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

21 Beyond major depression and euphoric maniaKrüger et al., 2003). In the classical descriptions of Kraepelin and Weygandt, aswell as the modern studies, such as Winokur et al. (1969), Post et al. (1989),Cassidy et a .(19 l 98 a, b); Dilsaver et al . (1999), and Marneros et a .(seeChapter9),lanxiety symptoms are not uncommon in mixed states. Anxiety symptoms appearto correlate with depressive symptomatology (Kraepelin, 1899, 1913; Post et al.,1989; Cassidy et al., 1998a, b; Dilsaver et al., 1999; see Chapter 9). Althoughsuicidal symptoms during mixed episodes clearly occur, their reported frequencyvaries considerably – between 55% (Dilsaver et al., 1994) and 14% (Marneros et al.,1991a, b). Nevertheless, all available data show a considerably greater frequencyof suicidal symptoms in mixed states than in pure mania (Dilsaver et al., 1994:55% versus 2%, Strakowski et a .(1996): l 26% versus 7%, Marneros et al., 2004: 14%versus 0% for pure manic disorder, and for schizoaffective mixed episodes22% versus 1% pure schizomanic episodes). It should be noted that the investigationsof Marneros et al.(1991a), in contrast to the other studies noted above, havethe advantage of being longitudinal, considering all episodes during a period ofmore than 25 years. As noted by Kraepelin, psychotic symptoms are not uncommonin mixed states. Nevertheless, the occurrence of psychotic symptoms, especiallymood-incongruent symptoms, gives rise to the question of differential diagnosis –mixed bipolar episode or schizoaffective? Although DSM-IV and ICD-10 defineschizoaffective bipolar mixed episode, there is limited research on the topic(Marneros, 1986–2004). Findings on schizoaffective mixed states are presentedin Chapter 8 of this book.Catatonic symptoms can also occur in mixed states. Krüger et al. (2003) assertthat, in spite of the assumption that catatonic symptoms are associated with goodprognosis in psychotic or affective disorders, the opposite is true in the case ofmixed states: catatonic symptoms in mixed bipolar states are associated withgreater severity and poor prognosis.Onset, course, and outcomeStudies on the onset, course, and outcome of mixed states are somewhat inconsistent.One of the problems in the literature are the terms ‘‘patients with mixedmania’’ or ‘‘patients with mixed states.’’ Perhaps the correct formulation is‘‘patients who have at least one mixed episode during their course.’’ That is, asnoted above, patients having mixed states usually also have pure depressiveand pure manic episodes during their course, and in some cases, also schizodepressiveand schizomanic episodes. Perhaps it would be helpful if mixed stateswere defined according to the predominance of mixed symptomatology over puremanic or schizoaffective symptomatology (Marneros et al., 1991a, b; see Chapter 9).The relationship between mixed states and age at onset is of interest. Somestudies have reported that patients with mixed states have a younger age at