Mixed Moods in Bipolar - The Most Dangerous Mood?

August 8, 2011 Natasha Tracy

I talk about bi-polar disorder. As in, two poles - mania/hypomania and depression. The name is extremely descriptive.

But as it turns out, there is something in the middle (besides normalcy, whatever that is); it's called a mixed mood episode. Mixed moods possess distinct characteristics of both depression and mania. Mixed moods severely impair judgement and carry a significant risk of suicide.

What is a Mixed Mood?

According to the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) a mixed mood must meet both the criteria for both depression and mania, although the depression only has to be present for one week whereas for a standard major depressive episode symptoms must be present for two.

That means you must show four distinct manic symptoms and five depressive symptoms.

Well, in clinical practice this is rarely the case.

42-17207233Mixed Mood Episodes in Reality

According to the DSM-IV-TR definition, mixed moods de facto only occur in bipolar 1 (as they contain mania). We know this isn't actually the case. Those of us living with bipolar 2 can tell you, we get mixed moods too. You don't have to be manic to be mixed.

Additionally, specifying three or more manic symptoms plus five or more depressive symptoms is extremely restrictive and subjective as some symptoms cross over from mania to depression. Insomnia can indicate mania or depression but obviously, in and of itself does not indicate a mixed mood.

New Criteria for Mixed Mood in the DSM

Now that the DSM is undergoing revision, there is an attempt to capture some of the issues seen in clinical reality and alter the current mixed mood definition. It's a step in the right direction.

How to Cope with Mixed Moods

The first thing to do is to recognize that you are having a mixed mood and to report it to your doctor as soon as possible. As I said, mixed moods carry an increased risk of suicide and that should not be taken lightly.

Your doctor may wish to change your medication at this time. For example, a newly-added antidepressant may be contributing to the mixed mood and your doctor may wish to discontinue it.

For reference, the following medications are FDA-approved for the treatment of mixed moods in bipolar disorder:

  • Carbamazepine (Tegretol)
  • Aripiprazole (Abilify)
  • Ziprasidone (Geodon)
  • Risperidone (Risperdal)
  • Asenapine (Saphris)
  • Olanzapine (Zyprexa)

These medications treat mania as well as mixed moods are currently considered a manifestation of mania; although doctors now recognize that, clinically, depression may be the predominant state rather than mania.

CB034623My recommendations?

Medication, yes. Doctor, yes. But also, try relaxation exercises. In my experience, mixed moods feel like they are ripping your body apart with serrated teeth and then pouring lemon juice all over you. They are highly unpleasant bits of business.

If you meditate - do it. If you do yoga - do that. If you normally don't do relaxation exercises then just sit quietly with your back against the wall and take deep breaths with your eyes closed. Focus on the rising and falling of your chest. Slow the breath. Feel the diaphragm expand and contract. Do this for as long as it takes to try to feel a bit more put together.

Mixed Mood Warning

But know this, mixed moods can severely impair judgement; so all the coping techniques in the world might not help you. The moment you feel like you're a danger to yourself or if you know that you cannot function in a mixed mood - get help. Mixed moods are dangerous; don't let them be the thing that bites you and never lets go.

You can find Natasha Tracy on Facebook or GooglePlus or @Natasha_Tracy on Twitter.

APA Reference
Tracy, N. (2011, August 8). Mixed Moods in Bipolar - The Most Dangerous Mood?, HealthyPlace. Retrieved on 2024, July 15 from

Author: Natasha Tracy

Natasha Tracy is a renowned speaker, award-winning advocate, and author of Lost Marbles: Insights into My Life with Depression & Bipolar. She's also the host of the podcast Snap Out of It! The Mental Illness in the Workplace Podcast.

Find Natasha Tracy on her blog, Bipolar BurbleTwitter, InstagramFacebook, and YouTube.

August, 9 2011 at 1:44 pm

So is mixed moods the same thing as relationship books will tell you to "take a walk for 15 minutes so that you can think straight again"?

August, 10 2011 at 1:04 pm

Roger: isn't being able to think straight again after 15 mins called "normality"..??!
Natasha: A few months ago I got into a state where my mood was high and yet I had suicidal thoughts. I was hallucinating vividly. One particular day I was high in the morning, depressed (catatonically so) in the afternoon, then so high in the evening my friends thought I had taken some drug when actually I was stone-cold sober. I never did find out whether this was "rapid cycling" or a "mixed state". According to the ICD10 it's a mixed state because I had full symptoms of mania and depression in the same 10-day period. The ICD10 criteria specify that the mania and depression may alternate over a period of hours as well as being concurrently present. I have to say the depression I felt then has to be the all-time worst. It's the only time I truly felt mentally wounded and injured. Normally no matter how bad I feel in the moment, I'm able to shrug it off afterwards, but not then.
PS are you diagnosed bipolar I or II, and do you agree with the diagnosis?

Natasha Tracy
August, 10 2011 at 2:14 pm

Hi Gledwood,
I would characterize that as a mixed mood - pretty classic actually. You were experiencing mania - the tell-tale sign in your example is that you were "high" and hallucinating. And the suicidal thoughts are obviously indicative of depression.
The area of mixed moods vs rapid cycling is one in which I'm discussing on my personal blog in a four-part series on mixed moods:ā€¦
(Note: that link is to my personal blog and is in no way affiliated with HealthyPlace.)
Depression can also contain psychotic thoughts like hallucinations, and I think most doctors agree that yes, psychotic depression is a very severe variety.
Mixed states can be more dangerous than either state alone and carry a risk of suicide. Believe me, you're not alone in finding them very scary and hard to handle. They are very serious.
Since you asked, I'm bipolar II, and yes, I agree with the diagnosis; I knew it long before they did.
- Natasha

jennifer a
September, 14 2016 at 4:50 pm

Mixed is Mania where your brain is speeding but you often get very depressed and have a lot of energy, and your mind may be speeding that you want to die all at the same time.
Speeding mentally and you cant slow down, and crashing, you may want to die.
Get medicine from Dr that will slow you down like anti=anxiety pill and lay down. Water tends to help me due to Oxygen in water.

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