Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

380 G. Sachs and M. GravesDSM-IV→Clinical status• DSM-IVAcute episode criteria• Depression• Hypomania• Mania• Mixed episodePartial remissionRecovered• Clinical statusAcute episode criteria• Depression• Hypomania• Mania• Mixed episodeContinued symptomaticRecoveringRecoveredRougheningIf DSM criteria for current episode are positiveAssociated symptomsof mania or depressionAssigned statusMajor depression ≥ 5 moderate DepressionMania ≥ 3 moderate ManiaHypomania ≥ 3 moderate HypomaniaMajor depression and mania≥ 3 moderate for mania and≥ 5 moderate for depressionMixedIf DSM criteria for current episode are negative"Recovered"from last acute episodeAssociated symptomsof mania or depressionAssigned statusNo ≥ 3 moderate symptoms Continued symptomaticNo ≤ 2 moderate symptoms RecoveringYes, if "recovering" ≥ 8 consecutive ≤ 2 moderate symptoms RecoveredweeksYes ≥ 3 moderate symptoms RougheningFig. 17.5Mapping DSM-IV to eight operationally defined clinical states. DSM-IV, Diagnostic andStatistical Manual of Mental Disorders, 4th edn.and randomizing only those subjects who have at least one prospectively observedphase change during any month. Subjects should be excluded who meet criteria forsecondary rapid cycling (see definitions and Table. 17.2).The difficulties in determination of mood state and cycle rate are magnified as thetime period being assessed becomes briefer. This problem may be better managed byavoiding fine but unreliable measurement of brief changes in mood. It is likely that