title: Toward a clinical delineation of dysphoric hypomania - operational and conceptual dilemmas.
abstract: OBJECTIVE
  Unlike dysphoric mania, we are unaware of any formal studies of dysphoric hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states.
  
  
  METHODS
  In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (> or =2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric hypomania had to last at least 1 week.
  
  
  RESULTS
  Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) 'pure' BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH.
  
  
  CONCLUSIONS
  The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.
authors.affiliation: International Mood Center, University of California at San Diego, La Jolla, 92161, USA. hakiskal@ucsd.edu
authors.forename: Hagop S
authors.initials: HS
authors.lastname: Akiskal
authors.forename: Franco
authors.initials: F
authors.lastname: Benazzi
mesh_terms: D000328:Adult; D000553:Ambulatory Care; D001714:Bipolar Disorder / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology*; D015897:Comorbidity; D003865:Major Depressive Disorder / Q000453:epidemiology; D003937:Diagnosis, Differential; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D011595:Psychomotor Agitation / Q000453:epidemiology