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

166 A. Koukopoulos et al.relate such a state of depressed mood to lower activity of the nervous system, asCullen did, and physicians today prescribe antidepressants to most patients wholook and behave depressed, just as they prescribe antimanic medication for thosewho behave in an excited way. This concept of depression being caused by lowernervous activity is also borne out by the medical terms and popular expressions fordespondent mood in most languages: like the Latin depressio, theGermanniedergedrückt,theEnglishdowncast or down in the dumps, the French abattement, theSpanish abatido, andtheItalianessere giù, theyallimplybeinglow.Nosologyandtherapy of the so-called functional psychoses can be based only on their phenomenology,course, and outcome. The extensive use of effective psychotropic drugs,however, sheds new light and provides meaningful information on the underlyingneurophysiologic conditions.There is important clinical evidence, in fact, that excitatory brain processes maycause despondent mood, anxiety, and symptoms of inhibition. Stages II and III ofmania, as described by Carlson and Goodwin (1973), with their dysphoric mood,panic, and hopelessness, are a perfect example of a condition that phenomenologicallylooks like a mixed state but neurophysiologically is a purely manic state,and useful treatments are exclusively antimanic.The same applies to dysphoric mania, which is still considered a mixed state(Secunda et al., 1987; Post et al., 1989; McElroy, 1997). The useful treatments areantimanic ones, and typically, under their effect, euphoria replaces dysphoriabefore the patient becomes euthymic or depressed. A similar phenomenon mayoccur between excitement and psychomotor inhibition. In manic stupor, there isno inhibition of thought, as Kraepelin believed. The patient does not speak, butwhen he or she recovers, the patient discloses that there were so many thoughts inhis or her head racing so fast that the patient could not utter them. Also in the fewcases of mania with poverty of ideas that the authors have seen, the patients havereported that their heads were so full of thoughts that they could not express themor hold a conversation. As with mood in dysphoric mania, here too the inhibitorysymptoms are solely due to an increase in the levels of excitement, and treatment isexclusively antimanic. Should they really be considered mixed states?The case of agitated depression is different. As discussed subsequently, elementsof clear excitement are bound together with authentic depressive elements. It isironic that today agitated depression has lost its status as a mixed state, whereasmanic stupor and dysphoric mania are still considered as such.Clinical picture of agitated depressionDepressed anxious mood and inner, psychic agitation dominate the clinicalpicture. Psychomotor agitation is present in many cases, but not in all. In the