What are the diagnostic criteria for bipolar disorder?

Diagnostic Criteria for Bipolar Disorder

Bipolar disorder is diagnosed based on specific criteria including distinct episodes of mania or hypomania alternating with depression, with marked changes in mood, energy, behavior, and sleep. 1

Types of Bipolar Disorder

Bipolar I Disorder

• Requires at least one manic or mixed episode lasting ≥7 days (or any duration if hospitalization is required) 2
• Episodes represent a significant departure from baseline functioning 2
• Depression episodes are common but not required for diagnosis 2
• Both DSM-IV-TR and ICD-10 stipulate that episodes represent a significant departure from baseline function 2

Bipolar II Disorder

• Requires periods of major depression and hypomania (episodes lasting at least 4 days) 2
• No history of full manic or mixed manic episodes 2

Bipolar Disorder Not Otherwise Specified (NOS)

• Used for cases that don't meet full criteria for other bipolar diagnoses 2
• Recommended for youths who don't have the classic adult presentation 2
• May include sub-threshold cases, which could represent an additional 5.1-6.4% of the population 3

Diagnostic Features of Mood Episodes

Manic Episode Criteria

• Duration: At least 7 days (unless hospitalization is required) 2
• Core symptoms include:
  • Elevated, expansive, or irritable mood 1
  • Increased energy and goal-directed activity 1
  • Decreased need for sleep without feeling tired 1
  • Racing thoughts/flight of ideas 1
  • Pressured speech/talkativeness 1
  • Distractibility 1
  • Grandiosity 1
  • Engagement in risky behaviors 1

Mixed Episode Criteria

• Period lasting ≥7 days where symptoms for both manic and depressive episodes are met 2

Hypomanic Episode Criteria

• Similar symptoms to mania but less severe
• Duration: At least 4 days 2
• Does not cause marked impairment in social or occupational functioning 2
• Does not require hospitalization 2

Depressive Episode in Bipolar Disorder

• Often presents with:
  • Psychomotor retardation
  • Hypersomnia
  • Significant suicide risk
  • Psychotic symptoms (more common than in unipolar depression) 1

Cycling Patterns

Rapid Cycling

• Occurrence of at least four mood episodes in 1 year 2
• Episodes must still meet duration criteria (e.g., 7 days for mania) 2

Ultrarapid Cycling

• Brief, frequent manic episodes lasting hours to days (less than 4 days)
• Defined as having 5 to 364 cycles per year 2

Ultradian Cycling

• Repeated brief (minutes to hours) cycles occurring daily
• Defined as greater than 365 cycles per year 2

Special Considerations in Diagnosis

Age-Related Presentation

• Early-onset cases (before age 13) are predominantly male 2
• Childhood presentations often show markedly labile and erratic symptoms rather than persistent episodes 1
• High rates of comorbid disruptive disorders in early-onset cases 1

Diagnostic Challenges

• Bipolar disorder is often misdiagnosed, particularly in adolescents with psychotic features who may be incorrectly diagnosed with schizophrenia 2
• Early diagnosis is challenging, with frequent misdiagnoses potentially resulting in missed early intervention 4
• Consider bipolar disorder in any patient presenting with depression 5

Premorbid Conditions

• Disruptive behavior disorders, irritability, behavioral dyscontrol, anxiety, and dysphoria are common in early-onset bipolar disorder 1
• Dysthymic, cyclothymic, or hyperthymic (irritable, driven) temperaments may precede eventual bipolar disorder 1

Genetic and Prognostic Factors

• Strong genetic component with approximately 70% heritability 1
• Four to sixfold increased risk in first-degree relatives 1
• Life expectancy reduced by 12-14 years 1
• 1.6-2 fold increased risk of cardiovascular mortality 1

The diagnosis of bipolar disorder requires careful assessment of symptom patterns, duration, and impact on functioning. Clinicians should be particularly vigilant about differentiating bipolar disorder from other conditions with similar presentations and recognize that presentation may vary significantly based on age of onset and individual factors.