What are the diagnostic criteria for bipolar disorder?

Diagnostic Criteria for Bipolar Disorder

The diagnosis of bipolar disorder requires distinct periods of mood changes, with mania lasting ≥7 days or hypomania lasting ≥4 days, representing a marked departure from baseline functioning and causing significant impairment. 1

Core Diagnostic Features

Bipolar I Disorder

• Essential criteria:
  • At least one manic or mixed episode lasting ≥7 days (or any duration if hospitalization is required)
  • Episodes represent significant departure from baseline functioning
  • Symptoms not better explained by other medical conditions or substance use 2

Bipolar II Disorder

• Requires:
  • Episodes of major depression
  • At least one hypomanic episode (lasting ≥4 days)
  • No history of full manic or mixed episodes 2

Bipolar Disorder NOS (Not Otherwise Specified)

• Used for cases that don't meet full criteria for other bipolar diagnoses
• Includes manic symptoms lasting hours to less than 4 days
• Often presents with chronic manic-like symptoms as baseline functioning 2

Specific Symptoms to Assess

Manic Episode Symptoms (need at least 3)

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Flight of ideas or racing thoughts
• Distractibility
• Increase in goal-directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities with high potential for painful consequences 1

Mixed Episode

• Meets criteria for both manic and depressive episodes for at least 7 days 2

Cycling Patterns

• Rapid cycling: ≥4 mood episodes in 12 months
• Ultrarapid cycling: 5-364 cycles per year
• Ultradian cycling: >365 cycles per year (multiple daily mood shifts) 2

Differential Diagnosis Considerations

• Rule out other psychiatric conditions:

  • Schizophrenia (assess for persistent psychotic symptoms without mood episodes)
  • Schizoaffective disorder (determine if psychotic symptoms occur only during mood episodes)
  • Unipolar depression (carefully assess for history of hypomania/mania)
  • ADHD (differentiate from chronic manic symptoms) 2, 1

• Rule out medical causes:

  • Substance-induced mood disorder
  • Mood disorder due to general medical condition
  • Medication side effects 2, 3

Assessment Approach

1. Structured clinical interviews based on DSM criteria

2. Life chart documentation to characterize:

   • Course of illness
   • Pattern of episodes
   • Severity
   • Treatment response 2, 1

3. Comprehensive evaluation for comorbidities:

   • Suicidality (high risk in bipolar disorder)
   • Substance abuse (common comorbidity)
   • Anxiety disorders
   • Developmental disorders
   • Medical conditions 2, 1

Special Considerations

Children and Adolescents

• Exercise caution in diagnosing young children, especially preschoolers
• Diagnostic validity in very young children not well established
• Assess for environmental triggers, developmental disorders, parent-child conflicts
• Differentiate from disruptive behavior disorders, PTSD, and developmental disorders 2

Diagnostic Challenges

• Early diagnosis is difficult and misdiagnoses are common
• First presentation is often depression, making differentiation from unipolar depression challenging
• Patients may not recognize hypomanic symptoms as abnormal
• No validated biomarkers currently exist 3, 4

Pitfalls to Avoid

• Misdiagnosing bipolar disorder as unipolar depression - always assess for history of manic/hypomanic episodes in patients presenting with depression 3
• Overreliance on cross-sectional assessment - longitudinal assessment is crucial 4
• Failing to differentiate manic grandiosity and irritability from situational reactions, temperamental traits, or anger outbursts 2
• Overlooking comorbid conditions that may complicate diagnosis and treatment 1
• Applying adult criteria to children without developmental considerations 2

By systematically assessing these diagnostic criteria and carefully documenting the longitudinal course of symptoms, clinicians can more accurately diagnose bipolar disorder and initiate appropriate treatment to improve patient outcomes.