Time to revisit the nosology of Bipolar Affective Disorder

Bipolar disorder (BD) is a chronic relapsing-remitting mental illness that follows the characteristic episodic pattern of two distinct polarities i.e. mania and depression. The classically described Manic depressive psychosis by Emil Kraepelin has evolved into a contemporary understanding of bipolar spectrum disorders. Accommodation of soft bipolar such as treatment-emergent affective switch, borderline personality disorder, hyperthymic temperament, and cyclothymia is debatable. Further syndromal mixed episodes, anxiety episodes, cognitive deficits, subsyndromal depressive symptoms, and progressive social deficits are not well captured in the nosology of DSM-5 and ICD-11. The term- ‘Bipolar’, restricts understanding of the patient as well as the psychiatrist to a set of two opposite syndromes and thus potentially could become reason for incomplete remission. Furthermore, recurrent mania (unipolar mania) do exist and they defy the nosology of ‘bipolar’. Preliminary observations point towards a higher prevalence of unipolar mania at our center that should be discussed epidemiologically and nosologically. Current nosology describes Bipolar Affective Disorder with current episode mania or depression which falls short of the absolute picture of the illness. Further, the psychiatrist should enable to communicate the complete diagnosis and illness course by using a standardized method. The sub-dimensional approach could be added to existing nosology that would represent the illness characteristic. We describe the relevance of recurrent mania to current nosology, and alternative approaches to describe course of the disorder, including response to medications, and associated disability. This could meet the goal of complete remission in bipolar disorder