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

12 A. Marneros and F. K. Goodwinit can be assumed that the final clinical description, the categorization, and thesystematic gathering of data on the topic is the common work of both men.In his slim, 63-page monograph Über die Mischzustände des manisch-depressivenIrreseins (1899), Weygandt gives a very plastic description of mixed states in a stylevery similar to that of Kraepelin. A year before the publication of his monograph,Weygandt presented his findings during the 29th meeting of the South-westernGerman Alienists, held in Heidelberg on 27 November 1898. Weygandt’s contributionwas cited pedantically, including the exact time of the session (from‘‘1.15 p.m. to 3.45 p.m.’’); perhaps a sign that it was the first oral presentation onthe subject of mixed states during a scientific conference. In his presentation(published a year later, in 1899), Weygandt spoke about many possible types ofmixed states, three of which (‘‘manic stupor,’’ ‘‘agitated depression,’’ and‘‘unproductive mania’’) he considered the most important (Weygandt, 1899).Weygandt wrote in his book:It is very common, both in the manic and in the depressive episodes of manic-depressive orcircular insanity, for there to be not only periods of time which are mostly without symptoms,but also, often, hours or days when the symptoms switch to the opposite pole. So, during amanic episode, euphoria can suddenly change into a deeply depressive mood, while the othersymptoms of exaltation, such as hyperkinesia and hyperactivity, distractibility and excitability,logorrhea, and flight of ideas, persist; or after a month-long depression, suddenly a smile can beobserved on the face of the patient and the depressive mood can change for hours or days into ahigh or manic mood, but without any change in psychomotor behavior, in the inhibition or,sometimes, in the severe stupor. Less common, but actually frequent enough if observation iscareful, is a temporary change in psychomotor behavior while the affective aspects of the psychosiscontinue without any change; the patients remain euphoric, but the manic excitability changesinto a psychomotor inhibition. Instead of tireless hyperactivity, the patients stay in bed, showslowness of movement and little or no mutism. In patients with the phenomenological picture ofdepression with stupor, one can sometimes observe a change to mild excitability, agitation and anurge to speak lasting for hours or days, while the depressive mood continues.Additionally, we have to consider one more pair of opposite symptoms, because this is theonly way that we can touch all the relevant points in their totality. Similar to the euphoric moodand the psychomotor excitability for mania are also morbid changes in the domain of thinking,the flight of ideas....In depressive episodes, instead of flight of ideas, one sees thought inhibition.These states, very well known, but because of their short duration, usually less noted, are a mix ofmanic and depressive episodes of circular insanity (Weygandt, 1899, pp. 1–2).Weygandt concluded:The co-existence of the main symptoms of both typical episodes of manic-depressive insanity,mostly only of short duration, is extraordinarily frequent: in some cases, the mixed states