Different versions of an individual suffering from bipolar disorder.

Artwork by Taniya Pramanik

Different versions of an individual suffering from bipolar disorder.

Bipolar Disorder Mixed Episode: All you need to know

Medically reviewed by

Written by Parth Sharma

Bipolar disorder was previously called Manic Depression, a mental health condition that is severely generalized and causes extreme mood swings that include emotional highs (mania or hypomania) and lows (Depression). It has a high prevalence of people stopping their medication mid-course of its administration. Causes for bipolar disorder are varied and can result in varied symptoms in different people. There are also multiple types of bipolar disorder that affect people including Bipolar I, Bipolar II, Cyclothymia, and more. Further, there is no single bipolar disorder test to diagnose the disorder. Only a trained psychiatrist or mental health professional can make a bipolar disorder diagnosis.

Bipolar Disorder: Mood elevation 

People diagnosed with bipolar disorder may feel sad or hopeless and lose interest or pleasure in most activities through their depressive episodes. At the same time, their mood may shift to mania or hypomania, where they feel full of energy or unusually irritable. These mood swings can affect their sleep, energy, judgment, and behavior. 

To further understand bipolar disorder, it is essential; to understand that to classify an episode as a mood elevation (that is, mania or hypomania), one must exhibit a prolonged, high energy-filled, unusual mood. This must be while also showing symptoms of mood elevation, including but not limited to, a sense of euphoria, increased self-esteem, reduced sleep, and racing thoughts. 

Are mixed episodes normal in bipolar?

Mixed Episodes of Bipolar Disorder then refer to the presence of both high and low symptoms co-occurring or as a part of a single episode. In most forms of Bipolar Disorder, the moods alternate between elevated and depressed over time; a person with mixed features experiences symptoms of both mood poles, mania, and depression, either simultaneously or in rapid sequence.

The terms mixed state bipolar and bipolar with mixed states are no longer used as a specifier for bipolar disorder. DSM 5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) changed the previously known mixed states to mixed features. This means one can have a depressive episode with mixed features, where the main symptoms are depressive, but subclinical manic signs are also present. 

For example, one may feel depressed and experience racing thoughts or rapid speech simultaneously. Or one can have a manic episode with mixed features, where the main symptoms are those of a manic episode, but depressive symptoms are also present. For example, one may be doing several high-energy activities and feel depressed simultaneously.

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Mixed Features: Symptoms and Clinical Picture 

Mixed episodes are common in people with bipolar disorder; research suggests that half or more people with bipolar disorder have at least some mania symptoms during an entire episode of depression. 

Those who develop bipolar disorder at a younger age, especially in adolescence, are more likely to have mixed episodes. People who develop episodes with mixed features may also develop pure depressed or pure manic or hypomanic phases of bipolar illness. It is also interesting that people who have episodes of major depression but not full episodes of mania or hypomania can sometimes have low-grade mania symptoms. However, these are symptoms that are not severe enough to be classified as bipolar disorder. 

Within Bipolar disorder, a person with mixed features can have either; Mania (with mixed features), usually involving irritability, high energy, racing thoughts, and overactivity/ agitation or Depression (with mixed features) with feelings of sadness, loss of interest in activities, low energy, feelings of guilt and worthlessness, and thoughts of suicide and self-harm.

Symptoms of Bipolar Disorder Mixed episode

Symptoms of bipolar disorder with mixed features may vary, depending on the mood episode in question. They can, however, include:

  1. feeling a mixture of high and low moods
  2. doing pleasurable activities while having depressive symptoms
  3. experiencing low mood with rapid speech/ racing thoughts
  4. experiencing elevated mood with suicidal ideation
  5. having a severe disturbance of appetite

This may seem very irregular and, in many cases, impossible. How can someone be in a state of mania and be depressed at the same time? Their co-occurrence is more common than people realize. 

For example, a person in an episode with mixed features could be crying uncontrollably while announcing they have never felt better in their life. Or they could be sky-high happy, only to unexpectedly collapse in misery. 

A short while later, they might suddenly return to an ecstatic state. Mood episodes with mixed features can last from days to weeks or months if untreated. They may recover, and recovery can be slower than during pure bipolar depression or pure mania or hypomania episodes.

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Treatment of Mixed Symptoms of Bipolar Disorder 

Experiencing both mania and depression at the same time can feel confusing or disorienting. Coping with a mixed features mood episode can be challenging, especially when you have difficulty remembering exactly how you feel. A rapidly shifting mood can create an abundance of emotional turmoil, and recurring, severe suicidal thoughts aren’t uncommon. The good news is that the proper bipolar disorder treatment and coping strategies can effectively help people manage these symptoms.

While administering a treatment plan for people with mixed feature bipolar disorder, it is important to note how well they function every day, depending on their exact diagnosis and symptoms. Manic or depressive episodes with mixed features typically require treatment with medication. 

Medication and Therapy

Unfortunately, such episodes are more challenging to manage than an episode of pure mania or depression. The treatment of a mixed episode of bipolar disorder is complex. It may involve a combination of mood stabilizers and atypical antipsychotics. 

Mood stabilizers are Mood-stabilising Medications for Bipolar Disorder that control manic or hypomanic episodes. In contrast, suppose symptoms of depression or mania persist despite treatment with other medications by adding antipsychotic drugs. In that case, the doctor may prescribe some of these medications alone or a mood stabilizer as part of a bipolar disorder mixed episode medication course.

Therapy with a trained mental health professional may not necessarily resolve severe mood symptoms. Still, it can be substantially helpful when you live with diagnosed bipolar disorder. A therapist can help you identify and manage overwhelming emotions, abrupt mood changes, and thoughts of suicide, even when you’re unsure precisely what you’re feeling. It also offers a safe space to build coping skills and create a crisis plan for future mood episodes.

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