CLINICAL PICTURE AND ETIOLOGIC MODELS OF MIXED STATES

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• 作者：Marlene P. Freeman ; MD^* ; Susan L. McElroy ; MD^*
• 刊名：Psychiatric Clinics of North America
• 出版年：1999
• 出版时间：1 September 1999
• 年：1999
• 卷：22
• 期：3
• 页码：535-546
• 全文大小：793 K

文摘

It has long been recognized that manic and depressive symptoms may co-occur in manic depressive illness. Episodes occurring during the course of bipolar disorder that consist of symptoms of mania and depression have typically been referred to as mixed states. Mixed mania, broadly denoting mania accompanied by prominent depressive symptoms, is also called dysphoric or depressive mania and has been defined in various ways. Kraepelin noted that ¡°very often we meet temporarily with states which do not exactly correspond either to manic excitement or to depression, but represent a mixture of morbid symptoms of both forms of manic-depressive insanity.?Kraepelin defined mixed states broadly, and he postulated six types, based on various combinations of manic and depressive mood, thought, and behavior: (1) depression with flight of ideas, (2) excited depression, (3) depressive-anxious mania, (4) unproductive mania, (5) inhibited mania, and (6) manic stupor.

According to Goodwin and Jamison, subsequent diagnostic systems were less specific in their treatment of mixed states. For example, both the World Health Organization and the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) simply specified that mixed bipolar disorder be defined as the co-occurrence of mania and depression as defined by their respective nomenclatures. The Vienna Research Criteria represent an exception in providing a valuable description. In the Vienna Research Criteria, a syndrome of unstable mixed states is defined, during which patients experience rapidly alternating affective states, with rapid changes between depressive or anxious, euphoric or expansive, and hostile mood or rapid change between inhibition, agitation, increased drive, or aggression. Sleep disturbances are also required for the diagnosis. In the DSM-IV, mixed states are defined in a much narrower manner, including only patients meeting criteria for both a manic episode and a major depressive episode concurrently.

Some investigators, of the opinion that such a definition is too strict, have proposed dimensional definitions of mixed states. McElroy et al proposed a definition for dysphoric mania or hypomania, requiring the presence of a full manic or hypomanic episode and the simultaneous presence of at least three associated depressive symptoms. This more inclusive definition permits the diagnosis of mixed states in the context of a subsyndromal depressive episode. Akiskal emphasized the need for broader definitions in the field of bipolar disorders¡ªinclusive of various depressive and hypomanic admixtures¡ªto diagnose properly and treat adequately many patients whose mood symptoms do not narrowly conform to prototypical definitions. This article reviews aspects of mixed states with emphasis on clinical characteristics, epidemiology, biologic factors, and treatment issues with the goal of further clarifying some of the uncertainty regarding mixed states. The focus is primarily on the dysphoric manic states, which represent the clinical mixed state most researched during the past decade.