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

161 Agitated depression: spontaneous and induceddepressive reaction.Theterminvolutional melancholia remained in use for a long time,and it was still present in DSM-II (American Psychiatric Association, 1968). It wasabandoned as the name of a separate entity in DSM-III, and the term melancholia wasrelegated to a subclassification at the fifth digit: major depressive episode with melancholia:‘‘a term from the past in this manual used to indicate a typically severe formof depression that is particularly responsive to somatic therapy.’’ This subclassificationmay be seen as an effort to preserve the oldest term in psychiatry. Certainly thesyndrome described here would have been called melancholia simplex in the past, butit does not bring out the dramatic picture of anxiety, fear, rage, and delusional ideasthat have traditionally been associated with the term melancholia and are still seen inclinical practice today. The term melancholia would have better suited the formdescribed as major depressive episode with psychotic features.Another key shift in DSM-III was the introduction of the term bipolar disorderin place of manic-depressive illness. In this regard, the authors fully share Jamison’s(1995) view:the word ‘‘bipolar’’ seems to me to obscure and minimize the illness it is supposed to represent... and it minimizes the importance of mixed manic and depressive states, conditions thatare common, extremely important clinically, and lie at the heart of many of the criticaltheoretical issues underlying this particular disease.Mixed affective states and agitated depressionMany authors clearly described mixed affective states well before Kraepelin,including Lorry (1765), mania melancholica; Heinroth (1818), melancholiamixta catholica, melancholia furens; Guislain (1852), melancholie maniaque;and Griesinger (1845), melancholia with persistent excitement of the will.Kraepelin conceptualized and described mixed states in a systematic way. Hemade them the cornerstone of the manic-depressive entity. In conceiving themanic-depressive mixed states, Kraepelin started from the excitement or depressionof the three domains of psychic life: (1) the intellect (train of thought ratherthan its contents); (2) mood; and (3) volition, expressed in psychomotoractivity.Distinguishing between the foregoing three domains of psychic life has been aconstant idea in western culture and stems both from Plato’s (1994) three elementsof the soul – rational, emotional, and appetitive – and from Aristotle’s (1970)psychic powers (faculties) – rational, sensory, and appetitive. Via the equivalentfaculties of Kant (1800) – the rational, the sense of pleasure or pain, and theappetitive faculty – these distinctions have had a great influence on psychiatry and