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:

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:

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.

Mixed Moods in Bipolar 1Depressive 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:

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About Natasha Tracy

Natasha Tracy is an award-winning writer, speaker and consultant from the Pacific Northwest. She has been living with bipolar disorder for 18 years and has written more than 1000 articles on the subject.

Natasha’s New Book

Find more of Natasha’s work in her new book: Lost Marbles: Insights into My Life with Depression & Bipolar. Media inquiries can be emailed here.

  1. I have only had a mixed episode three times since I was diagnosed in 2003. They are pure hell. I lash out at everyone I know. I usually just try to isolate so I won’t hurt anyone’s feelings. My rage is unbelievable! I want to smash plates and throw dishes. Everything pisses me off! I hate this! My manias are super happy and my depressions are super sad but the mixed, it’s just so foreign to me as I am not an angry person. All I can say is I will admit I am a total BITCH and I feel NO control over it :((

  2. Pingback: mixed feelings | blahpolar diaries

  3. Apparently I have a “mood disorder” but my diagnosis is still really vague.

    I know it’s probably not the same as being bipolar but I’m kind of lost and alone in this and I was wondering if anyone understands this or if I’m just exaggerating somehow.

    Apparently I’ve had almost constant dysthymia since I was about 8 (I’m 28 now) with episodes of major depression.

    but Because I never had the euphoria or grand expensive ideas I didn’t recognize what was happening but apparently I’ve also had hypomanic mixed states at times. Whatever I’m living with is kind of hard. Sometimes I can’t really function but I’ve never been delusional or dangerous (except for some superficial self-harm) or seriously suicidal so everybody basically ignores it.

    I don’t think I have ever been fully manic it is more like I have two kinds of depression!

    Stupid, slow, blank, numb, exhausted, empty, detached, foggy, achy, lazy “I don’t care, let me sleep.” depression!

    Then there is the frustrated, cynical, sarcastic, angry, hyper, squirmy, antsy, jittery, crazy, devastated, hopeless, self-destructive “my mind is a burring blender!” (thoughts) / “fuck life! Pass the vodka” / “I really really really despise myself!” depression that makes me just want to rip off my skin to escape!! I end up stomping around the house ranting and raving at myself because I have way too many thoughts and NEED to express them all immediately!! but then it’s also like a black hole that sucks in everything self-destructive I lose all self control and it’s like I absolutely NEED everything bad right then!

    These moods last a few hours and usually I get the second one at night more.

    I just started a med for it so hopefully that will help but I’m not as better as people think I am. I’m alone all the time so they don’t see what I’m going through and just assume I’m lazy or irresponsible. I try not to inflict my crap on them because they deserve better but hiding it and keeping in all inside is kinda wearing me out.

  4. Is it still a ‘mixed’ episode if you have no euphoria at all , just extreme agitation, anxiety,negative auditory hallucinations of people around criticising you,paranoid delusions about people you know, traumatic flashbacks, persecutory ideation,thinking nurses hate you, depression, associations.?Every episode I have had 3-4 have been this way.I am not schizoaffective, paranoia is always accompanied by depression.

    • For a quick synopsis, see Wikipedia.

      See wikipedia:

      In the context of mental disorder, a mixed state, also known as dysphoric mania, agitated depression, or a mixed episode, is a condition during which features of mania and depression, such as agitation, anxiety, fatigue, guilt, impulsiveness, irritability, morbid or suicidal ideation, panic, paranoia, pressured speech and rage, occur simultaneously.

      According to the MMDT, increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms of dysphoric mania. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some antidepressant drugs may trigger dysphoric mania in susceptible individuals.

      • Hi Lloyd

        I’m hoping you have come right by now! I had possibly the worst experience in my life when a psychiatrist “weaned” me off Effexor, but prescribed a neglible dosage of Valdaxane. In the week of my final dosage, I started “rapid cycling” – or dysphoric mania as it is mentioned. When the psychiatrist made a very poor attempt to get back to my numerous calls, i eventually checked myself into a psychiatric clinic on advice from my friend. I’d never been diagnosed or experienced any of these symptoms until then.

        I then went through a 1 month process of following a treatment plan which involved no anti-depressants because my new psychiatrist believed that giving anti-depressants to bipolar patients because it makes them cycle. So, I clawed my life through 1 month of hell. Extreme irritability, rage and then massive depression, crying and suicidal thoughts the next minute. I had to take all my sick leave and one month unpaid leave as I was totally incapable of doing anything. Anything taxing or complex made me shake my head and moan as I couldn’t deal with it. Basically like an autistic reaction to things. The only thing I could do was watch the most banal, unemotional movies or series. I would wake up every day and for a moment I would think that it was gone, until the anxiety basically felt like it was running up and down my arms and I had to go and jog to try and release it. To no avail. I was living in another city from my hometown. I moved in with my grandmother and my mother came up from my home town. It was that bad. I was getting psychological advice for coping – if I felt a wave of anxiety coming on, I was told to jump into a cold shower and stand there shivering until I couldn’t think of anything else. The other one was to eat super sour sweets. Anything to stop thinking along the cycle.

        In December I went to visit my mom, and saw a psychiatrist in my home town. He suggested lithium and electro convulsive therapy. that kind of shocked me into action. We found a doctor in Johannesburg where I was living at the time who was Mr Bipolar in SA. Only catch was I had to book myself into the psychiatric clinic where he worked in order to see him. otherwise i would’ve had to wait 3 weeks. SO I did. Basically the idea was to book in so they could change my meds quickly and speed up the process of finding the right combination. The side effects were pretty hectic with some of them. Every drug affects people differently, but I had terrible dystonic side effects on Geodon. I had no sex drive. No feeling. I started gaining weight from the Seroquel. Fun and games. I even started knitting because I couldn’t sit still and watch videos on my laptop.

        When I checked out I wasn’t quite right. I still had cycles. But eventually I stablised. It took me about 6 months from when I first started cycling until I was stablised. During that period, I’d have to deal with my fear that I would never return back to my stable state. I’d ask my doctor and he’d say “well, with the right medication it is possible for a person to enjoy a reasonable quality of life”. So not what you want to hear when your leg is jumping, you have no sex drive, you’re gaining weight and you are not able to be productive.

        The good news is that I am 100% back to normal. It was a case of getting the right med combo. I’m on a right cocktail of meds which cost me about R1400 a month (rand is almost ten to the dollar) – and that’s WITH the medical aid co -payment. But its a small price to pay for my sanity.

        I’m still about 8kgs over my goal weight, I eat a controlled diet, and I dont over eat. I also dont eat a lot of carbs. And I train as a cyclist – so I do about 6+ hours a week. minimum. I’ve been trying to find a combination of drugs that dont make me gain weight – but I think tis just something I have to live with. I’m also a recovering eating disordered – so weight gain is NOT easy to accept. I had a theory that it was the Epitec – so we started reducing my dosage – but I had an experience where I got really irritated with a movie, and was weapy about things I didn’t usually cry about. So I went straight back on. Not willing to sacrifice my sanity!

        So – anyone with any potential drugs that can replace Seroquel which is supposed to be the weight gain culprit?

    • I feel you!! That exactly the way I feel and I’m so powerless to stop it! All I can do is try to isolate and even then I’m seething!!

  5. 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.

  6. 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?

    • 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

  7. 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??!

  8. 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

    • 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

  9. 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!!

    • 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

  10. 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.

    • 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

  11. 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.

    • 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

    • James – i had exactly the same thing with the anxiety “crawling” up and down my arms. Very comforting to hear people explain the same symptoms. Very hard to explain these things to a doctor – especially when they don’t say, “hey! that’s typical of Soft Bipolar”

      My psychiatrist diagnosed me with Soft Bipolar as I my symptoms were more characteristic of Biploar 2, but I hadn’t had any bipolar symptoms until a meds change triggered the mixed state/rapid cycling. I dont have mania – they said I was HYPOmanic. which referred to the irritability and rage, followed by suicide an uncontrollably sobbing – depression or terror at what I was going through.

  12. 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

    • 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

  13. 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.

    • 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