A Guide to DSM-5

Bret S. Stetka, MD; Christoph U. Correll, MD

May 21, 2013

Mixed-Mood Specifier

The Change

In DSM-5, the new specifier "with mixed features" can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (previously called "NOS") and MDD. The change was made to reflect the clinical phenomenon of "mixed" mood states that do not meet full criteria for a mixed episode of bipolar I disorder, reflected by co-occurrence of full mania and MDD. Thus, the predominant mood can either be depression, mania, or hypomania. The secondary mood can be "subclinical," in that some aspects of the secondary mood diagnosis would be present but not sufficiently so to make a formal diagnosis.

Patients who meet the full criteria for both depression and mania together will be labeled as having a manic episode with mixed features owing to the clinical severity of mania. To be diagnosed with the "with mixed features" specifier, a person has to meet the full criteria for one mood (depression, mania or hypomania) and have 3 or more symptoms of the other mood pole. Symptoms that are common to both mood poles (mania/hypomania and depression) are not included in the possible criteria for a mixed mood. These include distractibility, irritability, insomnia, and indecisiveness.

For someone with predominant mania or hypomania, at least 4 of the following depressive symptoms must be present nearly every day during the most recent week of a manic episode or during the most recent 4 days of a hypomanic episode: depressed mood, diminished interest or pleasure, slowed physical and emotional reaction, fatigue or loss of energy, and recurrent thoughts of death. For someone with predominant depression, at least 3 of the following symptoms must be present nearly every day during the most recent 2 weeks of the major depressive episode: elevated mood, inflated self-esteem, decreased need for sleep, and an increase in energy or goal-directed activity.

The Implications

Until now, mixed mood, which is commonly seen in clinical practice, could only be diagnosed in bipolar I disorder, indicating the co-occurrence of full criteria for mania and MDD. The addition of a mixed-mood specifier to bipolar I disorder, bipolar II disorder, bipolar disorder NED, and MDD follows the dimensional approach of DSM-5 and allows clinicians to formally diagnose and treat subthreshold expressions of the admixture of depressive symptoms to mania or hypomania as well as of subthreshold mania-like symptoms to depression.

This is clinically relevant, because the availability of this specifier will sharpen clinicians' view on the dimensional overlap of such symptom admixtures, which have clear relevance for patients' functioning and clinicians' treatment selection. However, critics have raised the concern that classifying MDD with 3 relevant mania-like symptoms as a depressive disorder rather than a bipolar spectrum disorder may be misleading and that it is unclear what exact treatment recommendations are to be made for patients with MDD and mixed manic or hypomanic features or for patients with bipolar I or II disorder and mixed depressive symptoms.