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.”
