Like mania, bipolar depression may manifest psychotic symptoms of usually mood-congruent nature . However, delusional and hallucinatory experiences are less common. Stupor, uncommonly observed today, represents the most severe expression of the depressive phase of bipolar disorder. In the elderly, bipolar depression may present as a pseudodementia. "Neur-astheniform" symptoms  with reverse vegetative signs (i.e., "atypical depression" in the sense of DSM-IV) are more characteristic of juvenile bipolar depressives, particularly adolescents and young adult women.
Psychomotor retardation, with or without hypersomnia, is generally considered the hallmark of the uncomplicated depressive phase of bipolar disorder . Onset and offset are often abrupt, though gradual onset over several weeks can also occur. Patients may recover into a free interval or switch directly into mania [137, 138]: switching into an excited phase is not infrequently associated with somatotherapy (e.g., ECT, sleep deprivation, and antidepressants).
The characteristics which distinguish the depressive phase of bipolars from unipolars have been the subject of several prospective studies [31, 32]. Table 1.10 lists the most useful predictors of bipolar I outcome. The composite profile of such a depressive is that of a young person (< 25 years old), with "loaded" affective family history—or at least one definite bipolar first-degree kin—who is psychomotor retarded, or psychotically depressed; in a woman the depressive psychosis can be purperal. Bipolar II switching is more complex, as it involves temperamental factors (and is to be discussed later in this chapter under the heading of bipolar II disorder).
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