150 Bipolar and Related Disorders
4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely
self-reproach or guilt about being sick).
6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ide-
ation without a specific plan, or a suicide attempt or a specific plan for com-
mitting suicide.
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, due to the marked impairment and clinical severity of full mania.
D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, other treatment).
Depressive episode, wit h mixed features: 
A. Full criteria are met for a major depressive episode, and at least three of the fol-
lowing manic/hypomanic symptoms are present during the majority of days of
the current or most recent episode of depression:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school,
or sexually).
6. Increased or excessive involvement in activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual;
to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the