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Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications

Published online by Cambridge University Press:  21 November 2016

Gin S Malhi ,
Yulisha Byrow ,
Tim Outhred  and
Kristina Fritz
Gin S Malhi*
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Yulisha Byrow
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Tim Outhred
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
Kristina Fritz
Affiliation:
Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
*
*Address for correspondence, Professor Gin S. Malhi, Academic Department of Psychiatry, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia. (Email: [email protected])
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Abstract

This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin’s original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification—with mood, ideation, and activity as key axes—and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.

Keywords

Agitated depressionbipolar disorderdepressionDSM-5mixed featuresmixed maniamixed states
Type
Opinions
Information
CNS Spectrums , Volume 22 , Issue 2: Theme: Mixed features in major depressive episodes , April 2017 , pp. 126 - 133
Copyright
© Cambridge University Press 2016 

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