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

15 Beyond major depression and euphoric maniaKraepelin distinguished two groups of mixed states: (1) transitional forms,a stage in between, when depression changes to mania and vice versa; and(2) autonomic forms, a disorder on its own. Between these two groups relevantdifferences exist. The autonomic group is characterized by Kraepelin as the mostunfavorable form of manic-depressive insanity. The course is longer, with atendency to chronicity, and the individual episodes are longer than in othertypes of manic-depressive insanity (Kraepelin, 1899, 1904, 1913; Weygandt,1899) – findings that were confirmed 100 years later. Also confirmed by somemodern studies are the findings of Kraepelin and Weygandt:(1) Females are more frequently represented in groups of mixed states.(2) Using broad definitions, more than two-thirds of patients with manicdepressiveillness have a mixed state (usually a transitional form) at leastonce. Even when using narrow definitions, approximately 20% of themexperience mixed states (as many modern authors have also found, forexample, see Winokur et al., 1969; Himmelhoch et al., 1976a, b; AkiskalandPuzantian, 1979; Goodwin and Jamison, 1990; Marneros et al., 1991a, b,1996a, b; Akiskal, 1992; Himmelhoch, 1992; McElroy et al., 1995, 1997;Swann et al., 1995, 1997; Akiskal and Pinto, 2000)But even during the period after Kraepelin, in which the relevance of mixed statesfaded in scientific literature, many influential psychiatrists, such as Johannes Lange(1928) in Germany and Campbell (1953) in the English-speaking countries,continued to emphasize the relevance of mixed states.J. D. Campbell, in his book Manic-Depressive Disease: Clinical and PsychiatricSignificance, which was published exactly at the beginning of the psychopharmacologicalrevolution, but before its consequences, namely in 1953, emphasized theconceptual significance of mixed states in a way very similar to Kraepelin andWeygandt:The mixed type of manic-depressive psychosis epitomizes the entire cyclothymic process, in thatit contains the symptoms characteristic of the various phases. Whether it is a sustained reactionor represents a phase of metamorphosis between the major forms, the mixed type emphasizesthe underlying similarities between the depressive and hypomanic, the fact that the manic anddepressive reactions may be superimposed, and that the same individual possesses the potentialitiesfor either form.The renaissance of mixed statesThe renaissance of mixed states began in the USA at the end of the 1970s and thebeginning of the 1980s as a consequence of the pharmacological revolution inpsychiatry, especially through the contributions of Winokur et al. (1969), Kotinand Goodwin (1972), Himmelhoch et al.(1976a, b), Akiskal et al.(1979), Akiskal