Understanding Mixed Affective State
I’ve battled the furthest poles of bipolar, ranging from the depths of suicide to the highs of euphoria and psychosis, and every state is challenging. However, the most difficult state I have had to face is the mixed affective state. It is, for me, the most dangerous, terrifying and testing.
What Is a Mixed State?
In mixed episodes, manic and depressive symptoms occur simultaneously or extremely close together.
The Merck Manual of Diagnosis and Therapy (MMDT) splits the diagnosis into two further states:
- Dysphoric mania, which consists of a manic episode with depressive symptoms
- Agitated depression, which is a major depressive episode with overlaid hypomanic symptoms
Increased Suicide Risk
Unfortunately, statistics show that compared to other phases of the illness, the incidence of suicide attempts is much higher during mixed states. I have experienced this risk first-hand.
Although I have never attempted to take my life in a mixed episode, I was flooded with impulsive suicidal thoughts and graphic images, and as a result, formulated plans. Without my family and professional intervention I have no doubt I would have taken action on these plans as they were steadfast and I was focused. It was a very scary place to be.
What Triggered My Mixed Affective State?
Mixed states can occur in transitions between depressive and manic periods. I found my experiences were usually fueled by some sort of chemical reaction.
My most serious mixed states, in both 2008 and 2015, were triggered by serotonin syndrome, a rare poisoning of the nervous system due to medication interactions. After experiencing depression and feeling its physical impact, the onset of irritability would usually hit first combined with impulsiveness.
My Story
Mixed states are double the trouble: all the symptoms associated with both mania and depression are thrown into one pot and intertwined to isolate, confuse and frighten and it can feel impossible to contain.
Initially I felt completely alone, encapsulated in my own world. I didn’t take any interest in anything and I hated myself.
I started to write suicide notes in my head to friends and family, which was my sign that I had fallen into a deep, dark depression. I cried myself to sleep doing it every night. My bed was my home and I cared for nothing but my thoughts.
My Story
Entering a Mixed State
I developed symptoms for a mixed episode unexpectedly, and as a result I lost insight. I couldn’t prepare myself or ask for help because I was too far gone too quick.
It started with an uncomfortable feeling in my body where I felt boxed in and desperate to move — it didn’t feel good. I was agitated and it made me desperate for help, but I couldn’t reach out to anyone.
My irritability increased; it became impossible to communicate with people without misunderstanding them. Everyone and everything was a trigger and I internally begged for relief.
Things got worse as bipolar sound sensitivity or bright light triggered a feeling that made me think I was going to lose control. I didn’t want to be violent, but I felt like the Incredible Hulk, desperate to rip my skin off and release the pent up anger, irritability and energy.
Destructive Behavior
One of the most destructive symptoms was the impulsiveness. I suddenly wanted to drink alcohol after not caring about drinking for a long time.
I didn’t want to raise alarm to anyone so I started going to the local shop and drinking in the churchyard on the way back home. I don’t know whether subconsciously I was trying to subdue my manic symptoms, or whether my drinking was just a product of my impulsiveness. Regardless, I felt concerned for myself and knew it was out of character.
As the agitation increased, so did my need to self-harm. It was my only release when I was distressed. I knew it was serious, but I couldn’t tell anyone.
I didn’t have the capacity to take on any advice and the mere thought of explaining my symptoms to another was overwhelming. I was too busy fighting my thoughts telling me I was nothing and it was my time to die.
The combination of impulsive drinking and irritability spiraled one night into an act of violence where I tried to attack my dad. I had never been violent before, but an insensitive comment upset me and his lack of understanding towards me taking offense triggered a burst of anger. My family was disappointed in me and the guilt sent me deeper into my world of isolation.
Intervention
The lack of hope overwhelmed me until there was none left. I told everyone around me I was trying to pull on any emotive thought to try to save me. I thought of my little niece, who is my world, but nothing reached me.
My uncle spoke to me on the phone one night and drove hours to visit me the next day. He said he had never heard me so cold and monotonous. I can remember that phone call and I remember telling him if anyone called me selfish for wanting to die, they were selfish themselves.
I believed that anyone asking me to fight this life was asking the impossible. I am not a religious person, but I questioned how any god could put a person in so much beastly turmoil and expect them to live through it.
My Story
The crisis team visited me at my sister’s house because I decided my family home was full of triggers. I was given a bed in a local psychiatric hospital for respite. Unfortunately, the mixed state continued and I argued with any nurse who spoke to me out of turn.
Interestingly, I still stand by most of my comments and feelings as a result, it’s just my illness exacerbated them to the point I couldn’t control them in a calm and more effective manner.
Treatment
Unfortunately, mixed states offer therapeutic challenges and are more difficult to control than a pure episode of mania or depression. The main drugs used to treat mixed states are mood stabilizers and antipsychotics.
Common antidepressants have been shown to worsen mania symptoms without necessarily improving depressive symptoms in mixed states. Most experts therefore advise against using antidepressants during episodes with mixed features.
What Helped Me?
- Telling a professional about my symptoms and concerns. For example, phoning a mental health helpline and the crisis team who visited me at home.
- Educating my family and setting boundaries to avoid triggers and hostile situations. For example, giving me personal space and being mindful of uncontrollable irritability.
- Receiving calm, patience and understanding. Asking family and friends to speak to me in a kind, low tone of voice.
- Including family support in meetings where you discuss treatment and progress with all consultants and nurses. It is here family can listen and be educated further about the severity of mixed states.
- Allowing respite in hospital. The body needs time to calm itself from its stimulated, high alert state.
- The prescription of benzodiazepines (sedatives). These are often required when symptoms reach such a peak that self-harm, aggression or suicide are concerns.
- Reviewing medication. For example, introducing new mood stabilizers and/or the decrease of anti-depressant use.
- The use of mood charts. These are helpful to monitor how often the mood is changing and when improvement is evident.
- Continual professional support throughout recovery. Counselors and other members of your health care team offer constant reassurance that things will get better, and recommend coping strategies to get through the difficult mixed state phase.
As outlined, mixed states are one of the most difficult and dangerous phases in bipolar, but may be unavoidable. For me, the only route of treatment is telling a professional because it can be hard for family to cope with.
Medication, sedatives, therapy and support is often the framework for progress. It is difficult, but I am living proof you can recover from mixed state episodes.