The “Mental Tug-of-War” of Bipolar Mixed Episodes

Last Updated: 13 Aug 2020
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Mixed episodes of mania and depression aren’t easy to spot, but when they hit, they’re among my most exhausting experiences. Not only did I learn how these mood episodes affect me, but I realized the risk they carry—and that is my biggest fear.

mental tug-of-war bipolar disorder mixed episodes mania depression suicidal thinking anger

“Mood Episodes with Mixed Features,” aka Bipolar Mixed Episodes

Something that I don’t talk about often in public is mixed episodes. According to the DSM-5—the Diagnostic and Statistical Manual of Mental Disorders, which is the manual created by the American Psychiatric Association to outline the criteria for mental health conditions and treatment—these mood episodes are no longer considered distinct episodes on their own. Now they are considered a “specifier,” or a feature of another mood episode.

But, not being a medical professional, and for the sake of this writing—so I don’t confuse anyone or myself—I’ll use the phrase “mixed episodes.” Mixed episodes are yet another of what I call the “twisted” components of my bipolar disorder. I probably experience mixed and depressive episodes more often than full hypomanic or manic episodes. Not only that, it’s a part of my disorder that sometimes concerns me more than depression or mania. At least with depressive and manic episodes, I know distinctly what they are. Mixed episodes aren’t as easy to spot, but when they hit, they’re among my most exhausting experiences.

While I’ve heard of them before, the first time that I can recall being told that I have experienced mixed episodes was about eight years ago, when a psychiatrist had me take the Minnesota Multiphasic Personality Inventory (MMPI) and determined that I had traits of hypomania and “agitated depression.” Being the overly curious guy that I am, I looked it up and saw that it was one of two names for mixed episodes.

Like with almost everything else that I continue to learn about my bipolar disorder and the experiences of others, it was confusing but started to make sense. It explained why even during my depression that lasted from 2008 till around 2012 or so, excluding the almost half-year-long manic episode in 2011, I had moments when I would feel hyped and energetic, while also miserable and not wanting to get out of bed or see the world at the same time. My therapist at the time was very concerned about these episodes; she warned me that people experiencing mixed episodes were more prone to attempting and following through with suicidal thinking, so she paid close attention while lecturing me about taking my medication… I was notoriously noncompliant with my medication regimen back in those days and it showed.

The Exhaustion of Mental Illness … Amplified by Mixed Episodes

My personal experiences with these episodes, again, is that they are very exhausting. I can’t emphasize that enough. Mental illness is exhausting as it is, but I would say mixed episodes are just another beast altogether. It’s very conflicted for me, especially since these episodes are not as distinct and obvious as manic or depressed episodes are. One of the best ways I can define it is almost like a “mental tug-of-war.” Or perhaps imagine trying to mix gasoline with water and throwing a match into it. If either analogy didn’t make sense to you, you can now imagine the itch in my brain that it causes.

If you’ve followed any of my other blog posts, I’ve talked a lot about how difficult bipolar depression is for me. I think I have written more about depression than mania, so I don’t have to tell you how it sucks the soul out of me—and for any of you who feel this way, too. But with these mixed episodes, I deal with a mix of symptoms.

My Symptoms of Mixed Episodes

  • I’m extremely irritable.
  • I’m extremely energetic.
  • I don’t sleep.
  • I feel like I want to crawl into a hole.
  • Everything around me is nothing but darkness and sadness.
  • I feel like I’m the show starter and the showstopper.
  • I feel like I’m Superman.
  • I hate my life.
  • I can’t get out of bed.
  • I feel like all of my life’s energy is being drained, and I’m walking around with a metal ball and chain.
  • In the most extreme cases, I want to die.

I think you get the idea, so I don’t need to go any further. And these episodes can go on for days or even weeks. To be honest, I don’t think that I ever fully recover from them, because I always feel like I’m straddling the line between mania and depression, even on the days when I’m clearly fine and my moods are more in check.

Dealing with Mixed Episodes That Seem to Never End

So how do I deal with this? Sometimes, I don’t know how. Anyone who knows me knows that my go-to used to be to just try to drink it away. I HIGHLY DON’T RECOMMEND THAT. SERIOUSLY, JUST DON’T DO IT. At this point, I’m kind of trying to drill this into my head (“do as I say, not as I do” kind of thing), because when I tried to drink away the misery, it never ended up good. It either intensified my “mixed” symptoms or tilted the scale one way or the other. I try to handle it by doing the typical things that I would do in an episode: write, read something (no matter how big or small), watch funny videos, send stupid memes, listen to music, walk … whatever will take my mind off of things. But it’s not always that easy.

Efforts to Communicate and Connect with Others

I’m trying to get better at communicating these things—my struggles with bipolar and my mixed episodes—though it’s still not simple or natural. So, I try to talk with friends and I’m still trying to get therapy restarted. I’m compliant with my medicine regimen 99.5 percent of the time, but, to be honest, sometimes I feel like they don’t work when I’m experiencing mixed episodes. I could talk with my psychiatrist to change my dosages and medication, but I’m still fairly new with this current regimen, and it does work the majority of the time. One thing that concerns me with changing medication and dosages is that I hate the unknown variables. My first bipolar medication regimen had weird effects on me, and, because of that concern, I don’t want to adjust them at this time.

Suicidal Tendencies

What bothers me the most is when I think about what my past therapist warned me about when it comes to mixed episodes and the risk of suicidal impulses. Again, being the overly curious guy that I am, I went back and did my research. I saw how real the likelihood was during mixed episodes. The risk for suicidality is greater during mixed episodes because you’re depressed but you’re also more likely to have the energy and drive to carry out your impulses and/or plans.

This scares the living daylight out of me. Because back when I was told about mixed episodes, agitated depressions, and all of these other new terms that I had to learn, I was always grappling with these kinds of thoughts. It’s something I don’t talk publicly about often, but it’s an ugly truth. I once told someone that I was more afraid of my own hand than anything else. Over the years, there have been some close calls.

I even had a complete, thought-out plan, right down to how I would be found. So, years ago, it was a very real situation for me. Finding out that having mixed episodes increased the chances of it actually happening brought not only another sense of fear but also a new sense of determination to beat this thing. I admit that it wasn’t right away. But, eventually, I realized that I’m not ready to go, and I have to do something to keep these impulses under control.

Choosing to Fight for Myself

It’s hard. But I’m trying. Every day I’m trying. So far, I’m winning.

If you take anything out of this story, I would hope that it’s this: with everything else that is part of this disorder, you’re not alone in this struggle. We’re all living through this together, no matter how it manifests itself. If you’re dealing with mixed episodes, I completely understand you and how it makes a very confusing thing even more confusing.

But because I don’t have the answers, I wonder how some of you deal with mixed episodes. What would you recommend, to me or others, to make them a little more manageable?

Because even though almost ten years ago, a name was given to my experiences and I deal with them frequently, it’s still very tiring and I don’t always know what to do.

Stay safe. Stay focused. Keep striving.




Sources: Diagnostic and Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association; The Minnesota Reports, University of Minnesota; “MMPI-2, MMPI-A, and Minnesota Reports: Research and Clinical Applications,” James N. Butcher, PhD; Bipolar Disorders: An International Journal of Psychiatry and Neurosciences

About the author
JB Burrage is a writer living in the Atlanta, Georgia, area. A Meridian, Mississippi, native, he served in the US Army for over ten years. He started battling depression before he was a teenager. After years of receiving different diagnoses, he was diagnosed with bipolar disorder in 2011. For years, he was in self-denial before he finally accepted his diagnosis; he's slowly working to manage it, one day at a time. He’s the creator of The Diary of a Mad Writer, a blog that he uses to discuss various topics, especially mental health. He's a publisher of his own stories and is working on creating online courses. You can learn more about him, follow his blog, and contact him at jbburrage.com.
35 Comments
  1. Very comforting to read this. I was just diagnosed a couple of weeks ago at the age of 47. My life has been a rollercoaster, to say the least. The last few months after getting some devastating health news, I have been in a really scary mixed episode. Has cost me another relationship and just keeps happening and I am so tired from it all. Every time I see myself just destroying everything around me and I feel like I am having an out of body experience and keep telling myself to stop but I don’t listen. It has been hell, to say the least.

    Have been on meds for the last two weeks and it takes them a while to kick in, so every day has been an incredible struggle. Going from walking 4 miles in the morning like a marathon runner up hills, to the point I can’t walk for 2 days I am so sore. Then, bam, I just don’t want to be here anymore, and it’s so intense it scares the sh$t out of me and is what led me to finally get help for this illness that has ruined my life over and over again.

    I am 47 and have nothing, have no one, and have very little to be proud of… can’t hold a job or maintain a relationship no matter how much I love them and want to be with them. It’s heart-wrenching to go through over and over again. I think every time it’s a mixed episode. Describes what I go through more and more often over the years. And with every relationship lost and job that I walk out on after losing my shit and yelling at people. This has really been a [mess], to say the least. I have a couple of people that I talk to often, and they deserve a medal for sure. But probably wouldn’t be here without them. Was so bad a few days ago, I was sitting with a handful of pills in my hand and just wanted to leave so bad but at the same time being scared of myself and confused as to why I feel this way. I do want to be here and I do want a better life for myself. Just in a really bad place for the last few months.

    I have noticed that stress is usually the trigger for me, if things get stressful, it just all goes to hell I blow up and bail, then have a crazy few weeks, and then try to get back on track. Usually, find another partner quickly and it is great for 6 months, then the fight to maintain begins until it eventually burns down over petty little things.

    One of the hardest things since taking the medicine is how all of a sudden I feel all the pain and emotions from all the failed relationships. Never felt them until now and its all of them at once. Break out crying several times of day out of nowhere, listening to music gets me every time.

    Really appreciate the openness and insight in your post since it greatly describes what I am going through. I do have hope and hoping the meds start kicking in soon so I can feel more balanced. Been staying out of public since I just keep yelling at people, but that has been slowly getting better. Still feel the urge to, but have been able to keep my mouth shut most of the time this last week. Early effects of meds, I think.

  2. I have been going through this mixed up mania and depression together for the past 4 months. I can see the toll its taking on my life, it’s affecting everything and everyone I care about. I am so glad I read this because now I don’t feel so alone, and I can start to see that this really is part of my bi-polar symptoms. Thank you

    1. Thank you J.B for sharing your story. Sure helps me to hear about the term “mixed episodes” and the accompanying feelings of helplessness.

      My own experience in managing this condition comes in intervals- one step forward then two back… over and over again. I have to make light of it because this happens to me and I don’t want to beat myself up over it.

      It’s frustrating to not know when a mixed episode is going to occur. However, the feeling of being stuck comes out of nowhere and is usually triggered by something much deeper that my thoughts. Certainly have little control over when and why. The desire to do something constructive and then torn in the other direction because my energy is sapped happens so quickly. It can last a moment or a lengthy period. Just never know.

      If I choose to do nothing, I’ll become a prisoner within my own mind. And that’s not healthy place to be. This sort of experience leaves me feeling emotionally drained.

      What helps me is a little nudge from within – I’ll push myself and then afterwards find that doing so leaves me in a good space. I’ll look back and think I managed this illness today and with that said, I can hopefully do it again tomorrow.

      I now understand it’s something that is not within my control, but if I give myself permission to make a healthy decision the outcome is generally better.

      I take medication for both depression and hypomanic episodes, it helps level me off to a point. Medicine helps, but the remaining work is up to me.

      My Psychiatrist and Social Worker are both very supportive and helpful by actively listening and offering up good solutions.

      I was initially diagnosed with major reoccurring depression. ECT, and extensive cognitive behavior therapy elped along the way, but didn’t cure the illness. It took another 8 years for the bi-polar diagnosis and I’m just now beginning to see progress.

      I’m grateful for bphope and these blogs.

      Thank you.

  3. JB, THANK YOU for writing this article and sharing your experiences. Never before have I read an account of mixed episodes that I can so readily identify with. Finally, I feel that someone “gets it”. You are courageous to share your experiences and your determination to fight the good fight. I’m going to research some of your other writings. God bless you!

  4. Your explanation is one of the first times I’ve ever thought “someone else gets IT”! To not be able to get out of bed, but at the same time not being able to sleep because my mind is racing…it sounds crazy but it’s SO paralyzing. Thank you for putting it into the words I’ve struggled to find. It’s more helpful than you know.

  5. My english is not so good, but I recognize the mixed periodes. I always feel this way.

    1. Renate, me too. I pray for both of us. GOD loves you ❤

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