Hostname: page-component-7f64f4797f-g5lq8 Total loading time: 0.001 Render date: 2025-11-03T15:53:26.795Z Has data issue: false hasContentIssue false
  • English
  • Français

Dysphoric mania, mixed states, and mania with mixed features specifier: are we mixing things up?

Published online by Cambridge University Press:  21 November 2016

Susan L. McElroy  and
Paul E. Keck Jr.
Susan L. McElroy*
Affiliation:
Lindner Center of HOPE, Mason, Ohio, USA Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
Paul E. Keck Jr.
Affiliation:
Lindner Center of HOPE, Mason, Ohio, USA Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
*
*Address for correspondence: Dr. Susan L. McElroy, Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040, USA. (Email: susan.mcelroy@uc.edu or susan.mcelroy@lindnercenter.org)
Get access Rights & Permissions [Opens in a new window]

Abstract

Various terms have been used to describe mania when it is accompanied by depressive symptoms. In this article, we attempt to define and discuss 3 of these terms: dysphoric mania, mixed state, and mania with mixed features specifier. We conclude that whatever term is used, it is important to be aware that mania is more often unpleasant than pleasant, and that the unpleasantness is not limited to depression.

Keywords

Depressiondysphoric maniamaniamixed features specifiermixed states

Information

Type
Review Articles
Information
CNS Spectrums , Volume 22 , Issue 2: Theme: Mixed features in major depressive episodes , April 2017 , pp. 170 - 176
Copyright
© Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

1. Kraepelin, E. Manic-Depressive Illness and Paranoria. Edinburgh, Scotland: E & S Livingstone; 1921.Google Scholar
2. Winokur, G, Clayton, PJ, Reich, T. Manic Depressive Illness. St. Louis, MO: CV Mosby; 1969.Google Scholar
3. McElroy, SL, Keck, PE Jr, Pope, HG Jr, Hudson, JI, Faedda, GL, Swann, AC. Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry. 1992; 149(12): 1633–1644.Google Scholar
4. McElroy, SL, Freeman, MP, Akiskal, HS. The mixed bipolar disorders. In: Marneros A, Angst J, eds. Bipolar Disorders: 100 Years After Manic-Depressive Insanity. New York: Kluwer Academic Publishers; 2000: 63–87.Google Scholar
5. Goodwin, FK, Jamison, KR. Manic Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd ed. New York: Oxford University Press; 2007.Google Scholar
6. Cassidy, F, Yatham, LN, Berk, M, Grof, P. Pure and mixed manic subtypes: a review of diagnostic classification and validation. Bipolar Disord. 2008; 10(1 Pt 2): 131–143.Google Scholar
7. Swann, AC, Lafer, B, Perugi, G, et al. Bipolar mixed states: an International Society for Bipolar Disorders task force report of symptom structure, course of illness, and diagnosis. Am J Psychiatry. 2013; 170(1): 31–42.Google Scholar
8. Maina, G, Bertetto, N, Domene Boccolini, F, Di Salvo, G, Rosso, G, Bogetto, F. The concept of mixed state in bipolar disorder: from Kraepelin to DSM-5. J Psychopathol. 2013; 19: 287–295.Google Scholar
9. Perugi, G, Quaranta, G, Dell’Osso, L. The significance of mixed states in depression and mania. Curr Psychiatry Rep. 2014; 16(10): 486.Google Scholar
10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.Google Scholar
11. Swann, AC. Depression, mania, and feeling bad: the role of dysphoria in mixed states. Bipolar Disord. 2000; 2(4): 325–327.Google Scholar
12. Starcevic, V. Dysphoric about dysphoria: towards a greater conceptual clarity of the term. Australas Psychiatry. 2007; 15(1): 9–13.Google Scholar
13. Webster’s Third New International Dictionary. Springfield, MA: Merriam-Webster Inc; 1993.Google Scholar
14. dysphoria. Farlex Partner Medical Dictionary. 2012; http://medical-dictionary.thefreedictionary.com/dysphoria. Accessed January 25, 2016.Google Scholar
15. dysphoria. The American Heritage Medical Dictionary. 2007; http://medical-dictionary.thefreedictionary.com/dysphoria. Accessed January 25, 2016.Google Scholar
16. dysphoria. Mosby’s Medical Dictionary. 8th ed. 2009; http://medical-dictionary.thefreedictionary.com/dysphoria. Accessed January 25, 2016.Google Scholar
17. Cassidy, F, Forest, K, Murry, E, Carroll, BJ. A factor analysis of the signs and symptoms of mania. Arch Gen Psychiatry. 1998; 55(1): 27–32.Google Scholar
18. Berner, P, Musalek, M, Walter, H. Psychopathological concepts of dysphoria. Psychopathology. 1987; 20(2): 93–100.Google Scholar
19. Dayer, A, Aubry, JM, Roth, L, Ducrey, S, Bertschy, G. A theoretical reappraisal of mixed states: dysphoria as a third dimension. Bipolar Disord. 2000; 2(4): 316–324.Google Scholar
20. Bertschy, G, Gervasoni, N, Favre, S, et al. Frequency of dysphoria and mixed states. Psychopathology. 2008; 41(3): 187–193.Google Scholar
21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
22. Dilsaver, SC, Chen, YR, Shoaib, AM, Swann, AC. Phenomenology of mania: evidence for distinct depressed, dysphoric, and euphoric presentations. Am J Psychiatry. 1999; 156(3): 426–430.Google Scholar
23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed rev. Arlington, VA: American Psychiatric Association; 1987.Google Scholar
24. Carlson, GA, Goodwin, FK. The stages of mania. A longitudinal analysis of the manic episode. Arch Gen Psychiatry. 1973; 28(2): 221–228.Google Scholar
25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.Google Scholar
26. Dilsaver, SC, Chen, YW, Swann, AC, Shoaib, AM, Krajewski, KJ. Suicidality in patients with pure and depressive mania. Am J Psychiatry. 1994; 151(9): 1312–1315.Google Scholar
27. Akiskal, HS, Hantouche, EG, Bourgeois, ML, et al. Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). J Affect Disord. 1998; 50(2–3): 175–186.Google Scholar
28. Cassidy, F, Ahearn, E, Murry, E, Forest, K, Carroll, BJ. Diagnostic depressive symptoms of the mixed bipolar episode. Psychol Med. 2000; 30(2): 403–411.Google Scholar
29. Hantouche, EG, Akiskal, HS, Azorin, JM, Chatenet-Duchene, L, Lancrenon, S. Clinical and psychometric characterization of depression in mixed mania: a report from the French National Cohort of 1090 manic patients. J Affect Disord. 2006; 96(3): 225–232.Google Scholar
30. Swann, AC, Bowden, CL, Morris, D, et al. Depression during mania. Treatment response to lithium or divalproex. Arch Gen Psychiatry. 1997; 54(1): 37–42.Google Scholar
31. Swann, AC, Steinberg, JL, Lijffijt, M, Moeller, GF. Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features. World Psychiatry. 2009; 8(3): 166–172.Google Scholar
32. McIntyre, RS, Tohen, M, Berk, M, Zhao, J, Weiller, E. DSM-5 mixed specifier for manic episodes: evaluating the effect of depressive features on severity and treatment outcome using asenapine clinical trial data. J Affect Disord. 2013; 150(2): 378–383.Google Scholar
33. Cassano, GB, Rucci, P, Frank, E, et al. The mood spectrum in unipolar and bipolar disorder: arguments for a unitary approach. Am J Psychiatry. 2004; 161(7): 1264–1269.Google Scholar
34. Bauer, MS, Simon, GE, Ludman, E, Unutzer, J. ‘Bipolarity’ in bipolar disorder: distribution of manic and depressive symptoms in a treated population. Br J Psychiatry. 2005; 187: 87–88.Google Scholar
35. Cassidy, F, Carroll, BJ. Frequencies of signs and symptoms in mixed and pure episodes of mania: implications for the study of manic episodes. Prog Neuropsychopharmacol Biol Psychiatry. 2001; 25(3): 659–665.Google Scholar
36. Singh, V, Bowden, CL, Gonzalez, JM, et al. Discriminating primary clinical states in bipolar disorder with a comprehensive symptom scale. Acta Psychiatr Scand. 2013; 127(2): 145–152.Google Scholar
37. Cassidy, F. Anxiety as a symptom of mixed mania: implications for DSM-5. Bipolar Disord. 2010; 12(4): 437–439.Google Scholar
38. Vieta, E, Valenti, M. Mixed states in DSM-5: implications for clinical care, education, and research. J Affect Disord. 2013; 148(1): 28–36.Google Scholar
39. Verdolini, N, Agius, M, Ferranti, L, Moretti, P, Piselli, M, Quartesan, R. The state of the art of the DSM-5 “with mixed features” specifier. Scientific World Journal. 2015; 2015: 757258.Google Scholar
40. Shim, IH, Woo, YS, Bahk, WM. Prevalence rates and clinical implications of bipolar disorder “with mixed features” as defined by DSM-5. J Affect Disord. 2015; 173: 120–125.Google Scholar
41. McIntyre, RS, Soczynska, JK, Cha, DS, et al. The prevalence and illness characteristics of DSM-5-defined “mixed feature specifier” in adults with major depressive disorder and bipolar disorder: results from the International Mood Disorders Collaborative Project. J Affect Disord. 2015; 172: 259–264.Google Scholar
42. Vieta, E, Grunze, H, Azorin, JM, Fagiolini, A. Phenomenology of manic episodes according to the presence or absence of depressive features as defined in DSM-5: results from the IMPACT self-reported online survey. J Affect Disord. 2014; 156: 206–213.Google Scholar
43. Tohen, M, McIntyre, RS, Kanba, S, Fujikoshi, S, Katagiri, H. Efficacy of olanzapine in the treatment of bipolar mania with mixed features defined by DSM-5. J Affect Disord. 2014; 168: 136–141.Google Scholar
44. Young, AH, Eberhard, J. Evaluating depressive symptoms in mania: a naturalistic study of patients with bipolar disorder. Neuropsychiatr. Dis. Treat. 2015; 11: 1137–1143.Google Scholar
45. Reinares, M, Bonnín Cdel, M, Hidalgo-Mazzei, D, et al. Making sense of DSM-5 mania with depressive features. Aust N Z J Psychiatry. 2015; 49(6): 540–549.Google Scholar
46. Seo, HJ, Wang, HR, Jun, TY, Woo, YS, Bahk, WM. Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality. Gen Hosp Psychiatry. 2016; 39: 91–96.Google Scholar
47. Malhi, GS. Diagnosis of bipolar disorder: who is in a mixed state? Lancet. 2013; 381(9878): 1599–1600.Google Scholar
48. Bauer, MS, Whybrow, PC, Gyulai, L, Gonnel, J, Yeh, HS. Testing definitions of dysphoric mania and hypomania: prevalence, clinical characteristics and inter-episode stability. J Affect Disord. 1994; 32(3): 201–211.Google Scholar
49. Hantouche, EG, Allilaire, JP, Bourgeois, ML, et al. The feasibility of self-assessment of dysphoric mania in the French national EPIMAN study. J Affect Disord. 2001; 67(1–3): 97–103.Google Scholar
50. Cassidy, F, Ahearn, E, Carroll, BJ. Concordance of self-rated and observer-rated dysphoric symptoms in mania. J Affect Disord. 2009; 114(1–3): 294–298.Google Scholar
51. Angst, J. Bipolar disorders in DSM-5: strengths, problems and perspectives. Int J Bipolar Disord. 2013; 1: 12.Google Scholar