Some people with bipolar disorder may experience episodes of the condition with mixed features. These episodes include signs of both mania and depression. But they’re treatable.

People often think of bipolar disorder as involving separate episodes of mania and depression.

However, some people with the condition experience periods in which they have symptoms of both these mood states at the same time.

Doctors used to refer to these periods as “mixed episodes.” Now, they call them episodes with “mixed features.”

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR), provides mental health professionals with criteria for diagnosing a bipolar episode with mixed features.

A mental health professional may work with a primary care doctor to rule out other conditions that could explain your behavior.

A mental health professional will also consider your medical and family history and symptoms and specify the type of bipolar disorder upon providing a diagnosis.

A manic or hypomanic episode with mixed features will meet the full criteria for mania or hypomania, which are outlined below, but you’ll also have at least three depressive symptoms.

To meet the criteria for a depressive episode with mixed features, you must also have at least three symptoms of mania or hypomania.

Bipolar disorder is not self-diagnoseable. Nor can it be determined with one test alone.

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

Manic episodes last at least 7 consecutive days. If you have difficulty managing your symptoms during this time, hospital care may be beneficial.

Symptoms of a manic episode may include:

  • a persistently elevated or irritable mood
  • an increase in goal-directed activity
  • rapid speech
  • engaging in impulsive behaviors
  • reduced need for sleep
  • racing thoughts
  • decreased appetite
  • hypersexual activity

A hypomanic episode lasts at least 4 consecutive days. During this kind of episode, you may experience:

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

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

A depressive episode can range from mild to severe and typically lasts at least 14 days. This kind of episode may include:

  • a depressed mood for most of the day
  • anhedonia (inability to feel pleasure)
  • decrease or increase in appetite, which may lead to significant weight loss without dieting or weight gain
  • feelings of worthlessness or excessive guilt
  • sleeping more or less than usual
  • slowed movements or thoughts
  • trouble concentrating
  • fatigue
  • suicidal ideation

Help is out there

If you or someone you know is in crisis and considering suicide or self-harm, please seek support:

  • Call or text the 988 Suicide and Crisis Lifeline at 988 or chat at 988lifeline.org. Caring counselors are available to listen and provide free and confidential support 24/7.
  • Text HOME to the Crisis Text Line at 741741 to connect with a volunteer crisis counselor for free and confidential support 24/7.
  • Not in the United States? Find a helpline in your country with Befrienders Worldwide.
  • Call 911 or your local emergency services number if you feel safe to do so.

If you’re calling on behalf of someone else, stay with them until help arrives. You may remove weapons or substances that can cause harm if you can do so safely.

If you’re not in the same household, stay on the phone with them until help arrives.

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

Everyone has a different switch process, or a mechanism that triggers your mood changes.

Triggers and causes may include:

  • disrupted sleep-wake cycles
  • irregular schedules
  • taking antidepressants
  • genetic factors

Bipolar disorder treatment often includes medication, therapy, and lifestyle changes:

For bipolar disorder with mixed features, combinations of medications may work better than a single medication.

In situations where these treatments aren’t effective, electroconvulsive therapy may be considered.

Episodes with mixed features in bipolar disorder can be serious. People who experience them often have comorbid (co-occurring) anxiety and 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 getting support when needed can help manage bipolar disorder, reduce the frequency and severity of episodes, and improve daily life.

Although some people have distinct manic, hypomanic, and 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 to manage symptoms and reduce the impact of the episodes on your life.

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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