DSM-5: Bipolar and Related Disorders

Bipolar I Disorder: Coding and recording

*Based on type of CURRENT OR MOST RECENT episode and its status with respect to 1) current severity 2) presence of psychotic features 3) remission status **Current severity and psychotic features are only indicated if full criteria are CURRENTLY MET for a manic or major depressive episode. **Remission specifiers are only indicated if the full criteria are not current met for a manic, hypomanic, or major depressive episode.

With rapid cycling

*Can be applied to bipolar I and bipolar II disorder: *Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode.

Bipolar I disorder facts

*Necessary to meet the following criteria for a manic episode. *The main episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

Lability

*Rapid shifts in mood over brief periods of time

Unspecified bipolar and related disorder

*This applies to presentations that meet criteria for symptoms of a bipolar disorder that cause clinically significant distress and impairment but do mot meet the full criteria for any of the disorders in the bipolar and related disorders. *Used in which the clinical chooses NOT to specify reason why criteria are not met for a specific bipolar and related disorder. -insufficient information to make a more specific diagnosis. (emergency room settings)

Other specified bipolar and related disorder

*This applies when one has the symptoms of bipolar and related disorder that cause clinically significant impairment but does not meet all the other symptoms. *Used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria. 1) Short duration hypomanic episodes (2-3 days) and major depressive episodes 2) Hypomanic episodes with insufficient symptoms and major depressive episodes 3) Hypomanic episode without prior major depressive episode 4) Short duration cyclothymic (less than 24 months)

Bipolar and related disorders

1) Bipolar I disorder 2) Bipolar II disorder 3) Cyclothymic disorder 4) Substance/medication-induced bipolar and Related disorder 5) Bipolar and related disorder due to another medical condition 7) Other specified bipolar and related disorder 8) Unspecified bipolar and related disorder

Bipolar II disorder: specify if Bcurrent or most recent episode:

1) Hypomanic 2) Depressed

Bipolar II disorder: specify if full criteria for a mood episode are not currently met:

1) In partial remisson 2) In full remission

Bipolar II disorder: specify if full criteria for a mood episode are currently met:

1) Mild 2) Moderate 3) Severe

Specifiers for bipolar and related disorders

1) With anxious distress 2) With mixed features 3) Depressive episode, with mixed features 4) With rapid cycling 5) With melancholic features 6) With atypical features 7) With psychotic features 8) With permpartum onset 9) With seasonal pattern

Bipolar I Disorder: Specify if

1) With anxious distress 2) With mixed features 3) With rapid cycling 4) With melancholic features 5) With atypical features 6) With mood-congruent psychotic features 7) With mood-incongruent psychotic features 8) With catatonia 9) With peripartum onset 10) With seasonal pattern

Bipolar II disorder: specify if with

1) With anxious distress 2) With mixed features 3) With rapid cycling 4) With mood-congruent psychotic features 5) With mood-incongruent psychotic features 6) With catatonia 7) With permpartum onset 8) With seasonal pattern

With psychotic features

1) With mood-congruent psychotic features: -during manic episodes, the content of all delusions and hallucinations is consistent with the typical many themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others doubts about the individual's capacities, accomplishments and so forth. 2) With mood-incongruent psychotic features: -The content of the delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes.

Bipolar II disorder

A. *It is NECESSARY to meeting the following criteria for a current or past: 1) hypomanic episode AND -at least 4 days 2) major depressive episode -at least 2 weeks B. There has NEVER been a manic episode C. The occurrence of the hypomanic episode(s) and major depressive episode (s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social occupational, or other important areas of functioning.

Hypomanic episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting AT LEAST 4 CONSECUTIVE DAYS and present most of the day, nearly every day. B. During the period of mood disturbances and increased energy or 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: 1) Inflated self-esteem or grandiosity 2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3) More talkative than usual or pressure to keep talking 4) Flight of ideas or subject experience that thoughts are racing. 5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7) Excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investment). C. The episode is associated with an unequivocal (LEAVING NO DOUBT) change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is NOT SEVERE enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance. **NOTE: a full hypomanic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. HOWEVER, caution is indicated so that one or two symptoms (increased irritability, edginess, agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. ***NOTE: These episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Manic Episode

A. 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 1 week and present most of the day, nearly every day (or ANY duration if hospitalization is necessary). B. During the period of mood disturbances 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. 1) Inflated self-esteem or grandiosity 2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3) More talkative than usual or pressure to keep talking 4) Flight of ideas or subject experience that thoughts are racing. 5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7) Excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investment). C. 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. D. The episode is not attributable to the physiological effects of a substance or to another medical condition. **Note: A full manic episode that emerges during antidepressant treatment but persists at a fully syndrome level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and a bipolar I diagnosis **Note Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Substance/medication induced bipolar and related disorder

A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all activities. B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2) 1) The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. 2) The involved substance is capable of producing the symptoms in criterion A. C. The disturbance is not better explained by a bipolar or related disorder. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress/impairment.

Bipolar and related disorder due to another medical condition

A. A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. B. There is evidence that the disturbances is the direct pathophysiological consequence of another medical condition. C. The disturbance is not better explained by a mental disorder D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant impairment

Bipolar I disorder

A. Criteria have been met for at least one manic episode B. The occurrence of the manic and major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Major depressive episode

A. Five or more of the following symptoms have been present during the same 2 week period and represent a chance from previous functioning; at least one of the symptoms is either (1) DEPRESSED MOOD or (2) LOSS OF INTEREST OR PLEASURE. *NOTE: Do not include symptoms that are clearly attributable to another medical condition. 1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (NOTE: in children/adolescents. can be irritable mood.) 2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.) 4) Insomnia or hypersomnia nearly every day 5) Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings or restlessness or being slowed down.) 6) Fatigue or loss of energy nearly every day. 7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. **NOTE: Major depressive episodes are common in bipolar I but are not required for the diagnosis. **NOTE: Responses to a significant loss may include the feelings of intense sadness, etc, that are listed in criterion A. Clinical judgment will need to be used to determine if normal response to loss or if major depression episode based off of culture, history, etc.

Cyclothymic Disorder

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 in children and adolescents), 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. C. Criteria for a major depressive, manic, or hypomanic episode have never been met D. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, etc. E. The symptoms are not attributable to the physiological effects of a substance or another medical condition. F. the symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning.