How To Diagnose Bipolar Disorder: DSM-5 Criteria

Updated November 26, 2022 by BetterHelp Editorial Team

When Diagnosed Properly, Bipolar Disorder Is Treatable

Bipolar disorder affects millions of people around the world, and its extreme ups and downs can make living life challenging at times. This article will discuss the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) bipolar disorder criteria, which is the most up-to-date information on how the condition is diagnosed. Additionally, you will learn how a diagnosis can influence a course of treatment and what methods are effective.

What Is Bipolar Disorder?

Bipolar disorder is characterized by shifts in mood, and those who have it may experience high energy, euphoria, and hyperactivity. This is known as mania, and it can also include irritability. Manic episodes are also associated with risk-taking behaviors and increased impulsivity.

On the other end of the spectrum, people with bipolar disorder can have very low moods.  This is the depressive side of the condition. Just like with major depression, those with bipolar disorder who are having a depressive episode can feel down on themselves, have low energy and motivation, and think about death and suicide.

If you think you may hurt yourself or attempt suicide, reach out to 911 or call a suicide hotline. In the U.S., you can dial 1-800-273-TALK (1-800-273-8255) to reach the National Suicide Prevention Lifeline. Or, use the webchat at suicidepreventionlifeline.org/chat.

Nonetheless, these mood swings are not typically short and temporary. Instead, they must last at least a week for mania and two weeks for depression for the person to be diagnosed with bipolar I disorder. This is not only important for diagnosing bipolar disorder, in general, but it can also determine what type a person has.

  • Bipolar I Disorder: This type consists of manic episodes that last for a minimum of seven days and occur for most of the day, or when the symptoms require hospital care due to their severity. People with bipolar I will experience depressive episodes lasting two weeks or longer followed by periods of normal mood.

  • Bipolar II Disorder: This type is characterized by depressive and hypomanic episodes. The symptoms of mania are not as severe or long-lasting as with bipolar I.

  • Cyclothymic Disorder: Hypomanic and depressive symptoms are persistent but not intense enough or do not last long enough to qualify as hypomanic or depressive episodes. These symptoms can last for at least two years in adults, and for one year in kids and adolescents.

  • Other Specified and Unspecified Bipolar and Related Disorders: This category includes bipolar disorder symptoms that do not match any of the types previously mentioned.

The DSM bipolar section goes into greater detail as to what constitutes a manic, hypomanic, or depressive episode.

When Diagnosed Properly, Bipolar Disorder Is Treatable

The Official DSM-5 Bipolar Diagnostic Criteria

According to the DSM-5 of the American Psychiatric Association, here is, verbatim, the specifications for each type of episode:

For Manic Episodes

  1. 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 one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

Note: In the bipolar disorder DSM-5 versus DSM-IV, Criterion A is revised to include increased energy/activity as a core symptom.

2. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 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., feeling 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)

3. 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.

4. The episode is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medication.

At least one manic episode is required for a diagnosis of bipolar I disorder.

For Hypomanic Episodes

  1. 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 four consecutive days and present most of the day, nearly every day.

  2. During the period of mood disturbance and increased energy and activity, 3 (or more) of the following symptoms (4 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., feeling 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)

  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

  • The disturbance in mood and the change in functioning are observable by others.

  • The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic symptoms, the episode is, by definition, manic.

  • The episode is not attributable to the physiologic effects of a substance or another medication.

Hypomanic episodes are common in bipolar I disorder but are not required for a diagnosis. Criteria for a past or current hypomanic episode and a past or current major depressive episode are required for the diagnosis of bipolar II disorder.

For Depressive Episodes

Five or more of the following A Criteria (at least one includes A1 or A2).

(A1) Depressed mood-indicated by subjective report or observation by others (in children and adolescents, can be irritable mood).

(A2) Loss of interest or pleasure in almost all activities, indicated by subjective report or observation by others.

(A3) Significant (more than 5 percent in a month) unintentional weight loss/gain or decrease/increase in appetite (in children, failure to make expected weight gains).

(A4) Sleep disturbance (insomnia or hypersomnia).

(A5) Psychomotor changes (agitation or retardation) severe enough to be observable by others.

(A6) Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed.

(A7) A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick).

(A8) Impaired ability to think, concentrate, or make decisions-indicated by subjective report or observation by others.

(A9) Recurrent thoughts of death (not just fear of dying), suicidal ideation, or suicide attempts.

If you think you may hurt yourself or attempt suicide, reach out to 911 or call a suicide hotline. In the U.S., you can dial 1-800-273-TALK (1-800-273-8255) to reach the National Suicide Prevention Lifeline. Or, use the webchat at suicidepreventionlifeline.org/chat.

  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, a prescribed medication's side effects) or a medical condition (e.g., hypothyroidism).

  • The symptoms do not meet criteria for a mixed episode. A mixed episode is characterized by the symptoms of both a major depressive episode and a manic episode occurring almost daily for at least 1 week. This exclusion does not include episodes that are substance-induced (e.g., caffeine) or the side effects of medication.

  • There has never been a manic episode or hypomanic episode.

  • MDE is not better explained by schizophrenia spectrum or other psychotic disorders.

  • The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation). This differentiation requires clinical judgment based on cultural norms and the individual's history.

The DSM V also states that it is important to note that each symptom must either be new or must have worsened compared with the person's pre-episode status and must persist most of the day, daily, for at least two weeks in a row. Exclude symptoms that are clearly due to a general medical condition, mood-incongruent delusions, or mood-incongruent hallucinations. Additionally, symptoms must persist most of the day, daily, for at least two weeks in a row, excluding A3 and A9.

Takeaway

By knowing what each episode entails from the DSM 5 bipolar disorder listing, a doctor can better determine which variant of the condition a patient has. For example, if they see that someone has exhibited depressive symptoms and hypomania, a diagnosis of bipolar II can be made. If no manic or hypomanic symptoms were present at all, it would more than likely indicate major depression disorder, instead of bipolar.

Although some degree of mania is a core part of bipolar disorder, the specific type that someone is diagnosed with can influence what course of treatment they take, depending on specific symptoms. Antipsychotics might also be used in patients who have exhibited psychosis (i.e., delusions and hallucinations) in their severe manic episodes.

Psychotherapy can provide people with guidance on how to cope with bipolar disorder and provide them ways to address individual symptoms, especially ones that involve depressive thinking patterns. At BetterHelp, licensed counselors are available to help people learn to live happier and more productive lives despite their diagnoses.

Individuals experiencing symptoms of bipolar disorder may have difficulty getting to an in-person session for treatment. They may be significantly impaired by their condition, or they may feel shame and embarrassment. Online therapy options may be better suited for these people since they can be accessed from the comfort of your home.

Barriers to online treatment also exist, though. Specifically, some individuals fear this format for treatment is less effective. However, research suggests the opposite. A recent study showed that some therapeutic treatments for bipolar disorder are associated with positive outcomes when administered online. 

If you or a loved one is experiencing the symptoms presented above, it is important to talk to a mental health specialist. Effective treatments for bipolar disorder exist, and a doctor or other mental health professional can aid in the correct diagnosis and treatment.

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