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

170 A. Koukopoulos et al.of ideas. This observation by Richarz, 1858 in in his paper on melancholia agitans ,is fully confirmed by the patients seen today.Richarz (1858) also observed that in mania thoughts tend to form strings ofideas (Reihenbildung von Vorstellungen) that link together by their content,alliteration, or assonance. In racing thoughts, the ideas come and go rapidly as ifthey were hunting each other or continuously overlapping without any linkbetween them.In Braden and Qualls’ (1979) work, the phenomenon is described by theirpatients with metaphors implying rotation: like a whirlpool, a hurricane, a centrifuge.A patient of the authors said, ‘‘I felt like the thoughts were circling aroundin my head and somehow I felt trapped by them.’’ Another young woman said herthoughts were ‘‘like a raging river breaking through a dam and flooding my mind.’’In other cases, the phenomenon could be called crowded thoughts; the patientcomplains that his or her head is full of thoughts of all kinds, not merely depressiveones and sad memories, but prevalently trivial thoughts of little significance for thepatient. Not infrequently, patients report the presence of musical tunes that theykeep hearing in their heads. The most important feature of these crowded or racingthoughts is that they afflict the patient not only through their meaning but also bythe way they manifest themselves; there must be something unrelentingly painfuland oppressive in their impact on the patient’s mind.A male patient said, ‘‘I felt attacked by them.’’ Another male patient who triedunsuccessfully to shoot himself in the head said afterwards that he did it to stop histhoughts. This patient was of depressed mood and kept quiet. These kinds ofthoughts are typically intense at night and often prevent the patient from fallingasleep.Depressive ruminations are different. They consist of only a few thoughts thatcarry the anxieties and fears of the patient, and they are constantly present or recurfrequently. The patient complains of their content but not of their course. Thereare naturally cases of transition between crowded thoughts and ruminations, andmaking the distinction may be difficult.Flight of ideas, racing thoughts, and crowded thoughts are clearly excitatoryphenomena. Neuronal hyperactivity must underlie them. This hyperactivity isdramatically confirmed by the effect of antidepressant medication, especially givenwithout typical and atypical neuroleptics. The thoughts are further accelerated andintensified; the patient becomes exasperated to such a point that sometimes he orshe wants to commit suicide. This worsening may be induced within the space of afew days or even hours. In many cases, the suicidal impulses induced by antidepressantsseem to be linked to the acceleration of the thoughts and to theworsening of the agitation. Typical and atypical neuroleptics, on the contrary,are of great benefit.