title: Pure and mixed manic subtypes: a review of diagnostic classification and validation.
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.
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA. cassi002@mc.duke.edu
authors.forename: Frederick
authors.initials: F
authors.lastname: Cassidy
authors.forename: Lakshmi N
authors.initials: LN
authors.lastname: Yatham
authors.forename: Michael
authors.initials: M
authors.lastname: Berk
authors.forename: Paul
authors.initials: P
authors.lastname: Grof
mesh_terms: D000927:Anticonvulsants / Q000627:therapeutic use; D018692:Antimanic Agents / Q000627:therapeutic use; D001008:Anxiety Disorders / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology; D015415:Biomarkers / Q000097:blood; D001714:Bipolar Disorder / Q000145:classification / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology; D039721:Diagnostic and Statistical Manual of Mental Disorders; D006801:Humans; D038801:International Classification of Diseases; D011569:Psychiatric Status Rating Scales
chemical_list: D000927:Anticonvulsants; D018692:Antimanic Agents; D015415:Biomarkers