Mood episodes, or extreme shifts in emotion that can last several days, are the key symptom of bipolar disorder.

Bipolar disorder involves manic, depressive, or hypomanic episodes, but you could have more than one type of mood episode. The specific mood changes you experience depend on whether you have bipolar I, II, or cyclothymia.

Mood episodes associated with bipolar disorder do fall into three general categories. Still, around 40% of people living with bipolar disorder have a specific condition known as bipolar disorder with mixed features.

The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced “mixed features” as a specifier to replace the previous term, “mixed episodes.” Dysphoric mania and mixed mania, other older terms for this condition, have mostly fallen out of common use.

If you have bipolar with mixed features, your mood episodes will have mixed symptoms. Here’s what this means, according to DSM-5 diagnostic criteria:

  • During an episode of depression, you’ll have at least three symptoms of mania or hypomania.
  • During a manic or hypomanic episode, you’ll notice three or more symptoms of a depressive episode.

This differs from other types of bipolar disorder, where episodes involve only one type of mood symptom.

You may not have mixed symptoms for the entire length of the episode. Symptoms need only to last a majority of days during the episode. During a manic episode with mixed features that lasts a week, for example, you might have depression symptoms for 5 days, not the entire week.

Bipolar disorder with mixed features can be more severe than bipolar I or II without mixed features, since mood episodes tend to happen more frequently and last longer.

Symptoms might also be worse than typical bipolar symptoms and have more of an impact on your daily functioning.

Research has also linked mixed features to symptoms of psychosis, increased suicide risk, and substance use.

Bipolar disorder can involve a wide range of symptoms. If you live with bipolar I disorder, you might have a very different experience from someone else living with the same condition.

A mixed features mood episode generally won’t show up in the same way as a mood episode without mixed features, and you may not have an equal combination of symptoms. In other words, more of your symptoms might fall into one category — mania, depression, hypomania — than the other.

The combination of symptoms can lead to some clear contrasts and inconsistencies in your mood, speech, and behavior. Here’s what that can look like:

Symptoms of mania with mixed features

Your mood episode will meet the criteria for an episode of mania or hypomania, but you’ll also have at least three symptoms of depression:

  • feelings of uneasiness or disconnection from reality
  • extreme sadness or tearfulness
  • a sense of emptiness, worthlessness, or guilt
  • energy loss and fatigue
  • lack of interest or enjoyment in your usual activities
  • moving and speaking more slowly than usual

A mixed features episode won’t always involve the same euphoria or feelings of grandiosity that often accompanies mania. You won’t necessarily feel on top of the world or experience the same elevated self-confidence and self-esteem.

You’re more likely to notice rapid changes in mood, increased irritability, and difficulty controlling strong emotions. In addition:

  • Your thoughts might race, or your speech might become very rapid, while you feel very low and slowed down in mind and body.
  • You might find yourself unable to stop smiling or laughing despite persistent feelings of guilt or thoughts of suicide.
  • Feelings of hopelessness or sadness might show up alongside physical restlessness, anxiety, or increased energy.

Symptoms of depression with mixed features

A depressive episode with mixed features will also involve three or more symptoms of mania or hypomania:

  • increased talkativeness and rapid speech, often characterized by frequent or sudden shifts in topic
  • extreme excitement or restlessness
  • increased energy
  • racing thoughts
  • greater distractibility
  • less of a need for sleep, or feeling rested after very little sleep
  • impulsive behavior or lowered inhibitions

While the DSM-5 includes grandiosity and an elevated mood among the typical signs of a manic episode, research suggests these symptoms show up less commonly in depressive episodes with mixed mania. Some people do still experience these symptoms, though.

During a mixed depressive episode:

  • An emotional “high” or euphoric state of mind might conflict with extreme sadness or guilt.
  • You could feel irritable or tearful, even while completely focused on a creative project you usually enjoy.
  • Persistent feelings of emptiness or worthlessness can show up alongside increased energy or restless movement.
  • You might start several projects but get sidetracked easily and fail to get much done.

The combination of rapid shifts between emotional states, impulsivity and distractibility, and racing thoughts can feel frightening and unpredictable. Symptoms of psychosis, such as delusions, hallucinations, and paranoia, can make this distress worse.

Treatment for mood episodes without mixed features focuses on resolving either mania or depression symptoms — whichever you are experiencing at the time.

Treating mood episodes with mixed features, on the other hand, needs to address mania and depression at the same time. This can pose some challenges, since certain medical treatments may worsen some symptoms, sometimes without offering much relief from other symptoms.

Certain antidepressants, for example, might intensify manic symptoms without relieving depression. Many people take lithium to treat manic episodes, but mood episodes with mixed features may not respond in the same way.

These mood episodes are often more resistant to treatment, so it may take some trial and error to find the most effective approach for your specific symptoms. The right treatment will help improve many of your symptoms without making others worse.

Treatment for bipolar disorder with mixed features typically involves medication. Your doctor or psychiatrist may recommend one medication or a combination, such as:

  • atypical antipsychotics (also called second-generation neuroleptics), such as aripiprazole and olanzapine
  • mood stabilizers, such as lithium, valproic acid, or divalproex
  • anticonvulsants, such as carbamazepine or lamotrigine

Research also suggests electroconvulsive therapy as another potential treatment for bipolar disorder with mixed features. If you don’t see much improvement with medication alone, your mental health professional might also recommend ECT.

Experiencing both mania and depression at the same time can feel confusing or disorienting.

Coping with a mixed features mood episode can be difficult, particularly when you have a hard time identifying exactly how you feel. A rapidly shifting mood can create plenty of emotional turmoil, and frequent, intense suicidal thoughts aren’t uncommon.

The good news is that the right treatment and coping strategies can help people manage these symptoms effectively.

Therapy

Therapy with a trained mental health professional may not necessarily resolve severe mood symptoms, but it can be substantially beneficial when you live with bipolar disorder.

A therapist can help you begin to identify and manage overwhelming emotions, abrupt mood changes, and thoughts of suicide, even when you’re unsure exactly what you’re feeling or what kind of help you need.

Therapy also offers a safe space to build coping skills and develop a crisis plan for future mood episodes.

A therapist can also offer support with recognizing and tracking early signs of mood changes. When you catch a shifting mood early on, you can sometimes take steps to prevent an episode.

Bipolar disorder symptoms and mood episode cycles can change over time, so you might notice your treatment becomes less effective. Always let your therapist and the doctor who prescribed any medications know about new symptoms so that you can discuss more helpful treatments.

Manage stress

Stress in your day-to-day life can sometimes trigger mood episodes. While it’s not always possible to prevent stress, having a few go-to coping strategies in place can help you maintain a calmer mindset when challenges pop up.

Try these tips:

  • Make time for regular relaxation. This might include a nature walk, a warm bath, aromatherapy, or low-key pleasures like reading or coloring.
  • Try grounding techniques, such as deep breathing, when you find yourself in a stressful situation. Your favorite relaxing music can help, too.
  • Consider meditation to boost your ability to recognize and let go of unwanted thoughts.
  • Many people find that practicing mindfulness can help them reduce stress. However, it’s useful to remember that mindfulness can be challenging for people who have experienced trauma.
  • Progressive muscle relaxation is another tool for relaxing your mind and body. This involves slowly tensing and relaxing each muscle to relieve psychological stress and physical tension throughout your body.
  • A daily journal can help you express upsetting or painful feelings, keep track of mood symptoms, and increase emotional awareness.
  • Turn to loved ones for emotional support and help brainstorm problem-solving strategies or positive distractions during times of stress.

Follow a regular schedule

Since unpredictable or random daily routines can also lead to mood changes, keeping your days structured could help prevent mood episodes.

Consider creating a weekly schedule that outlines specific times for things like:

  • work
  • exercise
  • relaxation and alone time
  • time with friends and romantic partners
  • meals
  • chores and errands
  • switching off devices before bed

Choose a regular bedtime and wake time, and stick to these times as closely as possible, even on the weekends — a regular sleep-wake schedule can sometimes help prevent mood episodes.

Take care of your health

If you’ve heard of the mind-body connection, you’ll know physical and mental well-being are linked.

Good health can’t cure mental health conditions, but all the same, physical wellness can improve your outlook and boost resilience, giving you the emotional strength to manage life’s unpredictable aspects.

Try these self-care strategies:

  • Set aside 7–9 hours for sleep each night.
  • Eat balanced meals at regular times.
  • Stay hydrated.
  • Limit caffeine, alcohol, and other substance use, since they may prompt mood changes or make symptoms worse.
  • Try to get some exercise each day.
  • Make time for your favorite hobbies.

It can take some time to find the best treatment for bipolar disorder with mixed features, but don’t lose hope. Improvement is absolutely possible.

As you work with your care professional to find the right treatment, keep in mind that lifestyle changes can also help reduce symptoms and make it easier to manage mood episodes.