Confusing clinical presentations and differential diagnosis of bipolar disorder;Masques trompeurs et diagnostics différentiels du trouble bipolaire

Encephale

Volumn 30, Issue 2, 2004, Pages 182-193

  Gorwood, P ^a  

^a HÔPITAL LOUIS MOURIER   (France)

Author keywords

Bipolar spectrum; Comorbidity; Mania

Indexed keywords

AMPHETAMINE DERIVATIVE; ANTIDEPRESSANT AGENT; COCAINE; MOOD STABILIZER; NEUROLEPTIC AGENT; PSYCHOSTIMULANT AGENT; TRANQUILIZER; UNCLASSIFIED DRUG;

ANHEDONIA; ANXIETY DISORDER; ATTENTION DEFICIT DISORDER; BIPOLAR DISORDER; BORDERLINE STATE; CLINICAL FEATURE; COMORBIDITY; DEPRESSION; DIAGNOSTIC ACCURACY; DIFFERENTIAL DIAGNOSIS; DISEASE ASSOCIATION; DRUG DEPENDENCE; EARLY DIAGNOSIS; FAMILY HISTORY; FOLLOW UP; HOSTILITY; HUMAN; HYPERACTIVITY; IRRITABILITY; LONG TERM CARE; MAJOR DEPRESSION; MANIA; MIXED MANIA AND DEPRESSION; MOOD DISORDER; MORTALITY; ONSET AGE; ORGANIC BRAIN SYNDROME; PATIENT CARE; PATIENT COMPLIANCE; PRESCRIPTION; PROGNOSIS; PUERPERAL PSYCHOSIS; RAPID CYCLING BIPOLAR DISORDER; REVIEW; RISK ASSESSMENT; RISK FACTOR; SCHIZOAFFECTIVE PSYCHOSIS; SCHIZOIDISM; SCHIZOPHRENIA; SCHIZOPHRENIFORM DISORDER; SEX DIFFERENCE; SUICIDAL BEHAVIOR; SYMPTOM; TEMPERAMENT; TREATMENT PLANNING;

EID: 2442428244     PISSN: 00137006     EISSN: None     Source Type: Journal    
DOI: 10.1016/s0013-7006(04)95430-9     Document Type: Review

References (126)

1. AAGAARD J, VESTERGAARD P. Predictors of outcome in prophylactic lithium treatment: a 2-year prospective study. J Affect Disord 1989; 12: 259-66.
2. AKISKAL H. The prevalent clinical spectrum of bipolar disorders: beyond DSM IV. J Clin Psychopharmacol 1996; 16: 4S-14S.
3. AKISKAL H. Mood disorders: clinical features. In: Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry, VII. Baltimore, Md: Williams & Wilkins, 2000: 1138-377.
4. AKISKAL 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.
5. AKISKAL H, CHEN S, DAVIS G et al. Borderline: an adjective in search of a noun. J Clin Psychiatry 1985; 46: 41-8.
6. AKISKAL H, PINTO O. The evolving bipolar spectrum: prototypes I, II, III, and IV. Psychiatr Clin North Am 1999; 22: 517-34.
7. AKISKAL H, PUNZANTIAN V. Psychotic forms of depression and mania. Psychiatr Clin Noth Am 1979; 2: 419-39.
8. ALTSHULER LL, POST RM, LEVERICH GS et al. Antidepressant-induced mania and cycle acceleration: a controversy revisited. Am J Psychiatry 1995; 152: 1130-8.
9. AMERICAN PSYCHIATRIC ASSOCIATION DSM IV: Diagnostic and Statistical Manual of Mental Disorders 1998, 4th ed. Washington, DC.
10. ANGOLD A, COSTELLO EJ, ERKANLI A. Comorbidity. Child Psychol Psychiatry 1999; 40: 57-87.
11. ANGST J. L'hypomanie: À propos d'une cohorte de jeunes. Encephale 1992; XVIII: 23-9.
12. ANGST J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 1998; 50 (2-3): 143-51.
13. rd international Conference on Bipolar Disorder 1999, June 17, 1999, Pittsburgh, Pa.
14. ANGST J, GAMMA A, BENAZZI F et al. Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003; 73: 133-46.
15. ANGST J, SELLARO. Historical perspectives and natural history of bipolar disorder. Biol Psychiatry 2000; 48; 445-57.
16. AZORIN JM, HANTOUCHE EG. Évaluation de la manie: de la recherche à la pratique. Ann Med Psychol 2001; 159: 415-23.
17. BAILLARGER J. De la folie à double forme. Ann Med Psychol 1854; 6: 369-84.
18. BALLET G. Traité de pathologie mentale. Paris: Doin, 1903.
19. BARBATO N, HAFNER RJ. Comorbidity of bipolar and personality disorder. Aust N Z J Psychiatry 1998; 32 (2): 276-80.
20. BAUER M, SHEA N, McBRIDE L et al. Predictors of service utilization in veterans with bipolar disorder: a prospective study. J Affect Disord 1997; 44: 159-68.
21. BIEDERMAN J, FARAONE S, MICK E et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity. J Am Acad Child Adolesc Psychiatry 1996; 35: 997-1008.
22. BIEDERMAN J, MICK E, BOSTIC JQ et al. The naturalistic course of pharmacologic treatment of children with manic-like symptoms: A systematic chart review. J Clin Psychiatry 1998; 59: 628-37.
23. BIEDERMAN J, FARAONE SV, CHU MP et al. Further evidence of a bidirectional overlap between juvenile mania and conduct disorder in children. J Am Acad Adolesc Psychiatry 1999; 38: 468-76.
24. BIEDERMAN J, MICK E, FARAONE SV et al. Pediatric mania: a developmental subtype of bipolar disorder. Biol Psychiatry 2000; 48: 458-66.
25. BIEDERMAN J, KLEIN RG, PINE DS et al. Resolved: mania is mistaken for ADHD in prepubertal children. J Am Acad Child Adolesc Psychiatry 1998; 37: 1091-9.
26. BOLTON S, GUNDERSON J. Distinguishing borderline personality disorder from bipolar disorder: differential diagnosis and implications. Am J Psychiatry 1996; 153: 1202-7.
27. BOWDEN CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv 2001; 52: 51-5.
28. BOWDEN CL, LECRUBIER Y, BAUER M et al. Maintenance therapies for classic and other forms of bipolar disorder. J Affect Disord 2000; 59, 1: S57-S67.
29. BRADLEY C, ZARKIN G. Inpatient stays for patients diagnosed with severe psychiatric disorders and substance abuse. Health Serv Res 1996; 31: 339-408.
30. BRADY K, CASTO S, LYDIARD R et al. Substance abuse in an inpatient psychiatric sample. Am J Drug Alcohol Abuse 1991; 17: 389-97.
31. BRADY K, LYDIARD R. Bipolar affective disorder and substance abuse. J Clin Psychopharmacol 1992: 12 (Supp 1): 17-22.
32. BRADY K, SONNE S. The relationship between substance abuse and bipolar disorder. J Clin Psychiatry 1995; 56: S19-24.
33. BRIDGE T, MIRSKY A, GOODWIN F. Psychological, neuropsychiatric and substance abuse aspects of AIDS: advances in biochemical psychopharmacology, vol 44. New York: Raven Press, 1988.
34. BRIEGER P, EHRT U, MARNEROS A. Frequency of comorbid personality disorders in bipolar and unipolar affective disorders. Compr Psychiatry 2003; 44 (1): 28-34.
35. BROONER R, KING V, KIDORD M et al. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry 1997; 54: 71-80.
36. CARLSON GA, LONEY J, SALISBURY H et al. Young referred boys with DICA-P manic symptoms vs. two comparison groups. J Affect Disorder 1998; 51: 113-22.
37. CASSANO GB, DELL'OSSO L, FRANK E et al. The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology. J Affect Disord 1999; 54: 319-28.
38. COWDRY R, GARDNER D. Pharmacotherapy of borderline personality. Arch Gen psychiatry 1988; 45: 111-9.
39. DA SILVA L, JOHNSTONE EC. A follow-up of severe puerperal psychiatric illness. Br J Psychiatry 1981; 139: 346-54.
40. DANELUZZO E, ARDUINI L, RINALDI O et al. PANSS factors and scoresin schizophrenic and bipolar disorders during an index acute episode: a further analysis of the cognitive component. Schizophr Res 2002; 56: 129-36.
41. DAVIDSON J, ROBERTSON E. A follow-up study of postpartum illness, 1946-1978. Acta Psychiatr Scand 1985; 71: 451-7.
42. DEAN C. The Edinburgh study. In: Cox JL, Paykel ES, Page ML, eds. Current Approaches: Childbirth as a Life Event. Southampton: Duphar Laboratories, 1989.
43. DUNAYEVICH E, SAX KW, KECK PE Jr et al. Twelve-month outcome in bipolar patients with and without personality disorders. J Clin Psychiatry 2000; 61 (2): 134-9.
44. EVANS D. Bipolar disorder: diagnostic challenges and treatment considerations. J Clin Psychiatry 2000; 61 (S13): 26-31.
45. FALRET JP. Marche de la folie. Gaz Hôp 1851; 24: 18-9.
46. FALRET JP. De la folie circulaire ou forme de maladie mentale caractérisée par l'alternance régulière de la manie et de la mélancolie. Bull Acad Med (Paris) 1854; 19: 382.
47. FARAONE SV, BIEDERMAN J, WOZNIAK J et al. Is comorbidity with ADHD a marker for juvenile onset mania. J Am Acad Child Adolesc Psychiatry 1997; 36: 1046-55.
48. FARAONE SV, BIEDERMAN J, MENNIN D et al. Bipolar and antisocial disorders among relatives of ADHD children: parsing familial subtypes of illness. Neuropsychiatr Genet 1998; 64: 19-26.
49. FEINMAN J, DUNNER D. The effect of alcohol and substance abuse on the course of bipolar affective disorder. J Affect Disord 1996; 37: 43-9.
50. FÉLINE A. Maladie maniaco-dépressive... plutôt que psychose maniaco-dépressive. Med Ther 1997; 3 (4): 255-6.
51. FREEMAN MP, FREEMAN SA, McELROY SL. The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues. J Affect Disord 2002; 68: 1-23.
52. GABEL R, BARNARD N, NORKO M et al. AIDS presenting as mania. Compr Psychiatry 1986; 27: 251-4.
53. GAWIN F, KLEBER H. Cocaine abuse treatment: open pilot trial with desipramine and lithium carbonate. Arch Gen Psychiatry 1984; 41: 903-9.
54. GELLER B, ZIMERMAN B, WILLIAMS M et al. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 2000; 10: 157-64.
55. GHAEMI S, BOIMAN E, GOODWIN F. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry 2000; 61: 804-8.
56. GHAEMI S, SACHS G, CHIOU A et al. Is bipolar disorder still under-diagnosed. Are antidepressants overutilized. J Affect Disord 1999; 52: 135-44.
57. GIBBS F, GIBBS E. Atlas of electroencephalography 1952, vol. 2, Epilepsy. Cambridge, Mas: Addison-Wesley Press Inc, 1952.
58. GOLDSTEIN T, FRYE M, DENIKOFF K et al. Antidepressant discontinuation-related mania: Critical prospective observation and theoretical implications in bipolar disorder. J Clin Psychiatry 1999; 60: 563-7.
59. GONZALEZ-PINTO A, GUTIERREZ M, MOSQUERA F et al. First episode in bipolar disorder: misdiagnosis and psychotic symptoms. J Affect Disord 1998; 50: 41-4.
60. GOODWIN F, JAMISON K. Manic-depressive illness. New York: Oxford University Press, 1990: 938.
61. GORWOOD P. Évolution et retentissement psycho-social de la psychose maniaco-dépressive. Med Ther 1997; 3 (4): 275-9.
62. GORWOOD P. Biological markers for suicidal behaviors in alcohol-dependence. Eur Psychiatry 2001; 16: 410-7.
63. GORWOOD P, KESSLER V. La psychose puerpérale: un modèle du concept de vulnérabilité génétique. Devenir 2002; 14 (1): 17-26.
64. GRANVILLE-GROSSMAN K. Post-partum mental disorders. In: Granville-Grossman K, ed. Recent Advances in Clinical Psychiatry. London: J and A Churchill, 1971: 300-10.
65. GREENE R, DOYLE A. Toward a transactional conceptualisation of oppositional defiant disorder: implications for assessment and treatment. Clin Child Family Psychol Rev 1999; 2: 129-48.
66. HANTOUCHE E, AKISKAL H, LANCRENON S et al. Systematic clinical methodology for validating bipolar-II disorder: data in midstream from a French national multi-site study (EPIDEP). J Affect Disord 1997; 43: 163-73.
67. HANTOUCHE EG, KOCHMAN F, DEMONFAUCON C et al. Bipolar obsessive-compulsive disorder: confirmation of results of the « ABC-OCD » survey in 2 populations of patient members versus non-members of an association. Encephale 2002; 28: 21-8.
68. HARRIS E, BARRACLOUGH B. Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry 1997; 170: 205-8.
69. HAUSTGEN T. Aspects historiques des troubles bipolaires dans la psychiatrie française. Encephale 1995; Sp VI; 13-20.
70. HAYWOOD T, KARVITZ H, GROSSMAN L et al. Predicting the « Revolving Door » phenomenon among patients with schizophrenic, schizoaffective, and affective disorders. Am J Psychiatry 1995; 152: 856-61.
71. HENRY C, MITROPOULOS V, NEW A et al. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res 2001; 35: 307-12.
72. HIMMELHOCH J. Major mood disorders related to epileptic changes. In: Blumer D, ed. Psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press, 1984: 271-94.
73. HIMMELHOCH J, GARFINKEL M. Sources of lithium resistance in mixed mania. Psychopharmacol Bull 1986; 22: 613-20.
74. HIRSCHFELD R, WILLIAMS J, SPITZER R. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatry 2000; 157: 1873-5.
75. HIRSHFELD R. Bipolar spectrum disorder: improving its recognition and diagnosis. J Clin Psychiatry 2001; 62 (S14): 5-9.
76. HIRSCHFELD RM, CALABRESE JR, WEISSMAN MMD Screening for bipolar disorder in the community. J Clin Psychiatry 2003; 64: 53-9.
77. ISOMETSA ET, HENRIKSSON MM, ARO HM et al. Suicide in bipolar disorder in Finland. Am J Psychiatry 1994; 151: 1020-4.
78. JAMISON K. Night Falls Fast: understanding suicide. New York, NY: Knopf, 1999.
79. JORGENSEN P, BENNEDSEN B, CHRISTENSEN J et al. Acute and transient psychotic disorder: a 1-year follow-up study. Acta Psychiatr Scand 1997; 96: 2: 150-4.
80. JUDD L, AKISKAL H. The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord 2003; 73: 123-31.
81. KAY JH, ALTSHULER LL, VENTURA J et al. Prevalence of axis II comorbidity in bipolar patients with and without alcohol use disorders. Ann Clin Psychiatry 1999; 11 (4): 187-95.
82. KECK PE Jr, LIPINSKI JF, WHITE K. An inverse relationship between mania and obsessive-compulsive disorder: a case report. J Clin Psychopharmacol 1986; 123-4.
83. KENDELL RE. Emotional and physical factors in the genesis of puerperal mental disorders. J Psychosom Res 1985; 29: 3-11.
84. KLERMAN GL. The spectrum of mania. Compr Psychiatry 1981; 22: 11-20.
85. KUTCHER SP, MARTON P, KORENBLUM M. Relationship between psychiatric illness and conduct disorder in adolescents. Can J Psychiatry 1989; 34: 526-9.
86. LEWINSOHN PM, KLEIN DN, SEELEY JR. Bipolar disorders in a community sample of older adolescents: prevalence phenomenology, comorbidity and course. J Am Acad Child Adolesc Psychiatry 1995; 34: 454-63.
87. LEWIS D, FEDMAN M, GREENE M et al. Psychomotor epileptic symptoms in six patients with bipolar mood disorders. Am J Psychiatry 1984; 141: 1583-6.
88. LISH JD, DIME-MEENAN S, WHYBROW PC et al. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord 1994; 31: 281-94.
89. MAJ M. Bipolar disorder. WPA series evidence and experience in psychiatry, vol 5. Maj M, Akiskal HS, Lopez-Ibor JJ, Sartorius N, eds. John Wiley, 2002: 544.
90. MANNING JS, HAYKAL RF, CONNOR PD et al. On the nature of depressive and anxious states in family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally. Compr Psychiatry 1997; 38: 102-8.
91. MARNEROS A, DEISTER A, ROHDE A. Stability of diagnoses in affective, schizoaffective, and schizophrenic disorders. Cross-sectional versus longitudinal diagnosis. Eur Arch Psychiatry Clin Neurosci 1991; 241: 187-92.
92. MELTZER ES, KUMAR R. Puerperal mental illness, clinical features and classification: a study of 142 mother-and-baby admissions. Br J Psychiatry 1985; 147: 647-54.
93. MILBERGER S, BIEDERMAN J, FARAONE SV et al. Attention deficit hyperactivity and comorbid disorders. Issues of overlapping symptoms. Am J Psychiatry 1995; 152: 1793-800.
94. MUESER K, YARNOLD P, BELLACK A. Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder. Acta Psychiatr Scand 1992; 85: 48-55.
95. NUNES E, QUITKIN F, KLEIN D. Psychiatric diagnosis in cocaine abuse. Psychiatr Res 1989; 28: 105-14.
96. O'CONNELL, MAYO J, FLATOW L et al. Outcome of bipolar disorder on long-term treatment with lithium. Br J Psychiatry 1991; 159: 123-9.
97. PERUGI G, AKISKAL HS, PFANNER C et al. The clinical impact of bipolar and unipolar affective comorbidity on obsessive-compulsive disorder. J Affect Disord 1997; 46: 15-23.
98. PERUGI G, AKISKAL HS, LATTANZI L et al. The high prevalence of « soft » bipolar (11) features in atypical depression. Compr Psychiatry 1998; 39: 63-71.
99. POST R, RUBINOW D, BALLENGER J. Conditioning and sensitisation in the longitudinal course of affective illness. Br J Psychiatry 1986; 149: 191-201.
100. PRICE L, NELSON J. Alcoholism and affective disorder. Am J Psychiatry 1986; 143: 1067-8.
101. PROTHEROSE C. Puerperal psychoses: a long term study 1972-1961. Br J Psychiatry 1969; 115: 9-30.
102. REGIER D, FARMER M, RAE D et al. Comorbidity of mental disorders with alcohol and other drug abuse. J Am Med Assoc 1990; 264: 2511-8.
103. ROSSI A, MARINANGELI MG, BUTTI G et al. Personality disorders in bipolar and depressive disorders. J Affect Disord 2001; 65 (1): 3-8.
104. ROUNSAVILLE B, ANTON S, CARROLL K et al. Psychiatric diagnosis of treatment-seeking cocaine abusers. Arch Gen Psychiatry 1991; 48: 43-51.
105. SACHS GS, BALDASSANO CF, TRUMAN CJ et al. Comorbidity of attention deficit hyperactivity disorder with early-and late-onset bipolar disorder. Am J Psychiatry 2000; 157: 466-8.
106. SCOTT H, JOHNSON S, MENEZES P et al. Substance misuse and risk of aggression and offending among the severely mentally ill. Br J Psychiatry 1998; 172: 345-50.
107. SIMON NM, SMOLLER JW, FAVA M et al. Comparing anxiety disorders and anxiety-related traits in bipolar disorder and unipolar depression. J Psychiatr Res 2003; 37: 187-92.
108. SONNE S, BRADY K, MORTON W. Substance abuse and bipolar affective disorder. J Nerv Ment Dis 1994; 182: 349-52.
109. STEIN D, SIMEON D, FRENKEL M et al. An open trial of valproate in borderline personality disorder. J Clin Psychiatry 1995; 56: 506-10.
110. STONE M. The borderline syndromes: constitution, personality, and adaptation. New York: McGraw-Hill, 1980.
111. STROBER M, DEANTONIO M, SCHMIDT-LACKNER S et al. Early childhood attention deficit hyperactivity disorder predicts poorer response to acute lithium therapy in adolescent mania. J Affect Disord 1998; 51: 145-51.
112. SUPPES T, LEVERICH GS, KECK PE et al. The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients. J Affect Disord 2001; 67 (1-3): 45-59.
113. TAYLOR M, ABRAMS R, HAYMAN M. The classification of affective disorders: a reassessment of the bipolar-unipolar dichotomy: a clinical, laboratory, and family study. J Affect Disord 1980; 2: 95-109.
114. TOHEN M, WATERNAUX C, TSUANG M. Outcome in mania, a 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry 1990; 47: 1106-11.
115. TOHEN M, SHULMAN K, SATLIN A. First-episode mania in late life. Am J Psychiatry 1994; 151: 130-2.
116. UCOK A, KARAVELI D, KUNDAKCI T et al. Comorbidity of personality disorders with bipolar mood disorders. Compr Psychiatry. 1998; 39 (2): 72-4.
117. WADA K, YAMADA N, SUZUKI H et al. Recurrent cases of corticosteroid-induced mood disorder: clinical characteristics and treatment. J Clin Psychiatry 2000; 61: 261-7.
118. WARNER R, TAYLOR D, WRIGHT J et al. Substance use among the mentally ill: prevalence, reasons for use and effects on illness. Am J Orthopsychiatry 1994; 64: 30-9.
119. WEISS R, MIRIN S, GRIFFIN M et al. Psychopathology in cocaine abusers. J Nerv Ment Dis 1988; 176: 719-25.
120. WEISS R, GREENFIELD S, NAJAVITS L et al. Medication compliance among patients with bipolar disorder and substance use disorder. J Clin Psychiatry 1998; 59: 172-4.
121. WEST SA, McELROY SL, STRAKOWSKI SM et al. Attention deficit hyperactivity disorder in adolescent mania. Am J Psychiatry 1995; 152: 271-4.
122. WILENS T, BIEDERMAN J, ABRANTES A et al. Clinical characteristics of psychiatrically referred adolescent outpatients with substance use disorder. J Am Acad Child Adolesc Psychiatry 1997; 36: 941-7.
123. WINOKUR G, TURVEY C, AKISKAL H et al. Alcoholism and drug abuse in three groups-bipolar I, unipolar and their acquaintances. J Affect Disorder 1998; 50: 81-9.
124. WOZNIAK J, BIEDERMAN J, KIELY K et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 1995; 34: 867-76.
125. YOUNG R, KLERMAN G. Mania in late life: focus on age at onset. Am J Psychiatry 1992; 149: 867-76.
126. ZANARINI M, FRANCKENBURG F, DUBO E et al. Axis I comorbidity of borderline personality disorder. Am J Psychiatry 1998; 155: 1733-9.