Bipolar Mixed States: An International Society for Bipolar Disorders Task Force Report of Symptom Structure, Course of Illness, and Diagnosis
Abstract
Objective
Method
Results
Conclusions
Evolution of the Concept of Mixed States
Origins
Combinatorial Models
Noncombinatorial Models
Summary
Symptomatic Structure of Mixed Episodes
Predominant Polarity
Manic.
Depressive.
Independent of predominant polarity.
Threshold Symptom Levels
Clinical Characteristics
Affective symptoms in mixed states.
Depressive symptoms in mixed depressive episodes.
Symptoms regardless of polarity.
Nonmood Symptoms in Mixed Episodes
Anxiety.
Agitation.
Psychosis.
Structure of Episodes: Multivariate Analyses
Manic and mixed manic episodes.
Reference | Measures | Factor Structure | Subtypes |
---|---|---|---|
Cassidy et al. (3, 24) | Self-rating derived by authors from SCID, ROC, GOM | Depressed mood,b psychomotor acceleration, psychosis, increased hedonia, irritable-aggression | ROC: mixed > one depressed mood symptoms; GOM: hypomania, mania, delusional mania, two mixed states |
Dilsaver et al. (4) | SADS | Manic activation, depression, sleep disturbance, irritability-paranoia | Pure; two mixed states: depressive, irritable-dysphoric |
Sato et al. (39) | 37 symptoms from SADS | Depressed mood, irritable aggression, insomnia, depressive inhibition, mania, lability aggression, psychosis | Pure, aggressive, psychotic, depressive |
Swann et al. (27) | SADS | Impulsivity, hyperactivity, anxious pessimism,b distressed appearance, hostility, psychosis | Classic, delusional, depressive, irritable dysphoric |
Harvey et al. (95) | HAM-D, SADS, MRS | Five-factor solution in pretreatment subjects |
Depressive and mixed depressive episodes.
Reference | Measures | Factor Analysis | Classification |
---|---|---|---|
Henry et al. (32) | Multidimensional Assessment of Thymic States; beyond conventional affective symptoms | Emotional reactivity, psychomotor speed, psychomotor function, motor activity, sensory perception | Two depressive types, one with emotional hyperreactivity |
Benazzi (96) | SCID | Mania-related factors: irritability, increased mood, motor overactivity | Previous diagnosis: ≥2 manic symptoms, 73% bipolar, 42% unipolar; ≥3, 46% bipolar, 8% unipolar |
Biondi et al. (41) | Author-derived scale, broad range of behavior beyond conventional mood symptoms; MMPI-2 | Unipolar depressive patients: depression, anxiety, activation | Activation in subjects with diagnosis of unipolar depression suggests misdiagnosis |
Sato et al. (33) | 43 symptoms from SADS | Vegetative signs, depressive retardation/reduced feeling, hypomania, anxiety, psychosis, depression/hopelessness | Hypomanic factor in depression, ? of mixed depression or “latent hypomania” |
Episodes across polarities.
Reference | Measures | Results | Types |
---|---|---|---|
Meyer and Hautzinger (42) | CES-D plus SCID mania items | 2,059 healthy subjects, two factors: dysphoric-depression, euphoric-activation | Bipolar-like structure including “mixed” even in healthy subjects |
Adler et al. (43) | Affective Self-Rating Scale: depressive, manic, mixed | Mania and depression factors | Mixed subgroup with both factors elevated |
Bertschy et al. (34) | MINI plus dysphoria | Dysphoria: ≥3 of inner tension, irritability, aggressive behavior, hostility | Dysphoria in 17.5% of pure depression, 22.7% of pure mania, 73.3% of “full mixed” |
Perugi et al. (44) | TEMPS-A (temperament scale) plus interpersonal sensitivity, separation anxiety | Range of patients with bipolar disorder; cyclothymic-sensitive versus hyperthymic factors | Cyclothymic-sensitive associated with comorbidities and mixed states |
Swann et al. (6) | SADS | Measure of extent to which symptoms were mixed across polarities (MSI) | MSI correlated with anxiety and psychosis, higher with early onset and comorbidities |
Phenomenology.
Susceptibility to Mixed States and Course of Illness
Recurrence
Lifetime Number and Frequency of Episodes
Stability of Mixed States
Complications and Co-Occurring Illnesses
Suicidality
Predominantly manic.
Predominantly depressive.
Co-Occurring Conditions
Response to Treatment
Course of Illness
Discussion
Potential Mechanisms of Mixed States
Assessment of Mixed States
Need for comprehensive assessment.
Potential ascertainment bias.
Practical Identification of Mixed States
Primary Episode | Criteria | Remarks |
---|---|---|
Manic or hypomanic, research | At least three nonoverlapping depressive symptoms from DSM-IV major depressive episode criteria, OR | Based on criteria of McElroy et al. (17) and treatment response data (14) |
Score ≥10 on HAM-D (or equivalent on Inventory of Depressive Symptoms) modified to exclude agitation, irritability, and insomnia | Based on Stanley Foundation data (16) and factor/cluster analysis (27) | |
Duration of depressive symptoms: 1 week if mania and 4 days if hypomania | Current duration of DSM-IV mixed episode for mania | |
Manic or hypomanic, clinical | ≥3 nonoverlapping depressive symptoms nearly every day during the episode (4 days for hypomania, 7 days for mania) | Depressive symptoms exclude agitation, insomnia, irritability, and distractibility |
Major depressive, research | SADS mania factor score ≥8 (2) | YMRS numerically similar but SADS is designed to measure mania, depression, anxiety, and psychosis simultaneously |
≥3 mania symptoms non-overlapping with depressive symptoms (19) | Excluding insomnia other than decreased need for sleep, agitation other than increased goal-directed activity, and irritability | |
Duration of manic symptoms: 4 days | Criterion for DSM-IV hypomanic episode | |
Major depressive, clinical | ≥3 nonoverlapping manic symptoms nearly every day for at least 7 days of the episode | Manic symptoms excluding agitation, insomnia, irritability, and distractibility |
Conclusions
Acknowledgments
References
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