Download PDF
Fortschr Neurol Psychiatr 2007; 75(6): 323-330
DOI: 10.1055/s-2006-944274
Übersicht
© Georg Thieme Verlag Stuttgart · New York

Affektive Mischzustände bei Bipolaren Störungen: ein Überblick

Mixed Episodes in Bipolar Disorder: A ReviewA.  Merkl1 , F.  Regen1 , F.  Schindler1 , S.  Krüger2 , I.  Anghelescu1
  • 1Klinik und Hochschulambulanz für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin (Direktorin: Prof. Dr. med. Dipl.-Psych. I. Heuser)
  • 2Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl-Gustav Carus Dresden (Direktor: Prof. Dr. med. W. Felber)
Further Information

Publication History

Publication Date:
10 October 2006 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Affektive Mischzustände bei bipolaren Störungen sind derzeit Gegenstand zahlreicher wissenschaftlicher Diskussionen und stellen ein komplexes Krankheitsbild dar, in dem sowohl Symptome einer Manie als auch einer Depression gleichzeitig vorhanden sind. Außerdem sind Mischzustände durch eine große Vielzahl an Symptomen (Symptompolymorphismus) und eine Syndromlabilität (intraepisodisches Switching) gekennzeichnet. Deswegen stellt die Behandlung bipolar affektiver Mischzustände eine wichtige und besondere Herausforderung dar. Bislang erschweren diagnostische Unschärfen die systematische klinische Untersuchung dieser Patientengruppe, so dass gegenwärtig keine allgemeingültigen Richtlinien existieren. In dieser Übersichtsarbeit werden der Stellenwert sowie Probleme und Risiken aktueller Therapieoptionen diskutiert.

Abstract

Affective mixed states in bipolar disorders are a current matter of scientific debate and represent a complex clinical picture with coexisting manic and depressive symptoms. Treatment of mixed states is regarded as an important challenge. As diagnostic uncertainties complicate systematic clinical evaluations of this patient group, generally accepted clinical treatment guidelines are lacking yet. In this review the significance as well as the problems and risks of new treatment options are discussed.

Schlüsselwörter

Affektive Mischzustände - Bipolare Störungen - Pharmakotherapie

Key words

affective mixed states - bipolar disorder - Phamacotherapy

Literatur

  • 1 Marneros A. Manisch-depressive und andere bipolare Erkrankungen. Ein Leitfaden für Klinik und Praxis. Stuttgart: Thieme Verlag 2000
    Google Scholar
  • 2 Kraepelin E. Psychiatrie. Lehrbuch für Studirende und Aerzte. Zwei Bände. Sechste, vollständig umgearbeitete Auflage 1899. Leipzig: Johann Ambrosius Barth Großoktav, XIII, 362 und X
    Google Scholar
  • 3 Schneider K. Klinische Psychopathologie, unveränderte 14. Auflage. Stuttgart: Thieme Verlag 1992
    Google Scholar
  • 4 Jaspers K. Allgemeine Psychopathologie; 9. Auflage. Berlin Heidelberg New York: Springer 1973
    Google Scholar
  • 5 Akiskal H S. The distinctive mixed states of bipolar I, II and III.  Clinical Neuropharm.. 1992;  15 632-633
    PubMedGoogle Scholar
  • 6 Freeman M P, McElroy S L. Clinical picture and etiologic models of mixed states.  Psychiatr Clin North Am 1999. Sep;  22 (3) 535-546, vii
    PubMedGoogle Scholar
  • 7 Suppes T, Mintz J, McElroy S L, Altshuler L L, Kupka R W, Frye M A, Keck Jr P E. Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Network: a sex-specific phenomenon.  Arch Gen Psychiatry 2005. Oct;  62 (10) 1089-1096
    PubMedGoogle Scholar
  • 8 Kennedy N, Boydell J, Kalidindi S, Fearon P, Jones P B, Os J van, Murray R M. Gender differences in incidence and age at onset of mania and bipolar disorder over a 35-year period in Camberwell, England.  Am J Psychiatry. 2005 Feb;  162 (2) 257-262
    CrossrefPubMedGoogle Scholar
  • 9 Nolen W A, Leverich G S, Grunze H, Rush A J, Post R M. Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Network: a sex-specific phenomenon.  Arch Gen Psychiatry. 2005 Oct;  62 (10) 1089-1096
    CrossrefPubMedGoogle Scholar
  • 10 Saß H, Wittchen H U, Zaudig M, Houben I. Diagnostische Kriterien des Diagnostischen und Statistischen Manuals Psychischer Störungen DSM-IV-TR, Deutsche Bearbeitung. Göttingen; Bern; Toronto; Seattle: Hogrefe, Verlag für Psychologie 2003
    Google Scholar
  • 11 Dilling H, Mombour W, Schmidt M H. Internationale Klassifikation psychischer Störungen: ICD-10, Kapitel V (F); klinisch-diagnostische Leitlinien/Weltgesundheitsorganisation WHO. 2., korr. Aufl. Bern; Göttingen; Toronto; Seattle: Huber 1993
    Google Scholar
  • 12 McElroy S L, Keck Jr P E, Pope Jr H G, Hudson J I, Faedda G L, Swann A C. Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania.  Am J Psychiatry. 1992 Dec;  149 (12) 1633-1644
    PubMedGoogle Scholar
  • 13 Benazzi F, Koukopoulos A, Akiskal H S. Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression).  Eur Psychiatry. 2004 Apr;  19 (2) 85-90
    CrossrefPubMedGoogle Scholar
  • 14 Akiskal H S, Hantouche E G, Bourgeois M L, Azorin J M, Sechter D, Allilaire J F, Lancrenon S, Fraud J P, Chatenet-Duchene L. Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN).  J Affect Disord. 1998 Sep;  50 (2 - 3) 175-186
    CrossrefPubMedGoogle Scholar
  • 15 McElroy S L, Strakowski S M, Keck Jr P E, Tugrul K L, West S A, Lonczak H S. Differences and similarities in mixed and pure mania.  Compr Psychiatry. 1995 May - Jun;  36 (3) 187-194
    CrossrefPubMedGoogle Scholar
  • 16 Berk M, Dodd S, Malhi G S. “Bipolar missed states”: the diagnosis and clinical salience of bipolar mixed states.  Aust N Z J Psychiatry. 2005 Apr;  39 (4) 215-221
    CrossrefPubMedGoogle Scholar
  • 17 Mantere O, Suominen K, Leppamaki S, Valtonen H, Arvilommi P, Isometsa E. The clinical characteristics of DSM-IV bipolar I and II disorders: baseline findings from the Jorvi Bipolar Study (JoBS).  Bipolar Disord. 2004 Oct;  6 (5) 395-405
    CrossrefPubMedGoogle Scholar
  • 18 Marneros A. Affektive Erkrankungen: Konzepte und Definitionen. Ein fortführender Rückblick. In: Marneros A. (Hrsg.) Das Neue Handbuch der Bipolaren und Depressiven Erkrankungen. Stuttgart: Thieme 2004
    Google Scholar
  • 19 Judd L L, Akiskal H S, Schettler P J, Endicott J, Maser J, Solomon D A, Leon A C, Rice J A, Keller M B. The long-term natural history of the weekly symptomatic status of bipolar I disorder.  Arch Gen Psychiatry. 2002 Jun;  59 (6) 530-537
    CrossrefPubMedGoogle Scholar
  • 20 Cassidy F, Murry E, Forest K, Carroll B J. Signs and symptoms of mania in pure and mixed episodes.  J Affect Disord. 1998 Sep;  50 (2 - 3) 187-201
    CrossrefPubMedGoogle Scholar
  • 21 Dilsaver S C, Chen Y W, Swann A C, Shoaib A M, Krajewski K J. Suicidality in patients with pure and depressive mania.  Am J Psychiatry. 1994 Sep;  151 (9) 1312-1315
    PubMedGoogle Scholar
  • 22 Sato T, Bottlender R, Tanabe A, Moller H J. Cincinnati criteria for mixed mania and suicidality in patients with acute mania.  Compr Psychiatry. 2004 Jan-Feb;  45 (1) 62-69
    CrossrefPubMedGoogle Scholar
  • 23 Shah N N, Averill P M, Shack A. Mixed versus manic bipolar disorder: a comparison of demographic, symptomatic, and treatment differences.  Psychiatr Q. 2004 Summer;  75 (2) 183-196
    CrossrefPubMedGoogle Scholar
  • 24 Sachs G S, Joseph M F, Hwang C H, Marzilli G, Tran T B, Borrelli D J, Nierenberg A A. Mixed episodes: illness characteristics. 158th APA Annual Meeting 16: 68
    Google Scholar
  • 25 Freeman T W, Clothier J L, Pazzaglia P, Lesem M D, Swann A C. A double-blind comparison of valproate and lithium in the treatment of acute mania.  Am J Psychiatry. 1992 Jan;  149 (1) 108-111
    PubMedGoogle Scholar
  • 26 Swann A C, Bowden C L, Morris D, Calabrese J R, Petty F, Small J, Dilsaver S C, Davis J M. Depression during mania. Treatment response to lithium or divalproex.  Arch Gen Psychiatry. 1997 Jan;  54 (1) 37-42
    CrossrefPubMedGoogle Scholar
  • 27 Kruger S, Trevor Young L, Braunig P. Pharmacotherapy of bipolar mixed states.  Bipolar Disord. 2005 Jun;  7 (3) 205-215
    CrossrefPubMedGoogle Scholar
  • 28 Calabrese J R, Markovitz P J, Kimmel S E, Wagner S C. Spectrum of efficacy of valproate in 78 rapid-cycling bipolar patients.  J Clin Psychopharmacol. 1992 Feb;  12 (1 Suppl) 53-56
    PubMedGoogle Scholar
  • 29 Weisler R H, Kalali A H, Ketter T A. SPD417 Study Group . A multicenter, randomized, double-blind, placebo-controlled trial of extended-release carbamazepine capsules as monotherapy for bipolar disorder patients with manic or mixed episodes.  J Clin Psychiatry. 2004 Apr;  65 (4) 478-484
    CrossrefPubMedGoogle Scholar
  • 30 Ketter T A, Kalali A H, Weisler R H. SPD417 Study Group . A 6-month, multicenter, open-label evaluation of beaded, extended-release carbamazepine capsule monotherapy in bipolar disorder patients with manic or mixed episodes.  J Clin Psychiatry. 2004 May;  65 (5) 668-673
    PubMedGoogle Scholar
  • 31 Greil W, Kleindienst N, Erazo N, Muller-Oerlinghausen B. Differential response to lithium and carbamazepine in the prophylaxis of bipolar disorder.  J Clin Psychopharmacol. 1998 Dec;  18 (6) 455-460
    CrossrefPubMedGoogle Scholar
  • 32 Vieta E, Herraiz M, Parramon G, Goikolea J M, Fernandez A, Benabarre A. Risperidone in the treatment of mania: efficacy and safety results from a large, multicentre, open study in Spain.  J Affect Disord. 2002 Oct;  72 (1) 15-19
    CrossrefPubMedGoogle Scholar
  • 33 Benedetti A, Lattanzi L, Pini S, Musetti L, Dell'Osso L, Cassano G B. Oxcarbazepine as add-on treatment in patients with bipolar manic, mixed or depressive episode.  J Affect Disord. 2004 Apr;  79 (1 - 3) 273-277
    CrossrefPubMedGoogle Scholar
  • 34 Ghaemi S N, Berv D A, Klugman J, Rosenquist K J, Hsu D J. Oxcarbazepine treatment of bipolar disorder.  J Clin Psychiatry. 2003 Aug;  64 (8) 943-945
    PubMedGoogle Scholar
  • 35 Pande A C, Crockatt J G, Janney C A, Werth J L, Tsaroucha G. Gabapentin in bipolar disorder: a placebo-controlled trial of adjunctive therapy. Gabapentin Bipolar Disorder Study Group.  Bipolar Disord. 2000 Sep;  2 (3 Pt 2) 249-255
    CrossrefPubMedGoogle Scholar
  • 36 Chengappa K N. The evolving role of topiramate among other mood stabilizers in the management of bipolar disorder. 2001 3 (5): 215-232
  • 37 Anand A, Bukhari L, Jennings S A, Lee C, Kamat M, Shekhar A, Nurnberger Jr J I, Lightfoot J. A preliminary open-label study of zonisamide treatment for bipolar depression in 10 patients.  J Clin Psychiatry. 2005 Feb;  66 (2) 195-198
    PubMedGoogle Scholar
  • 38 McElroy S L, Suppes T, Keck Jr P E, Black D, Frye M A, Altshuler L L, Nolen W A, Kupka R W, Leverich G S, Walden J, Grunze H, Post R M. Open-label adjunctive zonisamide in the treatment of bipolar disorders: a prospective trial.  J Clin Psychiatry. 2005 May;  66 (5) 617-624
    PubMedGoogle Scholar
  • 39 Kaufman K R. Monotherapy treatment of bipolar disorder with levetiracetam.  Epilepsy Behav. 2004 Dec;  5 (6) 1017-1020
    CrossrefPubMedGoogle Scholar
  • 40 Tohen M, Sanger T M, McElroy S L, Tollefson G D, Chengappa K N, Daniel D G, Petty F, Centorrino F, Wang R, Grundy S L, Greaney M G, Jacobs T G, David S R, Toma V. Olanzapine versus placebo in the treatment of acute mania. Olanzapine HGEH Study Group.  Am J Psychiatry. 1999 May;  156 (5) 702-709
    PubMedGoogle Scholar
  • 41 Tohen M, Jacobs T G, Grundy S L, McElroy S L, Banov M C, Janicak P G, Sanger T, Risser R, Zhang F, Toma V, Francis J, Tollefson G D, Breier A. Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. The Olanzipine HGGW Study Group.  Arch Gen Psychiatry. 2000 Sep;  57 (9) 841-849
    CrossrefPubMedGoogle Scholar
  • 42 Baldessarini R J, Hennen J, Wilson M, Calabrese J, Chengappa R, Keck Jr P E, McElroy S L, Sachs G, Vieta E, Welge J A, Yatham L N, Zarate Jr C A, Baker R W, Tohen M. Olanzapine versus placebo in acute mania: treatment responses in subgroups.  J Clin Psychopharmacol. 2003 Aug;  23 (4) 370-376
    PubMedGoogle Scholar
  • 43 Tohen M, Chengappa K N, Suppes T, Zarate Jr C A, Calabrese J R, Bowden C L, Sachs G S, Kupfer D J, Baker R W, Risser R C, Keeter E L, Feldman P D, Tollefson G D, Breier A. Efficacy of olanzapine in combination with valproate or lithium in the treatment of mania in patients partially nonresponsive to valproate or lithium monotherapy.  Arch Gen Psychiatry. 2002 Jan;  59 (1) 62-69
    CrossrefPubMedGoogle Scholar
  • 44 Tohen M, Greil W, Calabrese J R, Sachs G S, Yatham L N, Oerlinghausen B M, Koukopoulos A, Cassano G B, Grunze H, Licht R W, Dell'osso L, Evans A R, Risser R, Baker R W, Crane H, Dossenbach M R, Bowden C L. Olanzapine versus lithium in the maintenance treatment of bipolar disorder: a 12-month, randomized, double-blind, controlled clinical trial.  Am J Psychiatry. 2005 Jul;  162 (7) 1281-1290
    Google Scholar
  • 45 Baker R W, Tohen M, Fawcett J, Risser R C, Schuh L M, Brown E, Stauffer V L, Shao L, Tollefson G D. Acute dysphoric mania: treatment response to olanzapine versus placebo.  J Clin Psychopharmacol. 2003 Apr;  23 (2) 132-137
    CrossrefPubMedGoogle Scholar
  • 46 Sachs G S, Grossman F, Ghaemi S N, Okamoto A, Bowden C L. Combination of a mood stabilizer with risperidone or haloperidol for treatment of acute mania: a double-blind, placebo-controlled comparison of efficacy and safety.  Am J Psychiatry. 2002 Jul;  159 (7) 1146-1154
    CrossrefPubMedGoogle Scholar
  • 47 Zarate Jr C A, Rothschild A, Fletcher K E, Madrid A, Zapatel J. Clinical predictors of acute response with quetiapine in psychotic mood disorders.  J Clin Psychiatry. 2000 Mar;  61 (3) 185-189
    PubMedGoogle Scholar
  • 48 Keck Jr P E, Marcus R, Tourkodimitris S, Ali M, Liebeskind A, Saha A, Ingenito G. Aripiprazole Study Group . A placebo-controlled, double-blind study of the efficacy and safety of aripiprazole in patients with acute bipolar mania.  Am J Psychiatry. 2003 Sep;  160 (9) 1651-1658
    CrossrefPubMedGoogle Scholar
  • 49 Keck Jr P E, Versiani M, Potkin S, West S A, Giller E, Ice K. Ziprasidone in Mania Study Group . Ziprasidone in the treatment of acute bipolar mania: a three-week, placebo-controlled, double-blind, randomized trial.  Am J Psychiatry. 2003 Apr;  160 (4) 741-748
    CrossrefPubMedGoogle Scholar
  • 50 Vieta E, Martinez-Aran A, Goikolea J M, Torrent C, Colom F, Benabarre A, Reinares M. A randomized trial comparing paroxetine and venlafaxine in the treatment of bipolar depressed patients taking mood stabilizers.  J Clin Psychiatry. 2002 Jun;  63 (6) 508-512
    PubMedGoogle Scholar
  • 51 Goren J L, Levin G M. Mania with bupropion: a dose-related phenomenon?.  Ann Pharmacother. 2000 May;  34 (5) 619-621
    CrossrefPubMedGoogle Scholar
  • 52 Chang K D, Keck Jr P E, Stanton S P, McElroy S L, Strakowski S M, Geracioti Jr T D. Differences in thyroid function between bipolar manic and mixed states.  Biol Psychiatry. 1998 May 15;  43 (10) 730-733
    CrossrefPubMedGoogle Scholar
  • 53 Calabrese J R, Keck Jr P E, Macfadden W, Minkwitz M, Ketter T A, Weisler R H, Cutler A J, McCoy R, Wilson E, Mullen J. A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression.  Am J Psychiatry. 2005 Jul;  162 (7) 1351-1360
    CrossrefPubMedGoogle Scholar
  • 54 Langosch J M. Bipolare Störungen. Die Pharmakotherapie der bipolaren affektiven Störungen (manisch-depressive Erkrankung). Hrsg.: Deutsche Gesellschaft für Bipolare Störungen e. V. (DGBS). 2002
    Google Scholar
  • 55 Goldberg J F, Garno J L, Leon A C, Kocsis J H, Portera L. Rapid titration of mood stabilizers predicts remission from mixed or pure mania in bipolar patients.  J Clin Psychiatry. 1998 Apr;  59 (4) 151-158
    PubMedGoogle Scholar

Dr. med. Dipl.-Psych. Angela Merkl

Klinik und Hochschulambulanz für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin

Eschenallee 3

14050 Berlin

Email: angela.merkl@charite.de