Bipolar Disorder with Mixed Features: What You Need to Know

What is bipolar disorder with mixed features?

“Mixed state bipolar” or “bipolar with mixed states” are outdated terms doctors previously used as a specifier for bipolar disorder. A specifier is a term healthcare professionals use to describe characteristics of mental health conditions.

When the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was released in 2013, the specifier became known as mixed features rather than mixed state.

During an episode of bipolar disorder with mixed features, you experience symptoms of both mania and depression.

You may have a depressive episode with mixed features, in which the main symptoms are depressive, but subclinical manic symptoms are also present. For example, you may feel depressed and also experience racing thoughts or rapid speech.

Or, you may have a manic episode with mixed features, in which the main symptoms are those of a manic episode, but depressive symptoms are also present. For example, you may be doing several high energy activities but also feeling depressed.

What are the symptoms?

Symptoms of bipolar disorder with mixed features may vary depending on the mood episode in question. They can include:

• feeling a mixture of elevated and low moods
• doing pleasurable activities but still having depressive symptoms
• experiencing a low mood with rapid speech
• experiencing an elevated mood with suicidal ideation
• experiencing severely disturbed sleep
• having a severe disruption of appetite

It’s important to note that how an individual functions in their everyday life during an episode can vary depending on their exact diagnosis and symptoms.

How do doctors diagnose bipolar disorder with mixed features?

The diagnostic criteria for bipolar disorder with mixed features in the DSM-5-TR include:

• experiencing three or more depressive symptoms during a manic or hypomanic episode (for mixed features with a manic or hypomanic episode)
• experiencing three or more manic or hypomanic symptoms during a major depressive episode (for mixed features with a depressive episode)

Depending on the person’s reported mood episodes and symptoms, a clinician may add a specifier like “with mixed features” once they have diagnosed bipolar disorder.

What are common risk factors for developing bipolar disorder with mixed features?

Although the exact cause of bipolar disorder is unknown, researchers have discovered common risk factors for developing the condition:

• Genetic factors: A family history of bipolar disorder or other mood conditions increases the risk of developing bipolar disorder with mixed features. Specific gene changes or variations might predispose individuals to the condition.
• Neurobiological factors: Differences in brain structure or function, particularly in areas like the prefrontal cortex, may contribute. Experts believe dysregulation of neurotransmitters, such as serotonin and dopamine, plays a role in mood regulation.
• Hormonal changes: Hormonal fluctuations may also play a role, as they are closely linked to hypothalamic function.
• Environmental factors: Stressful life events, such as trauma, abuse, or significant changes (e.g., the death of a loved one, divorce, or job loss), can trigger the onset of bipolar episodes. Childhood adversity, including neglect or maltreatment, can be a precursor to mood conditions, including bipolar disorder.
• Sleep disturbances: Irregular sleep patterns or lack of sleep are often linked with mood instability and can be a trigger for manic or depressive symptoms, especially in individuals with bipolar disorder.
• Co-occuring psychiatric conditions: Anxiety disorders, particularly generalized anxiety disorder or panic disorder, can co-occur with bipolar disorder, increasing the likelihood of experiencing mixed features. Personality disorders, particularly borderline personality disorder, may also overlap with bipolar disorder, complicating the clinical presentation.
• Medications: Certain medications, such as tricyclic antidepressants, can trigger mood instability and increase the risk of mixed episodes in individuals with bipolar disorder.
• Age of onset: The earlier the onset of bipolar disorder, the higher the likelihood of developing mixed features during the course of the condition, especially if symptoms present during adolescence or early adulthood (ages 15 to 24 years).
• Substance use: Alcohol or drug misuse can trigger or worsen manic or depressive symptoms, increasing the chances of mixed episodes. Stimulants, such as cocaine or amphetamines, may induce manic symptoms, whereas alcohol or sedatives might induce depressive symptoms.

The presence of these risk factors doesn’t guarantee the development of bipolar disorder with mixed features, but they may increase the likelihood of onset or severity of the condition.

Can you prevent bipolar disorder with mixed features?

There’s no known way to prevent bipolar disorder. However, if you experience a mixed episode during treatment, your care team can work on figuring out what might have caused it. If needed, they can adjust medications or offer advice on lifestyle factors that may help.

How is bipolar disorder with mixed features treated?

According to a 2017 article, episodes with mixed features typically indicate more severe bipolar disorder and potential treatment resistance.

No single medication is indicated for use in treating mixed features. Usually, a mental health professional will prescribe a combination of two or more medications, depending on your individual circumstances.

Combination therapy for bipolar disorder with mixed states may include:

• one or more atypical antipsychotic medications
• mood stabilizers, including newer anticonvulsants
• electroconvulsive therapy (ECT)

In severe cases where medication is not effective, ECT may very quickly resolve symptoms.

Atypical antipsychotics can include:

• risperidone
• olanzapine
• quetiapine
• ziprasidone
• asenapine
• lurasidone
• aripiprazole

Mood stabilizers can include:

• lithium
• divalproex sodium
• carbamazepine/oxcarbazepine/eslicarbazepine
• lamotrigine
• topiramate
• gabapentin/pregabalin

What’s the outlook for people with bipolar with mixed features?

While there’s currently no cure for bipolar disorder with mixed features, treatment can help you manage the condition.

Mixed episodes can be especially serious because they involve an increased risk of suicide. For this reason, symptom management and supportive treatment are extremely important during these episodes.

A mental health professional can help you manage symptoms and alter your treatment plan, if needed, to help stabilize moods and reduce subsequent mood shifts.

If there’s an underlying cause of episodes with mixed features, like medications, your care team can recommend other medication options to help with mood stabilization.

While more research is necessary to determine the underlying causes and triggers of episodes involving mixed features, there are ways to manage these episodes. If you’re experiencing symptoms of bipolar disorder with mixed features, it’s best to reach out to a mental health professional.