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

168 A. Koukopoulos et al.Table 7.1 Minor agitated depressionPatient displays: Patient complains of: Partner reports:Depressed mood Anxiety Continuous complainingPsychic agitation Inner tension Occasional overt expression ofirritabilityVivacious facial expression Muscular tension, subjectivefeelings of irritability andunprovoked feelings of rageDramatic descriptions of Crowded or racing thoughts Occasional sexual hyperactivitysufferingLack of retardationEarly or middle insomniaSpells of weepingSuicidal ideas and impulsesTalkativenessHigh diastolic blood pressureEmotional labilityImpulsive suicidal attempts(Table 7.1). We propose the term minor agitated depression or minor mixed depressionbecause the syndrome is less severe and requires lower doses of medication.The term minor agitated depression is replacing the term excited anxious depressionproposed by us in the past (Koukopoulos, 1999). We are now proposing theterm minor to indicate the lesser severity in comparison with the other two formsand because it is simpler. This syndrome is similar to Kraepelin’s (1913) depressionwith flight of ideas and Lange’s excitable depression (Lange, 1928), as describedearlier.These patients fully meet the DSM-III criteria for major depression. Because ofthe absence of psychomotor agitation, they do not meet the RDC criteria foragitated depression and do not meet the criteria for a DSM-IV mixed affectiveepisode because of the absence of a clear manic syndrome. Yet this form should beconsidered as a mixed state not only for the racing thoughts that are undoubtedly asign of excitation, for the irritability, and for the emotional lability, but also for thecourse of this disorder and the reaction to antidepressant treatment. Because of thelack of inhibition and because of the intense expression of their suffering, thesepatients are often diagnosed as presenting with reactive or personality disorders.The syndrome may resemble hysteroid dysphoria (Liebowitz and Klein, 1981; Kleinand Liebowitz, 1982) because of the vivacious expression of their suffering. Thesesyndromes may occur spontaneously or appear during antidepressant treatment.