Suppes Trisha, Ostacher Michael
1VA Palo Alto Health Care System,Palo Alto,California,USA.
CNS Spectr. 2017 Apr;22(2):155-160. doi: 10.1017/S1092852917000256.
For the first time in 20 years, the American Psychiatric Association (APA) updated the psychiatric diagnostic system for mood disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Perhaps one of the most notable changes in the DSM-5 was the recognition of the possibility of mixed symptoms in major depression and related disorders (MDD). While MDD and bipolar and related disorders are now represented by 2 distinct chapters, the addition of a mixed features specifier to MDD represents a structural bridge between bipolar and major depression disorders, and formally recognizes the possibility of a mix of hypomania and depressive symptoms in someone who has never experienced discrete episodes of hypomania or mania. This article reviews historical perspectives on "mixed states" and the recent literature, which proposes a range of approaches to understanding "mixity." We discuss which symptoms were considered for inclusion in the mixed features specifier and which symptoms were excluded. The assumption that mixed symptoms in MDD necessarily predict a future bipolar course in patients with MDD is reviewed. Treatment for patients in a MDD episode with mixed features is critically considered, as are suggestions for future study. Finally, the premise that mood disorders are necessarily a spectrum or a gradient of severity progressing in a linear manner is argued.
20年来，美国精神病学协会（APA）首次在《精神疾病诊断与统计手册》第五版（DSM - 5）中更新了情绪障碍的精神科诊断系统。DSM - 5中最显著的变化之一或许是认识到重度抑郁症及相关障碍（MDD）中存在混合症状的可能性。虽然MDD与双相情感障碍及相关障碍现在由两个不同的章节呈现，但在MDD中增加混合特征说明符代表了双相情感障碍和重度抑郁症之间的结构桥梁，并正式认可了在从未经历过轻躁狂或躁狂离散发作的个体中存在轻躁狂和抑郁症状混合的可能性。本文回顾了关于“混合状态”的历史观点以及近期文献，这些文献提出了一系列理解“混合性”的方法。我们讨论了哪些症状被考虑纳入混合特征说明符，哪些症状被排除。还回顾了MDD中的混合症状必然预示MDD患者未来双相病程的假设。对具有混合特征的MDD发作患者的治疗进行了批判性思考，并提出了未来研究的建议。最后，论证了情绪障碍必然是一个以线性方式进展的严重程度的谱系或梯度的前提。
