Mixed States

(updated  12/2014)

This is a copy of the material from my Diagnosis page, placed here for ease of access to this important, poorly understood issue. If you have already seen it there, move on.

Anxious depression could be “bipolar”?!

An international group of expertsISBD described anxiety in bipolar disorder thus:

  • General hyperarousal
  • Inner tension
  • Irritability /impatience
  • Agitation
  • “Frantically anxious”

These symptoms are not generally regarded as symptoms of bipolar disorder. Unfortunately, the very name “bi-polar” is misleading. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The “racing thoughts” can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: aninability to sleep, a desperate wish to be able to sleep to get out of the agitated state.

What is a mixed state?

One way to understand these symptoms is called “mixed states”. Bipolar disorder is an unfortunate name, as it implies a North/South Pole experience.  A better picture looks like this graph:


Both manic symptoms and depressive symptoms at the same time? Sure enough. Not intuitive, if you think North/South pole. But these symptoms can vary independently or occur together (For more on that, see mixed states as waves of depression, anxiety, and normal time.)

This is not controversial. Mixed states were officially recognized in the 1994 version of the DSM, and expanded to look more like the graph above in the 2013 version.

What’s the difference between “anxious depression” and a bipolar mixed state? Not enough to easily be able to tell them apart, unfortunately. The same group of experts quoted above also said: “some but not all agitated depressed states are bipolar.”ISBD

Worst of all, mixed states can be caused by antidepressants.ISBD Yet antidepressants are what depressed patients commonly receive, of course.right?  But some of those depressed folks have bipolar depression. The antidepressants can take them from pure depression to agitated depression. The good news is that slowly coming off the antidepressant is one way to address anxiety.Phelps Don’t do that on your own, of course. Here are some guidelines on stopping antidepressants in bipolar disorder.

Bottom line

Bipolar disorder is complicated, much more complex than “bipolar” (North/South) implies. Anxious depression can be bipolar. Tense, irritable agitation can be bipolar disorder. For more, see the Anxiety and Bipolar page.