Diagnostic Criteria for Bipolar Disorder
The diagnosis of bipolar disorder requires careful assessment of distinct periods of mood changes associated with sleep disturbances and psychomotor activation, following DSM criteria including duration requirements. 1
Core Diagnostic Criteria
- Psychiatric assessments should include specific screening questions for bipolar disorder, focusing on distinct, spontaneous periods of mood changes with associated sleep disturbances and psychomotor activation 1
- The DSM-IV-TR criteria (now updated in DSM-5), including duration criteria, must be followed when diagnosing mania or hypomania in both adults and children/adolescents 1
- Diagnostic assessment should incorporate both current and past history of symptomatic presentation, treatment response, psychosocial stressors, and family psychiatric history 1
Differentiating Bipolar Types
Bipolar I Disorder
- Requires at least one manic episode (can be diagnosed based on a single manic episode) 2
- Manic episodes are characterized by:
- Distinct period of abnormally and persistently elevated, expansive, or irritable mood
- Marked departure from baseline functioning
- Evident and impairing in different realms of the person's life 1
- Associated with decreased need for sleep, affective lability, and cognitive changes 1
- Duration of at least 7 days (or any duration if hospitalization is required) 3
Bipolar II Disorder
- Requires at least one depressive episode and at least one hypomanic episode, with no history of mania 4
- Often presents with recurrent depressive episodes that outnumber hypomanic episodes by a ratio of 39:1 4
- Frequently misdiagnosed as major depressive disorder, which can lead to inappropriate treatment with antidepressant monotherapy 4
Bipolar Disorder NOS (Not Otherwise Specified)
- Used to describe individuals with manic symptoms lasting hours to less than 4 days 1
- Also applies to those with chronic manic-like symptoms representing their baseline level of functioning 1
- These individuals are significantly impaired but don't meet full criteria for Bipolar I or II 1
Special Considerations in Assessment
Children and Adolescents
- Manic symptoms must be differentiated from symptoms of other common childhood disorders such as ADHD, disruptive behavior disorders, and PTSD 1
- Manic grandiosity and irritability present as marked changes in the individual's mental and emotional state, rather than reactions to situations or temperamental traits 1
- The diagnostic validity of bipolar disorder in very young children (preschoolers) has not been established, requiring caution in diagnosis 1
Comorbidities and Associated Problems
- Thorough evaluation for other associated problems is essential, including:
Diagnostic Challenges
- Bipolar II disorder is particularly difficult to diagnose accurately due to challenges in differentiating it from recurrent unipolar depression 2
- Cross-cultural issues may influence the expression or interpretation of symptoms and treatment response 1
- Using a longitudinal perspective (life chart) to characterize the course of illness helps with diagnostic accuracy 1
- Misdiagnosis is common and can lead to missed early intervention and increased risk of iatrogenic harm 3
Practical Diagnostic Approach
- Organize clinical information using a life chart to characterize course of illness, patterns of episodes, severity, and treatment response 1
- Consider bipolar disorder in any patient presenting with depression 5
- For children with manic-like symptoms, examine for environmental triggers, patterns of events that reinforce outbursts, language impairment, and risk factors (e.g., history of maltreatment) 1
- Pay special attention to hallmark manic symptoms that must be differentiated from normal childhood phenomena: grandiosity, psychomotor agitation, and reckless behavior 1