overview

Bipolar and related disorders are positioned in the DSM-5-TR between schizophrenia spectrum and other psychotic disorders and depressive disorders. This placement highlights their role as a bridge between these diagnostic categories, reflecting overlapping features in symptomatology, genetics, and family history. These disorders encompass a range of conditions characterized by mood disturbances, including episodes of mania, hypomania, and depression.

The disorders in this DSM chapter include:

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Substance/Medication-Induced Bipolar and Related Disorder
• Bipolar and Related Disorder Due to Another Medical Condition
• Other Specified Bipolar and Related Disorder
• Unspecified Bipolar and Related Disorder

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bipolar I disorder

Bipolar I disorder is characterized by the occurrence of at least one manic episode, which may be preceded or followed by hypomanic or major depressive episodes. The presence of a manic episode is the defining feature of this diagnosis. At least one manic episode is required to diagnosis Bipolar I disorder.

Manic Episode (Required):

• Duration: At least one week of abnormally elevated, expansive, or irritable mood, with increased energy or activity (or any duration if hospitalization is necessary).
• Symptoms: Must have five or more (four if mood is irritable) of the following:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep.
  3. Increased talkativeness or pressure to talk.
  4. Racing thoughts or flight of ideas.
  5. Distractibility.
  6. Increased goal-directed activity or psychomotor agitation.
  7. Risky behaviors (e.g., spending sprees, reckless sexual activity).
• Impact: Severe enough to cause marked social or occupational impairment, hospitalization, or psychosis.
• Exclusions: Not caused by substances or medical conditions.

Hypomanic Episode (Optional):

• Duration: At least four consecutive days of elevated, expansive, or irritable mood and increased energy or activity.
• Symptoms: Similar to mania but less severe and without significant impairment or hospitalization.
• Impact: Observable by others but not causing marked functional impairment.

Major Depressive Episode (Optional)

• Duration: At least two weeks of depressed mood or loss of interest/pleasure, with five or more symptoms including:
  1. Significant weight change or appetite disturbance.
  2. Sleep disturbances.
  3. Fatigue or energy loss.
  4. Feelings of worthlessness or excessive guilt.
  5. Concentration difficulties.
  6. Psychomotor agitation or retardation.
  7. Recurrent thoughts of death or suicide.
• Impact: Causes clinically significant distress or impairment.

Additional Diagnosis Highlights:

• Mild, moderate, severe, with psychotic features, in partial remission, in full remission, and unspecified.
• Specify if with: anxious distress, mixed features, rapid cycling, melancholic features, atypical features, mood-congruent psychotic features, mood incongruent psychotic features, catatonia, peripartum onset, and seasonal pattern.

bipolar II Disorder

Bipolar II disorder is defined by the presence of at least one hypomanic episode and at least one major depressive episode, with no history of manic episodes. The disorder is characterized by significant mood instability and impairment due to depressive episodes or the unpredictability of mood shifts.

1. Hypomanic Episode:

• Duration: At least four consecutive days of persistently elevated, expansive, or irritable mood, along with increased energy or activity.
• Symptoms: Requires three or more (four if mood is irritable) of the following:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep.
  3. Increased talkativeness or pressure to talk.
  4. Racing thoughts or flight of ideas.
  5. Distractibility.
  6. Increased goal-directed activity or psychomotor agitation.
  7. Risky behaviors with potential for painful consequences.
• Impact: Observable by others but does not cause marked impairment in social or occupational functioning or require hospitalization.

2. Major Depressive Episode:

• Duration: At least two weeks of depressed mood or loss of interest/pleasure, with five or more of the following symptoms:
  1. Depressed mood most of the day, nearly every day.
  2. Loss of interest or pleasure in activities.
  3. Significant weight/appetite change.
  4. Sleep disturbances (insomnia or hypersomnia).
  5. Fatigue or loss of energy.
  6. Feelings of worthlessness or excessive guilt.
  7. Diminished concentration or decisiveness.
  8. Psychomotor agitation or retardation.
  9. Recurrent thoughts of death or suicide.
• Impact: Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers:

• Current/Most Recent Episode: Hypomanic or Depressed.
• Specify Features:
  • With anxious distress.
  • With mixed features.
  • With rapid cycling.
  • With melancholic or atypical features.
  • With mood-congruent or incongruent psychotic features.
  • With catatonia.
  • With peripartum onset.
  • With seasonal pattern.
• Specify Course: In partial or full remission if criteria for an episode are not currently met.
• Specify Severity: Mild, moderate, or severe for current depressive episodes.

cyclothymic disorder

Cyclothymic disorder is a chronic mood disorder characterized by fluctuating periods of hypomanic-like and depressive-like symptoms that do not meet the full criteria for a hypomanic or major depressive episode. Cyclothymic disorder often presents as a milder, chronic form of bipolar disorder, characterized by ongoing mood instability.

Diagnostic Criteria

1. Duration:
   • Adults: Symptoms persist for at least two years.
   • Children/Adolescents: Symptoms persist for at least one year.
2. Symptoms:
   • Numerous hypomanic symptoms that do not meet full criteria for a hypomanic episode.
   • Numerous depressive symptoms that do not meet full criteria for a major depressive episode.
3. Consistency:
   • Symptoms present for at least half the time during the required duration.
   • Symptom-free periods do not exceed two months at a time.
4. Exclusions:
   • Criteria for major depressive, manic, or hypomanic episodes are never met.
   • Symptoms are not better explained by schizophrenia spectrum or other psychotic disorders.
   • Symptoms are not caused by a substance or medical condition (e.g., hyperthyroidism).
5. Impact:
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other key areas of functioning.
6. Specifier:
   • With anxious distress (if present).

substance/medication-included bipolar and related disorder

Substance/medication-induced bipolar and related disorder is characterized by significant mood disturbances, such as abnormally elevated, expansive, or irritable mood, alongside increased energy or activity, directly linked to substance use or medication effects. These symptoms develop during or shortly after intoxication, withdrawal, or medication changes and are severe enough to impair functioning or require clinical attention.  The diagnosis is assigned only when mood symptoms are the primary focus of clinical attention and severe enough to require intervention.

Key Diagnostic Features:

• Core Symptom (Criterion A): A prominent and persistent mood disturbance characterized by abnormally elevated, expansive, or irritable mood, along with increased activity or energy, which dominates the clinical presentation.
• Evidence of Substance/Medication Involvement (Criterion B):
  1. Symptoms develop during or soon after substance intoxication, withdrawal, or medication use/change.
  2. The substance or medication is known to cause such symptoms.
• Exclusions (Criterion C):
  • Symptoms are not better explained by a non-substance/medication-induced bipolar disorder.
  • Evidence of an independent bipolar disorder includes symptoms that:
    • Occur before substance/medication use.
    • Persist for an extended period (e.g., one month or longer) after cessation of use.
    • Include a history of non-substance-induced episodes.
• Other Considerations:
  • Symptoms do not occur exclusively during delirium (Criterion D).
  • The mood disturbance causes clinically significant distress or impairment in functioning (Criterion E).

Specifiers -“With”:

1. Onset During Intoxication: Symptoms emerge while the individual is intoxicated.
2. Onset During Withdrawal: Symptoms appear during or shortly after withdrawal.
3. Onset After Medication Use: Symptoms develop at medication initiation, during dosage changes, or during withdrawal.

Bipolar and Related Disorder Due to Another Medical Condition

This diagnosis is characterized by a prominent and persistent disturbance in mood, such as abnormally elevated, expansive, or irritable mood with increased activity or energy, which is directly caused by a medical condition. Evidence linking the mood disturbance to the medical condition must come from clinical history, physical examination, or lab findings. The symptoms cannot be better explained by another mental disorder, must not occur exclusively during delirium, and must cause significant distress, impairment, or necessitate hospitalization. Specifiers identify whether symptoms present as manic features, manic- or hypomanic-like episodes, or mixed features, and the medical condition causing the disorder is coded alongside the diagnosis.

other specified bipolar and related disorder

This diagnosis is used when symptoms characteristic of bipolar and related disorders cause significant distress or impairment but do not meet full criteria for any specific disorder in this category. The clinician specifies the reason the criteria are not met (e.g., “short-duration cyclothymia”). Examples include:

1. Short-Duration Hypomanic Episodes (2–3 Days) with Major Depressive Episodes.
2. Hypomanic Episodes with Insufficient Symptoms alongside Major Depressive Episodes.
3. Hypomanic Episodes without a Prior Major Depressive Episode.
4. Short-Duration Cyclothymia (less than 24 months for adults, 12 months for children).
5. Manic Episodes Superimposed on Schizophrenia Spectrum Disorders.

Unspecified Bipolar and Related Disorder

Unspecified bipolar and related disorder applies when symptoms of a bipolar or related disorder cause significant distress or impairment but the exact diagnosis is unclear. It is often used when there is insufficient information to make a more specific diagnosis, such as in emergency settings, or when the clinician opts not to specify the reason the criteria are unmet.

Unspecified mood disorder

Unspecified mood disorder is used when mood disorder symptoms are present and cause significant distress or impairment but do not fully meet the criteria for any specific bipolar or depressive disorder. It is applied when it is unclear whether the symptoms align more closely with bipolar or depressive disorders, such as during acute agitation or in ambiguous clinical presentations.

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