Experiences with Mixed Episodes
Mixed episodes are, for me, the worst thing about Bipolar Disorder. Yet I experience them more regularly than mania or depression alone, even on medication.
What is a Mixed Episode
A mixed episode, or episode with mixed features as it is now classified, happens when symptoms of mania and depression are experienced at the same time. To read more about the diagnostics of mixed episodes see my post on them here.
What does a Mixed Episode feel like
Mixed episodes are incredibly hard to explain to somebody who isn’t Bipolar due to the addition of mania to depression. Mania is the lesser understood side of Bipolar Disorder. People are becoming more and more aware of depression and its symptoms, which can make it harder to understand the difference as it contains lesser experienced symptoms, or symptoms experienced differently to what most people have come to understand.
Mixed episodes are always just described as ‘uncomfortable’ and well, this is both a good and bad description of the feeling.
Yes it is incredibly uncomfortable, I have at times felt physically hot due to the intense energy and agitation I experienced in mixed episodes. It felt like a fire inside that has nowhere to go, no way out. It is a lot more however than just uncomfortable, it is life threatening. Mixed episodes increase suicide risks significantly. In this post I will outline some of the symptoms I experience in mixed episodes.
Shifts of Dominance
Mixed episodes consist of both mania and depression, one is usually seen as predominant and the other like an unfortunate add-on to the mix. Therefore you may suffer with mania or depression with mixed features under the DSM5.
I experience this as a shift over time from feeling more manic or more depressed, however this is not a full shift, just the dominant mood will change over. These shifts occur over the course of a few days or occasionally throughout the day I will experience the shift noticeably taking place. Noticing these shifts takes a great deal of self awareness but for me can be achieved through noticing individual symptoms such as those listed below.
Intrusive Thoughts and Suicidal Ideation
Intrusive thoughts are one of the worst things to experience within Mixed episodes. For me they start off quite mild, telling me I am a bad personality or bad at my job but these develop into suicidal ideation where the thoughts tell me to kill myself. For those who know me don’t worry, I won’t listen to these thoughts.
Suicidal ideation is a common symptom of bipolar disorder, hence the suicide rate of 1/4 people with Bipolar. Suicidal ideation can range from mild visions or urges of getting hurt or just disappearing, to violent flashing images and disturbing urges to cause serious physical harm to ourselves.
I experience theses thoughts too often in mixed episodes and the longer the episode goes on the more frequent and severe the thoughts become.
They do occasionally go away on their own at the end of the episode, but generally the best course of action here is medication to get the brain stable as quickly as possible.
I have reason to believe that the intrusive thoughts experienced in Bipolar Disorder are different to those experienced by many without the disorder. The reason I feel this way is the coping mechanisms I have come across.
For example one that was suggested to me was ABC, standing for Activating event, Belief, Consequences. The general idea is by identifying the activating event and the belief behind the thought you can overcome it. However this just does not work for me. Firstly there is no activating event. They just pop into my mind at random intervals. Secondly there is no underlying belief, I never agree with the thoughts. I have no desire to hurt myself, no belief that I am a bad or undeserving person. The thoughts are not my thoughts, and that makes them scary as hell.
Crying is a common symptom of depression and therefore can be experienced as part of a mixed episode. In a mixed episode crying will be experienced along side mania. This means you get all those wonderful happy feelings (or horrible agitated ones!) but will have seemingly random outbursts of tearfulness or crying.
This happened to me recently in the car, I was feeling elated driving to work, singing along to my music when I just started crying for no reason, it wasn’t prompted by anything, a thought, a sad song, nothing. This lasted for about 5 minutes then completely went away, leaving me feeling stupid and confused.
The difficulty comes with symptoms like this when you are so used to identifying symptoms of mania or depression, you don’t expect a misfit to take place. Even if like me you experience mixed episodes frequently. It is confusing to know if its a mood swing or a mixed episode. That day I was ready to be more hypomanic then everything else and was prepared with ways to not step over any boundaries of appropriateness whilst in that state, I had nothing ready to combat random crying so it caught me off guard.
Surges of creativity and motivation
Heightened feelings of creativity and motivation are symptoms of mania, whereas lesser feelings of both of these are symptoms of depression. In a mix episode you experience both, either simultaneously or in phases. When they switch it is quite frustrating, you can be in the middle of something and suddenly lose interest or the mental ability to continue and then you just sit and stare at the thing. Having both at the same time is even more confusing, you both really want to pursue this great idea you have but at the same time have no desire to do anything at all.
This is more frustrating than dangerous, I cant see this resulting in destructive behaviours other than getting agitated over the experience. It is still unpleasant.
Changes in Energy
Similarly to creativity and motivation a feeling of heightened energy is a symptom of mania and a lessened feeling is a symptom of depression. Again, this is very frustrating to experience, perhaps more so when you suddenly feel so exhausted it is like you cannot move. The heightened energy can be unpleasant too when it forms anxiety, jitteriness and overthinking start to occur as the mind and body go into overdrive.
To cope with this, particularly at work, I ensure I stay focused during the heights and get as much work done as is possible so that I have some leeway when I haven’t got the mental capacity to do very much.
Irritability is part of Mania, too much energy in your mind and body leads you to feel like things aren’t happening fast enough. Before the onset of the DSM5, the DSM4 categorised mixed episodes as either agitated depression or dysphoric mania. It is the agitated depression that causes the irritability causing you to have an extremely short fuse for no apparent reason.
This can be problematic, at work, within relationships, even within your own wellbeing as it is not a nice feeling to experience. This is difficult to deal with and manage but the best approach honestly here is to just remove yourself from situations you might damage as much as possible, don’t go out socialising, work alone etc. Staying away from people for me lessens the triggers for the irritability and agitation and also means I don’t damage any relationships as a cause of the symptom.