CLINICAL SUBTYPES OF BIPOLAR MIXED STATES - VALIDATING A BROADER EUROPEAN DEFINITION IN 143 CASES

Objective: To validate and clinically characterize mixed bipolar state s derived from the concepts of Kraepelin and the Vienna School and def ined as sustained instability of affective manifestations of opposite polarity - that usually fluctuate independently of one another - in th e setting of marked emotional perplexity. Method: Our criteria for mix ed states represent a modified ''user-friendly'' operationalization of these classical concepts. We compared 143 mixed state patients, so de fined, with 118 DSM III-R manic patients, systematically evaluated wit h the Semistructured Interview for Depression (SID) in our in-patient and day-hospital facilities. Results: The two groups were comparable f rom demographic and familial standpoints (including family history for bipolar disorder), Mixed states were predominant in the past history of index mixed patients who were more likely to have experienced stres sors and to have attempted suicide; manic and hypomanic episodes were more common in the past history of the index manic patients who, in ad dition, had more episodes and hospitalizations. Although rates of chro nicity and rapid cycling were not significantly different in the two g roups, the modal episodes in the mixed states were 3-6 months, and in mania they were less than 3 months, Two thirds of both groups arose fr om a dysregulated baseline temperamental dysregulation, which, in mani cs, was largely hyperthymic, and in mixed patients, was both hyperthym ic and depressive. Of our 143 mixed states, only 54% met the DSM III-R criteria for mixed states (which conformed to ''dysphoric mixed mania ''); of the remaining, 17.5% could be described as ''mixed agitated ps ychotic depressive states'' with irritable mood and flight of ideas, a nd 26% as ''unproductive-inhibited manic'' with fatigue and indecisive ness. The family history and course of these ''non-DSM III-R'' mixed s tates were essentially similar to DSM III-R mixed states. Limitation: Family history could not be obtained blind to clinical status in patie nts with severe psychotic mood states. Clinical Relevance: These data favor the classical European approach to mixed states over the grossly under-inclusive current official diagnostic systems. Conclusion: The phenomenology of mixed states is more than the mere superposition of o pposite affective symptoms and, in many instances, it represents an ex pansive-excited phase intruding into a depressive temperament, and a m elancholic episode intruding into a hyperthymic temperament. (C) 1997 Elsevier Science B.V.