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

17 Beyond major depression and euphoric maniaat self-treatment, are common comorbid conditions. These cases are then mistakenfor borderline personality disorder, as shown by the University of Tennesseeresearch on over 200 probands studied to date (Akiskal and Pinto, 2000).B-III mixed states are increasingly seen following the overzealous treatment ofretarded, seemingly unipolar depressions arising from a stable hyperthymic temperamentalbackground without hypomanic episodes. As reported by Akiskal andMallya (1987), based on a series of 25 cases, the end results of multiple antidepressanttrials in these patients could manifest as follows: unrelenting dysphoriaand irascibility; agitation against a background of retardation; extreme fatiguewith racing thoughts; panic and insomnia; suicidal obsessions and impulses;unendurable sexual excitement; histrionic countenance, yet genuine expressionsof intense suffering. Here, too, abuse of stimulants and alcohol is commonlyobserved. These patients are often misdiagnosed as being agitated depressiveswhen symptoms are severe, or neurotic depressives when they are moderate inintensity. It is here, according to Akiskal, that lithium ‘‘augmentation’’ works best.(Lithium alone might work as well.) This highly refractory group of patients,whose temperament is seriously compromised by the protracted ‘‘depression,’’presents a major therapeutic challenge (Akiskal, 1992).Another aspect of the evolution of the concept of mixed states is their extensioninto the group of schizoaffective disorders. Marneros et al. have described thefrequency, clinical characteristics, and prognostic value of ‘‘schizoaffective mixedepisodes’’ (Marneros, 1989; Marneros et al., 1986, 1988a–c, 1989a–c, 1991a, b,1996a, b, 2000). It seems that mixed states in schizoaffective disorders are not rare:33% of bipolar schizoaffective patients in the Cologne study had at least oneschizomanic–depressive mixed episode during an average duration of illness of25 years (Marneros et al., 1991a, b, 1996a, b). Unfortunately, however, no othersystematic investigations on this topic have been carried out with the exception ofthe Halle Bipolarity Longitudinal Study (HABILOS), the preliminary findings ofwhich we present in this book.The HABILOS showed that 32.2% of patients with bipolar schizoaffectivedisorder have at least one mixed episode showing no significant difference fromthe frequency of the pure bipolar affective disorder (Fig. 1.8). Additionally, thestudy shows that schizoaffective mixed states are apparently the most severe type ofbipolar disorders in general (see Chapter 8).It can be concluded that mixed states are well established. Diagnostic andStatistical Manual of Mental Disorders, 3rd edn (DSM-III) (American PsychiatricAssociation, 1980), DSM-III-R (American Psychiatric Association, 1987), andDSM-IV (American Psychiatric Association, 1994), as well as Tenth Revision ofthe International Classification of Diseases (ICD: World Health Organization,1991) include definitions and diagnostic criteria. The modern definitions of