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Section 9
Characteristics of Mixed-Episode in Bipolar Patients

CEU Question 9 | CE Test | Table of Contents | Bipolar
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

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On the last track, we discussed techniques to cope with a paranoid or fearful bipolar child client.  Three techniques for treating a paranoid client were:  Waiting It Out; Reality Check; and Staying on Guard.  Two Techniques for treating a fearful client were:  Breathing Exercises; and Counting.

Feeling manic and depressed at the same time is not common in adult bipolar clients.  However, a mixed state is fairly common in child bipolar clients. 

On this track, we will examine three characteristics of mixed states which include irritability; distractibility; and boiling point. We will also include three techniques for children who experience mixed states, which are Define your Emotions; Sensory Focus; and Contract to Avoid Conflict.

3 Characteristics of Mixed States

1. Irritability
The first characteristic of a mixed state is irritability. This characteristic can occur in both manic and depressive states or it could be the transitional state, marking a shift of moods. Many bipolar children are cryptic about their moods. When they are in such a state, I emphasize interpreting their body language.

Mary was an 8 year old client who would hunch over in her seat, shift from foot to foot, and mumble incoherently about things that were bothering her. During such irritable states, she became hypersensitive to sensory stimuli such as sights, smells, and sounds. Too much light often bothered her, so I turned down the dimmers in my office to make her more comfortable. A sensory overload in an irritable child client can soon lead into rage, which we discussed on track 7. 

Technique:  Define Your Emotions
To communicate with clients who are irritated, but won’t voluntarily define their moods, I use the "Define Your Emotions"  technique. Mary only displayed irritation through her body language. I asked Mary to define her emotions for me, so that I could better understand. Mary stated, "Nothing goes right.  No one listens to me." I stated, "You’re frustrated because things don’t go your way." Mary said, "Yeah, no one understands me." I responded, "You’re angry because you try to show that you feel bad, but your mommy and daddy don’t see that. They get mad at you." Mary stated, "Yes.  They don’t care if I feel bad."

I asked Mary, "What else is bothering you?" Mary stated, "Sometimes, I can’t choose anything. My mommy baked cookies and she asked me what kind of frosting I wanted. I couldn’t choose." I stated, "You’re feeling indecisive."

As you can see, once Mary related to me specific incidences, I responded by repeating in a different manner what she had just related to me. In irritable children, a sense of someone understanding, even if it is superficial, can ease their frustration. Using this technique, Mary’s posture straightened and she became less irritated. Think of your "Mary". Would he or she benefit from "Defining your Emotions"?

2. Distractibility
A second characteristic of mixed states is distractibility.  Children with these indescribable emotions have a hard time focusing on one task.  Unlike rage during which a child should be separated, a distracted child only becomes more upset by being alone.  Their unfocused thoughts begin to pile up until they become more and more frustrated and again are in danger of flying into a rage.  Sydney was a 6 year old bipolar client.  When she was in her mixed states, she couldn’t focus on any one thing.  Sydney appeared lost and described herself as not knowing what to do. 

Technique: Sensory Focus
To help young children like Sydney who are suffering from unfocused thoughts, I find the "Sensory Focus" technique to be beneficial. The object of this technique is to ask the child client to focus their attention on one sensory image or stimuli. For example, I keep a glass crystal in my office. I put the crystal up to the light and asked Sydney to just watch the colors that came out of the crystal and onto the wall.

There are several ways to go about helping your bipolar child client to focus on one sense. I have also found keeping a small easy bake oven in my office is one way to help the distracted client focus on his or her olfactory sense. Mixing the ingredients, shaping the dough, and smelling the cooking pastry will help your child client center their thoughts on one task rather than the million other thoughts rising in his or her mind. Think of your "Sydney". What other techniques could you use to help him or her focus?

3. Boiling Point
In addition to irritability and distractibility, a third characteristic of a mixed state in bipolar children is the boiling point. Despite efforts by parents to keep their bipolar children from flying into a rage during a mixed state, some things just can’t be prevented. The bipolar child reaches a point in which they know they are about to blow, but they can’t express it in words. I have told several of my child bipolar clients to work out a signal with their parents so that they will know when a rage is imminent after a mixed state. 

Such signals include a code word, gesture, or lunge for one particular toy that he or she might use. Eleven year old Walt would turn up the music on his stereo or headphones to indicate an impending rage. When he did this, his parents both knew that Walt had reached his boiling point.

Technique:  Contract to Avoid Conflict
As you know, much of the treatment of early onset bipolar disorder must occur within the family unit.  Most of the symptoms are expressed when the child client is in the comfort of his or her home.  To help parents whose children often go past the boiling point, I suggest creating "A Contract to Avoid Conflict". 

When a rage is over, only then can parents revisit the issues that instigated it.  I ask them to write down goals and rewards for preventing rages. For instance, Lawrence, Walt’s father, wrote out, "Everyday you must take your medicines, do your homework, and go to your room when you are feeling angry." On the other side of the paper, Lawrence also wrote rewards that Walt could earn by following the conditions: "In return, you will earn two books from the school book club each month." For those parents who wish to make a contract, I give them the following guidelines:

1. Keep it simple and be specific.  Make sure that the goals and terms of your contract are stated in language your child can understand.
2. Make the requirements... just challenging enough for your child to find interesting, keeping in mind that his or her ability to address these challenges may fluctuate with his or her moods.
3. Make sure there’s a "buy-in".  For the child to succeed, he or she must buy into the deal.  Set goals together, and agree on the terms of your contract.
4. Use feedback techniques to give the child pointers on his or her performance.  This can be done on a daily, weekly, or monthly basis.
5. Remember to update and change the contract regularly.
Using this contract, parents and bipolar children can work together to avoid unbridled rages.

On this track, we presented three characteristics of mixed states which included irritability; distractibility; and boiling point.  We also included three techniques for children who experience mixed states, which include  Define your Emotions; Sensory Focus; and Contract to Avoid Conflict.

On the next track, we will examine three difficulties in prescribing medication to bipolar children.  These difficulties include:  taking regular doses; rebellious teens; and side effects.  We will also include two techniques for combating these difficulties, which are Medication Routine and Other Non-Medicinal Treatments.

Peer-Reviewed Journal Article References:
Basso, M. R., Lowery, N., Neel, J., Purdie, R., & Bornstein, R. A. (2002). Neuropsychological impairment among manic, depressed, and mixed-episode inpatients with bipolar disorder. Neuropsychology, 16(1), 84–91.

Johnson, S. L., Tharp, J. A., Peckham, A. D., & McMaster, K. J. (2016). Emotion in bipolar I disorder: Implications for functional and symptom outcomes. Journal of Abnormal Psychology, 125(1), 40–52. 

Kato, T. (2021). Moderation effects of coping flexibility on the association between depressive symptoms and suicidal risk. Crisis: The Journal of Crisis Intervention and Suicide Prevention.

Shahar, F. G. (2020). When bipolar was still called manic depression: Getting sick in the era of the DSM–II. Psychological Services. Advance online publication.

Swartz-Vanetik, M., Zeevin, M., & Barak, Y. (2018). Scope and characteristics of suicide attempts among manic patients with bipolar disorder. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 489–492.

Online Continuing Education QUESTION 9
What are three characteristics of mixed states? To select and enter your answer go to CE Test.


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