Influenced by generalized anecdotes and Hollywood’s portrayal of the condition, the average person may think of bipolar disorder as seemingly random mood fluctuations from one emotional and behavioral extreme to the other. The assumption that those with bipolar disorder are volatile is inaccurate, disrespectful, and damaging as it contributes to a culture that treats those with this mental illness as a liability. In fact, bipolar disorder was clinically referred to as “manic-depressive illness” or “manic depression” until the publication of the DSM-3 in 1980, and a large reason the American Psychiatric Association (APA) revised the name to “bipolar disorder” was to aid in destigmatizing the condition with a name that better captured its true nature.
By definition, bipolar disorder is a psychiatric condition characterized by discrete periods of alternating manic/hypomanic and major depressive symptoms. Manic episodes are characterized by elevated, expansive, or irritable mood, and persistently increased activity or energy that is present for most of the day, every day, for at least a week. According to the DSM-5, a manic episode must also be accompanied by 3 (4 is mood is only irritable) of the following symptoms:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (i.e. feeling rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility, as reported or observed
- Increase in goal-directed activity or psychomotor agitation (i.e. purposeless non-goal-directed activity)
- Excessive involvement in activities that have a high potential for painful consequences
Major depressive episodes are often characterized by persistent hopelessness, pessimism, and anhedonia – an inability to enjoy. According to the DSM-5, a major depressive episode includes five or more of the following symptoms during the same 2-week period:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death, suicidal ideation, or attempted suicide
An important third state to note is hypomania. Hypomanic episodes are described as less severe than manic episodes. However, manic and hypomanic episodes have the same set of identifiers (i.e. inflated self-esteem, decreased need for sleep, etc). There are two key distinguishing features of a hypomanic episode from a manic episode. First, the disturbance in mood and functioning is not enough to cause marked impairment. Second, their duration is different – manic episodes last at least a week and hypomanic episodes last at least 4 consecutive days.
Previously categorized as a mood disorder in the DSM-4, the DSM-5 replaced the Mood Disorders section by separating it into two sections: Bipolar Disorders and Depressive Disorders. The Bipolar Disorders section is now aptly placed between Psychotic Disorders and Depressive Disorders in recognition of their place as “a bridge between the two diagnostic classes in terms of symptomatology, family history, and genetics.” The DSM-5 recognizes seven types of bipolar disorders, listed below. They each have a particular set of specifiers the diagnosing clinician may use to more accurately describe the individual’s condition. The final four types are briefly described here as the main bipolar types we will focus on understanding (further below) are the first three.
- Bipolar I Disorder
- Bipolar II Disorder
- Cyclothymic Disorder
- Substance/Medication-induced Bipolar and Related Disorder is diagnosed when a substance, such as alcohol, drugs, or medication, causes manic/hypomanic and/or depressive symptoms during or after intoxication or withdrawal
- Note: If hypomania or mania persists after antidepressant treatment, this is considered an indicator of true bipolar disorder – not substance/medication-induced bipolar and related disorder
- Bipolar and Related Disorder due to another medical condition is diagnosed when prominent and persistent periods of manic/hypomanic symptoms are attributable to another medical condition, such as multiple sclerosis or a traumatic brain injury
- Other Specified Bipolar and Related Disorder is diagnosed when symptoms characteristic of bipolar and related disorder cause clinically significant distress or impairment, but do not meet the full criteria for any of the disorders in the Bipolar and Related Disorders class. This category is used when the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any other bipolar and related disorder. Examples of presentations that can be specified using this diagnosis include:
- Short-duration hypomanic episodes (2-3 days) and major depressive episodes
- Hypomanic episodes with insufficient symptoms and major depressive episodes
- Hypomanic episode without prior major depressive episode
- Short-duration cyclothymia (less than 24 months)
- Unspecified Bipolar and Related Disorder is similar to the last type in that it is diagnosed when symptoms characteristic of bipolar and related disorders cause clinically significant distress or impairment, but do not meet the full criteria for any of the disorders in the Bipolar and Related Disorders class. However, this category is used when the clinician chooses not to specify the reason that the criteria are not met for another bipolar and related disorder, or has insufficient information to make a more specific diagnosis (i.e. in emergency room settings)
Bipolar I Disorder
The DSM-5 notes bipolar I disorder diagnostic criteria as the “modern understanding of the classic manic-depressive disorder” described in the nineteenth century. In the simplest terms, bipolar I is what the average person thinks of when they describe bipolar disorder: a fluctuation between manic and major depressive episodes. However, diagnostically, bipolar I is most characterized by the presence of a manic episode. The DSM-5 diagnostic criteria for bipolar I are:
- Criteria have been met for at least one manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes
- The occurrence of the mani and major depressive episode(s) is not better explained by a psychotic disorder (i.e. schizoaffective disorder, schizophrenia, or delusional disorder)
The specifiers for bipolar I disorder include:
- With anxious distress
- With mixed features
- With rapid cycling
- With melancholic features
- With atypical features
- With mood-congruent psychotic features
- With mood-incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
Bipolar II Disorder
Unlike bipolar I disorder which involves a fluctuation between manic and depressive episodes, bipolar II involves a fluctuation between hypomanic and depressive episodes. Bipolar II is characterized by a course of recurring mood episodes consisting of one or more major depressive episodes and at least one hypomanic episode. The depressive episode must last at least two weeks and the hypomanic episode must last at least four consecutive days. The DSM-5 diagnostic criteria for bipolar II is:
- Criteria must be met for a least one hypomanic episode and at least one major depressive episode
- Hypomanic and major depressive episode criteria is detailed above
- There has never been a manic episode
- The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by a psychotic disorder (i.e. schizoaffective disorder, schizophrenia, or delusional disorder)
- The symptoms of depression or the unpredictability frequent mood fluctuation causes clinically significant distress or impairment
The specifiers for bipolar II disorder include:
- With anxious distress
- With mixed features
- With rapid cycling
- With mood-congruent psychotic features
- With mood-incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
Cyclothymic Disorder
The key diagnostic feature of cyclothymic disorder is chronically fluctuating mood disturbances involving numerous hypomanic and depressive episodes. However, the hypomanic and depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet the full criteria for either type of episode. Fluctuating, discrete periods of hypomanic and depressive symptoms must be persistent for the initial two year period (one year for children and adolescents), and any symptom-free period must last no longer than two months. If an individual experiences a true major depressive, manic, or hypomanic episode, the cyclothymic diagnosis is dropped and the diagnosis changes to major depressive disorder, bipolar I disorder, or other specified or unspecified bipolar and related disorder, respectively. The DSM-5 diagnostic criteria for cyclothymic disorder are:
- For at least 2 years there have been numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode
- During the above 2-year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time
- Criteria for a major depressive, mani, or hypomanic episode have never been met
- The symptoms in Criterion A are not better explained by a psychotic disorder (i.e. schizoaffective disorder, schizophrenia, or delusional disorder)
- The symptoms are not attributable to the physiological effects of a substance or another medical condition
- The symptoms cause clinically significant distress or impairment
The only specifier for cyclothymic disorder is:
- With anxious distress
