Bipolar disorder is a condition in which a person experiences dramatic shifts in mood and energy, but at severities that are different from the mood changes the average person goes through. But a common misconception about bipolar disorder is that a person with the diagnosis only experiences two distinct moods: either really high highs (mania), or really low lows (depression). For starters, people with bipolar disorder are not always experiencing symptoms, known as bipolar “episodes.” Plus, these episodes aren't always as simple as high or low.
Many episodes that people with a bipolar diagnosis experience are considered “mixed” episodes, sometimes also described as “switching” episodes, or manic/hypomanic or depressive episodes with mixed features. A mixed episode signals that the person is experiencing both aspects of mania or hypomania as well as symptoms of bipolar depression.
Before we get into mixed episodes, let’s go over what constitutes a standard episode of mood elevation (mania or hypomania) versus a depressive episode.
“Bipolar historically was known as manic depression, and some people will still call it that. So it makes sense to me that many people only associate it with two sort of categories of mood, those being mania and depression,” Wendy Marsh, M.D., director of the Bipolar Disorders Specialty Clinic and an associate professor in the department of psychiatry at the University of Massachusetts Medical School, tells SELF.
Symptoms associated with an episode of bipolar depression include lower energy and/or activity levels, difficulty concentrating, loss of interest in things, and changes in appetite and sleep, among others. “And to classify as having an episode of depression, you need to be experiencing a gateway symptom of either a sad mood or loss of interest in life pervasively, in addition to at least five of the other symptoms for two weeks,” Dr. Marsh says.
To classify an episode as a mood elevation—meaning mania or hypomania—you must exhibit a prolonged, unusual, high-energy mood, while also showing at least three additional symptoms of mood elevation, including (but not limited to) feeling a sense of euphoria, having increased energy and/or self-esteem, racing thoughts, reduced sleep, and others. (If someone experiences hallucinations or psychosis or is hospitalized as a result of manic symptoms, this would also be considered mania.)
A mixed bipolar episode is when a person experiences depressive symptoms and those of a mood elevation at the same time.
Dr. Marsh points out that “bipolar” is somewhat of a misnomer, “because while there are two poles, they’re not necessarily experienced separately,” she says. “This can be a very hard concept to grasp for someone observing a patient who is having symptoms associated with both poles at the same time, and for the patients themselves.”
With bipolar disorder in general, it’s actually quite common for a person to experience episodes that are mixed, Igor Galynker, M.D., associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel, tells SELF. (Research suggests an estimated 20 to 40 percent of people with bipolar have mixed episodes.)
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) included specific diagnostic criteria for mixed episodes, Dr. Marsh says. But the DSM-5, the latest version of the manual, replaced the “mixed episode” diagnosis with a “mixed-features specifier” that clinicians now apply to episodes of depression, hypomania, or mania. The issue that some researchers took with the DSM-4 mixed episode diagnosis was that it required a person to meet the complete diagnostic criteria for a depressive episode, as well as the full criteria for a manic episode, for a week or longer. “Simply put, you had to be experiencing ongoing full mania and full depression simultaneously,” Dr. Marsh says. But in reality, a person may present mixed features but not necessarily check every single diagnostic box for both.
According to the latest edition of the DSM, a bipolar episode may be clinically classified as having mixed features if a person is experiencing one mood episode along with at least three symptoms of the opposite mood episode for the majority of the time. So, for instance, you may have a week-long manic episode with at least three symptoms of a depressive episode for five of those days. You can find a list of diagnostic symptoms for mania/hypomania and depression here. And it’s worth noting that episodes with mixed features can present in both bipolar I and II.
So what does a mixed episode look like exactly?
This will typically depend on which mood episode is the predominant one—for instance, are you having a manic/hypomanic episode with symptoms of depression, or having a depressive episode with symptoms of mania? In some cases, a person presenting mixed features may be in a full mania and a full depression at the same time; in other cases, a person may be experiencing all of the symptoms of mania/hypomania and only a few depressive symptoms (or the other way around). “Bipolar is not an alternating disorder of mood, it’s a dysregulation of mood,” Dr. Galynker says. “The mood can be all over the place.”
Speaking generally, “This is a person who is really ramped up, their thoughts are racing, they’re talking a mile a minute, they don’t need as much sleep—mood elevations symptoms,” Dr. Marsh explains. “But at the same time, they feel sad and blue, they’re beating themselves up in their head, their self-worth is down.” Dr. Marsh also says a person experiencing a mixed episode commonly has thoughts of escaping the misery or even death. “While they may not have suicidal ideation, they may ask themselves questions like, What would happen if I died? What would happen to my children?” she describes. This can be particularly dangerous for a person in a depressive episode with manic symptoms—they’re feeling helpless and miserable and they have the energy to act on that.
Initially, you might think it sounds pretty impossible to experience depression and mania at the same time. “It’s very hard to conceptualize,” Dr. Marsh says. “But when you hear people express their own experience with it, it becomes a lot more clear.”
For an individual in a mixed episode, it can be one of the most distressing mood states to be in.
Gracie, 30, who was diagnosed with bipolar II in July 2018, tells SELF that her episodes are usually mixed. “One minute you’re full of energy, cleaning the house, feeling great about life, having some great ideas, getting your excitement back. Then the next, [you’re] about to cry and over-emotional for no reason, so lost in life you don’t know where you’re going [or] how you’re feeling, just that you’re not feeling good at all, feeling like you’ve not slept in weeks, irritated beyond belief by anything and everything,” she describes. “You want your significant other there to hug you and hold you and tell you it’s going to be ok but at the same time the idea of someone touching you makes your skin crawl.”
Joey, 41, who was diagnosed with bipolar II in 2006, also experiences episodes with mixed features. “Even when [I’m] hypomanic I’m still suffering, as the manic energy just drives the depression,” he tells SELF. “And I’m even more aware that my depression prevents me from doing most of the things my manic side screams at me to do.”
He describes periods of more standard hypomania as a “little moment of clarity and relief, [like] when you are looking through binoculars and finally get them perfectly focused.”
For Emma, 20, mixed states are the most common. “I get extremely agitated. I'm very short with people. Even the smallest things can set off my anxiety. I'm quick to snap when I'm in a mixed state, because my mind and body are so confused. How can you be manic and depressed at the same time? [It feels like] your brain isn't equipped to handle that,” she tells SELF. (In April 2017, she was diagnosed with bipolar II.)
“So one minute I could feel totally fine. A few hours later, a text message could burst my entire day into flames and I can't see any of the good that happens,” Emma continues. “And then if I ask for help, it's like my mind doesn't want it, and I flip out on whoever I was asking.”
Treatment and management of bipolar disorder can vary greatly depending on the individual and their type of bipolar, as well as their episode patterns.
Whether or not you have bipolar I or II—and even if you’re not completely sure if your mood episodes present with mixed features—taking mood-stabilizing medications is the standard of care for bipolar disorder as a whole, Dr. Marsh says. “But there are a lot of exceptions and caveats—for instance, these drugs come with side effects,” she adds. “So there is a lot of discussion with the patient when prescribing treatment.”
Dr. Galynker also points out that it can take several months to find the right combination of medication, and the most effective medications for a person can change over time, too. “The illness is cyclical, and the same medication that may work at one point, let’s say in the more depressive phase of their cycle, may not work in the more manic phase of their cycle or in a period with mixed features,” he explains. “That’s why it’s very important to learn the very subtle behavioral changes a person exhibits at the early stages of their cycle.”
Therapy is also often helpful for this reason. “One of the ways that therapy has been found to be beneficial for people with bipolar disorder is that psychoeducation aspect—teaching people what there first symptoms of a mood elevation are, for instance, so they can catch them as quickly as possible when they present and implement the necessary interventions,” Dr. Marsh says.