Bipolar I disorder diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Bipolar I disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well. It is a sub-diagnosis of bipolar disorder, and conforms to the classic concept of manic-depressive illness.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Manic Episode

“

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). AND B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). AND C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others,or there are psychotic features. AND D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

”

Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and,therefore, a bipolar I diagnosis .

Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder .

DSM-V Diagnostic Criteria for Hypomanic Episode

“

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. AND B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). AND C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. AND D. The disturbance in mood and the change in functioning are observable by others. AND E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. AND F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).

”

Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. Note: Criteria A-'F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

DSM-V Diagnostic Criteria for Major Depressive Disorder

“

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note:Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful).(Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain .) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. 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. AND B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. AND C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

”

DSM-IV Diagnostic Criteria for Bipolar I Disorder

According to the DSM-IV-TR, a diagnosis of Bipolar I disorder requires one or more manic or mixed episodes. The criteria for Bipolar I (Bipolar Type 1, BP 1, or BPD 1) are defined in the DSM-IV-TR. The current or previous course of the illness may include hypomanic and depressive episodes also, but the diagnosis of BP I requires only one manic or mixed episode. A depressive episode is not required for a diagnosis of BP I disorder, although the overwhelming majority of people with BP I suffer from them as well.

Bipolar II, the more common but by no means less severe type of the disorder, is characterized by episodes of hypomania and disabling depression. A diagnosis of bipolar II disorder requires at least one hypomanic episode. This is used mainly to differentiate it from unipolar depression. Although a patient may be depressed, it is very important to find out from the patient or patient's family or friends if hypomania has ever been present using careful questioning. This, again, avoids the antidepressant problem.

A diagnosis of cyclothymic disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low grade cycling of mood which appears to the observer as a personality trait, but does not interfere with functioning.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the conditions laid out above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).

The criteria for a "major depressive episode" directly below refers also to a bipolar depression. These criteria may apply to unipolar or bipolar depression.

Criteria for a Major Depressive Episode DSM-IV-TR

1. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2).
   1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
   2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
   3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
   4. Insomnia or Hypersomnia nearly every day
   5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
   6. fatigue or loss of energy nearly every day
   7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
   8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
   9. 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
2. The symptoms do not meet criteria for a Mixed Episode.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for a hypomanic episode DSM-IV-TR

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity
   2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
   3. more talkative than usual or pressure to keep talking
   4. flight of ideas or subjective experience that thoughts are racing
   5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for a mixed episode DSM-IV-TR

1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
2. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
3. The symptoms are not due to the direct physiological effects of a substance (e.g., an illicit drug, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for a manic episode DSM-IV-TR

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity, potentially including grandiose delusions
   2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep) or persistent difficulty falling asleep
   3. more talkative than usual or pressure to keep talking
   4. flight of ideas or subjective experience that thoughts are racing
   5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The symptoms do not meet criteria for a Mixed Episode.
4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

This last point has been under scrutiny for some time. One of the leaders in mood disorders research, Hagop Akiskal, M.D., believes that medications (particularly antidepressants) that induce hypomania, mania or mixed states "unmask" bipolar disorder.