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15 - The treatment of bipolar mixed states

Published online by Cambridge University Press:  10 August 2009

By
John Cookson  and
Saad Ghalib
Edited by
Andreas Marneros  and
Frederick Goodwin
John Cookson
Affiliation:
Royal London Hospital London UK
Saad Ghalib
Affiliation:
Royal London Hospital London UK
Andreas Marneros
Affiliation:
Martin Luther-Universität Halle-Wittenburg, Germany
Frederick Goodwin
Affiliation:
George Washington University, Washington DC
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Summary

Mixed states pose particular problems in their classification, diagnosis, and treatment, because they may be conceptualized as arising in a variety of ways (Table 15.1).

Mixture of elements (mood, activity, thinking)

Mixed states may represent a mixture of different elements of depressed and manic conditions. For Kraepelin, the core pathology of clinical depression was expressed in separate areas of functioning: lowering of mood, and slowed or retarded mental and physical activity. The opposite applied in mania: euphoria, flight of ideas, and hyperactivity. Kraepelin (1913) recognized six mixed states, the most common being depressive or anxious mania, excited depression, and depression with flight of ideas. Others were manic stupor, mania with poverty of thought, and inhibited mania (without flight of ideas). Other combinations were theoretically possible but rarely recognized in practice. Kraepelin distinguished “autonomous” mixed episodes from those occurring during transitions from one mood phase to another (see transition state during a cycle, below) and thought them to be “the most unfavourable form of manic-depressive insanity.”

Severe stage of mania

The mixed state may represent a qualitatively distinct presentation of mania, with classical manic symptoms accompanied by marked anxiety, depression, or anger. These symptoms tend to emerge in more severe stages of the illness and then to be correlated in severity; thus Carlson and Goodwin (1973) described three stages of mania through which an episode may develop, corresponding to mild, moderate, and severe levels of symptoms.

Keywords

antidepressantsbipolar disorderdepressionDMIlamotriginemixed statesdysphoric maniahaloperidolrapid cycling bipolar patients
Type
Chapter
Information
Bipolar Disorders
Mixed States, Rapid Cycling and Atypical Forms
 , pp. 324 - 352
Publisher: Cambridge University Press
Print publication year: 2005

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