How To Diagnose Bipolar Disorder Symptoms Using The DSM-5 Criteria

Bipolar disorder affects millions of people around the world. An awareness of this mental illness is brought to light for World Bipolar Day on March 30th, a celebration that promotes a more profound understanding of bipolar disorder and aims to address the stigma surrounding this mental illness. 

Understanding the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for bipolar disorder can ensure you receive the most up-to-date information on how the condition is diagnosed. Additionally, you may learn how the diagnostic criteria for bipolar disorder can influence a course of treatment and what methods are effective.

What is bipolar disorder?

Bipolar disorders are a group of brain disorders characterized by shifts between hypomania, mania, and depression. Those experiencing this condition may experience high energy, euphoria, hyperactivity, irritability, and delusions when in a manic episode. Manic symptoms are also associated with risk-taking behaviors and increased impulsivity and only occur in those diagnosed with bipolar I disorder. People with bipolar II disorder may experience a less severe form of mania called hypomania. 

People with bipolar disorder also experience periods of low mood and depression. Like those living with depressive disorders, those with bipolar disorder who are having a depressive episode can be unkind to themselves, have low energy and motivation, and think about death and suicide. In addition, significant weight loss or gain is a possible symptom that can further complicate the clinical picture.

These mood swings are not 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. People with bipolar II disorder may experience longer periods of depression than those with bipolar I disorder and at least four days of hypomania in some cases. 

Types of bipolar disorder

Below are the primary subtypes of bipolar disorders listed in the DSM and the symptoms required for them to be diagnosed:

Bipolar I Disorder

Bipolar I disorder 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 also experience depressive episodes lasting two weeks or longer, followed by periods of “normal” or controlled moods. 

Bipolar II Disorder

Bipolar II disorder is characterized by depressive and hypomanic episodes. Individuals must have experienced at least one major depressive episode and one hypomanic episode with no occurrence of a manic episode. The episodes of hypomania and major depression cannot be caused by schizoaffective disorder, schizophreniform disorder, delusional disorder, or any conditions within the unspecified schizophrenia spectrum and other psychotic disorders. In addition, the major depressive episodes or the erratic shifts between hypomanic and depressive states often lead to distress or problems in social, work, or other life areas.

Cyclothymic Disorder

In 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 at least two years in adults and one year in those under 18. 

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 disorder section goes into more significant detail as to what constitutes a manic, hypomanic, or depressive episode.

How to diagnose bipolar disorder using the official DSM-5 criteria

According to the DSM-5 by the American Psychiatric Association, the following are the criteria for each type of episode that may occur in bipolar disorder. 

Manic episode criteria 

Below are the criteria listed in the DSM-5 for a manic episode to be diagnosed: 

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 category versus DSM-IV, Criterion A is revised to include increased energy and activity as a core symptom.

2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feeling rested after only three hours of sleep)
• Being more talkative than usual 
• Flight of ideas or the subjective experience of racing thoughts 
• Distractibility (i.e., attention too quickly drawn to unimportant or irrelevant external stimuli), as reported or observed
• An increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or risky business investments)

People experiencing severe mania may also experience significant delusions, psychosis, or paranoia, which are not present in hypomania. 

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 present.

4. The episode is not attributable to the physiologic effects of a treatment or medication, including cases of substance abuse.

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

Hypomanic episode criteria 

Below are the requirements for a hypomanic episode to be diagnosed in someone with bipolar II disorder or bipolar I disorder: 

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, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
   
   

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feeling rested after only three hours of sleep)
• Being more talkative than usual 
• Flight of ideas or the subjective experience of racing thoughts 
• Distractibility (i.e., attention too quickly drawn to unimportant or irrelevant external stimuli), as reported or observed
• An increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or risky business investments

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

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

5. 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.

6. 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.

Depressive episode criteria 

Below are the required criteria for a depressive episode in both bipolar I disorder and bipolar II disorder: 

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

• (A1) A depressed mood indicated by subjective report or observation by others (in children and adolescents, can be an irritable mood)

• (A2) A loss of interest or pleasure in almost all activities, indicated by subjective report or observation by others

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

• (A4) Sleep disturbance (insomnia or hypersomnia)

• (A5) Psychomotor changes (agitation or a slow down) severe enough to be observable by others

• (A6) Tiredness, fatigue, 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) An impaired ability to think, concentrate, or make decisions indicated by subjective report or observation by others

• (A9) Recurrent thoughts of death (not a fear of dying), suicidal ideation, or a suicide attempt

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

3. The symptoms are not due to the direct physiological effects of a substance or medical condition, such as hypothyroidism. 

4. The symptoms do not meet the 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 one week. This exclusion does not include episodes that are substance-induced or the side effects of medication.

5. Depression is not better explained by schizophrenia spectrum or other psychotic disorders.

6. 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, recurrent suicidal ideation, psychotic symptoms, or psychomotor retardation). This differentiation requires clinical judgment based on cultural norms and the individual's history.

The DSM criteria for bipolar disorder also suggests physicians note that each symptom must be new or worsened compared with the person's pre-episode status and must persist most of the day, daily, for at least two weeks. 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.

How to find support for a manic or major depressive episode

By knowing what each episode entails from the DSM-5 bipolar disorder listing, a doctor or psychologist can better determine which subtype of the condition someone might be living with. For example, if they see that someone has exhibited depressive symptoms and hypomania, a diagnosis of bipolar II can be made after ruling out a different mood or psychotic disorder. If no manic or hypomanic symptoms were present at all, the person may instead be living with a depressive disorder, such as major depressive disorder (MDD).

Alternative support options for people with bipolar disorder

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 feel shame and embarrassment. In these cases, online therapy sessions through a platform like BetterHelp may be better suited, as they can be done from home. 

Through an online therapy platform, clients can fill out a questionnaire upon signing up to get matched with a therapist who has experience treating their symptoms or condition. In addition, clients can choose between phone, video, or live chat sessions, allowing them control over how they receive guidance. 

In some cases, clients may worry online formats for treatment are less effective. However, research suggests the opposite. A recent study showed that some therapeutic interventions for bipolar disorder are associated with positive outcomes when administered online.