The DSM was created to help standardize the diagnosis of mental health disorders, including bipolar disorder. But this tool does have some limitations.

Understanding bipolar disorder begins with recognizing the crucial role the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) plays in accurately diagnosing the condition. For individuals experiencing mood changes, it can be a daunting journey to figure out what’s happening with their mental health.

The DSM-5-TR provides mental health professionals with a standardized approach to identifying and distinguishing between different types of bipolar disorder. This helps ensure that people receive the correct diagnosis and appropriate treatment.

Whether you’re a person living with bipolar disorder, a loved one of someone with this condition, or simply seeking to better understand the diagnostic process, this guide will walk you through the key criteria and methods that clinicians use to navigate the complexities of a bipolar disorder diagnosis.

The DSM-5-TR plays a crucial role in the identification and classification of bipolar disorder.

It helps clinicians categorize the condition based on observable mood episodes, such as mania, hypomania, and depression. These mood episodes serve as the foundation of the diagnostic process.

The DSM-5-TR outlines specific criteria for each type of bipolar disorder, guiding clinicians in determining whether a person’s symptoms align with the characteristics of a particular disorder.

The diagnostic process typically follows a two-step approach:

  1. The clinician identifies the mood episodes experienced by the patient.
  2. Second, the clinician assesses whether these episodes match up with the criteria for a specific bipolar disorder diagnosis.

The clinician’s goal is to make the most accurate diagnosis, which is essential for effective treatment planning.

The DSM describes three primary types of bipolar disorder, each with its own diagnostic criteria.

Bipolar I disorder

For a diagnosis of bipolar I disorder, the DSM-5-TR requires the presence of at least one manic episode.

A manic episode is characterized by an elevated, expansive, or irritable mood lasting for at least 7 days or requiring hospitalization due to the severity of symptoms. Additionally, the symptoms must be significant enough to cause a significant impairment in social, occupational, or other important areas of functioning.

Although a history of depressive episodes is common in individuals with bipolar I disorder, it is not a prerequisite for diagnosis.

Bipolar II disorder

Bipolar II disorder is diagnosed when a person experiences at least one hypomanic episode (a less severe form of mania) and at least one major depressive episode.

The hypomanic episode must last for at least 4 days and involve a noticeable change from regular behavior, but it does not cause the severe impairment seen in mania.

A major depressive episode is also required, which involves symptoms of depression lasting for at least 2 weeks and causing significant distress or impairment.

Other specified bipolar disorders and related disorders

The DSM-5-TR also includes categories for conditions that have bipolar-like symptoms but do not fully meet the criteria for bipolar I disorder or II disorder.

For example, cyclothymic disorder is characterized by alternating hypomanic and depressive symptoms lasting for at least 2 years.

Bipolar disorder unspecified applies when the symptoms involve mood elevation but do not fit the criteria for bipolar I disorder or bipolar II disorder.

Clinicians use several diagnostic methods to accurately assess and diagnose bipolar disorder, according to the DSM-5-TR:

  • Clinical interviews: The clinician will conduct structured or semistructured interviews to evaluate the person’s symptoms in relation to the DSM-5-TR criteria. These interviews allow the clinician to gather detailed information about the individual’s mood episodes and behavioral patterns.
  • Mood charting: The clinician may ask the person to maintain a daily record of their moods, sleep patterns, and other relevant factors. This documentation helps clinicians track the frequency, duration, and intensity of mood changes, which are critical for accurate diagnosis.
  • Screening tools: Standardized assessment tools, such as the Patient Health Questionnaire 9-item depression scale (PHQ-9), can help identify potential symptoms of bipolar disorder. These tools are useful for identifying areas of concern that require further evaluation.
  • Differential diagnosis: Clinicians must differentiate bipolar disorder from other mental health conditions that share similar symptoms, such as major depressive disorder, borderline personality disorder, and substance-induced mood disorders.

The DSM-5-TR allows clinicians to specify certain patterns when diagnosing bipolar disorder, which can help guide treatment decisions. These include:

  • Rapid cycling: This refers to the occurrence of four or more mood episodes within a 12-month period. Rapid cycling is associated with a more complex and challenging course of bipolar disorder.
  • Seasonal pattern: This indicates that mood episodes tend to occur at specific times of the year, such as during the winter months, which can influence treatment planning.
  • Mixed features: When a person meets the criteria for one mood pole (either mania/hypomania or depression) but experiences symptoms of the opposite pole during the episode, this is known as mixed features. For example, a patient may exhibit depressive symptoms while experiencing elevated mood.

Despite its usefulness, the DSM-5-TR’s criteria-based approach to diagnosing bipolar disorder is not without challenges:

  • Diagnostic delay: Research from 2020 shows that the average delay between symptom onset and diagnosis is around 6 to 7 years, and it can last up to 15 years. This delay can result in missed opportunities for early intervention and effective treatment.
  • Overlap with other disorders: Bipolar disorder shares symptoms with other mental health conditions, such as major depressive disorder and borderline personality disorder. This overlap can complicate the diagnostic process, making it difficult to distinguish between disorders.
  • Reliance on self-reporting: An accurate diagnosis often depends on a person’s self-report of their symptoms, but individuals may lack insight into their condition or have difficulty recalling past episodes, particularly hypomanic episodes. This can result in misdiagnosis.
  • Cultural considerations: The DSM-5-TR acknowledges that cultural factors can influence the presentation of symptoms. Clinicians must be mindful of cultural differences in how mood episodes are expressed or interpreted, as these differences can affect diagnosis.

The DSM-5-TR provides a standardized framework for diagnosing bipolar disorder, but an effective diagnosis requires clinical expertise, comprehensive assessment, and often, long-term observation.

Clinicians must use various diagnostic methods to ensure an accurate understanding of a person’s condition and differentiate bipolar disorder from other mental health disorders.

By considering the full range of symptoms and course patterns, clinicians can make a more informed diagnosis, leading to more effective treatment and better outcomes for people living with bipolar disorder.