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

DSM Criteria for Bipolar Disorder

Bipolar disorder is diagnosed based on the presence of distinct manic, hypomanic, or mixed episodes that represent a significant departure from baseline functioning, with specific duration and symptom requirements that differ between Bipolar I and Bipolar II subtypes. 1

Core Diagnostic Requirements

Bipolar I Disorder

• Requires at least one manic episode lasting ≥7 days (or any duration if hospitalization is required), with no requirement for depressive episodes to establish the diagnosis 1
• A manic episode consists of abnormally and persistently elevated, expansive, or irritable mood PLUS abnormally increased activity or energy as coprimary criteria 1, 2
• Must include ≥3 additional symptoms (or ≥4 if mood is only irritable): decreased need for sleep, pressured speech, racing thoughts, grandiosity, psychomotor agitation, distractibility, and excessive involvement in pleasurable activities with high potential for painful consequences 1
• The episode must cause marked impairment in functioning or require hospitalization 1

Bipolar II Disorder

• Requires both major depressive episodes AND hypomanic episodes lasting ≥4 days, with no history of full manic or mixed episodes 1
• Hypomanic episodes have similar symptoms to mania but are less severe, do not cause marked impairment, and do not require hospitalization 1
• The presence of even one full manic episode changes the diagnosis to Bipolar I 1

Mixed Episodes

• A period lasting ≥7 days where symptoms for both manic and depressive episodes are met simultaneously, involving both elevated mood/increased energy and depressive symptoms occurring together 1
• This represents concurrent symptoms, not sequential episodes separated by wellness 3

Critical Diagnostic Features

Hallmark Symptoms to Assess

• Decreased need for sleep without feeling tired is a hallmark sign that distinguishes mania from other conditions 3
• Euphoria or grandiosity strongly suggests bipolar disorder when present, particularly in distinguishing from other causes of irritability 3
• The mood disturbance must represent a significant departure from baseline functioning that is evident and impairing across different realms of life, not isolated to one setting 3

Episode Duration Requirements

• Manic episodes: ≥7 days (unless hospitalization required) 1
• Hypomanic episodes: ≥4 days 1
• Mixed episodes: ≥7 days 1
• Note: Research suggests these duration criteria may be overly restrictive, as brief episodes of 1-3 days show comparable clinical validity 4

Rapid Cycling Specifier

• Four or more distinct mood episodes (manic, hypomanic, mixed, or depressive) occurring within 12 months 5
• Each episode must still meet full duration criteria 5
• This is a course specifier, not a separate diagnosis 5
• Ultrarapid cycling (5-364 cycles/year) and ultradian cycling (>365 cycles/year) represent more frequent patterns 5

Key Diagnostic Challenges and Pitfalls

Distinguishing from Other Conditions

• Irritable mood alone requires ≥4 symptoms (versus ≥3 for elevated/expansive mood) to meet diagnostic threshold 4
• Chronic baseline irritability and emotional dysregulation without distinct episodes departing from baseline do not constitute hypomania 1
• Brief mood swings lasting minutes to hours do not meet criteria, as hypomania requires ≥4 days duration 1
• Mood changes that are purely reactive to stress or interpersonal conflict rather than spontaneous do not meet criteria 1

Common Misdiagnoses

• Bipolar disorder with psychotic features is frequently misdiagnosed as schizophrenia, particularly in adolescents—confirm the episodic nature with clear periods of normal functioning between episodes 1
• Bipolar depression is often misdiagnosed as unipolar depression, with significant diagnostic delays 1
• Patients with mood dysregulation are often misdiagnosed as bipolar when they may have borderline personality features 1

Substance-Induced Considerations

• Antidepressant-induced mania or hypomania should NOT be excluded from bipolar diagnosis under certain conditions, as this represents underlying bipolar vulnerability 4, 6
• Alcohol misuse and illicit drug use may simulate mood changes and complicate diagnosis 7

Essential Assessment Approach

Longitudinal Evaluation

• A life chart approach is essential to map mood patterns over time, documenting exact duration of activated states, sleep changes, and functional impairment across multiple settings 1
• Assess whether distinct periods represent a significant departure from baseline functioning 1
• Evaluate episode duration and cycling patterns 1
• Document temporal relationship between mood symptoms and any psychotic features 1

Key Clinical Questions

• Are there distinct periods of decreased need for sleep during elevated mood states? 1
• Do mood changes occur spontaneously or only in reaction to stressors? 1
• Is there impairment across multiple settings, not just one environment? 3
• Are there associated psychomotor, sleep, and cognitive changes accompanying the mood disturbance? 3

Additional Considerations

• Evaluate for psychotic features, which are common in adolescent presentations 1
• Assess family psychiatric history, particularly for bipolar disorder, as strong genetic loading increases likelihood 3
• Screen for suicidality, comorbid disorders (especially ADHD and substance abuse), and psychosocial stressors 1

Bipolar Disorder Not Otherwise Specified (NOS)

• Diagnosed for patients with bipolar features who do not meet full criteria for Bipolar I or II 1
• This includes presentations with insufficient symptom count, inadequate duration, or atypical patterns 1

Special Considerations in Youth

• Bipolar disorder in children and adolescents may present with more irritability, mixed states, and rapid cycling compared to adults 1
• Changes in mood, energy, and behavior are often more labile and erratic rather than persistent 1
• High rates of comorbidity with ADHD and disruptive behavior disorders complicate diagnosis 8
• The diagnostic validity of bipolar disorder in preschool children has not been established 1