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

56 G. Perugi and H. S. AkiskalTable 2.6 Relationships between temperamental dispositions and affective episodesTemperament Depression ManiaHyperthymic Agitated Euphoric–paranoidDepressive Inhibited Dysphoric–mixedCyclothymic Atypical–anxious Irritable–unstable–labileTable 2.7 Relationships between temperamental dispositions and long-term complicationsof manic-depressive illnessTemperament Bipolar II Bipolar IHyperthymic Rapid-cycling Chronic maniaDepressive Residual symptomatology Chronic mixed stateCyclothymic Borderline features Continuous cycling (deteriorative)hypothesis that the presence of different affective temperaments influences thephenomenology of mania. Hyperthymic temperament seems to underlie the excitedpole with euphoric–accelerated-paranoid phenomenology; by contrast, the depressivetemperament seems to mute the expression of mania into a depressive–manicphenomenology. Finally, patients with a constellation of the traits of both temperamentsseem to emerge as irritable–agitated manics with more severe symptomatologyand treatment refusal.The foregoing findings and considerations suggest the model reported inTable 2.6:(1) The hyperthymic temperament underlying major depression producesagitated depressive MS and, combined with mania, gives rise to pureepisode.(2) The depressive temperament produces inhibited melancholic depression aswell as mixed mania (which, of all mixed states, probably best deserves thedesignation of ‘‘dysphoric mania’’).(3) The cyclothymic temperament underlies atypical depression or unstable–labile mixed state.As regards the long-term complications of manic depressive illness (Table 2.7),we propose that the hyperthymic temperament is related to the development ofrapid cycling in bipolar II and chronic mania in bipolar I, the depressive temperamentto residual symptomatology and chronic mixed states, and the cyclothymictemperament to ‘‘borderline features’’ and/or to a deteriorating course of continuouscycling.