Understanding Bipolar Disorder: DSM-5 Criteria And Treatment Options

Bipolar disorder is a mental health condition marked by the presence of hypomania or mania, often alongside depressive episodes. Misconceptions and misdiagnoses may surround this complex condition, underscoring the benefit of accurate treatment and psychoanalysis. To understand bipolar disorder and its subtypes in further detail, looking at the criteria outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) can be helpful. 

What is bipolar disorder?

Bipolar disorder, formerly known as manic depression, is a mental health condition often characterized by extensive mood swings. The mood episodes of bipolar disorders may range from elevated and energized (manic episodes) to sad and hopeless (depressive episodes). Individuals experiencing bipolar disorder have periods of intense emotion, changes in sleep patterns and activity levels, and altered behavior.

Note that not everyone with bipolar disorder experiences mania or depressive episodes. Some people live with only manic episodes, while others shift between depressive and hypomanic phases. Other people experience mixed episodes, in which manic and depressive symptoms are present simultaneously. There are three primary subtypes of bipolar disorder that can be essential to understand when looking at the diagnosis of this condition. 

Signs and symptoms

Bipolar disorder symptoms vary among individuals and depend on the subtype of diagnosis. The most common may include the following: 

• Mood swings between mania or hypomania and depression

• Changes in energy levels, sleep patterns, and appetite

• Difficulty concentrating and making decisions

• Increased risk-taking behaviors

• Suicidal thoughts

Causes and risk factors

There is no one primary cause of bipolar disorder. However, researchers believe that a combination of genetic, environmental, and biological factors contributes to the development of the condition, including the following: 

• A family history of bipolar disorder or other mental health conditions 

• Periods of high-stress or traumatic events

• Substance use 

• Imbalances in brain chemicals and neural circuits

Types of bipolar disorder

There are seven brain disorders listed under the category of bipolar and related disorders in the DSM-V:

• 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

The following subtypes—bipolar I, bipolar II, and cyclothymic disorder—are considered the most common. 

Bipolar I disorder: Characteristics and impact on daily functioning

Bipolar I disorder is a subtype of bipolar disorder distinguished by at least one manic episode. People with bipolar I disorder may not have depressive episodes, but they can occur.  

Symptoms of a manic episode

Manic episodes in bipolar I disorder are characterized by a distinct period of abnormally elevated, expansive, or irritable mood, which persists for at least seven days or necessitates hospitalization due to the severity of symptoms. 

During a manic episode, individuals may exhibit symptoms like the following: 

• Inflated self-confidence

• Decreased need for sleep

• Increased talkativeness

• Racing thoughts 

• Distractibility 

• Heightened goal-directed activity or agitation

• Engagement in risky behaviors with potentially severe consequences

• Paranoia

• Delusions 

• Psychosis (in some cases) 

Effects of elevated energy, irritable mood, and potential depressive symptoms

The intensity of these symptoms often interferes with daily functioning, leading to disruptions in work, school, social, or family life. Depressive episodes may accompany these episodes, but their presence is unnecessary for a diagnosis. 

Bipolar I disorder may cause significant distress for affected individuals and their families, as the severity of manic episodes may result in marked impairment in various aspects of life. The unpredictable nature of a person’s mood swings may also contribute to difficulties in maintaining stable relationships, employment, or academic progress. Social interactions can be challenging as—according to the DSM-V—manic symptoms can cause an individual to feel “pressure to keep talking” and become “too easily drawn to unimportant or irrelevant external stimuli”. 

The risky behaviors associated with manic episodes can also lead to significant concerns. Based on the symptoms in the DSM-V, an individual with bipolar disorder may participate in “activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)”. Because of these challenges, early diagnosis and appropriate intervention are often crucial. 

Bipolar II disorder: Features and effects on daily life

Bipolar II disorder is another subtype of bipolar disorder, differentiated by at least one major depressive episode and one hypomanic episode, a milder form of mania. Unlike bipolar I disorder, bipolar II disorder does not involve manic episodes. However, this condition still causes significant distress and impairment in daily functioning. 

Symptoms of a hypomanic episode

Hypomanic episodes in bipolar II disorder are often characterized by a distinct period of elevated, expansive, or irritable mood lasting at least four consecutive days. The symptoms may be like those in manic episodes but are less severe and do not require hospitalization. 

Common manifestations during a hypomanic episode include the following: 

• Increased self-esteem

• A decreased need for sleep

• Heightened talkativeness

• Racing thoughts

• Distractibility

• Increased goal-directed activity

• Engagement in activities with potentially harmful consequences

Symptoms of a major depressive episode 

Major depressive episodes in bipolar II disorder involve symptoms of major depressive disorder (MDD), like the following: 

• A persistent depressed mood

• Diminished interest or pleasure in activities

• Significant changes in weight or appetite

• Sleep disturbances 

• Psychomotor agitation

• Fatigue

• Thoughts of worthlessness 

• Excessive guilt or shame 

• Difficulty concentrating 

• Recurrent thoughts of suicide  

Effects of low mood, sadness, and potential hypomanic symptoms

The combination of depressive and hypomanic episodes in bipolar II disorder often leads to difficulty functioning in areas of work, school, social interactions, and relationships. The alternating mood episodes may create challenges in maintaining consistency in daily functioning and managing stress effectively. Thus, timely diagnosis and intervention are often beneficial. 

Cyclothymic disorder

Cyclothymic disorder is a subset of bipolar disorder that may be diagnosed when one does not meet the criteria for bipolar I disorder or bipolar II disorder. It involves chronic, fluctuating mood disturbances involving numerous hypomanic and depressive symptoms.

In addition, symptoms persist for at least two years in adults or one year in children and adolescents. The depressive episode cannot meet the criteria for a major depressive disorder diagnosis and cannot involve a manic episode, which is only found in bipolar I disorder. 

DSM-5 criteria for bipolar disorder

Developed by the American Psychiatric Association, the DSM-5 provides criteria for diagnosing bipolar disorder. Unlike the DSM-IV, the DSM-V placed bipolar and related disorders in their own category. To be diagnosed with a mental health condition, it can be crucial to consult a doctor or mental health professional for a thorough evaluation, as the symptoms may overlap with other psychiatric conditions. 

To receive a diagnosis of bipolar I disorder, individuals must have experienced at least one manic episode, described as a “period of abnormally and persistently elevated, expansive, or irritable mood”, in which symptoms “are present to a significant degree and represent a noticeable change from usual behavior”. The manic episode must be severe enough that the individual experiences impaired functioning, signs of psychosis, or symptoms that necessitate hospitalization (to prevent a suicide attempt or other potentially harmful acts). Also, their symptoms must not arise out of schizophrenia, schizophreniform disorder, delusional disorder, or schizoaffective disorder. 

In contrast, individuals with bipolar II disorder must experience at least one major depressive episode and one hypomanic episode. To meet the criteria for an episode of major depression, an individual must have experienced at least five depressive symptoms for the majority of the day, every day, during a two-week period. Such symptoms must have caused impairment to everyday functioning or a substantial amount of distress. A diagnosis of cyclothymic disorder requires chronic, fluctuating mood disturbances involving numerous hypomanic and depressive symptoms. 

Treatment options

While there might not be a cure for bipolar disorder, a combination of medication, psychotherapy, lifestyle changes, and other treatment options may help individuals manage symptoms and improve their quality of life. Below are a few of these options. 

Medication

The option to use medication might be available for individuals with bipolar disorder, depending on the severity and frequency of symptoms. However, consult your primary care physician or psychiatrist before starting, changing, or stopping any medication. 

Psychotherapy

Therapy is often an effective method of treating bipolar disorder. A few of the most recommended modalities include the following: 

• Cognitive-behavioral therapy (CBT)

• Family-focused therapy

• Interpersonal and social rhythm therapy

• Psychoeducation

Lifestyle changes

People with bipolar disorder can make a few lifestyle changes to improve daily life and potentially reduce symptom severity, including but not limited to the following: 

• Regular sleep schedule

• Balanced diet

• Exercise

• Stress reduction techniques

• Avoiding substance use 

Support options 

If you’re living with bipolar disorder or believe you may have this condition, you’re not alone. Various support options are available for mental health conditions, and you don’t have to be diagnosed to attend therapy. In addition, if you face barriers to reaching in-person therapy or affordable counseling, online platforms like BetterHelp may offer more care options. 

Through an online platform, individuals with bipolar disorder or any mental health challenge can receive support from home or anywhere with an internet connection. In addition, online platforms allow users to choose between phone, video, or live chat sessions and have unique resources like journaling prompts, group sessions, classes, and worksheets. 

Studies showcase that online therapy can also be as effective as face-to-face options. In one study of online therapy for bipolar disorder, 95% of participants reported an increased quality of life after treatment, with results similar to in-person studies on therapy.