Mixed affective state

Mixed affective state
Classification and external resources
Specialty	psychiatry
ICD-10	F38.0
ICD-9-CM	296.6

A mixed affective state, also known as a mixed or mixed-manic episode, is a condition during which features of mania and depression—such as agitation, anxiety, fatigue, guilt, impulsiveness, irritability, morbid or suicidal ideation, panic, paranoia, pressured speech, and rage—occur simultaneously or in very short succession.

In current psychiatric nomenclature, they are a defining feature of bipolar I disorder, a type of bipolar disorder wherein mania or, less commonly, mixed-mania alternate with euthymia and, in the vast majority of cases, depression.

As mentioned below, the diagnostic criteria specify that at least the minimum number of symptoms required for an independent diagnosis of both mania and depression be consistently present for at least one week (or less should psychiatric hospitalization be required); in reality, however, this criterion is rarely met, with "dysphoric mania" (up to three concurrent depressive symptoms) being much more common. Mixed affective states with a heavy preponderance of depressive symptoms may also be seen, although these may be more difficult to diagnose, as, for example, flight of ideas and "racing thoughts" may be confused for depressive rumination, and a certain tense excitation for agitation.

Diagnostic criteria

As affirmed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a mixed state must meet the criteria for both a major depressive episode and a manic episode nearly every day for at least one week.^[1] However, mixed episodes rarely conform to these qualifications; they may be described more practically as any combination of depressive and manic symptoms.^[2][3][4]

In cases where psychomotor disturbances in a depressive state tend towards agitation, it is often difficult to ascertain whether the agitation is occurring on the basis of a unipolar agitated depression or bipolar mixed affective state. Psychomotor retardation is more common in bipolar depression than is agitation but it is not conclusive. If more than 2 signs and symptoms specific to mania, and that cannot be accounted for by depression, are present, then the diagnosis of a bipolar mixed state is favored; such symptomology may include racing thoughts and flight of ideas, impulsivity, grandiosity, and an increase in goal-directed behavior. General agitation, a sense of inner tension, rumination, etc., are not counted as these can be accounted for on the basis of depression. Should a mixed affective state not be confirmed by these means, it is often prudent to attend to certain features pertaining to family history, onset, and overall course (e.g., family history of bipolar disorder, early age of onset, recurrent episodes) to determine whether or not the patient has bipolar disorder.^[5]

According to the MMDT, increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms of dysphoric mania. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some antidepressant drugs may trigger dysphoric mania in susceptible individuals. A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression".^[6]

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 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.^[7][8] 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.^[9]

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.
2. Akiskal, H.S. Pinto, O. (1999). The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr Clin North Am. 22(3):517–34.
3. Goldman, E. (1999). Severe Anxiety, Agitation are Warning Signals of Suicide in Bipolar Patients. Clin Psychiatr News. pg 25.
4. Perugi, G. Toni, C. Akiskal, H.S. (1999). Anxious-bipolar comorbidity. Diagnostic and treatment therefore challenges. Psychiatr Clin North Am. 22(3):565–83.
5. 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.
6. Goodwin FK, Ghaemi SN (December 2003). "The course of bipolar disorder and the nature of agitated depression". Am J Psychiatry 160 (12): 2077–9. doi:10.1176/appi.ajp.160.12.2077. PMID 14638572.
7. Pharmacotherapy of manic-depressive mixed States
8. 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
9. Thase ME, Sachs GS. Bipolar depression: pharmacotherapy and related therapeutic strategies. Biol Psychiatry. 2000 Sep 15;48(6):558-572.