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

169 Agitated depression: spontaneous and inducedAn interesting split is often observed between motor agitation and racing orcrowded thoughts. Their relationship appears to be inversely proportional. Mentalexcitement is more frequent and more intense in patients who do not showmarked motor agitation. There is a striking analogy with manic states, in whichthe presence of delusional ideas is inversely proportional to psychomotor excitement.This phenomenon may have played a decisive role in the success of politicaland religious fanatics who created a vast popular following. It can be assumed that,if their delusional or semidelusional ideas had been accompanied by patent motorexcitement, they would not have had the same charismatic influence on theiraudience.Because the term agitation usually means motor agitation, as in the RDC, andneglects the cases of mental and psychic agitation, the term mixed depression(MxD) is suggested for all the clinical forms of agitated depression.It is also suggested that the old term melancholia be reused for the psychoticform of agitated depression. This name not only represents a great psychiatrictradition, but also fully conveys the tragic human experience of these patients andbears out a deeply significant fact – that the major psychiatric syndromes haveremained unchanged over the course of thousands of years. If they are not diseaseentities, they surely are what Kraepelin would have called natural realities.Flight of ideas, racing and crowded thoughtsIn all three forms of agitated depression delineated here, many patients complainof a disturbance of the train of thought that they call crowded or racing thoughtsor other similar names. In the literature, this is often called depression with flight ofideas. This disturbance is, in many respects, different from the flight of ideasobserved in manic state.Flight of ideas in manic patients is expressed verbally in an abundance of wordsor pressured or clearly logorrheic speech. When racing thoughts are present indepressed patients, speech is limited or at normal tempo.In flight of ideas, the content of these ideas and somehow the pattern ofthoughts are reflected in the content and pattern of the speech itself. In racingthoughts, there is not such a close relationship. On the contrary, the patient talksabout the thoughts and reports on their course and their content and his or her ownsensations. Racing thoughts are not expressed directly in the speech. The patientrepeats monotonous laments, but the great energy involved in these depressivelamentations and in this speech denote the mixed depressive–manic nature of thissymptom. In some cases, there is a certain degree of pressured speech.The agitated melancholic patient complains of this course of thought as atorment, but the exalted (manic) patient never complains about his or her flight