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

34 A. Marneros and F. K. GoodwinTable 1.6 Criteria for atypical features specifiers (Diagnostic and Statistical Manual of MentalDisorders: DSM-IV)A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)B. Two (or more) of the following features:1. significant weight gain or increase in appetite2. hypersomnia3. leaden paralysis (i.e., heavy, leaden feeling in arms or legs)4. long-standing pattern of interpersonal rejection sensitivity (not limited to episodes ofmood disturbances) that results in significant social or occupational impairmentC. Criteria are not met for ‘‘with melancholic features’’ or ‘‘with catatonic features’’ during thesame perioddefinition of West and Dally differs from the later definition applied by theColumbia group (Quitkin et al., 1978, 1993; Davidson et al., 1982; Parker et al.,2002). Angst et al. (2002) pointed out that a major impediment to the validity ofatypical depression is the lack of consistency in the definitions employed by studiesthat have investigated the clinical significance of this depressive subtype.According to Parker et al. (2002), the current definition and modelling of theDSM-IV atypical features specifier for a major depressive episode and majordepressive disorder appears problematic. As suggested by earlier descriptions ofatypical depression, certain manifestations of anxiety may have primacy, andsome clinical features associated with the DSM-IV model may be adaptivehomeostatic responses, rather than pathological symptoms. The authors supportthe opinion of Davidson et al. (1982) that the relationship between anxiety andatypical depression requires further investigation. Substantial clinical researchhas also yielded indirect support for an association between atypical depressionand the bipolar subtype of affective disorders, particularly subthreshold bipolardisorders and bipolar disorder II (Perugi et al., 1998; Angstet al., 2002; seeChapter 6). But, nevertheless, the results of recent research are controversial.While Angst et al. (2002) conclude that their findings from the Zurich studysupport the validity of the atypical depression subtype, considering it to be animportant classifier, Parker et al.(2002) recommended a redefinition of atypicaldepression. Benazzi suggests in this book (see Chapter 6) a significant relationshipbetween atypical depression and bipolar II disorder, which is consistentwith the findings of Perugi et al. (1998) and Benazzi (1999a, b).For a long time, agitated depression has been considered by some authors to be atype of mixed state (Koukopoulos and Koukopoulos, 1999; Akiskal and Pinto,2000; Marneros, 2001). Kraepelin (1899, 1913) and Weygandt (1899) described