
- Vol 35, Issue 9
- Volume 35
- Issue 9
How to Diagnose Mixed Features Without Overdiagnosing Bipolar
Hypomania looks very different when it’s mixed with depression.
RESEARCH UPDATE
Mixed features are common in practice but poorly described in DSM. They are caused by the overlap of depressive and manic symptoms, but it’s hard to understand them by reading separate descriptions of these two states. It would be like trying to imagine green by studying yellow and blue.
Classic
A diagnostic chameleon
Mixed features can look like anxiety, ADHD, borderline personality disorder, or depression with an agitated edge. The Table contrasts the features of hypomania as they appear in mixed and pure forms. Unlike euphoric hypomania, mixed symptoms are not pleasurable, and the interview needs to be adjusted to capture that.
Ask a patient with mixed features, “Do you have times when you don’t need much sleep” and he or she will answer “No.” In truth, these patients do keep going with little rest, but they usually have a strong desire to sleep. Often the desire is not to sleep but to “turn my mind off,” a dangerous wish that can lead to sedative overdose when sleep does not come.
Ask a patient with mixed features, “Do you feel unusually confident, happy, or euphoric” and you’ll get a big “No.” How does confidence look when mixed with depression? Self-esteem is low, but patients are also demanding and aggressive, asserting themselves in a way that’s not consistent with the usual passivity of depression. Euphoria is replaced by lability, and most of these patients recall only the aversive turns of that emotional carousel. Relatives, on the other hand, may notice rare bursts of giddy excitation.1
DSM-5 made an important advance in understanding mixed states: it removed the word “pleasurable” from the impulsivity criteria. Sometimes these patients do pursue hedonic pleasures, but they are quick to point out that they only shop, binge on carbs, or masturbate excessively to “relieve the depression” and “not because I’m manic.” More often, the impulsivity is destructive. They will quit jobs, end relationships, break television sets, fire their psychiatrist, and tragically turn to self-harm and suicide, the rates of which are higher in mixed states than they are in depression.2
Substance abuse is also elevated. The association between depression and addiction may be entirely explained by mixed features, according to three studies involving more than 12,000 patients followed for at least 10 years. However, most of the mixed features in those studies would not be classified as bipolar, as we’ll see next.3-5
Clinical implications
Mixed hypomania is more common than the purer form, and it’s more likely to bring patients into treatment. It also counts toward a bipolar diagnosis. As long as the hypomanic symptoms are long enough in duration (4 or more days) and sufficient in number, the diagnosis is bipolar, even if the patient never has an episode of pure hypomania. Often, these symptoms don’t cross the bipolar threshold and are due to a form of unipolar depression newly recognized in DSM-5 as Major Depressive Episode with Mixed Features. This diagnosis is surprisingly common, occurring in up to 25% of patients with unipolar depression.6
Mixed unipolar disorder
Is mixed unipolar a form of bipolar disorder? Yes, and no. It falls somewhere between bipolar and unipolar in terms of family history, course of illness, associated features, and treatment response.7 Those four areas are the
The bottom line
In the end, this is a diagnosis that matters. Antidepressants are a two-edged sword that can make these states better in some and worse in others. The latest treatment guidelines recommend minimizing antidepressants, even in the unipolar form of mixed features and argue instead for mood stabilizers and atypical antipsychotics.2
This article was originally published on 7/6/18 and has since been updated.
Disclosures:
Dr. Aiken is the Director of the
References:
1. Koukopoulos A, Faedda G, Proietti R. et al.
2. Stahl SM, Morrissette DA, Faedda G, et al.
3. Zimmermann P, Brückl T, Nocon A, et al.
4. Angst J, Gamma A, Endrass J, et al.
5. Angst J, Azorin JM, Bowden CL, et al.
6. Vázquez GH, Lolich M, Cabrera C, et al.
7. Aiken C. “The Bipolar Spectrum,” in Bipolar II Disorder: Modelling, Measuring and Managing, 3nd Edition, Parker G editor. Cambridge University, in press.
8. Aiken CB, Weisler RH, Sachs GS.
9. Apfelbaum S, Regalado P, Herman L, et al.
Articles in this issue
about 7 years ago
Introduction: The Evolution of ADHDabout 7 years ago
Do Diet and Nutrition Affect ADHD? Facts and Clinical Considerationsabout 7 years ago
Issues Pertaining to Misuse of ADHD Prescription Medicationsabout 7 years ago
The Quiz: Cognitive-Behavioral Therapy and Chronic Painabout 7 years ago
Is Kansas a Real Place?about 7 years ago
Questions and Answers for Clinicians Facing the Opioid Epidemicabout 7 years ago
Psychocardiology: Understanding the Heart-Brain Connection: Part 1about 7 years ago
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