Understanding Episodes of Bipolar Disorder with Mixed Features

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Many people think of bipolar disorder as a mental health condition where a person has episodes of mania or depression. However, some people with bipolar disorder have periods of time when they may experience both. These periods of time were formerly called “mixed episodes,” but are now known as “mixed features.” During these times, individuals have symptoms of mania and depression at the same time.

About one-third to one-half of people with bipolar disorder have mixed states. Knowing more about mixed features can help people navigate an episode and get help.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), provides doctors with criteria for determining a bipolar episode with mixed features. This criteria is outlined below.

How does a bipolar mixed feature episode compare with a bipolar manic episode?

In a manic episode, symptoms can include:

  • elevated mood
  • doing enjoyable activities
  • rapid speech
  • risky behaviors
  • less sleep
  • racing thoughts
  • disrupted eating
  • hypomanic episodes lasting about 4 days

Manic episodes may last up to 7 days. For people having difficulty managing their symptom or behaving in ways that may be harmful, hospital care may be beneficial.

In contrast, an episode with mixed features can include:

  • a mix of elevated and depressed mood
  • incongruent speech and thoughts, such as rapid speech but depressed mood
  • elevated mood but experiencing suicidal thoughts
  • disrupted sleep
  • changes in appetite

Episodes with mixed features can vary in duration.

There are elements of depressive episodes present alongside symptoms of a manic episode.

How does bipolar disorder with a mixed depressive episode compare?

A depressive episode may include the following symptoms:

  • depressed mood
  • inability to feel pleasure
  • feelings of guilt or worthlessness
  • slowed rate of speech or soft speech
  • suicidal behaviors
  • usually wakes early morning
  • trouble thinking or concentrating
  • minimal appetite

A depressive episode can range from mild to severe and typically lasts about 14 days.

Bipolar disorder, formerly known as manic depression, is a chronic mental health condition. It causes shifts in mood, energy, activity levels, and the ability to do daily activities.

Moods can include periods of feeling very up or energized (manic periods), sad or depressive periods, and periods of mixed emotions.

Three main symptoms of bipolar disorder are mania, hypomania, and depression. Symptoms and behaviors can include:

  • mania, which may present as:
    • periods of euphoria or very high energy levels
    • lack of sleep
    • engaging in activities on impulse, such as:
      • overspending
      • excessive drug or alcohol use
      • sex without a condom or other barrier method
  • hypomania, a milder form of mania that may present with less extreme behaviors
  • depression

Diagnosing bipolar disorder can be difficult. There is no one test. Instead, a variety of tools are used. Once bipolar disorder is confirmed, the type of bipolar disorder (bipolar disorder I or bipolar disorder II) will be determined, as well.

Bipolar disorder is diagnosed by a psychiatrist or another mental health professional. They will take a medical history and discuss symptoms. They may work with a primary care doctor to rule out any other conditions that could explain the behavior.

A bipolar episode with mixed features can be diagnosed, per the DSM-5, if:

  • there are three or more manic or hypomanic symptoms during a major depressive episode
  • there are three or more depressive symptoms during a manic or hypomanic episode

While there are noted risk factors for bipolar disorder and bipolar episodes, risk factors for episodes with mixed features are less clear.

The switch process, or the mechanisms that trigger the changes in mood, needs to be discovered in each individual. Triggers may include things like disrupted sleep-wake cycles, irregular schedules, or taking antidepressants. Genetic factors may also play a role.

Bipolar disorder is typically treated in several ways, including medication, therapy, and lifestyle changes.

Treatments can include:

  • medication
    • antipsychotic medications
    • antidepressant medications
  • therapy
  • lifestyle changes
    • learning to recognize changes in mood
    • finding support among friends and family
    • following a routine for eating and sleeping

For bipolar disorder with mixed features, combinations of medications may work better than a single medication. In situations where these treatments options are not effective, electroconvulsive therapy may be considered.

Episodes with mixed features in bipolar disorder can be serious. People who experience them often have comorbid anxiety and/or substance use disorders.

Psychotic features may also be more common in episodes with mixed features, so it’s important to treat symptoms of these episodes and work with your doctor to manage bipolar disorder.

Following a treatment plan and support when needed can help with managing bipolar disorder, reducing the frequency and severity of episodes, and improve daily life.

Although some people have distinct manic, hypomanic, or depressive episodes in bipolar disorder, some people experience episodes with mixed features. These contain symptoms of both mania or hypomania and depression. Appropriate treatment is necessary in order to manage symptoms and reduce the impact the episode has on your life.

Treatments are available for bipolar disorder with mixed features. Let your treatment team know what symptoms you are experiencing so they can work with you to manage your symptoms, minimize the impact of the episode, and help you manage bipolar disorder.



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