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DSM-5 Diagnostic Criteria for Bipolar Disorder

Reviewed by: HU Medical Review Board | Last reviewed: September 2023

Bipolar disorder (BPD) is a mental health condition that doctors diagnose using a specific list of symptoms. Those symptoms are listed in a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). The fifth edition is the most current version of the DSM. It was last updated in 2022.1

The DSM-5 defines the basic types of BPD as:1

  • Bipolar 1 (BD-I) – The person has had at least 1 episode of mania and 1 episode of depression.
  • Bipolar 2 (BD-II) – The person has had at least 1 episode of depression and 1 episode of hypomania, but not mania and never psychosis.
  • Cyclothymic disorder, or cyclothymia – The person has cycled between episodes of hypomania and mild depression for at least 2 years (1 year for children) with no major depression or mania.

Each type of BPD has a unique list of symptoms doctors use to diagnose the condition. The specific symptoms are described in detail below.1

Doctors also recognize that there are types of BPD that do not fit these categories. These are grouped under the diagnosis of bipolar disorder, other specified or unspecified. These conditions may be caused by drug side effects, alcohol use, or another medical condition. Sometimes, the cause is unknown or the symptoms simply do not fit the usual criteria.1

Bipolar 1 disorder

To be diagnosed with bipolar type 1, a person must have had at least 1 episode of mania (manic episode) that lasted at least 7 days or required hospitalization. An episode of hypomania or major depression may come before or follow the manic episode.1

Mania

During a manic phase, a person may have an unusually and consistently “high” mood for most of the day. Or they may be extremely irritable instead. They also have unusually high energy compared to their typical level. Most people with bipolar 1 also experience bouts of major depression in addition to mania.1

Mania affects a person’s work, school, and social interactions in noticeable and significant ways. It sometimes requires a hospital stay to prevent the person from harming themselves or others.1

For a bipolar 1 diagnosis, a person must have 3 or more of the following symptoms of mania. These must be a change from the person’s usual behavior.1

  • Inflated or unrealistic self-esteem
  • Little or no need for sleep
  • More talkative or unable to stop talking
  • Racing thoughts, or thoughts coming so fast they don’t make sense when they talk
  • Distracted by unimportant or irrelevant things
  • Physically restless or agitated
  • Increase in goal-directed activities – May be social, sexual, or related to work or school
  • Involvement in risky activities with a high potential for painful consequences – Might include buying sprees, unwise sexual encounters, or foolish business investments
  • Hallucinations, delusions, or other signs that show someone cannot tell what is real and what is not (psychosis)

Depression

After a manic phase, a person with bipolar 1 often swings into an episode of major depression. To be considered bipolar depression, the episode must last for at least 2 weeks and be a change to the person’s regular life. Depression includes having 5 or more of the following symptoms on all or most days:1

  • Low mood or loss of interest or pleasure in activities
  • Feeling sad, hopeless, worthless, empty, or tearful
  • Significant weight loss or weight gain due to decreased or increased appetite (more than a 5 percent change in body weight in a month)
  • Sleeping too little (insomnia) or too much (hypersomnia)
  • Others reporting that the person seems restless, agitated, or slowed down
  • Fatigue or loss of energy
  • Feeling inappropriate guilt, possibly to the point of delusion
  • Inability to think, concentrate, or make decisions
  • Lack of movement, communication, or reactions to stimulus (catatonia)
  • Recurring thoughts of death or dying, making plans to die, or trying to die by suicide

Children and teens with major depression may appear irritable rather than sad. All of these symptoms are severe enough to cause significant distress and affect school, work, and social life.1

Bipolar 2 disorder

To be diagnosed with bipolar type 2, a person must have had at least 1 episode of major depression and at least 1 episode of hypomania (not mania). The depression must last at least 2 weeks, and the hypomania must last at least 4 days.1

The criteria for depression in bipolar 2 disorder is the same as for bipolar 1. But a person with bipolar 2 tends to have more episodes of depression. The depression lasts longer and is more severe than in people with major depressive disorder.1

Hypomania

Hypomania is a less severe form of mania. The person may feel unusually good or unusually irritable. They may be more active than usual. But they are often able to maintain their daily life. They may feel nothing is wrong or even good, but their loved ones often notice a difference.1

The DSM-5 defines an episode of hypomania as 3 or more of the following symptoms for at least 4 days, most of the time:1

  • Inflated or unrealistic self-esteem
  • Less need for sleep
  • More talkative than usual or unable to stop talking
  • Racing thoughts
  • Getting distracted by unimportant things around them
  • Physical agitation or increased goal-oriented activities
  • Involvement in unwise activities that will have painful consequences

While hypomania is not as severe as mania, it can still be disruptive in day-to-day life and may cause issues in work, school, etc. It does not require hospitalization or cause psychosis.1

Cyclothymic disorder

Cyclothymic disorder is also known as cyclothymia. To be diagnosed with cyclothymic disorder, a person must cycle between hypomania and depression without ever moving into full mania or major depression. The cycles must last for at least 2 years in adults and 1 year in children.1

Definitions of mild, moderate, and severe symptoms

Along with listing specific symptoms that must be present in BPD, the DSM-5 rates how severe episodes are by stage. These stages are called severity specifiers.1

Depression and mania, by definition, impact a person’s ability to function. So, they should always be taken seriously. But doctors can assign them a stage of severity based on the following criteria.1

The stages of mania are:1,2

  • Mild – The person meets the minimum number of symptoms for a manic episode.
  • Moderate – There is a significant increase in activities and a decrease in the person’s ability to make wise decisions for themselves.
  • Severe – The person needs supervision almost all the time to prevent them from harming themselves or others.

The stages of depression are:1,2

  • Mild – Few, if any, symptoms of depression are present. The intensity of these symptoms is distressing but manageable. They affect a person’s social life, school, or work, but the effects are minor.
  • Moderate – Here, there is more impact on the person’s life. The number and intensity of depression symptoms falls between those of the mild and severe stages.
  • Severe – Many or all symptoms of depression are present. The intensity of those symptoms is distressing and unmanageable. The person’s symptoms interfere with their ability to work, go to school, or socialize.

Your doctor will diagnose BPD through a process of elimination. They first need to rule out other health conditions, like hypothyroidism, that may cause bipolar-like symptoms. They must also rule out other mental health conditions that result in similar symptoms. These conditions include major depressive disorder, schizophrenia, and substance use disorder.1

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