title: Subthreshold bipolarity: diagnostic issues and challenges.
abstract: BACKGROUND
  Research suggests that current diagnostic criteria for bipolar disorders may fail to include milder, but clinically significant, bipolar syndromes and that a substantial percentage of these conditions are diagnosed, by default, as unipolar major depression. Accordingly, a number of researchers have argued for the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to better account for subsyndromal hypomanic presentations.
  
  
  METHODS
  The present paper is a critical review of research on subthreshold bipolarity, and an assessment of some of the challenges that researchers and clinicians might face if the DSM-5 were designed to systematically document subsyndromal hypomanic presentations.
  
  
  RESULTS
  Individuals with major depressive disorder (MDD) who display subsyndromal hypomanic features, not concurrent with a major depressive episode, have a more severe course compared to individuals with MDD and no hypomanic features, and more closely resemble individuals with bipolar disorder on a number of clinical validators.
  
  
  CONCLUSIONS
  There are clinical and scientific reasons for systematically documenting subsyndromal hypomanic presentations in the assessment and diagnosis of mood disorders. However, these benefits are balanced with important challenges, including (i) the difficulty in reliably identifying subsyndromal hypomanic presentations, (ii) operationalizing subthreshold bipolarity, (iii) differentiating subthreshold bipolarity from borderline personality disorder, (iv) the risk of over-diagnosing bipolar spectrum disorders, and (v) uncertainties about optimal interventions for subthreshold bipolarity.
authors.affiliation: Department of Psychology, Northwestern University, Evanston, IL 60208, USA. nusslock@northwestern.edu
authors.forename: Robin
authors.initials: R
authors.lastname: Nusslock
authors.forename: Ellen
authors.initials: E
authors.lastname: Frank
mesh_terms: D001714:Bipolar Disorder / Q000145:classification* / Q000175:diagnosis* / Q000453:epidemiology; D003937:Diagnosis, Differential; D039721:Diagnostic and Statistical Manual of Mental Disorders; D006801:Humans; D011569:Psychiatric Status Rating Scales; D015203:Reproducibility of Results
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