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

163 Agitated depression: spontaneous and inducedIn 1888, Clouston from Edinburgh described excited motor melancholia, a termthat stresses the excitatory nature of the agitation. In 1899, a monograph appearedon Mixed States of Manic Depressive Insanity by Kraepelin’s pupil Weygandt, basedon a study carried out in Heidelberg. He focused on only three types of mixedstate: manic stupor, unproductive mania, and agitated depression (agitirteDepression) with depressed mood, psychomotor excitement, and flight of ideas.This is the first time to the authors’ knowledge that the term agitated depressionwas used. Weygandt pointed out the similarity with agitated forms of involutionalmelancholia and, similar to Lange (1928), Specht (1908), and Thalbitzer (1908),considered melancholia agitata a mixed state of manic-depressive insanity, incontrast to Wernicke’s (1906) school of thought, which viewed it as a form ofanxiety psychosis.Stransky, in 1911, wrote in Aschaffenburg’s handbook that the anxiety ofmelancholia agitata, or depression with anxious excitation, does not containmixed elements. He also remarked that inhibition of thought is not always presentin manic stupor, and motor inhibition does not affect facial expressiveness. He didnot consider dysphoric mania a mixed state because the basic mood is an expansiveone.In 1928, Lange discussed mixed states and noted that classic, pure clinicalpictures of mania or depression are rarely found. He recognized melancholiaagitata as a mixed state. Among the mixed states, he described a form that henamed excitable depression (anregbare Depression), marked by inner anxiety andlack of motor agitation. Some patients present with inhibition of thought, andsome have flight of ideas. If they are somehow stimulated, these patients showmotor agitation and exaggerated expressive movements. Lange pointed out thatin many patients depressive mood and motor inhibition coexist with hyperactivityof thought.Interest in mixed states was waning by the 1920s. In 1923, Jaspers wrote that theissue of mixed states ‘‘did not have any further development, and this was verynatural since elements of understanding psychology had been considered asobjective components and factors of psychic life.’’ Schneider (1962) was morehasty: ‘‘We no longer believe in manic-depressive mixed states. Anyway, what maylook like this is a change or a switch, if it pertains to Cyclothymia at all.’’On purely psychopathologic grounds, without any knowledge of the underlyingneuropathologic alterations, it is difficult to make significant progress in this field.The present interest in mixed states is due to the adverse effects of antidepressantsand the beneficial effects of lithium, anticonvulsant mood stabilizers, and atypicalantipsychotics.At present, agitated depression has lost its status as a mixed state, not only in theDSM system, but also in the view of most psychiatrists worldwide. Apart from the