DSM-5 Diagnostic Criteria for Bipolar I Disorder
Bipolar I disorder is diagnosed based on the occurrence of at least one lifetime manic episode, which requires abnormally elevated or irritable mood PLUS increased activity/energy lasting at least 7 days (or any duration if hospitalization is required), accompanied by at least 3 additional manic symptoms (or 4 if mood is only irritable). 1, 2
Core Diagnostic Requirements
Entry Criterion A: Mood and Energy Changes
- Both abnormally elevated or irritable mood AND increased energy/activity are required as the entry criterion 2
- This dual requirement represents a critical change from DSM-IV, where mood changes alone were sufficient 2
- The mood disturbance must be abnormal for the individual and observable by others 3
Duration Requirement
- Symptoms must persist for at least 7 days (or any duration if hospitalization is required) 3, 4
- This duration criterion must be strictly followed in children and adolescents, not shortened 3
Associated Symptoms (Need 3, or 4 if mood is only irritable)
- Decreased need for sleep 4
- Increased talkativeness or pressured speech 4
- Racing thoughts or flight of ideas 4
- Distractibility 4
- Increased goal-directed activity 4
- Excessive involvement in pleasurable activities with high potential for negative consequences 4
- Inflated self-esteem or grandiosity 4
Critical Diagnostic Features
Functional Impairment
- The episode must cause marked impairment in functioning or require hospitalization 3, 4
- Symptoms should be evident and impairing across different realms of the person's life, not isolated to one setting 3
Distinguishing from Baseline
- The manic episode represents a marked departure from baseline functioning 3
- Manic grandiosity and irritability present as marked changes in mental/emotional state, rather than reactions to situations, temperamental traits, or anger outbursts 3
Pattern Recognition
- The pattern of illness, duration of symptoms, and association with psychomotor, sleep, and cognitive changes are important diagnostic clues 3
- Using a life chart to characterize the course of illness, patterns of episodes, severity, and treatment response improves diagnostic accuracy 3
Substance-Induced Mania Considerations
Antidepressant-induced manic or hypomanic episodes can count toward a bipolar I diagnosis under certain conditions in DSM-5 1, 2
- This represents a significant change from previous editions 2
- History of mania or hypomania after antidepressant treatment is a specific risk factor for bipolar disorder 1
Common Diagnostic Pitfalls
Symptom Specificity Issues
- Irritability, reckless behaviors, or increased energy occur in multiple conditions and lack specificity 3
- Manic-like symptoms of irritability and emotional reactivity may be found in disruptive behavior disorders, PTSD, and pervasive developmental disorders 3
Context-Dependent Assessment
- Emotional and behavioral difficulties in children are often context-dependent and must be assessed in perspective given family, school, peer, and psychosocial factors 3
- Avoid using simple checklists to identify psychopathology without considering longitudinal patterns 3
Acute Psychosis Presentation
- Acute psychosis in an adolescent may be the first presentation of mania 3
- Assess carefully for associated features including marked decrease in sleep need, affective lability, lack of negative symptoms, and positive family history 3
Assessment Approach
Longitudinal Perspective Required
- Incorporate both current and past history regarding symptomatic presentation, treatment response, psychosocial stressors, and family psychiatric history 3
- Organize clinical information using a life chart to characterize course of illness 3
- Conduct direct patient and family interviews specifically assessing symptom onset, duration, and functional impairment patterns 5