Mixed Episode - Demystifying the DSM-5

CW: suicide

Basically, in a mixed episode, the character experiences the symptoms of a major depressive episode AND a manic / hypomanic episode at the same time.

While "mixed episode” is a common term, the DSM-5 actually doesn’t have a single diagnosis for it; instead, it has been split into “major depressive episode with mixed features” and “manic/hypomanic episode with mixed features.”

Here’s a visual guide type thing.

[[Image description: 4 lines of white text with different colored backgrounds. From top to bottom, “Major depressive episode” is dark blue, “major depressive episode with mixed features” is bluish purple, “manic/hypomanic episode with mixed features” is reddish purple, and “manic/hypomanic episode” is red]]

Essentially, people call anything purple a mixed episode, but nowadays psychologists like to be a little more specific about what kind of purple it is.

Note - if a character meets all the criteria for both a manic and a depressive episode, they should be diagnosed with a manic episode with mixed features. Mania always wins the tiebreaker.

Major depressive episode with mixed features

The depressive episode (see criteria here) has some symptoms of a manic (see here) or hypomanic episode (see criteria here), but not enough for a full diagnosis.

Your character doesn’t have to have bipolar I or II to have this diagnosis; however, they’re at extremely high risk to develop a bipolar disorder in the future, and as such may be diagnosed with “other specified bipolar or related disorder” instead of “major depressive disorder.”

This requires 3 or more of the following symptoms nearly every day, more days than not, during a depressive episode:

Elevated, expansive mood (defined here)
Inflated self esteem or grandiosity
The character is more talkative than usual, and feels a pressure to keep talking.
Flight of ideas or racing thoughts (Will be the topic of a future post).
The character has an increase in goal directed activity in their social life, at work or school, or sexually.
The character becomes excessively involved in things that have a high risk of painful consequences (such as reckless driving, maxing out credit cards on shopping sprees, foolish business investments).
The character has much less of a need for sleep.

These symptoms need to be observable by other people and are a significant change in behavior from how the character usually acts.

These symptoms cannot be the result of a drug (such as meth).

Manic/hypomanic episode with mixed features

The full criteria for a manic episode (see here) or a hypomanic episode (see here) need to be met, and the character has to have 3 or more of the following symptoms, which have to be present in the majority of the days of the manic/hypomanic episode:

The character generally feels bad / sad / depressed. This can be reported by the character themself, or observed by others.
The character loses interest or take less pleasure in almost every activity they formerly enjoyed.
The character has psychomotor agitation or retardation (see here) nearly every day. This has to be observed by other people, not just reported by the character themselves.
The character feels fatigued / drained of energy.
The character feels worthless or excessively guilty.
The character has any of the following:
Repeated thoughts of death
Suicidal ideation (without a plan for committing suicide)
Suicide attempt
Specific plan for committing suicide

These symptoms are observable by other people and are a change from the character’s usual behavior.

These symptoms cannot be the result of a drug.

But these dry criteria don’t truly convey just how awful a mixed mood episode is. Stay tuned, Shrinky-dinks, for some posts about what a character having a mixed episode might actually experience.

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Bipolar I and II - Demystifying the DSM-5

Bipolar I

The character needs to have had at least one manic episode. See here for what criteria is required for a manic episode.

The manic episode / subsequent major depressive episodes (if any) aren’t better explained by any of the psychotic disorders (schizoaffective, schizophrenia, etc.)

That’s literally it. There’s nothing else required for a diagnosis.

There are a lot of possible specifiers, but that will be gone into in a future post.

Bipolar II

The character needs to have had a hypomanic episode (see criteria here) AND a major depressive episode (see criteria here).

These episodes need to cause the character stress or make their lives more difficult.

These episodes aren’t due to a substance (like drugs) or another medical condition.

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Hypomanic Episode - Demystifying the DSM-5

There needs to be a distinct period of time where the character experiences at least one of the following moods most of the day, nearly every day, for at least four days in a row:

Elevated - the character feels euphoric or excessively happy
Expansive - there’s a lot of definitions for this. It can be shown through the character overly expresses their feelings, to the point that they disregard the reactions of others. The character may feel that they’re more important or significant than they actually are, seeming grandiose or superior to others.
Irritable - the character is easily angered

The character also needs to be consistently more energetic or active for at least those four days.

While the character is in this state, they have to show at least three of the following symptoms (4 if their mood is irritable), which have to be a significant change in behavior from how the character usually acts:

Inflated self esteem or grandiosity (see expansive mood above).
The character has much less of a need for sleep.
The character is more talkative than usual, and feels a pressure to keep talking.
Flight of ideas or racing thoughts (Will be the topic of a future post).
The character is easily distracted.
The character either has an increase in goal directed activity OR psychomotor agitation (see link here) .
Goal-directed activity typically means that the character frequently takes on ambitious new projects without necessarily thinking it through or completing previous projects first.
The character becomes excessively involved in things that have a high risk of painful consequences (such as reckless driving, maxing out credit cards on shopping sprees, foolish business investments).

These symptoms have to be a complete change from how the character normally acts.

The symptoms have to be noticeable by other people.

The symptoms cannot be severe enough to cause the character great difficulty in their occupation or in interacting with others.

The character cannot be psychotic - if they are, it’s a manic episode. The character also cannot need hospitalization - again, that’d be a manic episode.

These symptoms cannot be the result of a drug (such as meth) or a medical condition.

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#text #bipolar #bipolar II #demystifying #demystifying the DSM #hypomanic episode #future posts #mania #this is not psychological or medical advice #this is writing advice