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", illustration portraying the "inbetween" like state that many people in a mixed episode might feel
SymptomsDepressed mood, racing thoughts, agitation, anxiety, irritability/aggression, emotional lability, suicidal ideation[1]
Differential diagnosisanxiety, 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.

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 recognized in patients with, in addition to bipolar I disorder, 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[edit]

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, rather than a singular one, being touched upon. 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 in nature or dysphoric in nature. these episodes are extreme. 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 on the more extreme levels of mania episodes of euphoria may be dangerous, unhealthy, or unhelpful. People with emotional lability may seemed to have suddenly developed anger issues or an anxiety disorder. they may seem to overreact in many or most situations. they may go to being 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 cause severe, life changing. or even deadly problems. like binge eating, excessive arguments, and an increased chance for suicides. irritability can also be present among mixed affective states. irritability is present in all affective disorders. in depression the irritability is more subtle but still noticeable. in mixed episodes the irritability is intense and way more noticeable. 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 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[edit]


  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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