Mixed Episodes In Bipolar Disorder: Ways To Cope

Maybe you are newly diagnosed with bipolar or maybe your loved one has it. Either way, you may have heard of “mixed episodes” and wondered what they are. It’s possible you’ve had the diagnosis for a while but are lucky enough to not have had one. It’s important to understand mixed episodes if you are going to manage this illness effectively or help someone else manage it, so read on.

What Does Bipolar Disorder Look Like?

Bipolar Disorder is a lifelong condition that involves going through periods of depression and mania or hypomania. Depression, of course, is a time of sad and low mood. Mania, on the other hand, is when you feel elated and on top of the world but are also irritable and easy to anger. You may also have delusions and hallucinations. Hypomania is a less intense form of mania in which these psychotic symptoms don’t show up.

Depression can last for weeks or months, destroying your quality of life. Manic and hypomanic episodes are usually shorter than depressive ones, but they can cause just as much, if not more, damage. You may become incredibly impulsive, engage in risky behaviors, and alienate friends and family. Bipolar disorder is a leading cause of disability around the world because as these polarized episodes can be very hard to manage.

What Is A Bipolar Mixed Episode?

Much like the name implies, a mixed episode combines parts of depression and mania into one big cup of “no, thank you.” About half of all people with bipolar are diagnosed with “bipolar with mixed features.” In mixed episodes, depression usually dominates and mania is manifested in anger and unusual levels of energy.

When you are in the midst of a mixed episode, you may feel tired and sleepy, yet agitated and irritable. Anxiety shoots up to sky-high levels, exacerbated by racing thoughts. It becomes hard to focus on one thing, which can lead to further frustration. You may lash out at loved ones only to feel intensely guilty later, making depressed feelings worse.

How To Cope With Mixed Episodes

Mixed episodes are hard to manage precisely because they are mixed. How do you cope with feeling down and up at the same time? You should take these episodes very seriously and be ready to call on your most advanced coping skills. This isn’t the time to phone it in.

Know Triggers And Warning Signs

Much like with depression and (hypo)mania, it’s important to know what triggers mixed episodes and how you can tell you are about to have one. The best way to identify the warning signs and symptoms is to track them over time. That’s why tracking is so important to managing bipolar.

Common triggers of mixed episodes include combining medication with drugs and alcohol or combining different types of drugs together (stimulants and depressants), losing loved ones, and traveling through several time zones. It’s important to identify what triggers you specifically.

Since mixed episodes have symptoms of both depression and (hypo)mania, you will usually see warning signs of both mood states. For example, you may start sleeping a lot while noticing that small things annoy you a lot more than they used to. You may start feeling “slow” on the outside and “fast” of the inside or vice versa.

Have A Plan

It is crucial to plan for mixed episodes ahead of time because you won’t have energy or focus to do much spontaneous self-care when they come around. Prepare routines and ask people you trust to keep you accountable. You can make it easier on yourself by creating a “coping box.”

Grab a shoebox or a similar container and fill it with whatever helps you get through tough times. Coping techniques, notecards with activities or kind words from loved ones, quotes, pictures, a coloring book, ticket stubs, stress balls, fidget toys, poems, jokes, journals, crafts, etc. Schedule time with this box when warning signs start to appear.

Regulate Your Sleep Schedule

A part of your plan should revolve around having a consistent sleep schedule. If you typically forgo the advice of putting devices away two hours before sleep, it’s time to heed it now. Good sleep hygiene is a must when trying to gain control of a mixed episode. If you’re really struggling, ask your doctor about taking a natural sleep aid like melatonin and using a sun lamp after waking up.

Watch Out For Agitation

One of the most unpleasant symptoms that can appear in mixed episodes is agitation. Agitation is when you feel extremely restless, fidgety, and uneasy to the point of not being able to focus on anything and sometimes even wanting to hurt yourself. Agitation can lead to hostility, tension, and even violent behavior. It’s important to address it early on with your doctor and mental health provider.

Agree To Postpone Decision-Making

Mixed episodes are not a good time to make major decisions, especially not life-changing ones (the same can be said of manic episodes). Make a pledge to yourself to avoid starting big projects, investing/spending money, starting or ending relationships, and altering appearance. Remember, this is temporary – you’ll thank yourself later.

Reach Out To Your Support Network

Whether you have family, partner or online friends supporting you, now is the time to summon the backup. They can help with practical things like regulating sleep, eating healthy food, going outside, and getting light exercise. They can also be more understanding about irritability, agitation, and anxiety if they know what’s happening.

Distract Yourself

Distraction is good when your inner world is on fire, which is what mixed episodes can feel like. Dialectical behavioral therapy teaches a skill for tolerating distress called “ACCEPTS” – see if it works for you:

A – Activities

Do an activity that requires thought or concentration. Examples are journaling, doing work/personal projects or exercising.

C – Contributing

Do something that allows you to focus on another person. Examples include reaching out to others, sending a thoughtful card/email or volunteering.

C – Comparisons

Put your situation in perspective by comparing it to something more painful or distressing. Examples include comparing yourself to your more distressing moments and to people who cope less well than you do.

E – Emotions

Do something to create a new emotion that will compete with your distressing emotion. Examples are watching a sad/happy movie, listening to sad/happy music or creating calm with breathing/meditation.

P – Pushing Away

Avoid a painful situation or block it from your mind using a technique such as imagery. You can imagine putting your distressing thoughts and emotions into a container, closing it shut, and putting it away out of sight.

T – Thoughts

Use a mental strategy or an activity to shift your thoughts to something neutral. You can count down from 100 by 7s, name all objects around you starting with a certain letter or spell your full name backwards.

S – Sensations

Find safe physical sensations to distract you from distressing emotions. Examples are eating something spicy or sour, taking a hot/cold shower or holding an ice cube.

Stay Safe

Suicidality is more likely in mixed episodes. Addressing this should be a part of your plan mentioned above. Have an idea of what to do in an emergency – have the crisis line number prominently displayed and create a pact with yourself to reach out for help/distraction/support if you feel like killing yourself. It’s a good idea to ask your loved ones to help you make your home safer by removing guns, ropes, razor blades, and extraneous pills.

Give Yourself Grace

This is difficult to do, but you must have some self-compassion. Having bipolar disorder requires many life adjustments. You are doing your best after being dealt a bad hand. Mixed episodes in particular are a reminder to give yourself some grace. This is really, really hard. Yet here you are, doing it.

Consider Bipolar Disorder Therapy

If you struggle with mixed episodes, it may be time for professional help. There are several kinds of therapy for bipolar disorder. The most popular kind is cognitive behavioral therapy, which focuses on changing negative or overly emotional thoughts into more neutral and rational ones. This therapy usually involves questioning your thoughts and doing homework in the form of thought logs.

Another kind of bipolar disorder therapy is called interpersonal social rhythm therapy. It revolves around stabilizing circadian rhythms, encouraging routines, improving social connectedness, and grieving the loss of “the healthy self.” This therapy especially focuses on times of transition, such as losing a job or moving to a different town, which can be triggering.

If you have bipolar disorder, you may have suffered related trauma, like hospitalizations, extreme behavior or relationship ruptures. This is where EMDR therapy can help. While it is not a typical therapy for bipolar disorder, it is highly effective at processing trauma and reducing distress associated with unpleasant memories.

One of the problems with bipolar is that you start to expect the worst to happen based on your previous experiences. If memories of these experiences are not as disturbing, you are more likely to stay positive and have hope that this, too, shall pass. This is something EMDR therapy can tackle.

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