What Is a Mixed Episode in Bipolar Disorder? Signs & Causes

Bipolar disorder is notorious for its presentation of depressive and manic episodes. Most people associate the condition with extreme swings between highs and lows in energy, mood, or activity. But bipolar disorder can also produce a mixed episode, which causes distress and confusion in a combination of symptoms.

A bipolar mixed episode carries specific risks that make timely treatment important. This guide explains what a mixed episode is, how it’s diagnosed, and the treatment options available.

What is a Mixed Episode?

A mixed episode, also called a mixed state or presentation, is a period in which symptoms of depression and symptoms of mania or hypomania occur at the same time. Someone may feel restless and full of energy while also feeling hopeless, or be deeply depressed while their thoughts race.

The DSM-5 describes this as the “mixed features specifier,” which can apply to the current

manic, hypomanic, or major depressive episode in bipolar I disorder or bipolar II disorder. The specifier recognizes people whose mixed symptoms are clinically significant even when they don’t meet the full criteria for both episodes.

Signs of a Bipolar Mixed Episode

In other words, a mixed episode refers to mixed features present in a manic or hypomanic episode, or mixed features present in a depressive episode. Here are the criteria for each, as defined by the DSM-5.

Manic or hypomanic episode, with mixed features

Full criteria are met for a manic episode or hypomanic episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania:

• Prominent dysphoria or depressed mood as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
• Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others).
• Psychomotor retardation nearly every day (observable by others; not merely subjective feelings of being slowed down).
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Depressive episode, with mixed features

Full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:

• Elevated, expansive mood.
• Inflated self-esteem or grandiosity.
• More talkative than usual or pressure to keep talking.
• Flight of ideas or subjective experience that thoughts are racing.
• Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
• Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
• Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).

In either case, the mixed symptoms are observable by others and represent a change from the person’s usual behavior. The mixed symptoms are not attributable to the physiological effects of substance use, whether an illicit drug, prescribed medication, or another treatment.

How to Differentiate a Mixed Episode From Other Conditions

In general, bipolar disorder’s symptoms can overlap with symptoms of various other conditions. Rapid emotional shifts and impulsive behaviors can be present in bipolar disorder or borderline personality disorder (BPD). In severe cases, bipolar disorder can present hallucinations and delusions, similar to schizoaffective disorder and schizophrenia.

Because it can present various combinations of symptoms, a mixed episode may be even harder to spot.

Diagnosis requires a clinical evaluation, which may involve:

• A full symptom history
• A timeline of episodes
• Family psychiatric history
• Review of current medications, including antidepressants, and any substance use
• Medical workup to rule out conditions such as thyroid disease that can produce similar symptoms

From there, a clinical professional can use the criteria outlined by the DSM-5 to narrow down your diagnosis accordingly.

Causes of a Bipolar Mixed Episode

Although research hasn’t identified a concrete cause of mixed episodes, there are a set of factors that disrupt the biological rhythms underlying mood. Mixed states appear to be closely tied to that disruption.

One study groups the research into the following areas:

• Disrupted body clock. The review places circadian rhythm disturbance at the core of mood disorders. Sleep, daily activity, hormone levels, and body temperature all run on that clock, and those rhythms tend to be irregular in bipolar disorder.
• Genetics and family history. Variants in the genes that run the circadian system have been linked to bipolar disorder, and animal studies have produced a mixed-state-like picture by disabling one of them. Where seasonal patterns are a feature, a family history of the disorder is present in 60% to 80% of cases. Having a family history does not mean you will experience mixed episodes, and many people with no family history do.
• Sleep and schedule disruption: Going without sleep entirely can produce a manic exacerbation in up to 30% of people with bipolar disorder. Shift work, overnight travel, and irregular sleep and meal times can precipitate episodes. Season matters too, with manic episodes occurring at a higher rate in spring and summer.
• Substance use: Alcohol and drug use can worsen mood symptoms, even if the substance used was prescribed by a medical doctor. For example, the study points out that tricyclic antidepressants have been associated with a switch into mania or hypomania in up to 70% of people taking them long term. This can especially complicate mixed episodes, since symptoms can vary from both extremes of the emotional spectrum. When both substance use and bipolar disorder are present, dual diagnosis treatment is needed to address both issues together.

While none of the above factors should be taken as a guarantee for your experience with a mixed episode, they do offer insight into potential treatment approaches once the mixed episode is identified.

Treatment Approaches for Bipolar Mixed Episodes

Medication

Medication is usually the first step in treating a mixed episode. According to NIMH, the medications most commonly prescribed for bipolar disorders are mood stabilizers and atypical antipsychotic medications that have shown benefits for mixed symptoms.

Antidepressants are generally used with caution during mixed episodes. On their own, they may worsen agitation or manic symptoms, so psychiatrists typically consider them only alongside a mood stabilizer, if at all.

Finding the right medication or combination can take time. Close monitoring during this period helps your psychiatrist adjust your care plan safely.

Psychotherapy

Psychotherapy is a category of talk therapies designed to help someone understand their symptoms and build tools for managing them. While medication is the primary treatment choice for mixed episodes, psychotherapy can be an invaluable addition to a comprehensive treatment plan.

Helpful approaches include:

• Cognitive behavioral therapy (CBT), which helps you recognize thought patterns that fuel distress and practice healthier responses
• Dialectical behavior therapy (DBT), which teaches skills for tolerating intense emotions and reducing impulsive behavior
• Family therapy sessions, which gives loved ones the knowledge to respond with support instead of conflict

The care setting when participating in these therapies is also important, because it affects the frequency and depth of treatment received. For example, a person whose symptoms are agitated because they’re unable to sleep may find that residential care is the most effective path forward. In this setting, they’ll have access to daily clinical contact in an environment removed from daily stressors that make it difficult to rest.

No treatment plan completely eliminates the possibility of future episodes, but it’s worth weighing inpatient versus outpatient care to decide what level of intervention you need. You can also learn more about what residential treatment involves to know what to expect day to day.

Daily Routines and Lifestyle

A well-rounded approach to treatment for mixed episodes takes your regular habits and activities into consideration. Some lifestyle changes that can support medication and therapeutic work include:

• A consistent sleep schedule
• Regular meal times
• Physical activity
• Limited alcohol consumption
• Stress-reduction techniques

If you’re wondering how to help a loved one through a mixed episode, do what you can to support these lifestyle changes while encouraging them to seek professional help. Bipolar disorder, particularly when it presents a mixed episode, requires clinical diagnosis and intervention. The best thing you can do for your loved one is direct them to a mental health professional for evidence-based care.

Treatment for Bipolar Disorder at Red Top Wellness Center

A bipolar mixed episode can feel disorienting, but it is treatable. The right diagnosis, medication plan, and therapy can help you regain steadiness and reduce the risk of future episodes.

Red Top Wellness Center provides residential treatment for bipolar disorder in Cartersville, Georgia, and mixed episodes are one of the presentations our clinical team treats. Our 30-day program involves a combination of:

• One-on-one therapy sessions with your primary therapist
• Group therapy sessions with other residents facing similar challenges
• Family therapy
• Evidence-based therapeutic approaches, like CBT and DBT
• Recreational activities and time for rest in between therapy sessions
• Holistic therapies, like red light therapy and biosound therapy

If you’re considering treatment for yourself or looking into options for someone in your family, our team is here to help. Call (470) 227-7574 to talk through whether residential care fits your situation, or verify your insurance to find out what your plan covers.