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dontbedenied

Help Me Understand Mixed State vs Agitated Depression

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Hi everyone,

 

I'm relatively new here and had a recent tentative diagnosis of Bipolar II after months of being MDD only. The tl;dr of this is that I'm not sure I understand the difference between "agitated depression" and "mixed states," and how those related to a dx of MDD versus Bipolar. Read more below.

 

I've struggled with depression for years, and finally saw a pdoc and started an SSRI in October '12. Still having breakthrough episodes in Jan so upped dose to 15 mgs and promptly went into my first real manic episode -- hypersexuality, spendy, restless, considered divorce, flying high for days, etc. I found it both thrilling and troubling and knew something was "wrong" but wasn't sure what. Googling revealed that antidepressants can trigger mania in people who are bipolar. Further reading on bipolar helped me realize that I've probably been experiencing hypomania for years, primarily in the spring: restlessness, agitation, super bitchy/angry, unable to feel settled or content, taking on lots of new projects/hobbies, spending money, wanting to move (or moving!), wanting to have a baby (and getting pregnant!), wishing for major life changes, etc etc. But I wasn't ever flying, happy, or euphoric, and had a lot of bad, grumpy, unhappy days.

 

When I described this to my pdoc at our last appt, when I finally 'fessed up about the manic behavior and we were discussing mood stabilizer options, she mentioned "agitated depression" as another possibility. I'm confused as to what the difference is. Is there a difference? Is it just a matter of terminology? Does the fact that I was triggered into mania by my antidepressant mean I'm not "really" bipolar? Could it just be atypical depression? She was less interested in nailing down a dx than understanding and treating the symptoms (for now, I am continuing the Lexapro and titrating Lamictal, with plans to lower the Lexapro dosage after I'm stable on Lamictal). Which is the right thing to do, I'm sure. But in trying to wrap my head around all of this stuff, I'm finding myself wanting to be able to say "I have MDD" or "I have Bipolar Affective Disorder" or whatever. Can y'all help?

 

Thanks for any insights you might have.

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hi dontbedenied,

 

i don't know the answer.  i've had pdocs who used both terms to describe the same thing.  as it stands they've put me in the bipolar box, but for years, past pdocs have called it agitated depression, or mistook the agitated part for high anxiety.  you're right that it's being treated properly that's the important thing, but i know it is frustrating to not have a "name" for what's wrong.

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Maybe agitated depression is more like depression with high anxiety? I remember reading in the DSM IV (I dunno about V) that there is a place in the major depression criteria for people who experience psychomotor agitation, instead of the more typical psychomotor retardation. So, it's possible to be unipolar depressive but have this so called "agitated depression." I found this link: http://www.psnpaloalto.com/wp/wp-content/uploads/2010/12/Depression-Diagnostic-Criteria-and-Severity-Rating.pdf that lists the criteria for major depressive disorder from the DSM IV, and you can see that psychomotor agitation is listed as a possible indicator. 

 

A mixed state has manic features, so not just restlessness and agitation. It includes recklessness, impulsiveness. racing thoughts, flight of ideas, and pressured speech. Just with great dysphoria instead of euphoria. From what I understand (and from experience), a mixed state is like a manic episode with depressed thoughts and feelings, but all the energy and whatnot of mania. Buuuut, everyone experiences mixed states differently, so what I just said doesn't apply to everyone and could just be me talking out my ass. 

 

Finally, we come to "dysphoric mania" which is apparently different from a mixed state according to some of what I've read. Don't ask me how it's different, I have no clue. Edited to add again: I have had dysphoric hypomania (irritable hypo) which was VASTLY differently from the mixed state I had that was induced by Celexa. How could I forget that? Clearly I'm talking out my ass today. 

 

All of this is just my best guesses, I'm not actually sure about anything.  :blink:

 

Edited to add: According to the DSM V, hypomania or mania induced by antidepressant medication can be good enough for a diagnosis of bipolar disorder, as long as the hypo/manic episode is not largely symptoms like agitation. anxiety, and irritability. So, basically, they are looking for classic euphoric hypo/mania in reaction to antidepressants. 

Edited by Parapluie

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I used to not be able to tell the difference, either, but I recently had a definite mixed state and everything became "clear" to me. :glare:

 

My thoughts were going SO fast... they were so elusive, and I still felt powerful, but I also felt guilty, and the thoughts were incredibly dark, and I couldn't escape them. It was the worst feeling I've ever had, that mixed state. I'd prefer depression or mania over a mixed state any day.

 

Sorry I couldn't be more helpful. :(

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Sometimes it really seems the terms are used interchangeably.  Dysphoric hypomania.  Mixed features.  Agitated depression.  Mixed state.

 

Some of it is really more doctor lingo to each other and insurance or disability things.

 

For me I've chosen to use the terms in my own way just... like, for me.  My hypomania is always dysphoric.  Different from mixed, lots more depression in mixed.  My depression can often be agitated/with mixed features.  For me that's how it goes.  I always seem to have mixed features blurring the lines in there.

 

I believe the qualifier "mixed featres" has been added to some parts of the BP spectrum stuff in DSM V.

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Though, despite having the mixed featured depression, and mixed features/dysphoric hypomania... I've flat-out had just depression too (it's weird for me 'cause it's not so common.)  And I've had a couple mixed states.  To me, they feel distinctly different.

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I was finally told I was experiencing dysphoric manias last August. It has probably been going on for about 15 yrs, but my psychiatrists always saw me after I had "peaked," so it was always called dysphoric hypo. My pdoc finally saw me full blown, plus psychotic features for the first time that I was aware of (in retrospect, I can think of one time I was probably experiencing psychotic features before this pdoc). I guess it is just more intense than hypo. It feels WAY more intense.

 

I have been told I am mixed many times. When my pdoc saw me, he said it wasn't mixed, it was dysphoric mania. I have no idea what that even means. I've been a little freaked, because that totally changed my diagnosis, and I have been treated for 25 years for BP II. In fact, even though I was re-diagnosed over a year ago, I finally changed my signature to BP 1 last week. It took me that long to accept that was *really* what it was.

 

So I guess my long-winded answer is that your guess is as good as mine.

 

Lysergia, just curious, are you doing okay?

 

ETA: The reason no one said "mania" before is because my pdoc's vacation *always* corresponded to my worst episode, so covering pdocs who didn't know me were reporting to him.

Edited by crtclms

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Mixed is what I usually get.  Mixed as it is described by my Dr. and how I experience it.

 

I am suicidal - have a plan, could be driving down the freeway and spontaneously want to go flying over the guard rail and into the river and end it.  When I am mixed, I feel like choking everyone and fantasize.  I am generally very agitated. My head hurts as in it is so busy on the inside.  So many things going on.  everyone talks to slow.  I get homicidal thoughts, urges.  I'll bang my head repeatedly against the wall just to try and get rid of the noise in my head. IRRITABILITY  Everyone and everything that everyone does is so annoying and irritating.  When I am mixed I go for a run with the intent of slowing my body and mind down.  It slows the body down, but working out does not slow down the mind. I have my worst suicidal plans when I am running or lifting weights etc. No mental fatigue or happy endorphins.  Body is tired - mind is not.

 

Then mix in a sprinkling of depression where you want to sleep here and there because you (I) can't have a mixed stated without it rapid cycling. :)

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Mixed is what I usually get.  Mixed as it is described by my Dr. and how I experience it.

 

I am suicidal - have a plan, could be driving down the freeway and spontaneously want to go flying over the guard rail and into the river and end it.  When I am mixed, I feel like choking everyone and fantasize.  I am generally very agitated. My head hurts as in it is so busy on the inside.  So many things going on.  everyone talks to slow.  I get homicidal thoughts, urges.  I'll bang my head repeatedly against the wall just to try and get rid of the noise in my head. IRRITABILITY  Everyone and everything that everyone does is so annoying and irritating.  When I am mixed I go for a run with the intent of slowing my body and mind down.  It slows the body down, but working out does not slow down the mind. I have my worst suicidal plans when I am running or lifting weights etc. No mental fatigue or happy endorphins.  Body is tired - mind is not.

 

Then mix in a sprinkling of depression where you want to sleep here and there because you (I) can't have a mixed stated without it rapid cycling. :)

 

 

 

 

 

This sounds like .. No shit ... 75 % of my days 

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Thanks for all of your perspectives. This is really helpful. Hypomania/BP II "feels" more accurate to me and I guess it doesn't matter in the end. I appreciate your input!

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I have had one mixed episode a few years back, and for me it was racing thoughts (all of the racing thoughts were images or fantasies about every object I saw being sharp and stabbing into my neck to kill me.. like the edge of a picture frame, or a fork, or whatever was around me. Only my mother's xanax and my klonopin helped calm this down), agitation, energy, and rage/anger. At the exact same time though, I was sad and lonely and I cried. It was probably the most horrible episode I've ever had.

 

I am assuming agitated depression comes with the type of symptoms that people experience with dysphoric mania, but no euphoria, thus not quite classifying it as bipolar.

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Hi everyone,

 

I'm relatively new here and had a recent tentative diagnosis of Bipolar II after months of being MDD only. The tl;dr of this is that I'm not sure I understand the difference between "agitated depression" and "mixed states," and how those related to a dx of MDD versus Bipolar. Read more below.

 

I've struggled with depression for years, and finally saw a pdoc and started an SSRI in October '12. Still having breakthrough episodes in Jan so upped dose to 15 mgs and promptly went into my first real manic episode -- hypersexuality, spendy, restless, considered divorce, flying high for days, etc. I found it both thrilling and troubling and knew something was "wrong" but wasn't sure what. Googling revealed that antidepressants can trigger mania in people who are bipolar. Further reading on bipolar helped me realize that I've probably been experiencing hypomania for years, primarily in the spring: restlessness, agitation, super bitchy/angry, unable to feel settled or content, taking on lots of new projects/hobbies, spending money, wanting to move (or moving!), wanting to have a baby (and getting pregnant!), wishing for major life changes, etc etc. But I wasn't ever flying, happy, or euphoric, and had a lot of bad, grumpy, unhappy days.

 

When I described this to my pdoc at our last appt, when I finally 'fessed up about the manic behavior and we were discussing mood stabilizer options, she mentioned "agitated depression" as another possibility. I'm confused as to what the difference is. Is there a difference? Is it just a matter of terminology? Does the fact that I was triggered into mania by my antidepressant mean I'm not "really" bipolar? Could it just be atypical depression? She was less interested in nailing down a dx than understanding and treating the symptoms (for now, I am continuing the Lexapro and titrating Lamictal, with plans to lower the Lexapro dosage after I'm stable on Lamictal). Which is the right thing to do, I'm sure. But in trying to wrap my head around all of this stuff, I'm finding myself wanting to be able to say "I have MDD" or "I have Bipolar Affective Disorder" or whatever. Can y'all help?

 

Thanks for any insights you might have.

 

WOW....this sounds so much like me. About the only difference is the spending money part, because I haven't had any money to spend...not even on credit cards.

 

I was diagnosed major depression, moderate/severe, recurring, then Depression NOS...then because of negative hypomanic episodes (such as you described) they have now concluded I have BP2...also severe anxiety. 

 

The DSM guidebook is just....arrgh. I think scientists/doctors are finally recoginzing that there may be a touch of bipolarity in what was once thought to be "just depression".

 

Ok sorry for the rambling

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I think it's a pretty controversial subject where you'll get different answers from different sources. I was diagnosed with a somewhat agitated depression at one point and read up a little on it. I do remember reading about a distinction between agitation in depression as more restlessness and kind of pacing, wringing of hands, vs. more goal directed activation in a mixed or manic state. That sort of makes sense to me, don't know if it's at all helpful.

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HI Dontbedenied...I'm a lot like you. I just wanted to reply because of what you mentioned about Lexapro. I am Bipolar 2 but only found out at the start of 2013. I've been mostly depressed for 4 years, with a few hypomanic episodes (thought this was normal 'me'). When I first sought treatment in 2011, the GP thought it was clinical depression, so prescribed Lexapro. I went hypomanic almost immediately and stayed that was for about 3 months. When I came down, I was depressed again and doubling the dose did nothing. I went off Lexapro, still not knowing I was bipolar but knowing the drugs werent helping. Now I rapid cycle but I'm mostly depressed. There is evidence that SSRIs cause this effect. Mania and rapid cycling. From my research (and experience), the Lexapro could be worsening the bipolar. So when you ask: "Does the fact that I was triggered into mania by my antidepressant mean I'm not "really" bipolar?". Absolutely the opposite: it probably means you are! After Lexapro, now I also have mixed states a lot: either hypomanic predominant- where I want to divorce, move to another city, move house, start multiple new projects which I lose interest in later; or predominantly depressed- where everything feels hopeless, everything is overwhelming, don't want social contact mixed with crying, irritability and frustration. Basically I feel my life is ruined and I'll never be the person I thought I would be. 

I'm really sorry to hear you are going through this too. I'm new to this all and am on the med journey as well. There is a lot of advice on this forum from people who have been doing this longer- but I wanted to give you my perspective on SSRIs as we have had a very similar experience so far. From what I've been told here and read, Lamictal will be a good choice and there are a lot of people who swear by it. I weaned off Lexapro in a week by taking the dose down regularly and the only side effect was a bit of dizziness.

Good luck, and please post an update.

all the best TL

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Oh and Dontbedenied- obviously, get your pdocs advice if things arent working for you and dont go off Lexapro on your own because of what I said ^. Just thought I'd add that in case you think Im suggesting anything like that :-). 

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Just putting my thoughts in there... I don't have bipolar, but my boyfriend does. It's tough... but here's what I've observed through his swings:

 

Mixed state: definitely depressed, however things seem clear and logical. This is this and that is that; why can't everyone see that? Blames everyone for the world being in such a horrid state and hates that he has to live in the midst of it. Doesn't want to go anywhere or do anything. Complains a lot about other people and their stupidity for how they live their lives. Mainly, anger toward others and an inability to understand why people don't "fucking wake up."

 

Agitated depression: definitely depressed, but doesn't want to talk or think about anything. Would rather just waste time watching movies or listening to angry music. However, during all times of the day, most everything sets off yelling. Mainly, angry about being depressed, not other people. Angry at me that I'm not doing "enough" or "supporting me enough" because I can't handle a lot. However, quick to realize that there's a lot of anger and warns me that he's agitated. This does NOT happen when there's a mixed state.

 

I'm just an observer and we've been together for a little over a year. So I can't really tell you much in the way of mentally and from a first hand experience. But I sure can tell the difference. 

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I'm not sure if my interpretation of my symptoms fits with how doctors would label things, but there at least two sets of symptoms that feel very different from me.

 

What I'd call agitated depression is when I am primarily depressed but oddly restless, I keep pacing around aimlessly, can't concentrate on anything and I am incredible irritable, people piss me off by just breathing. However, I feel primarily depressed, self-hate, pessimism, feeling that I am worthless and all that stuff. I also feel tired a lot. It is basically depression, just while being jumpy and very irritable. I find it incredibly annoying, but bearable.... Well, or this is at least what I for myself consider agitated depression.

 

Mixed state is a different thing for me, I got diagnosed bipolar when I was in a mixed state, so that at least my pdoc thinks is a mixed state. For me, mixed states have all the features of mania, extreme (!) racing thoughts (much more than in euphoric mania), pressured speech with very quick topic changes, very little need for sleep and when I sleep, I tend to have very vivid and incredibly violent dreams (usually me being chased, shot...), memories are very vivid. For me, this is the worst feeling in the world, or maybe the second worst after being psychotic (but I'm not even sure about that). It makes me feel like I just want to bang my head against the wall to make it stop.

 

Those feel very different for me, though it's hard to describe well, and maybe hard to know the difference if one has only experienced one of those.

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I'm not sure if my interpretation of my symptoms fits with how doctors would label things, but there at least two sets of symptoms that feel very different from me.

 

What I'd call agitated depression is when I am primarily depressed but oddly restless, I keep pacing around aimlessly, can't concentrate on anything and I am incredible irritable, people piss me off by just breathing. However, I feel primarily depressed, self-hate, pessimism, feeling that I am worthless and all that stuff. I also feel tired a lot. It is basically depression, just while being jumpy and very irritable. I find it incredibly annoying, but bearable.... Well, or this is at least what I for myself consider agitated depression.

 

Mixed state is a different thing for me, I got diagnosed bipolar when I was in a mixed state, so that at least my pdoc thinks is a mixed state. For me, mixed states have all the features of mania, extreme (!) racing thoughts (much more than in euphoric mania), pressured speech with very quick topic changes, very little need for sleep and when I sleep, I tend to have very vivid and incredibly violent dreams (usually me being chased, shot...), memories are very vivid. For me, this is the worst feeling in the world, or maybe the second worst after being psychotic (but I'm not even sure about that). It makes me feel like I just want to bang my head against the wall to make it stop.

 

Those feel very different for me, though it's hard to describe well, and maybe hard to know the difference if one has only experienced one of those.

 

Yup. Verbatim.

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