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

268 P. Briegeranxiety. For example, one Italian study found no differences concerning self-ratedor observer-rated anxiety (Dell’Osso et al., 2000) in 90 patients with mixed andpure mania with psychotic features.Patients with mixed bipolar affective disorder may also exhibit higher frequenciesof full-blown anxiety disorders than patients with pure mania. This was alreadyobserved in the Iowa study (Winokur et al., 1969). A later study (Feske et al., 2000)showed that, amongst bipolar affective patients, those with a depressive or mixedepisode fulfilled criteria of an anxiety disorder in roughly half of cases, while this wasonly the case in every fifth patient with a pure manic episode. Yet, partially negativestudies can also be found: in a comparison of patients with mixed mania, puremania, and bipolar depression with psychotic features, only two differences concerninganxiety disorders were reported: depressive patients had higher rates ofOCD and simple phobia (Dell’Osso et al., 2000).The temporal relationship between anxiety disorder and mixed bipolar affectivedisorder remains complex. A certain proportion of panic disorders in bipolaraffective patients presents during hypomanic episodes, while social phobia nearlyalways precedes (hypo)mania (Perugi et al., 2001). Therefore, Perugi et al. concludethat in such patients panic disorder may be a reflection of mixed (hypo)manicsymptomatology (Perugi et al., 2001).Altogether there is some indication that mixed bipolar affective episodes correspondwith an elevated risk for co-occurring anxiety disorders and higher rates oftrait anxiety (or anxious temperament). Concerning OCD, it was once observed(Strakowski et al., 1998) that OCD occurred more often in mixed mania than inpure mania, although full-blown OCD had a relatively lower prevalence thanmany other psychiatric disorders – a result stemming from a rather small samplesize (12 patients in both groups).We are not aware of substantial data that support the idea that rapid cycling hasa special link to anxiety disorders, including OCD.Personality disordersPersonality disorders in affective disorders occur at higher rates (Brieger et al.,2003a). Nevertheless, interactions between personality and affective disorder arecomplex (Akiskal et al., 1983): is the assessed personality a predisposing orcomplicating factor, or is it a result or an epiphenomenon of the affective disorder?The present diagnostic system of personality disorders has undergone fundamentalcritique (Livesley, 1998). The relevance of comorbid personality disorders inaffective disorder may be more complex than generally assumed; for example,there is an indication that only specific patterns of personality disorders have aprognostic value (Brieger et al., 2002a). With regard to mixed episodes, there is