Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN)

Background: This research derives from the French national multisite collab orative study on the clinical epidemiology of mania (EPIMAN). Our aim is to establish the validity of dysphoric mania along a "spectrum of mixity" ext ending into mixed mania with subthreshold depressive manifestations; to dem onstrate the feasibility of obtaining clinically meaningful data on this en tity on a national level; and to characterize the contribution of temperame ntal attributes and gender in its origin. Methods: EPIMAN involves training 23 French psychiatrists in four different sites, representing four regions of France; to rigorously apply a common p rotocol deriving from the criteria of DSM-IV and McElroy et al.; the use of such instruments as the Beigel-Murphy, Ahearn-Carroll, modified HAM-D; and measures of affective temperaments based on the Akiskal-Mallya criteria; o btaining data on comorbidity, and family history (according to Winokur's ap proach as incorporated into the FH-RDC); and prospective follow-up for at l east 12 months. The present report concerns the clinical and temperamental features of 104 manic patients during the acute hospital phase. Results: Dysphoric mania (DM defined conservatively with fullblown depressi ve admixtures of five or more symptoms) occurred in 6.7%; the rate of dysph oric mania defined broadly (DM, presence of greater than or equal to 2 depr essive symptoms) was 37%. Depressed mood and suicidal thoughts had the best positive predictive values for mixed mania. In comparison to pure mania (0 -1 depressive symptoms), DM was characterized by female over-representation ; lower frequency of such typical manic symptomatology as elation, grandios ity, and excessive involvement; higher prevalence of associated psychotic f eatures; higher rate of mixed states in first episodes; and complex tempera mental dysregulation along primarily depressive, but also cyclothymic, and irritable dimensions; such irritability was particularly apparent in mixed mania at the lowest threshold of depressive admixtures of two-symptoms only . Limitation: In a study involving hospitalized affectively unstable psychoti c patients, it was difficult to assure that psychiatrists making the clinic al diagnoses would be blind to the temperamental measures. However, bias wa s minimized by the systematic and/or semi-structured nature of all evaluati ons. Conclusions: Mixed mania, defined cross-sectionally by the simultaneous pre sence of at least two depressive symptoms, represents a prevalent and clini cally distinct form of mania. Subthreshold depressive admixtures with mania actually appear to represent the more common expression of dysphoric mania . Moreover, an irritable dimension appears to be relevant to the definition of the expression of mixed mania with the lowest threshold of depressive s ymptoms. Neither an extreme, nor an endstage of mania, "mixity" is best con ceptualized as intrusion of mania into its "opposite" temperament - especia lly that defined by lifelong depressive traits - and favored by female gend er. These data suggest that reversal from a temperament to an episode of "o pposite" polarity represents a fundamental aspect of the dysregulation that characterizes bipolar disorder. In both men and women with hyperthymic tem perament, there appears "protection" against depressive symptom formation d uring a manic episode which, accordingly, remains relatively "pure". Becaus e men have higher rates of this temperament, pure mania is overrepresented in men; on the other hand, the depressive temperament in manic women seems to be a clinical marker for the well-known female tendency for depression, hence the higher prevalence of mixed mania in women. (C) 1998 Elsevier Scie nce BN. All rights reserved.