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

326 J. Cookson and S. GhalibWhether there is a sharp separation between pure and dysphoric mania isdoubtful. Bauer et al. (1994b) assessed 37 outpatients with mania or hypomania(65% bipolar II and 92% rapid cycling) using five different definitions of dysphoricmania (all based upon the number of depressive symptoms). In this groupno bimodality was found in the depression scores that would allow a separationinto dysphoric and pure mania, and dysphoria was not found consistently insuccessive episodes.Depression as characterological response to maniaThe manic state may predominate while depressive elements are present to a lesserdegree, perhaps fleetingly. The depressive symptoms may then be viewed as acharacterological response to the occurrence of mania (Akiskal, et al., 1998a).Treatment of mania would be predicted to improve the depressive symptoms.The development of the concept of temperament in relation to bipolar disorderwas reviewed by Angst (2000). There is as yet little direct evidence to linktemperament and mixed presentation, or indeed any particular personality typewith bipolar disorder. In the French national Epidemiology of Mania (EPIMAN)study, mixed manic patients had a higher rate of depressive temperamental traitscompared with those with pure mania (Akiskal et al., 1998a). Bourgeois (2002)reviewed the evidence that temperament, whether depressive or hyperthymic, maycolor the acute episode (Akiskal and Akiskal, 1992; Cassano et al., 1992; Akiskalet al., 1998b; Henry et al., 1999; Perugi et al., 2001). He also concluded thattwo subtypes of bipolar type I disorder may be differentiated: on the one hand,a subtype ‘‘with a predominance of manic psychopathology’’ and on the othera ‘‘preponderantly depressed’’ (Angst, 1978) or ‘‘depression-prone’’ type (Quitkinet al., 1986) or a ‘‘poor prognosis subtype marked by a relative persistence ofdepressive symptoms’’ (Coryell et al., 1998).Manic defense in depressionThe depressive state may predominate, but with elements of manic thinking, asimplied in the concept of ‘‘manic defense’’ against depression, described by DonaldWinnicott (1935) and Melanie Klein (1935), who had herself been psychoanalyzedby Karl Abraham, one of the first in 1924 to apply psychoanalytical ideas to manicdepressiveillness. The manic defenses (omnipotent control, triumph, and contempt)protect the ego against despair, but interrupt the process of reparation, andproduce a vicious circle by further attacks upon the ‘‘object.’’ However, a manicform of reparation can occur and some of the identifications made in mania can beseen as potential advances in individual development. This psychoanalytically