Just what is Bipolar Mixed States. As seen previously in the General Page it is not easy to define. One thing that you can forget about is the symptoms of Bipolar I and II and Cyclothymia Bipolar. As said before this can be very confusing to the person who has Mixed States Bipolar Disorder.

You will see on this page that extensive use has been made of the information contained on Wikipedia.

You will also notice how confusing it currently is, with the different ideas as to what Bipolar Mixed States is. For the present it makes more "sence" to us that Mixed Bipolar States, are dysphoric mania and agitated depression.

As this page is so long and to made is easier there are quick links to the various sections of this page. Life Events and Experiences - DSM - Cognitive Defects - Older Age - Prognosis - Mortality - Recovery - Recurrence.

Sub threshold mixed states are clinically important but not part of the DSM-IV system. It is not clear what symptoms of depression and mania represent the minimum threshold for mixed states, but it is probably less than concurrent full symptoms of both mania and depression⁶.

Essentially, though many experts will quibble on the finer details, Mixed States are depressive episodes that are "soldered to" manic behavior. The bipolar person will have high energy levels, racing thoughts, trouble sleeping, all elements of hypomania or full blown mania----yet instead of euphoria or grandiosity, the individual will be filled with negative emotions, typically expressed as irritability or even, in some instances, as extreme anger or even rage. (not forgettng that others also refer to manic episodes)

In the context of mental illness, a Mixed State (also known as dysphoric mania or agitated depression) is a condition during which symptoms of mania and depression occur simultaneously (e.g., agitation, anxiety, fatigue, guilt, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, pressured speech and rage). Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. Mixed States can be the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicide attempts, and other complications increase greatly⁹

A dysphoric mania consists of a manic episode with depressive symptoms. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms (MMDT). Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some antidepressant drugs may trigger dysphoric mania in susceptible individuals.

An agitated depression is a "major depressive [episode] with superimposed hypomanic symptoms" (Benazzi, 2000). Mixed episodes in which major depression is the primary state, concurrent with atypical manic features were described in two studies (Benazzi & Akiskal, 2001; Perugi et al., 2001). A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression"⁸.

Most researchers find that the cause of Bipolar Disorder is related to Genetic factors which may contribute substantially to the likelihood of developing bipolar disorder. And environmental factors are also implicated. Scientists also believe that bipolar disorder may be caused when chemicals in the brain are out of balance.⁵

 

Evidence suggest that environmental factors play a significant role in the development and course of Bipolar Disorder, and that individual psychosocial variables may interact with genetic dispositions. There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of Bipolar Mood Episodes, as they do for onsets and recurrences of unipolar depression.

There have been repeated findings that between a third and a half of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as Post Traumatic Stress Disorder (PTSD). The total number of reported stressful events in childhood is higher in those with an adult diagnosis of Bipolar Spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior. Early experiences of adversity and conflict are likely to make subsequent developmental challenges in adolescence more difficult, and are likely a potentiating factor in those at risk of developing bipolar disorder

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The current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) recognizes only one form of Mixed State in Bipolar Disorder, that of Depressive Mania. Many individuals who have suffered a mixed episode, and many psychiatrists would carry this farther. Although psychiatrists do not yet agree on the defining characteristics for this state, they have long recognized that the symptoms of mania and depression seem to co-exist in some patients⁷

Non-DSM-IV-TR concepts of Mixed States include dimensional mixing and trait mixing. Dimensional mixing, for example, could be a manic state combined with 2 or more depressive symptoms or a depressive state combined with 3 or more manic symptoms though definitions of dimensional mixing vary.

Even newer is the concept of trait mixing, wherein individuals who have predominately depressive temperaments carry those depressive temperaments into mania.

Or conversely, Bipolar individuals with early onset, habitual, low-grade manic symptoms carry their manic temperament into a major depressive episode, thus coloring the syndromal depression or mania with features of the opposite temperament.

So called cognitive deficits in Bipolar Disorder are relatively mild and can only be detected by comparing performance in neuropsychological tests between groups of patients compared to those without the diagnosis. It should be stressed that although on average those with Bipolar Disorder perform worse in some tasks compared to controls, some patients will actually perform better than controls because of the large variation in test scores.

So called cognitive deficits in Bipolar Disorder are relatively mild and can only be detected by comparing performance in neuropsychological tests between groups of patients compared to those without the diagnosis. It should be stressed that although on average those with Bipolar Disorder perform worse in some tasks compared to controls, some patients will actually perform better than controls because of the large variation in test scores.

It has been concluded from recent reviews that most individuals who were diagnosed with bipolar disorder but who are euthymic (have not experienced major depression or (hypo)mania for some time) do not show neuropsychological deficits on most tests. Meta-analyses have indicated, by averaging the variable findings of many studies, impaired performance on some measures of sustained attention, executive function and memory, in terms of group averages. The effects of sub threshold mood states and psychiatric medications appear to account for some of the association.

It is not known whether specific cognitive deficits are disorder-specific features of Bipolar Disorder5.

There is a relative lack of knowledge about Bipolar Disorder in late life. There is evidence that it becomes less prevalent with age but nevertheless accounts for a similar percentage of psychiatric admissions. It is noted that older bipolar patients have first experienced symptoms at a later age; that later onset of mania is associated with more neurologic impairment cardiovascular. Substance abuse is considerably less common in older groups.

There is probably a greater degree of variation in presentation and course, for instance individuals may develop new-onset mania associated with vascular changes, or become manic only after recurrent depressive episodes, or may have been diagnosed with bipolar disorder at an early age and still meet criteria. There is also some weak evidence that mania is less intense and there is a higher prevalence of mixed episodes, although there may be a reduced response to treatment. Overall there are likely more similarities than differences from younger adults⁵.

For many individuals with Bipolar Disorder a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because Bipolar Disorder continues to have a high rate of both under-diagnosis and mis-diagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.

Bipolar disorder can be a severely disabling medical condition. However, many individuals with Bipolar Disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.

Ultimately one's prognosis depends on many factors, several of which may, in fact, be under the individual's control, these may include: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive and warm therapist; a supportive family or significant other; adequate health insurance; secure finances and housing, and a balanced lifestyle including a regulated stress level, regular exercise and regular sleep and wake times.

Note: We recognise that the comments re prognosis in the previous paragraph are pointing to an ideal world. Not all are lucky enough to have the mentioned support. In fact rather doubtful to our mind if many do.

There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes^.5

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Mortality studies have documented an increase in all-cause mortality in patients with Bipolar Disorder. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in Bipolar Disorder. The standardized mortality ratio from suicide in Bipolar Disorder is estimated to be approximately 12 to 25, further emphasizing the lethality of the disorder.

Although many people with Bipolar Disorder who attempt suicide never actually complete it, the annual average suicide rate in males and females with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population.

Individuals with Bipolar disorder may become suicidal, especially during mixed states such as dysphoric mania and agitated depression. Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental health conditions, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and there is evidence that sufferers of this disorder spend proportionally much more of their life in the depressive phase of the illness than their counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007).

A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.

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Discontinuing or lowering the dose of medication, without consulting the physician, can lead to depressive or manic recurrence.

Being under or over-medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant, may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania. An inconsistent sleep schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania. Caffeine can cause destabilization of mood toward irritability, dysphoria, and mania. Anecdotal evidence seems to suggest that lower dosages of Caffeine can have effects ranging from anti-depressant to mania-inducing. And inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress will still causes relapse.

Often Bipolar Individuals are subject to self-medication, the most common drugs being alcohol, and marijuana. Sometimes they may also turn to hard drugs, which can cause the condition to worsen. Studies show that tobacco smoking induces a calming effect on most Bipolar people, and a very high percentage of those suffering from the disorder smoke.

Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events. This theorizes that a close friend could notice which moods, activities, behaviours, thinking processes, or thoughts typically occur at the outset of Bipolar Episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging. These sensitivity triggers show some similarity to the traits of a highly sensitive person.

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5.http://en.wikipedia.org/wiki/Bipolar_disorder#Mixed_affective_episode 6.Diagnosing bipolar disorder: how can we do it better? Michael Berk, Lesley Berk, Kirsteen Moss, Seetal Dodd and Gin S Malhi MJA 2006; 184 (9): 459-46 7. http//www.findthelight,net/Mood@20Disorders/bipolar/Mixed_episodes.htm 8.Importance of a Correct Initial Diagnosis and Stabilization to Avoid Social and Economic Consequences J. Sloan Manning, MD From the Mood Disorder Clinic, Moses Cone Family Practice Residency, and Private Practice, Greensboro, NC 8a.http://en.wikipedia.org/wiki/Agitated_depression. 9.http://www.nationmaster.com/encyclopedia/Mixed-state-(psychiatry)

The information on this page is to us, reasonably complex. Which of course points to rhe confusion in regard to the current thoughts as to what are exactly the symptoms of Bipolar Mixed States. if you find it difficult to read while you are on line it may be helpful and for your own personal use to print out this page. The right click, copy function has not been inactivated on this site.       

Some people describe Mixed Mania, as the "tired but wired" feeling. A person can feel extraordinarily pessimistic and hopeless, fatigued and unable to concerntrate, but still feel "revied", anxious, irritable, driven and sleep deprived, with thoughts moving very rapidy.

As a person who has had Mixed Episodes, you are probably familiar with the feeling of being fatigued and drained but also charged up, irritable and anxious, (tired but wired). In the same way mania is not always a happy state and depression is not always a sad state. But unlike mania, depression is almost never enjoyable or intoxicating Page 218. 9

A person feels over energised to the point of agitation, and yet they are terribly depressed. The person may feel extremenly irritable and extremely hopeless at the same time, giving an angry, "What's the point anyway?" attitude. Their mind is racing with thoughts, nearly all of them negative. Perhaps worst of all is reversed self-confidence, where the grandiosity of mania is instead experienced as a profound lack of self-esteem. To the point where the person feels worse than worthless:they believe they are slime, and are a burden to others and they cannot say anything correctly or of any value.10

In the context of Bipolar Disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously (for example, agitation, anxiety, aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech, racing thoughts, restlessness, and rage5

Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. One may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states can be the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicide attempts, and other complications increase greatly8

It has been argued by Cassano et al, that if diagnostic emphasis is placed on alterations in mood, this distracts from detecting the more subtle but meaningful symptoms, such as neurovegetative symptoms, distored cognitions and changes in energy levels which charactierise the mania or hypomanic symptoms of Mixed States 15.

Two reserach groups found that patients with mixed states have higher rates of comorbid substance use and a greater propensity for psychosis, suicidal ideation and attempts (11) (12). There is also and increased emotional intensity and reactivity and which are thought to be a core feature of manic and mixed states13.

In a study of 183 manic Bipolar I patients Goldberg et al found that mixed states manic patients had fewer manic symptoms than the patients with pure mania. 14

As you will have seen from the above there appears at this current time to be some “confusion” in regard to the symptoms of Bipolar Mixed States. It appears that now there are quite a few researchers who are going away from the DSM-IV criteria of Mixed States. What the criteria for Mixed States will be in DSM-V is not yet known.

We suspect from the findings of a reasonable number of research projects that good arguments have been put forward for Manic Depressive Mixed States (depressive symptoms within mania) and Depressive Manic Mixed States (manic symptoms within depressive symptoms). However Dayer et al, have put forward a third state and this is one of Dysphoria. (17) This state of Dysphoria consists of (1) mania, depression and dysphoria and, (2) depression, dysphoria and mania. Whether these findings may be reflected in DSM-V: only time will tell.

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Manic Depressive Mixed States.

McElroy et al in regard to Manic Depressive Mixed States, accept that mania or hypomania exists with two or three depressive symptoms (18).

Dilsaver et al found four factors which corresponded with manic activation: depressed state, sleep disturbance and irritability/paranoia.(20)

Akiskal et al found that Mixed States are a common and clinically distinct form of mania, with sub threshold depressive features the most common variety (21).

Akiskal et al also found that Mixed States are predominantly shown in females and they have a lower level of manic symptoms and more complex temperamental dysregulation including cychothymic and irritable dimensions. (20)

Depressive Manic Mixed States.

Benazzi et al define depressive mixed states as major depressive episode with two or more or with three or more hypomanic signs or symptoms (16).

Kukopoulos proposed a type of Depressed Mixed States which mixed depression is a major depressive episode plus any two of the following features. Motor agitation, psychic agitation or intense inner tension and racing or crowed thoughts.(19)

Benazzi F and Akiskal HS have also came to the conclusion by using the current definations of hypomanic features would limit the detection of Mixed states. They also noted like another researcher that the Mixed States patients' hypomanic symptoms also included distractibility, irritability, racing thoughts. However, they also noted that there are a reduced need for sleep, grandiosity, increased time spend in pleasurable activities, psychomoter agitation and pressured speach which pointed to flight of ideas 16.

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5.http://en.wikipedia.org/wiki/Bipolar_disorder#Mixed_affective_episode
8.http://www.nationmaster.com/encyclopedia/Mixed-state-(psychiatry)
9.Bipolar Disoder Survivla Guide. What you need to know. Bu David J Miklowit Ph. D.
10 Why am I still depressed, Regcognising and Managing the Ups and Down of Bipolar II and Soft Bipolar Disorder. Jim Phelps
11 Keller MB, Lavori PW, Coryell W, Endicott J, Mueller TI, Bipolar I: a five-year prospective follow-up. Journal of Nervous
and Mental Disease 1993; 181:238–245.
12 Strakowski SM, McElroy SL, Keck PE, West SA. Suicidality among patients with mixed and manic bipolar disorder.
American Journal of Psychiatry 1996; 153:674–676
13 Henry C, Swendsen J, Van den Bulke D, Sorbara F, Demotes-Mainard J, Leboyer M. Emotional hyper-reactivity as
a fundamental mood characteristic of manic and mixed states. European Psychiatry 2003; 18:124–128.
14. Goldberg JF, Garno JL, Portera L, Leon AC, Kocsis JH. Qualitative differences in manic symptoms during mixed versus pure mania. Comprehensive Psychiatry 2000; 41:237–241
15.Cassano GB, Dell’Osso L, Frank E et al. The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology. Journal of Affective disorders 1999; 54:319–328.
16 Benazzi F, Akiskal HS. Delineating bipolar II mixed states in the Ravenna-San Diego collaborative study: the relative prevalence and diagnostic significance of hypomanic features during major depressive episodes. Journal of Affective disorders 2001; 67:115–122.
17. Dayer A, Aubry JM, Roth L, Ducrey S, Bertschy G. A theoretical reappraisal of mixed states: dysphoria as a third dimension. Bipolar Disorders 2000; 2:316–324.
18. McElroy SL, Strakowski SM, Keck PE, Tugrul KL, West SA, Lonczak HS. Differences and similarities in mixed and pure mania. Comprehensive Psychiatry 1995; 36:187–194.
19. Koukopoulos A. Agitated depression as a mixed state and the problem of melancholia. Psychiatric Clinics of North America 1999; 22:547–564.
20. Dilsaver SC, Chen YR, Shoaib AM, Swann AC. Phenomenology of mania: evidence for distinct depressed, dysphoric, and euphoric presentations. American Journal of Psychiatry 1999; 156:426–430
21. Akiskal HS, Hantouche EG, Bourgeois ML et al. Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). Journal of Affective disorders 1998; 50:175–186.
22. Dilsaver SC, Chen YR, Shoaib AM, Swann AC. Phenomenology of mania: evidence for distinct depressed, dysphoric, and euphoric presentations. American Journal of Psychiatry 1999; 156:426–430

 

The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

 NOTE: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder10.

Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. There are lists of criteria to be used when diagnosing.

These critera depend on both the presence and duration of certain signs and symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies.

An initial assessment may include a physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests may be carried out to exclude medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic infection or chronic disease, and syphilis or HIV infection. An EEG may be used to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Investigations are not generally repeated for relapse unless there is a specific medical indication.

There are several other mental disorders which may involve similar symptoms to bipolar disorder. These include schizophrenia, schizoaffective disorder, drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder. Both borderline personality and Bipolar Disorder can involve what are referred to as "mood swings".

In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months. The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days.

A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute. Some hold that borderline personality disorder represents a subthreshold form of mood disorder, while others maintain the distinctness, though noting they often coexist 5.

A phenomenon known as rapid cycling is difficult to distinguish from mixed mania. Rapid cycling occurs in up to 20% of bipolar patients. In rapid cycling, manic and depressive episodes alternate frequently; at least 4 times in 12 months. In some cases, the episodes may alternate between depression and mania as frequently as several times a day. This ultra-rapid cycling can be easily mistaken for mixed mania.

Patients with mixed mania, especially when it is marked by irritability and paranoia, are at higher risk for suicide. Studies show that Bipolar patients who suffer from mixed episodes rather than pure manic episodes are more likely to develop substance abuse problems11.

Accurate diagnosis of Bipolar Disorder is essential for effective treatment. The diagnosis of bipolar disorder is particularly complex, resulting in lengthy delays between first presentation and initiation of appropriate therapy. Inappropriate therapy destabilises the course and outcome of the disease. Although the defining features of Bipolar Disorder are manic or hypomanic episodes, patients typically present for treatment of depression and commonly deny symptoms of mood elevation.

 A correct diagnosis can easily be masked by comorbidities, personality issues and complex phenomenology. A diagnosis of bipolar disorder can be assisted by:

Asking about symptoms of mania or hypomania in every patient presenting with symptoms of depression.

 Recognising mixed states in which manic and depressive symptoms occur simultaneously.

 Identifying the features of bipolar depression that distinguish it from unipolar depression.

There is a risk of over-diagnosis of Bipolar Disorder among patients who are histrionic, show  abnormal illness behaviour and/or have issues of secondary gain

Difficulties and delay in the diagnosis of Bipolar Disorder impede effective treatment and amplify the burden of illness on the individual, the family and society. The 2000 National Depressive and Manic-Depressive Association survey estimated the prevalence of Bipolar I and II disorder in the United States to be 3.4%. Of people with Bipolar Disorder, almost a third (31%) had been incorrectly diagnosed as suffering from unipolar depression and, in nearly half (49%), the condition was both unrecognised and undiagnosed. Remarkably, just over a third (35%) of these individuals had been symptomatic for more than 10 years before the correct diagnosis was made6.

We are aware of a five year old being given a series of medications one after the other to treat his Bipolar (?). We find it hard to believe that a five year old can be diagnosed with Bipolar Disorder. When this child "preformed" in regard to doing his homework, the therapist treating this child (now eight) recommened to his mother to call the police so that they could take the child from his home and place him in hospital. If this story is true this is a good very reason to get a second diagnosis.

We understand one of the most common pitfalls in the diagnosis of Bipolar Disorder is that of mixed symptoms. In a mixed episode, criteria are met for both manic and depressive episodes simultaneously. In practice, this manifests as the intrusion of depressive symptoms into a predominantly manic presentation or the intrusion of manic symptoms into what looks like a depressive presentation.

Research suggests that this delays diagnosis, perhaps because the predominant complaint is that of depressed or dysphoric mood, with key manic features (eg, increased motor drive, reduced sleep, crowded or racing thoughts) receding into the background. Mixed states have particularly high rates of comorbidity with anxiety, personality disorders and the use of antidepressants and substance misuse. An implication of this is that inappropriate diagnosis may drive inappropriate therapy, which can create clinical scenarios that are more difficult to recognise. One of the important differences between mixed and pure mania is that suicidality is a far greater risk in the former.6

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5.http://en.wikipedia.org/wiki/Bipolar_disorder#Mixed_affective_episode.
6.Diagnosing bipolar disorder: how can we do it better? Michael Berk, Lesley Berk, Kirsteen Moss, Seetal Dodd and Gin S Malhi MJA 2006; 184 (9): 459-462
10. http://www.angelfire.com/home/bphoenix1/mixed.html
11.http://www.manic-depression.net/mania/mixed_mania.htm