Mixed affective state

A mixed affective state, formerly known as a mixed state, mixed-manic episode, or mixed episode, has been defined as a state wherein features and symptoms unique to both depression and hypomania occur either simultaneously or in very short succession. This includes episodes of anguish, despair, diminished pleasure in enjoyed activities, feelings of guilt or self-loathing, excessive impulsivity and suicidal ideation, racing thoughts, heightened irritability, agitation or restlessness, increased goal-directed activity, increased talkativeness, or decreased need for sleep.

In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition nomenclature, 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.

Diagnosis

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.

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. A depressive mixed state in a patient, even in the absence of discrete periods of mania or hypomania, effectively rules out unipolar depression.

Nevertheless, the DSM-5's narrower definition of mixed episodes may result in fewer patients meeting mixed criteria compared to DSM-IV. 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.

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.