Have you ever felt that along with feeling down or depressed, you also experience other intense emotions and behaviors that seem out of character?
Understanding mixed states: The 4 A’s
Psychiatrists sometimes refer to mixed states as a condition where people feel a mix of high-energy symptoms (like those seen in mania) and low-mood symptoms (like those in depression) at the same time.
This can be very hard to identify because the symptoms overlap with other common conditions.
Roger McIntyre and colleagues outlined four key signs to look out for that might indicate this mixed state.
They call these symptoms the “4 A’s,” and they include:
- Agitation: Feeling restless or unable to sit still.
- Anger: Experiencing more irritability or outbursts than usual.
- Anxiety: Feeling intense worry or fear that doesn’t go away.
- Attention problems: Having trouble focusing or feeling like your thoughts are scattered.
If you’ve been feeling down but also have a couple of these “4 A’s,” it can be part of several different mental health conditions, like anxiety disorders, PTSD (post-traumatic stress disorder), ADHD (attention deficit hyperactivity disorder), or even what some call “borderline” traits.
It can be tough to figure out exactly what’s going on because many symptoms of these conditions overlap.
For example, if you’re feeling anxious all the time and can’t focus, is it more related to depression, anxiety, ADHD, or something else? It might seem daunting since all of these conditions share similar symptoms.
A spectrum approach to mixed states
Think of your mood as a colorful landscape with many shades rather than just black or white.
Previously, doctors used to categorize mixed moods based on very specific guidelines that were a bit rigid, kind of like only recognizing the North Pole and the South Pole.
But now, imagine we have this cool graph where we can map out our mood states.
Source: CANMAT Guidelines
On one side, we count how many high-energy (manic) symptoms someone has, and on the other side, we count how many low-energy (depressive) symptoms there are.
In the past, having a full-blown mix of both types of symptoms would place you in the upper corner of our graph.
The interesting part comes with some new thinking from experts who wrote the CANMAT and ISBD recommendations.
They’re suggesting that our emotional world is much more varied. So now, any combination of high and low-energy symptoms can be seen as a mix.
Instead, they want us to look at the most common high-energy symptoms that people experience when they’re in this mixed emotional state.
Enhancing diagnosis through your personal story
When you talk to your clinician about how you’re feeling, they’ll consider more than just your current symptoms.
They’ll look at:
- your family history,
- when your symptoms started,
- how they’ve changed over time,
- and how you’ve responded to treatments in the past.
This helps them get a clearer picture of what’s going on.
One tool that can help with this is something called the MoodCheck. It’s a quick way to collect information that can guide your treatment plan.
Publisher’s note. This article was initially published as the Quick Take “Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) Recommendations for the Management of Patients With Bipolar Disorder With Mixed Presentations“ at the Psychopharmacology Institute for a medical audience. It has been adapted for clarity.