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

18 A. Marneros and F. K. GoodwinBipolar affective(n = 100)Bipolar schizoaffective(n = 177)Mixed25.0%Mixed32.2%Non-mixed75.0%Non-mixed67.8%NSFig. 1.8Frequency of patients with mixed course in the Halle Bipolarity Longitudinal Study(HABILOS). NS, not significant.mixed states are similar to those of Kraepelin and Weygandt, who distinguishedbetween narrow (coexistence of the full symptomatology of a manic and a depressiveepisode) and broad definitions (‘‘cardinal’’ depressive symptoms in manicepisodes, and vice versa). The modern definitions can be divided into threegroups:(1) Broad definitions: the presence of single depressive symptoms within a manicepisode is considered sufficient for diagnosis of a mixed episode.(2) Narrow or strict definitions: only the coincidence of the full symptomatologyof a manic and a depressive episode allows for the diagnosis of a mixedepisode. This category corresponds to the diagnostic criteria of ICD-10(Table 1.3) and DSM-IV (Table 1.4).(3) Moderate definitions: according to moderate definitions, the coincidence ofthe full syndromes of mania and melancholia is not necessary. However, thepresence of either the depressive or manic syndrome is not sufficient. Thesedefinitions demand prominent depressive symptoms within a manic syndrome,or vice versa. The Cincinnati, Pisa, and Vienna criteria belong tothis category (Berner et al., 1983; McElroy et al., 1992; Perugi et al., 1997).McElroy et al. (2000) pointed out that numerous modern phenomenologicalstudies, including factor-analytic studies, have confirmed the occurrence ofdepressive symptoms in mania, and have provided support for the hypothesisthat mixed mania (mania with depressive features) may be distinct from pure oreuphoric mania (mania without depressive features). Moreover, these studiessuggest that systems used to define mixed states should be broad and dimensional,as well as categorical, rather than overly narrow. As Goodwin and Jamison (1990)wrote, ‘‘in general, it is best to consider the depressive spectrum and the manicspectrum as independent and capable of interacting in a variety of combinations