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

327 The treatment of bipolar mixed statesderived formulation of manic or hypomanic responses can be helpful in understandingthe personal and interpersonal dynamics or relationships in which thebipolar person may become involved. However their etiological significance is lessclear, a fact recognized by Freud, who referred to the ‘‘economic problem’’ of thelibido in mania and depression.In Winston Churchill’s case, Storr (1969) emphasized the creative use of wordsand ideas; his writing, painting, and oratory were ‘‘manic defenses’’ against thedepressive tendencies which could be traced in the family to the first Dukeof Marlborough. His daughter, however, has stated that her mother ‘‘very largelykennelled the black dog’’ of Churchill’s melancholia except in his old age(Soames, 1993).Specific issues to be addressed with manic patients are the alienation of familymembers, the progressive testing of limits by the patient, the over involvementwith other patients, and the tendency to dominate the ward. Janowsky et al.(1974)described these tendencies as ‘‘the manic game’’ and implied that the manic patientdemands care without having to admit a need for it. Staff need to understand thesemaneuvers in order to avoid becoming too personally involved, for instance inangry exchanges. Community meetings are helpful as they allow the responses ofother patients to the manic’s behavior to be recognized and guided.Transition state during a cycle: MDI/DMIKraepelin (1899) suggested that a distinction should be made between ‘‘transitionalforms’’ (mixed episodes representing a transitional point or interval duringthe switch from depression to mania or vice versa) and ‘‘autonomous forms’’(mixed episodes as a separate disorder) of mixed episodes (Marneros and Angst,2000). Thus the opposite affective state may emerge during recovery from the firststate, as in postmanic depression, and the mixed state may occur during thetransition. In some patients the ‘‘switch ’’ occurs rapidly (in 24 h or overnight)but in others it is much slower (Sitaram et al., 1978; Post et al., 1981). Such cyclesor periods of illness were first clearly recognized by Falret, in what he called foliecirculaire (1854), and less clearly by Baillarger as folie à double forme (1854).Koukopoulos (2002) has emphasized the importance of these early ideas ofFalret to contemporary clinical diagnosis and treatment.The emergence of the second state may be due to adaptations occurring duringthe former. In this view the order of the sequence of mood states is important.Koukopoulos has used the sequence of mood changes to distinguish patients inwhom an episode of mania is followed immediately by depression, followed by awell interval (MDI), from those with depression followed by mania or hypomania(DMI), those with a continuously circular (CC) pattern, and those with completely