What are the DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria for diagnosing bipolar disorder?

DSM Criteria for Diagnosing Bipolar Disorder

According to the DSM, bipolar disorder is diagnosed based on the presence of manic, hypomanic, or mixed episodes, with specific duration and symptom requirements for each subtype.

Bipolar I Disorder

• Requires at least one manic or mixed episode lasting at least 7 days (unless hospitalization is required) 1
• Episodes must represent a significant departure from the individual's baseline functioning 1
• Episodes of depression are not required for diagnosis, though most patients experience major or minor depressive episodes during their lifetime 1

Bipolar II Disorder

• Requires periods of major depression and hypomania (episodes lasting at least 4 days) 1
• No history of full manic or mixed manic episodes 1
• Hypomania is similar to mania but less severe and doesn't cause marked impairment 2

Mixed Episode

• A period lasting 7 days or more in which symptoms for both manic and depressive episodes are met simultaneously 1
• Involves both elevated mood/increased energy and depressive symptoms occurring together 2

Bipolar Disorder Not Otherwise Specified (NOS)

• Used for cases that do not meet full criteria for other bipolar diagnoses 1
• Often used to describe presentations that don't match classic adult presentation, particularly in youth 1

Rapid Cycling Specifier

• Defined as the occurrence of at least four mood episodes in a 1-year period 1, 2
• Each episode must still meet the prerequisite duration criteria (e.g., 7 days for a manic episode) 1
• This differs from some research definitions used in studies of youth 1

Key Diagnostic Features of Episodes

Manic Episode

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood 1, 2
• Increased energy or activity 2
• Decreased need for sleep without feeling tired 2
• Racing thoughts, pressured speech, grandiosity 2
• Increased goal-directed activity or psychomotor agitation 2
• Excessive involvement in pleasurable activities with high potential for painful consequences 1
• Duration of at least 7 days (unless hospitalization is required) 1

Hypomanic Episode

• Similar symptoms to mania but less severe 2
• Duration of at least 4 days 1
• Does not cause marked impairment in social or occupational functioning 2
• Does not require hospitalization 1
• No psychotic features 2

Depressive Episode

• Similar to major depressive disorder with depressed mood, loss of interest/pleasure 2
• Often presents with psychomotor retardation and hypersomnia in bipolar disorder 2
• May include irritability and anger, especially in youth 1

Diagnostic Challenges and Considerations

• Bipolar disorder in children and adolescents may present differently than in adults, with more irritability, mixed states, and rapid cycling 1
• Diagnostic confusion can occur between bipolar disorder and other conditions, particularly in adolescents with psychosis who may be misdiagnosed with schizophrenia 1
• Changes in mood, energy, and behavior in juvenile bipolar disorder are often more labile and erratic rather than persistent 1
• High rates of comorbidity, especially with ADHD and disruptive behavior disorders in youth, can complicate diagnosis 1

Clinical Pitfalls to Avoid

• Overlooking mixed states can lead to misdiagnosis, as a depressed patient who is also not sleeping may be experiencing a mixed episode rather than pure depression 2
• Failing to recognize hypomanic episodes can result in misdiagnosis of bipolar II as recurrent major depression 3
• Focusing only on mood symptoms without considering changes in energy, activity, and sleep patterns 2
• Relying solely on cross-sectional assessment rather than longitudinal history 1