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Signs and symptoms of mania in pure and mixed episodes
1Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
Background:
Debate continues about the diagnosis of mixed mania and the restrictiveness of the DSM-III-R and DSM-IV criteria for Bipolar Disorder, mixed. Although awareness of dysphoric features during mania continues to grow, standard mania rating instruments do not adequately assess mixed states and there is a striking disparity between the dysphoric signs and symptoms emphasized in research studies and the commonly employed DSM criteria.
Methods:
Three hundred sixteen inpatients meeting DSM-III-R criteria for Bipolar Disorder, manic or mixed, were evaluated by rating 20 signs and symptoms. The frequencies of these signs and symptoms were computed for both diagnostic subtypes and compared using chi2 statistics and conditional probability parameters.
Results:
The most frequently noted signs and symptoms in mania are motor activation, accelerated thought process, pressured speech and decreased sleep. Although euphoric mood was present in a large portion of the cohort, irritability, dysphoric mood and mood lability were also prominent in the entire cohort. Dysphoric mood, mood lability, anxiety, guilt, suicidality, and irritability were the only symptoms significantly more common in the mixed group. In contrast, grandiosity, euphoric mood, and pressured speech were significantly more often observed in the pure manic group. Contrary to popular belief, paranoia did not differ significantly between the two groups. Suicidality was present in a non-trivial 7% of the entire cohort, including some subjects who did not meet the criteria for mixed mania.
Limitations:
The comparison of mixed and manic episodes requires the appropriate definition of mixed states. In the current report we use the DSM-III-R definition of Bipolar Disorder, mixed, which may be too rigid.
Conclusions:
The data underscore that mania is not a purely euphoric state. Substantial rates of dysphoria, lability, anxiety and irritability were noted in the "pure" manic patients, as well as in those who meet the full DSM criteria for Bipolar Disorder, mixed, suggesting, that perhaps a less restrictive definition of mixed states would be more appropriate.
Insights
Mixed mania symptoms are common, even in pure manic episodes. Current diagnostic criteria for Bipolar Disorder, mixed, may be too restrictive, suggesting a need for broader definitions.
Area of Science:
- Psychiatry
- Clinical Psychology
- Neuroscience
Background:
- The diagnostic criteria for Bipolar Disorder, mixed, are debated for restrictiveness.
- Standard mania rating instruments inadequately assess mixed states.
- A disparity exists between research on dysphoric symptoms and current diagnostic criteria.
Purpose of the Study:
- To evaluate the frequency and significance of various signs and symptoms in manic and mixed episodes of Bipolar Disorder.
- To compare symptom profiles between DSM-III-R defined manic and mixed subtypes.
- To assess the adequacy of current diagnostic criteria for mixed states.
Main Methods:
- Evaluated 316 inpatients diagnosed with Bipolar Disorder, manic or mixed, using DSM-III-R criteria.
- Rated 20 specific signs and symptoms for each patient.
- Computed frequencies and compared symptom prevalence between diagnostic subtypes using chi2 statistics and conditional probability.
Main Results:
- Motor activation, accelerated thought, pressured speech, and decreased sleep were most frequent in mania.
- Irritability, dysphoric mood, and mood lability were prominent across all patients.
- Dysphoric mood, anxiety, guilt, suicidality, and irritability were significantly more common in the mixed group.
- Grandiosity, euphoric mood, and pressured speech were more common in the pure manic group.
- Suicidality was present in 7% of all patients, including those not meeting mixed criteria.
Conclusions:
- Mania is not exclusively a euphoric state; dysphoric symptoms are prevalent.
- The current DSM-III-R definition of Bipolar Disorder, mixed, may be too rigid.
- A less restrictive definition for mixed states could better capture the clinical presentation of Bipolar Disorder.