{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T17:50:25Z","timestamp":1792000225910,"version":"4.4.0"},"reference-count":44,"publisher":"Cambridge University Press (CUP)","issue":"2","license":[{"start":{"date-parts":[[2016,11,21]],"date-time":"2016-11-21T00:00:00Z","timestamp":1479686400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/www.cambridge.org\/core\/terms"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["CNS Spectr."],"published-print":{"date-parts":[[2017,4]]},"abstract":"<jats:p>This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the <jats:italic>Diagnostic and Statistical Manual of Mental Disorders<\/jats:italic>, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin\u2019s original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification\u2014with mood, ideation, and activity as key axes\u2014and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.<\/jats:p>","DOI":"10.1017\/s1092852916000614","type":"journal-article","created":{"date-parts":[[2016,11,21]],"date-time":"2016-11-21T10:15:16Z","timestamp":1479723316000},"page":"126-133","source":"Crossref","is-referenced-by-count":26,"title":["Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications"],"prefix":"10.1017","volume":"22","author":[{"given":"Gin S","family":"Malhi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yulisha","family":"Byrow","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"Outhred","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristina","family":"Fritz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"56","published-online":{"date-parts":[[2016,11,21]]},"reference":[{"key":"S1092852916000614_ref23","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2011.11.024"},{"key":"S1092852916000614_ref26","doi-asserted-by":"publisher","DOI":"10.1177\/0004867415585858"},{"key":"S1092852916000614_ref20","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-5618.2007.00558.x"},{"key":"S1092852916000614_ref6","volume-title":"Diagnostic and Statistical Manual of Mental Disorders","year":"1980"},{"key":"S1092852916000614_ref12","doi-asserted-by":"publisher","DOI":"10.1016\/S0165-0327(97)01446-8"},{"key":"S1092852916000614_ref25","article-title":"Mixed depression in bipolar disorder: prevalence rate and clinical correlates during naturalistic follow-up in the Stanley Bipolar Network","author":"Miller","journal-title":"Am J Psychiatry"},{"key":"S1092852916000614_ref2","first-page":"381","volume-title":"Clinical Psychiatry: A Textbook for Students and Physicians, Abstracted and Adapted from the 7th German Edition of Kraepelin\u2019s Lehrbuch Der Psychiatrie","author":"Diefendorf","year":"1907"},{"key":"S1092852916000614_ref38","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2014.06.039"},{"key":"S1092852916000614_ref44","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2013.04.032"},{"key":"S1092852916000614_ref33","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2013.08.037"},{"key":"S1092852916000614_ref13","doi-asserted-by":"publisher","DOI":"10.1016\/S0165-1781(01)00258-X"},{"key":"S1092852916000614_ref17","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0447.2007.00963.x"},{"key":"S1092852916000614_ref14","doi-asserted-by":"publisher","DOI":"10.1016\/S0193-953X(05)70095-2"},{"key":"S1092852916000614_ref19","doi-asserted-by":"publisher","DOI":"10.1111\/nyas.13048"},{"key":"S1092852916000614_ref40","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.15cs09841"},{"key":"S1092852916000614_ref1","doi-asserted-by":"crossref","DOI":"10.1037\/10789-000","volume-title":"Clinical psychiatry: a text-book for students and physicians","author":"Kraepelin","year":"1904"},{"key":"S1092852916000614_ref16","doi-asserted-by":"publisher","DOI":"10.1111\/acps.12140"},{"key":"S1092852916000614_ref15","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.bp.112.124404"},{"key":"S1092852916000614_ref35","doi-asserted-by":"publisher","DOI":"10.3390\/ijms17020241"},{"key":"S1092852916000614_ref18","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2014.09.026"},{"key":"S1092852916000614_ref32","doi-asserted-by":"publisher","DOI":"10.1177\/0004867415607644"},{"key":"S1092852916000614_ref41","doi-asserted-by":"publisher","DOI":"10.1177\/0004867415617657"},{"key":"S1092852916000614_ref9","volume-title":"Diagnostic and Statistical Manual of Mental Disorders","year":"2000"},{"key":"S1092852916000614_ref36","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.14m09410"},{"key":"S1092852916000614_ref30","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.159.6.968"},{"key":"S1092852916000614_ref10","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2015.01.053"},{"key":"S1092852916000614_ref11","doi-asserted-by":"publisher","DOI":"10.1016\/S0165-0327(98)00113-X"},{"key":"S1092852916000614_ref34","doi-asserted-by":"publisher","DOI":"10.1016\/j.comppsych.2014.01.012"},{"key":"S1092852916000614_ref28","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-5618.2010.00824.x"},{"key":"S1092852916000614_ref39","unstructured":"National Institute for Health and Care Excellence. 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