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

50 G. Perugi and H. S. AkiskalDepressionAgitated-depressivemixed statesMixed statesHysterical psychosisand borderline statesDSM-IVmixed stateSchizophreniform andschizoaffective disorderManiaDysphoric maniaFig. 2.1The relationships of Kraepelinian, Vienna, and Pisa–San Diego mixed states (shaded area) toDiagnostic and Statistical Manual, 4th edn (DSM-IV) mixed state and related entities.also document the existence of at least two other forms of MS. The first one(accounting for 26% of our patients) is best characterized as mania with fatigueand indecisiveness. The second mixed bipolar form (17% of our patients) is bestdescribed as agitated psychotic depression with pressure of speech and flight ofideas. These two mixed subgroups, which do not meet DSM-IIIR criteria formixed bipolar episode, were well described by Kraepelin (1899) as, respectively,‘‘inhibited-unproductive mania’’ and ‘‘excited depression with flight of ideas.’’The results of the Pisa–San Diego collaborative study are in agreement with thesuggestions made by McElroy et al.(1992) that an MS can exist with full syndromalmania and less than syndromal depression. In line with suggestions by Kraepelin(1899), Weygandt (1899), Akiskal and Mallya (1987), and Koukopoulos et al.(1992), we further delineated a mixed depressive state which consists of fullsyndromal depression and less than syndromal mania.The descriptions that we adopted from Kraepelin (1899) and the Vienna school(Berner et al., 1993) seem to be more inclusive than those proposed in DSM-IVand ICD-10 (Fig. 2.1). Indeed, utilizing these criteria we can redefine as MS asubstantial proportion of manic and major depressive episodes according to DSMcriteria. Some of the clinical pictures that could be defined as MS according to ourcriteria are probably covered under the non-affective psychoses and borderlinepersonality disorder in DSM-IV and ICD-10. The validity of our broadly definedsubtypes of bipolar MS is supported by the fact that their family history and coursecharacteristics are essentially indistinguishable from those of the core dysphoricmixed-mania group (Perugi et al., 1997). Moreover, our criteria appear useful indetecting an MS even as a first episode. In fact, although the most frequent polarity