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

159 Agitated depression: spontaneous and inducedaffective states. The first and one of the best descriptions of agitated melancholia isfound in Diseases II by Hippocrates (1988):Anxiety: the patient feels something like a thorn stinging his innards. He flees from light and frompeople, loves the dark and he is caught by panic ... he is terrified and sees frightening visions,dreadful nightmares and sometimes dead people. The disease attacks most people in spring.Aretaeus (1735) stated that melancholics suffer from ‘‘violent rage and sadness andawful dejection.’’ The nosologists of the eighteenth century, such as Boissier de laCroix de Sauvages (1768) and Cullen (1785a), classified among the melancholiassuch forms as melancholia phrontis, melancholia moria, melancholia saltans, melancholiaerrabunda, melancholia silvestris, melancholia furens, and melancholiaenthusiastica.Heinroth (1818) abandoned the intellectualistic conception of melancholia andconsidered it a disease of the mood (Gemüth). In his classification of the morbidconditions of the soul, he placed melancholia metamorphosis among states ofexaltation (hypersthenia), whereas among the manias he listed melancholia saltans.Among the mixtures of exaltation with weakness (hyperasthenia), he cited ecstasismelancholica, melancholia furens, mania melancholica, and athymia melancholicomaniaca(timidity with melancholia and rage).Griesinger (1845) considered melancholia a disease of the affects (intense,altered emotional states), distinguishing them into two major classes: (1) theexpansive, affirmative ones, such as happiness, joy, and hope; and (2) the depressive,negative ones, such as dejection, sadness, and fear. He placed rage in anintermediate position between the two kinds of affect. Griesinger described,among the states of mental depression, melancholia in the strict sense, melancholiawith destructive tendencies, and melancholia with persistent excitement of thewill. As noted earlier, he had the great insight that processes of cerebral excitationmay be the cause of psychic pain and depression. Griesinger saw the cause ofmelancholia in a state of hyperesthesia, and Kahlbaum (1863) saw the cause in astate of hyperthymia. As Schmidt-Degenhardt (1983) points out, there is anevident contrast with the concept of depression, which implies suppression orweakening of brain processes.The first to use the term melancholia agitans was Richarz in 1858 in hisremarkable work On the Nature and Treatment of Melancholia with Excitement(Melancholia Agitans), in which he differentiates ‘‘racing thoughts’’ of agitatedmelancholia from the flight of ideas of mania. He introduced the term melancholiaagitans instead of melancholia activa because it better suited the aimless restlessnessof the patient. More commonly termed as melancholia agitata, it waswidely employed in the second half of the nineteenth century, and it was laterreplaced by Angstmelancholie and eventually agitated depression.