Diagnosis by the DSM
The Bipolar Disorder Classification as Defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
Meeting criteria for any diagnosis in the DSM is based upon the presence of certain symptoms over a specified period of time. In its description of bipolar disorder, the DSM first explains what is required for the different behavioral mood episodes: Major Depressive Episode, Manic Episode, Mixed Episode and Hypomanic Episode. It then differentiates the diagnosis according to the presence, sequence and history of those episodes.
Of note: Since 2001, there has been much discussion as to whether a sub-threshold presentation of bipolar disorder may be a developmental version of the condition or a different disorder entirely. The decisions of the DSM5 committees responsible for this update have concluded that a large percentage of the sub-threshold cases are a different disorder. The new classification is called Disruptive Mood Dysregulation Disorder (DMDD). Research that defined DMDD purports that those children whose manic symptoms appear only as severe and chronic (rather than episodic) irritability are not bipolar.
The inclusion of DMDD into DSM5 is seen as a corrective classification for children who might have otherwise received a BP-NOS diagnosis. Other children, whose manic behavior is not uniquely irritable (would include grandiose/elated behavior) but nevertheless does not meet the criteria for full episodes or those who are uniquely irritable but on an episodic basis, would continue to receive a diagnosis of BP-NOS. No further specificity of the BP-NOS classification has been proposed for DSM 5.
What follows below is from the DSM, 4th Edition, Text-Revision. It is the current criteria for Bipolar Disorder I, II and NOS. When the 5th edition is released we will update this section. There will be quite a few changes which will reflect the inclusion of DMDD to the manual.
DSM Bipolar I and Bipolar II
The Behavioral Episodes:
A Major Depressive Episode includes at least 5 of the following symptoms occurring over the same 2-week period and must include either #1 or #2. :
- Depressed mood most of the day, nearly every day, as reported by self (i.e. I feel sad or empty) or others (i.e. he appears tearful) Note: in children and adolescents, can be irritable mood.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
- Significant weight loss or gain, or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains.
- Insomnia or hypersomnia nearly every day (difficulty or delay in falling asleep or excessive sleep).
- Psychomotor agitation (such as pacing, inability to sit still, pulling on skin or clothing) or retardation (such as slowed thinking, speech or body movement) nearly every day that can be observed by others.
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive, inappropriate, or delusional guilt nearly every day.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
A Manic Episode includes a period of at least one week during which the person is in an abnormally and persistently elevated or irritable mood. While an indiscriminately euphoric mood is the classical expectation, the person may instead be predominately irritable. He or she may also alternate back and forth between the two. This period of mania must be marked by three of the following symptoms to a significant degree. If the person is only irritable, they must experience four of the following symptoms:
- Inflated self-esteem or grandiosity (ranges from uncritical self-confidence to a delusional sense of expertise).
- Decreased need for sleep.
- Intensified speech (possible characteristics: loud, rapid and difficult to interrupt, a focus on sounds, theatrics and self-amusement, non-stop talking regardless of other person’s participation/interest, angry tirades).
- Rapid jumping around of ideas or feels like thoughts are racing.
- Distractibility (attention easily pulled away by irrelevant/unimportant things).
- Increase in goal-directed activity (i.e. excessively plans and/or pursues a goal; either social, work/school or sexual) or psychomotor agitation (such as pacing, inability to sit still, pulling on skin or clothing).
- Excessive involvement in pleasurable activities that have a high risk consequence.
A Hypomanic Episode is very similar to a manic one, but less intense. It is only required to persist for 4 days and it should be observable by others that the person is noticeably different from his or her regular, non-depressed mood and that the change has an impact on his or her functioning.
A Mixed Episode would fulfill the symptom requirements for both a Major Depressive Episode and a Manic Episode nearly every day but the mixed symptoms only need to last for a 1-week period.
For all four of these episodes, the symptoms must have an impact on the person’s ability to function and can’t derive from some other circumstance or illness that would logically, or better, account for its expression.
Differentiation of the Diagnoses
The main difference between Bipolar I (BP I) and Bipolar II (BP II) is the presence of mania (7 days) v. hypomania (4 days). Once a person experiences a full manic episode, they will receive a BP I diagnosis.
Bipolar I Disorder
As stated just above, the cardinal criteria for a BP I diagnosis is the presence of mania. BP I then gets broken down into six different sub-diagnoses defined by which type of episode the patient is currently in or has most recently experienced and which types of episodes (if any) they have experienced in the past. Two of the six diagnoses do not require the experience of any Major Depressive Episodes.
Bipolar II Disorder
For a BP II diagnosis, (based on the presence of hypomania, or manic behvaior of 4 days or less) the person must have experienced at least one Major Depressive Episode and at least one Hypomanic Episode.
DSM Bipolar NOS: A Classification for Sub-threshold Symptoms
The BP-NOS sub-classification includes disorders with bipolar features that do not meet criteria for any specific Bipolar Disorder. Examples include:
- Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for Manic, Hypomanic or Major Depressive Episodes
- Recurrent Hypomanic Episodes without intercurrent depressive symptoms
- A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified
- Hypomanic Episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of Cyclothymic Disorder [see below]
- Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a general medical condition or substance induced