Get access

Subthreshold bipolarity: diagnostic issues and challenges


  • Robin Nusslock,

    1. Department of Psychology, Northwestern University, Evanston
    2. Department of Psychiatry, Northwestern University, Chicago, IL
    3. Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
    Search for more papers by this author
  • Ellen Frank

    1. Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
    Search for more papers by this author

  • EF serves on an advisory board for Servier and receives royalties from Guilford Press. RN has no conflicts of interest to report.

Corresponding author:
Robin Nusslock, Ph.D.
Departments of Psychology and Psychiatry
Northwestern University
2029 Sheridan Road
Evanston, IL 60208, USA
Fax: 847-491-7859


Nusslock R, Frank E. Subthreshold bipolarity: diagnostic issues and challenges. Bipolar Disord 2011: 13: 587–603. © 2011 The Authors. Journal compilation © 2011 John Wiley & Sons A/S.

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.

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.