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

29 Beyond major depression and euphoric maniasystematic research regarding association with rapid cycling (Brieger andMarneros, 1999; Calabrese et al., 2000; see Chapter 12). Finally, a few reports,essentially anecdotal, suggest an association between rapid cycling and neuropsychologicaldeficits (Calabrese et al., 2000; see Chapter 12).Longitudinal prognosisThe impact of rapid cycling on longitudinal prognosis is also uncertain. WhileCoryell et al. (1992) and Wu and Dunner (1993) do not find an association betweenrapid cycling and a worsening of long-term prognosis, Okuma (1993) did.Thesedifferences may reflect sampling. That is, among patients for whom rapid cycling istransient and intermittent, one might not expect a negative effect or prognosis.TreatmentThe treatment of rapid cycling is discussed extensively by Calabrese et al.(2000), aswell as by Elhaj and Calabrese (see Chapter 3).Bipolar schizoaffective mixed statesSchizoaffective disorders present as unipolar or bipolar forms in a way similar tomood disorders (Marneros et al., 1989a–c; 1990a–c; 2000), as is reflected in bothDSM-IV and ICD-10 (American Psychiatric Association, 1994; World HealthOrganization, 1993). However, there are differences between DSM-IV and ICD-10.While DSM-IV defines two subtypes based on longitudinal course, namely bipolarand depressive, ICD-10 defines three types (manic, depressive, and mixed) basedon the most recent episode, rather than longitudinal course (World HealthOrganization, 1993). These differences present a difficulty for cross-nationalresearch.Tables 1.4 and 1.5 illustrate how differently ICD-10 and DSM-IV handle thedefinition of schizoaffective disorder.While the main problem with the definition of ICD-10 concerns the longitudinalissue, the problem with DSM-IV concerns both – cross-sectional andlongitudinal issues. The problem with the cross-sectional definition of DSM-IVconcerns time criteria for criterion B (during the period of illness there have beendelusions or hallucinations for at least 2 weeks in the absence of prominent moodsymptoms). Obviously, that is an attempt of the DSM-IV to separate schizoaffectivedisorders from psychotic mood disorders. The DSM-IV definition of mooddisorders is broad, including even those with mood-incongruent symptoms (evenfirst-rank schizophrenic symptoms) as the mood disorders. But the chronologicalcriterion is an arbitrary one (2 weeks of psychotic symptoms without mooddisorders is schizoaffective; less than 2 weeks is a psychotic mood disorder). One