3. Bipolar and Related Disorders
3.1. Bipolar I Disorder
3.2. Bipolar II Disorder
3.3. Cyclothymic Disorder
3.4. Substance/Medication-Induced Bipolar and Related Disorder
3.5. Bipolar and Related Disorder Due to Another Medical Condition
Bipolar and related disorders are separated from the depressive disorders in
DSM-5 and placed between the chapters on schizophrenia spectrum and other 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 diagnoses
included in this chapter are 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,
and unspecified bipolar and related disorder.
The bipolar I disorder criteria represent the modern understanding of the classic manic-depressive disorder or affective psychosis described in the nineteenth century, differing from that classic description only to the extent that neither psychosis nor the lifetime experience of a major depressive episode is a requirement. However, the vast majority of individuals whose symptoms meet the criteria for a fully syndromal manic episode also experience major depressive episodes during the course of their lives.
Bipolar II disorder, requiring the lifetime experience of at least one episode of major depression and at least one hypomanie episode, is no longer thought to be a "milder" condition than bipolar I disorder, largely because of the amount of time individuals with this condition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and social functioning.
The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years (for children, a full year) of both hypomanie and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression. A large number of substances of abuse, some prescribed medications, and several medical conditions can be associated with manic-like phenomena. This fact is recognized in the diagnoses of substance/medication-induced bipolar and related disorder and bipolar and related disorder due to another medical condition. The recognition that many individuals, particularly children and, to a lesser extent, adolescents, experience bipolar-like phenomena that do not meet the criteria for bipolar I, bipolar II, or cyclothymic disorder is reflected in the availability of the other specified bipolar and related disorder category. Indeed, specific criteria for a disorder involving short-duration hypomania are provided in Section III in the hope of encouraging further study of this disorder.
The essential feature of a manic episode is a distinct period during which there is an abnormally,
persistently elevated, expansive, or irritable mood and persistently increased
activity or energy that is present for most of the day, nearly every day, for a period of at
least 1 week (or any duration if hospitalization is necessary), accompanied by at least three
additional symptoms from Criterion B. If the mood is irritable rather than elevated or expansive,
at least four Criterion B symptoms must be present.
Mood in a manic episode is often described as euphoric, excessively cheerful, high, or "feeling on top of the world." In some cases, the mood is of such a highly infectious quality that it is easily recognized as excessive and may be characterized by unlimited and haphazard enthusiasm for interpersonal, sexual, or occupational interactions. For example, the individual may spontaneously start extensive conversations with strangers in public. Often the predominant mood is irritable rather than elevated, particularly when the individual's wishes are denied or if the individual has been using substances. Rapid shifts in mood over brief periods of time may occur and are referred to as lability (i.e., the alternation among euphoria, dysphoria, and irritability). In children, happiness, silliness and "goofiness" are normal in the context of special occasions; however, if these symptoms are recurrent, inappropriate to the context, and beyond what is expected for the developmental level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e., distinct from baseline), and the mood change occurs at the same time as symptoms that meet Criterion B for mania, diagnostic certainty is increased; however, the mood change must be accompanied by persistently increased activity or energy levels that are obvious to those who know the child well.
During the manic episode, the individual may engage in multiple overlapping new projects. The projects are often initiated with little knowledge of the topic, and nothing seems out of the individual's reach. The increased activity levels may manifest at unusual hours of the day.
Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked grandiosity, and may reach delusional proportions (Criterion Bl). Despite lack of any particular experience or talent, the individual may embark on complex tasks such as writing a novel or seeing publicity for some impractical invention. Grandiose delusions (e.g., of having a special relationship to a famous person) are common. In children, overestimation of abilities and belief that, for example, they are the best at a sport or the smartest in the class is normal; however, when such beliefs are present despite clear evidence to the contrary or the child attempts feats that are clearly dangerous and, most important, represent a change from the child's normal behavior, the grandiosity criterion should be considered satisfied. One of the most common features is a decreased need for sleep (Criterion B2) and is distinct from insomnia in which the individual wants to sleep or feels the need to sleep but is unable. The individual may sleep httle, if at all, or may awaken several hours earlier than usual, feeling rested and full of energy. When the sleep disturbance is severe, the individual may go for days without sleep, yet not feel tired. Often a decreased need for sleep heralds the onset of a manic episode.
Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individuals may talk continuously and without regard for others' wishes to communicate, often in an intrusive manner or without concern for the relevance of what is said. Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of speech often become more important than what is conveyed. If the individual's mood is more irritable than expansive, speech may be marked by complaints, hostile comments, or angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., depressive) Pole.
Often the individual's thoughts race at a rate faster than they can be expressed through speech (Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is severe, speech may become disorganized, incoherent, and particularly distressful to the individual. Sometimes thoughts are experienced as so crowded that it is very difficult to speak. Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external stimuli (e.g., the interviewer's attire, background noises or conversations, furnishings in the room) and often prevents individuals experiencing mania from holding a rational conversation or attending to instructions.
The increase in goal-directed activity often consists of excessive planning and participation in multiple activities, including sexual, occupational, political, or religious activities. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often display psychomotor agitation or restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media.
The increased activity criterion can be difficult to ascertain in children; however, when the child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations (not accounted for by sexual abuse or exposure to sexually explicit material), then Criterion B might be met based on clinical judgment. It is essential to determine whether the behavior represents a change from the child's baseline behavior; occurs most of the day, nearly every day for the requisite time period; and occurs in temporal association with other symptoms of mania.
The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless involvement in activities such as spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have catastrophic consequences (Criterion B7). The individual may purchase many unneeded items without the money to pay for them and^ in some cases, give them away. Sexual behavior may include infidelity or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually transmitted diseases or interpersonal consequences.
The manic episode must result in marked impairment in social or occupational functioning or require hospitalization to prevent harm to self or others (e.g., financial losses, illegal activities, loss of employment, self-injurious behavior). By definition, the presence of psychotic features during a manic episode also satisfies Criterion C. Manic symptoms or syndromes that are attributable to the physiological effects of a drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or another medical condition do not count toward the diagnosis of bipolar I disorder. However, a fully syndromal manic episode that arises during treatment (e.g., with medications, electroconvulsive therapy, light therapy) or drug use and persists beyond the physiological effect of the inducing agent (i.e., after a medication is fully out of the individual's system or the effects of electroconvulsive therapy would be expected to have dissipated completely) is sufficient evidence for a manic episode diagnosis (Criterion D). Caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a manic or hypomanie episode, nor necessarily an indication of a bipolar disorder diathesis. It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar I disorder, but it is not required to have hypomanie or major depressive episodes. However, they may precede or follow a manic episode. Full descriptions of the diagnostic features of a hypomanie episode may be found within the text for bipolar II disorder, and the features of a major depressive episode are described within the text for major depressive disorder.
During a manic episode, individuals often do not perceive that they are ill or in need of treatment and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany the manic episode. Some individuals may become hostile and physically threatening to others and, when delusional, may become physically assaultive or suicidal. Catastrophic consequences of a manic episode (e.g., involuntary hospitalization, difficulties with the law, serious financial difficulties) often result from poor judgment, loss of insight, and hyperactivity. Mood may shift very rapidly to anger or depression. Depressive symptoms may occur during a manic episode and, if present, may last moments, hours, or, more rarely, days.
Little information exists on specific cultural differences in the expression of bipolar I disorder. One possible explanation for this may be that diagnostic instruments are often translated and applied in different cultures with no transcultural validation. In one U.S. study, 12-month prevalence of bipolar I disorder was significantly lower for Afro-Caribbeans than for African Americans or whites.
Females are more likely to experience rapid cycling and mixed states, and to have patterns of comorbidity that differ from those of males, including higher rates of lifetime eating disorders. Females with bipolar I or II disorder are more likely to experience depressive symptoms than males. They also have a higher lifetime risk of alcohol use disorder than are males and a much greater likelihood of alcohol use disorder than do females in the general population.
The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one-quarter of all completed suicides. A past history of suicide attempt and percent days spent depressed in the past year are associated with greater risk of suicide attempts or completions.
Although many individuals with bipolar disorder return to a fully functional level between
episodes, approximately 30% show severe impairment in work role function. Functional
recovery lags substantially behind recovery from symptoms, especially with respect
to occupational recovery, resulting in lower socioeconomic status despite equivalent levels
of education when compared with the general population. Individuals with bipolar I
disorder perform more poorly than healthy individuals on cognitive tests. Cognitive impairments
may contribute to vocational and interpersonal difficulties and persist through
the lifespan, evex^ during euthymie periods.
Bipolar II disorder is characterized by a clinical course of recurring mood episodes consisting
of one or more major depressive episodes (Criteria A-C under "Major Depressive
Episode") and at least one hypomanie episode (Criteria A-F under "Hypomanie Episode").
The major depressive episode must last at least 2 weeks, and the hypomaruc episode
must last at least 4 days, to meet the diagnostic criteria. During the mood episode(s),
the requisite number of symptoms must be present most of the day, nearly every day, and
represent a noticeable change from usual behavior and functioning. The presence of a
manic episode during the course of illness precludes the diagnosis of bipolar II disorder
(Criterion B under "Bipolar II Disorder"). Episodes of substance/medication-induced depressive
disorder or substance/medication-induced bipolar and related disorder (representing
the physiological effects of a medication, other somatic treatments for depression,
drugs of abuse, or toxin exposure) or of depressive and related disorder due to another
medical condition or bipolar and related disorder due to another medical condition do not
count toward a diagnosis of bipolar II disorder unless they persist beyond the physiological
effects of the treatment or substance and then meet duration criteria for an episode. In
addition, the episodes must not be better accounted for by schizoaffective disorder and are
not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or
other specified or unspecified schizophrenia spectrum or other psychotic disorders (Criterion
C under "Bipolar II Disorder"). The depressive episodes or hypomanie fluctuations
must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criterion D under "Bipolar II Disorder"); however, for hypomanie
episodes, this requirement does not have to be met. A hypomanie episode that
causes significant impairment would likely qualify for the diagnosis of manic episode and,
therefore, for a lifetime diagnosis of bipolar I disorder. The recurrent major depressive episodes
are often more frequent and lengthier than those occurring in bipolar I disorder.
Individuals with bipolar II disorder typically present to a clinician during a major depressive
episode and are unlikely to complain initially of hypomania. Typically, the hypomanie
episodes themselves do not cause impairment. Instead, the impairment results
from the major depressive episodes or from a persistent pattern of unpredictable mood
changes and fluctuating, unreliable interpersonal or occupational functioning. Individuals
with bipolar II disorder may not view the hypomanie episodes as pathological or disadvantageous,
although others may be troubled by the individual's erratic behavior.
Clinical information from other informants, such as close friends or relatives, is often useful
in establishing the diagnosis of bipolar II disorder.
A hypomanie episode should not be confused with the several days of euthymia and restored energy or activity that may follow remission of a major depressive episode. Despite the substantial differences in duration and severity between a manic and hypomanie episode, bipolar II disorder is not a "milder form" of bipolar I disorder. Compared with individuals with bipolar I disorder, individuals with bipolar II disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/ or disabling. Depressive symptoms co-occurring with a hypomanie episode or hypomanie symptoms co-occurring with a depressive episode are common in individuals with bipolar Π disorder and are overrepresented in females, particularly hypomania with mixed features. Individuals experiencing hypomania with mixed features may not label their symptoms as hypomania, but instead experience them as depression with increased energy or irritability.
A common feature of bipolar II disorder is impulsivity, which can contribute to suicide attempts and substance use disorders. Impulsivity may also stem from a concurrent personality disorder, substance use disorder, anxiety disorder, another mental disorder, or a medical condition. There may be heightened levels of creativity in some individuals with a bipolar disorder. However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity has been found in unaffected family members. The individual's attachment to heightened creativity during hypomanie episodes may contribute to ambivalence about seeking treatment or undermine adherence to treatment.
The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise specified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher rates (2.7% inclusive) in youths age 12 years or older.
Whereas the gender ratio for bipolar I disorder is equal, findings on gender differences in
bipolar II disorder are mixed, differing by type of sample (i.e., registry, community, or
clinical) and country of origin. There is little to no evidence of bipolar gender differences,
whereas some, but not all, clinical samples suggest that bipolar II disorder is more common
in females than in males, which may reflect gender differences in treatment seeking
or other factors.
Patterns of illness and comorbidity, however, seem to differ by gender, with females being more likely than males to report hypomania with mixed depressive features and a rapid-cycling course. Childbirth may be a specific trigger for a hypomanie episode, which can occur in 10%-20% of females in nonelinieal populations and most typically in the early postpartum period. Distinguishing hypomania from the elated mood and reduced sleep that normally accompany the birth of a child may be challenging. Postpartum hypomania may foreshadow the onset of a depression that occurs in about half of females who experience postpartum "highs." Accurate detection of bipolar II disorder may help in establishing appropriate treatment of the depression, which may reduce the risk of suicide and infanticide.
Suicide risk is high in bipolar II disorder. Approximately one-third of individuals with bipolar II disorder report a lifetime history of suicide attempt. The prevalence rates of lifetime attempted suicide in bipolar II and bipolar I disorder appear to be similar (32.4% and 36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio of attempts to completed suicides, may be higher in individuals with bipolar II disorder compared with individuals with bipolar I disorder. There may be an association between genetic markers and increased risk for suicidal behavior in individuals with bipolar disorder, including a 6.5-fold higher risk of suicide among first-degree relatives of bipolar II probands compared with those with bipolar I disorder.
Although many individuals with bipolar II disorder return to a fully functional level between
mood episodes, at least 15% continue to have some inter-episode dysfunction, and
20% transition directly into another mood episode without inter-episode recovery. Functional
recovery lags substantially behind recovery from symptoms of bipolar II disorder,
especially in regard to occupational recovery, resulting in lower socioeconomic status despite
equivalent levels of education with the general population. Individuals with bipolar
II disorder perform more poorly than healthy individuals on cognitive tests and, with the
exception of memory and semantic fluency, have similar cognitive impairment as do individuals
with bipolar I disorder. Cognitive impairments associated with bipolar II disorder
may contribute to vocational difficulties. Prolonged unemployment in individuals
with bipolar disorder is associated with more episodes of depression, older age, increased
rates of current panic disorder, and lifetime history of alcohol use disorder.
The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance
involving numerous periods of hypomanie symptoms and periods of depressive symptoms
that are distinct from each other (Criterion A). The hypomanie symptoms are of
insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypomanic
episode, and the depressive symptoms are of insufficient number, severity, pervasiveness,
or duration to meet full criteria for a major depressive episode. During the initial
2-year period (1 year for children or adolescents), the symptoms must be persistent (present
more days than not), and any symptom-free intervals last no longer than 2 months
(Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major
depressive, manic, or hypomanie episode have never been met (Criterion C).
If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in
adults or 1 year in children or adolescents) experiences a major depressive, manic, or hypomanie
episode, the diagnosis changes to major depressive disorder, bipolar I disorder,
or other specified or unspecified bipolar and related disorder (subclassified as hypomanie
episode without prior major depressive episode), respectively, and the cyclothymic disorder
diagnosis is dropped.
The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders (Criterion D), in which ease the mood symptoms are considered associated features of the psychotic disorder. The mood disturbance must also not be attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) (Criterion E). Although some individuals may function particularly well during some of the periods of hypomania, over the prolonged course of the disorder, there must be clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged periods of cyclical, often unpredictable mood changes (e.g., the individual may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable).
The lifetime prevalence of cyclothymic disorder is approximately 0.4%-l%. Prevalence in
mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic
disorder is apparently equally common in males and females. In clinical settings, females
with cyclothymic disorder may be more likely to present for treatment than males.
The diagnostic features of substance/medication-induced bipolar and related disorder are essentially the same as those for mania, hypomania, or depression. A key exception to the diagnosis of substance/medication-induced bipolar and related disorder is the case of hypomania or mania that occurs after antidepressant medication use or other treatments and persists beyond the physiological effects of the medication. This condition is considered an indicator of true bipolar disorder, not substance/medication-induced bipolar and related disorder. Similarly, individuals with apparent electroconvulsive therapy-induced manic or hypomanie episodes that persist beyond the physiological effects of the treatment are diagnosed with bipolar disorder, not substance/medication-induced bipolar ^ d related disorder. Side effects of some antidepressants and other psychotropic drugs (e.g., edginess, agitation) may resemble the primary symptoms of a manic syndrome, but they are fundamentally distinct from bipolar symptoms and are insufficient for the diagnosis. That is, the criterion symptoms of mania/hypomania have specificity (simple agitation is not the same as excess involvement in purposeful activities), and a sufficient number of symptoms must be present (not just one or two symptoms) to make these diagnoses. In particular, the appearance of one or two nonspecific sjonptoms—irritability, edginess, or agitation during antidepressant treatment—in the absence of a full manic or hypomanie syndrome should not be taken to support a diagnosis of a bipolar disorder.
Etiology (causally related to the use of psychotropic medications or substances of abuse based on best clinical evidence) is the key variable in this etiologically specified form of bipolar disorder. Substances/medications that are typically considered to be associated with substance/medication-induced bipolar and related disorder include the stimulant class of drugs, as well as phencyclidine and steroids; however, a number of potential substances continue to emerge as new compounds are synthesized (e.g., so-called bath salts). A history of such substance use may help increase diagnostic certainty.
There are no epidemiological studies of substance/medication-induced mania or bipolar
disorder. Each etiological substance may have its own individual risk of inducing a bipolar
The essential features of bipolar and related disorder due to another medical condition are presence of a prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy predominating in the clinical picture that is attributable to another medical condition (Criterion B). In most cases the manic or hypomanie picture may appear during the initial presentation of the medical condition (i.e., within 1 month); however, there are exceptions, especially in chronic medical conditions that might worsen or relapse and herald the appearance of the manic or hypomanie picture. Bipolar and related disorder due to another medical condition would not be diagnosed when the manic or hypomanie episodes definitely preceded the medical condition, since the proper diagnosis would be bipolar disorder (except in the unusual circumstance in which all preceding manic or hypomanie episodes—or, when only one such episode has occurred, the preceding manic or hypomanie episode—were associated with ingestion of a substance/medication). The diagnosis of bipolar and related disorder due to another medical condition should not be made during the course of a delirium (Criterion D). The manic or hypomanie episode in bipolar and related disorder due to another medical condition must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning to qualify for this diagnosis (Criterion E).
Etiology (i.e., a causal relationship to another medical condition based on best clinical evidence) is the key variable in this etiologically specified form of bipolar disorder. The listing of medical conditions that are said to be able to induce mania is never complete, and the clinician's best judgment is the essence of this diagnosis. Among the best known of the medical conditions that can cause a bipolar manic or hypomanie condition are Cushing's disease and multiple sclerosis, as well as stroke and traumatic brain injuries.
Culture-related differences, to the extent that there is any evidence, pertain to those associated with the medical condition (e.g., rates of multiple sclerosis and stroke vary around the world based on dietary, genetic factors, and other environmental factors).
Gender differences pertain to those associated with the medical condition (e.g., systemic lupus erythematosus is more common in females; stroke is somewhat more common in middle-age males compared with females).
Functional consequences of the bipolar symptoms may exacerbate impairments associated with the medical condition and may incur worse outcomes due to interference with medical treatment. In general, it is believed, but not established, that the illness, when induced by Cushing's disease, will not recur if the Cushing's disease is cured or arrested. However, it is also suggested, but not established, that mood syndromes, including depressive and manic/hypomanie ones, may be episodic (i.e., recurring) with static brain injuries and other central nervous system diseases.