What are the diagnostic criteria for bipolar disorder?

Diagnostic Criteria for Bipolar Disorder

The DSM-5 criteria for bipolar disorder require distinct mood episodes of depression and either mania or hypomania, with Bipolar I requiring at least one manic episode and Bipolar II requiring at least one hypomanic episode plus one depressive episode, following the full duration criteria. 1

Types of Bipolar Disorder

• Bipolar I Disorder: Requires at least one manic episode (can be diagnosed based on a single manic episode)
• Bipolar II Disorder: Requires at least one hypomanic episode AND at least one depressive episode, with no history of mania
• Cyclothymic Disorder: Hypomanic and depressive symptoms that don't meet full criteria for episodes
• Bipolar Disorder Not Otherwise Specified (NOS): Used for manic symptoms lasting hours to less than 4 days or chronic manic-like symptoms 2, 1

Diagnostic Criteria for Manic Episode

A manic episode is characterized by:

1. Distinct period of abnormally and persistently elevated, expansive, or irritable mood AND abnormally and persistently increased activity or energy
2. Duration of at least 1 week (or any duration if hospitalization is required)
3. At least 3 of the following symptoms (4 if mood is only irritable):
   • 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
4. Marked impairment in functioning or necessitates hospitalization or has psychotic features
5. Not attributable to substances or another medical condition 1

Diagnostic Criteria for Hypomanic Episode

A hypomanic episode is characterized by:

1. Same symptoms as mania but less severe
2. Duration of at least 4 consecutive days
3. Observable change in functioning
4. Not severe enough to cause marked impairment in social or occupational functioning
5. No psychotic features
6. Not attributable to substances or another medical condition 1

Cycling Patterns

Bipolar disorder may present with various cycling patterns:

• Rapid cycling: At least 4 distinct mood episodes in 12 months
• Ultra-rapid cycling: Mood cycles as short as 4 hours
• Ultradian cycling: Multiple cycles per day (average 3.7 cycles/day in some pediatric cases) 2, 1

Diagnostic Challenges

Differential Diagnosis

• Unipolar Depression: Failure to screen for past hypomanic episodes is a common reason for misdiagnosis 1
• ADHD and Disruptive Behavior Disorders: High rates of comorbidity complicate diagnosis 2, 1
• Substance-Induced Mood Disorders: Must rule out substance use as cause 3
• Medical Conditions: Endocrine, metabolic conditions, tumors can mimic manic symptoms 4

Special Considerations in Children and Adolescents

• Juvenile mania often presents differently than adult mania:

  • More irritability and belligerence rather than euphoria
  • More labile and erratic mood changes
  • More mixed manic-depressive features 1

• Caution in diagnosing young children: The diagnostic validity of bipolar disorder in preschool children has not been established 2

Bipolar Disorder NOS

Should be used to describe:

• Youths with manic symptoms lasting hours to less than 4 days
• Those with chronic manic-like symptoms representing their baseline functioning 2

Diagnostic Assessment Approach

1. Comprehensive evaluation for:

   • Current and past mood episodes
   • Suicidality
   • Comorbid disorders (especially substance abuse)
   • Psychosocial stressors
   • Medical problems 2

2. Life chart approach to characterize:

   • Course of illness
   • Patterns of episodes
   • Severity
   • Treatment response 2

3. Assessment for environmental triggers and patterns of events that reinforce outbursts 2

Common Pitfalls to Avoid

1. Misdiagnosis as unipolar depression: Always screen for past hypomanic/manic episodes in patients presenting with depression 1

2. Overlooking comorbidities: Especially ADHD, substance use disorders, anxiety disorders 2, 1

3. Ignoring duration criteria: The full DSM duration criteria should be followed when making a diagnosis of mania or hypomania 2

4. Misinterpreting irritability: Manic grandiosity and irritability present as marked changes in mental/emotional state, not just reactions to situations 2

5. Premature diagnosis in very young children: Caution must be taken before applying this diagnosis in preschool children 2

6. Failure to recognize that symptoms must represent a change from baseline: The illness represents a marked departure from baseline functioning and should be evident across different settings 2

By following these diagnostic criteria and being aware of the potential pitfalls, clinicians can more accurately diagnose bipolar disorder and its subtypes, leading to more appropriate treatment and better outcomes for patients.