Bipolar disorder is a serious mental health condition that severely affects a person’s mood. It is a relapsing-remitting condition. It might more accurately be called ‘bipolar spectrum disorder’. At one end of the spectrum is profound depression. At the other end of the spectrum is mania. In between these two poles are the less severe forms of depression and mania: moderate depression and hypomania. At the very centre of the spectrum is normal mood.
People with bipolar depression might feel hopeless, desperate and suicidal. They may have little energy or interest in doing things and be unable to enjoy things that they would normally find pleasurable. When I have experienced severe depression, I have been almost completely paralysed by it and felt constantly suicidal. Antidepressant treatment never helped me, nor did electroconvulsive therapy (ECT).
People with mania can often feel euphoric, energetic, excitable and invincible. It can be a time of great creativity. However, this can quickly spiral out of control into overspending and other excessive behaviours. At the extreme, people with mania can also experience psychosis, including hallucinations and delusions. When I had psychotic mania, I did a lot of thinking and writing. I had a heightened sense of awareness where every little thing seemed to carry great significance and importance. I had insights into life that I am unable to access whilst in a normal mood state. It was when I started hearing voices that I agreed with my psychiatric care team that I needed to be admitted into hospital. They had been threatening to section me for several weeks.
In some people with bipolar, the two poles of depression and mania coexist in tension with each other. The result can be a tangled web of unpredictable thoughts, feelings and behaviours. It’s not nice and it’s not comfortable. This is called a mixed affective state. Approximately 40% of patients with bipolar disorder will experience mixed episodes, defined as a manic state with depressive features, or manic symptoms in a patient with bipolar depression.
It is thought that people with bipolar disorder who have a history of mixed states are overall at a higher risk of suicide than those who do not experience mixed states. Moreover, research suggests that young adults with bipolar disorder in a mixed state are at a higher risk of suicide compared with those in a depressive episode.
This is an account of my very personal experience of a mixed affective state. However, all mixed states are different. No two people with bipolar disorder will have the same experience.
I knew that something was wrong on that June day back in 2016 when I walked through M&S Home and felt compelled to buy everything in sight. Not just things that I actually needed, but also things I liked the look of. I managed to restrain myself, but it was a very clear warning sign. The next time I walked through the same shop a couple of days later, I gave in and I shopped! I knew that this was hypomania. I was going high.
I am now 61 years old. I have had bipolar disorder since I was 21. I experienced the manic psychotic episode when I was 25, and had since then suffered numerous profound depressive episodes, but I had experienced no further episodes of pure mania or hypomania. However, I knew all the signs.
Why should I have gone high again at the age of 56?
At the time I was receiving a powerful drug called Rituximab, which is used to treat some cancers and autoimmune conditions. I had a type of blood cancer. Rituximab is often given by intravenous infusion. I had six infusions, each given three weeks apart. It was in the days leading up to the final infusion that I noticed that my mood was slipping.
The hypomania in itself was not particularly uncomfortable. It was a lot easier for me to manage than full mania or depression. I was spending too much money and I was aware that I was talking more quickly than usual. I accessed an appointment with a psychiatrist, who confirmed the hypomania. I was prescribed a higher dose of my mood stabiliser, and I believed that my mood would stabilise quickly over a couple of weeks.
Things became a lot darker for me. I became very agitated.
I went out for long walks to try to walk through the agitation, but it didn’t go away.
I am a keen gardener but there were times when I couldn’t even go into my garden because the colours were too bright for my brain. I felt paranoid, confused and overwhelmed.
My mind was a chaotic mess. I knew something was very wrong.
I went to see the Crisis Team. About half an hour into the meeting, I had to leave when I felt compelled to throw my metal thermos flask through the window, which I really didn’t want to do. I was on edge, agitated, highly emotionally reactive, my mind was racing and I was frequently so distraught that I cried uncontrollably. The depth of my distress was very scary. It was as though I was feeling all the losses I had ever experienced throughout my whole life all at once. These overwhelming feelings would come over me suddenly with no warning. I couldn’t deal with this so I regularly started taking high doses of my mood stabiliser, which was very sedating, to try to get through the distress and the agitation.
I was inadvertently overdosing. I was in a dangerous place.
My brain was overactive. I pursued lines of thought compulsively. I did a lot of thinking when I was out walking. I was like a dog with a bone; tossing ideas around in my mind constantly, pursuing one line of thought and then another. It was very wearing. Some lines of thinking were productive, others not.
When I had met with the Crisis Team, they decided that I was exhibiting the symptoms of Emotionally Unstable Personality Disorder, and that I required no further assessment. I am not quite sure how this happened as my medical records very clearly showed that I had a bipolar diagnosis. Only eight days before meeting with them, I had been diagnosed with hypomania by a Consultant Psychiatrist, which was also clearly documented in my records.
I managed to get taken on by the local mental health service. However, as the months went by, I wasn’t getting any better. I went to A&E departments to try to get help. Some of my behaviours were extreme and erratic. I was becoming increasingly desperate.
At one A&E visit, I was lying on the floor and later screaming at the top of my voice. I felt out of control. I repeatedly went to see my GP, who on one occasion tried to persuade me that I was depressed. I told him that I wasn’t depressed. I told all the mental health professionals who I met with that I didn’t know what was wrong with me, but I knew that it wasn’t depression or hypomania because I knew these mental states well. Looking back, I presume that the doctors treating me were interpreting my symptoms and behaviours within the framework of a personality disorder.
I had the feeling that my ‘care team’ were trying to control my erratic behaviours rather than trying to understand the underlying cause of them.
Finally, after all the months of trying to get help, the breakthrough came.
I happened to be in email contact with a psychiatrist. I told him that I wasn’t getting any meaningful help locally. He suggested that I ask my GP to refer me to the Affective Disorders Service at the Maudsley Hospital in London for an assessment. Prior to the assessment, I was sent a lot of questionnaires to complete and return.
I was eventually seen at the Maudsley. The assessment was very thorough. At the end of it, the Consultant Psychiatrist who saw me said: “You are in a mixed state”. He advised me to stop taking the antidepressant that I was being prescribed, and he recommended a different mood stabiliser for me to take. Finally, he said, “This will pass”.
It took about eight weeks after this before I could honestly say that I was fully out of it. The mixed state had lasted for nine months.
I was diagnosed with Hypomania with Mixed Features (of depression). This described my mental state perfectly; with the compulsive trains of thought, agitation and emotional reactivity, alongside the all-consuming distress. It explained the overdosing and other risky behaviours.
The relief I felt from receiving the diagnosis was overwhelming. It was all completely explainable. The madness had a name. It was going to end. I had hope that I could become sane again. I could rejoin humanity.
Slowly but surely I came out of the mixed state. I became calmer and the compulsive thinking slowed down and eventually stopped. The distress subsided. I started to feel as though my feet were getting back on firm ground.
Why didn’t I myself realise that I had been in a mixed state? This was mainly because I had never knowingly experienced one before so had no personal knowledge of it. Also, I knew very little about mixed states. I barely even knew they existed. If I had realised what was happening to me, then I could have accessed expert help far sooner. The psychiatrist who assessed me at the Maudsley concluded that it was most probably the Rituximab that had destabilised my mood all those months earlier. Indeed, unwanted side effects of Rituximab include “confusion”, “nervousness”, and “feeling sad or empty”. He also considered that the antidepressant medication which I was being prescribed at quite a high dose may have contributed to the mixed state.
My main motivation for writing this piece is to try to raise awareness of mixed affective states, most especially for health professionals and for people with bipolar. It is potentially a very dangerous state to be in. I suspect that other people with bipolar disorder are having their mixed states missed or misdiagnosed just as mine was. It effectively trashed nine months of my life, which I will never get back. I survived it but others may not. My concern is for those people who do not come out of the other side to tell their stories.