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

174 A. Koukopoulos et al.experiences, and powerful fits of anger when irritated. The escalation of angerfrom initial irritation to outright rage typifies their reactive processes under stressor emotional stimuli. Their temperamental energy intensifies their emotions, andthe emotions fire their energy. The authors’ hypothesis is the following: when a sador stressful event provokes a depressive reaction, or a seasonal or endogenousdepression occurs in such a person, the psychic reaction is intense and exacerbatesthe depression itself. In turn, the emotional reaction heightens and unleashes thisenergy, which produces manic symptoms, such as restlessness and racingthoughts, while it also triggers anxiety and aggravates the depressive psychicpain. This tight interweaving of manic traits and depressive states of agitateddepression makes it an authentic mixed state.The nature and definition of agitated depressionAgitated depression should not be considered a depressive syndrome in whichsome manic or hypomanic symptoms coexist. No such symptoms can be presentin agitated depression or in agitated mixed states in general. They are certainlysymptoms of an excitatory nature, but there is nothing manic or hypomanic indepressive mixed states if we accept expansiveness as the essential feature of maniaor hypomania. The cardinal symptom of agitated depression is psychic agitationwith or without motor agitation and this agitation torments the patient andinhibits every activity and every pleasure. Even the racing thoughts are verydifferent from the manic flight of ideas. The flight of ideas is expressed in speechand even facilitates, together with expanded emotion, literary creativity. Racingthoughts of agitated depression are not verbalized and are very tormenting to thepoint that some patients wish to die just to stop them. Kraepelin’s conception ofmixed states was the coexistence of manic and depressive symptoms. Nevertheless,in all the forms of agitated depression he described, from melancholia activa of1883 to the evolutional melancholia and the excited depression of 1913, heemphasized the inner motor agitation of the patient. Since psychic agitation isvery intense also in patients with motor agitation and even in psychotic agitateddepression there is often a tormenting, inner agitation, it should be considered asthe fundamental symptom of all these depressive mixed states.But what is this agitation from the psychopathological point of view? Kraepelinand all the authors at the turn of the nineteenth century defined it with the termanxiety, Angst. On the other hand, agitation is synonymous with anxiety in lay andpsychiatric language. Day reviews and highlights the ambiguities of the termagitation (Day, 1999). In the Hamilton scale for depression, psychic agitationhas the meaning of psychic anxiety. Furthermore, patients suffering from agitateddepression express their suffering in terms of anxiety and anxious fears. Patients,