The Mixed State

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I often sit down to write a post and wonder what might be the most useful thing to elucidate.  Milly, my ASD girl, is struggling a bit, and Grace’s daily journey is always full of unexpected twists and turns.  I do not want to indulge “victim thinking” so I try to reframe circumstances.  I’ll admit that I have, at times, slipped and fallen in this area.  I have had the occasional “Why us?”, but I am hopeful that I have moved past that part of the grieving process.  Our normal changed.  Adapt.

So, what have I learned in the past month? What can I share with another parent, friend, or caregiver who might have or know a child struggling with schizophrenia or even bipolar disorder because this would apply as well.  I want to talk about the “mixed state” for a moment.  What is a mixed state?

In the context of mental disorder, a mixed state, also known as dysphoric maniaagitated depression, or a mixed episode, is a condition during which symptoms of mania and depression occur simultaneously, such as agitationanxietyfatigueguiltimpulsivenessirritability, morbid or suicidal ideationpanicparanoiapressured speech and rage. Typical examples include tearfulnessduring a manic episode or racing thoughts during a depressive episode. One may also feel incredibly frustrated or be prone to fits of rage in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states are often the most problematic period of mood disorders, during which susceptibility to substance abusepanic disorder, commission of violence,suicide attempts, and other complications increase greatly. (online source)

In general, a mixed state is a term applied to mood disorders, but what happens when a person has a psychotic disorder in addition to a mood disorder? Remember, schizoaffective disorder is a schizophrenia spectrum disorder meaning the positive, negative, and cognitive symptoms of schizophrenia might be at play at any time along with symptoms of a mood disorder (see The Lingo).  A person might have schizoaffective disorder-depressive type, for example.  Grace has schizoaffective disorder-bipolar type.  Our biggest struggle in stabilizing her has been controlling her mixed states.  They are torturous and very difficult to manage.  They wreak havoc on our family life and terrify our children. Containing her during these times has been a challenge.  We usually have to isolate her and put our other children elsewhere.  These states can last for hours upon hours.

In cooperation with her many treating psychiatrists, what we have realized is that Grace’s mixed states are a state of psychosis.  Why have we come to that conclusion? Grace is always hallucinating during these episodes.  She is also cycling rapidly between depression and mania.  When I say rapid cycling, I mean 10 minutes between both.  Very high to very low with no attachment to reality for hours on end.

Grace’s antipsychotic medications are maxed out, and she still hallucinates.  She is still mildly paranoid as well.  The Lithium is doing a good job keeping her mood relatively stable, but I have seen evidence of the dreaded mixed state trying to emerge.  Grace describes its onset as “Restless Leg Syndrome in my brain.”  So, what can you do to stop a mixed state? This was the question I put to her last psychiatrist.  He was very thoughtful and paced the room back and forth in his Italian leather shoes and funky socks.

What I have observed in Grace’s recovery from the mixed state is that sleep resets her.  I don’t know what sleep does to her brain, but a few hours of deep sleep brings increased stability.  After much rumination, Dr. Klerpachik’s recommendation was a PRN (as needed) dose of Seroquel; in other words, use Seroquel as a rescue medication at the onset of a mixed state.  Seroquel is another atypical antipsychotic used to treat schizophrenia and bipolar disorder.  It is used a lot for treating acute bipolar mania and bipolar depression.  Also, it is very soporific.

You wouldn’t know it from my blog, but I’m not a fan of throwing drugs at all forms of human suffering so I was nervous to add yet another drug to Grace’s “Better Living Through Pharmacology” regimen.  There came a time, however, to try the Seroquel.  What happened? Er…hmmm….well, the mixed state was prevented.  She was a drooling idiot within 45 minutes of her first 50 mg dose of Seroquel.  She will sleep for 4 hours when given one PRN dose of Seroquel and wake up stable.  This has become our solution to preventing a mixed state.

One question that often comes to mind is: How do I know that this is the onset of a mixed state? The clue is the beginning of rapid cycling.  There is the presence of hypomania and depressive symptoms almost simultaneously as well as psychotic symptoms in the form of paranoia and hallucinations.  She usually starts crying and grabbing her head, saying, “I can’t decide, I can’t decide, I can’t decide.”  Then she stops immediately, gets a crazed look on her face akin to one of our cat’s expressions right before they start ripping around the house, and declares that she knows what she wants.  This is followed up by tearfulness and declarations of feeling like she’s being watched.  For Grace, these symptoms are the harbinger of the mixed state.

Here is the pertinent issue: There are no perfect medications for children with psychotic and mood disorders.  It’s crucial to remember that when trying to get help for a child who is suffering with something as burdensome as one of these disorders.  Talking to your child’s psychiatrist about a PRN dose of a neuroleptic drug like Seroquel is valuable because it’s something you can keep in your back pocket for the inevitable mood crisis.  A child’s brain is growing and changing.  How they metabolize these drugs is always changing, too, and the dose of these drugs will have to be tweaked for years until they reach adulthood.  Waiting to see a child’s psychiatrist in order to discuss medication dosage changes often comes at the expense of the child and, hence, their family.  Having a rescue medication on hand to increase the likelihood of their stability until an appointment can be made to discuss emerging symptoms is invaluable not only to the child’s well-being but to their family life as well.

This is certainly not a panacea, but it’s one strategy in managing this form of mental illness in children where the rubber meets the road.

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6 thoughts on “The Mixed State

  1. My heart goes out to you. I suffer from extreme mixed states.and they are scary from the inside. I can’t imagine what it seems like from the point of view of loved one.

    I think having an emergency med in your back pocket is a great idea. Especially with children, waiting until the next doctors visit is not enough.

    I take 200 mg of Seroquel at night and am relatively stable on this regimen, But have occasional break throughs, especially when stressed out. For this i have a separate “emergency” prescription for 50 mg of quetiapine (generic seroquel) to head off mixed state episodes. Knocking myself out and sleeping for a while almost always nips these episode in the bud. I like having this flexibility as apposed to taking stronger or higher mgs.of meds on a daily basis.

    • 50 mg of quetiapine is exactly what Grace takes. I’m sorry that you suffer with this. I have tried to imagine what this must be like from the inside. What has caused me to scratch my head is that it took so long for the docs to figure out that she could use a rescue med. Now that we have access to this option, we all feel better. There is less anxiety about our day-to-day living which is so amazing. Best to you! MJ

  2. Thanks for sharing what you have learned by living with a child with mental illness. Your post fits perfectly with a professional development class I took last week addressing “mental health in children.” What’s interesting is the teacher said “you will know if the child is bipolar because their moods switch from manic to depressive quickly and often.” She said it is unlike adults who tend to have longer periods of mania and/or depression. I’m sure that may not be the case for all adults (as the previous reply shows I am learning adults can have mixed states, too).

    You are a good mom and unselfish in the way you share your personal experiences with others. I just love your perspective on parenting and your blog!

    -Fern

    • That’s really interesting that you are learning that! And I can’t tell you how grateful I am that someone is teaching that bipolar disorder presents differently in children! If I had a dollar for every time that bipolar disorder in kids is minimized because an educator/spec. ed teacher knows someone who knows some adult who’s bipolar and “they’re fine”, I would have a lot of dollars. Thanks for your sweet words. I’m trying to be transparent so that people know that even though we have figured some things out, it’s still quite the misadventure. Alas, I want to learn to enjoy it because if Grace sees me making the most of it, then she’ll know that she can, too. That doesn’t mean I don’t want to lock myself in the bathroom with a tub of peanut butter and chocolate ice cream every so often and never come out….because I do. 😉

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