Mixed affective state

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Mixed affective state
Other namesMixed affective state, mixed episode, mixed-manic episode, dysphoric mania
'Melancholy passing into mania' Wellcome L0022595.jpg
"Melancholy passing into mania", illustration portraying the "inbetween" like state that many people in a mixed episode might feel
Specialty Psychiatry
Symptoms Depressed mood, racing thoughts, agitation, anxiety, irritability/aggression, emotional lability, suicidal ideation [1]
Differential diagnosis Anxiety, borderline personality disorder, ADHD

A mixed affective state, formerly known as a mixed-manic or mixed episode, has been defined as a state wherein features and symptoms unique to both depression and (hypo)mania, including episodes of anguish, despair, self doubt, rage, excessive impulsivity and suicidal ideation, sensory overload, racing thoughts, heightened irritability, decreased "need" for sleep and other symptoms of depressive and manic states occur either simultaneously or in very short succession.

Contents

Previously, the diagnostic criteria for both a manic and depressive episode had to be met in a consistent and sustained fashion, with symptoms enduring for at least a week (or any duration if psychiatric hospitalization was required), thereby restricting the official acknowledgement of mixed affective states to only a minority of patients with bipolar I disorder.

In current DSM-5 nomenclature, however, a "mixed episode" no longer stands as an episode of illness unto itself; rather, the symptomology specifier "with mixed features" can be applied to any major affective episode (manic, hypomanic, or depressive), meaning that they are now officially also recognized in patients with bipolar II disorder and, by convention, major depressive disorder. A depressive mixed state in a patient, however, even in the absence of discrete periods of mania or hypomania, effectively rules out unipolar depression.

Diagnostic criteria

As affirmed by the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-5), the symptomology specifier "with mixed features" can be applied to manic episodes of bipolar I disorder, hypomanic episodes of either bipolar I disorder or bipolar II disorder and depressive episodes of either bipolar disorder or major depressive disorder, with at least three concurrent features of the opposite polarity being present. As a result, the presence of "mixed features" are now recognized in patients with bipolar II disorder and major depression; as earlier noted, however, although it is customary to withhold a diagnosis of a bipolar disorder until a manic or hypomanic episode appears, the presence of such features in a depressed patient even with no history of discrete mania or hypomania is strongly suggestive of the disorder.

Nevertheless, the DSM-5's narrower definition of mixed episodes may result in fewer patients meeting mixed criteria compared to DSM-IV. [2] A call was made by Tohen in 2017 for introducing changes from a currently phenomenological to a target oriented approach to DSM-5 mixed mood criteria in order to achieve more personalized medical attention. [3]

Two features of both mania or hypomania and depression may superficially overlap and even resemble each other, namely "an increase in goal-directed activity" (psychomotor acceleration) vs. psychomotor agitation and "flight of ideas" and "racing thoughts" vs. depressive rumination. Attending to the patient's experiences is very important. In the psychomotor agitation commonly seen in depression, the "nervous energy" is always overshadowed by a strong sense of exhaustion and manifests as purposeless movements (e.g., pacing, hand-wringing); in psychomotor acceleration, however, the excess in movement stems from an abundance of energy and is often channelled and purposeful. Likewise, in depressive rumination, the patient experiences the repetitive thoughts as heavy, leaden, and plodding; in psychic acceleration, however, (as seen in mania or hypomania) the thoughts move in a rapid progression with many themes being touched upon, rather than a singular one.

There may also be emotional lability, a usual consequence of hypomania and mania but usually not depression unless caused by borderline personality disorder or just emotional lability itself with or without any disorder. It can either be euphoric or dysphoric in nature. These episodes are extreme. Lability may be uncalled for in a depressive episode (if euphoric in nature) and it can present itself in four ways: anger, anxiety, happiness, and extreme excitement. It is to be noted that a more extreme severity of manic euphoria may be dangerous, unhealthy, or unhelpful. People with emotional lability may seem to have suddenly developed anger issues or an anxiety disorder; they may seem to overreact in many or most situations; they may go from depressed to rapidly being "cured" or manic in just a few hours. Episodes of sudden mood change must be in a situation that promotes the feelings of anger, anxiety, and happiness or excitement. There also may be inappropriate and impulsive decision making, which can have severe, life changing, or even deadly consequences (like binge eating, excessive arguments, and an increased chance for suicide).

Irritability can also be present among mixed affective states. While irritability is present in all affective disorders, in depression it is often more subtle. In mixed episodes, the irritability is intense and easily noticed. Even when such experiences are accounted for on the basis of depression, the possibility does still exist, however, that the depressive episode may be complicated by other manic or hypomanic symptoms, in which case it is often prudent to attend to the patient's personal and family history (e.g., family history of bipolar disorder, early age of onset) to determine whether or not the patient has bipolar disorder. [4]

Treatment

Treatment of mixed states is typically based upon administration of mood stabilizing medication, which may include anticonvulsants such as valproic acid; atypical antipsychotics such as quetiapine, olanzapine, aripiprazole, and ziprasidone; or first-generation antipsychotics such as haloperidol. There is question of lithium's efficacy for treatment of mixed states due to conflicting conclusions drawn from various trials and research. [5] [6] Mood stabilizers work to reduce the manic symptoms associated with the mixed state, but they are not considered particularly effective for improving concurrent depressive symptoms. [7]

See also

Related Research Articles

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention, while the depressive episodes last at least 2 weeks.

Mania, also known as manic syndrome, is a mental and behavioral disorder defined as a state of abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation with enhanced affective expression together with lability of affect." During a manic episode, an individual will experience rapidly changing emotions and moods, highly influenced by surrounding stimuli. Although mania is often conceived of as a "mirror image" to depression, the heightened mood can be dysphoric as well as euphoric. As the mania intensifies, irritability can be more pronounced and result in anxiety or anger.

<span class="mw-page-title-main">Mood stabilizer</span> Psychiatric medication used to treat mood disorders

A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, such as bipolar disorder and the bipolar type of schizoaffective disorder.

<span class="mw-page-title-main">Mood disorder</span> Mental disorder affecting the mood of an individual, over a long period of time

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia (psychosis) and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.

<span class="mw-page-title-main">Mood swing</span> Extreme or rapid change in mood

A mood swing is an extreme or sudden change of mood. Such changes can play a positive part in promoting problem solving and in producing flexible forward planning, or be disruptive. When mood swings are severe, they may be categorized as part of a mental illness, such as bipolar disorder, where erratic and disruptive mood swings are a defining feature.

Atypical depression is defined in the DSM-IV as depression that shares many of the typical symptoms of major depressive disorder or dysthymia but is characterized by improved mood in response to positive events. In contrast to those with atypical depression, people with melancholic depression generally do not experience an improved mood in response to normally pleasurable events. Atypical depression also often features significant weight gain or an increased appetite, hypersomnia, a heavy sensation in the limbs, and interpersonal rejection sensitivity that results in significant social or occupational impairment.

The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

Cyclical variations in moods and energy levels have been recorded at least as far back as several thousand years. The words "melancholia" and "mania" have their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας, meaning "black", and chole/χολη, meaning "bile" or "gall", indicative of the term's origins in pre-Hippocratic humoral theories. A man known as Aretaeus of Cappadocia has the first records of analyzing the symptoms of depression and mania in the 1st century of Greece. There is documentation that explains how bath salts were used to calm those with manic symptoms and also help those who are dealing with depression. Even today, lithium is used as a treatment to bipolar disorder which is significant because lithium could have been an ingredient in the Greek bath salt. Centuries passed and very little was studied or discovered. It wasn't until the mid-19th century that a French psychiatrist by the name of Jean-Pierre Falret wrote an article describing "circular insanity" and this is believed to be the first recorded diagnosis of bipolar disorder. Years later, in the early 1900s, Emil Kraepelin, a German psychiatrist, analyzed the influence of biology on mental disorders, including bipolar disorder. His studies are still used as the basis of classification of mental disorders today.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

The associated features of bipolar disorder are clinical phenomena that often accompany bipolar disorder (BD) but are not part of the diagnostic criteria for the disorder. There are several childhood precursors in children who later receive a diagnosis of bipolar disorder. They may show subtle early traits such as mood abnormalities, full major depressive episodes, and attention-deficit hyperactivity disorder. BD is also accompanied by changes in cognition processes and abilities. This includes reduced attentional and executive capabilities and impaired memory. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Some studies have found a significant association between bipolar disorder and creativity.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

<span class="mw-page-title-main">Hypomania</span> Mental health condition

Hypomania is a mental and behavioral disorder, characterised essentially by an apparently non-contextual elevation of mood (euphoria) that contributes to persistently disinhibited behavior.

The General Behavior Inventory (GBI) is a 73-question psychological self-report assessment tool designed by Richard Depue and colleagues to identify the presence and severity of manic and depressive moods in adults, as well as to assess for cyclothymia. It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder and the fluctuation of symptoms over time. The GBI is intended to be administered for adult populations; however, it has been adapted into versions that allow for juvenile populations, as well as a short version that allows for it to be used as a screening test.

The following outline is provided as an overview of and topical guide to bipolar disorder:

Sleep is known to play an important role in the etiology and maintenance of bipolar disorder. Patients with bipolar disorder often have a less stable and more variable circadian activity. Circadian activity disruption can be apparent even if the person concerned is not currently ill.

Unipolar mania is a form of bipolar disorder whereby individuals only experience manic episodes without depression. Depression is often characterised by a persistent low mood, decreased energy and thoughts of suicide. What is seen as its counterpart, mania, can be characterized by racing thoughts, less need for sleep and psychomotor agitation.

References

  1. ↑ "Mixed States, Depression & Anxiety". 7 October 2014.
  2. ↑ Tohen, Mauricio; Gold, Alexandra K.; Sylvia, Louisa G.; Montana, Rebecca E.; McElroy, Susan L.; Thase, Michael E.; Rabideau, Dustin J.; Nierenberg, Andrew A.; Reilly-Harrington, Noreen A.; Friedman, Edward S.; Shelton, Richard C. (2017-08-01). "Bipolar mixed features - Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) study". Journal of Affective Disorders. 217: 183–189. doi:10.1016/j.jad.2017.03.070. ISSN   1573-2517. PMID   28411507.
  3. ↑ Tohen, Mauricio (2017). "The need to change from a phenomenological to a target engagement approach". Bipolar Disorders. 19 (6): 513–514. doi:10.1111/bdi.12533. ISSN   1399-5618. PMID   28892289.
  4. ↑ Swann AC (2013). "Activated depression: mixed bipolar disorder or agitated unipolar depression?". Curr Psychiatry Rep. 15 (8): 376. doi:10.1007/s11920-013-0376-1. PMID   23881708. S2CID   24851675.
  5. ↑ Krüger S, Young T, Bräunig P (2006). "[Pharmacotherapy of manic-depressive mixed States]". Psychiatr Prax. 33 (Suppl 1): S32-9. doi:10.1055/s-2005-867019. PMID   16511729.
  6. ↑ Muzina D. J. (2009). "Pharmacologic treatment of rapid cycling and mixed states in bipolar disorder: an argument for the use of lithium". Bipolar Disorders. 11: 84–91. doi:10.1111/j.1399-5618.2009.00713.x. PMID   19538688.
  7. ↑ Thase ME, Sachs GS (Sep 2000). "Bipolar depression: pharmacotherapy and related therapeutic strategies". Biol Psychiatry. 48 (6): 558–572. doi:10.1016/s0006-3223(00)00980-x. PMID   11018227. S2CID   1192362.
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