Mixed Features: The Fight Between Emotions

Mixed Features: The Fight Between Emotions

Imagine being happy, yet sad at the same time. Overjoyed but devastated. Arrogant and insecure. Having a bipolar episode with mixed features is like simultaneously experiencing opposing emotions. Emma, a 20 year old with bipolar II, describes her bipolar episodes with mixed features as confusing. “‘How can you be manic and depressed at the same time? [It feels like] your brain isn’t equipped to handle that,”’(Andriakos, 2018). Bipolar disorder is often thought of as a cycling between episodes of mania and depression. Although periods of mania and depression are what determine bipolar disorder, they are not always experienced separately. For many people, the periods of mania or depression are not so clear-cut, there can be overlap. It can be hard to understand how two feelings that are complete opposites could potentially intersect and cause such distress, especially for the person experiencing it. 

Prior to 2013, bipolar episodes that had features of the opposing episode were referred to as a mixed episode. With the release of the DSM-V, the term “mixed episode” was replaced with a specifier of “mixed features.” The specifier is used to include the symptoms of the mixed features into the diagnosis of the episode. Before the change to the term mixed features, it was much more difficult to diagnose impure bipolar episodes. In addition, the change in terminology from mixed episode to mixed features allows more people to get an accurate and specific diagnosis. In order to diagnose a mixed episode, the entire criteria for both mania/hypomania and depression would need to be met. Although this happens for some people, in most cases only a few symptoms from the non-dominant emotion are expressed. In a bipolar episode with mixed features however, the criteria for the primary episode, manic or depressive, is met along with at least three symptoms of the opposing episode. Experiencing a bipolar episode with mixed features can be extremely challenging to understand and manage because the emotions are fighting with each other to be experienced and expressed. 

In a manic or hypomanic episode with mixed features, the full criteria for mania or hypomania are met. This includes elevated mood, irritability, and inflated self-esteem. In addition to manic symptoms there are symptoms of depression like depressed mood, disinterest, and feelings of hopelessness. Manic episodes with depressive features in particular can be extremely alarming and dangerous leaving individuals “feeling helpless and miserable and they have the energy to act on that” (Andriakos, 2018). In depressive episodes with mixed features, there is a similar protocol for diagnosis. The full criteria for a depressive episode must be met, with at least three features of mania or hypomania. The feelings of depression can be so intense, that hypomania can be a relieving break from intense depression. Joey describes his experience with mixed depressive episodes as “a relief.” While experiencing hypomania during a depressive episode, he is able to get a moment of clarity. 

Treating people who have bipolar episodes with mixed features is a complicated and difficult process. Up to 34% of people diagnosed with bipolar disorder experience episodes with mixed features. Each of these people experience it differently, and require personalized treatment. Sometimes the feelings they are experiencing simultaneously can be direct opposites of one another. Other times, the opposing moods can happen back to back in rapid succession. Joey, who experiences bipolar episodes with mixed features, describes them as having one emotion driving the other in a chaotic and debilitating way. Gracie, who also experiences mixed episodes, describes them more like intense and confusing mood swings without much reason. The differences in individual experiences makes bipolar disorder with mixed features difficult to treat. Additionally, while one treatment may improve one portion of the symptoms, it may exacerbate other symptoms, making them worse. For example, taking a typical antidepressant (like a selective serotonin uptake inhibitor), can improve feelings of sadness and depression but make manic symptoms worse. Oftentimes more than one form of treatment is needed for people that experience bipolar episodes with mixed features, like a mood stabilizer in addition to an antidepressant. There is currently limited knowledge regarding bipolar episodes with mixed features, particularly surrounding why mixed features happen to some people and not others. This makes bipolar episodes with mixed features harder to treat and for people experiencing it to understand what is going on. 

In addition to having bipolar disorder, having episodes with mixed features is a challenging additional issue being faced by people with bipolar disorder. It can make things more confusing and complicated to understand. By improving awareness and knowledge of bipolar episodes with mixed features, there is hope for better experiences for those struggling with it. 



American Psychiatric Association. (2013). Bipolar and Related Disorders. in Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Retrieved from https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm03#x38498.2610324

Andriakos, J. (2018). This Is What a Mixed Episode Feels Like. Retrieved from https://www.self.com/story/mixed-bipolar-episodes

Hu, J., Mansur, R., & McIntyre, M.S. (2014). Mixed Specifier for Bipolar Mania and Depression: Highlights of DSM-5Changes and Implications for Diagnosis and Treatment in Primary Care. The Primary Care Companion For CNS Disorders, Volume 16 (2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116292/

McIntyre, R.S., Soczynska J.K., Cha D.S., Woldeyohannes H.O., Dale R.S., Alsuwaidan M.T., . . . Kennedy S.H.. (2015) The prevalence and illness characteristics of DSM-5-defined “mixed feature specifier” in adults with major depressive disorder and bipolar disorder: Results from the International Mood Disorders Collaborative Project. Journal of Affective Disorders, Volume 172 Pages 259-264. Retrieved from https://www.sciencedirect.com/science/article/pii/S0165032714005801

Muneer, A.. (2017). Mixed States in Bipolar Disorder: Etiology, Pathogenesis and Treatment. Chonnam Medical Journal. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5299125/

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