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

47 Longitudinal perspective of mixed statescases in which expansive and depressive elements are combined without fullysatisfying the criteria for one or the other type of episode. Second, DSM-IVstipulates an exclusion criterion that mixed symptomatology is ‘‘not due to thedirect physiological effects of a substance or a general medical condition’’ (DSM-IV, p. 333). To evaluate if a mixed episode is a direct consequence of brain damage,substance abuse and/or toxicity may be rather difficult; moreover, these conditionsare frequently reported in the personal history of patients with MS (Post andKopanda, 1976; Himmelhoch, 1979).Tenth Revision of the International Classification of Diseases (ICD-10: WorldHealth Organization, 1992) gives a less strict definition, including, en passant, thepossibility of MS consisting of major depression plus hypomania (rather than fullblownmania). But, like the DSM concept, it requires that ‘‘the diagnosis of mixedbipolar disorder should be made only if the two sets of symptoms are bothprominent for the greater part of the current episode’’ (ICD-10, p. 119). Inaddition, ICD-10 requires at least one past affective episode for the diagnosis ofMS, and therefore does not recognize that mixed symptomatology frequentlyrepresents the first expression of a bipolar mood disorder.In the last part of the past century, most research on MS has been focused onmanic states coexisting with some depressive features. These conditions are generallydefined as ‘‘dysphoric mania’’ and variously considered as a subtype ofmania (Murphy and Beigel, 1974), a more severe manic state (Post et al., 1989),or a transitional state between mania and depression (Bunney et al., 1972). Inthe same period, the agitated depressive forms of MS, originally delineated byKraepelin (1899) and Weygandt (1899), and consisting of intrusions of psychomotorrestlessness, hypersexuality, and racing thoughts into depression (Akiskaland Mallya, 1987; Koukopoulos et al., 1992) have been relatively neglected. Wewill consider both forms of MS in this chapter. We will also consider the hypothesisthat derives MSs from the intrusion of a temperament into an episode ofopposite polarity (Akiskal, 1992), i.e., depressive temperament into mania (manicmixed state) and hyperthymic temperament into major depression (depressivemixed state).Dysphoric maniaWe will first describe clinical research on dysphoric mania. A large literature(Bauer et al., 1994; McElroy et al., 1995; Perugi et al., 1997; Swann et al., 1997;Akiskal et al., 1998) is now available indicating that the DSM-IV threshold forsyndromal depression during mania is too restrictive, and suggesting that fewdepressive symptoms would suffice in validating the clinical diagnosis of mixedmania. The McElroy et al. (1992) operationalization of mixed mania (Table 2.3)