Mixed Episode Bipolar Disorder: What It Is, Symptoms, & Treatment Options

What Is Mixed Episode Bipolar Disorder?

Bipolar mixed episodes are a distinct feature of bipolar disorder, where somebody simultaneously experiences symptoms of both mania and depression or in rapid sequence. These episodes are marked by a combination of elevated mood, energy, and activity levels, along with depressive symptoms such as sad mood, irritability, and decreased interest or pleasure in activities.

During these bipolar mixed episodes, people may feel intense racing thoughts and high energy levels, like a manic episode. They may engage in impulsive and risky behaviors, have inflated self-esteem, and have rapid speech. At the same time, they also exhibit symptoms associated with depression including feelings of hopelessness, worthlessness, or guilt, plus changes in appetite, sleep disturbances, and difficulty concentrating.

Mixed episode bipolar disorder, also referred to as a mixed state, is a manifestation of bipolar disorder in which an individual experiences symptoms of both mania and depression concurrently.

Mixed Episode Vs. Rapid Cycling Bipolar Disorder

While mixed episode bipolar disorder and rapid cycling bipolar disorder are both types of bipolar disorder, they differ in the duration and kind of mood episodes experienced. People with bipolar mixed episodes have mania and depression symptoms simultaneously or interchangeably within a single episode. Rapid cycling bipolar disorder refers to frequent mood episodes (manic, hypomanic, depressive, or mixed) within a shorter duration, like within a year or even a week.

Symptoms of Mixed Episode Bipolar Disorder

While traditional bipolar disorder is typically characterized by distinct episodes of either mania or depression, people with bipolar mixed episodes often experience a mixture of bipolar disorder symptoms from both extremes creating a complex emotional state. They also might not always show classic signs of an extreme mood state, making it difficult to diagnose and treat effectively.

Potential symptoms of a bipolar mixed episode include:

• Irregular mood swings: People may experience rapidly shifting and unpredictable changes in mood, often feeling both the symptoms of mania and depression within a short period of time. For example, they could feel restless, irritable, and agitated while also feeling sad, hopeless, and lethargic.
• Agitation and restlessness: People might feel a constant inner restlessness or agitation, as if they can’t sit still. This can manifest as pacing, racing thoughts, feeling on edge, or being highly irritable.
• High energy levels: People may experience a surge of energy and accelerated thinking; similar to a manic episode. Their thoughts may jump from one idea to another, making it difficult to concentrate or stay focused.
• Depressed mood and hopelessness: Despite having increased energy and restlessness, they may also have a profound sense of sadness, hopelessness, or emptiness. This contrasting feeling can intensify the overall emotional turmoil.
• Increased impulsivity and risk-taking behaviors: Bipolar mixed episodes can lead to impulsive decision-making and increased engagement in high-risk activities. This could include reckless spending, excessive substance use, engaging in unsafe sexual behavior, or other impulsive actions.
• Thoughts of self-harm or suicide: A combination of heightened energy and agitation with depressive feelings can amplify suicidal thoughts or behaviors. It is crucial to reach out for professional help if experiencing these thoughts.
• Sleep disturbances: Bipolar mixed episodes can disrupt normal sleep patterns, leading to insomnia or a reduced need for sleep. People may find it challenging to fall asleep or wake up feeling fully rested.

How Does a Mixed Bipolar Episode Feel?

Because a bipolar mixed episode involves concurrent or rapidly alternating symptoms of both mania and depression, it can create a confusing, intense, and highly distressing experience for the person with mixed bipolar disorder. The simultaneous manifestation of contrasting mood states adds complexity and intensity to the episode, making it challenging for most people to navigate and deal with.

Does a Person Having a Bipolar Mixed Episode Know It’s Happening?

Recognizing a bipolar mixed episode can be challenging for somebody who is going through it. When depressive and manic symptoms occur together it may create a confusing internal state. The person might feel unusually agitated, restless, or have racing thoughts while also experiencing profound sadness or hopelessness. It can be disorienting when these contrasting mood states shift rapidly. Keep in mind that bipolar mixed episodes can vary.

What Causes Mixed Episode Bipolar Disorder?

Bipolar mixed episodes result from a complex interplay of genetic, biological, and environmental factors. Unraveling the origins of these episodes requires figuring out how these elements interact with each other. Knowing the intricate causes of this unique form of bipolar disorder is crucial for effective diagnosis, treatment, and support for those affected by mixed episode bipolar disorder.

Causes of bipolar mixed episode include:

• Genetics: Research suggests that certain genetic variants increase the likelihood of developing bipolar disorder.(FN1) Family history of bipolar disorder or other mood disorders substantially raises the risk of mixed episodes. Specific genes associated with bipolar disorder are thought to contribute to irregularities in neurochemical functioning, potentially increasing susceptibility to mixed episodes.
• Environment: Stressful life events such as significant loss, trauma, or relationship difficulties may contribute to the onset or exacerbation of mixed episodes. Research also suggests that disruptions in sleep patterns, exposure to excessive light, or seasonal affective disorder can trigger mixed episodes in vulnerable individuals.(FN2)
• Brain structure: Bipolar disorder, which includes bipolar mixed episodes, is believed to be influenced by an imbalance in brain chemicals (neurotransmitters) that regulate mood, such as dopamine, serotonin, and norepinephrine. The complex interplay between these neurotransmitters affects the brain’s overall functioning, leading to fluctuations in mood and behavior.
• Medication and Substance Use: Antidepressants, when prescribed without a mood-stabilizing medication, may trigger a switch between depression and mania or induce mixed episode symptoms. Overindulgence in alcohol or drug use can disrupt neurochemistry and trigger mixed episodes. That’s why it’s important for people with bipolar disorder to communicate openly with healthcare providers regarding their medication and substance use to minimize the risk of mixed episodes.

Can Bipolar Mixed Episodes Be Prevented?

Bipolar mixed episodes can be challenging. Fortunately, there are strategies to help prevent or reduce the frequency and intensity of mixed episodes. It involves managing medication, learning stress reduction techniques, making certain lifestyle adjustments, having a strong support system in place, and avoiding or reducing substance use, including alcohol and recreational drugs. Working closely with mental health professionals can help manage bipolar mixed episodes.

Risk Factors for Developing Mixed Episode Bipolar Disorder

Understanding the risk factors for developing mixed episode bipolar disorder is crucial for early detection and intervention. Early detection and the right treatment protocol can significantly improve people’s lives with bipolar disorder. Note that having one or more of the following risk factors does not guarantee that somebody has mixed episode bipolar disorder.

Risk factors for developing mixed episode bipolar disorder include:

• Previous bipolar disorder diagnosis: People who have previously been diagnosed with bipolar disorder, specifically the manic or depressive type, are more likely to experience mixed episodes as well. While not everyone with bipolar disorder will develop mixed episodes, having a history of the disorder puts people at a higher risk.
• Substance use disorder: The impulsivity and risk-taking behavior associated with substance abuse can exacerbate the person’s mood instability, leading to a higher likelihood of experiencing mixed episodes.
• Stressful life events: Divorce, loss of a loved one, financial difficulties, or trauma, can contribute to the development of mixed episodes in people already at risk for bipolar disorder. These events can disrupt the person’s mood stability and trigger episodes of both mania and depression.
• Co-occurring mental health disorders: People with other mental health disorders, such as anxiety disorders, attention-deficit hyperactivity disorder (ADHD), or borderline personality disorder, are at an increased risk of developing mixed episode bipolar disorder. The presence of these co-occurring disorders may complicate the diagnosis and treatment process.
• Medication non-compliance: Non-compliance with prescribed medications or abrupt discontinuation of medication can trigger mixed episodes. Disregarding the prescribed treatment plan can disrupt the delicate balance and lead to episodes of mixed moods.
• Sleep disturbances: Irregular sleep patterns, such as insomnia or sleeping too much, can contribute to mood instability and trigger mixed episodes in people at risk. People with bipolar disorder should aim to maintain a regular sleep schedule and prioritize healthy sleep hygiene.
• Hormonal changes: Hormonal changes, particularly in women, may increase the risk of developing mixed episodes. Women with bipolar disorder may experience mood fluctuations linked to their menstrual cycle, pregnancy, or menopause.

Risk Factors for Developing Mixed Episode Bipolar Disorder

Understanding the risk factors for developing mixed episode bipolar disorder is crucial for early detection and intervention. Early detection and the right treatment protocol can significantly improve people’s lives with bipolar disorder. Note that having one or more of the following risk factors does not guarantee that somebody has mixed episode bipolar disorder.

Risk factors for developing mixed episode bipolar disorder include:

• Previous bipolar disorder diagnosis: People who have previously been diagnosed with bipolar disorder, specifically the manic or depressive type, are more likely to experience mixed episodes as well. While not everyone with bipolar disorder will develop mixed episodes, having a history of the disorder puts people at a higher risk.
• Substance use disorder: The impulsivity and risk-taking behavior associated with substance abuse can exacerbate the person’s mood instability, leading to a higher likelihood of experiencing mixed episodes.
• Stressful life events: Divorce, loss of a loved one, financial difficulties, or trauma, can contribute to the development of mixed episodes in people already at risk for bipolar disorder. These events can disrupt the person’s mood stability and trigger episodes of both mania and depression.
• Co-occurring mental health disorders: People with other mental health disorders, such as anxiety disorders, attention-deficit hyperactivity disorder (ADHD), or borderline personality disorder, are at an increased risk of developing mixed episode bipolar disorder. The presence of these co-occurring disorders may complicate the diagnosis and treatment process.
• Medication non-compliance: Non-compliance with prescribed medications or abrupt discontinuation of medication can trigger mixed episodes. Disregarding the prescribed treatment plan can disrupt the delicate balance and lead to episodes of mixed moods.
• Sleep disturbances: Irregular sleep patterns, such as insomnia or sleeping too much, can contribute to mood instability and trigger mixed episodes in people at risk. People with bipolar disorder should aim to maintain a regular sleep schedule and prioritize healthy sleep hygiene.
• Hormonal changes: Hormonal changes, particularly in women, may increase the risk of developing mixed episodes. Women with bipolar disorder may experience mood fluctuations linked to their menstrual cycle, pregnancy, or menopause.

Diagnosis of Mixed Episode Bipolar Disorder

Diagnosing mixed episode bipolar disorder is complex as there is a lot of overlap between bipolar symptoms and other mental health disorders. The DSM-5, published by the American Psychiatric Association, serves as a classification system for mental health disorders. The manual includes criteria for the diagnosis of bipolar disorder to help mental health professionals standardize the identification and treatment of conditions like bipolar disorder.

Besides the DSM-5, mental health professionals often consider a range of factors, including clinical judgment, patient history, and other diagnostic tools when assessing and diagnosing mental health disorders like mixed episode bipolar disorder.

According to the DSM-5, the diagnostic criteria for mixed episode bipolar disorder include:

• Meeting the criteria for a major depressive episode and a manic episode nearly every day for at least one week.
• Experiencing predominantly irritable mood along with other symptoms of depression and mania.
• Having symptoms that persist for most of the day, nearly every day, for at least one week.
• Exhibiting a minimum number of symptoms associated with both manic and depressive episodes concurrently like inflated self-esteem, decreased need for sleep, distractibility, and psychomotor agitation.
• Having severe enough symptoms to cause significant distress or impairment in social, occupational, or other important areas of functioning. Also, requiring hospitalization to prevent harm to themselves or others. [FN3]

Impact of Mixed Episode Bipolar Disorder

Living with mixed bipolar disorder is like embarking on a turbulent journey where emotions, thoughts, and energy levels collide. The presence of manic and depressive symptoms can at the same time be exhausting. Since the unpredictability of bipolar mixed episodes can cause erratic energy levels, there may be a constant battle of trying to maintain a consistent level of productivity during manic phases while facing lethargy during depressive states.

Mixed bipolar disorder can strain relationships because of the emotional volatility involved. The impulsivity of manic episodes may lead to strained interactions. Meanwhile, withdrawal and isolation during depressive phases can create emotional distance. Manic episodes can also contribute to risky financial behaviors like excessive spending, gambling, or risky investments.

Treatment for Mixed Episode Bipolar Disorder

Managing bipolar mixed episodes requires a comprehensive approach that may combine medication, therapy, and lifestyle modifications. About 40% of patients with bipolar disorder experience mixed episodes. [FN4] It is essential for people going through bipolar mixed episodes to collaborate closely with healthcare professionals to create and execute a comprehensive treatment strategy.

Medication for Mixed Episode Bipolar Disorder

While therapy and lifestyle adjustments play crucial roles in managing symptoms of bipolar mixed episodes, medication also plays an important role. Medication management stabilizes mood swings, manages impulsivity and risky behaviors, improves sleep patterns, enhances cognitive function, and plays a complementary role with psychotherapy. Because the medication effectiveness varies from person to person, regular monitoring and adjustment of the individualized treatment plan may be necessary.

Medications commonly used to treat mixed episode bipolar disorder include:

• Mood stabilizers: Lithium is one of the classic mood stabilizers that has proven efficacy in managing both manic and depressive episodes. Valproate is an anticonvulsant commonly used as a mood stabilizer for treating mixed episodes.
• Antipsychotics: Atypical antipsychotics like olanzapine and quetiapine may be used to address symptoms of both mania and depression. Olanzapine is FDA-approved for the treatment of bipolar mixed episodes and helps to manage manic symptoms.
• Antidepressants: While the use of traditional antidepressants alone can potentially trigger manic episodes, Selective Serotonin Reuptake Inhibitors (SSRIs) may be cautiously prescribed in combination with mood stabilizers or antipsychotics. Bupropion may be considered in certain cases but needs to be carefully monitored.
• Anti-anxiety medications: Benzodiazepines such as clonazepam or lorazepam may be prescribed on a short-term basis. Anti-anxiety medications can help manage acute anxiety or agitation associated with bipolar mixed episodes.

Therapy for Mixed Episode Bipolar Disorder

The integration of psychotherapy, support groups, and counseling into the individualized treatment plan for mixed episode bipolar disorders offers a refreshing holistic approach. All these therapeutic interventions contribute to emotional regulation, improved coping mechanisms, stronger support networks, and enhanced overall quality of life for those suffering from the mood disorder.

Effective therapy options for mixed episode bipolar disorder include:

• Cognitive behavioral therapy (CBT): CBT for bipolar disorder works to treat mixed episodes by identifying and changing negative thought patterns and behaviors. CBT helps people with mixed episodes to manage distorted thinking, regulate emotions, and develop coping strategies for mood swings.
• Dialectical Behavior Therapy (DBT): DBT combines cognitive-behavioral techniques with mindfulness strategies. It is effective in addressing impulsivity, emotional dysregulation, and interpersonal difficulties often associated with mixed episodes.
• Interpersonal and Social Rhythm Therapy (IPSRT): IPSRT integrates psychoeducation and interpersonal therapy to help people regulate daily routines and stabilize social rhythms. The therapy emphasizes maintaining regular sleep and daily routines to prevent mood destabilization.
• Family-Focused Therapy (FFT): FFT involves family members in the treatment process to provide support and improve communication. It helps family members understand the challenges of bipolar disorder and learn effective ways to cope and communicate with the individual.
• Psychoeducation: Learning about the nature of bipolar disorder, its symptoms, and triggers is crucial. Psychoeducation helps enhance awareness, self-management, and adherence to treatment plans.
• Mindfulness-Based Therapies: Mindfulness techniques, such as mindfulness-based cognitive therapy (MBCT) or mindfulness-based stress reduction (MBSR), can help manage stress and promote emotional regulation.
• Supportive Therapy: This type of therapy provides a safe space for people to express their feelings and concerns. It focuses on building a therapeutic alliance and providing emotional support during challenging times.

How to Cope with Mixed Episode Bipolar Disorder

Coping mechanisms are essential tools to help navigate life’s complexities, manage stress, maintain mental and physical health, and foster positive relationships. People with mixed episode bipolar disorder can embrace a proactive approach to take charge of their mental health, build resilience, and cultivate a sense of well-being.

Here are 10 ways to cope with mixed episode bipolar disorder:

1. Recognize the Warning Signs

It’s important to recognize the early warning signs and triggers of bipolar mixed episodes. Recognizing the early warning signs allows for timely intervention. Different types of interventions may involve adjusting medication, therapy, and support from mental health professionals. Early intervention can improve outcomes and help manage the impact of bipolar mixed episodes on daily functioning and overall well-being.

Early warning signs of mixed episode bipolar disorder include:

• Intense irritability: unexplained and heightened irritability that is out of proportion to the situation.
• Rapid changes in mood: abrupt and frequent mood swings, moving from extreme highs to extreme lows within a short period.
• Impulsivity: increased impulsivity, such as engaging in risky behaviors without considering the consequences.
• Agitation: restlessness and a sense of inner tension, leading to an inability to sit still or focus.
• Increased energy: elevated energy levels, accompanied by a decreased need for sleep.
• Racing thoughts: rapid thought patterns, a flood of ideas, and difficulty concentrating.
• Flight of ideas: speaking rapidly, jumping from topic to topic, and having a mind that races with thoughts.
• Increased talkativeness: talking more than usual, feeling pressured to keep talking, and difficulty in slowing down speech.
• Distractibility: difficulty maintaining attention on one task, being easily distracted by irrelevant stimuli.
• Decreased need for sleep: a noticeable reduction in the need for sleep without experiencing fatigue.
• Feelings of hopelessness: concurrent feelings of sadness, hopelessness, and worthlessness.
• Changes in appetite: significant changes in appetite, either an increase or decrease, leading to weight fluctuations.

2. Exercise Daily

Exercise can help play a positive role in managing bipolar mixed episodes and promoting overall positive mental health. Since exercise has mood-regulating effects, it can help stabilize mood swings associated with bipolar disorder. Physical activity can have positive effects on mood by boosting the release of neurotransmitters like serotonin and norepinephrine, which act as natural antidepressants. Regular exercise also provides structure and routine, enhancing overall lifestyle stability.

3. Follow a Treatment Plan

Consistently take prescribed medications as directed by your healthcare provider. Consider using pill organizers and setting alarms as reminders. Don’t change medication without consulting healthcare providers. Make therapy appointments a priority and attend them regularly. By doing so, it can help prevent relapse and the recurrence of mixed bipolar episodes. Following a treatment plan can promote long-term stability.

4. Maintain a Regular Schedule

Establish a daily routine with consistent sleep, wake times, meals, and other activities. Routine provides stability as it offers a sense of predictability and control while preventing episodes of mania or depression.

5. Monitor Mood Changes

Keep a mood journal to track fluctuations in mood, energy levels, and sleep patterns. A mood journal can serve as a valuable tool for sharing with healthcare providers to evaluate the effectiveness of the treatment plan. Mood journals provide a valuable record of mood cycles, duration, and intensity and make it easier to assess progress and make informed decisions regarding treatment.

6. Reach Out for Support

Stay connected with friends, family, or support groups. Share your feelings with people you trust. Inform your loved ones about the nature of mixed bipolar episodes and how they can support you. Having a support system in place can help prevent and manage crisis situations. Supportive people can recognize warning signs of a potential manic or depressive episode and intervene when needed.

7. Learn Stress Reduction Techniques

Stressful life events such as increased responsibilities, relationship struggles, work-related pressures, financial difficulties, and major life changes can disrupt the delicate balance of bipolar symptoms. Relaxation exercises, deep breathing, or meditation are useful techniques to help manage stress. It’s vital to identify and avoid triggers that may exacerbate symptoms.

8. Try Mindfulness and Grounding Techniques

Practicing mindfulness is about being fully present in the current moment without passing any judgment. By nurturing mindfulness, you can cultivate a heightened awareness and comprehension of your thoughts, emotions, and physical sensations. Incorporate mindfulness practices to stay present and manage overwhelming thoughts. Focusing on the senses is a grounding technique that can help anchor the person during intense moments.

9. Limit Substance Use

Substance use can interfere with how effective prescribed medications are as it can disrupt the balance of chemicals in the brain, making it harder to stabilize mood swings, and manage symptoms. Drugs or alcohol can trigger episodes of mania or depression. These episodes can be intense and potentially dangerous, leading to impulsive behavior, impaired judgment, and increased risk of harm to oneself or others. Impulsive or risky behavior can lead to excessive spending, getting involved in dangerous activities, or can damage relationships.

10. Look for Creative Outlets

Engage in creative activities or hobbies as an outlet for self-expression and stress relief. Creative outlets might include activities like art, music, writing, or dancing. Creativity allows people to explore and express their unique perspectives, thoughts, and experiences. It can provide a sense of identity, enabling people to understand better and connect with themselves.

When to Seek Professional Support

If you have been diagnosed with bipolar disorder or suspect that you may have it, seek professional support as soon as possible. A psychiatrist or psychologist can help you understand and cope with your diagnosis, develop a treatment plan, and provide guidance on managing your negative symptoms.

If you are on medication for bipolar disorder and find that it is no longer effective or causing unwanted side effects, contact a psychiatrist about your medication regimen to make necessary adjustments. Seek professional help to address any negative symptoms associated with their bipolar disorder. An online therapist directory or online therapy platform can be helpful. Consider seeing a psychiatrist for medication management. To get started, consider different online psychiatrist options.