Mixed episodes

People who read about bipolar will have heard the disorder summarised as follows: bipolar disorder is a mood disorder where sufferers will experience both manic highs and depressive lows. When someone is manic they feel elated and on top of the world. They may spend more, talk rapidly, take on new projects, have grandiose ideas, feel sped up, indulge in risky behaviours and may be extremely restless.  When they are depressed they have a low mood, feel alone and worthless, have no energy or motivation and may have suicidal thoughts. The textbook bipolar person has periods maybe lasting a few months of both mania and depression and will have periods in between this of normal mood.

However, this picture is too simplistic. Bipolar sufferers may not (or only rarely) experience normal moods. They may experience many other mood states that sit somewhere between these mood poles. First of all, it is very common for bipolar sufferers to experience periodic or constant anxiety. I have always had an unhealthy level of anxiety. I worry about everything and often withdraw from situations that lead me to feel anxious. I suffer with the constant feeling that something bad is going to happen and sometimes this gets so bad that I have panic attacks. This can happen whilst I am manic, whilst I am depressed or in between mood states.

The other kind of mood state which many people suffer from is called a mixed state. I am unsure of how many people suffer with these (I can’t find reliable statistics) but I think they are a fairly common occurrence with bipolar sufferers. Basically a mixed state is when someone experiences both elements of mania and depression simultaneously or in rapid succession.

When I suffer from mixed states, I may feel an incredible sense of well-being and euphoria for a few hours and then crash into a depression where I feel hopeless and worthless and can’t stop crying. These rapid mood changes are very disconcerting and seem to occur for no obvious reason, i.e. there are no external events that seem to justify the mood change or certainly not its intensity.

Even more confusing is a mixed state where you feel depressed and manic at exactly the same time. How can this be possible? Mania and depression appear to be opposite kinds of moods. However you can have some symptoms of mania and some symptoms of depression happening together. This is the kind of mixed episode that I experience regularly. These mixed states may occur in a number of different variations.

I sometimes experience what I call a mixed-manic mood state (this is just my terminology, not an official diagnosis). In this state I primarily have symptoms of mania but also have one or more symptoms of depression. When I have mixed-manic states my brain feels like it has been electrocuted. I have racing thoughts where I am thinking too quickly and my brain keeps jumping around topics in a hectic, unpleasant way. I may start rapidly talking about a favourite topic without making much sense whilst pacing up and down. I feel an intense drive to get on with things and start new projects. I approach them in a chaotic and disorganised way. I start to see things moving and the colours look all crazy and bright. Basically I have all the energy and sped up feeling of a manic episode but I feel none of the euphoria associated with mania. Instead there are feelings of despair, distress and irritability. I want to hurt myself and stop the horrible buzzing brain feeling. You feel like you have been wound up tightly and sped up but your mood is all negative.

Another state I experience is what I call  a mixed-depressive state. In this state I primarily have symptoms of depression with one or more symptoms of mania. I am in this kind of state now. I feel like I have no energy and there is no point to anything. I can’t concentrate on anything or think straight. My head is full of negative thoughts about myself and the world. My whole body feels slowed down and heavy. I don’t want to wake up in the morning as it means another day is ahead of me. I have all the low mood of a depressed episode but also something else: my brain feels like it is buzzing. Unlike a typical depression I feel mentally alert. I feel agitated and like my brain and like my body don’t belong together. I end up crying and wailing on the floor and I can’t stop thinking about hurting myself. It almost feels like someone is scratching a blackboard with their nails inside my mind. I want to scream to make it stop.

I have just described two kinds of mixed states which I have experienced but I am sure that there are many kinds of combinations of mania and depression. I personally find mixed states by far the hardest to deal with. You have all of the dysphoria of a depression but somehow the mental agitation of mania. It is a state that for me often leads to some of the more serious symptoms of bipolar. For example, I may start to feel very paranoid that I am being watched. Probably because I am having the negative thoughts associated with depression but the extreme mental energy that leads to excessive rumination. I may hear voices telling me that I must die. I may experience agitated catatonia where I can’t stop pacing the room round and round in circles, often screaming, crying and babbling words over and over again. This is down to the horrific feeling of both mental agitation and dysphoric mood.

In my experience, severe mixed episodes are not treatable by cognitive behavioural therapy (CBT) or relaxation techniques. Although these may help many people in other scenarios, when you are experiencing a severe mixed (or manic) state you are too ill for any rationalising or calming. You need medication to physically force your body and brain to come down from their extreme energised state.

CBT and relaxation techniques may prove to be useful when you are calm enough to be able to engage with them. Hopefully, a combination of approaches together with medication can help prevent mixed states from reoccurring. I have yet to find the right method of coping with these states and hope that mine will become less severe as I learn new techniques and try new medications.