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

167 Agitated depression: spontaneous and inducedcases without psychomotor agitation, the inner unrest is the main symptom. Thisinner agitation makes the patient very anxious and fearful, hence the condition isvery difficult to distinguish from anxiety, as will be discussed later. The innerunrest manifests itself with irritability or feelings of unprovoked rage, racing orcrowded thoughts, talkativeness, and dramatic descriptions of psychic pain. Atypical feature of agitated depression is the absence of retardation in speech andmovement; yet, there is an inhibition of purposeful activity, which in more severecases is nearly complete. In mild forms, the patient is quite active and sometimesanxiously hyperactive. Complete anhedonia and lack of interest are marked in allcases. Psychic pain is particularly severe and is often accompanied by suicidalthoughts and impulses. In more severe forms, the psychic pain is constant while inmilder cases there is lability of mood and emotional reactivity. Early insomnia,often sustained by racing thoughts, is common.Clinical forms of agitated depressionThe following clinical forms can be distinguished.Psychotic agitated depressionThese patients present with depressed mood, restlessness, anxiety, delusions ofguilt and persecution, hypochondriacal ideas and, often, strong suicidal impulses.The similarity of this syndrome with that of other psychotic depressions thatdo not present with motor agitation is notable (Nelson and Bowers, 1978;Frances et al., 1981). In the latter, the patient lies silently in bed. On questioning,the patient describes an intense inner agitation, often located in the chest, abdomen,or head. A young patient said he felt ‘‘blades ripping through his guts’’ – a similarimage to that employed by Hippocrates. Some patients describe racing or crowdedthoughts.Agitated depression (non-psychotic) with psychomotor agitationPatients do not present with delusions or hallucinations. The picture is dominatedby depression, anxiety, and motor agitation similar to that described in the RDCcriteria (Spitzer et al., 1978). The patient may complain of crowded thoughts.Minor agitated depressionThe patient does not appear outwardly agitated, or the motor agitation is limited,but there is total lack of retardation. The patient speaks fluently and moves normally.The patient complains of intense inner agitation. The psychic pain of the patientis relentless, and the patient feels unable to perform normal tasks or enjoyanything. Frequently the patient complains of racing or crowded thoughts