“With mixed features” is a specifier that can be added to either major depressive disorder or bipolar I or II disorder, and it applies when a person experiences both symptoms of depressed mood and mania (though one or the other would be considered predominant) within the same episode.
As described in detail below, the mixed features specifier would be applied following the current or most recent state the person is/has been in: manic, hypomanic, or depressed.
Manic or hypomanic episode, with mixed features:
This specifier applies when full criteria are met for a current or most-recent manic episode or hypomanic episode, and at least three symptoms of depression are also present during the majority of days within this episode. These depressive symptoms (listed below) must be distinct from the person’s usual behavior and able to be observed by others who are close to or in regular contact with the person (e.g., a partner, family member, coworker, or friend).
- Experiencing significantly depressed mood where the person feels sad or empty or the observation is made by others (e.g., “he appears tearful”).
- Losing interest or pleasure in all, or almost all, activities the person would usually enjoy doing (e.g., hobbies, exercise), as indicated by either the person’s account or observations made by others.
- Speaking or talking more slowly than is normal for the person nearly every day (this “psychomotor retardation” can be observable by others).
- Fatigue or loss of energy.
- Feelings of worthlessness or excessive or inappropriate guilt (e.g., focusing on things the person feels they could have or should have done in the past).
- Recurrent thoughts of death (not just fear of dying) or suicidal ideation/actions. Intensity of suicidal thoughts/behaviors range from fleeting morbid thoughts to making an actual suicide attempt. Also included along this spectrum are suicidal thoughts without a specific plan, and thoughts that include forming a specific plan for committing suicide with or without actual intent to carry it out.
- For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania.
- The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication, other treatment).
Depressive episode, with mixed features:
This specifier applies when full criteria are met for a current or most-recent major depressive episode. Thus, a person can have Major Depressive Disorder (MDD) with mixed features and not necessarily meet for a bipolar spectrum disorder (i.e., the person does not fully meet for mania or hypomania to qualify for a bipolar diagnosis). However, Mixed features in MDD are usually a “red flag” and an indicator the person will go on to develop bipolar I or II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.
In a depressive episode with mixed features, full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days during the current or most recent episode of depression:
- Experiencing an excessively elevated, expansive mood (e.g., feeling high, excited or hyper).
- Inflated self-esteem or grandiosity (e.g., feeling like you are especially important in some way akin to a deity or an authority figure).
- More talkative than usual or feeling pressured to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
- Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
- Decreased need for sleep (feeling rested despite sleeping less than usual — not simply inability to sleep as in insomnia).
- For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features.
- The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication, or other treatment).
Prior to the 2013 DSM-5, this mood disorder specifier was referred to as an ‘episode’. Other specifiers have also been added to Bipolar Disorder and Major Depressive Disorder. See additional specifiers here.
Medina, J. (2014). Mixed Features Specifier of Bipolar Disorder & Depression. Psych Central. Retrieved on October 1, 2014, from http://psychcentral.com/disorders/bipolar-disorder-with-mixed-features/
Symptom criteria summarized from:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
Last reviewed: By John M. Grohol, Psy.D. on 24 Jul 2014
Published on PsychCentral.com. All rights reserved.