Tripolar Disorder

Mixed mania is a type of depression, but it’s very hard to explain it to people I work with.  In the view of mental health professionals, it makes a lot of sense to talk about a “mixed” state, which is a state of depression that generates lots of energy and agitation.

The lethargy and slow speech of “typical” depression looks very different to an observer than the severe agitation of the mixed depressed state, but from the perspective of the person who is experiencing the mood, calling it “mixed mania” makes no sense at all.  A mixed state feels very similar to a severe depression and feels not at all like the euphoric state of a typical mania.

How many states are there?

I think the problem is that we have this word called “bipolar” and we are essentially trying to shoe-horn people’s subjective experience into a two-state model when, in fact, there are three (and sometimes more) states, each of which is very different and distinct. That’s why it may make more sense to the patient to speak of “tripolar disorder”.

The reason we think of mixed states in this way is that it helps us as practitioners make sense of a complicated phenomenon, and it helps us when we are thinking about treatments. A mixed state is not the same as a “typical” depression, and treating it as if it were, (for instance adding an antidepressant or some other “upper”) would be like pouring gasoline on a fire.

What are the three states of tripolar disorder?

  1. The first is a lethargic (slowed down) and obsessional kind of depression. In this state, the person feels like staying in bed a lot, looks slowed down and shows very little emotion. It’s very hard to make any decisions, any choice is thought through over and over again.
  2. The second state is the “classic” manic state: generally, very positive and optimistic with lots of energy and ideas, talking a lot and e-mailing or texting people and perhaps more interest in romance and sexuality.
  3. Finally, there is the “mixed” state. This is often a very unpleasant experience. It is associated with lots of negative thoughts and judgments and a great deal of internal agitation as well as irritability. It may be a relatively stable state, or it may involve rapid fluctuations of mood from depression to agitation and perhaps even classic mania. In other words, it’s a turbulent, negative, critical and agitated state.

Diagnosis of bipolar with anxiety and/or mixed mania can be tricky, and practitioners need to go slow and listen carefully to the patient’s description of their experienced moods to be sure they have a clear path forward with treatment.