Mixed Bipolar States, Dysphoric Mania and Hypomania

Patient Expert

The latest in my series on "Up" ...

With your help, we have been exploring psychiatry's dirty dark secret - dysphoric and dark mania and hypomania in bipolar, loosely described as agitated or morbid states of intense psychic distress. Hagop Akiskal of UCSD and his collaborators around the world have led the way in shining a light on this very common but long-neglected aspect of our illness.

Inevitably (say five seconds into a talk) Dr Akiskal will refer to his hero, Emil Kraepelin. Kraepelin's classic 1921 "Manic-Depressive Insanity" to this day is by far the best piece of writing on your reality and my reality. (In contrast to the work of fiction known as the DSM-IV.)

Much of Kraepelin's text is given over to the transient "mixed" states that defy the simplistic labels of depression and mania. Rather, elements of both are at play, but that, too, is a gross oversimplication. Kraepelin, instead, asks us to conceptualize not just mood cycling up and down, but also intellect and volition (motivation), and not necessarily in sync.

In other words, there is a lot more to a mood disorder than just mood. The cycle is the dynamic that drives our illness, but also in a state of flux are our thoughts and feelings. So, instead of thinking of bipolar as simply a choice between "pure mania" (flight of ideas, exalted mood, pressure of activity) or "pure depression" (inhibition of thought, mournful moodiness, irresoluteness), Kraepelin has us looking at all those infernal states in between.

Here is how he broke it down:

  • Depressive or anxious mania (where depression takes the place of a cheerful mood).
  • Excited depression (where flight of ideas is replaced by inhibited thought).
  • Mania with poverty of thought (instead of flight of ideas).
  • Manic stupor (a depression with cheerful mood).
  • Depression with flight of ideas (instead of inhibited thought).
  • Inhibited mania (flight of ideas with cheerful mood and psychomotor inhibition).

"That's me" I can almost hear you say in relation to one or more of these. Here is a snippet of what Kraepelin had to say about "depressive or anxious mania":

If in the picture depression takes the place of cheerful mood, a morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything, catch up words and continue spinning out the ideas stirred up by these ...

Anxious mania - so obvious, yet there is no mention of it in the current DSM nor will there be in the next one (due out in 2013). Yet, Kraepelin got it right in 1921.

Don't worry if you have trouble distinguishing "mania with poverty of thought" from "manic stupor" from "depression with flight of ideas" from "inhibited mania." The point is that for a good many of us a good deal of the time, our manias and hypomanias don't fit the classic stereotype. Yes, we may find ourselves in one of those dancing-on-tables moments, feeling way too good for our own good, but nothing lasts forever. Suddenly, our thoughts betray us. Maybe they've gone AWOL or maybe they're crashing to earth. And here we are, still in orbit, cut off.

One part of our brain is pushing, the other pulling. Or, maybe we only feel we should be dancing on the table (or simply asking someone to dance).   But we're immobilized. All systems are go, but we find ourselves going nowhere. The thrusters are firing, but the rocket stays on the launching pad.

On and on it goes, infinite combinations of push-pull, infinite signs of our signaling out of whack, our psyches in profound disharmony. Eventually, maybe, all the pieces come together again, but this time as a manifestation of classic depression. But, again - as Kraepelin made perfectly clear way back in 1921, at any given time we are merely in one phase of the inexorable cosmic dance. Already, something in our brain is pulling while something else is pushing.

This time, we may want to go to sleep and never wake up, but our racing thoughts won't let us. Or we may want to smash all the furniture in the room, but instead we find ourselves curling into a foggy shroud of despair. Agitated depression? Dysphoric mania or hypomania? The distinctions almost don't matter in these states of inner torment, especially with our brains in constant flux - cycling, cycling, cycles within cycles.

What does matter is recognition of our own inner realities, all those times in our life when depression and mania both occupy our brains at the same time, when our neurons send us conflicting messages - our thoughts going this way and our feelings that way, our energy at this level and our motivation at that level, on and on and on.

At least, when we know what we're living with, we can learn to live with it. Listen to our illness, listen to Kraepelin, live well ...