Bipolar Disorder With Mixed Features: What to Know | Psych Central (2022)

Mood episodes, or extreme shifts in emotion that can last several days, are the key symptom of bipolar disorder.

Bipolar disorder involves manic, depressive, or hypomanic episodes, but you could have more than one type of mood episode. The specific mood changes you experience depend on whether you have bipolar I, II, or cyclothymia.

Mood episodes associated with bipolar disorder do fall into three general categories. Still, around 40% of people living with bipolar disorder have a specific condition known as bipolar disorder with mixed features.

The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced “mixed features” as a specifier to replace the previous term, “mixed episodes.” Dysphoric mania and mixed mania, other older terms for this condition, have mostly fallen out of common use.

If you have bipolar with mixed features, your mood episodes will have mixed symptoms. Here’s what this means, according to DSM-5 diagnostic criteria:

  • During an episode of depression, you’ll have at least three symptoms of mania or hypomania.
  • During a manic or hypomanic episode, you’ll notice three or more symptoms of a depressive episode.

This differs from other types of bipolar disorder, where episodes involve only one type of mood symptom.

You may not have mixed symptoms for the entire length of the episode. Symptoms need only to last a majority of days during the episode. During a manic episode with mixed features that lasts a week, for example, you might have depression symptoms for 5 days, not the entire week.

Bipolar disorder with mixed features can be more severe than bipolar I or II without mixed features, since mood episodes tend to happen more frequently and last longer.

Symptoms might also be worse than typical bipolar symptoms and have more of an impact on your daily functioning.

Research has also linked mixed features to symptoms of psychosis, increased suicide risk, and substance use.

(Video) Mixed Features in Mood Disorders – Historical and Current Clinical Implications

Bipolar disorder can involve a wide range of symptoms. If you live with bipolar I disorder, you might have a very different experience from someone else living with the same condition.

A mixed features mood episode generally won’t show up in the same way as a mood episode without mixed features, and you may not have an equal combination of symptoms. In other words, more of your symptoms might fall into one category — mania, depression, hypomania — than the other.

The combination of symptoms can lead to some clear contrasts and inconsistencies in your mood, speech, and behavior. Here’s what that can look like:

Symptoms of mania with mixed features

Your mood episode will meet the criteria for an episode of mania or hypomania, but you’ll also have at least three symptoms of depression:

(Video) Bipolar disorder (depression & mania) - causes, symptoms, treatment & pathology

  • feelings of uneasiness or disconnection from reality
  • extreme sadness or tearfulness
  • a sense of emptiness, worthlessness, or guilt
  • energy loss and fatigue
  • lack of interest or enjoyment in your usual activities
  • moving and speaking more slowly than usual

A mixed features episode won’t always involve the same euphoria or feelings of grandiosity that often accompanies mania. You won’t necessarily feel on top of the world or experience the same elevated self-confidence and self-esteem.

You’re more likely to notice rapid changes in mood, increased irritability, and difficulty controlling strong emotions. In addition:

  • Your thoughts might race, or your speech might become very rapid, while you feel very low and slowed down in mind and body.
  • You might find yourself unable to stop smiling or laughing despite persistent feelings of guilt or thoughts of suicide.
  • Feelings of hopelessness or sadness might show up alongside physical restlessness, anxiety, or increased energy.

Symptoms of depression with mixed features

A depressive episode with mixed features will also involve three or more symptoms of mania or hypomania:

  • increased talkativeness and rapid speech, often characterized by frequent or sudden shifts in topic
  • extreme excitement or restlessness
  • increased energy
  • racing thoughts
  • greater distractibility
  • less of a need for sleep, or feeling rested after very little sleep
  • impulsive behavior or lowered inhibitions

While the DSM-5 includes grandiosity and an elevated mood among the typical signs of a manic episode, research suggests these symptoms show up less commonly in depressive episodes with mixed mania. Some people do still experience these symptoms, though.

During a mixed depressive episode:

  • An emotional “high” or euphoric state of mind might conflict with extreme sadness or guilt.
  • You could feel irritable or tearful, even while completely focused on a creative project you usually enjoy.
  • Persistent feelings of emptiness or worthlessness can show up alongside increased energy or restless movement.
  • You might start several projects but get sidetracked easily and fail to get much done.

The combination of rapid shifts between emotional states, impulsivity and distractibility, and racing thoughts can feel frightening and unpredictable. Symptoms of psychosis, such as delusions, hallucinations, and paranoia, can make this distress worse.

Treatment for mood episodes without mixed features focuses on resolving either mania or depression symptoms — whichever you are experiencing at the time.

Treating mood episodes with mixed features, on the other hand, needs to address mania and depression at the same time. This can pose some challenges, since certain medical treatments may worsen some symptoms, sometimes without offering much relief from other symptoms.

Certain antidepressants, for example, might intensify manic symptoms without relieving depression. Many people take lithium to treat manic episodes, but mood episodes with mixed features may not respond in the same way.

These mood episodes are often more resistant to treatment, so it may take some trial and error to find the most effective approach for your specific symptoms. The right treatment will help improve many of your symptoms without making others worse.

(Video) How to Diagnose and Treat Major Depressive Disorder with Mixed Features - A Rapid Summary

Treatment for bipolar disorder with mixed features typically involves medication. Your doctor or psychiatrist may recommend one medication or a combination, such as:

  • atypical antipsychotics (also called second-generation neuroleptics), such as aripiprazole and olanzapine
  • mood stabilizers, such as lithium, valproic acid, or divalproex
  • anticonvulsants, such as carbamazepine or lamotrigine

Research also suggests electroconvulsive therapy as another potential treatment for bipolar disorder with mixed features. If you don’t see much improvement with medication alone, your mental health professional might also recommend ECT.

Experiencing both mania and depression at the same time can feel confusing or disorienting.

Coping with a mixed features mood episode can be difficult, particularly when you have a hard time identifying exactly how you feel. A rapidly shifting mood can create plenty of emotional turmoil, and frequent, intense suicidal thoughts aren’t uncommon.

The good news is that the right treatment and coping strategies can help people manage these symptoms effectively.


Therapy with a trained mental health professional may not necessarily resolve severe mood symptoms, but it can be substantially beneficial when you live with bipolar disorder.

A therapist can help you begin to identify and manage overwhelming emotions, abrupt mood changes, and thoughts of suicide, even when you’re unsure exactly what you’re feeling or what kind of help you need.

Therapy also offers a safe space to build coping skills and develop a crisis plan for future mood episodes.

A therapist can also offer support with recognizing and tracking early signs of mood changes. When you catch a shifting mood early on, you can sometimes take steps to prevent an episode.

Bipolar disorder symptoms and mood episode cycles can change over time, so you might notice your treatment becomes less effective. Always let your therapist and the doctor who prescribed any medications know about new symptoms so that you can discuss more helpful treatments.

(Video) Case study clinical example: Session with a client with Bipolar Disorder (fluctuations in mood)

Manage stress

Stress in your day-to-day life can sometimes trigger mood episodes. While it’s not always possible to prevent stress, having a few go-to coping strategies in place can help you maintain a calmer mindset when challenges pop up.

Try these tips:

  • Make time for regular relaxation. This might include a nature walk, a warm bath, aromatherapy, or low-key pleasures like reading or coloring.
  • Try grounding techniques, such as deep breathing, when you find yourself in a stressful situation. Your favorite relaxing music can help, too.
  • Consider meditation to boost your ability to recognize and let go of unwanted thoughts.
  • Many people find that practicing mindfulness can help them reduce stress. However, it’s useful to remember that mindfulness can be challenging for people who have experienced trauma.
  • Progressive muscle relaxation is another tool for relaxing your mind and body. This involves slowly tensing and relaxing each muscle to relieve psychological stress and physical tension throughout your body.
  • A daily journal can help you express upsetting or painful feelings, keep track of mood symptoms, and increase emotional awareness.
  • Turn to loved ones for emotional support and help brainstorm problem-solving strategies or positive distractions during times of stress.

Follow a regular schedule

Since unpredictable or random daily routines can also lead to mood changes, keeping your days structured could help prevent mood episodes.

Consider creating a weekly schedule that outlines specific times for things like:

  • work
  • exercise
  • relaxation and alone time
  • time with friends and romantic partners
  • meals
  • chores and errands
  • switching off devices before bed

Choose a regular bedtime and wake time, and stick to these times as closely as possible, even on the weekends — a regular sleep-wake schedule can sometimes help prevent mood episodes.

Take care of your health

If you’ve heard of the mind-body connection, you’ll know physical and mental well-being are linked.

Good health can’t cure mental health conditions, but all the same, physical wellness can improve your outlook and boost resilience, giving you the emotional strength to manage life’s unpredictable aspects.

Try these self-care strategies:

  • Set aside 7–9 hours for sleep each night.
  • Eat balanced meals at regular times.
  • Stay hydrated.
  • Limit caffeine, alcohol, and other substance use, since they may prompt mood changes or make symptoms worse.
  • Try to get some exercise each day.
  • Make time for your favorite hobbies.

It can take some time to find the best treatment for bipolar disorder with mixed features, but don’t lose hope. Improvement is absolutely possible.

As you work with your care professional to find the right treatment, keep in mind that lifestyle changes can also help reduce symptoms and make it easier to manage mood episodes.

(Video) A Clinical Discussion of Mixed States in Bipolar Disorder


What is bipolar with mixed features? ›

What Are Mixed Episodes in Bipolar Disorder? Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time.

How long can a mixed episode last? ›

A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that last a week or two, or sometimes longer. During an episode, the symptoms last every day for most of the day.

How are mixed features diagnosed? ›

8 To receive the mixed features specifier, the patient must have 3 or more of the following symptoms of mania/hypomania: (1) elevated or expansive mood, (2) inflated self-esteem or grandiosity, (3) increased talkativeness or pressured speech, (4) flight of ideas or racing thoughts, (5) increase in energy or goal- ...

What is a mixed mood state? ›

A mixed affective state, formerly known as a mixed-manic or mixed episode, has been defined as a state wherein features unique to both depression and mania—such as episodes of despair, doubt, anguish, rage or homicidal ideation, suicidal ideation, splitting, racing thoughts, sensory overload, pressure of activity, and ...

What are mixed features in psychology? ›

Mixed features means manic/hypomanic symptoms are present, but it doesn't mean the person will develop a bipolar disorder. Due to similarities to bipolar disorder, mixed features usually require psychiatry, along with psychotherapy, to stabilize.

What does mixed features mean? ›

According to the DSM-5, the "with mixed features" specifier can be added to a diagnosis of major depressive disorder to indicate that a person has symptoms of both depression and mania but doesn't quite meet the diagnostic criteria for a diagnosis of bipolar disorder.

How many hours should bipolar sleep? ›

People living with bipolar disorder should aim to get the recommended amount of sleep for their age. The Centers for Disease Control and Prevention (CDC) recommends more than seven hours per night for adults.

Can you live with bipolar without medication? ›

Counseling, cognitive behavioral therapy (CBT), and a range of lifestyle changes can help people with bipolar disorder to manage their symptoms and improve their overall quality of life.

What triggers bipolar disorder? ›

A stressful circumstance or situation often triggers the symptoms of bipolar disorder. Examples of stressful triggers include: the breakdown of a relationship. physical, sexual or emotional abuse. the death of a close family member or loved one.

How fast are bipolar mood swings? ›

Some people with bipolar disorder develop “rapid cycling” where they experience four or more episodes of mania or depression within a 12-month period. Mood swings can occur very quickly, like a rollercoaster randomly moving from high to low and back again over a period of days or even hours.

What it feels like to have bipolar? ›

People with bipolar experience both episodes of severe depression and episodes of mania – overwhelming joy, excitement or happiness, huge energy, a reduced need for sleep, and reduced inhibitions. The experience of bipolar is uniquely personal. No two people have exactly the same experience.

Can a bipolar person be manic and depressed at the same time? ›

Dysphoric mania is when you have symptoms of depression and mania at the same time. It's sometimes called a "mixed state," "mixed mania," "mixed episode," or "mixed features." While experts used to think it was rare, they now realize it's common. About 40% of people with bipolar disorder have dysphoric mania at times.

How can you tell the difference between bipolar 1 and 2? ›

The main difference between bipolar 1 and bipolar 2 disorders lies in the severity of the manic episodes caused by each type. A person with bipolar 1 will experience a full manic episode, while a person with bipolar 2 will experience only a hypomanic episode (a period that's less severe than a full manic episode).

What is a major depressive episode in bipolar disorder? ›

Someone with bipolar disorder can sometimes feel very sad but also full of energy. The surest sign of a phase of depression is that you feel down for a long time -- usually at least 2 weeks. You might have these episodes rarely or several times a year.

What are good mood stabilizers? ›

Lithium, anticonvulsants and antipsychotics are the three main types of drug which are used as mood stabilisers.
Anticonvulsants which are used as mood stabilisers include:
  • carbamazepine (Tegretol)
  • lamotrigine (Lamictal)
  • valproate (Depakote, Epilim).

What is the best mood stabilizer for bipolar? ›

Lithium: The first mood stabilizer for bipolar disorder. Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They are the cornerstone of treatment, both for mania and depression. Lithium is the oldest and most well-known mood stabilizer and is highly effective for treating mania.

Do bipolar people need more rest? ›

Sleep disturbance is a core symptom of bipolar disorder. The diagnostic criteria indicate that during manic episodes there may be a reduced need for sleep and during episodes of depression, insomnia or hypersomnia can be experienced nearly every day (American Psychiatric Association, 2000).

Is melatonin good for bipolar? ›

Melatonin tablets are commonly recommended to bipolar disorder patients who have trouble sleeping, however there are few studies to guide the optimal dose and timing of administration. Anecdotally, some bipolar disorder patients are “melatonin responders” but others discern no noticeable effects.

What vitamins are good for bipolar disorder? ›

Vitamins for Bipolar
  • Vitamin B1 (aka thiamin) - many use vitamin B1 to manage the irritability and anxiety associated with bipolar disorder. ...
  • Ginkgo Biloba – this supplement is a popular natural approach in the treatment of bipolar disorder.

What is the newest medication for bipolar? ›

Caplyta is now FDA-approved for depressive episodes from bipolar I and II. The US Food and Drug Administration (FDA) has approved Caplyta (lumateperone) for the treatment of bipolar depression in adults.

What are the best supplements for bipolar disorder? ›

Some people have reported feeling increased benefits when combining the two together.
  1. Fish oil. Fish oil and fish are common sources of two of the three main types of omega-3 fatty acids: ...
  2. Rhodiola rosea. ...
  3. S-adenosylmethionine. ...
  4. N-acetylcysteine. ...
  5. Choline. ...
  6. Inositol. ...
  7. St. ...
  8. Calming techniques.

Is bipolar inherited from mother or father? ›

In some studies studying the parental effects in bipolar disorder, the father's effect is also reported. In a study conducted with a large sample, the prevalence of disease was found to be higher in children of fathers with bipolar disorder than in the children of mothers with bipolar disorder (15).

What is a bipolar meltdown? ›

Advertisement. Children with bipolar disorder, on the other hand, have what are known as “affective storms,” which are uncontrolled rages that follow a minor (or no) provocation. If you've ever seen one, you'll never forget it. These are way, way beyond temper tantrums.

What happens in the brain with bipolar disorder? ›

Bipolar disorder may change the brain's chemical balance

Experts believe that bipolar disorder is associated with a chemical imbalance in the brain. Brain chemicals called neurotransmitters help deliver messages between areas of the brain. An imbalance of these chemicals may cause symptoms of bipolar disorder.

What drugs can trigger bipolar disorder? ›

Drugs with a definite propensity to cause manic symptoms include levodopa, corticosteroids and anabolic-androgenic steroids. Antidepressants of the tricyclic and monoamine oxidase inhibitor classes can induce mania in patients with pre-existing bipolar affective disorder.

Can bipolar be triggered by trauma? ›

Childhood trauma

Some experts believe that experiencing a lot of emotional distress as a child can cause bipolar disorder to develop. This could be because childhood trauma and distress can have a big effect on your ability to manage your emotions.

What does a mixed episode feel like? ›

A mixed episode, sometimes called a mixed state, is when you feel both high and low. You may experience symptoms of depression, plus mania or hypomania at the same time. For example, you may feel very energised and impulsive, while feeling upset or tearful. Or you may feel very agitated or irritable.

What is bipolar personality? ›

Overview. Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities.

Who is most affected by bipolar disorder? ›

The average age-of-onset is about 25, but it can occur in the teens, or more uncommonly, in childhood. The condition affects men and women equally, with about 2.8% of the U.S. population diagnosed with bipolar disorder and nearly 83% of cases classified as severe.

How can you tell if someone is bipolar? ›

Symptoms - Bipolar disorder
  1. feeling sad, hopeless or irritable most of the time.
  2. lacking energy.
  3. difficulty concentrating and remembering things.
  4. loss of interest in everyday activities.
  5. feelings of emptiness or worthlessness.
  6. feelings of guilt and despair.
  7. feeling pessimistic about everything.
  8. self-doubt.

What is the difference between bipolar 1 and bipolar 2? ›

Bipolar I disorder involves periods of severe mood episodes from mania to depression. Bipolar II disorder is a milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression.

Can bipolar turn into schizophrenia? ›

While bipolar disorder cannot develop into schizophrenia, it's possible to experience symptoms of both. Before you consult a mental health professional, here are a few things you should know about the two conditions.


1. Bipolar Disorder Type 1 vs Type 2 | Risk Factors, Symptoms, Diagnosis, Treatment
(JJ Medicine)
2. What is a mixed episode of bipolar disorder ? | Mega Health Channel & Answers
3. Mood disorders (depression, mania/bipolar, everything in between)
4. Bipolar Disorder: criteria, types, symptoms, and treatment
(Dirty Medicine)
5. Three Signs Your Mania Is Coming (The Manic Prodrome)
(Dr. Tracey Marks)
6. Depressive and Bipolar Disorders: Crash Course Psychology #30

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