Subthreshold bipolarity: Diagnostic issues and challenges

Robin Nusslock*, Ellen Frank

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

83 Scopus citations


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 5 th 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. Conclusion: 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.

Original languageEnglish (US)
Pages (from-to)587-603
Number of pages17
JournalBipolar Disorders
Issue number7-8
StatePublished - Nov 2011


  • Bipolar disorder
  • Depression
  • Diagnosis
  • Hypomania

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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