What is a Mixed State?

While many people think of untreated bipolar disorder as mood swings that range from manic or hypomanic to depressed states, the mixed state can also be a feature of this condition. It is arguably one of the most dangerous and difficult for those with mood disorders. Instead or being solely manic or depressed, bipolar I or II sufferers may become ill with a condition where they have aspects of both poles. This is often divided into two diagnostic subgroups called dysphoric mania and agitated depression. Both conditions are challenging and increase a patient's risk for self-injury and suicide because they are so difficult to bear.

In dysphoric mania, the person is principally manic, but has other symptoms that are consistent with depression. This form of the mixed state is more common in bipolar I, though it may occasionally occur in bipolar II, especially if people receive medications like antidepressants that may create mania. Generally, the patient with bipolar II has hypomania and does not progress to full mania.

The features of depression that may be present in dysphoric mania are usually more active and energetic than sad or desolate. A person could be extremely angry or filled with fury, but at the same time be profoundly suicidal. Sometimes this mixed state progresses to the highly delusional and people with dysphoric mania may hear or see things that are not there, believe they are being persecuted, or in other ways lose touch with reality.

Agitated depression is in contrast to dysphoric mania, and its principal feature is depression. This is usually accompanied by hypomanic symptoms like restlessness, inability to sit still, racing thoughts, poor sleep, and activities like wringing of the hands. People with bipolar II disorder, when in a depressed state, may be more prone than bipolar I sufferers to experience this mixed state. Although it is possibly "quieter" than dysphoric mania, it is no less dangerous, and people can easily become obsessed with the idea of suicide, in part to escape what seem like inescapable thoughts and feelings.

Anytime a mixed state occurs, it indicates that the person suffering is not being adequately medicated or requires adjustments to their medication. For both types of bipolar disorder, treating the individual is a matter of fine tuning and finding what works. Using a mood stabilizer like lithium, lamotrigine, carbamazepine, or divalproex is usually the first step, but additional medications may be needed to treat other symptoms. Atypical antipsychotics may form part of a treatment plan, and sometimes medications like tranquilizers or antidepressants are also used, though the latter must be used with care to avoid inducing a mixed state or a manic episode.

Depending on the patient, initial medication changes may be undertaken in a hospital to minimize the risk that the patient will harm him or herself. Others, under the vigilance of family and friends, get through these states and medication changes at home. Finding the right medication combination can take time, and as long as a person remains in this state, they need careful surveillance and support.