Category: Mental Health
June 17, 2011 (Pittsburgh, Pennsylvania) — The upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
may include revisions for diagnosing mixed episodes while keeping the
current duration criteria for hypomanic episodes in bipolar disorders,
according to 2 presentations by members of the DSM-5 Mood Disorders Work Group at the 9th International Conference on Bipolar Disorder (ICBD).
Clinicians frequently refer to episodes of bipolar illness as "mixed"
when in fact these episodes infrequently meet the criteria listed in
the DSM, Fourth Edition (DSM-4).As a result, the Work Group is now proposing the addition of a mixed specifier to the new manual.
"This would allow the clinician to indicate the presence of 2 to 3
manic or hypomanic symptoms occurring for at least 2 to 3 days
simultaneously with a fully syndromal episode of depression," Ellen
Frank, PhD, distinguished professor of psychiatry at the University of
Pittsburgh School of Medicine in Pennsylvania, told ICBD delegates.
She added that these manic/hypomanic symptoms "would be limited to
those that do not have the potential for overlap with the symptoms of
Dr. Frank told Medscape Medical News that the Work Group wants the criteria to better reflect clinical practice.
"In the DSM-5, we've tried to make the criteria for mixed
episodes conform to how clinicians actually use that terminology. The
criteria, as previously listed, rarely existed in the real world," she
More Realistic Criteria
Mixed episode criteria described in the DSM-4 includes the
simultaneous presence of a fully manic and a fully depressive syndrome
nearly every day during at a minimum a 1-week period.
However, she said, the full criteria are too restrictive and often not present.
"From my perspective, it's a lovely idea but just like I have never
seen a unicorn, I don't think I have ever seen a patient in my 30 years
of working in bipolar disorder who simultaneously met all those
criteria," said Dr. Frank.
"So for the DSM-5, we set out to elaborate a set of criteria
that are more consistent with the way in which the term 'mixed episode'
is used — and more consistent with what is found in clinical
The proposed mixed specifier would apply to episodes of both depression and mania.
Dr. Frank added that the criteria will not be limited to bipolar
disorder but could be applied to episodes of depression experienced by
patients with a lifetime diagnosis of a unipolar or bipolar disorder.
She explained that the specifier would be used if full criteria are
met for a manic or hypomanic episode with at least 3 of the following
depressive symptoms occurring concurrently nearly every day during the
- Subjective depression;
- Negative evaluation of self;
- Suicidal ideation or behavior;
- Fatigue; or
- Psychomotor retardation.
It would also be used if full criteria are met for a major depressive
episode with at least 3 of the following concurrent hypomanic symptoms:
- Elevated mood;
- Decreased need for sleep;
- Goal-directed activity;
- Increased energy and visible hyperactivity;
- Accelerated speech; or
- Racing thoughts.
Symptoms that are characteristic of both depression and mania are not
included in the new mixed specifier, including distractibility,
irritability, insomnia, or indecisiveness.
Risks of Incorrect Use
Dr. Frank noted that the consequences of incorrectly using the
current mixed episode definitions include an underestimation of suicide
risk, inappropriate treatment selection, and a failure to identify those
at an increased risk of progressing from unipolar disorder to bipolar
"I think we're talking not simply about something that we
conceptualize from our rating scales but something that is very
pronounced in the lives of patients. And we hope that this proposed
revision to the DSM-5 will fit better with the reality."
The Work Group is also recommending that the DSM-4's 4-day requirement for a diagnosis of a hypomanic episode be retained.
"The appropriate and best definition for the duration of symptoms
used to define hypomanic episodes has been long debated with passionate
proponents on all sides of the discussion," said Trish Suppes, MD, from
Stanford University School of Medicine in Palo Alto, California, and the
Veterans Affairs Palo Alto Health Care System during the second
Dr. Trish Suppes
She noted that although the 4-day duration has been questioned
vigorously, "review of the existing literature does not necessarily
clarify the impact of changing the duration requirement."
So the recommendation to keep the current duration essentially preserves the diagnostic criteria for bipolar II disorder.
However, the committee is proposing that bipolar disorder not
otherwise specified (NOS) will now include specified and coded
subcategories, including those specifically designed to discuss patients
who have shorter durations of hypomania (of 2 to 3 days).
"We're suggesting that the NOS be divided into 3 broad categories:
subsyndromal, other specified, and unspecified due to insufficient
Activity as Important as Mood
The committee is also recommending the addition of "activity or energy" to the Criterion A section of the Manual.
"This is based on many studies supporting that activity or energy is as important as mood. This was implicit in the DSM-4 but it was important to make it explicit in the DSM-5 to heighten clarity that this is a core symptom of mania and hypomania."
The activity inclusion will now specify "a distinct period of
abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy." The symptom
lists, as shown in Criterion B, will essentially not be changed.
"Many of these revisions are an effort to capture more clearly what
our patients experience and to provide an opportunity to study in a more
focused manner the full spectrum of mood disorders," said Dr. Suppes.
"We're basically working towards a new classification system, with
new codes and new billable options, and I think it's likely that out of
this, new [Food and Drug Administration] targets for drug development
9th International Conference on Bipolar Disorder (ICBD): Symposium 2, # 6 and 7. Presented June 9, 2011.
Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to
Authors and Disclosures
Journalist -Deborah Brauser
is a freelance writer for Medscape.Deborah Brauser has disclosed no relevant financial relationships.