Frequency of Dysphoria and Mixed States

Abstract

Background: Mixed states are a complex entity in the field of mood disorders. Dysphoria has been advocated as an important clinical dimension of mixed states. The objective of this work is to study the frequency of dysphoria within a population of patients with DSM-IV major depressive and/or manic episodes and to determine if it may help establish diagnostic criteria for subthreshold cases of depressive or manic mixed states. Sampling and Methods: A total of 165 patients were assessed using the Mini International Neuropsychiatric Interview complemented by a section defining dysphoria as a constellation of 3 among 4 symptoms (inner tension, irritability, aggressive behavior and hostility). Results: When classifying patients according to the number of symptoms of the opposite polarity, changes in the frequency of dysphoria revealed a clear contrast between the 2 opposite manic and depressive poles and the full mixed state (DSM-IV definition). The frequency of dysphoria was 17.5% in pure depression, 22.7% in pure mania and 73.3% in full mixed state. Two threshold effects were identified: (1) the frequency of dysphoria increased from 17.5 to 61.1% (p = 0.002) when the number of manic symptoms in DSM-IV depressed patients increased from 0 to 1, and (2) dysphoria increased from 14.3 to 69.2% (p = 0.057) when the number of depressive symptoms increased from 2 to 3 in DSM-IV manic patients. Conclusion: Dysphoria is strongly but not necessarily associated with mixed states. When used as a clinical marker for mixed states, dysphoria confirms the modern delimitations of sub-threshold mixed states by specifying the required number of symptoms of the opposite polarity (which could be lower for depressive mixed states than for manic mixed states). The study has limitations related to the inclusion of patients who are not drug-free, to the definition of dysphoria and to the sample size.

Phenomenology of racing and crowded thoughts in mood disorders: A theoretical reappraisal

“…In a more clinical perspective, we propose the existence of an interaction between a depressive element (deficit of inhibition of previous thoughts) and a manic element (excess of production of new thoughts), and that this interaction can result in a specific by-product: the phenomenon of crowded thoughts. This has some analogy with a previous construct proposed by our group: the dysphoric syndrome (irritability, inner tension, impulsivity, painful hypersensoriality), frequently associated to mixed states (Bertschy et al, 2008), which was similarly proposed to emerge through an interaction between thought excitation and depressive mood (Bertschy et al, 2007). Moreover, irritability and crowded thoughts are very frequently associated.…”

“…It has also a potential therapeutic importance, notably concerning the adequate use of antidepressants and mood stabilizers. As suggested by our and others' clinical experience (Akiskal et al, 2005;Benazzi, 2005bBenazzi, ,c, 2007aBertschy et al, 2008;Koukopoulos, 1999), a significant number of mixed depressions occur during antidepressant treatments and the therapeutic management of these mixed patients is difficult.…”

DSM‐5 criteria for depression with mixed features: a farewell to mixed depression

“…Dysphoria, defined as a constellation of symptoms such as inner tension, irritability, aggressive behaviour and hostility, was ascertained in 73.3% of patients with a mixed state . Similarly, Olgiati et al.…”

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

“…However, several authors have conceptualized dysphoria as a “third possibility of mood swing,” a “third emotional field,” or a “third dimension” in addition to mania and depression, and defined it as “a morose, tense, and irritated mood.” 12 , 18 – 20 Dayer et al 19 argued that dysphoria was a combination of irritability and aggression, and proposed the dysphoric syndrome be defined as the presence during at least 24 hours of overt irritability with 2 of the following 4 criteria: expressed (subjective) internal tension; expressed (subjective) irritability or feelings of hostility in reaction to external stimuli; aggressive or destructive behaviors; and suspiciousness. Starcevic 12 argued that dysphoria was “a complex emotional state, consisting of intense unhappiness and irritability” (p 12).…”