DSM Guidelines for Bipolar Disorder Diagnosis and Treatment
Diagnostic Criteria
The DSM-IV-TR criteria must be strictly followed when diagnosing bipolar disorder, requiring distinct episodes of abnormally elevated, expansive, or irritable mood with increased energy lasting at least 7 days for mania (or any duration if hospitalization required) or at least 4 days for hypomania. 1
Core Manic Episode Features
A manic episode requires a distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased activity or energy, plus at least three of the following symptoms (four if mood is only irritable): 2
- Inflated self-esteem or grandiosity 2
- Decreased need for sleep (feels rested despite sleeping only 2-4 hours) 1, 2
- More talkative than usual or pressure to keep talking 2
- Racing thoughts or flight of ideas 1, 2
- Distractibility 2
- Increase in goal-directed activity or psychomotor agitation 2
- Excessive involvement in pleasurable activities with high potential for painful consequences 2
The episode must represent a marked departure from baseline functioning and cause significant impairment in social or occupational functioning, or require hospitalization. 1, 2
Hypomanic Episode Features
Hypomania shares the same symptom criteria as mania but differs in severity and duration: 3, 4
- Duration of at least 4 days (versus 7 days for mania) 1
- Observable change in functioning but NOT severe enough to cause marked impairment 4
- Does not require hospitalization 4
- No psychotic features 4
- Often increases functioning (key distinguishing feature from mania) 3, 4
Bipolar Disorder Subtypes
Bipolar I Disorder: Requires at least one manic episode (may also have depressive episodes) 3
Bipolar II Disorder: Requires at least one major depressive episode AND at least one hypomanic episode, with no history of full manic episodes 3, 4
Essential Diagnostic Assessment Components
Psychiatric History
Document past and current psychiatric diagnoses, including any prior misdiagnoses (particularly unipolar depression), history of psychiatric hospitalizations, and response to past treatments—especially noting any antidepressant-induced mood elevation or agitation, as this strongly suggests underlying bipolar disorder. 1
Approximately 20% of youths with major depression eventually develop manic episodes. 1, 3
Critical Screening Questions
Focus on distinct, spontaneous periods of mood changes with: 1
- Decreased need for sleep with psychomotor activation (not just insomnia) 1
- Spontaneous periods of abnormally elevated, expansive, or euphoric mood clearly different from baseline 1
- Periods of markedly increased goal-directed activity or physical restlessness 1
Longitudinal Assessment
Use a life chart to map the longitudinal course of symptoms, documenting when specific symptom clusters began, their duration, periods of remission, and treatment responses. 1
This helps distinguish episodic bipolar disorder from chronic conditions like ADHD or disruptive behavior disorders. 1
Family Psychiatric History
First-degree relatives of individuals with bipolar disorder have a 4- to 6-fold increased risk of developing the condition. 1, 3
Family history of mood disorders significantly increases diagnostic likelihood. 1, 2
Substance Use Assessment
Obtain detailed substance use history and toxicology screening to rule out substance-induced mood disorder, as manic episodes precipitated by antidepressants or substances are characterized as substance-induced per DSM criteria. 1, 3
Medical Evaluation
Complete a thorough medical workup including thyroid function tests, complete blood count, and comprehensive metabolic panel to exclude organic causes of mood symptoms. 1, 3
Vital signs and neurologic examination are necessary to identify medical conditions causing or exacerbating symptoms. 1
Comorbidity Assessment
Assess for suicidality thoroughly, as bipolar disorder has high rates of suicide attempts and completed suicides. 1
Screen for commonly comorbid conditions: 1
- ADHD and disruptive behavior disorders (very high comorbidity in pediatric populations) 1
- Anxiety disorders 1, 3
- Substance use disorders (particularly high in adolescents) 1
- PTSD 1
- Developmental and cognitive/language impairments 1
Collateral Information
Obtain information from family members or other collateral sources whenever possible, as patients often lack insight during manic episodes, and family members can describe behavioral changes and episodic patterns more objectively. 1
Differential Diagnosis Considerations
Distinguishing from Other Conditions
Manic symptoms must be differentiated from: 1
- ADHD (chronic symptoms versus episodic mood changes) 1
- Disruptive behavior disorders (reactive anger versus spontaneous mood elevation) 1
- PTSD (trauma-reactive irritability versus spontaneous manic irritability) 1
- Borderline personality disorder (chronic emotional dysregulation versus episodic mood changes with decreased sleep need) 1
Key Distinguishing Features
Decreased need for sleep is a hallmark of manic episodes in bipolar disorder, whereas sleep problems in other conditions are typically related to emotional distress rather than reduced sleep need. 1
Manic grandiosity and irritability present as marked changes in the individual's mental and emotional state, rather than reactions to situations or temperamental traits. 1
Mixed Features
Depressive symptoms with concurrent subsyndromal hypomanic symptoms (racing thoughts, increased energy, irritability) are common and should raise suspicion for bipolarity. 3, 5
Mixed presentations carry increased suicide risk and require careful treatment planning. 2, 6
Special Populations
Children and Adolescents
The DSM-IV-TR criteria, including duration criteria, must be followed when diagnosing mania or hypomania in both adults and children/adolescents. 1
Pediatric presentations differ from classic adult descriptions: 1
- Irritability, belligerence, and mixed features are more common than euphoria 1
- Changes in mood, energy, and behavior are often more labile and erratic rather than persistent 1
- Psychotic symptoms are frequently present in adolescent mania 1
The diagnostic validity of bipolar disorder in very young children (under age 6) has not been established, requiring extreme caution. 1
Consider alternative explanations first: developmental disorders, psychosocial stressors, parent-child relationship conflicts, and temperamental difficulties. 1
Treatment Guidelines
Acute Mania Treatment
For mania in well-defined DSM-IV-TR Bipolar I Disorder, pharmacotherapy is the primary treatment. 7
First-line medications (FDA-approved for acute mania in adults): 7
- Lithium (approved down to age 12 for acute mania and maintenance) 7
- Valproate/divalproex sodium 7, 6
- Atypical antipsychotics: aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone 7, 8
For severe mixed mania, combination therapy is usually required: valproate or lithium plus an atypical antipsychotic. 6
Hypomania Treatment
Hypomania should be treated even if associated with overfunctioning, because depression often soon follows hypomania. 4
Mood-stabilizing agents and second-generation antipsychotics are effective. 2
Bipolar Depression Treatment
For Bipolar II depression, quetiapine or lamotrigine are first-line treatments. 3
Antidepressant monotherapy is contraindicated in bipolar depression. 3
If antidepressants are necessary for severe depression, they must be combined with a mood stabilizer. 3
The combination of olanzapine and fluoxetine is FDA-approved for bipolar depression in adults. 7
Maintenance Treatment
Lithium has strong long-term evidence and is FDA-approved for bipolar disorder maintenance, reducing frequency and intensity of episodes. 7, 3
Lamotrigine is FDA-approved for maintenance therapy in adults. 7
Treatment Selection Factors
Base medication choice on: 7
- Evidence of efficacy 7
- Phase of illness (acute mania, depression, or maintenance) 7
- Presence of confounding presentations (rapid cycling, psychotic symptoms, mixed features) 7
- Agent's side effect spectrum and safety 7
- Patient's history of medication response 7
- Family history of treatment response (may predict response in offspring) 7
Adjunctive Treatments
Psychoeducation about symptoms, course, treatment options, impact on functioning, and heritability is necessary. 3
Family-focused therapy and interpersonal/social rhythm therapy have demonstrated benefit. 3
Critical Pitfalls to Avoid
Do not confuse behavioral activation from SSRIs with hypomania: activation typically occurs in the first month and improves quickly with dose reduction, while hypomania may appear later and persists despite medication changes. 2
Do not overlook the possibility of both bipolar disorder and comorbid conditions being present simultaneously. 1
Do not apply adult diagnostic criteria to children without considering developmental context. 2
Do not diagnose bipolar disorder in preschoolers without extreme caution and consideration of alternative explanations. 7, 1
Avoid unnecessary polypharmacy, though multiple agents are often required. 7