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Dr. Goldberg: DSM 5, Mixed States, and NOS
RogueFemale2 posted:
Dear Dr. Goldberg:

I see from news reports that DSM 5 was at last released (this morning, I believe)!

As someone saddled with that problematic NOS label, owing to clear but sub-total manic features during my depressive episodes (or vice versa), I am quite curious to hear your impressions about how DSM 5 deals with the mixed episode problem--that is, the fact that a mixed episode has in the past been defined too narrowly. I believe I read somewhere that Bipolar Mixed will no longer be included as a separate diagnostic category. Is that in fact the case? What's the latest on how the psychiatric community will interpret the mixed features that are so common, whether in full-blown form or--more commonly--if present only to a lesser degree?

Thanks for your insight!

Joseph F Goldberg, MD responded:
Dear Karen,

DSM-IV technically, and arbitrarily, defines a "mixed episode" as the occurrence of a full manic (not hypomanic) episode plus a full major depression in people with bipolar I (not II or NOS) disorder, lasting for at least a week. DSM-5 has eliminated this designation and instead created the "specifier" term "with mixed features" to be applied to a full manic or hypomanic or depressive episode with some elements of the opposite pole, but falling short of a full episode of the opposite pole. DSM-5 also will for the first time "allow" for the designation of "with mixed features" in people with unipolar depression who have never had a full manic or hypomanic episode -- furthering the perspective that the line between unipolar and bipolar disorders is often fuzzy.

Currently, frankly, most practitioners are quite unaware of these technical designations and tend to take a more, let's say, "impressionistic" approach to diagnosing mixed states -- I don't think very many are even aware of the DSM-IV criteria, for example. The value may be a greater recognition of the co-occurrence of manic/hypomanic and depressive symptoms arising simultaneously; the hazard will be sloppy, casual diagnoses based on recognizing only one or two symptoms without imposing at least some degree of rigor on identifying symptoms that are present versus absent.

The changes to DSM-5 in the mood disorders section are far less sweeping than many people had hoped for, and are more a reshuffling of the symptom deck (e.g., in diagnosing mania or hypomania, increased energy is being elevated to an "A" [necessary> criterion than a "B" criterion), rather than any keen new insights or great scientific advances. So, I would not expect DSM-5 to create any big changes in how patients with mood disorders are recognized or treated. IMHO.

Dr. G.

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Joseph F. Goldberg, MD, is a Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. He also maintains a private prac...More

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