De plus en plus d'arguments plaident en faveur d'une identification précoce du trouble bipolaire, qui semble constituer un enjeu thérapeutique majeur. Le diagnostic précoce, sous réserve qu'il se traduise par la mise en route rapide d'un traitement adapté (et ce n'est pas toujours le cas), évitera en effet des errances thérapeutiques (neuroleptiques au long cours, antidépresseurs devant tout symptôme dépressif, abstention thérapeutique) dont on connaît la nocivité (virages, accélération des cycles, souffrance non soulagée, stigmates des effets indésirables...). La prise en charge précoce permettra également de réduire la durée et la sévérité des épisodes, ainsi que leur retentissement délétère sur la vie du sujet, et de diminuer le risque suicidaire, qui semble majoré chez le sujet non ou mal pris en charge (notamment sans thymorégulateur). Enfin, la compliance thérapeutique, paramètre essentiel dans l'efficacité du traitement au long cours, pourrait être améliorée si le sujet était correctement pris en charge au début de sa maladie, avant que ne surviennent les effets délétères des phases thymiques sur sa vie et son entourage. Cette revue de la littérature propose de rappeler les différents pièges diagnostiques (troubles de l'humeur non bipolaires, schizophrénie, bouffée délirante aiguë, personnalité borderline, pathologie organique, dépendance, psychose puerpérale, hyperactivité-déficit de l'attention et troubles anxieux) dont les limites avec le trouble bipolaire sont parfois difficiles à tracer.

An early recognition of bipolar disorders may have an important impact on the prognosis of this disorder according to different mechanisms. Bipolar disorder is nevertheless not easy to detect, the diagnosis being correctly proposed after, in average more than a couple of years and three different doctors assessments. A short delay before introducing the relevant treatment shoulp help avoiding inappropriate treatments (prescribing, for example, neuroleptics for long periods, antidepressive drugs each time depressive symptoms occurs, absence of treatment despite mood disorders), with their associated negative impact such as mood-switching, rapid cycling or presence of chronic side-effects stigmates. Furthermore, non-treated mood disorders in bipolar disorder are longer, more stigmatizing and may be associated with an increased risk of suicidal behaviour and mortality. Lastly, compliance, an important factor regarding the long term prognosis of bipolar disorder, should be improved when there is a short delay between correct diagnosis and treatment and onset of the disorder. We therefore propose to review the literature for the different pitfalls involved in the diagnosis of bipolar disorder. <sup>[1AAGAARD J, VESTERGAARD P. Predictors of outcome in prophylactic lithium treatment : a 2-year prospective study. J Affect Disord 1989 ; 12 : 259-66.

Cliquez ici pour aller à la section Références]</sup>Non-bipolar mood-disorders are frequently quoted as one of the alternative diagnosis. Hyperthymic temperament, side-effects of prescribed treatments and organic comorbid disorders may be involved. Bipolar disorders have a sex-ratio closer to 1 (men are thus more frequently of the bipolar type in mood-disorders), with earlier age at onset, and more frequent family history of suicidal attempts and bipolar disorder. <sup>[2AKISKAL H. The prevalent clinical spectrum of bipolar disorders : beyond DSM IV. J Clin Psychopharmacol 1996 ; 16 : 4S-14S.

Cliquez ici pour aller à la section Références]</sup>Schizo-affective disorders are also a major concern regarding the diagnosis of bipolar disorder. This is explained by flat affects sometimes close to anhedonia, presence of a schizoïd personality in bipolar disorder, persecutive hostily that can be considered to be related to irritability rather than a schizophrenic symptom. Rapid cycling, mixed episodes and short euthymia periods may also increase the risk to shift from bipolar to schizophrenia diagnosis. <sup>[3AKISKAL H. Mood disorders : clinical features. In : Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry, VII. Baltimore, Md : Williams & Wilkins, 2000 : 1138-377.

Cliquez ici pour aller à la section Références]</sup>Schizophreniform disorder (« bouffée délirante » aiguë in France) is a frequent form of bipolar disorder onset when major dissociative features are not obvious. The borderline personality is also a problem for the diagnosis of bipolar disorder, some authors proposing that bipolar disorder is a mood-related personality disorder, sometimes improved by mood-stabilizers. Phasic instead of reactional, weeks and not days-length, clearcut onset and recovery versus non-easy to delimit mood-episodes may help to adjust the diagnosis. <sup>[4AKISKAL HS, BOURGEOIS ML, ANGST J et al . Re-evaluating the prevalence of, and diagnostic composition within, the broad clinical spectrum of bipolar disorders. J Affect Disord 2000 ; 59 : S5-S30.

Cliquez ici pour aller à la section Références]</sup>Organic disorders may lead to diagnostic confusion, but it is generally proposed that bipolar disorder should be treated the same way, whether or not an organic condition is detected (with special focus on treatment tolerance). <sup>[5AKISKAL H, CHEN S, DAVIS G et al . Borderline : an adjective in search of a noun. J Clin Psychiatry 1985 ; 46 : 41-8.

Cliquez ici pour aller à la section Références]</sup>Addictive disorders are frequent comorbid conditions in bipolar disorders. Psychostimulants (such as amphetamins or cocaine) intoxications sometimes mimic manic episodes. As these drugs are preferentially chosen by subjects with bipolar disorder, the later diagnosis should be systematically assessed. <sup>[6AKISKAL H, PINTO O. The evolving bipolar spectrum : prototypes I, II, III, and IV. Psychiatr Clin North Am 1999 ; 22 : 517-34.

Cliquez ici pour aller à la section Références]</sup>Puerperal psychosis is a frequent type of onset in female bipolar disorder. The systematic prescription of mood-stabilizers for and after such episode, when mood elation is a major symptom, is generally proposed. <sup>[7AKISKAL H, PUNZANTIAN V. Psychotic forms of depression and mania. Psychiatr Clin Noth Am 1979 ; 2 : 419-39.

Cliquez ici pour aller à la section Références]</sup>Attention deficit-hyperactivity disorder also has unclear border with bipolar disorder, as a quarter of child hyperactivity may be latterly associated with bipolar disorder. The assessment of mood cycling and their follow-up in adulthood may thus be particularly important. <sup>[8ALTSHULER LL, POST RM, LEVERICH GS et al . Antidepressant-induced mania and cycle acceleration : a controversy revisited. Am J Psychiatry 1995 ; 152 : 1130-8.

Cliquez ici pour aller à la section Références]</sup>Lastly, presence of some anxious disorders may delay the diagnosis of comorbid bipolar disorder.