The information below may be useful in better understanding various normal and abnormal mood states that people experience. Mixed bipolar states, in particular, are often difficult for patients to conceptualize, and I hope that the following material will help advance understanding. Before a discussion of mixed states, learning about other mood states will prove beneficial.
Euthymia describes a normal mood or emotional state. Our moods are normally tied appropriately to life events and developments. A job promotion, for example, may lead to a “good mood” of happiness and pride in our work, which is entirely appropriate. Also appropriate to that event may be some measure of anxiety, associated , for example, with the prospect of meeting increased job demands or responsibilities. In either case, the resulting emotional changes should be neither extreme nor very long lasting. We may “ride a high” to some degree for a few days or so, but typically things balance out and a more neutral mood ensues. And even when we’re feeling good about ourselves as a result of the promotion, we don’t normally take the occasion to develop an extreme sense of self-importance or grandiosity, become overactive or overtalkative, or engage in productive or pleasurable activity to such a degree that it assumes more importance to us than getting adequate sleep.
If that promotion produces anxiety, or if some other life event about which we are sad or anxious occurs, we don’t typically become so distressed that we develop hopelessness or suicidal thoughts, severe anxiety and self-loathing, sleeplessness, or appetite declines with significant weight loss. Our “negative” emotions are normally not extreme enough to affect our functioning in any way, and are normally not long-lived. We “bounce back” in a few days or weeks. We might represent such a normal mood state over time with an irregular wavy line, each point on which represents our average mood state in response to life events at a given moment in time:
The affective domain of our experience is the feeling, as opposed to the thinking, part of our minds. The affective realm involves emotions, moods, and drives.
Emotions are brief or fleeting feeling states that typically change over seconds or minutes—such as anger when another driver cuts us off, or pleasure at experiencing something humorous. Moods are longer-lasting feeling states that color our experience, and typically change over hours or days or weeks. If we are having a “bad day”, we may evaluate or experience the same event more negatively than we would on a good day. Such a low mood may make similar events more likely to “bring us down” when mood is low. Drives are normally persistent and relatively unchanging affective elements that greatly influence our behavior, such as hunger for food, sexual urges, and sleep.
Mood disorders involve more than just disturbances in mood, and are thus often called affective disorders. Signs and symptoms include not only disturbances of mood, but of the entire affective domain, including emotions and drives as well. One useful way to think about people suffering from affective disorders is that their emotions/moods/drives are prone to become disconnected from, or are no longer normally tied to, life events. Someone suffering from classical, severe depression, for example, continues to feel downhearted regardless of life events, and may be unable to experience pleasure or happiness even with the most positive developments.
Affective disorders typically are associated with episodes of abnormally low or elevated mood states, in which emotional state is no longer normally responsive to life events, and drives become disturbed. In an episode of mood disorder, the severity of the symptoms fluctuates over time, and in some sufferers may resolve completely, possibly even without treatment. Treatment reduces the severity, duration and frequency of episodes but, especially without treatment, affective disorders tend to be recurrent, episodic conditions--not unlike an asthma sufferer who is prone to episodes of difficulty breathing. Between episodes, people with mood disorders may have no symptoms whatsoever, their moods again become normally tied to life events, and drives return to normal patterns, as in non-affected individuals.
Mood disturbances in depression lead us to feel persistently and pervasively low or unable to experience joy or pleasure. When depressed, we may be pessimistic and tend to view the “glass half empty” rather than half-full. We may be so devoid of hope that we see no reason to go on living, our future (and past) colored in a negative light as far as the eye can see. Our sense of physical vitality and health fades, and seems nowhere to be found. In addition, there are changes in our emotions: we may be frequently sad or tearful, anxious, irritable, or incapable of laughter and the positive feelings associated with it. Reduced appetite, weight, and sexual interest, as well as impaired sleep, represent disturbed drives that are often experienced in depression. We might represent an episode of depression as a line remaining below a baseline, normal mood state, until an eventual return to normal in this example:
Each point on this line represents total depression severity at a given point in time, by adding up a score of individual symptoms and rating their severity. People with major depression have
severe enough symptoms that their score exceeds a certain severity threshold (dotted line). There are numerous rating scales for depression that could be used in this way. For example, here is the
Zung self-rated scale. Here is a modified Young Mania rating scale, which would allow a similar score for the presence and severity of manic symptoms.
Dysthymic disorder is a long-lasting type of depression not symptomatically severe enough to warrant a diagnosis of major depression. People with dysthymia may have complaints lasting 6 months or longer (typically many years) of, for example, low mood, irritability, anxiety and sleep difficulties. The symptoms by definition never meet or exceed the severity threshold for a diagnosis of major depression, but dysthymia nevertheless results in real suffering and impairs functioning in various ways. A depiction of symptoms over time may be as follows:
These affective states are characterized by abnormal and sustained elevations in sense of well-being, mood, speech, energy, sense of self-importance and similar symptoms. Individuals with mania or hypomania often have less need for sleep and typically engage excessively in productive or pleasure-seeking behaviors. There may be a sense of increasing closeness with God or preoccupation with spiritual themes and universal meaning. Less extreme symptoms are seen in hypomania, whereas mania involves the severest symptoms such as grandiose delusions (fixed, false beliefs of, for example, our special significance or power), rapid or incoherent speech, hallucinations, and/or major impairments in judgment. On a mood graph, mania and hypomania may be represented as follows:
In these common but underrecognized bipolar states, both manic symptoms and a full syndrome of depression are present at the same time. In clinical practice, pure bipolar depressive states and pure manic states are likely less common than mixed states, where significant elements of both states are present simultaneously. One useful way to conceptualize this is to recognize that, in bipolar individuals, both manic elements and depressive elements may vary somewhat independently of each other. Such states are hard for patients to describe, not only because they are inherently unstable and changeable states, but also because they seem contradictory: “Am I depressed because my mood is low and I’m hopeless, or am I manic because I’m restless, don't seem to need sleep, and am impulsive?”
Doctors seeing only the depressive elements may prescribe an antidepressant, which not infrequently leads to worsening of manic (and depressive) symptoms, or increases the rate or severity of cycling of manic and depressive elements of the illness. In general, the key is to increase mood stabilization and remove or reduce antidepressants, stimulants, drugs of abuse, and other factors which can worsen mood stability. Mixed states may be represented graphically as follows:
The graphical depictions above are examples only: individual episodes of depressive, manic or mixed states show no uniform set of symptoms or course over time. This is true not only from one individual to the next, but also true for recurrent episodes in the same individual.