B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and
depression simultaneously, the diagnosis should be manic episode, with mixed
features.
D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, or other treatment).
Note:  Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar 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.
With rapid cycling  (can be applied to bipolar I or bipolar II disorder): Presence of at
least four mood episodes in the previous 12 months that meet the criteria for manic,
hypomanic, or major depressive episode.
Note:  Episodes are demarcated by either partial or full remissions of at least 2 months
or a switch to an episode of the opposite polarity (e.g., major depressive episode to
manic episode).
Note:  The essential feature of a rapid-cycli ng bipolar disorder is the occurrence of
at least four mood episodes during the previous 12 months. These episodes can
occur in any combination and order. The episodes must meet both the duration and