As I mentioned, mixed moods are technically considered part of the manic phase of bipolar disorder and thus, by definition, are only a part of bipolar disorder type 1. However, those of us with bipolar type 2 can tell you we mix it up with the best of them.
So, in part II of this series on mixed moods in bipolar disorder, I look at mixed moods in bipolar type II.
Mixed Moods in Bipolar Type II
Now that we’ve wandered into Diagnostic and Statistical Manual (DSM)-free territory, definitions on mixed states get a bit looser.
Mixed mood states may be, in fact, the most common way of experiencing bipolar type II. I find most people have a hard time distinctly separating “depression” from “hypomania” from “normal” moods. There is just too much crossover.
Two Types of Mixed Moods in Bipolar Disorder
Additionally, considering mixed moods to be part of the manic phase of bipolar disorder becomes useless when looking at bipolar II. As an article in Psychiatric Times suggests, there are really two types of mixed moods in bipolar disorder:
- Mixed mood with depression as the primary mood (meeting the criteria for depression with some hypomania symptoms present)
- Mixed mood with hypomania as the primary mood (meeting the criteria for hypomania with some depression symptoms present)
Those two mood types better reflect my own experience and I think the clinical experience of other patients and doctors.
What is Hypomania in Bipolar Disorder Type II?
Refresher – here is the DSM-IV-TR criteria for hypomania:
A. Distinct period of persistently elevated, expansive or irritable mood, lasting throughout >4 days
B. During the period of mood disturbance, 3+ of the following symptoms have persisted (4 if the mood is only irritable) to a significant degree
- Inflated self-esteem or grandiosity
- Decreased need for sleep (eg, feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed activity (work, school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
D. The disturbance in mood and the change in functioning are observable by others
E. The mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features
F. The symptoms are not due to the direct physiological effects of a substance or a general medical condition
(Criteria taken from Psychiatric Times article, from the DSM-IV-TR.)
Do Mixed Moods Exist in Bipolar Type II?
Clearly, they do. Two studies showed they exist in a decent proportion of hypomanic patients:
- In one study 14% of patients met the criteria for a mixed mood
- In another study 57% met the criteria for a mixed mood
In fact, studies suggest that almost all depressions (like, 98%) contain at least one symptom of hypomania (this isn’t enough to qualify for a mixed mood, however).
Mixed Mood Hypomania with Ultradian Cycling
What is Ultradian Cycling?
Refresher – bipolar disorder cycling (for bipolar types 1 and 2) comes in three types:
- Rapid cycling – more than 3 mood episodes per year
- Ultra-rapid cycling – moods last only days or a small number of weeks
- Ultradian – moods can last only hours
Ultradian isn’t something most people have heard of, but it’s out there. Myself, I’m ultradian-y.
Bipolar Mixed Mood with Ultradian Cycling
This Psychiatric Times article points out there exists a variant of mixed mood – mixed mood with ultradian cycling. As I mentioned last time, there seems to be some confusion about whether a mixed mood only means symptoms from both mood poles at once or whether it can refer to rapid switching of moods as well. The article suggests ultradian cycling constitutes a mixed mood and is very common.
Temporal Aspects to Mixed Moods with Ultradian Cycling
I have experienced this exact scenario many times but have never heard it described before:
This variant of mixed hypomania is characterized by marked ultradian cycling between morning depression and a combination of nocturnal rising of elevated mood or euphoric mood, irritability, pressured speech, heightened level of energy, psychomotor agitation (excessive, purposeless movement), and increased goal-directed activity . . . In addition, a marked phase delay in the onset of nocturnal sleep is normative…
As is laid out in the article about patients with mixed hypomania with marked ultradian cycling:
- In the morning, they seem depressed only
- Mid- to late afternoon, they seem to be coming out of the depression
- In the afternoon, patients seem irritable and begin seeming more talkative, restless and distractible
- At night they move into hypomania
Mixed Moods in Bipolar Disorder Type II
So although the DSM doesn’t recognize them, it’s clear people with bipolar II do experience mixed moods just as those with bipolar I.
And as a quick reminder, mixed moods can be very dangerous in terms of risk of suicide and should always be taken seriously and treated promptly. Stability is the goal in bipolar disorder, and mixed moods or cycling is something that takes us away from that goal.
Series on Mixed Moods in Bipolar Disorder
- Mixed moods in bipolar disorder type 1 – as recognized by the DSM
- Mixed moods in bipolar disorder type 2 – although not currently recognized in the DSM, they are studied and seen in practice
Up next:
- 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
“» In the morning they just seem to be depressed
In the late afternoon they seem to come out of the depression
In the afternoon, patients appear irritable and more talkative, restless, and distracting
They fall into hypomania at night «”
No that is not correct!
In my opinion.
This is a normal variant of the course of bipolar disorder type 2. But even with unipolar depression, this can show up in the course of the evening so that the mood is clearly raised.
after waking up the so-called ‘morning low’ and in the course of the day the mood improves until the evening in a good mood, and the next day the same process againso that one is afraid of the next day because one wakes up again very depressed and the good plans are forgotten in the evening. Until the depression shows a constant bad course again or dissolves or ends in hypomania.
This is not an “ultradian cycle = Mixed mood”.
It looks a bit more violent from the disturbed one, really, I had to go through that, that’s really hard.
(Or what do I not understand again here?!)
I wish everyone concerned a speedy recovery!
Sometimes, the underlying cause is a sheer lack of sleep.
When this sends you into a more manic type of mixed episode, you simply can’t sleep.
It is indeed, a downward spiral.
Medicated or not, you’ll feel the reprocussions.
Take that with a grain of salt, because we all know it was never truly your fault to begin with; however, you’re going through the reprocussions anyway.
I was stable on a medication but I stopped using it due to problems in my family due to which I had a lot of self neglect. That has led me into a relapse. I cannot go to college so frilled out without even starting it. I am so upset. I was diagnosed with bipolar 2 disorder five years ago when I was eighteen. Now I’m twenty three and I feel like I’ve accomplished very little in life. It is so hard to live with bipolar type two disorder because of the recurring suicidal thoughts in depression etc. I’m single and I don’t intend to marry because I fear I could ruin someone’s life because of my illness and I would gate myself even more if I would do that?
I am an only child therefore a bit lonely … What do you recommend, how should people with bipolar 2 manage their relationships and should they even marry someone in an arranged marriage?
I feel like you just wrote MY story. Cheers to you for your vulnerability and awareness.
After almost 2 decades of therapists/psch visits, residential, and PHP programs… I met w/ a psych (new) that said due to my reactions/inactions of the meds I have been on (and weened myself off of) were also partial indicators of bi-polar. While none of the specialists that I have seen have diagnosed me as bi-polar (milder form), more than a handful of friends (that I’ve know since 19, I’m 40) just recently started to open up about their agreement with this diagnosis. Still wrapping my head around it
I have experienced ultradian (sp?) as well. I didn’t know it had a name! Awesome! Now I know what to tell my Doc. next week. It happens on my cycle. It could be PDD, though. Who knows?! I DO know that it is horrible!!
I absolutely need to keep reading and learning about my mind. The morning depression scenario is so familiar! Great post! I’m looking forward to reading more.
Thank you so much. I have never fit in those cycling scenarios because it never really lasts longer than several hours. Ultradian is so me. I am so happy to have a label now. Why?….I don’t have a clue.
You’re description of Ultradian Cycling sounds like exactly what I’ve been going through lately. I wake up and feel depressed and by nighttime I’m crazed. Right now it’s after 11pm and I’ve been pacing in the kitchen. My mind is working overtime and I can’t stop it.
The least I can do is get the dishes done.
Hi David,
Hey, don’t knock doing the dishes – wanna come and do mine? ;)
– Natasha Tracy
If nothing else, my wife will be pleasantly surprised tomorrow morning….
And hey, that’s not a bad result either ;)
– Natasha
Actually, Natasha… this is what I was looking for more or less.
I haven’t just been depressed for the past few months, I have been cycling since at least late January. It took a breakup for me to actually recognize the symptoms and now am realizing how my illness was the contributing factor (I couldn’t see the forest through the trees)
I am seeing a new shrink tomorrow, so hopefully we can a) change my medication, and b) get me back to stable.
Hi Carey,
I can honestly say we all miss the forest sometimes – the disease is like that; it’s very good at hiding in plain sight. It’s an improvement that you’re seeing it now though, and hopefully your new doctor can help. Once you know there’s a problem, you can actually work on fixing it :)
– Natasha Tracy
Have to say appreciate reading up on your very educating information regarding Bipolar , mental health as my husband had a break down last year! He was diagnosed with bipolar 2 however after numerous assessment hes bn told m$ay bé borderline personality disorder then manic depression, agitated depression! Then back to bipolar on going!! Unreal with all theses conditions and still no real outcome of what condition he has! However we re enclined to believe the first of bipolar 2 maybe right! It s so good to read and learn as there isnt real support and enough guidence and understanding for me as his wife! And seems to bé the case all over! A consideration that needs assessing after all i need the right knowledge and help to get my husband back to the man i married !
Hi Michaela,
First, bipolar disorder and borderline personality disorder can get confused by professionals and many people have had both diagnoses so he’s not alone there. Secondly, you might already know this but manic depression actually is bipolar disorder. They are two names for the same thing. Bipolar disorder is the medically correct term in North America.
I know it’s hard when no condition can be pinpointed but it can take time and experience with the person. Because it’s all about what the individual reports, it can be tough to know that you have it right. I know that might be of cold comfort, but try to remember, the treatment matters much more than the diagnosis.
I’m sorry you’re not finding support. Family members need it sometimes as much as the person with mental illness. If you contact a group like NAMI, they have programs for family members and make sure and ask the doctor about support groups as they may also be available.
Yes, you do need the right information, no argument from me here. I recommend you take a look at my resources page as these are resources I personally believe to be trustworthy: https://natashatracy.com/bipolar-and-mental-health-resources/
Good luck. Comment any time.
– Natasha Tracy
my mom and i will be going to the doctor in a matter of 11 hours. what am i gonna tell the doctor? what if he’d just tell me that i’m insane? help me. dont know what to do. asap please. tnx.
Hi Hungup,
You are _not_ insane. You are experiencing some symptoms that may be a mental illness. That is a medical problem just like any other. You are seeing a doctor just like any other.
It’s completely understandable to be nervous and even scared. That’s OK. That just makes you normal :) But you’re talking to a doctor, and there’s nothing special about them other than the fact that they have some knowledge you don’t have. Which is good, because it means they can help you.
Your job is to be an honest as possible with the doctor. If you have taken online tests that concern you, you could print one out and take it with you if that gives you a place to start your conversation. You might also want to write down the issues that concern you ahead of time so that you don’t forget when you’re actually in front of the doctor (which can happen when you’re nervous, believe me).
Just try to remember, the doctor is there to help, but they can’t if you’re not honest. You’re not alone. We’ve all been through what you’re going through right now. It’s scary, but you’ll get through it.
I hope that helps.
– Natasha
i know i have a problem.i looked up on the internet. answered some psychiatric tests and all of em said that i have bipolar. and yes i am experiencing these situations often. Should i go to the doctor? what kind of doctor?
i am 16 years old. i don’t know what to do. i haven’t told my parents yet. help me!
Hi Hungup111,
Keep in mind that _no_ online test can make a diagnosis, only a professional can do that.
I don’t know you or your situation, but here are some things to consider:
1 If you have a good relationship with your parent, sit them down and tell them first. Tell them what you have been experiencing and tell them why you think you might be bipolar. Try to look at it from a logical perspective if you can, rather than being completely emotional. I understand, of course, this might not be possible, but try to think about it that way so that your parents can get some information about why you feel the way they do. Then go to point three.
2 If you don’t have a good relationship with your parents, try another adult friend
3 If neither of those works for you, then talk to your family doctor (GP). Your family doctor should be able to refer you to a psychiatrist which is the person who should make the final diagnosis.
Also make sure you see a therapist to talk about your problems. Talk to someone who specializes in teen bipolar disorder.
And remember this: you are not alone.
See here for some mental health resources you can tun to: https://natashatracy.com/get-mental-illness-help/
– Natasha Tracy
Hi Natasha,
Excellent article and explanations.
I agree with what you’re saying.
I’ve experienced mixed moods when I had hypomania and later on when i developed mania and psychosis.
The good news is .. now I’ve Recovered!!
Hi Karen,
That’s great to hear and great for other people to hear too – recovery happens :)
– Natasha Tracy
I had been so frustrated by “rapid-cycling, intractable” bipolar disorder that I hadn’t done any research for quite some time.
Thank you for putting “Ultradian cycling” on my radar! That’s my everyday life! Now I know what information to hunt for!
Hi RapidSquirrelGirl,
I know the feeling of research burnout. If it weren’t for the fact that I write about this stuff for a living, I’m sure I would experience it too.
Happy I could help.
– Natasha Tracy
I am a psychiatrist who treats a great many patients with bipolar disorder. I have a questions for those of you with such a disorder who read this blog. I ask all patients not merely whether they have racing thoughts, which is a DSM-IV criterion for hypomania/mania, but also “crowded thoughts…” Crowed thoughts are likened to “too many people jammed into this office…” Crowded thoughts constitute the experience of having too many thoughts are one time.
My first questions are:
Do you experience racing thoughts without crowded thoughts when symptomatic?
Do you experience both racing and crowded thinking when symptomtic?
Do you experienced crowded thoughts without racing thoughts?
If you experience both racing and crowded thoughts which of the two bothers you the most?
I often ask patients, “if we could make just the racing thoughts or the crowded thoughts go away which would you choose to do away with?
What is your age?
What is your gender?
If you would be so kind, you may send your response via e-mail to “dilsavermd@aol.com.”
I thank you!
Steven C. Dilsaver, MD
Steven,
That’s a very interesting question and a very interesting point. I get what I might call “loud” thoughts which tend to be the same thought over and over again, louder and louder with an inability to control it. They aren’t disturbing thoughts, generally, just thoughts that invade my consciousness and won’t go away. Like a song that plays really loudly in my brain over and over and over for hours. And it absolutely makes me want to yell “shut up” as if it were a din in my office. I can’t really explain it but it’s like a din even though there’s really only one discernible voice.
Oddly, racing thoughts tend to be less “noisy.” Racing thoughts are just normal thoughts, but just really fast. And between the two, racing thoughts are easier to deal with short-term in that they don’t make me want to yell at my brain but are probably more damaging if prolonged as they tend to make any reasonable logical communication difficult if not impossible.
(In case you’re wondering, I’m a 33-year-old female.)
– Natasha Tracy
I experience “crowded thoughts”. I don’t think I have ever experienced “racing thoughts” Whether I am in an episode or not I tend to have a mercurial mind. I was also diagnosed with ADHD. I am 48 years old. I am a female I was diagnosed as having Bipolar type II at the age of 45. Before that I had never seen a psychiatrist.
thankyou
Carolyn
Have you mentioned somewhere about “switching”? Probably but I’ve missed it! You know, when the mood changes within a few minutes without any external prompting? I too am Ultradian – I worked that out for myself and my psychiatrist had never heard of the term! I occasionally get hit with a switch, and it can be very embarrassing. It sometimes occurs when I am speaking about something (overly?) elatedly and enthusiastically, when I suddenly feel the mood change and, sometimes within seconds, tears start welling up. Part of my recovery therapy was working as a volunteer in a school. I found this happening when I was trying to inspire a kid in a 1-2-1 situation, so it was pretty obvious that I was beginning to start to cry! Not good! Same thing sometime used to happen at business meetings. The “best” advice I got from the pDocs was “accept it as part of you…” All very well to say that on a philosophical level and I’d tend to agree with that – but such advice isn’t practical when trying to manage such an event in the middle of a business meeting!
Hi Graham,
Actually, I don’t recall an article on that topic in particular. It’s a good suggestion for one though.
Switching can be very difficult for those of us who do it quickly. We just read as “overly emotional” which isn’t exactly true. We’re overly bipolary-switchy. Which is a bit different.
All I can tell you is that while I can’t stop the moods, I have learned how to hide them better during times like business meetings. That’s the best I, personally, know how to do.
– Natasha Tracy
“We’re overly bipolary-switchy.” I like that and will borrow the phrase !!
I would love to hear more of your thoughts on switching, Natasha. There are times I can see it coming and times it happens in a flash.
Your postings have been dead-on for what’s going on with me right now. Thanks!
– Katie
Hi Katie,
Glad to hear you are relating. I’ll put switching down on my list of writing topics as I think you’re not the only one who would like to hear more about that topic.
– Natasha Tracy
You have really interesting blog, keep up posting such informative posts!
Again, really great information here. My own experience tends to be extremely rapid mixed states (hours to a day) followed by a typical days-to-weeks depressive state. I’m curious to know how the new DSM will address ultradian and ultra-rapid cycling. The current version seems to preclude diagnosis if the length of episode is not met. In the real world we can mostly agree people have bipolar even though we all have a different cycling speed. Will the new DSM acknowledge this, or just leave it for the n.o.s. category?
Hi Rob,
Thanks.
You’re in good company as that’s similar to me :)
The DSM-V is a bit of a cluster. It’s sort of like 20,000 psychiatrists all screaming at the page. It’s all a hodgepodge of ideas expressed differently. So it’s hard to tell exactly what’s up.
However, I see no reference to ultra-rapid or ultradian cycling so I don’t think it’s even up for consideration.
Of course, there is this odd thing, “Subsyndromal Hypomania – Short Duration,” which sort of fits with ultra-rapid cycling if you have mild depression.http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=494
But it’s all _so_ complicated we all could have very long diagnoses.
For example:
Bipolar type II
Subtype: Current or Most Recent Episode Depressed
Specified: With Mixed Features
Severity: 5=Markedly ill
All that, and no ultra-rapid cycling options. Like I said, it’s a complicated jungle out there in the DSM-V.
If you’re feeling masochistic feel free to peruse: http://www.dsm5.org/proposedrevision/Pages/BipolarandRelatedDisorders.aspx
(Oh, and they changed NOS to Unspecified.)
– Natasha Tracy