Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 2
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.
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
- 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
- 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