Mixed States

Mixed states are thought to look different in everyone, and a single person might experience multiple different mixed states.  If you think you are experiencing mixed states, the best thing to do is to consult a psychiatrist.

My opinion is slightly non-standard, but I like to think of it this way: mania is an episode centered around feeling good and depression is an episode centered around feeling bad.  I believe there are other feelings that can anchor an episode such as anger, or fear.  In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience.  So that anger becomes a rage episode and fear becomes a paranoia episode. These emotional episodes are called mixed, because they are said to have symptoms of both classical mania and depression.  For instance a rage episode might be considered energetic and may also involve suicidal thoughts.  Or a paranoid episode might be sleepless and may also involve difficulty with concentration.

Recognizing Mixed States
The definition of a mixed state is still being developed.  Here is what the DSM IV-TR says:

A. 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.
B. 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.
C. 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)

There seems to be considerable discussion about how the definition of mixed episodes should be written.  Some doctors require a few symptoms from both mania and depression, other doctors require more than a few symptoms.  Some doctors will disagree on the classification of a particular symptom, for example, extreme fear and it's cognitive dysfunction, into mania or depression.

I believe that mixed states are particularly difficult to diagnose because the subjective experience of the person who experiences them is so much different than the objective experience of an observer.  I also believe that this is an instance where language fails to capture the experience and discussion of these things is extremely difficult.

I believe that I experience mixed episodes, both anger-based episodes and fear-based episodes.  Detecting the onset of these episodes is critical.  Since I have been experience anger episodes, I have long since learned to spot the change in thinking that accompanies it.  Fear-based episodes are more challenging, and I have a two-pronged strategy to detect thought changes and cognitive decline.  To detect changes in my thinking process, I compare my current thoughts to past thoughts about similar situations.  To detect the fear-induced cognitive decline, I use my activity log (discussed in depression). When there is a sudden gap in my productive activities, I try to determine whether the cause is a depressive episode or a fear-based episode, and my overall emotional tenor usually answers this.

Preventing and Treating Mixed States
Similar to mania and depression, drugs are commonly thought to be the best treatment.  The appropriate drugs include mood stabilizers and anti-psychotics.  There have been a number of studies claiming that mood stabilizers are less effective for people who experience mixed episodes than those who do not.  It is not clear why this might be or what to do about it.

Drugs are not the only treatment, it is necessary to employ other coping skills.  In this it is best if the person with bipolar takes charge of their illness, as attempts to force the person to comply will likely destroy the very trust needed for success.  This can involve contingency planning for future episodes.  Discussions with family can cover when family might be requested to aid in decision making.  A high level of trust is required to make such discussions useful.  (Note, trust will be broken if family involve themselves in decision making without permission.)  If family is not available, one can turn to close friends, often termed chosen family.  As part of contingency planning, one can decide at which stage of an episode voluntary hospitalization will be sought.  Having a plan ahead of time makes implementation easier.

Whereas for depression I mentioned that keeping an activity log could be helpful, I am not sure that is helpful during these episodes.  In my experience these episodes get entrenched much faster and much deeper than some depressions.  I do, however, find the activity log useful for charting recovery, and it is encouraging to use the log to watch improvements in activity levels and cognitive function.