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

13 Beyond major depression and euphoric maniacan occupy the entire episode or at least the greater part of its duration. Usually, it is thelater episodes that have the tendency to change to long-lasting mixed states. The course isin many aspects somewhat more chronic than that of the pure manic or depressive episodes,but in other ways, the prognosis regarding the recovery of the episode is exactly the same(Weygandt, 1899, p. 63).Weygandt explained the manifestation of mixed states as follows:It is relevant to consider that the two symptom lines, i.e. euphoric mood, psychomotorexcitability and flight of ideas, on the one hand, and depressive mood, psychomotor inhibitionand thought inhibition, on the other hand, are not stable. But the disorders are characterized byinstability in the domain of mood, psychomobility and thought, and this is a characteristic of thewhole circular or manic-depressive insanity (Weygandt, 1899, p. 5).The mixture of the three opposite pairs of symptoms mentioned above couldgive rise – according to Weygandt – to the six possible types of mixed statespreviously mentioned but occasionally, and only for a short period, perhapsmore than six. Three of the six types are most relevant: ‘‘We are forced by reasonsof practical psychiatry, because we are opposed to speculation, to distinguish anddescribe only three groups of mixed states as the most relevant; they are the mostfrequent and have the longest duration ... manic stupor ... agitated depression... and unproductive mania ...’’(Weygandt, 1899, p.20).Heusedtheremaining two-thirds of his book to describe only these three types of mixedstates, not the other three possible types, which he mentioned but did not name(pp. 20–36). In 1913, Kraepelin gave extensive descriptions of all six types ofmixed states (Table 1.2).According to Koukopoulos and Koukopoulos (1999), Weygandt was the firstto introduce the term ‘‘agitated depression’’ (agitierte Depression) in his book,although in fact the syndrome had been described by Frank Richarz (melancholiaagitans) more than 40 years earlier (1858). Weygandt himself quoted Richarz’spaper in his book (pp. 41, 42). Koukopoulos and Koukopoulos’ paper contains avery interesting discussion on the origin and diagnostic placement of agitateddepression. The authors argue that agitated depression is in fact a form of mixedstate, as Kraepelin and Weygandt assumed. According to the opinion of Akiskaland Pinto (2000), the term ‘‘hyperthymic depression’’ can more closely be associatedwith mixed states than the term ‘‘agitated depression.’’Kraepelin thought that the first three types of mixed states (‘‘depressive oranxious mania,’’ ‘‘excited or agitated depression,’’ and ‘‘mania with thoughtpoverty’’) were based on the three fundamental symptoms of mania, namely flightof ideas, euphoria, and hyperactivity (Fig. 1.7). A depressive or anxious mania canarise if two of the three basic symptoms of mania, namely flight of ideas andhyperactivity, are present, but euphoria is replaced by depressive mood. If,