Criteria
Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR)[1]
Bipolar I disorder:
Characterised by the occurrence of 1 or more manic episodes (the manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes, but these are not required for diagnosis).
Criteria for a manic episode:
Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and increased activity or energy lasting ≥1 week (any duration if hospitalised), present most of the day, nearly every day
During the mood disturbance and increased energy or activity, ≥3 (or ≥4 if irritable mood only) of the following are present to a significant degree and represent a noticeable change from usual behaviour:
Inflated self-esteem or grandiosity
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
Pressured speech or more talkative than usual
Racing thoughts or flight of ideas
Distractibility (may be reported or observed)
Increased goal-directed activity or psychomotor agitation (purposeless, non-goal-directed activity)
Excessive involvement in pleasurable activities that have a high potential for adverse consequences (may include engaging in unrestrained buying sprees, sexual indiscretions, or unwise business investments)
In addition, these symptoms:
cause functional impairment, necessitate hospitalisation, or there are psychotic features
are not related to substance misuse
are not due to a general medical condition
are not caused by a medication or other treatment; however, note that a full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a syndrome level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Bipolar II disorder:
Never had a full manic episode; at least 1 hypomanic episode and at least 1 major depressive episode
Criteria for a hypomanic episode:
Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and increased activity or energy lasting ≥4 days, present most of the day, nearly every day
During the hypomanic episode, ≥3 (or ≥4 if irritable mood only) of the following are present to a significant degree and represent a noticeable change from usual behaviour:
Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech or more talkative than usual
Racing thoughts or flight of ideas
Distractibility (may be reported or observed)
Increased goal-directed activity or psychomotor agitation (purposeless, non-goal-directed activity)
Excessive involvement in activities that have a high potential for adverse consequences (may include engaging in unrestrained buying sprees, sexual indiscretions, or unwise business investments)
Episode is unequivocal change in functioning, uncharacteristic of person, and observable by others
Not severe enough to cause marked impairment or hospitalisation, not due to illicit or prescribed substance use or medical condition, and no psychosis (if present, then this is mania by definition); however note that a full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a syndrome level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis.
Criteria for a major depressive episode
During the major depressive episode, ≥5 of the following symptoms are present during the same 2-week period, and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure:
Depressed mood most of the day, nearly every day (reported or observed)
Markedly diminished interest or pleasure, in all, or almost all, activities, most of the day, nearly every day (reported or observed)
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite, nearly every day
Insomnia or hypersomnia, nearly every day
Psychomotor agitation or retardation, nearly every day (observable by others)
Fatigue or loss of energy, nearly every day
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional), nearly every day
Diminished ability to think or concentrate, or indecisiveness, nearly every day (reported or observed)
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with or without a specific plan, or a suicide attempt or a specific plan for attempting suicide
In addition, these depressive symptoms:
cause functional impairment (e.g., social, occupational) or clinically significant distress and
are not better explained by prescribed or illicit substance misuse or another medical condition.
Criteria for mixed features
The mixed features specifier can apply to the current manic, hypomanic, or major depressive episode in bipolar I disorder (or the most recent episode if bipolar I disorder is in partial or full remission) or to the current hypomanic or major depressive episode in bipolar II disorder (or the most recent episode if bipolar II disorder is in partial or full remission).
Manic or hypomanic episode, with mixed features:
Full criteria are met for a manic episode or hypomanic episode, and at least 3 of the following symptoms are present during most of the days of the current or most recent episode of mania or hypomania:
Prominent dysphoria or depressed mood (may be reported or observed)
Diminished interest or pleasure in all, or almost all, activities (reported or observed)
Psychomotor retardation nearly every day (observable by others)
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Recurrent thoughts of death, recurrent suicidal ideation, suicide attempt, or a specific plan for attempting suicide
Depressive episode, with mixed features:
Full criteria are met for a major depressive episode, and at least 3 of the following manic/hypomanic symptoms are present during the most of the days of the current or most recent episode of depression:
Elevated, expansive mood
Inflated self-esteem or grandiosity
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing. Increase in energy or goal-directed activity (either socially, at work or school, or sexually)
Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or unwise business investments)
Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia)
Criteria for rapid cycling:
Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode in bipolar I disorder or that meet the criteria for hypomanic or major depressive episode in bipolar II disorder.
Note: Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity (e.g., major depressive episode to manic episode).
Note: The essential feature of rapid-cycling bipolar disorder is the occurrence of at least four mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and the symptom number criteria for a major depressive, manic, or hypomanic episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Manic and hypomanic episodes are counted as being on the same pole. Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapid-cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g., cocaine, corticosteroids) or another medical condition.
Substance-/medication-induced bipolar and related disorder:
Prominent and persistent disturbance of mood characterised by elevated, expansive, or irritable mood and abnormally increased activity or energy
Symptoms developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication
The substance or medication is capable of producing the symptoms, and there is evidence of use from history, physical examination, or laboratory findings
The disturbance causes clinically significant distress or functional impairment
The disturbance is not better explained by a bipolar or related disorder that is not substance-/medication-induced, and does not occur exclusively during the course of a delirium.
Other specified bipolar and related disorder and unspecified bipolar and related disorder:
Symptoms characteristic of a bipolar and related disorder are present, and cause clinically significant distress or functional impairment, but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class
Examples include:
Short duration hypomania (i.e., 2-3 days) and a major depressive episode
Major depressive episode and insufficient criteria hypomania
Hypomania without major depressive episode
Cyclothymia for less than 24 months.
International Classification of Diseases, 11th edition (ICD-11): bipolar affective disorder[2]
Bipolar and related disorders are episodic mood disorders defined by the occurrence of manic, mixed, or hypomanic episodes or symptoms. These episodes typically alternate over the course of these disorders with depressive episodes or periods of depressive symptoms.
Bipolar type I disorder
A history of at least one manic or mixed episode. Although a single manic or mixed episode is sufficient for a diagnosis of bipolar type I disorder, the typical course of the disorder is characterised by recurrent depressive and manic or mixed episodes. Although some episodes may be hypomanic, there must be a history of at least one manic or mixed episode.
Bipolar type II disorder
A history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterised by recurrent depressive and hypomanic episodes.
There is no history of manic or mixed episodes.
Cyclothymic disorder
Mood instability over an extended period (2 years or more) characterised by numerous hypomanic and depressive periods.
Hypomanic periods may or may not have been sufficiently severe or prolonged to meet the diagnostic requirements for a hypomanic episode.
Mood symptoms are present for more days than not. While brief symptom-free intervals are consistent with the diagnosis, there have never been any prolonged symptom-free periods (e.g., lasting 2 months or more) since the onset of the disorder.
There is no history of manic or mixed episodes.
During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a depressive episode.
The symptoms are not a manifestation of another medical condition (e.g., hyperthyroidism) and are not due to the effects of a substance or medication on the central nervous system (e.g., stimulants), including withdrawal effects.
The symptoms result in significant distress about experiencing persistent mood instability or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
Other specified bipolar or related disorders
The presentation is characterised by manic or hypomanic symptoms (with or without depressive symptoms) that share primary clinical features with other bipolar or related disorders (e.g., persistent elevation of mood).
The symptoms do not fulfil the diagnostic requirements for any other disorder in the bipolar or related disorders grouping.
The symptoms are not better accounted for by another mental, behavioural, or neurodevelopmental disorder (e.g., schizoaffective disorder; a disorder due to addictive behaviours; a personality disorder).
The symptoms and behaviors are not a manifestation of another medical condition and are not due to the effects of a substance or medication (e.g., alcohol, cocaine) on the central nervous system, including withdrawal effects.
The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
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