What Is A Bipolar Mixed Episode?

Many of us might be familiar with the fact that people with bipolar disorder may experience states of mania, hypomania or depression—either occurring separately, or all at once. One piece of bipolar disorder that can be overlooked, though, is the possibility for mixed features and episodes that might overlap with each other in symptomatic expression. 

A “mixed episode” may present signs of mania, hypomania and depression at the same time, which can make determining the best course of action for treatment a challenge for some. However, there are steps you can take to prepare for and manage mixed feature episodes effectively.

Read on to define what mixed episodes might be for many, and learn how those living with the condition can possibly attain a higher quality of life using targeted supportive strategies.

What is bipolar disorder?

Bipolar disorder is a mental health condition characterized by fluctuations in mood, cognition, and behavior. Individuals with bipolar disorder experience shifts between depressive and manic (or hypomanic) states, which are periods of low and high mood, respectively. People typically develop bipolar disorder during adolescence or early adulthood, though symptoms sometimes occur during childhood. There are three types of bipolar disorder: bipolar I, bipolar II, and cyclothymia. 

For a mental health professional to diagnose bipolar I disorder, an individual must have experienced a manic episode that persisted for at least a week. While people with bipolar I can experience symptoms of depression, the presence of a depressive episode is not a requirement for a diagnosis. 

To be diagnosed with bipolar II disorder, both a major depressive and hypomanic episode must have occurred. A hypomanic episode is a less severe form of mania, marked by symptoms that do not significantly impair functioning in everyday life. 

Cyclothymia, also called cyclothymic disorder, may be diagnosed when an individual experiences periods of depressive and hypomanic symptoms that do not meet the criteria for an episode of depression or hypomania. 

While the exact cause of bipolar disorder is unknown, genetics and abnormalities in brain structure and function are considered primary contributors. Other risk factors include drug misuse, highly stressful or traumatic events, and disrupted sleep patterns.  

Bipolar disorder mixed episode: Definition

Typically, bipolar disorder symptoms occur during distinct mood episodes, confining the features of mania and depression to manic and major depressive episodes, respectively. However, during some mood states, manic and depressive symptoms occur simultaneously. 

Mental health professionals generally recognize certain symptoms that can come with bipolar disorder as mixed episodes when they occur together. This terminology has recently been transitioned to the specifier “mixed features” for many, which can be applied to manic, hypomanic, and depressive episodes. 

Mixed (depressive and manic) episodes in the DSM

The Diagnostic and Statistical Manual (DSM-5) is generally used by mental health professionals as a standard tool for the diagnosis of mental health disorders. 

In its most recent edition, the terminology used to describe mixed features has generally become broader. Instead of being classified as its own separate phenomenon, a mixed feature state is now generally, diagnostically seen as a variation of the intense highs and lows that might typically accompany bipolar disorder for many. 

By clinical definition, a mixed feature episode can be detailed as being either of the following:

• Three or more depressive symptoms during a manic or hypomanic episode

• Three or more hypomanic or manic symptoms during a major depressive episode

The symptoms of a mixed features episode must be present more days than not during the phase of the predominate polarity. 

How prevalent is bipolar disorder with mixed features?

Since the DSM-5 has broadened the definition of bipolar disorder episodes with mixed features, old statistics have generally become outdated. However, some studies have explored how many people have mixed features along with bipolar disorder. 

For example, one recent study found statistics that suggest that 40% of major depressive episodes also included at least one symptom of hypomania for some patients living with bipolar disorder. What's more, those in the study who had that experience were statistically suggested to be more likely to be diagnosed with bipolar disorder later on. While many might agree that more research needs to be done to get a full picture, doctors and scientists have enough information to clinically suggest that bipolar disorder episodes with mixed features are not necessarily uncommon.

Mixed affective episode symptoms

Bipolar disorder with mixed features can create symptom groups that can fall into the categories of manic, hypomanic, and depressed classifications. However, it's generally the fact that the opposite symptoms occur together that can indicate an episode that contains mixed features. For example, an individual experiencing a manic episode with mixed features may exhibit the elevated energy levels and rapid speech of mania along with the feelings of sadness and guilt of depression. This can be helpful for many to keep in mind as they work to determine what symptoms may be affecting them predominantly, and what type of episode they may be experiencing.  

Here is a list of common symptoms that can be related to each type of mood disturbance, followed by a look into how they can show up together in some: 

Symptoms of a manic episode

The following are symptoms that can be commonly associated with bipolar disorder manic episodes:

• Euphoric or elated moods

• Grandiosity or overinflated self-esteem

• Irritability

• Rapid, excessive or pressured speech

• Personality changes

• Racing thoughts

• Excessive energy

• Decreased need for sleep

• Distractibility

• Working feverishly towards goals, even if the goals don't make much sense

• Engaging in risky behaviors and activities

Severe symptoms may also lead to hospitalization due to injury, a lack of sleep, and similar concerns.

If you believe that you may be a danger to yourself or others, please contact the Crisis Text Line by texting HOME to 741741. There are resources available to help. 

Symptoms of a hypomanic episode

Hypomanic symptoms often look like a milder version of manic symptoms. In fact, the DSM-5 notes the same symptoms of hypomania as for mania, barring a few key differences. 

For diagnostic purposes, hypomanic symptoms generally only need to be present for 4 consecutive days for a formalized diagnosis. 

Symptoms of a depressive episode

These symptoms can be common in bipolar disorder depressive episodes:

• Intense sadness or numbness

• Finding little or no pleasure in once-enjoyed activities

• Weight loss or weight gain

• Sleeping too much or too little

• Feeling guilty, even if there is no clear reason

• Waking up too early

• Experiencing trouble thinking or concentrating

Mixed features

Any of the above symptoms can be a part of a mixed state that can be caused by bipolar disorder. If you or a loved one experiences characteristic signs of depression, for instance, but also things like impulsivity, a reduced need for sleep, or feelings of sadness, it may be worth noting. 

Discussing your concerns with a trusted healthcare professional may be the best way to determine what your symptoms may mean and how to best address them in your specific case.

How long do bipolar episodes last?

Bipolar episodes can last for a week, several weeks, or longer.  In a mixed-episode bipolar disorder, emotional states can last equally as long. Sometimes, though, they can resolve quite quickly or switch to another distinct state (mania, depression, etc.) instead. Also, like other forms of the condition, bipolar disorder with mixed features is thought to follow seasonal patterns. These seasonal patterns typically depend on the predominate polarity. For example, manic episodes with mixed features are thought to peak in late summer, while depressive episodes occur most frequently in winter.  

Treatments for bipolar disorder with mixed features

Mixed bipolar disorder episodes can require specialized treatment. Effective treatment might include a combination of medications and therapy for many, as well as other supportive strategies (such as lifestyle changes). 

When you're being treated for this type of mental health disorder, it can be helpful to work together with your doctor and therapist to get the most possible support from your course of treatment. That may mean reporting symptoms as soon as possible and discussing the concerns you notice as openly as you can. 

Medications for bipolar disorder with mixed features

The medications used to address mixed states in bipolar disorder can be the same medications used for depression or mania. However, your doctor may need to keep a close eye on how things are going and make adjustments as needed. Being as transparent as you can with your medical care team can help you to get the most help from a course of treatment, pharmaceutical or otherwise. 

Examples of medications that can be used for mixed-state bipolar disorder are mood stabilizers, which can help diminish mood swings, antidepressants, and antipsychotics. Often, a professional will prescribe two or more medications. Finding the right combination of medications that can successfully manage symptoms without causing any negative side effects can take time, but for many, this step can be an important part of finding a sense of stability that can make healing possible. 

Some medications may work well for those with certain symptoms, but others might be more likely to cause unwanted side effects or exacerbate symptoms. For example, tricyclic antidepressants have been found to cause mixed features during depressive episodes. 

Researchers have found that atypical antipsychotics, also called second generation antipsychotics, and anticonvulsants can manage symptoms of mixed bipolar episodes effectively. Certain medications, such as the mood stabilizers lithium and valproate, may be prescribed between depressive, manic, and mixed episodes. Maintenance treatment can help reduce the likelihood of recurrence of bipolar mixed episodes, as well as acute depressive or acute manic episodes. 

Online therapy for mixed state bipolar disorder: Is it worth it?

Therapy can help many to live with the range of possible effects of mixed episodes in bipolar disorder. 

Talking to a counselor can be a great way to navigate confusing moods, thoughts, and behaviors. It can also help you during times of remission when the symptoms are mild or not present. At those times, you can gain perspective on the course of your disorder and learn better ways to respond when symptoms do arise.

You may find that resources like online therapy can make it especially easy to get the support you deserve. Because you only need an internet connection to attend sessions, online therapy can help you save time and money that might otherwise go to things like gas costs, childcare, and other expenses. 

Is online therapy effective? 

A recent study published in PLOS Digital Health has found information that suggests that online therapy use by patients living with bipolar disorder attained similar gains that pharmaceutical intervention did—which could potentially have powerful implications for patients who may not tolerate (or who might not prefer) pharmaceutical courses of treatment.