What is a Mixed Episode in Bipolar Disorder

Bipolar Mixed Episodes are something I have written about a lot lately, but not something I feel I have fully explained. There are numerous reasons for this, it is extremely difficult to explain the experience of a mixed episode, and they can be experienced on so many different ways. Not only are they difficult to explain, but psychiatry doesn’t fully understand them either and their diagnostic criteria has changed drastically recently. 
Disclaimer. I currently live in the UK and have been diagnosed with Bipolar Disorder under UK specifications, however in America this is broken down further into Bipolar 1, 2, Schizoaffective and NOS. I understand a lot of bipolar disorder through the American definitions and will discuss these in depth in this post.

Overview, Mania, Depression and Mixed Episodes. 

Bipolar Disorder, previously named Manic Depression is known as such due to mood fluctuations where the affected person may switch between the two poles of mania, or depression.


under the DSM-5 is diagnosed due to displaying 3 of the following symptoms for at least one week-

  • feeling happy, euphoric, with a sense of heightened wellbeing
  • having lots of energy
  • feeling sociable
  • experiencing racing thoughts
  • feeling extremely creative and full of ideas and plans
  • feeling like you can perform tasks better and more quickly than normal
  • being impatient, irritable or angry
  • feeling confident, with high self-esteem
  • experiencing hyper-sexuality, feeling attractive, flirtatious with more sexual desire
  • feeling restless, on edge and having difficulty relaxing
  • experiencing heightened senses – colours may seem brighter, sounds are louder and things are more beautiful than usual
  • psychosis, experiencing hallucinations and delusions


is a lesser experience of mania, and only needs to last 4 days.


in bipolar disorder is diagnosed through experiencing 4 of the following symptoms for at least two weeks-

  • feeling down, upset or tearful
  • feeling tired or sluggish
  • not finding enjoyment in things
  • experiencing low self-esteem and lacking in confidence
  • feeling guilty, worthless or hopeless
  • feeling agitated and tense
  • experiencing suicidal thoughts or feelings
  • psychosis

Mixed Episodes

Under this basic understanding the diagnosis of bipolar disorder does not explain or identify the existence of mixed episodes. A mixed episode is where a sufferer experiences both manic and depressive symptoms and this can manifest in a number of ways.

Diagnostic Criteria and Historic Changes

As previously mentioned under the American DSM-5 to be diagnosed with Bipolar Disorder you must experience these two mood extremes. This is broken down into four main types, the two primary types being Bipolar 1 and Bipolar 2 disorder.

  • Bipolar 1 is diagnosed due to the presence of mania, with at least 3 symptoms experienced for one week. There only needs to be one manic episode to receive a diagnosis of Bipolar 1 Disorder.
  • Bipolar 2 is diagnosed due to the presence of hypomania, a lesser form of mania where symptoms only need to persist for 4 days, alongside meeting the depression diagnostic of at least 4 symptoms present for at least two weeks.
  • Schizoaffective disorder is essentially where the psychotic symptoms associated with the mood episodes of bipolar disorder are experienced in the absence of mania or depression.
  • Bipolar Not Otherwise Specified is where the symptoms of bipolar disorder are met in atypical timescales, I don’t fully understand this one to be honest.
  • Cyclothymia is another diagnosis under the Bipolar Disorder Spectrum where the sufferer experiences hypomania and Dysthymia. Dysthymia, similarly to hypomania, is a lesser form of depression.

Diagnostic Criteria

Just and these disorders have diagnostic criteria, mixed episodes are diagnosed alongside specific criteria as well.

The DSM-4 prior to 2013 outlined a mixed episode as when all criteria for mania and depression are met at the same time, and therefore only existed among the Bipolar 1 diagnosis as the full criteria for mania must be reached.

The DSM-5 changes this drastically from an ‘episode’ in it’s own right to a ‘specifier’ which is like an add-on. This specifier can be added to Bipolar 1 or 2 or other as long as the diagnostic criteria is met. This criteria includes meeting the criteria for mania/hypomania/depression plus 3 or more symptoms of the opposite mood episode.

This shows a huge increase in understanding of mixed episodes I believe, but there is still so little information out there on what this specifier actually means.

How Mixed Episodes Manifest. 

The mixed episode, or mixed features can manifest in many different ways as everybody experiences bipolar disorder in different ways. For some people the symptoms are experienced at the same time, someone could feel euphoric but be crying with sadness at the same time. For others, it is a constant shift between mania and depression within shorter timescales as outlined by the DSM.

Not only do the timescales shift form person to person but so can the severity of the symptoms, from a mild experience of some mania and depressive symptoms but a relatively stable mood, to feeling overwhelmed with full blown mania and depression coexisting.

How a Mixed Episode feels. 

I experience Bipolar Disorder somewhere on the line of Bipolar 1 and 2 according my my Psychiatrist, as my psychosis and full blown mania have been alcohol assisted but my hypomanic spikes are not. I can only comment on my own experience.

Mixed episodes are like being in hell, they are awful. You feel like everything is pointless, not worth doing, unenjoyable. At the same time you are desperate to do something, anything to channel high levels of irritable energy and anger.

You feel fidgety and have racing thoughts, but they are horrible, they keep telling you all the reasons you are a failure, a bad person, undeserving of life. You become desperate to escape yourself through alcohol, drugs, suicide, spending sprees, disappearing, any kind of release.

But you cannot escape and you feel this growing, burning energy inside of you that feels like it has nowhere to go, no way to escape. This increases the frustration, the anger and the irritability that we experience and becomes a vicious cycle.

Have you ever had a fever and felt hot and cold at the same time, remember how uncomfortable that feels. Now imagine that sensation through your entire body and mind and that is how a mixed episode feels.

It is no surprise that the suicide rate is increased within a mixed episode, you feel hopeless and like life is pointless but so much desire to do something about that. Mix that with constant suicidal thoughts and the results can be extremely dangerous.

Photo by airfin – from FreeImages


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