bipolar mixed states: all the flavors of suckage

July 8, 2007

People with bipolar disorder often have symptoms of hypo/mania and depression at the same time, and everything I’ve heard or experienced suggests that this is much, much worse than depression alone.  (The first time I had plain vanilla depression instead of anxious misery, I thought I was just fine because I was so relaxed after six years of unrelenting anxiety – it was entirely unlike what I thought of as “depression”.  I just couldn’t manage any stress, started crying all the time, and couldn’t function very well.)

Under the current DSM, in order to be diagnosed with a mixed state, you have to meet ALL the criteria for BOTH a depressive episode and a manic episode (not hypomanic, but actually manic) almost every day for at least a week.

In practice, though, things that don’t meet that definition – like depressive symptoms occurring with hypomania – still occur plenty often. For example, in a study published in 2005 that assessed mixed and euphoric hypomanias (i.e., mixed and regular) in 908 patients over 7 years found that mixed hypomania was more common than euphoric hypomania (and especially in women) (Suppes et al., 2005, cited in Goodwin & Jamison, 2007). You can get mixed symptoms at different levels of severity, for example “only” with hypomanic and dysthymic symptoms (I really recommend this link for anyone with a mood disorder who is stressed out and miserable all the time – when I first read that page I realized that maybe all those things I thought were components of my personality were actually related to mental illness. More on this when I do a post on personality and identity later.)

The notion here is that mania and depression are not polar opposites, but separate systems. This is where the idea of mixed states as mania + depression comes from.

But, more complicatedly, bipolar disorder may involve several separate systems each of which can be overactive or underactive, and which can cycle independently. Those mood, activity, and thought. So you can have euphoric or depressed mood; be over- or underactive; and have too rapid thought or too little thought. Dr. Jim Phelps of has a quick presentation of the ideas, complete with graphs and he cites the original which I have not yet gotten ahold of (MacKinnon and Pies, 2006).

So, according to this model, you can have different kinds of mixed states. Goodwin and Jamison go into more depth on each and I’m cribbing from that here, and adding some subjective descriptions (beware: anecdotes follow and may not be accurate).

Situation 1: depressed mood, manic activity, and manic thought. You’re miserable, can’t stop moving, your thoughts are racing and your concentration sucks.

Situation 2: you’re just as depressed (mood) and just as physically agitated (activity), but you can’t think. You’re going going going but you’re miserable and your brain just won’t kick in.

Situation 3: your physical energy bottoms out and your mental energy is going and going. You’re still depressed, and have no energy, but your thoughts are going like crazy. You’re miserable and you just sit there while your thoughts churn and you can’t stop them.

I don’t have intuitive descriptions for the euphoric mood ones (off meds my own mood stays almost exclusively in the depressed-dysthymic range), but I hope someone will share some.

Situation 4: your mood is euphoric, you’re overactive, but you can’t think.

Situation 5, a “manic stupor”, you’re still euphoric, but you can’t move or think – except occasionally when you (meaning, some but not all patients) suddenly get loud or violent.

Situation 6: “inhibited mania”, in which you’re euphoric, you still can’t move unless you suddenly get loud or violent (again meaning some, not all, patients) and you can’t stop thinking.

Whee.  Anyway, I like this research (and these classification schemes) because it accounts for a broader range of symptoms  than manic/depressed.  I really hope it’s going to leak into the hypersimplified and inaccurate common stereotype where bipolar disorder = unhappy vs. real real happy.