How is Bipolar Disorder Diagnosed?

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A mental health professional makes a diagnosis of bipolar disorder by taking a careful personal history from the client/patient. It is important to the therapist to learn the details that surround any stressful event or events in that person's life.

Most people with mania show hyperactivity in their thoughts, words, and actions. They usually speak rapidly and are commonly over-talkative. The manic phase of bipolar disorder, with its elevated or euphoric mood, usually begins over a period of one to two weeks. Severe irritability may cause some people with mania to experience and express rage quickly. If such a condition worsens, that person can lose control and the mania can lead to psychotic thinking and bizarre behavior.

No laboratory tests are required to make a diagnosis of bipolar disorder nor are there any physical conditions that must be met. However, it is very important not to overlook a physical illness that might mimic or contribute to this psychological disorder. If there is any question that the individual might have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. Laboratory tests might then be necessary as a part of the physical workup.

Diagnostic Criteria for a Manic Episode (DSM-IV-TR)

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The symptoms do not meet criteria for a Mixed Episode.
4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Diagnostic Criteria for a Major Depressive Episode (DSM-IV-TR)

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2).
   • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
   • 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 made by others)
   • 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 gains.
   • Insomnia or Hypersomnia nearly every day
   • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
   • fatigue or loss of energy nearly every day
   • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
   • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
   • 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
2. The symptoms do not meet criteria for a Mixed Episode.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Diagnostic Criteria for a Mixed Episode (DSM-IV-TR)

1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
2. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
3. The symptoms are not due to the direct physiological effects of a substance (e.g., a illicit drugs, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Diagnostic Criteria for a Hypomanic Episode (DSM-IV-TR)

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person 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, and there are no psychotic features.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

According to the DSM-IV-TR, a diagnosis of bipolar I disorder requires at least one manic or mixed episode, but may also include hypomanic or depressive episodes. A depressive episode is not required for a diagnosis of bipolar I disorder.

A diagnosis of bipolar II disorder requires neither a manic nor mixed episode, but requires at least one hypomanic episode and one major depressive episode.

A diagnosis of cyclothymic disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet the criteria for major depressive episodes.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the conditions laid out above, he or she receives a diagnosis of Bipolar, Not Otherwise Specified (NOS).

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Reviewed: 03/2006