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Changes to Bipolar Disorder Criteria Proposed in DSM-5

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Bipolar Disorder in DSMBipolar Disorder is characterized by radical mood swings with intense periods of mania and periods of depression. When these episodes of mania and depression simultaneously occur, it is known as a mixed episode.

In the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4), criteria for a mixed episode of Bipolar Disorder includes the simultaneous presence of a fully manic and a fully depressive syndrome nearly every day for at least one week.

However, clinicians often refer to mixed episodes of Bipolar Disorder when those episodes rarely meet the criteria listed in the DSM-4. That is because the current criteria are too restrictive and often not present. An incorrect diagnosis of a mixed episode can result in the wrong Bipolar Disorder treatment and underestimating a patient’s risk of suicide.

Proposed revisions to the upcoming DSM-5 would change the criteria for mixed episodes of Bipolar Disorder to better reflect clinical practice.

“[The proposed changes] would allow the clinician to indicate the presence of two to three manic or hypomanic symptoms occurring for at least two to three days simultaneously with a fully syndromal episode of depression,” Ellen Frank, Ph.D., distinguished professor of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania, told delegates at the 9th International Conference on Bipolar Disorder.

“So for the DSM-5, we set out to elaborate a set of criteria that are more consistent with the way in which the term ‘mixed episode’ is used — and more consistent with what is found in clinical epidemiologic studies,” she said.

Proposed Mixed Episode Bipolar Disorder Criteria

Under the proposed revisions to the DSM-5, a mixed episode of Bipolar Disorder would be diagnosed if full criteria are met for a manic or hypomanic episode with at least three depressive symptoms simultaneously occurring every day during the episode, according to a June 17 article on The symptoms of depression that need to occur include the following:

  • Hopelessness
  • Fatigue
  • Negative self-evaluation
  • Worry
  • Self-reproach/guilt
  • Suicidal ideation or behavior

A mixed episode of Bipolar Disorder would also be diagnosed if the full criteria for a major depressive episode are met along with at least three of the following hypomanic symptoms occurring simultaneously:

  • Increased energy and visible hyperactivity
  • Elevated mood
  • Accelerated speech
  • Racing thoughts
  • Decreased need for sleep
  • Grandiosity

According to the article, symptoms that are characteristic of both depression and mania – such as irritability, indecisiveness, and insomnia – are not included in the proposed mixed episode criteria.

Other Proposed Changes to Bipolar Disorder Criteria

The following changes have also been proposed to the diagnostic criteria for Bipolar Disorder:

  • Bipolar Disorder Not Otherwise Specified (NOS) would be broken into subcategories, including those for patients who have shorter durations of hypomania
  • The addition of “increased activity or energy” to the Criterion A section of the DSM, which currently looks for “a distinct period of abnormally and persistently elevated, expansive, or irritable mood”

The four-day duration required for the diagnosis of a hypomanic episode will likely go unchanged. This would preserve the diagnostic criteria for Bipolar II Disorder.

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