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. 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. A depressive mixed state in a patient, even in the absence of discrete periods of mania or
hypomania, effectively rules out unipolar depression. Nevertheless, the DSM-5's narrower definition of mixed episodes may result in fewer patients meeting mixed criteria compared to
DSM-IV. 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. 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 channeled 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 being touched upon, rather than a singular one. == Treatment ==