What are the diagnostic criteria and treatment options for bipolar disorder?

Diagnostic Criteria for Bipolar Disorder

Bipolar disorder is diagnosed when a patient experiences at least one distinct manic episode (lasting ≥7 days or requiring hospitalization) characterized by abnormally elevated, expansive, or irritable mood PLUS abnormally increased activity or energy, with at least 3 additional symptoms (4 if mood is only irritable) including decreased need for sleep, grandiosity, racing thoughts, pressured speech, distractibility, increased goal-directed activity, or excessive involvement in risky activities. 1

Core Diagnostic Requirements

The diagnosis hinges on identifying distinct mood episodes that represent a clear departure from baseline functioning 2, 1:

Manic Episode Criteria (Bipolar I Disorder)

• Duration: At least 7 consecutive days (or any duration if hospitalization is required) 1
• Mood disturbance: Abnormally and persistently elevated, expansive, OR irritable mood 1
• Energy change: Abnormally and persistently increased activity or energy 1
• Functional impairment: Severe enough to cause marked impairment in social/occupational functioning or necessitate hospitalization 1
• Associated symptoms: At least 3 of the following must be present (4 if mood is only irritable): inflated self-esteem/grandiosity, decreased need for sleep, pressured speech, racing thoughts/flight of ideas, distractibility, increased goal-directed activity, excessive involvement in pleasurable activities with high potential for painful consequences 1

Hypomanic Episode Criteria (Bipolar II Disorder)

• Duration: At least 4 consecutive days 3
• Same mood and energy criteria as mania but less severe 3
• Observable change in functioning but not severe enough to cause marked impairment or require hospitalization 3

Depressive Episode Criteria

• Must meet standard DSM criteria for major depressive episode (≥2 weeks duration) 2
• In bipolar disorder, depression often presents with psychomotor retardation and hypersomnia (excessive sleep) 3
• May include mixed features (depressive symptoms with concurrent irritability, racing thoughts, or increased energy) 2

Critical Diagnostic Distinctions

Hallmark Features That Differentiate Bipolar Disorder

Decreased need for sleep is the single most important differentiating feature—the patient feels rested despite sleeping only 2-4 hours and can stay awake for days with little fatigue 2, 3. This differs fundamentally from insomnia (wanting to sleep but unable) seen in other conditions.

• Episodic pattern: Symptoms occur in distinct time periods with clear onset and offset, not chronic irritability 2
• Spontaneous mood changes: Episodes arise without environmental triggers, unlike reactive mood changes 2
• Grandiosity: Marked changes in self-perception beyond normal confidence, not situational reactions 2
• Psychomotor activation: Observable increase in goal-directed activity and physical restlessness 2

Differential Diagnosis Considerations

In children and adolescents, manic symptoms must be carefully differentiated from 2:

• ADHD (chronic symptoms vs. episodic mood changes)
• Disruptive behavior disorders (reactive anger vs. spontaneous mood elevation)
• PTSD (trauma-triggered irritability vs. spontaneous episodes)
• Borderline personality disorder (emotional dysregulation vs. distinct mood episodes with decreased sleep need)

Critical pitfall: Irritability alone is non-specific and occurs across multiple diagnoses—focus on the constellation of decreased sleep need, distinct episodes, and psychomotor activation 2.

Essential Diagnostic Assessment Components

History Taking

Document the following systematically 2:

• Longitudinal course: Use a life chart to map when symptom clusters began, their duration, and periods of remission
• Episode characteristics: Duration, severity, functional impairment during each episode
• Treatment response: Past psychiatric treatments, particularly noting any antidepressant-induced mood elevation or agitation (strongly suggests bipolar disorder) 2
• Substance use: Detailed history with toxicology screening to rule out substance-induced mood disorder 2
• Family psychiatric history: Particularly mood disorders and bipolar disorder 2
• Suicidality: Prior and current suicidal ideation, plans, attempts, and impulsivity (bipolar disorder has exceptionally high suicide rates) 2

Collateral Information

Obtain information from family members or other sources whenever possible, as patients often lack insight during manic episodes and family members can describe behavioral changes and episodic patterns more objectively 2.

Medical Evaluation

Complete thorough medical workup to exclude organic causes 2:

• Thyroid function tests
• Complete blood count
• Comprehensive metabolic panel
• Toxicology screening

Special Populations

Pediatric Considerations

• Bipolar disorder can be diagnosed in adolescents (ages 13-17) using the same DSM criteria as adults 2, 4
• Peak age of onset is 15-30 years, making mid-to-late adolescence a common presentation period 2, 5
• Exercise extreme caution in children under age 6—diagnostic validity has not been established in preschoolers 2
• In youth, mania frequently presents with psychotic symptoms, markedly labile moods, and mixed manic-depressive features 2
• Irritability, belligerence, and mixed features are more common than euphoria in pediatric presentations 2

Substance-Induced Considerations

• Manic episodes precipitated by antidepressants are classified as substance-induced per DSM criteria 2, 1
• Approximately 20% of youths with major depression eventually develop manic episodes, particularly after antidepressant exposure 2

Diagnostic Subtypes

• Bipolar I Disorder: At least one manic episode (may also have hypomanic or depressive episodes) 1, 5
• Bipolar II Disorder: At least one hypomanic episode AND at least one major depressive episode, but never a full manic episode 5, 6
• Rapid Cycling: Four or more mood episodes within one year, with each episode meeting duration criteria 3
• Mixed Episodes: Both manic and depressive symptoms occurring simultaneously for at least 7 days 3

Monitoring and Reassessment

• Schedule follow-up visits to observe symptom evolution over time 2
• Reassess diagnosis periodically, as the clinical picture may evolve 2
• Track mood patterns, sleep changes, and functional impairment prospectively using a life chart 2
• Monitor for comorbidities including anxiety disorders, substance use disorders, and developmental disorders 2

Treatment Implications

First-Line Pharmacotherapy

Mood stabilizers are the cornerstone of treatment and should be continued indefinitely due to high relapse risk 7, 5:

• Lithium: Most effective drug overall for bipolar disorder 8, 5
• Anticonvulsants: Valproate and lamotrigine 7, 5
• Atypical antipsychotics: Quetiapine, aripiprazole, asenapine, lurasidone, cariprazine 5

For acute mania in adults, olanzapine 5-20 mg/day has established efficacy, with response typically seen within 3-4 weeks 4. For adolescents with acute mania, olanzapine 2.5-20 mg/day (mean dose 8.9 mg/day) demonstrated efficacy in 3-week trials 4.

Critical Treatment Warnings

• Antidepressant monotherapy is contraindicated in bipolar I disorder, during manic episodes, and during episodes with mixed features 7
• More than 50% of patients with bipolar disorder are non-adherent to treatment 5
• Adjunctive psychotherapy (interpersonal social rhythm therapy, family-focused treatment, cognitive-behavioral therapy) is often necessary 9

Prognostic Considerations

• Early diagnosis and treatment are associated with more favorable prognosis 5
• Diagnosis is often delayed by a mean of 9 years following initial depressive episode 5
• Life expectancy is reduced by 12-14 years, with 1.6-2-fold increase in cardiovascular mortality 5
• Annual suicide rate is approximately 0.9% (compared to 0.014% in general population), with 15-20% of individuals with bipolar disorder dying by suicide 5
• Approximately 75% of symptomatic time consists of depressive episodes or symptoms 5