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

165 Agitated depression: spontaneous and inducedhave expressed disenchantment with the official view, proposing agitated depressionas a mixed form of affective disorders. The DSM system opposes this viewbecause agitated depressives do not simultaneously meet the criteria for mania andmajor depression. Schatzberg (1998) findsa number of key differences in the seeming overlap of symptoms: manic or mixed patientsdemonstrate a decreased need for sleep while agitated depressives complain of insomnia. Thebipolar patient has increased thinking and increased speech, while agitated depressives haveespecially depressive ruminations and decreased speech. The increased motor activity of theagitated depressive is purposeless and unpleasant, while in bipolar patients it is often aimed atsome grandiose goal.One could object that the state of depression inevitably modifies the excitatorysymptoms and vice versa. The DSM system not only conceives a mixed state as anoverlap of manic and depressive symptoms, but also requires the rare simultaneouspresence of a full manic and a full depressive syndrome. The symptoms ofagitated depression are of a different kind, as their response to treatment demonstrates.The current interest in this topic stems from the clinical observation thatantidepressant drugs exacerbate agitation, insomnia, anxiety, and suicidal ideas inthese patients (Koukopoulos et al., 1992).The parallelism between drive, mood, and thoughtNormal human behavior, and especially behavior during affective episodes, hascreated the impression that good mood is allied with good drive and fluentthinking and vice versa. Hypomania with euphoric mood with hyperactivity,and depression with retardation are typical examples of this parallelism. Cullen(1785b), who ascribed the state of excitement and state of collapse (asthenia,depression) to changes in nervous power, remarked that ‘‘these different statesof the brain are expressed in the body by strength or debility, alacrity or sluggishness;and in the mind by courage or timidity, gaiety or sadness.’’This bipolarity is certainly a clinical reality, but the mixture of elements ofexcitement with elements of depression (inhibition) creates clinical pictures calledmixed states. These elements manifest themselves as symptoms and the clinicalpictures are syndromic sets of symptoms. As Goodwin and Jamison (1990) state,‘‘mixed states can be broadly defined as the simultaneous presence of depressiveand manic symptoms.’’ Nevertheless, physicians cannot help associating themwith an underlying, analogous physiopathologic alteration that they try to modifyby treatment. Part of the problem lies in the term depression, which probablydisplaced melancholia because it was thought to convey the meaning of a state ofmood rather than that of a disease entity. Clinicians and laypersons automatically