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

49 Longitudinal perspective of mixed statesTable 2.4 Pisa–San Diego criteria for mixed state based on Perugi et al. (1997)A. A state of sustained (at least 2 weeks) emotional instability and/or perplexity in whichdepressive and manic symptoms are simultaneously present in a fluctuating manner.Opposite extreme manifestations in at least two of the following five areas should bepresent at the same time:1. Mood (anxious–sad versus euphoric–irritable)2. Thought flow (slowing versus racing)3. Thought content (depressive versus expansive)4. Perceptual disturbance (depressive versus expansive)5. Motility (retardation versus acceleration)B. At least two of the following:1. Labile or hypersyntonic, i.e., heightened emotional resonance2. Low threshold for anger–hostility, especially impulse dyscontrol3. Major shifts in sexual drive from habitual baseline4. Marked sleep disturbances5. Diurnal variations of at least one of the items listed under AC. Adequate interpersonal relationships and affective responses in the premorbid and/orinterepisodic phasesThe mixed state so defined could, in addition, be characterized as ‘‘non-psychotic’’ or ‘‘psychotic’’(in which case further specified as mood-congruent or-incongruent) by Diagnostic and StatisticalManual, 3rd edn revised (DSM-IIIR) criteria; ‘‘chronicity’’ refers to duration of at least 2 years; and‘‘rapid-cycling’’ is to be used as a qualifier if the patient has had four or more episodes (of whatevertype) per year.Toward a broader definition of mixed maniaAs discussed, in the contemporary literature, bipolar MSs have been defined on thebasis of a combination of manic with depressive symptoms, varying primarily onthe basis of the minimum number of depressive symptoms required. In a collaborativestudy between the Department of Psychiatry at the University of Pisaand the International Mood Center at the University of California San Diego(Perugi et al., 1997), we developed a more specific set of MS criteria based on theconcepts of Kraepelin and the Vienna school (Table 2.4). These criteria includepsychotic and non-psychotic forms. Clinical, temperamental, and familial characteristicsof 143 patients so defined were compared with those of a group of 118patients who met DSM-IIIR criteria for mania. The major finding of this study wasthat MS as defined by DSM-III-R criteria identified only half of all mixed states(Fig. 2.1). This subgroup conforms to the concept of dysphoric mania, which is theprototype of MS in the current literature (Post et al., 1989; McElroy et al., 1992).Kraepelin (1899) had described this entity as depressive-anxious mania. Our data