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

16 A. Marneros and F. K. Goodwin(1981, 1992, 1997), Secunda et al. (1987), Goodwin and Jamison (1990),Himmelhoch (1992), McElroy et al. (1992, 1995, 1997, 2000), Swann et al.(1995), and Akiskal and Pinto (2000). The cooperation between the groups ofAkiskal and Cassano led to the Memphis–San Diego–Pisa study on mixed states(Dell’Osso et al., 1991). The work of Cassano et al. (1992) as well as that of thePerugi group in Pisa (end of 1997), Koukopoulos and Koukopoulos (1999),Koukopoulos et al. (1992, 1995) in Italy, and Bourgeois and colleagues in France(1995) supported this renaissance.An interesting enrichment was introduced by Hagop Akiskal (Akiskal, 1981,1992; Akiskal and Mallya, 1987; Akiskal and Pinto, 2000). He suggested a mixing ofmanic or depressive symptoms with cyclothymic, hyperthymic, or depressivetemperament. The seed of this idea can be found in Griesinger (1845, p. 205),adapted later by Kraepelin (1913). The mixing of symptoms and temperament cangive rise, in Akiskal’s view, to three different types of mixed states:(1) Type B-I: ‘‘depressive temperament þ psychosis’’(2) Type B-II: ‘‘cyclothymic temperament þ depression’’(3) Type B-III: ‘‘hyperthymic temperament þ depression’’The Pisa–Memphis collaborative study (Dell’Osso et al., 1991) on the temperamentand course of mood disorders of over 200 classical B-I manic-depressivepatients suggests that B-I mixed states are typically psychotic, often moodincongruent,and seem to arise from a depressive temperament. The clinicalpicture is in conformity with Kraepelin’s classic description of a mixed state wheredepression and mania coexist more or less syndromally. Its distinctive featuresderive from the simultaneous occurrence of numerous signs and symptoms of thetwo syndromes: crying, euphoria, racing thoughts, grandiosity, hypersexuality,suicidal ideation, irritability and anger, psychomotor agitation, severe insomnia,persecutory delusions, auditory hallucinations, and confusion (Akiskal andPuzantian, 1979). Alcohol abuse, a not infrequently associated finding, can be acontributory cause or a complication. B-I mixed states thus overlap with schizoaffectiveconditions (Marneros and Tsuang, 1986) and with what in francophonepsychiatry is labelled as bouffées délirantes.B-II mixed states are typically non-psychotic and consist of cyclothymic intrusionsinto a retarded depression (Akiskal, 1981). That is, the unstable cyclothymicbackground (Akiskal et al., 1979) serves to change the clinical phenomenology ofthe depression. Thus, depressed mood, hyperphagia, hypersomnia, fatigue, andlow self-esteem can be mixed with racing thoughts – which may manifest in spurtsof creativity, such as writing verses – jocularity, angry outbursts, tension, restlessness,impulsive hypersexuality, other evidence of uninhibited behavior, gambling,or dramatic suicide attempts. Abuse of stimulants (including caffeine) andof sedatives–hypnotics (including alcohol), either as sensation-seeking or attempts