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

2Emerging concepts of mixed states:a longitudinal perspective1 2G iulio Perugi and Hagop S. Akiskal1 University of Pisa, Pisa, Italy2 University of California at San Diego and Veterans Administration Medical Center, La Jolla, CA, USAMixed state (MS) refers to an affective condition in which depressive and manicsymptoms are simultaneously present. It may manifest as a transitional condition,bridging one phase of the illness with another, or may exist as an independentclinical attack. In the latter case, along with mania and depression, MS represents amajor phase of manic-depressive illness; however, it is often misdiagnosed becauseof its pleomorphic symptomatological presentation, as well as underdiagnosedbecause of inadequate diagnostic delimitation. There is no terminological uniformityin the literature, and there is a regrettable tendency to use terms such as‘‘mixed state,’’ ‘‘mixed mania,’’ ‘‘depression during mania,’’ and ‘‘dysphoric mania’’interchangeably. In this chapter, we critically review the empirical literature ondifferent definitions of MS, focusing on their clinical validity. In doing so, wedevote special attention to the evolution of MS in the overall course of manicdepressiveillness.Definition of bipolar mixed statesIn the original description of MS given by Kraepelin (1899) and by his pupilWeygandt (1899), one or more of the main psychopathological features of mania(mood, cognition, psychomotor activity) were replaced by one or more of themain features of depression, and vice versa. This approach led Kraepelin topostulate six putative subtypes: (1) depression with flight of ideas; (2) exciteddepression; (3) depressive-anxious mania; (4) unproductive mania; (5) inhibitedmania; and (6) manic stupor. In addition, Kraepelin described some specificcharacteristics of MS, such as the tendency to become chronic and the frequentpresence of psychotic features (Table 2.1).More recently, Berner et al. (1983, 1993) provided operational criteria (Viennaresearch criteria) for MS based on the ‘‘dynamic’’ concept proposed by Janzarik(1959). ‘‘Dynamic’’ in this context indicates a dimension of psychic life, biologically# Cambridge University Press, 2005.