diagnosis of NIA of clinical significance. The importance of an accurate diagnosis of NIA is now further highlighted by the inclusion of NIA as one of the neurolepticinduced movement disorders in DSM-IV. In fact, Weiden et al. (1987) found that akathisia was commonly under diagnosed by residents on a university hospital teaching unit. We have developed a 16 session videotape to train raters in the diagnosis of NIA. The syndrome is clinically described and instructions are given as to the administration of the Barnes Akathisia Scale (BAS) (1989), which was used in all ratings. The BAS separately rates objective motor movements (0 - 3), subjective awareness of and distress from restlessness (each 0 - 3) and a global assessment of akathisia (0- 5). Subjective awareness and distress ratings are summed to form a single rating of subjective akathisia. The first 5 ratings are used as practice sessions and subsequent ratings are used for determining reliability ratings. Descriptions of standardized ratings are presented at the completion of practice (n - 5) and training (n - !!) sessions. We now present results on the use of this videotape to train physicians in rating NIA. Four physicians in the Clinical Psychopharmacology Unit at Massachusetts General Hospital participated in the ratings. Ratings are presented for the practice sessions and the mining sessions (n - 5 ) completed to date. These akathisia ratings improved from the practice to the training sessions. This was demonstrable in several ways. There was a decrease in the co-efficient of variation ($D/ mean) for all akathisia ratings (objective + subjective + global subsets) from 0.337 during practice ratings to 0.255 during training ratings. The mean difference from standardized ratings for all subsets (objective + subjective + global) significantly decreased from ! 1.2% during practice to 5.5% during training 0(28) - !.972, p<0.05). At the time of presentation we will also discuss: I) differences in mining among subjective, objective and global ratings, 2) data from physician mining on the full 16 session tape, 3) data from training of non-physician and resident physician raters and how training of these raters differed from the clinical investigators described above.
294. TESTING DEFINITIONS OF DYSPHORIC MANIA AND HYPOMANIA M. Bauer 1,2, L. Gyulai 3, & P. Whybrow 3 'Dept. of Psychiatry and Human Behavior, Brown University, ?rovidence, RI; 2Dept. of Veterans Affairs Medical C e n t er, Providence RI; 3Dept. of Psychiatry, University of Pennsylvania, Philadelphia, PA 37 outpatients with at least one prospectively observed manic or hypomanic episode comprised a sample for comparison of five definitions of dysphoric mania or hypomania. No differences in dysphoria were seen between manic and hypomanic subjects, and the groups were combined for further analyses. Dysphoric symptoms were continuously rather than bimodally distributed both for index episodes (n-37) and for all prospectively observed episodes (n-64). Prevalence varied from 5-73% depending on the definition used. No pair of definitions stood out as having high diagnostic concordance. Multivariate analysis indicated that among nine demographic, clinical, and treatment characteristics only female gender was associated with dysphoria, and this was so under two of the five definitions. Interepisode stability in patients with at least two prospectively observed episodes (n=!5) was not significantly different from chance by any definition. These data do not support a single definition, or set of highly concordant definitions, as optimal for dichotomizing (hypo)mania into dysphoric and non-dysphoric subtypes. Advantages and disadvantages of dimensional and categorical approaches to specifying mood in (hypo)mania are discussed.