Bipolar Disorder DSM-5 Definition

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and the American Psychological Association, bipolar spectrum disorders, formerly called manic-depressive illness, represents a group of disorders that cause extreme fluctuation in a person’s mood, energy, and ability to function, in which symptoms of mania and depression alternate.

Subtypes of Bipolar Disorder

There are three main subtypes of bipolar disorder, classified under the DSM-5 Chapter on Bipolar and Related Disorders:1

  • Bipolar 1 – The individual fluctuates between episodes of mania or hypomania and major depressive episodes, or experiences a mix of these; at least one manic episode (that lasts 1 week or leads to hospitalization) is required but a depressive episode is not required for diagnosis.
  • Bipolar 2 – The individual fluctuates between major depressive and hypomanic episodes; at least one depressive episode and one hypomanic episode (lasting 4 or more days) are required for diagnosis. Anxiety and substance use disorders are common comorbidities.
  • Cyclothymic disorder (or cyclothymia, often considered a mild bipolar disorder) – the individual experiences periods of hypomania and depressive symptoms that occur over at least 2 years. To rule out, the number, duration, and severity of symptoms must not meet the full criteria for a major depressive episode or a hypomanic episode (defined below).

Other specified or unspecified bipolar and related disorders may be considered when the patient does not meet diagnostic criteria for the above three subtypes but still experiences clinically significant and abnormal periods of mood elevation. See more detail on diagnostic criteria.

A noted specifier in the bipolar spectrum is substance/medication-induced bipolar disorder. This occurrence refers to an episode of mania, hypomania, or depression (described below) that may be caused by alcohol, phencyclidine, hallucinogens, or amphetamines. SAMHSA notes that there are nine potential substance-induced disorders.

Bipolar Episodes

Bipolar episodes, whether they occur alone or mixed, may be defined as follows:

  • mania (manic episode) – abnormally elevated mood and related symptoms, marked by severe impairment for at least 7 consecutive days; symptoms present most of the day may generally include a state of excitement, overactivity, and psychomotor agitation, often accompanied by over-optimism, grandiosity, or impaired judgment; a period of elevated, expansive, or irritable mood accompanied by various combinations of inflated self-esteem, a decreased need for sleep, increased speech, racing thoughts, distractibility, increased activity or psychomotor agitation, and increased involvement in risky activities (eg, buying sprees, sexual indiscretions).
  • hypomania (hypomanic episode) – abnormally elevated mood and related symptoms, present for at least 4 consecutive days; symptoms present most of the day may mirror those of a manic episode
  • mixed episode (mixed features)­ – episode of a mood disorder in which symptoms meeting criteria for both a major depressive episode and a manic episode are prominent
  • major depressive episode (a depressive episode with a history of mania/bipolar diagnosis, sometimes called bipolar depression) – a period in which an individual experiences anhedonia (the inability to experience pleasure) or is persistently sad, pessimistic, or otherwise overly negative. Symptoms may include poor or increased appetite with significant weight loss or gain; insomnia or excessive sleep; psychomotor agitation or psychomotor retardation; loss of energy with fatigue; feelings of worthlessness or inappropriate guilt; reduced ability to concentrate or make decisions; and recurrent thoughts of death, suicidal ideation, or suicidal behavior.

Of note, in the DSM-5, bereavement is no longer a qualified exclusion for a major depressive episode unless symptoms last longer than 2 months after the death.

Bipolar 1 Diagnostic Criteria

The diagnosis of bipolar 1 disorder requires the presence of a manic episode of at least 1 week’s duration or that leads to hospitalization or other significant impairment in occupational or social functioning. The episode of mania cannot be caused by another medical illness or by substance abuse. The manic episode may come before or after a hypomanic or major depressive episode.

Manic Episodes

Manic episodes are characterized by at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness. At least 3 of the following symptoms must also be present:

  • diminished need for sleep
  • grandiosity
  • pressured speech or excessive talking
  • racing thoughts/ideas
  • distractibility
  • increased level of goal-focused activities
  • excessive pleasurable activities, often with painful consequences.

The mood disturbance is sufficient to cause impairment at work or danger to the patient or others.

Hypomanic Episodes

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive days. At least 3 of the following symptoms are also present:

  • diminished need for sleep
  • grandiosity
  • pressured speech or excessive talking
  • racing thoughts/ideas
  • distractibility
  • increased level of goal-focused activities
  • excessive pleasurable activities, often with painful consequences

The mood disturbance is observable to others. The episode, however, is not severe enough to cause social or occupational impairment.

Major Depressive Episode

If present, a major depressive episode may be defined as a period in which an individual experiences anhedonia (the inability to experience pleasure) or is persistently sad, pessimistic, or otherwise overly negative.

Symptoms may include poor or increased appetite with significant weight loss or gain; insomnia or excessive sleep; psychomotor agitation or psychomotor retardation; loss of energy with fatigue; feelings of worthlessness or inappropriate guilt; reduced ability to concentrate or make decisions; and recurrent thoughts of death, suicidal ideation, or suicidal behavior.

In the DSM-5, bereavement is no longer a qualified exclusion for a major depressive episode, unless symptoms last longer than 2 months after the death.

Treating Bipolar Spectrum Disorders

Early assessment and treatment of bipolar spectrum disorders is crucial, especially considering that both medical and psychiatric comorbidities are common in this patient population. Further, the rate of suicide among individuals diagnosed with bipolar disorder is approximately 10 to 30 times higher than that of the general population.

See our bipolar 1 disorder treatment guidelines for mental health clinicians and new research on how brain patterns tied to reward anticipation may help clinicians differentiate bipolar disorder from schizophrenia.

References
Last Updated: Jun 3, 2021