Skip to main content Accessibility help

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

  • Susan L. McElroy (a1) (a2) and Paul E. Keck (a1) (a2)


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.


Corresponding author

*Address for correspondence: Dr. Susan L. McElroy, Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040, USA. (Email: or


Hide All
1. Kraepelin, E. Manic-Depressive Illness and Paranoria. Edinburgh, Scotland: E & S Livingstone; 1921.
2. Winokur, G, Clayton, PJ, Reich, T. Manic Depressive Illness. St. Louis, MO: CV Mosby; 1969.
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): 16331644.
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: 6387.
5. Goodwin, FK, Jamison, KR. Manic Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd ed. New York: Oxford University Press; 2007.
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): 131143.
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): 3142.
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: 287295.
9. Perugi, G, Quaranta, G, Dell’Osso, L. The significance of mixed states in depression and mania. Curr Psychiatry Rep. 2014; 16(10): 486.
10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
11. Swann, AC. Depression, mania, and feeling bad: the role of dysphoria in mixed states. Bipolar Disord. 2000; 2(4): 325327.
12. Starcevic, V. Dysphoric about dysphoria: towards a greater conceptual clarity of the term. Australas Psychiatry. 2007; 15(1): 913.
13. Webster’s Third New International Dictionary. Springfield, MA: Merriam-Webster Inc; 1993.
14. dysphoria. Farlex Partner Medical Dictionary. 2012; Accessed January 25, 2016.
15. dysphoria. The American Heritage Medical Dictionary. 2007; Accessed January 25, 2016.
16. dysphoria. Mosby’s Medical Dictionary. 8th ed. 2009; Accessed January 25, 2016.
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): 2732.
18. Berner, P, Musalek, M, Walter, H. Psychopathological concepts of dysphoria. Psychopathology. 1987; 20(2): 93100.
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): 316324.
20. Bertschy, G, Gervasoni, N, Favre, S, et al. Frequency of dysphoria and mixed states. Psychopathology. 2008; 41(3): 187193.
21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
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): 426430.
23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed rev. Arlington, VA: American Psychiatric Association; 1987.
24. Carlson, GA, Goodwin, FK. The stages of mania. A longitudinal analysis of the manic episode. Arch Gen Psychiatry. 1973; 28(2): 221228.
25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.
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): 13121315.
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): 175186.
28. Cassidy, F, Ahearn, E, Murry, E, Forest, K, Carroll, BJ. Diagnostic depressive symptoms of the mixed bipolar episode. Psychol Med. 2000; 30(2): 403411.
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): 225232.
30. Swann, AC, Bowden, CL, Morris, D, et al. Depression during mania. Treatment response to lithium or divalproex. Arch Gen Psychiatry. 1997; 54(1): 3742.
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): 166172.
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): 378383.
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): 12641269.
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: 8788.
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): 659665.
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): 145152.
37. Cassidy, F. Anxiety as a symptom of mixed mania: implications for DSM-5. Bipolar Disord. 2010; 12(4): 437439.
38. Vieta, E, Valenti, M. Mixed states in DSM-5: implications for clinical care, education, and research. J Affect Disord. 2013; 148(1): 2836.
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.
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: 120125.
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: 259264.
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: 206213.
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: 136141.
44. Young, AH, Eberhard, J. Evaluating depressive symptoms in mania: a naturalistic study of patients with bipolar disorder. Neuropsychiatr. Dis. Treat. 2015; 11: 11371143.
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): 540549.
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: 9196.
47. Malhi, GS. Diagnosis of bipolar disorder: who is in a mixed state? Lancet. 2013; 381(9878): 15991600.
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): 201211.
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): 97103.
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): 294298.
51. Angst, J. Bipolar disorders in DSM-5: strengths, problems and perspectives. Int J Bipolar Disord. 2013; 1: 12.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

CNS Spectrums
  • ISSN: 1092-8529
  • EISSN: 2165-6509
  • URL: /core/journals/cns-spectrums
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed