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Revista de Psiquiatria do Rio Grande do Sul

Print version ISSN 0101-8108

Rev. psiquiatr. Rio Gd. Sul vol.26 no.3 Porto Alegre Sept./Dec. 2004 



Review of the book entitled Temperamento forte e bipolaridade: dominando os altos e baixos do humor, by Diogo Lara (Temperament and bipolarity: controlling the ups and downs of mood)


Reseña del libro Temperamento forte e bipolaridade: dominando os altos e baixos do humor, de Diogo Lara



Rogéria Recondo

Psychiatrist, Masters Degree in Neuroscience, Universidade Federal do Rio Grande do Sul, Brazil. Preceptor, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Brazil. Coordinator, Department of Psychiatry and Outpatient Clinic for Childhood and Adolescence Anxiety Disorders, Centro de Estudos, Atendimento e Pesquisa na Infância e Adolescência, Brazil





Diogo Lara
Porto Alegre: Armazém de imagens; 2004



It was with great satisfaction that I accepted responsibility for reviewing our colleague Diogo Lara's book. I would like to start, as I couldn't avoid doing, with the title, which, creatively, highlights uneven temper and its implications for bipolarity, i.e. , for the ups and downs of mood. Over several chapters the author tacks together, with great mastery and in an extremely didactic manner, the concepts needed to understand how this disorder is possible.

I will, basically, attempt to provide a panoramic view of the many chapters, ordered, as they are, in echo of house construction, in such a way as to guide the reader from the foundations to the final finishing touches.

In the first chapter the author explains the relationship between temper and mood and defines concepts such as temper, character, personality and mood types in a didactic and lucid manner using analogies and with grounding in recent theories.

The author describes how temperament is linked to a person's sensations and basic and automatic motivations within the emotional sphere and how it is inherited genetically and regulated biologically, being the foundation of our mood. Consequently, mood disorders are compatible with our temperaments.

Diogo quotes Cloninger's current classification describing the four basic elements of the temperament: novelty and sensation seeking, damage and danger avoidance, the need for social contact and approval and persistence.

For Akiskal temperaments can be understood as predominant mood patterns or affective styles and he describes them as hyperthymic , depressive, cyclothymic and irritable.

According to Diogo, the key to understanding people on the so-called "bipolar spectrum" is to focus on uneven tempers: hyperthymic, cyclothymic or intense novelty seeking. Hyperthymia and hypomania are located between normal, euthymic, moods and their extreme, which is mania.

Diogo describes types of individuals, schematically, according to their expenditure, risk taking, social group, verbal communications, ideation, affective relationships and driving style, which, taken together, are considered a sounding board for mood.

In the next chapter, the author describes bipolarity and emphasizes the importance of differential diagnosis to distinguish between unipolar and bipolar depression, pointing out that a few years ago it was thought that around 90% of people with depressive symptoms suffered from unipolar depression. Nowadays we know that in up to one half of the cases in which patients exhibit depression it is of the bipolar type. In other words, at some point in their lives, they have or have had, even if briefly or in a mild form, upwardly altered moods, mood swings of greater than normal amplitude or an uneven temper.

The author stresses the pointy that, "many bipolar patients have periods of depression and anxiety that are much more marked and frequent than their periods of elevated mood and for this reason end up being confused with unipolar patients".

Next, the bipolar spectrum is defined, as is the classification into bipolar types I, II, III or IV, from greater to lesser degrees of symptom severity. The author states that around 1% of the population is type I bipolar and that 6 to 8% manifest one of the milder forms of the disorder (types II to IV and cyclothymia).

Diogo points out that the initial symptomology of bipolar spectrum may be poorly defined, with obsessive symptoms, excessive worry over the body and eating disorders, hypochondria, phobias, nervous tics, substance abuse and aggressive or irresponsible behavior. He describes what the bipolar style is considered to be, giving several examples and describing the defense mechanisms that these people use.

In the next chapter a number of case histories of people with uneven tempers, but without mood disorder are described and then the progression from uneven temper to mood disorder is described.

Diogo dedicates a whole chapter to the description of mild bipolar patients and the most common features in bipolar depression, including postnatal depression. He emphasizes that a thorough evaluation of the patient's temperament and style can be of great help to identifying the type of mood disorder, and adds that type IV bipolar disorders are the easiest to confuse with pure depression. The text is enriched with clinical material, exploring the different temperaments associated with mild type II bipolar disorder.

Next, the author describes type I bipolar mood disorder, formerly known as manic-depressive psychosis. This section also offers clinical examples, enriching understanding of the theoretical material.

The chapter dealing with the identification of mood disorders, i.e. how to correctly diagnose them, is essential. In this chapter the author comments that contemporary criteria used for diagnosis are excessively reliant on manifest signs and symptoms and suggests that, to achieve a more complete evaluation, the following list of patient variables be analyzed: signs and symptoms, the course of symptoms or behavioral manifestations, temperament and style, family history, environmental risk factors (previous abuse and traumas, recent losses); response to pharmaceuticals, clinical assessment and work-up examinations.

The points out that an assessment based exclusively on symptoms will confuse mild bipolar cases with, for example, unipolar depression, attention deficit/hyperactivity or anxiety disorders, to name but a few.

The chapter dedicated to treatment, how to deal with bipolarity, covers psychoeducation, psychotherapy and pharmacotherapy. The same chapter also explains how to deal with the pitfalls of ideation and how to smooth out the personalities of these patients.

On the subject of pharmacotherapy, Diogo describes the necessary precautions for antidepressant use and warns of their popularization. He also cautions against the use of psychostimulants, without mood stabilizers, for bipolar spectrum patients. The most damaging effect of ignoring these warnings would be a manic episode. The most common bipolar responses to the use of antidepressants are also described with a view to call attention to indications that diagnosis should be reconsidered.

Later on the author writes of famous people with uneven tempers and asks :do we live in a novelty-seeking and bipolar society? After listing several features that betray the bipolar tone of western society, he offers hypotheses on the reasons for a possible increase in bipolarity.

The final chapter asks: what if I were bipolar? Here the author emphasizes the importance of accurate diagnosis and the perspectives gained from successful treatment.

To finish, I would like to emphasize the ease of reading and the pleasurable nature of the didactic experience offered. I would also like to contemplate what I imagine to be one of the author's primary objectives: to call attention to the need for correct diagnosis with bipolar disorders, particularly types II, III and IV, which can, and unfortunately often are, easily be confused with other psychiatric diagnoses, "particularly if we only attend to signs and symptoms". This situation, generally as a result of antidepressant prescription, result in iatrogeny. A second objective, which the book fully meets, is to inform patients and their families about the disorder, demystifying it. This in itself is a therapeutic tool.

Summing up, this is a book written by a competent psychiatrist, who holds a doctorate and is a Neuroscience researcher and who is dedicating himself with assiduity and enthusiasm to the care of and study of patients with bipolar mood disorders

Bipolar mood disorders. That fact that a second edition has become necessary in such a short time speaks for itself, as does the book's ever-growing usage by patients, find many of the answers for their questions and suffering.



Correspondence to
Dr. Rogéria Recondo
Rua Alvares Machado, 44/208
CEP 90630-000 — Porto Alegre — RS — Brazil

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