Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 1
Ask a Bipolar – What is a mixed mood in bipolar disorder?
As one of the Burble’s commenters mentioned, there seems to be a lack of good information on mixed moods available. After some Googling, I would tend to agree. While mixed mood episodes are pretty common for us bipolar folk, few people seem to be discussing it.
This is the beginning of a four-part series on mixed moods in bipolar disorder:
- Mixed Mood Episodes in Bipolar Type I
- Mixed Mood Episodes in Bipolar Type II
- Changes to Mixed Mood Episode Diagnosis in the Revision of the DSM
- Treating Mixed Mood Episodes
What is a Mixed Mood Episode?
By definition, a mixed mood in bipolar disorder is the presence of both depression and mania. According to the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), mixed moods are only present in bipolar disorder type 1 as mixed moods require the presence of mania.
Mixed mood episodes are (officially) found in bipolar disorder 1 and are characterized by:
- Persons must meet both the criteria for mania and major depression; the depressive event is required to be present for 1 week only.
- The mood disturbance results in marked disruption in social or vocation function.
- The mood is not the result of substance abuse or a medical condition.
Mixed mood episodes are officially considered part of the manic phase of bipolar disorder.
What is Bipolar 1 Mania?
As a quick refresher, mania is a part of bipolar disorder type 1 and is diagnosed as the following:
Manic episodes are characterized by at least one week of profound mood disturbance, characterized by elation, irritability, or expansiveness. At least three of the following symptoms must also be present:
- Grandiosity
- Diminished need for sleep
- Excessive talking or pressured speech
- Racing thoughts or flight of ideas
- Clear evidence of distractibility
- Increased level of goal-focused activity at home, at work, or sexually
- Excessive pleasurable activities, often with painful consequences
The mood disturbance is sufficient to cause impairment at work or danger to the patient or others. The mood is not the result of substance abuse or a medical condition.
(A more technical definition of mania/hypomania can be found in the next post. Mania and hypomania are diagnostically the same – the difference is in the degree of symptomology. Also in that mania may include hallucinations whereas hallucinations are not present in hypomania.)
What is a Major Depressive Episode?
Refresher two, a depressive mood (in bipolar 1 or bipolar 2) is diagnosed by the following:
For the same two weeks, the person experiences five or more of the following symptoms, with at least one of them being either a depressed mood or characterized by a loss of pleasure or interest:
- Depressed mood
- Markedly diminished pleasure or interest in nearly all activities
- Significant weight loss or gain or significant loss or increase in appetite
- Hypersomnia or insomnia
- Psychomotor retardation or agitation
- Loss of energy or fatigue
- Decreased concentration ability or marked indecisiveness
- Preoccupation with death or suicide; patient has a plan or has attempted suicide
- The symptoms cause significant impairment and distress.
- The mood is not the result of substance abuse or a medical condition.
Mixed Moods in Bipolar 1 Disorder
So, though a major depressive episode requires two weeks of symptoms, an official mixed mood only requires one week of depressed symptoms. While mania has a relatively low incidence of suicide, in mixed episodes the depressive phases increase the risk of suicide.
Depressive Phases?
Seems so. There seems to be a general confusion between extremely rapid-cycling moods and mixed moods as outlined in the DSM. People in a mixed mood episode can either oscillate rapidly between severe mania and depression or they can experience the moods simultaneously, as outlined above.
What’s the difference between rapid cycling and mixed moods? From my research, it’s not clear that we understand the difference, but if I had to guess, I’d say psychiatric history probably separates the two.
What Do We Know About Mixed Moods in Bipolar Disorder?
Patients with a mixed mood in bipolar disorder type 1 often exhibit:
- Marked irritability / aggression
- Delusions and hallucinations consistent with either depression or mania or both
- Dramatic oscillations between depression and euphoria
- Severely impaired judgement and insight
Because mixed moods are technically considered part of mania, they are generally treated with lithium, an anticonvulsant or an antipsychotic. Antidepressants could make the mixed state worse. However, treating a mixed mood is difficult particularly if the person doesn’t fit into the textbook definition (and most don’t) and primarily have depressive symptoms.
Series on Mixed Moods in Bipolar Disorder
Stay tuned: Upcoming in this series:
- Mixed moods in bipolar type II – although not currently recognized in the DSM, they are studied and seen in practice
- Mixed mood diagnostic revisions in the new DSM – the DSM-V will likely try to take into account more of what is actually clinically seen in regards to mixed mood episodes
- Treating mixed mood episodes – what we know about treatment
Lisa Helms - January 11, 2013 ←
I was diagnosed as Bipolar 1 13 years ago, after a long period of “pure” mania and “pure” depression that was devistating. I also experienced being depressed, feeling hopeless and helpless and, at the same time desperate, frantic, hyper, tearful, talking and talking and, basically overwhelmed. I still have these episodes frequently, despite medication. I didn’t learn about the term “mixed state” until a year ago! Well, that explains a lot. I went through a long period of functioning decline after my diagnosis, going from being a well paid teacher to being on general relief and seeking Social Security. I heard the word “decompensation” for the first time at my appeal two days ago. I went home and looked it up. It expains a lot, too. You learn something new every day. I sure wish I’d known this stuff earlier in my illness. By the way, I won my appeal.
Lori - December 28, 2012 ←
Hi, I have a question regarding mixed moods… My spouse is bipolar I and was diagnosed 20 yrs ago. He often experiences mixed moods and is also a rapid cycler. It seems obvious to me that it’s during the transition from mania to the inevitable “crash” that the mixed mood manifests itself. I believe(d?) that my husband skips or reduces his lithium because he likes the hypo-manic state which inevitably leads to full blown mania/mixed mood/crash. However, latelyI’ve read that lithium is not the best medication for mixed mood, so perhaps I’m blaming him for something he can’t help. Any ideas on this or the most effective meds for someone with chronic mixed moods?
Natasha Tracy - December 30, 2012 ←
Hi Lori,
In my opinion, lithium is probably a fine treatment for mixed moods as it’s technically approved for both manic and maintenance bipolar treatment. But that’s just my opinion.
According to what is FDA approved, these are the medications for mixed mood:
- Carbamazepine
- Aripiprazole
- Ziprasodone
- Risperidone
- Asenapine
- Olanzapiine
http://emedicine.medscape.com/article/286342-treatment#showall
You’ll notice that 5 of the 6 are antipsychotics. I would ask your husband’s doctor about the best medication(s) for him.
- Natasha Tracy
Stacey - November 16, 2012 ←
I’m feeling pretty pissed off at the moment.
I was first diagnoised at 15, I’m now 40. Yesterday I was tagged bipolar I mixed, with possible psychosis. And PTSD.
They put me back on my usual lithium candy. Now they added Serquel.
I hate taking new meds! And I’m lost on them throwing “mixed” into the label. I was so angry I didn’t ask about it & don’t see doctor again til January! See therapist Wednesday. But I don’t wana wait for a answer! What’s the whole “mixed” ??? Is this just another way to describe??!
kay - November 12, 2012 ←
I feel like I’m drowning and flying at same time
kay - November 12, 2012 ←
I have this and hate it.
Jeff - November 24, 2011 ←
I just read this and found it unique and informative. Yes, mixed moods tend to get swept under the carpet in the presence of the biggies, bipolar I and II. I gained a new perspective on mixed moods from your article and its comments. Take care, Jeff
Natasha Tracy - November 25, 2011 ←
Hi Jeff,
Glad I could help.
The funny thing about mixed moods is that they do get quite a bit of coverage in the literature, especially lately, but doctors don’t really emphasize them (in person, in my experience). And they really are known as some of the most dangerous moods so it really shouldn’t be that way.
- Natasha Tracy
Gretchen W - October 1, 2011 ←
I’m embarrassed to admit I only started learning more about bipolar disorder when I went into a manic phase in June of 2010. I was only diagnosed in 2007, but now, of course…. I can see patterns from very early childhood. I have wanted to know more about mixed states for quite a while … I mean I knew the basic idea…. but your well written articles have been helpful. I thank you. While reading today I have realized I have been in “a mixed state” for the past week or more. Crying during the better part of the day… to the point of suicidal thoughts or being near to checking myself into the hospital… and then suddenly, when working and finding myself, “in the zone” euphoric…. only to return to the despondent feeling a few hours later….No wonder I have few friends or even family that even want me around. I AM EXHAUSTING. They have no idea how tiring it can be INSIDE THIS HEAD!!
Natasha Tracy - October 1, 2011 ←
Hi Gretchen,
Oh, I don’t think you need to be embarrassed about that. Most of us don’t learn about mental illness until we have to. I think that’s pretty natural.
I’m so glad this information could help your understanding, in researching it, it helped mine as well. I think mixed moods are underemphasized in medicine while those of us with bipolar actually experience them quite regularly. And I think this has clinical and treatment implications which we often overlook. If mixed states are more like mania, then treating them is distinctly different than treating straight depressive moods.
“Crying during the better part of the day… to the point of suicidal thoughts or being near to checking myself into the hospital… and then suddenly, when working and finding myself, “in the zone” euphoric…. only to return to the despondent feeling a few hours later”
Sounds familiar.
“….No wonder I have few friends or even family that even want me around. I AM EXHAUSTING. They have no idea how tiring it can be INSIDE THIS HEAD!!”
Yes. Crazy is very high-maintenance. ;)
- Natasha Tracy
tara - August 11, 2011 ←
Thanks so much for the information in these posts! I’m really interested to read the rest of the series; it’s refreshing to see information about mixed moods (and rapid cycling!) that goes beyond the usual description tacked onto the end of information about mania/depression.
Natasha Tracy - August 11, 2011 ←
Hi Tara,
I would tend to agree. It’s interesting that mixed moods are considered so dangerous but as you say, they’re just tacked onto the end of other information.
I’m glad to see the interest :) I know I haven’t seen much on these topics either.
- Natasha Tracy
James Claims - August 11, 2011 ←
From personal experience, I’ve always separated ultradian rapid-cycling from mixed states. I’ve had days where I’ve had two or three manic periods and in between cry uncontrollably and think only of suicide. These days are rough, but I can still distinguish the states of mind as manic and depressed.
On the other hand, mixed states are truly when I have both. I get enormous amounts of energy to the point that my skin crawls while sitting and thoughts racing at a thousand miles an hour, yet all these thoughts are depressive, paranoid, and suicidal. I also have the physical sensation of my brain splitting apart and my head fracturing.
It is the latter that I’ve come to describe as mixed since it is neither depressive nor manic, but really both simultaneously. I find that the DSM-IV doesn’t quite capture the difference between marked mood swings, however fast they might be (I’ve had them over the course of minutes), and mixed which is the presence of these moods simultaneously. But I also feel that mixed states are hard to categorize since they seem to be unique to each individual. The only thing I can say in terms of a definition is that when you’re in a mixed state, you really know it since there is no classification or word to describe it.
Natasha Tracy - August 11, 2011 ←
Hi James,
I do agree that when distinct depressive and manic/hypomanic symptoms appear together it sort of defies words and it easy to discern (if you’re the one going through it).
Not sure if you read the second part of this article, but I talk a bit more about mixed vs. cycling moods. There is a description of what I would normally consider cycling that may actually represent a mixed mood, according to one definition anyway.
Really it’s just a matter of language in many cases. I suspect doctors would treat the two in the same way anyway.
- Natasha Tracy
Shah Wharton - August 10, 2011 ←
God I love it here – even when I think I know stuff, I always find out more here. Loving this article and I may have to link it up for you ;D IT is begging to be shared because all bipolar sufferers never really get all this info when diagnosed. I didn’t and I was one of those irritating patients who asked a lot of questions, after the breakdown which lead to the diagnosis. I have been told I suffer cyclic episodes and mixed states. I looked them up but nothing really ‘explained’ them. So thank you.
I actually came by to tell you you will be featured again at Monday Madness this week – the addiction article – because I have a guest post by an addiction professional, so it fits perfectly and will be of additional support to the post.
Take care Natasha – keep up the fabulous work. Shah .X
Natasha Tracy - August 10, 2011 ←
Hi Shah,
Thank-you; you are so generous with your praise. I’m glad I could help give you some new information. I’m always learning too.
I love those “irritating” patients that ask lots of questions. I hope we can all be one of those :)
Again, thank-you for the feature. I appreciate your help in getting the word out there.
- Natasha Tracy
Alexia - August 9, 2011 ←
It is 08:59 and my first words of the day were: OH MY GOD!
I can’t believe Bipolar II mixed states are not recognised by the DSM IV. I mean, I guess, in the grand scheme of things it’s not that big of a deal. I guess. I had a very intense 3-month experience last year and it feels strange knowing it’s not recognised.
Natasha Tracy - August 10, 2011 ←
Hi Alexia,
Well, I can understand your surprise. But, if it makes you feel better, rapid cycling isn’t in the DSM either.
Bipolar II isn’t as well understood as bipolar I and it’s in bipolar II that rapid cycling most commonly appears.
And no, it’s not that big a deal. Rapid cycling is commonly understood as more than 3 distinct mood episodes in a year (really) and so isn’t classified in and of itself. It’s ultra-rapid cycling and ultradian that people have more trouble with and for which there is no real equivalent in the DSM.
However, the article I’ll be publishing today will talk about mixed states in bipolar II because while it may not be in the DSM, it is definitely recognized and definitely a problem for many people.
- Natasha Tracy