Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

7Agitated depression: spontaneous andinducedAthanasios Koukopoulos, Gabriele Sani, Matthew J. Albert,Gian Paolo Minnai, and Alexia E. KoukopoulosCentro Lucio Bini, Center for the Treatment and Research of Affective Disorders, Rome, ItalySometimes it is more ‘‘inward anxiety and trembling,’’ a painful tension; sometimesit is an anxious restlessness, which finds an outlet in the most varied gestures,in states of violent excitement, and in heedless attempts at suicide. These moodsare most frequently found in the periods of transition between states of depressionand mania; they are, therefore, probably most correctly regarded as mixed states ofdepression and manic excitability (Kraepelin, 1913).The inner unrest is the constant thing, while the motor unrest is variable (Lewis,1934).IntroductionThe greatest shortcoming of psychiatry is the near complete lack of knowledgeof the pathophysiological processes underlying our clinical entities. Kahlbaum(1863) was the first to distinguish clearly between symptomatic clinical picturesand the disease process that was responsible for them. Kraepelin took this concepta step further and based the idea of the disease process (Vorgang) on the conditionsunder which the disease starts, its course, and outcome. This method of clinicalpsychiatry achieved the separation of manic-depressive illness from dementiapraecox. But the real identity of the pathophysiological process underlying theclinical entities still remains obscure. Our psychiatric nosology is entirely based onphenomenology and course.We do, however, have important tools at our disposal, which are the psychoactivedrugs. The response to these drugs not only indicates the pharmacological actionof the drug itself but also provides important clues about the nature of theneuropathologic process upon which the drug acts. Thus far we have not fullyprofited from these responses to enhance our understanding of clinical entitiesand improve our nosology. On the contrary, clinical entities are taken as firm# Cambridge University Press, 2005.