Phenomenological subtypes of severe bipolar mixed states: a factor analytic study

Perugi, Giulio; Medda, Pierpaolo; Swann, Alan C.; Reis, João; Rizzato, Salvatore; Mauri, Mauro

doi:10.1016/j.comppsych.2014.01.012

Cited by 24 publications

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“…Research that has examined subtypes of mixed presentations, of which DIP and anxiety symptoms are prominent features, 33 , 34 has found that psychomotor agitation and distractibility are likely core features of mixed mania, 24 , 31 while irritability lends itself more to nonmelancholic depression (admixture of depressive and anxiety symptoms) 31 . In a similar vein, Perugi et al 34 suggest that mixed states can be characterised by different combinations of 6 distinct dimensional factors: “ psychotic-positive symptoms (suspiciousness, hallucinations, unusual thought content, bizarre behavior, conceptual disorganization), mania (hostility, elated mood, grandiosity, uncooperativeness, excitement, motor hyperactivity), disorientation/unusual motor behavior (neglect, disorientation, motor retardation, uncooperativeness, and mannerisms and posturing), depression (anxiety, depression, suicidality, guilt, tension, without elated mood), negative symptoms (blunted affect, emotional withdrawal, and motor retardation), and anxiety (anxiety, somatic concern, and motor retardation).” (p. 801). Koukopolous et al 15 , 17 advocate for distinction between subtypes of depressive episodes with mixed features; they propose partitioning of these into “agitated depression” and “mixed depression.” Although these findings are preliminary and require replication in larger, more diverse samples, collectively they support the notion that DIP features along with anxiety play a key role in mixed states, especially given that these subtypes differ not only in terms of clinical phenomenology, but also illness course, comorbidity, and treatment response 33 …”

Section: Manifestations Of Mixed Statesmentioning

confidence: 99%

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

et al. 2016

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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.

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Section: Manifestations Of Mixed Statesmentioning

confidence: 99%

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

et al. 2016

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“…In the presence of depressive symptoms during mania, Valproate and Carbamazepine has been shown to be more effective than lithium . In a severe mixed state, however, sustained protracted affective instability has been frequently associated with non‐mood symptoms such as anxiety, cognitive and motor indecisiveness, emotional perplexity, perceptual disturbances, sense of external interference, depersonalization and grossly disorganized behaviour . These characteristics have been shown to be very common in severe mixed states, and cannot be derived from the mere superposition of depressive and manic symptomatology.…”

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confidence: 99%

“…These characteristics have been shown to be very common in severe mixed states, and cannot be derived from the mere superposition of depressive and manic symptomatology. In a recent study on 202 Bipolar I patients with severe mixed states, treated with ECT, 62% of the cases were considered neither predominately‐manic nor predominately‐depressive. Only 14% of the sample can be described as “Dominant Manic” and 24% should be considered as “Dominant Depressive.” Interestingly, prominent “Psychotic Symptoms” and “Anxiety” characterized respectively 20% and 15% of the patients.…”

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“…Anxiety, dysphoric/irritable/hostile mood, inner tension, mood lability and impulsivity have been shown to characterize mixed mania . Finally rapidly alternating swings in affectivity, emotional resonance, or drive, associated with cognitive‐emotional‐motor indecisiveness, behavioural disorganization (including auto‐ and etero‐aggressive conducts) and psychotic features have been shown to characterize severe mixed state …”

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confidence: 99%

“…The proper identification of mixed episodes has critical implications not only for research, but also for clinical practice. When not characterized by prevalent manic or depressive features, these conditions might be confused with a number of other psychiatric disorders, including borderline personality disorder, psychotic depression, schizophrenia, and organic mental disorder . Therefore, it would be important to distinguish mixed states from these conditions so that treatments (eg, antidepressants), which might worsen their symptomatology, would be utilized with due caution and treatments that might be particularly effective (eg, mood stabilizers and ECT) would not go underutilized.…”

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ICD‐11 mixed episode: Nothing new despite the evidence

Perugi

2019

Bipolar Disorders

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The modern concept of mixed state was introduced by Kraepelin 1 to identify "phases" characterized by the contemporary presence of manic and depressive features, in patients with manic-depressive insanity. He formulated the hypothesis that each of the domains of mood, cognition, and activity would change at a different pace over time, thereby leading to selective increases or decreases of each of these three domains. In this model, different types of mixed states reflected the instability of underlying brain mechanisms governing the three fundamental domains of psychic life and are not considered just a complication of mania and depression, but the most common clinical manifestation and the most important unifying core feature of manic-depressive insanity.In DSM-III, -IV, and -5 mixed episode has not received specific criteria characterization and is basically defined as the combination of mania and major depression "co-occurring or rapidly alternating" in the same period. This approach, which in part reflects the recent empirical Zeitgeist of descriptive psychiatry, shaped the kind of research that was conducted in recent years and mixed state has been mainly considered as a subtype of manic or depressive episodes, rather than in Kraepelinian terms of specific features or episode components.The inclusion of symptoms of the opposite polarity in depressive and manic episode implicitly recognizes the existence of a mood spectrum, suggesting a continuum ranging from pure major depression to pure mania. The DSM-5 definition of mixed features reflects this spectrum approach and captures subthreshold non-overlapping symptoms of the opposite pole using a "with mixed features" specifier to be applied to manic, hypomanic, and major depressive episodes, experienced in bipolar I, II, and major depressive disorder. The criteria are in part data-driven and overcome the problems derived from the extremely narrow definition of the previous editions of the manual. The possibility of classifying depression "with mixed features" represents another major improvement. However, the DSM-5 definition is based on the speculative wish to avoid "overlapping" manic and depressive symptoms, such as psychomotor agitation, irritability, and mood lability, the most common features of mixed depression across the literature. This opinion-based aspect of the DSM-5 definition is very restrictive, allowing the diagnosis of mixed depression only in 1 out of 4 cases. 2 Certainly, these symptoms may be nonspecific, but to exclude them entirely may be not justified, in the absence of any evidence that the remaining criteria are sufficiently sensitive. Without empirical evidence, the theoretical wish to avoid over-diagnosis cannot be considered a criterion of validity in itself.Fortunately, in the ICD-11 a specific diagnostic category for mixed episode has been preferred to a "specifier" for depressive and manic episodes. A diagnostic category is obviously more likely to improve diagnostic sensitivity and to ensure specific treatment strategy than a sim...

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The Reality Distortion and Thought Disorganisation Dimensions

Tarsitani

Maraone

2018

Dimensional Psychopathology

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Phenomenological subtypes of severe bipolar mixed states: a factor analytic study

Cited by 24 publications

References 38 publications

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

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

ICD‐11 mixed episode: Nothing new despite the evidence

The Reality Distortion and Thought Disorganisation Dimensions

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