Diagnosis of Bipolar Disorder
The DSM-IV-TR describes criteria that must be present when making the diagnosis of all mental disorders. Sections of the DSM are written by committees of experts to ensure that the latest science is incorporated, and that common standards for diagnosis are made available to all professionals. The severity of manic and depressive episodes that a bipolar person experiences determines how they will be diagnosed. The DSM's chapter on bipolar disorders presently includes Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar Disorder, Not Otherwise Specified (NOS). These diagnosis subtypes vary depending on the different patterns of mood amplitude (energy state) that different patients experience. In other words, the severity of ups and downs determines the appropriate diagnosis or sub-diagnosis. There are four defined bipolar disorders in the DSM-IV-TR, each defined by a particular pattern of severity of spontaneous depressions, manias, and hypomanias:
Bipolar I Disorder diagnosis is appropriate when a patient has experienced at least one complete full manic episode and one full major depressive episode.
Bipolar II Disorder diagnosis is appropriate when a patient has experienced at least one full major depressive episode, but no full manic episodes. Instead of a full manic episode, at least one hypomanic episode must have been experienced.
Cyclothymic Disorder is diagnosed when a patient has experienced repeated mood swings, none of which are severe enough to have met criteria for full mania or depression episodes.
Bipolar Disorder, Not Otherwise Specified (NOS) is diagnosed when a patient has bipolar symptoms that do not fit cleanly into the categories defined above.
Bipolar I Disorder
This form of bipolar disorder is characterized by a clinical history of both documented manic/mixed episodes and major depressive episodes, any of which might have been severe enough to have required hospitalization. A manic episode lasts for at least one week. During the manic episode, the patient feels elated and will generally display grandiose, talkative, hyperactive, impulsive and distractible behavior. Poor judgment during the manic episode can lead to marked social or occupational problems. In a mixed episode, the patient swings between mania and a major depression every day for less than a week. In a major depressive episode, a patient has at least 2 weeks of depressed mood or loss of interest in life with problems sleeping, trouble concentrating, feelings of guilt, loss of energy, and/or thoughts about death. One mood episode is said to have occurred when a person shifts from one mood state into another and then back again. Most individuals with bipolar I disorder will shift episode polarity repeatedly throughout their lives (moving from a depressed state into a manic state, or vice versa and then back again). Multiple months may be spent moving between states, however. Typically, each individual develops a personal pattern of episode timing to their disorder. They will tend to have manic episodes followed by depressive episodes in a characteristic pattern that is unique to them.
Suicide risk is a major concern for Bipolar I Disordered patients. The rate of completed suicide in these patients is between 10-15%. Suicidal behavior is most likely to occur during depressive or mixed states. During a manic phase, patients may participate in violent behavior, including behavior that would qualify as child and/or spouse abuse, but the risk of intentional suicide is less likely. Substance abuse issues, eating disorders, including anorexia nervosa and bulimia nervosa, attention-deficit / hyperactivity disorder, and anxiety disorders (including panic disorder and social phobia) may accompany bipolar I disorder.
There appears to be no distinction in the incidence of bipolar depression among men and women. Both sexes experience typical onset of the condition around age 20. However, the first episode in males tends to be manic and the first episode in females tends to be depressive. In men, the episodes of mania and depression are of approximately equal duration, whereas depression tends to dominate in women. Furthermore, rapid cycling is most likely to occur in women. Further complications of female biology such as hormones associated with pre-menstruation and postpartum are known to exacerbate already vulnerable moods (See our sections on PMDD and Endocrine Disturbances).
Lifetime prevalence of Bipolar I Disorder is 0.4%-1.6% in community samples.