Pure and mixed manic subtypes: a review of diagnostic classification and validation

Authors


  • FC has received grants/research support from Pfizer, Organon, Corcept and NARSAD; has participated in advisory boards for Shire; has been a past speaker for Pfizer; and has owned stock in Pfizer. LNY has received grants/research support from AstraZeneca, Janssen, Eli Lilly & Co., GlaxoSmithKline, Servier, Novartis, Bristol-Myers Squibb; has participated in advisory boards for AstraZeneca, Janssen, Eli Lilly & Co., GlaxoSmithKline, Servier, Novartis, Bristol-Myers Squibb, Wyeth; and has served on the speakers bureau for AstraZeneca, Janssen, Eli Lilly & Co., GlaxoSmithKline, Servier, Ranbaxy, Sanofi. MB has received grants/research support from the Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Geelong Medical Research Foundation, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Organon, Novartis, Mayne Pharma, Servier; served as a consultant for AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Cilag, Lundbeck, Pfizer and has served on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Cilag, Lundbeck, Organon, Pfizer, Sanofi Synthelabo, Solvay, Wyeth. PG has no reported conflict of interest.

Frederick Cassidy, MD, Associate Professor of Psychiatry, Duke University Medical Center, Box 3414, Durham, NC, 27710, USA. Fax: 919 575 7079; e-mail: cassi002@mc.duke.edu

Abstract

Objective:  To review issues surrounding the diagnosis and validity of bipolar manic states.

Methods:  Studies of the manic syndrome and its diagnostic subtypes were reviewed emphasizing historical development, conceptualizations, formal diagnostic proposals, and validation.

Results:  Definitions delineating mixed and pure manic states derive some validity from external measures. DSM-IV and ICD-10 diagnosis of bipolar mixed states are too rigid and less restrictive definitions can be validated. Anxiety is a symptom often overlooked in diagnosis of manic subtypes and may be relevant to the mixed manic state. The boundary for separation of mixed mania and depression remains unclear. A ‘pure’ non-psychotic manic state similar to Kraepelin’s ‘hypomania’ has been observed in several independent studies.

Conclusions:  Issues surrounding diagnostic subtyping of manic states remain complex and the debates surrounding categorical versus dimensional approaches continue. To the extent that categorical approaches for mixed mania diagnosis are adopted, both DSM-IV and ICD-10 are too rigid. Inclusion of non-specific symptoms in definitions of mixed mania, such as psychomotor agitation, does not facilitate and may hinder the diagnostic separation of pure and mixed mania. The inclusion of a diagnostic seasonal specifier for DSM-IV, which is currently based on seasonal patterns for depression might be expanded to include seasonal patterns for mania. Boundaries between subtypes may be ‘fuzzy’ rather than crisp, and graded approaches could be considered. With the continued development of new tools, such as imaging and genetics, alternative approaches to diagnosis other than the purely symptom-centric paradigms might be considered.

Ancillary