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

15The treatment of bipolar mixed statesJohn Cookson and Saad GhalibRoyal London Hospital, London, UKMixed states pose particular problems in their classification, diagnosis, andtreatment, because they may be conceptualized as arising in a variety of ways(Table 15.1).Mixture of elements (mood, activity, thinking)Mixed states may represent a mixture of different elements of depressed and manicconditions. For Kraepelin, the core pathology of clinical depression was expressedin separate areas of functioning: lowering of mood, and slowed or retarded mentaland physical activity. The opposite applied in mania: euphoria, flight of ideas, andhyperactivity. Kraepelin (1913) recognized six mixed states, the most commonbeing depressive or anxious mania, excited depression, and depression with flightof ideas. Others were manic stupor, mania with poverty of thought, and inhibitedmania (without flight of ideas). Other combinations were theoretically possiblebut rarely recognized in practice. Kraepelin distinguished ‘‘autonomous’’ mixedepisodes from those occurring during transitions from one mood phase to another(see transition state during a cycle, below) and thought them to be ‘‘the mostunfavourable form of manic-depressive insanity.’’Severe stage of maniaThe mixed state may represent a qualitatively distinct presentation of mania, withclassical manic symptoms accompanied by marked anxiety, depression, or anger.These symptoms tend to emerge in more severe stages of the illness and then to becorrelated in severity; thus Carlson and Goodwin (1973) described three stages ofmania through which an episode may develop, corresponding to mild, moderate,and severe levels of symptoms. At moderate severity, the euphoric mood isincreasingly interrupted by periods of irritability and depression, and thinkingbecomes delusional. In the severe stage, there is frenzied overactivity, mood is# Cambridge University Press, 2005.