Hostname: page-component-848d4c4894-ttngx Total loading time: 0 Render date: 2024-06-02T10:37:54.529Z Has data issue: false hasContentIssue false
  • English
  • Français

Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications

Published online by Cambridge University Press:  21 November 2016

Gin S Malhi ,
Yulisha Byrow ,
Tim Outhred  and
Kristina Fritz
Gin S Malhi*
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Yulisha Byrow
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Tim Outhred
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Kristina Fritz
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
*
*Address for correspondence, Professor Gin S. Malhi, Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia. (Email: Gin.malhi@sydney.edu.au)
Get access Rights & Permissions [Opens in a new window]

Abstract

This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin’s original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification—with mood, ideation, and activity as key axes—and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.

Keywords

Agitated depressionbipolar disorderdepressionDSM-5mixed featuresmixed maniamixed states
Type
Opinions
Information
CNS Spectrums , Volume 22 , Issue 2: Theme: Mixed features in major depressive episodes , April 2017 , pp. 126 - 133
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.)

References

1. Kraepelin, E. Clinical psychiatry: a text-book for students and physicians, New York: Macmillan; 1904.Google Scholar
2. Diefendorf, RA. IX. Manic-depressive insanity. In: Clinical Psychiatry: A Textbook for Students and Physicians, Abstracted and Adapted from the 7th German Edition of Kraepelin’s Lehrbuch Der Psychiatrie. 7th ed. New York: Macmillan & Co.; 1907: 381–422.Google Scholar
3. Maina, G, Bertetto, N, Boccolini, FD, Di Salvo, G, Rosso, G, Bogetto, F. The concept of mixed state in bipolar disorder: from Kraepelin to DSM-5. Journal of Psychopathology. 2013; 19: 287–295.Google Scholar
4. Trede, K, Salvatore, P, Baethge, C, Gerhard, A, Maggini, C, Baldessarini, RJ. Manic-depressive illness: evolution in Kraepelin’s Textbook, 1883–1926. Harv Rev Psychiatry. 2005; 13(3): 155–178.Google Scholar
5. Marneros, A. Origin and development of concepts of bipolar mixed states. J Affect Disord. 2001; 67(1–3): 229–240.Google Scholar
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.Google Scholar
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed rev. Washington, DC: American Psychiatric Association; 1987.Google Scholar
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
10. Faedda, GL, Marangoni, C, Reginaldi, D. Depressive mixed states: a reappraisal of Koukopoulos’criteria. J Affect Disord. 2015; 176: 18–23.Google Scholar
11. 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
12. Perugi, G, Akiskal, HS, Micheli, C, et al. Clinical subtypes of bipolar mixed states. J Affect Disord. 1997; 43(3): 169–180.Google Scholar
13. Benazzi, F. Age at onset of bipolar II depressive mixed state. Psychiatry Res. 2001; 103(2–3): 229–235.Google Scholar
14. Koukopoulos, A, Koukopoulos, A. Agitated depression as a mixed state and the problem of melancholia. Psychiatr Clin North Am. 1999; 22(3): 547–564.Google Scholar
15. Koukopoulos, A, Sani, G, Ghaemi, SN. Mixed features of depression: why DSM-5 is wrong (and so was DSM-IV). Br J Psychiatry. 2013; 203(1): 3–5.Google Scholar
16. Koukopoulos, A, Sani, G. DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand. 2014; 129(1): 4–16.Google Scholar
17. Koukopoulos, A, Sani, G, Koukopoulos, A, Manfredi, G, Pacchiarotti, I, Girardi, P. Melancholia agitata and mixed depression. Acta Psychiatr Scand Suppl. 2007;(433): 50–57.CrossRefGoogle ScholarPubMed
18. 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
19. Harrison, PJ, Cipriani, A, Harmer, CJ, et al. Innovative approaches to bipolar disorder and its treatment. Ann N Y Acad Sci. 2016; 1366(1): 76–89.Google Scholar
20. 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
21. Perugi, G, Angst, J, Azorin, J-M, et al. Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study. J Clin Psychiatry. 2015; 76(3): e351–e358.Google Scholar
22. Judd, LL, Schettler, PJ, Akiskal, H, et al. Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord. 2012; 138(3): 440–448.Google Scholar
23. Pae, CU, Vohringer, PA, Holtzman, NS, et al. Mixed depression: a study of its phenomenology and relation to treatment response. J Affect Disord. 2012; 136(3): 1059–1061.Google Scholar
24. Targum, SD, Suppes, T, Pendergrass, JC, et al. Major depressive disorder with subthreshold hypomania (mixed features): clinical characteristics of patients entered in a multiregional, placebo-controlled study. Prog Neuropsychopharmacol Biol Psychiatry. 2016; 68: 9–14.Google Scholar
25. Miller, S, Suppes, T, Mintz, J, et al. Mixed depression in bipolar disorder: prevalence rate and clinical correlates during naturalistic follow-up in the Stanley Bipolar Network. Am J Psychiatry. In press. doi:10.1176/appi.ajp.2016.15091119.Google Scholar
26. Malhi, GS, Fritz, K, Allwang, C, et al. Agitation for recognition by DSM-5 mixed features specifier signals fatigue? Aust N Z J Psychiatry. 2015; 49(6): 499–501.CrossRefGoogle ScholarPubMed
27. 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
28. Cassidy, F. Anxiety as a symptom of mixed mania: implications for DSM-5. Bipolar Disord. 2010; 12(4): 437–439.Google Scholar
29. 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
30. Sato, T, Bottlender, R, Kleindienst, N, Möller, HJ. Syndromes and phenomenological subtypes underlying acute mania: a factor analytic study of 576 manic patients. Am J Psychiatry. 2002; 159(6): 968–974.Google Scholar
31. Malhi, GS, Fritz, K, Allwang, C, et al. Are manic symptoms that “dip” into depression the essence of mixed features? J Affect Disord. 2016; 192: 104–108.Google Scholar
32. Malhi, GS, Masson, M, Bellivier, F. Teasing apart bipolar III: the causes and consequences of a treatment-emergent affective switch (TEAS) into mania. Aust N Z J Psychiatry. 2015; 49(10): 866–868.Google Scholar
33. Perugi, G, Medda, P, Reis, J, Rizzato, S, Giorgi Mariani, M, Mauri, M. Clinical subtypes of severe bipolar mixed states. J Affect Disord. 2013; 151(3): 1076–1082.Google Scholar
34. Perugi, G, Medda, P, Swann, AC, Reis, J, Rizzato, S, Mauri, M. Phenomenological subtypes of severe bipolar mixed states: a factor analytic study. Compr Psychiatry. 2014; 55(4): 799–806.Google Scholar
35. Fornaro, M, Stubbs, B, De Berardis, D, et al. Atypical antipsychotics in the treatment of acute bipolar depression with mixed features: a systematic review and exploratory meta-analysis of placebo-controlled clinical trials. Int J Mol Sci. 2016; 17(2): 241.Google Scholar
36. McIntyre, RS, Cucchiaro, J, Pikalov, A, Kroger, H, Loebel, A. Lurasidone in the treatment of bipolar depression with mixed (subsyndromal hypomanic) features. J Clin Psychiatry. 2015; 76(4): 398–405.Google Scholar
37. Medda, P, Toni, C, Mariana, MG, De Simone, L, Mauri, M, Perugi, G. Electroconvulsive therapy in 197 patients with a severe, drug-resistant bipolar mixed state: treatment outcome and predictors of response. J Clin Psychiatry. 2015; 76(9): 1168–1173.Google Scholar
38. 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
39. National Institute for Health and Care Excellence. Bipolar disorder: assessment and management. Clinical Guideline [CG185]. London: National Institute for Health and Care Excellence; 2014. http://www.nice.org.uk/guidance/cg185/chapter/introduction.Google Scholar
40. Ostacher, MJ, Tandon, R, Suppes, T. Florida Best Practice Psychotherapeutic Medication Guidelines for Adults with Bipolar Disorder: a novel, practical, patient-centered guide for clinicians. J Clin Psychiatry. 2016; 77(7): 920–926.Google Scholar
41. Malhi, GS, Bassett, D, Boyce, P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015; 49(12): 1087–1206.Google Scholar
42. Benazzi, F, Berk, M, Frye, MA, Wang, W, Barraco, A, Tohen, M. Olanzapine/fluoxetine combination for the treatment of mixed depression in bipolar I disorder: a post hoc analysis. J Clin Psychiatry. 2009; 70(10): 1424–1431.Google Scholar
43. Fountoulakis, KN, Kontis, D, Gonda, X, Siamouli, M, Yatham, LN. Treatment of mixed bipolar states. Int J Neuropsychopharmacol. 2012; 15(7): 1015–1026.Google Scholar
44. Muralidharan, K, Ali, M, Silveira, LE, et al. Efficacy of second generation antipsychotics in treating acute mixed episodes in bipolar disorder: a meta-analysis of placebo-controlled trials. J Affect Disord. 2013; 150(2): 408–414.Google Scholar