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Unspecified Bipolar: Thermoregulatory Sleep Dysregulation Disorder

AKA “Fear of Harm”

Criteria A–F are required for diagnosis and must be present most days for at least 6 months, without any symptom free periods that exceed 2 months in duration and cause functional impairment in one or more settings (e.g., significant behavioral problems at home but not necessarily in the school setting).

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A: Mood Disorder

Typically characterized by episodic and abrupt transitions in mood state accompanied by rapid alternations in levels of arousal, emotional excitability, sensory sensitivity, and motor activity.

1. Meets DSM-5 criteria for any form of bipolar disorder (bipolar I, bipolar II, mixed episodes, major depression with short duration mania, major depression with insufficient criteria hypomania, hypomania without major depression, cyclothymia). Manic, hypomanic and mixed episodes are defined by DSM-5 symptom criteria but not by DSM-5 duration criteria.

B: Fear of Harm

Fear that physical harm will come to self or others; easily misperceives and experiences neutral stimuli such as tone of voice or facial expression as threatening; obsessive bedtime rituals; fear of the dark; fear of intruders; separation anxiety; contamination fears; hyper-vigilance.

Three (or more) of the following are required: 

1. Obsessive fears that something awful may happen to self or significant others; 

2. Obsessive fears that they will harm themselves or others;

3. Reacts with excessive anxiety and fearfulness in novel situations or with strangers;

4. Reacts with excessive anxiety in situations involving separation;

5. Is self-conscious and feels easily humiliated in social situations; 

6. Easily misjudges other people as threatening, intimidating or critical.

C: Thermoregulatory Disturbance

Experiences thermal discomfort such as feeling hot, or excessively sweating in neutral ambient temperature environments, as well as little or no discomfort during exposure to moderate or extreme cold, and alternates noticeably between being excessively hot in the evening and cold in the morning.

Two (or more) of the following are required:

1. Feels excessively warm/hot at bedtime or overheats during the night;

2. Feels cold in the morning having felt hot at bedtime;

3. Feels excessively warm during day in neutral temperatures;

4. Has moderate to extreme cold tolerance (able to go out into the cold without a jacket);

5. Overheats or sweats profusely with exertion.

D: Sleep/Wake Disturbances

Most specifically characterized by highly disturbing nightmares or night terrors resulting in fear of going to sleep and auto-traumatization.

Two (or more) of the following are required: 

1. Frequent night-terrors or nightmares – often containing images of gore and mutilation; 

2. Fear of going to sleep because of disturbing dreams; 

3. Hypnogogic hallucinations; 

4. Excessively restless sleep.

E: Aggression 

Territorial and reactive aggression in response to limit setting and perceived threat or loss including aggressive fight-based speech or actions or self-directed aggression such as head banging, cutting or scratching self, suicidal thoughts or actions. 

Two (or more) of the following are required: 

1. Excessively aggressive or controlling speech (critical, sarcastic, demanding, “bossy”); 

2. Excessive anger and oppositional/aggressive responses to situations that elicit frustration; 

3. Self-directed aggression (head-banging, skin-picking, cutting, suicidal ideations or actions); 

4. Temper tantrums; 

5. Often threatens or breaks objects, slams doors, smashes walls.

F: Symptoms Are Not Due to a General Medical Condition 

(e.g. hypothyroidism) Criteria may overlap with symptomatology from other DSM classifications.

G: A family history of recurrent mood disorder

And/or alcoholism, as well as other bipolar spectrum disorders, lends further support to the diagnosis.