Mixed Episodes Out, Mixed Features In

DSM-5 Makes Much-Needed Changes - and More

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Doctors and patients alike have long known that a change needed to be made regarding the official definition of bipolar mixed episodes. The criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - the DSM-IV-TR (the TR stands for "text revision") limited mixed episodes to people who have bipolar I disorder. A history or presence of mania was required.

This ruled out the possibility that people with bipolar II or cyclothymia could - again, officially - have mixed episodes. Fortunately, that didn't prevent psychiatrists from treating mixed hypomania if it occurred.

In addition, the diagnostic criteria for a mixed episode were simplistic, merely stating that the patient had to meet the full criteria for both a manic and a depressive episode at the same time. In preparing the DSM-5, the APA realized that this really didn't fit with symptoms doctors were finding in their practices, and made substantial changes.

In addressing these issues, the DSM-5 made an important change. "Mixed Episodes" are gone from the terminology. Instead, there is a new specifier: "With Mixed Features." Where the original Mixed Episode definition required a person to have all the symptoms of both mania and depression, the DSM-5 has written the Mixed Features specifier in two parts, with different criteria depending on whether the patient is having a primarily manic/hypomanic or depressive episode.

Manic or Hypomanic Episode With Mixed Features

The criteria are as follows:

A. First of all, the patient has to have all the required symptoms of mania or of hypomania. In addition, at least three of these depressive symptoms must be occurring:

  1. Feeling depressed, dysphoric, sad or empty, crying or appearing tearful, feeling hopeless, etc.
  1. Losing interest or pleasure in most activities normally enjoyable.
  2. Physically slowing down to a point that others can notice it (see psychomotor retardation).
  3. Tiredness or energy loss.
  4. Feeling worthless, or feeling extremely or unreasonably guilty.
  5. Any of the following:

    *Recurring thoughts of death
    *Recurring suicidal ideation without a plan
    *A suicide attempt.
    *Making a specific plan to commit suicide.

B. Other people can see the mixed symptoms, and they are different from the person's normal behavior.

C. If all criteria are met for both a manic and a depressive episode (what used to be the definition of a mixed episode), the diagnosis should be manic episode, with mixed features. The DSM-5 says this is "due to the marked impairment and clinical severity of full mania."

D. The mixed symptoms aren't caused by a substance, whether an abused drug, a medication (prescription or over-the-counter), a treatment, etc.

Depressive Episode With Mixed Features

A. The patient has all the required symptoms for a major depressive episode.

In addition, at least three of these seven symptoms of mania/hypomania are occurring:

  1. Elevated, expansive mood.
  2. Grandiosity or inflated self-esteem.
  3. Pressured speech or increased talkativity.
  4. Racing thoughts or flight of ideas
  5. Increase in energy or goal-directed activity.
  6. Increased or excessive risky behavior.
  7. Decreased need for sleep.

B. The mixed symptoms can be observed by others and are a departure from normal behavior.

Items C. and D. are the same as above.

The DSM-5's description of the "With Mixed Features" specifier ends with this note:

Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. Arlington, VA: American Psychiatric Publishing, 2013. 149-150. Print.

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