Seems like bipolar type 2 , organic causes should be ruled out especially thyroid , lamotrigine or quietiapine is a good choice ! Quietiapine more so as child bearing age , mood stabilisers would be a problem I suppose .

No organic cause apparent. The current episode is almost resolved with valproate. I was rather interested in phenomenology. It looks like a subtype of bipolar, but I haven't found any similar case report. Are You aware of any?

Is there any evident environmental factor responsible like stress to bring on the episodes ?

What about nature of symptoms like is it more feeling of emptiness and suicidality or typical low mood. Can it be onset of a personality disorder ?

The patient is now 63 so I would not think about personality disorder onset. First episode (some 20 years ago) seemed to be linked (and least by time) to a significant other loss, while next episodes (including the current one) are without any obvious triggers. Mood is low, worse in the morning, no suicidality, rather feelings of worthlessness and ideations like "it would be better for my family without me".

I have seen one female ,whose first episode was postpartum all other episodes were mixed episodes without postpartum specifier ,she also responded to magnesium valproate very well she is now episode free from last 4yrs.I am also clinically recognising more and more mixed episodes who were previously diagnosed as agitated depressive episodes with very poor response to antidepressants ,but recognising mixed episode and response to valproate is really dramatic

So that makes 2 unusual cases :-) And, indeed, I also see more and more mixed episode, but usually it looks like the complication of previous antidepressant treatments not an individual phenotype.

There is some evidence to suggest that type II bipolar may not be closely related to type I bipolar. Some of us think type II is driven by dietary factors, mainly long term exposure to processed food. We now call this form of food-induced brain dysfunction Carbohydrate Associated Reversible Brain syndrome or CARB syndrome. It is more or less an expansion of Hudson and Pope’s Affective Spectrum Disorder Concept.

The incidence of bipolar I doesn’t seem to be increasing yet bipolar II is increasing at a rapid rate, especially in children. This seems to mirror the increase in common metabolic disorders like insulin resistance, obesity and type II diabetes. Years ago we never saw this form of diabetes in young people but today we do. The same is true for bipolar II and as scientists we need to explain this change.

Dear Dr Wislon, can You suggest any references to this CARB theory? Sounds very interesting.

Tomasz--This article discusses the CARB syndrome concept in relation to autism:

http://najms.net/v06i03p158w/

It is a new and unproven concept but in view of the changes we are seeing I think we need some new concepts. Show me a better one and I will use it.

First of all it is quite common to observe the characteristics of the disease you described. In BDs first epysodes are often started by a stressor but as long as the disease lasts the phases are unlinked with daily events. (kindling)

I am quite convinced that BD type I and II are very different diseases, I am not fond on CARB theory I am more close to Akiskal - Perugi point of view. I have to say that I know that epidemiology of BDII disorder is rapidly increasing but there is a diagnostic bias due to more attention about bipolar spectrum.

About VPA you were really lucky because It is not common in mixed epysodes good responses to low doses MSs. I am now involved in a trial with asenapine in mixed states but I am not able to give you further deep informations about this drug.

My 2 cents...

I am aware of the fact that first episode (or any other episode) might be triggered (or at least timely associated) with stressful event. I was rather surprised with mixed episodes only disease course. To my experience mixed episodes tend to appear later on during the disease and might rather be associated with antidepressant use that a disease phenotype.

You are right but take a look at Kraepelin's Handbook...No antidepressant in 1907 ;)

Could you be more explicit about the nature of racing thoughts? Tthey seem pivotal in your differentiation between mixed affective state and agitation...

I agree with what was said above lack of evidence typical for  manic symptoms and racing thoughts i.e. is typical for anxiety or panic attack too.