What are the changes in the diagnosis of Bipolar I disorder across Diagnostic and Statistical Manual of Mental Disorders (DSM) (Diagnostic and Statistical Manual of Mental Disorders) versions 3, 4, 5, and 5-Text Revision (TR), and International Classification of Diseases (ICD) (International Classification of Diseases) versions 10 and 11?

Evolution of Bipolar I Disorder Diagnostic Criteria Across DSM and ICD Versions

Major Requirement Change: Activity/Energy Criterion

Both DSM-5 and ICD-11 now require increased activity or energy as a mandatory criterion (Criterion A) for diagnosing manic and hypomanic episodes, in addition to elevated or irritable mood—this represents the most significant diagnostic change affecting Bipolar I disorder. 1, 2, 3

• This restriction means some patients previously diagnosed with DSM-IV Bipolar I or II disorder would now be reclassified to subdiagnostic bipolar syndromes if they lack the activity/energy component 1
• The change aims to reduce false positive diagnoses by requiring both mood elevation AND observable behavioral activation 2, 3

DSM Evolution (DSM-3 through DSM-5-TR)

DSM-IV to DSM-5 Changes

Threshold modifications:

• DSM-5 eliminated the mixed episode as a separate diagnostic entity, replacing it with a "with mixed features" specifier applicable to manic, hypomanic, or depressive episodes 4, 3
• The mixed features specifier is not separately codable, reducing its clinical visibility 3
• DSM-5 requires at least three contrapolar manic symptoms (elevated mood, grandiosity, increased risky behavior) for major depression with mixed features 3

Antidepressant-induced mania:

• DSM-5 now accepts manic or hypomanic episodes arising during antidepressant treatment as qualifying for bipolar disorder diagnosis, provided symptoms persist beyond the physiological effects of the medication 1, 3
• This was not accepted in DSM-IV 3

Dimensional assessment:

• DSM-5 introduced severity specifiers and dimensional parameters to assess symptoms, moving beyond purely categorical diagnosis 4, 1
• New subthreshold categories were operationally defined to reduce the overuse of "NOS" (not otherwise specified) diagnoses 1

Bereavement exclusion:

• DSM-5 eliminated the special status of bereavement as an exclusion criterion for major depressive episodes, a change not followed by ICD-11 3

DSM-5 to DSM-5-TR

• The evidence provided does not detail specific changes between DSM-5 and DSM-5-TR for Bipolar I disorder

ICD Evolution (ICD-10 to ICD-11)

Major Structural Changes

Bipolar II disorder recognition:

• ICD-11 introduced Bipolar II disorder as an independent diagnostic category, whereas ICD-10 only mentioned it as an example under "other bipolar affective disorders" 4, 3

Mixed episodes retained:

• Unlike DSM-5, ICD-11 maintained mixed episode as a separate diagnostic entity 4, 2, 3
• ICD-11 defines mixed episodes by prominent manic and depressive symptoms occurring simultaneously or alternating rapidly (day-to-day or within the same day) for at least two weeks 3
• When depressive symptoms predominate, contrapolar symptoms include irritability, racing thoughts, increased talkativeness, and increased activity 3
• When manic symptoms predominate, contrapolar symptoms include dysphoric mood, worthlessness, hopelessness, and suicidal ideation 3

Depressive episode threshold:

• ICD-11 increased the threshold for depressive episodes to match DSM-5: now requires at least five symptoms out of ten (ICD-10 required only four out of ten) 3
• ICD-11 added "hopelessness" as a tenth symptom, which research shows outperforms more than half of DSM symptoms in differentiating depressed from non-depressed individuals 3
• At least one symptom must be depressed mood or diminished interest/pleasure 3

Bereavement consideration:

• ICD-11 maintains that depressive episodes should not be diagnosed if symptoms are consistent with normative grief responses within the individual's cultural/religious context 3
• The diagnostic threshold is raised (not eliminated) during bereavement, requiring symptom persistence for at least one month plus at least one atypical grief symptom (extreme worthlessness, psychotic symptoms, suicidal ideation, or psychomotor retardation) 3
• Research evidence supports this approach, showing bereavement-related depression has significantly lower recurrence risk than non-bereavement depression 3

Qualifiers/specifiers:

• ICD-11 introduced "qualifiers" (equivalent to DSM-5 "specifiers") for the first time, based on symptomatology and course aspects 3

Dimensional assessment:

• ICD-11 incorporated dimensional parameters to assess symptoms alongside categorical diagnosis 4
• The classification underwent the largest participatory revision in history with field studies demonstrating higher reliability and clinical utility compared to ICD-10 5

Key Convergences Between DSM-5 and ICD-11

Harmonization efforts:

• The American Psychiatric Association and World Health Organization collaborated extensively to align DSM-5 and ICD-11, creating the same organizational "metastructure" 6, 3
• Both require increased activity/energy plus mood elevation for hypo/mania diagnosis 4, 1, 2, 3
• Both accept antidepressant-induced mania as qualifying for bipolar diagnosis 1, 3
• Both use five-symptom threshold for depressive episodes 3
• Both introduced dimensional assessment approaches 4

Key Divergences Between DSM-5 and ICD-11

Mixed states conceptualization:

• ICD-11 retained mixed episode as a separate category based on classic and recent research evidence, while DSM-5 eliminated it 4, 2, 3
• The ICD-11 approach appears more inclusive and consistent with clinical experience 2, 3

Bereavement handling:

• ICD-11 maintains raised (not eliminated) diagnostic threshold during bereavement, supported by longitudinal research showing lower recurrence rates 3
• DSM-5 removed bereavement's special status entirely 3

Dysthymia:

• ICD-11 kept dysthymic disorder as a separate entity, while DSM-5 combined it with chronic major depression into "persistent depressive disorder" 3

Clinical Implications and Limitations

Diagnostic restrictiveness:

• The mandatory activity/energy criterion may result in underdiagnosis of some bipolar cases that would have been captured under DSM-IV criteria 1
• Whether current criteria achieve optimal balance between sensitivity and specificity remains unclear 2

Reliability concerns:

• Initial field studies show promising reliability and clinical utility for ICD-11 bipolar disorder diagnosis 2
• However, field study participants may have selection bias (practitioners favorable to ICD-11 more likely to participate) and vignette-based studies may not reflect real-world complexity 5

Categorical limitations:

• Both DSM-5-TR and ICD-11 remain primarily categorical systems based on observable symptoms rather than neurobiological dimensions 5
• Neither adequately addresses biological heterogeneity within diagnostic categories 5
• The restrictive categorical approach of both DSM-IV and ICD-10 contributed to historical underdiagnosis and misdiagnosis of bipolar disorder 7

Implementation challenges:

• Further ecological field studies are needed to evaluate how ICD-11 performs under regular clinical conditions 5
• The focus must shift to implementation, dissemination, and training in the new diagnostic guidelines 2