Mental health professionals may refer to dysphoric mania as bipolar disorder with mixed features, symptoms, or states. It can feel like mania but with a low mood and feelings of hopelessness or sadness at the same time.

The most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) does not separate the mental health issue formerly known as dysphoric mania from bipolar disorder. Instead, it classifies it as a specifier of the disorder — a particular presentation of symptoms.

Bipolar disorder is a mental illness that occurs in around 2.8 percent of people in the United States.

An estimated 40 percent of people who live with bipolar disorder experience mixed symptoms, according to a 2015 report in CNS Drugs.

People with bipolar disorder who experience mixed episodes might experience mania, hypomania, and depression symptoms at the same time.

Experiencing these different states at the same time makes this presentation of bipolar disorder challenging to treat. In this article, we explore the characteristics, diagnosis, and treatments of bipolar disorder with mixed states.

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When bipolar disorder presents with mixed episodes, they are states that are familiar to most people with bipolar disorder and include depression, mania, and a milder form of mania known as hypomania. Not everyone with bipolar I disorder will experience depression.

However, people with mixed features experience mania and depression at the same time. This increases the risk of extreme behavior and means that the symptoms are generally more severe and longer-lasting than those in people who do not experience mixed episodes.

Often, the clinical outcomes are worse because treatment for one element of bipolar disorder with mixed features, such as anti-depressants, will sometimes make the other, co-occurring element more severe.

The DSM-5 defines depression and mania in the following ways:

Depressive symptoms

  • extended or severe periods of depressed mood that a person might report themselves, such as feelings of sadness or emptiness, or that others might observe, such as visible crying or tearfulness
  • self-reported or observed lack of interest or pleasure in almost all activities
  • observable slowing down of thoughts and reduction in activity
  • alterations in sleep or eating patterns, or dramatically increased or reduced appetite
  • extreme lethargy or lack of energy
  • persistent and excessive feelings of guilt or worthlessness
  • repeatedly thinking about or planning death

A person experiencing these symptoms might become socially isolated and even experience physical pains and aches.

Manic symptoms

  • an overstated good mood and confidence
  • sleeping less and feeling tired less often, often feeling fully rested after just a brief period of sleep
  • racing thoughts and a rush of ideas
  • increasingly or excessively acting in potentially harmful ways, for example, indulging in high-risk sexual behavior or making knowingly ill-advised financial decisions
  • experiencing delusions or hallucinations
  • demonstrating an increased sense of self-importance or grandiosity

Dr. Michael Grunebaum, Associate Professor of Psychiatry at Columbia University Medical Center and a research psychiatrist at the New York State Psychiatric Hospital, added the following when MNT reached out:

The pleasurable mood elevation common with mania is usually missing from dysphoric mania, although sometimes the elevated and depressed mood symptoms may be mixed together or rapidly alternating.”

A person with mixed features during bipolar disorder might appear to feel euphoric while crying or may experience a rush of thoughts while also in a state of lethargy.

If another individual appears to be experiencing these mixed states, the risk of suicidal ideation or potential harm to another person is high. The mixed features that constitute this state constitute a medical emergency.

Take the following steps:

  • Contact local emergency services.
  • Do not leave the individual until medical assistance arrives.
  • Keep any sharp objects, weapons, medications, or narcotics out of reach.
  • Listen without judgment or interruption.
  • Do not make threats or raise your voice.

What does it feel like?

Understanding more about the way bipolar disorder with mixed episodes can feel might help people around the individual offer support.

Dr. Susan Noonan, a physician and certified peer specialist and consultant at the Massachusetts General Hospital and McLean Hospital, gave MNT an account of her own experience of a mixed episode, as a person with bipolar disorder.

She told MNT:

“When it happens, the world is all dark gray and murky, with no hope of it ever changing or improving, no hope for a life of any meaning to you, and it physically feels as if you are moving through heavy molasses. Fatigue is huge and sleep never comes, and I could be wide awake for 4 to 5 days straight.

“At night I get energized in spite of fatigue and take on projects like rearranging the books on my bookcase or painting my basement walls different colors.”

“Thoughts are negative and apparently distorted,” she added. “It feels like there’s a storm in my head, and I am irritated by everyone and everything around me, and constantly agitated.”

“I am told that I walk and move more slowly, and that my speech and thoughts are more rapid and racing, although at the time I do not have insight into this and do not realize it. Sometimes I just walk and pace continuously, sometimes just sit in one place for hours.”

Medical researchers have not yet identified the causes of bipolar disorder and its presentations.

Some researchers have noted that genetic factors contribute to the development of bipolar disorder. The DSM-5 has reported that there is an average “10-fold increased risk among adult relatives of individuals with bipolar I and bipolar II disorders.”

A 2014 study, however, points out that many cases of bipolar disorder are isolated. The authors state that families in which several members live with bipolar disorder are rare.

The authors also note that alcohol and drug dependence are potential nongenetic factors that could act as triggers for the mixed specifier of bipolar disorder.

Other reports, such as this 2017 report in the journal Synapse, suggest that genetic factors influence the speed and severity of switching emotional states.

Other possible but unconfirmed risk factors of mixed states in bipolar disorder include:

  • changes in light intensity and seasonal changes impacting on Circadian rhythm, which affects the sleep cycle and other aspects of a person’s psychological well-being.
  • state-switching caused by certain medications, such as tricyclic antidepressants (TCAs), amphetamine, and bupropion.
  • little or a complete lack of sleep.

The following might contribute to the development of bipolar disorder:

  • brain structure
  • stress, such as a bereavement, financial difficulties, or a relationship breakdown

Further understanding of what causes the ‘switch’ between emotional states will help the development of more effective treatments for this severe specifier of bipolar disorder.

Bipolar disorder with mixed features is difficult to treat.

Most often, doctors will prescribe mood stabilizers, including newer anticonvulsant drugs, and atypical antipsychotic medications. A mixture of drugs will almost always be necessary to control mixed states.

Some antipsychotic options include:

  • risperidone, which might be more effective for treating manic symptoms than depressive presentations
  • olanzapine
  • quetiapine, which is effective for all presentations of bipolar disorder
  • asenapine, a 2nd-generation antipsychotic
  • aripiprazole, a 3rd-generation antipsychotic sometimes classed as a 2nd-generation antipsychotic

Effective mood-stabilizing medications include:

  • divalproex sodium
  • carbamazepine
  • oxcarbazepine, although the data on this compound is minimal
  • gabapentin and pregabalin, which are effective when bipolar disorder accompanies anxiety disorders

However, current combinations of medication often lead to intolerable side effects and poor adherence to a treatment plan from people taking this route of treatment.

Some research suggests that anticonvulsants may be more effective for people with mixed states than the more traditional antimanic drugs. If these drugs are not sufficient, a doctor may add antipsychotic or anti-anxiety medication.

It is essential that people with a mixed specifier of bipolar disorder take their medicines on time and regularly to avoid triggering an episode.

Electroconvulsive therapy (ECT) is another possible treatment option for individuals who have not responded well to medications. ECT involves applying electrical shocks to the brain to induce a seizure. The actual mechanism by which ECT is effective is not known.

ECT is particularly effective for people with bipolar disorder who are suicidal, catatonic, and people who experience persistent mixed states.

Dr. Noonan recommends the following lifestyle habits:

  • treating all physical and co-occurring conditions
  • taking medications as prescribed
  • avoiding excess caffeine, tobacco use, drinking alcohol, and using street drugs
  • maintaining regular hygiene and a consistent sleep schedule
  • following a healthful diet and nutrition plan
  • daily physical exercise and a regular daily routine
  • avoiding isolation and maintaining social exposure
  • using inpatient hospital treatment in urgent circumstances

Psychotherapy and supportive counseling can also help to alleviate stress and depressive symptoms.

It is essential to see a doctor as soon as a mixed episode starts to develop. An episode can put an individual at risk of harm, and symptoms can worsen without treatment.

Treatment is easier when symptoms are less severe, Dr. Grunebaum told MNT.

Episodes can lead persons suffering from dysphoric mania to make impulsive decisions which can cause problems they later regret, another reason why earlier treatment is better. Lastly, there is some evidence that remaining in a state of dysphoric mania is not good for the brain and may lead to more difficult to treat symptoms if prolonged.”

Dr. Noonan adds that bipolar disorder with mixed features is difficult to treat, but seeking treatment is essential because of the risks involved. Hospitalization may be necessary if the person attempts or is considering suicide.

All forms of bipolar disorder can be extremely disruptive, but Dr. Noonan’s closing advice to people with the disorder is:

“Don’t give up, no matter how bleak.”


How do I recognize a mixed episode in myself before it’s too late?


For many people, recognizing the onset of a mixed episode can be difficult. Family, friends, and co-workers often notice the signs before others do.

With some effort, some people will be able to recognize changes in their mood. Others may come to depend on someone they feel close to and trust to alert them to the subtle changes in their mood.

Timothy J. Legg, PhD, CRNP Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

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