Bipolar disorder

Mixed symptoms

What are mixed symptoms in bipolar disorder?

Bipolar disorder is characterised by recurrent episodes of depression and mania. Some people with bipolar disorder also show episodes of mixed symptoms or states. Mixed states involves having three or more manic/hypomanic symptoms within a depressive episode, or depressive symptoms within a manic/hypomanic episode.

A depressive episode is at least two weeks in which a person has at least five of the following symptoms. Intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide.

A mania episode is at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. A manic episode involves exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction. A hypomanic episode is a less severe manic episode and need only last four days in a row.

What is the evidence for mixed states in bipolar disorder?

Moderate quality evidence finds the prevalence of mixed states in bipolar disorder is around 35%. The prevalence of mixed states in children with bipolar disorder is around 55%. There were high rates of comorbidities in these children, particularly ADHD, oppositional defiant disorder, and anxiety disorders. The prevalence of mixed states during hypomania is around 27%. The prevalence of mixed states during bipolar depression is around 18%.

Compared to those without mixed features, those with mixed features report more unemployment, rapid cycling, anxiety, and suicide attempts. These were particularly apparent in people in a hypomanic or manic episode rather than a depressive episode.

September 2021

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Last updated at: 1:10 am, 8th October 2021
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