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Mixed States

When symptoms of mania and depression are present at the same time it is referred to as a mixed state. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation.

Mixed states are believed to be under-recognized by mental health professionals, with approximately 40% of manic episodes having prominent depressive elements. Studies have shown that suicidal thoughts are greatly increased in people in the midst of a mixed state, and the presence of manic activation means a greater risk that these people will have the energy and motivation to carry out their suicidal plans.

Symptoms during a mixed state can vary, but most individuals experience a full range of both depression and irritable mania symptoms. The deep despair and hopelessness of depression often occurs simultaneously with the increased energy, and impulsivity seen in mania. Thoughts often race as in a manic episode, but the content is often dark and full of pessimism, worry, guilt, and self-hatred. Anxiety is also often a prominent feature of mixed mood states, evidenced by an increase in panic attacks and compulsions. Many persons with bipolar disorder describe mixed episodes as feeling much worse than either mania or depression alone.

DSM-IV Criteria for Mixed States:

The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

NOTE: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Treatment of Mixed States:

Treatment of mixed states can be tricky, as use of antidepressants can increase manic symptoms or induce rapid cycling. Many prefer treatment with some of the newer antipsychotic medications in combination with mood stabilizers. Care must be taken to ensure the safety of the patient, as the risk of substance abuse, suicide attempts, and other complications increases greatly during a mixed episode. Self-Injury and rage is also not uncommon.

Personal Descriptions of Mixed States:

Here are some descriptions of mixed states written by members of the BPhoenix support groups:

"It is impossible to explain the pain, anger, and exhaustion a mixed episode causes. It is to be filled with rage, at yourself and others and at the world. It is to have so much angry energy inside that you are sure you will explode. The mind can focus on nothing but death and hate. There is no reason. And there is no escape.
At least during a depressive episode you can escape in sleep, but when mixed there is no way out. There is no outlet for the fire, no way to ignore the pain of being."
- S.K.L.

"For me mixed states have always been moods of perpetual euphoria veiled with clouds of dread. Not enjoyable."
- kalith

"Mixed states are my most frequent. They vary - some more manic and some more depressive. Prefer the latter, seemingly have more control of these. In the last few years I seem to be having more mood states than not."
- Nicolette


All information contained in this web site is strictly for informational purposes only and is not intended as a substitute for consultation with your medical doctor or psychiatrist.
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This Site Updated 04/09/11