What is mixed mood disorder


Criteria for a mixed episode

A. Both criteria for a manic episode and a major depressive episode (other than duration) coincide almost every day for a period of at least one week.

B. The mood disorder is severe enough to cause significant impairment in job duties or in usual social activities or relationships with others, or to require hospitalization to protect yourself or others, or it has psychotic traits.

C. The symptoms are not caused by the direct physiological effects of a substance (e.g. substance abuse, medication, or other treatments) or a general medical condition (e.g. overactive thyroid).

Comment: This may be in an example in which the DSM-IV definition is a little too narrow. Many sufferers report having lived through the mixed phase with hypomanic, but not fully manic, characteristics.

The following letters in italics from the patient W. D. to his attending physician, Dr. Leo Navratil, in the following excerpt from the book by

Leo Navratil: manic-depressive

On the psychodynamics of the artist

© Verlag Christian Brandstätter, Vienna 1999


ISBN 3-85498-006-X clearly.

Published here with the kind permission of the author and the publisher:

Manic-depressive mixed states

The connection between mania and depression is expressed in the fact that they are opposing modes of experience and behavior that can alternate in one and the same person, but in rare cases their appearance can also be mixed, so that a person is manic and depressive at the same time Has symptoms. These mixed states1 occur relatively frequently at the transition from one phase to the other, but they can also persist for a long time as special conditions. In milder cases, mixed states are often manic-depressive events, which are then often chronic. Mixed states usually respond less well to therapy than the pure forms of mania and depression.

Kraepelin distinguished the following mixed states: 1. anxious (or depressive) mania; 2. agitated depression; 3. low-thought mania; 4. manic stupor; 5. Depression fleeing from ideas; 6. Inhibited mania.

Today, according to Peters, three forms of mixed states are recognized as clinically evident: 1. agitated depression; 2. irritable (angry) mania; 3. Manic stupor. ²

Contrary to what Peters said, both Bleuler and Kraepelin knew the depressive "anxious mania" as a manic-depressive mixed state, whereby the patients with depressive affect with sinful ideas talk and write a lot and complain that the thoughts come to them by themselves .³

The "thoughtless mania" is according to Kraepelin and Bleuler4 another mixed state. It often occurs as a severe manic phase is waning: the sick are in good spirits, very agile, often noisy, but do not pick up and try to speak, but cannot say much and repeat themselves. As a transition to thoughtless mania, there are sometimes endless lists of similar things, personal names, place names. We got to know such accumulations of words with the same or similar meaning in Robert Burton's book.

In the "manic stupor" the patient is in a happy mood, but inhibited in his movements, in speaking and thinking.

I have described a manic-depressive mixed state as a transition phenomenon from depression to mania in my patient August F., who, towards the end of a depressive phase, described his state as "photophobia, leutscheu, work-shy" and thus began to write poetry in the depression, so to speak. This example also shows, however, that even in a single utterance by a patient, the depressive (the content) and the manic (the form) can combine.

A typical example of a mixed state as a transition phenomenon from mania to depression is Johann Hauser's “hearse” (Fig. 17, p. 227). Here, too, the form of the drawing stems from mania, while the depressive aspect is already expressed in the content. The black color of the hearse corresponds completely to the sad subject, but with the red decorative caps of the wheels a manic dot is added.


1 The term mixed state only refers to the simultaneous presence of manic and depressive components, whereas the term “mixed psychosis” means the combination of schizophrenia and manic-depressive illness. Today one speaks in this case mostly of "schizoaffective psychosis"

2 Peters (1990), p. 353 [Peters. U. H .: Dictionary of Psychiatry and Medical Psychology. Munich:

Orbis Verlag]

3 Bleuler (1983), p. 476 f. [Bleuler, E .: Textbook of Psychiatry. 15th edition, Berlin: Springer Verlag]

4 Ibid., P. 477


The fear of hell

In the following I want to give an example of the very rare mixed state of depressive anxious mania, which is particularly impressive thanks to the patient's willingness to write, his high intelligence and unusual eloquence. I believe that these letters, like the mixed manic-depressive state from which the patient suffered, are rare.

In this case, I made a special effort to ensure the anonymity of the letter writer by not only changing the initials of the name, but also by omitting any information from which one could in any way draw conclusions about the patient.

Many years ago, Mr. W. D., a middle-aged man who was being treated for manic-depressive illness at a young age, was admitted to our hospital. Mr. W. D. was briefly inpatient with us three times. I was in contact with him for a number of years as part of the outpatient follow-up care. During this time I received an unusually large number of letters from him, in which his illness and the mixture of the depressed and the manic are very clear.

There are contradicting statements about the childhood of Mr. W. D., on the one hand he was spoiled, on the other hand he was brought up strictly. The religious upbringing in particular must have been strict. Even at the time when I was in contact with him, W. D. was religious, a regular church-goer and recipient of the sacraments. The first clear manic-depressive phases appear around the age of 20. Mr. W. D. later married. During the manic phase, he screamed and scolded his wife; He has already dealt with his mother and sister in the same way, and has even beaten them; During the depression he was plagued by self-reproach and above all by fear.

He acquired professional qualifications, but failed more and more in his profession as a result of his illness and was finally declared unable to work in middle age, which resulted in additional self-reproach.

According to his mother, he always showed a very heightened self-confidence at a young age, thought better than everyone else and was of the opinion that he had to become something very special. He had rejected the mother's proposals to strive for a secure job.

Before he came to our hospital, Mr W. D. was inpatient four times at the Vienna Psychiatric University Clinic and was treated there once with electric shocks because of a depressive stupor. During his second stay in the clinic, the mother reported that she had been careful all her life to be energetic towards him. Now it seems to give him particular satisfaction that she cares about him and is mothering him. She is doing it now because she feels sorry for her son and she is deeply depressed by his condition.

At a later point in time, the wife stated that since I had known Mr. W. D. had reacted differently from other people. In the first few years of their marriage, he was still on top, despite professional failure. He saw everyone else far below. A special feature was that he talked all the time. In practice he always failed. Since he lost his last job because of an argument, his mood has shifted more into a depressed state. An anxious depression developed, and he feared that his wife would leave him. Then he hardly spoke any more, started to speak, but got nothing out, began to whine and voiced ideas of suicide.

Mr. W. D. was described by his wife as "strange"; she said that even in the times between the manic and depressive phases he never got completely well, but was always weird and shot one buck after the other. His wife would have said, remembered Mr W. D., that for him the leading of life had to be in the book so that he could read it; even in school - despite above-average school success - he was perceived as strange. This comedy is also expressed in the following passages; it goes back to the coexistence of manic and depressive drives and is a pure expression of this “mixed state”.

Mr W. D. writes that depression has grown into a "super depression". It consists mainly of 2 points: 1. Inability to work, 2. "Fixed idea about the inevitable entrance into hell at the moment of my death." "For points 1 and 2 I would be grateful for a targeted treatment, especially for point 2." " With the best recommendations, also on behalf of my wife, your very devoted WD "

“Thank you very much for your well-intentioned attempt at mediation that you made between my wife and me. I could have predicted that it would fail. My debt to my wife is perhaps so great that even if she wanted to, she could not relent ... I (Logorroe) talked so incessantly and persistently about topics of interest to me that my wife was pushed into the exclusive role of the listener and when she wanted to tell me something, I hardly listened to her ... She sensed, as my wife recalls, looking back, that everything I did was disinterested. Now I am terribly sorry for everything, I recognize my mistakes, but see no way out, no way to find a common topic of conversation for my wife and me ... "

“Now my wife, who is easy to talk to and who dares to say a word, could easily have told me in my young marriage that the lectures were too long for her. I would have been the last not to give in. It wouldn't have been easy then, because I was a fanatic. "

“In this respect, my wife is right, a conjugal sex get-together requires a successful conjugal conversation. Perhaps at the next interview you could give my wife a few tips on how she can have a harmonious marriage conversation with me. Of course, I have to give up these stereotypical conversations about hell, profession etc. as a prerequisite. My wife should learn to understand that I am a person with joys and sorrows and not a "sick cretin" as I always call myself.

Best recommendations W. D. "

From another letter:

“The specialists who treated me before you all said to my wife that I was one Borderline case. But nothing or too little has happened yet to bring my psyche into the realm of normal. Maybe you could do that. I don't want to be a borderline case all of my life ... my wife said I've offended her with every act since the beginning of the marriage. Normal actions would now have to be practiced, preferably with the help of my wife. "

“I think the most important thing at the moment would be to get rid of the severe depression in order to finally get an interval. As an expert, you will know best how. "

"My wife allows me to write, but is personally not in favor of it because she thinks writing is 'stupid'. She definitely doesn't want to identify with it. "

"So please bring me into the 'normal zone' ... You could make my everyday life easier through this 'normalization', I could read again with pleasure, etc. etc. "

"In the hope that you will find a solution that will advance my case, I draw with great respect W. D."

From another letter:

I am weak and poor in contact ... this is how a doctor described me to my wife on the occasion of the treatment of a depressive stupor. This is also the root of my grief, because since my youth I have never had real contact with others. This is also the main part of my depression. As a therapist, take care of my emotional weakness so that I can come back normal can cry and laugh. To eliminate the severe depression, 1-2 strong antidepressants would be required, the weak contact would not go away so easily, some therapeutic sessions would be required here, and I do not know whether you can and want to take on these yourself. What do you think of depth psychology anyway? Sometimes I fear my depression will never go away in my whole life. Please do everything in your power, with or without medication, to free me from the painful depression. "

"The depression hasn't changed for three years. Before that, I was severely manic for 4½ months."

"Your dear Dr. F. introduced me to the equilibrium theory. Because I was severely manic for 16 years, I would have to be depressed for 16 years to restore my balance. God and your medical art deliver me from another 13 years of depression. Please help me.

Your W. D. "

"Please excuse me once again for disturbing you on vacation. But I have a big calamity with my psychotic depression, which I have been dragging around with me again without an interval for over 3 years. In the month of June I registered a strong swelling of the depression. The symptoms are:

1. Great internal tension that the drug does not relieve.

2. The feeling that one is about to explode. You see no way out of your tension.

3. Very poor ability to concentrate, because the entire interior of the depression is in

Is claimed.

4. The fear that this depression will never go away in life.

5. The fear of hell as an unimaginably excruciating state that always

will last.

6. Great despondency because of the lack of harmonious emotional interrelationships

between my wife and me.

To 6. My wife recently said to me that she had always looked for these interrelationships in a person and had not found it in me from the start. I have always missed something in my relationships with my wife, but now I can see clearly that it is my fault or my MDK. One more reason for you, dear Mr. Primar, to give me the right medication (strong antidepressants) shortly interval to accomplish. Because as a normal person, and I am one of those in the interval, I will also be able to create normal relationships with my wife. Hence my plea to you because I am through your help normal human I hope to become: Put away the Valium, Kemadrin, Ludiomil and Dapotum, and instead prescribe them with strong antidepressants such as B. Trofanil and Tryptizol, which have already taken away a depression in me. In any case, I now want to have the agonizing depression gone. Mania is not to be feared because I have too much insight into the disease. I am only defenseless against depression. "

“I so long to become and be normal.Otherwise life has no meaning at all for me ... The depression is extremely agonizing. W. D. "

“The depression, I emphasize again, is excruciating. W. D. "

"Please make me healthy and normal! I really can't stand the depression, which gets worse every day, and the fear of hell that goes hand in hand with it ... Yours W. D. "

“Extremely depressive state of affairs… countless self-reproaches push me to the ground. I'm in a dead end and don't know how to get out of there ... And the fear of hell every day! "

“The reason I am writing to you today is that after years of thinking, I figured out where the roots of all evil lie. In both mania and depression I am total unable to loveWith the difference that I find this ego isolation in the depression extremely agonizing, while in the mania, concerned with my own ideas of overvalue, I didn't mind. The agony I am currently going through for the inability to love is indescribable. W. D. "

"The connection between the inability to love and the fear of hell is causal."

"The Fear of hell is getting stronger and more hopeless ... I think that the only way to cure depression is to go through the fear of hell. The depression cannot be tackled independently, it is only the effect of the Fear of hell. It is regrettable that I am incapable of love in both depression and mania. As a result, we are deprived of an important helping factor, love. "

"Please prepare yourself on the basis of cases similar to the one you gave me Fear of hell can take away. Because with the Fear of hell it is not a life worth living. W. D. "

“I have to correct my letter. Not the fear of hell, but mine Inability to love is the root of depression. The fear of hell is only the result of the inability to love. My great concern now is whether you will be able to take my inability to love through relaxation exercises, etc. The inability to love and the fear of hell are both agonizing and I can't laugh as long as I am afflicted with them ... something has to be done with the inability to love, and not just with drug therapy, as has been the case before. Psychotherapy would also have to be used, if you cannot take the time for it, please refer me to a colleague who is familiar with the subject. "

“Your well-intentioned attempts at mediation did not fall on fertile ground with my wife. I noticed that from the angry face my wife put on when we left the hospital ... "

“At home my wife told me I was stupid and you can see it on my face. If she had known what a nut I was, she would never have married me ... "

“My illness is called fear, fear and again fear! Anxiety Disease. Can You Cure Anxiety Disease Completely ??? I would be glad I have been waiting for 3 years with no hope. The complaints of fear: a completely desperate life, no happy hours, no laughing and joking, no joy, no peace, no glimmer of happiness, no ray of sunshine, agonizing unrest, a life without meaning. And this desperate fear goes with me for the rest of my life, until it plunges me into an agonizing and hopeless death. And what am I afraid of? Before hell. For believing Christians, this fear is the most extreme fear of all. "

“Perhaps you will find a case in a specialist book where a person in my position was completely cured of the anxiety disorder ... This letter does not make me feel relieved of my fear of the mountains, because I cannot hope. In order for you to cure my fear, a miracle would have to happen. Don't blame me for the openness. There is only fear in my soul. W. D. "

“Now I have only one wish for you: that normalization mineemotional Sphere. You know it professionally: The forms of cyclothymia. Feeling either above or below normal, but never coinciding with normal. Since I've lived I've always had abnormal phases, I don't exaggerate. I am excluded from the normal emotional scale. Talking to me about normal feelings is like talking to a blind person about color. I suffer unimaginable agony because of my emotional exclusion from the normal. Listen to my shocking appeal: give me the emotional eyesight of the normal world! "

“Since Tryptizol and Ludiomil, the two antidepressants, did not produce an interval for me despite a relatively long intake, please try another preparation to give me an interval. Because without a preceding interval, Quilonorm is useless. "

“The depressive pressure is unbearable, I cannot read, do not concern myself with anything because I cannot concentrate. And that for years! Couldn't you remedy this with a suitable medication that stabilizes the normal position? There must be such a thing when a flood of new drugs comes onto the market every year. "

“I don't think much of an inpatient cure. Please prepare yourself until next time which drug you can use to normalize me emotionally. I hope that this letter adequately describes my state of illness. It is important, please read it twice. W. D. "

"P. S. Can you give me a normal emotional scale? I beg you, please make an effort! "

“Now at the end of the year, I have to go with you great Regret to find that your therapeutic measures are neither i. S. Depression still i. S. fear of hell succeeded. So you took these 3 years from me and I don't have much time left because I'm getting closer ... "

“Heal, but please soon: a) my depression, which has lasted for so long, b) my fear of hell (obsession for 3 years). Apart from e-shock, every remedy is fine with me. "

"" Please tell me, because it is important to me whether you have cured only one patient, diagnosis 'fear of hell' in all of your medical work so far. "

"" If you now fail to completely cure my fear of hell with obsession, everything up to now has been in vain and we have to look for another specialist, which we would be very sorry for. W. D. "

That worries me that the permanent depression along with the exploding fear psychosis (fear of hell) is tending steeply downwards. That suggests there is going to be a crisis, some sort of explosion. 'Cause I'm ready to burst tense with body and soul in the direction Full healing. I definitely don't want to live among mentally healthy people with obsessions that block my brain completely ... I want to have them removed by the competent doctor ... I long for nothing more than a very competent doctor who can cope with my complicated illness. W. D. "

A red ballpoint pen was used for this letter in addition to the blue one; there are red underlines and multiple red underlines of individual words; the word "Hell" is only written in red pen.

“... that's why I complained to you last September, I miss the emotional ability to love. At that time you mistakenly redirected to the physical ability to love, which, however, plays no role for me, because I have been impotent for 3 years. As a psychiatrist, what do you think of my problem? Can you show me the way to the full psychological ability to love? That would solve my problem ... Think about emotional concerns. My wife loves me. W. D. "

"Additions to my medical history: Before the start of your treatment, two-cyclic MDK, rapid phase change, 3 depressions and 3 manias at an interval of ½-years, no normal intervals, constant psychiatric treatment."

“You could neither cure the current permanent depression nor the fear of hell. I note this disgruntled. All of the previous drugs have not worked (Ludiomil, Dapotum, etc.). Please prescribe me a completely new drug, even if it has not yet been clinically tested. Should the health insurance not pay for it, I am ready to sacrifice my meager savings to my health. All that matters to me is that you take away my fear of hell - fear psychosis, fear neurosis - with your medical art (comes from being able to!). W. D. "

"Your s.g. Dr. F. told me last time that only the priest could take away the fear of hell, not the doctor. If that were the case, I would be sitting between two armchairs. For in the last 3 years I have been discussing my fear of hell with priests for hours, unfortunately without the slightest result, without the slightest relief. W. D. "

“At the beginning of my illness, a psychiatrist told my mother that I was suffering from late adolescent maturation. This 'ripening delay' has never been regulated. I keep failing because I'm not a mature man. I doubt if I can be helped on this. I would have to attain the maturity of a 50-year-old through psychotherapeutic treatment, then I would find myself in the currently completely lacking equilibrium. W. D. "

"... I haven't made any progress in terms of maturity. I stand there now, barely with the maturity and emotional maturity of a 20 year old. Guys. I have never had an education in my heart (according to my mother). Because I'm so full of immaturity and have no chance of becoming more mature, I also know that I'm damned to hell. Unless there is a possibility within the framework of the med. Treatment. I suffer tremendously from my maturation delay because I cannot escape the inevitable consequence of damnation to hell ... Make me a normal and healthy man, but a mature man appropriate for his age. The chemotherapy will not be enough! I am terribly afraid of hell! W. D. "

“I can't stand the fear of hell any longer!

I can't stand the fear of hell anymore!

I can't stand the fear of hell anymore!

When I come back on ... please take a therapeutic measure, which will take away my fear of hell. I can't take it anymore. Please free me from the fear of hell! Please help me, I can't stand this fear of hell anymore! But please don't keep there stationary. I have to stay with my wife.

Please free me from the fear of hell. Every day is a torture for me. I can no longer stand the fear of hell! Try to empathize with myself, how I suffer from the fear of hell, how I suffer unimaginably.

Take this letter as an SOS shout and think of something you can do to take away my fear of hell.

In the hope of not having made a wrong request, with the utmost respect, W. D. "

"Please give me strong injections, I am very persistent against medication ... I am so afraid that the whole treatment will fail and it will be a blow in the water, I fear that despite your ability and experience ... I am very despondent. W. D. "

“… I am exposed to a negative judgment from God the Lord. It is the fear of hell Not a delusional idea that can be driven out with the help of Haldol and lithium, but a real fear. Sacramental confession has failed because I keep thinking of new bad things from my past life and because I am not doing as well as I would for the purpose, recall can. I am therefore afraid of such a death that I will one day die with the thought of going straight to hell. I'm afraid continuously such a death throes, which by nature are tough enough.

I will not be able to forget this anguish fear.

W. D. "

force, I emphasize this word because it is the key to the background of my illness, the AvdH [Fear of hell], is. My ghost want do not think the thoughts of fear, but he has to think them because of the compulsion present ... W. D.“

The writer of these lines was a highly intelligent man. His tireless writing and the large number of letters correspond to his increase in manic drive. The tormenting feeling of emptiness between him and his wife and the painful feeling of being excluded from the community are clear signs of an endogenous depressive experience. Daniel hell speaks of the "changed humanity - alienation and emptiness" of the endogenous depressed person.1 And the "fear of hell" is a fitting metaphor for this feeling of having lost all relationships with other people - forever - to have fallen out of the human world as a person.

Especially the comparison with others shows the depressed person his failure, heightened his feeling of inferiority and his dejection. It would be possible that in the case of severely depressed self-reproaches, which have become delusional, represent an attempt to at least not completely abandon self-assessment through excessive self-criticism, says Daniel Hell.2

So I believe that in this case there is no doubt about the severe depression. But it cannot be overlooked that this condition is also manic. The desire to get well again, to be a normal person again, cannot be expressed in this intensity by a depressed person; Nor is the urgency of the desire for effective treatment or the disappointment and displeasure that he has not received one so far. A depressed person would neither have the strength nor the courage to write to his doctor: "If you now ... fail, everything has been in vain and we have to look for another specialist ..." the outpatient treatment in our hospital was completely free and voluntary.

Even hours of discussions with priests could not take away Mr. W. D.'s fear of hell. Severe depression also extinguishes the possibility of believing trust in religious people. Melancholy was therefore called a mortal sin by the Church in earlier centuries. In Hasidic doctrine, melancholy was called worse and more pernicious than sin.3

He was full of immaturity, wrote Mr W. D., and therefore knew that he was "condemned to hell. Unless there is a possibility within the scope of the med. Treatment. ”If the first sentence has to be described as a depressive delusional idea (the delay in maturation inevitably leads to the condemnation to hell), the second sentence is no less absurd: How can medical treatment save from hell?

On the one hand, Mr. WD has a high opinion of the doctor, as is typical for depressed people, he idealizes him, projects certain omnipotent fantasies onto him: the doctor can give him a normal range of emotions, make him a mature man, but above all his tormenting ones Take away fear; on the other hand, he is not afraid to ask him to try hard to think, to look up books, to prepare for his next visit. He also interferes in psychotherapeutic treatment: one should give his wife “tips”, one should practice normal actions with him, one should do relaxation exercises with him; Do not even shy away from interweaving doctrinal explanations (“art comes from being able”) and accusing the doctor of having robbed him of three years of his life because of the failure of the therapy.

The eloquence in the letters and the fluency of speech are extraordinary. Mr. W. D. speaks of a "mountain fear" and calls for a "complete healing".The constant repetition of the word "fear of hell" or even the threefold repetition of the sentence "I can no longer stand the fear of hell" is really very haunting.

So many Underlines as in W. D.'s letters, manic people appear only in the letters and do not fit into the picture of depression. You can even find them in a letter Red and multiple red underlines, is the word "hell“Always written in red.

It is also hard to imagine that a depressed person, without the addition of manic components, could fall into the term “superdepression” or use the abbreviation AvdH (fear of hell), as Mr W. D. did in his last letter.

All in all, the letters seem to me to be a classic example of this very rare mixed manic-depressive state, which is described in psychiatric textbooks as depressive "anxious mania". Because of the strength of the suffering, Mr W. D. himself rightly spoke of depression. The outsider is blinded by the manic manifestations. Depending on the point of view, one can speak of depression or mania.



1 Hell (1992), p. 56 ff. [Hell, D: What sense does depression make? The depressive event as protection and

Embassy. An integrative and evolutionary approach. Hamburg: Rowohlt Verlag]

2 Ibid. P.56

3 Buber (1994, p. 476. (cf. “Depression and mania in a religious perspective, p. 109 ff.).


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