Dysphoric Mania in Bipolar Disorder

Episodes With Mixed Features

Dysphoria
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Dysphoric mania is the term that was used in the past for what we now call an episode with mixed features, though some health professionals may still use this term. Around 40 percent of people who are diagnosed with bipolar disorder experience episodes with mixed features.

Understanding Dysphoria

Dysphoria is a word that turns up often in the literature describing bipolar disorder.

By definition, dysphoria is a profound state of unease or a general dissatisfaction with life. From a clinical standpoint, dysphoria suggests a serious depressive episode accompanied by a manic psychosis (the loss of external reality). As such, it is not considered a reasonable response to an event or stimulus but rather a feature of an ever-changing cycle in moods that can lead, often inexplicably, to profound episodes of emotional dysfunction.

Simply put, it is a disconnect in emotion that has little or no relation to what is actually going on.

Dysphoria is not only associated with bipolar disorder, it's associated with other psychiatric and nonpsychiatric conditions. These can include schizophrenia, gender dysphoria, illicit drug use, and even premenstrual cycles (premenstrual dysphoric disorder).

Diagnosing Dysphoric Mania

Dysphoric mania is not a term we use often these days but it's one that can help clarify how dysphoria applies to bipolar disorder.

In this instance, a bipolar person might concurrently exhibit signs of mania along with signs of depression. Today, this is described as a mixed feature of bipolar disorder.

People with dysphoric mania or mixed features will experience at least three symptoms of mania with a depressive episode or at least three symptoms of depression with a manic or hypomanic episode.

The symptoms can be wide-ranging but are ultimately characterized by a contradiction in action and state, such as a person who is frenetic and loud even if he or she is emotionally drained and depressed.

Symptoms of mania can include:

  • Grandiosity and exaggerated feelings of self-importance
  • Hallucinations or delusions
  • Racing thoughts
  • Rapid, frenzied speech (pressured speech)
  • Recklessness and risk-taking behavior
  • Aggressiveness or irritability
  • Needing less sleep or not feeling tired
  • Purposeless, often relentless, activity (psychomotor agitation)

Symptoms of depression, by contrast, can include:

  • Inexplicable crying or long periods of sadness
  • Curtailed sleep or appetite
  • Thoughts of death or suicide ( suicidal ideation)
  • Feelings of worthlessness or guilt
  • Lethargy
  • Losing interest in activities once enjoyed
  • Social isolation
  • Indecisiveness or confusion

When these ranges of symptoms co-occur, the state can then be broadly described as being dysphoric, or what we now call a manic or hypomanic episode with mixed features, or a depressive episode with mixed features.

Treating Dysphoric Mania

It's important to remember, first and foremost, that dysphoria is not a condition. It is a symptom in the same way that euphoria (intense feelings of happiness or well-being) is a symptom.

As such, you do not "treat" dysphoria per se, but the underlying condition.

With that being said, dysphoric/mixed episodes are often difficult to treat because the majority of drugs used to treat bipolar disorder address either depression or mania, not both. Antipsychotic drugs by themselves or along with lithium or anticonvulsants may be effective, but the process of finding the right combination can take time. Oftentimes, treatment is a process of trial-and-error.

When dysphoria occurs in relation to a mixed episode, the risk of suicide is considered high. In people having suicidal thoughts or those whose behavior is erratic and intensifying, hospitalization may be needed.

Treatment Is Essential

Dysphoric mania is a serious disorder that needs immediate and ongoing treatment and support. If you or a loved one are experiencing symptoms of a mixed bipolar episode, seek help as soon as possible. Early intervention is often key to treatment success.

Sources:

Fagiolini A, Coluccia A, Maina G, et al. Diagnosis, Epidemiology and Management of Mixed States in Bipolar Disorder. CNS Drugs. 2015;29:725. doi:10.1007/s40263-015-0275-6.

Hu J, Mansur R, McIntyre RS. Mixed Specifier for Bipolar Mania and Depression: Highlights of DSM-5 Changes and Implications for Diagnosis and Treatment in Primary Care. The Primary Care Companion for CNS Disorders. 2014;16(2):PCC.13r01599. doi:10.4088/PCC.13r01599.