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

325 The treatment of bipolar mixed statesTable 15.1 Concepts of mixed statesModelAuthors1. Mixture of elements (mood, activity, thinking) Kraepelin2. Severe stage of mania Carlson and Goodwin3. Dysphoric mania Post4. Depression as characterological response to mania Akiskal, Bourgeois5. Manic defense in depression Klein, Winnicott6. Transition state during a cycle (MDI/DMI) Falret, Koukopoulos7. Predominantly depressed (BP-II, Dm) Dunner, Angst8. Mania modified by substance misuse Himmelhoch9. Modified by organic brain disease Himmelhoch and Garfinkel10. Ultrarapid cycling DSM-IV11. With mood-incongruent psychotic features Dell’Osso12. Mixed schizoaffective disorder MarnerosSee text for definition of abbrevations.experienced by the patients as unpleasant or even terrifying, delusional thinkingbecomes bizarre and they have hallucinations, and in some cases disorientation.Dysphoric maniaThe term ‘‘dysphoric mania’’ has been used to describe patients in whom classicalmanic symptoms are accompanied by marked anxiety, depression, or anger (Postet al., 1989). Some patients present with these symptoms throughout an episodeand might be described as having dysphoric, mixed, irritable–paranoid or evenparanoid–destructive mania. Thus, Beigel and Murphy (1971) studied, prior totreatment, 12 consecutive patients admitted to the National Institute of MentalHealth (NIMH). Eight were characterized as ‘‘elated–grandiose’’ and four as‘‘paranoid–destructive,’’ on the basis of their scores on the nurses’ Manic Staterating scales. Patients with repeated manic attacks tended to exhibit similarbehavior and mood patterns during subsequent episodes and the pattern seemedto persist independently of the overall severity of mania. These authors founddepressive symptoms in 11 of the 12 patients with mania. A similar division wasfound in a later factor analysis of 30 patients (Murphy and Beigel, 1974). Theseverity of dysphoria has been found to correlate with the level of norepinephrine(noradrenaline) in the lumbar cerebro-spinal fluid (CSF) (Post et al., 1989).Likewise, levels of the norepinephrine metabolite methoxy-hydroxy phenylglycolwere more elevated in mixed mania than in depression (Swann et al., 1994).