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Treating the Highs & Lows of Bipolar Adults
Bipolar Adults  continuing education psychologist CEUs

Section 19
The Clinical Picture of Agitated Depression in Bipolar Clients

CEU Question 19 | CE Test | Table of Contents | Bipolar
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Depressed anxious mood and inner, psychic agitation dominate the clinical picture of agitated depression. Psychomotor agitation is present in many cases, but not in all. In the cases without psychomotor agitation, inner unrest is the main symptom. This inner agitation makes the patient very anxious and fearful, hence very difficult to distinguish from anxiety, as will be discussed later. The inner unrest manifests itself also with irritability or feelings of unprovoked rage, racing or crowded thoughts, talkativeness and dramatic descriptions of psychic pain. A typical feature of agitated depression is the absence of retardation in speech and movement; yet there is an inhibition of purposeful activity, which in the more severe cases is nearly complete. In mild forms, the patient is quite active and sometimes anxiously hyperactive. Anhedonia and lack of interest are marked in all cases. Psychic pain is particularly severe and is often accompanied by suicidal thoughts and impulses. ‘I wanted to kill myself in order to stop my agitation’ a patient said. In more severe forms, the psychic pain is intense and constant while in milder cases there is lability of mood and emotional reactivity. Early insomnia, often sustained by racing thoughts, is common (Koukopoulos, Sani, Albert, Minnai & Koukopoulos, 2004). Maj et al. (2003), in a sample of 61 agitated depressions of BPI patients, reported the following symptom frequencies: psychomotor agitation 61 (100%), depressed mood 61 (100%), sleep difficulty 46 (75.4%), loss of interest in usual activities 38 (62.3%), decreased ability to think/concentrate 34 (55.7%), irritable mood 31 (50.8%), poor appetite or weight loss 30 (49.2%), suicide/suicidal ideation/attempts 29 (47.5%), loss of energy or fatigability 27 (44.3%), more talkative 25 (41.0%), excessive guilt 24 (39.3%), distractibility 20 (32.8%), racing thoughts/flight of ideas 18 (29.5%), sexual hyperactivity 10 (16.4%), inflated self-esteem 0 (0%), and elevated mood 0 (0%). I the clinical picture of agitated depression, depressed mood, anhedonia and inhibition of working activity are always present as is psychic agitation, which is often expressed in motor agitation.

The relationship between affective disorders and age is certainly very complex. The perimenopausal years, for example, are a time of increased emotional lability and reactivity. The mean at onset of agitated depression in our sample was 45.9 for men and 44.9 for women.

Clinical forms of agitated depression
The following clinical forms can be distinguished: •Psychotic agitated depression. These patients present with depressed mood, restlessness, anxiety, delusions of guilt and persecution, hypochondriacal ideas and, often, strong suicidal impulses. The similarity of this syndrome with that of other psychotic depressions that do not present with motor agitation is notable (Frances, Brown, Kocsis & Mann, 1981; Nelson & Bowers, 1978). In the latter, the patient lies silently in bed. On questioning, the patient describes an intense inner agitation, often located in the chest, abdomen, or head. A young patient said he felt ‘blades ripping through his guts’—a similar image to that employed by Hippocrates. Some patients describe racing or crowded thoughts. • Agitated depression (non-psychotic) with psychomotor agitation. Patients do not present delusions or hallucinations. The picture is dominated by depression, anxiety and motor agitation similar to that described in the RDC criteria (Spitzer et al., 1978a; 1978b). The patient may complain of crowded thoughts. • Minor agitated depression. The patient does not appear outwardly agitated, or the motor agitation is limited, but there is total lack of retardation. The patient speaks fluently and moves normally. The patient complains of intense inner agitation. The psychic pain of the patient is relentless, and the patient feels unable to perform normal tasks or enjoy anything. Frequently the patient complains of racing or crowded thoughts. We propose the term Minor Agitated Depression or Minor Mixed Depression because the syndrome is less severe and requires lower doses of medication.

An interesting split is often observed between motor agitation and racing or crowded thoughts. Their relationship appears to be inversely proportional. Mental excitement is more frequent and more intense in patients who do not show marked motor agitation. There is a striking analogy with manic states, in which the presence of delusional ideas is inversely proportional to psychomotor excitement. This phenomenon may have played a decisive role in the success of political and religious fanatics who created a vast popular following. It can be assumed that if their delusional or semi-delusional ideas had been accompanied by patent motor excitement, they would not have had the same charismatic influence on their audience.

Flight of ideas, racing and crowded thoughts
Many patients suffering from agitated depression of each of the three forms herein delineated complain of a disturbance of the train of thought that they call crowded or racing thoughts or other similar names. This is often described in the literature as depression with flight of ideas. This disturbance is, in many respects, different from the flight of ideas observed in manic states: 1. Flight of ideas in manic patients is expressed verbally in an abundance of words or pressured or clearly logorrheic speech. When racing thoughts are present in depressed patients, speech is limited or at normal tempo. 2. In manic flight of ideas, the content of these ideas and somehow the pattern of thoughts are reflected in the content and pattern of the speech itself. In the racing thoughts of agitated depression, there is not such a close relationship. On  the contrary, the patient talks about the thoughts and reports on their course and their content and his or her own sensations. Racing thoughts are not expressed directly in the speech. The patient repeats monotonous laments, but the great energy involved in these depressive lamentations and in this speech denotes the mixed depressive-manic nature of this symptom. In some cases, there is a certain degree of pressured speech. 3. The agitated melancholic patient complains of this course of thought as a torment, but the exalted (manic) patient never complains about his or her flight of ideas. This observation by Richarz in 1858 in his paper on Melancholia Agitans is fully confirmed by the patients seen today. 4. Richarz (1858) also observed that in mania thoughts tend to form strings of ideas (Reihenbildung von Vorstellungen) that link together by their content, alliteration, or assonance. In racing thoughts, the ideas come and go rapidly as if they were hunting each other or continuously overlapping without any link between them. In Braden and Qualls’ work (Braden & Qualls, 1979), the phenomenon is described by their patients with metaphors implying rotation: like a whirlpool, a hurricane, a centrifuge. A patient of the authors said, ‘I felt like the thoughts were circling around in my head and somehow I felt trapped by them’. Another young woman said her thoughts were ‘like a raging river breaking through a dam and flooding my mind’. In other cases, the phenomenon could be called crowded thoughts; the patient complains that his or her head is full of thoughts of all kinds, not merely depressive ones and sad memories, but prevalently trivial thoughts of little significance for the patient. Not infrequently, patients report the presence of musical tunes that they keep hearing in their heads. The most important feature of these crowded or racing thoughts is that they afflict the patient not only through their meaning but also by the way they manifest themselves; there must be something unrelentingly painful and oppressive in their impact on the patient’s mind. A male patient said, ‘I felt attacked by them’. Another male patient who tried unsuccessfully to shoot himself in the head said afterwards that he did it to stop his thoughts. This patient was of depressed mood and kept quiet. These kinds of thoughts are typically intense at night and often prevent the patient from falling asleep.

Depressive ruminations are different. They consist only of a few thoughts that carry the anxieties and fears of the patient, and they are constantly present or recur frequently. The patient complains of their content but not of their course. There are naturally cases of transition between crowded thoughts and ruminations and making the distinction may be difficult. Flight of ideas, racing thoughts, and crowded thoughts are clearly excitatory phenomena. Neuronal hyperactivity must underlie them. This hyperactivity is dramatically confirmed by the effect of antidepressant medication, especially given without typical and atypical neuroleptics. The thoughts are further accelerated and intensified; the patient becomes exasperated to such a point that sometimes he or she wants to commit suicide. This worsening may be induced within the space of a few days or even hours. In many cases, the suicidal impulses induced by antidepressants seem to be linked to the acceleration of the thoughts and to the worsening of the agitation. Typical and atypical neuroleptics, on the contrary, are of great benefit.

Restlessness, inner agitation and anxiety
‘I was awfully restless; I kept wringing my hands and pulling my hair. I couldn’t sit still but had to keep pacing around all the time. I was not able to read or listen to music, I couldn’t play the piano, I couldn’t concentrate at all, I was unable to eat or sleep. I was irritable and constantly tired, I suffered from fears of going insane, of having contracted AIDS or syphilis and these thoughts would not leave me alone. I started thinking of oblivion, about suicide. I was so restless that I began to think of ending my life just to get some peace of mind’. This young woman called her agitated depression a horror. Other patients exhibit much less psychomotor agitation, but they clearly suffer from inner agitation. They describe it as intense inner tension and use metaphors such as ‘I feel like I’m bursting inside’, or ‘I feel a violent force inside me as if I wanted to smash everything’, or ‘I feel there are blades tearing through my guts’. They describe an internal shaking or an electrical current passing through the body. This tension is also manifested as muscular tension or pains. Diastolic blood pressure is found typically increased to 90 or 100 mmHg. Psychomotor agitation and inner agitation are equally significant. Both are worsened by antidepressants and improved by neuroleptics. Psychic agitation is a subjective symptom, but it has objective manifestations observable by others, and the descriptions given by the patients are so characteristic as to make this symptom as reliable as any other aspect of affect and mood. Closely related to this inner tension and agitation is a feeling of rage arising without external provocation and in most cases not directed against anything. The patient just complains about it. In other cases, there is irritability and, at times, verbal and rarely physical violence, usually within the family environment as noted by Lange (1928). In extreme cases, this rage combined with hopelessness is the cause of the violent character of suicide attempts, of which raptus melancholicus is the utmost example. At least some suicide-homicide cases are due to agitated depression. The difference from manic aggressiveness is that in manic patients anger is provoked by some external cause and is directed outward. The clinical picture comprises depressed mood, total anhedonia, exhaustion, and inability to perform simple tasks or take part in usual activities, and it is marked by intense anxiety and fears—fear of everything or psychotic fears, often hypochondriacal, especially the fear of losing one’s mind. The devil figures frequently in these fears. One of the most common colloquial expressions for feeling low and fearful is ‘the blues’, which originates from an old English expression alluding to an attack by ‘the blue devils’. Anxiety seems highly related not only to psychomotor agitation, but also to inner, psychic agitation.
- Koukopoulos, Athanasios et al; Mixed Depressive States: Nosologic and Therapeutic Issues; International Review of Psychiatry; Feb 2005, Vol. 17 Issue 1, p 21

Personal Reflection Exercise #5
The preceding section contained information about the clinical picture of agitated depression in bipolar clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.

Hogarth, L., Hardy, L., Mathew, A. R., & Hitsman, B. (2018). Negative mood-induced alcohol-seeking is greater in young adults who report depression symptoms, drinking to cope, and subjective reactivity. Experimental and Clinical Psychopharmacology, 26(2), 138–146.

Mneimne, M., Fleeson, W., Arnold, E. M., & Furr, R. M. (2018). Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder. Personality Disorders: Theory, Research, and Treatment, 9(2), 192–196.

Ong, D. C., Zaki, J., & Gruber, J. (2017). Increased cooperative behavior across remitted bipolar I disorder and major depression: Insights utilizing a behavioral economic trust game. Journal of Abnormal Psychology, 126(1), 1–7.

Online Continuing Education QUESTION 19
According to Koukopoulos, what are the three key difference between a "flight of ideas" in a manic episode and in a mixed depression episode? Record the letter of the correct answer the CE Test


CE Test for this course | Bipolar
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