Chapter 1

Grasping Bipolar Disorder: Symptoms and Diagnosis

IN THIS CHAPTER

Meeting the manual used to diagnose bipolar disorder

Recognizing the two "poles" of bipolar: mania and depression

Telling the difference between bipolar I, bipolar II, and other types

Augmenting the diagnosis with specifiers and distinguishing it from other conditions

Diagnosing bipolar in children . or not

When you initially encounter bipolar disorder, one of the first questions you're likely to ask is, "What is it?" The short answer is this: Bipolar disorder is a medical illness characterized by alternating periods of persistent abnormally elevated and depressed mood. The second question that most people ask is, "Can I get tested for it?" And the short answer is no. Doctors arrive at a diagnosis by conducting a physical and mental status examination; taking a close look at a person's symptoms, medical history, and family history; and ruling out other possible causes. For guidance, doctors use a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which presents the diagnostic criteria for determining whether a person is likely to have bipolar disorder.

This chapter digs deep into the DSM to reveal what bipolar disorder is and isn't. It describes what elevated and depressed moods look like and provides you with the details you need to tell the difference between the various bipolar diagnoses, including bipolar I, bipolar II, and a related cycling mood disorder called cyclothymia. We discuss diagnostic specifiers that enable doctors to more precisely describe a person's symptoms and inform their treatment decisions. We distinguish bipolar disorder from conditions that may have similar symptoms and discuss other conditions that commonly accompany bipolar disorder, such as alcohol and substance use disorder. We wrap up with a discussion of the challenges of diagnosing bipolar in children and young adults.

Cracking Open the Diagnostic Manual: DSM-5-TR

When a doctor in the United States diagnoses a mental illness, such as bipolar disorder, they turn to the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) for guidance. This manual defines numerous patterns of symptoms and illnesses that are supported by scientific research and a consensus among a wide variety of experts. During the writing of this book, the APA recommends using DSM-5-TR, the fifth edition text revision, which was published in March 2022. Don't be surprised if you see references to earlier editions, such as DSM-IV, the fourth edition.

Throughout this chapter, we describe the symptoms of bipolar disorder according to the diagnostic criteria presented in DSM-5-TR. Although the fundamental criteria haven't changed much over the past decade, some of the language has been modified and criteria have been added in the most recent edition to help doctors arrive at and describe a person's condition more precisely.

Diagnosis isn't a simple matter of matching a list of symptoms to a label. Doctors are expected to use the DSM along with their training, clinical experience, and professional judgment to arrive at the correct diagnosis.

THE INTERNATIONAL CLASSIFICATION OF DISEASES (ICD)

Doctors in countries throughout the world rely on the World Health Organization's (WHO) International Classification of Diseases, a classification system for all health issues. Chapter V of the ICD specifically addresses mental and behavioral disorders. The first edition of DSM (DSM-I), in 1952, grew out of ICD-6, which was the first ICD to include a section on mental disorders. Since 1980, Medicare and Medicaid (and therefore all other insurers) have required an ICD-9 code to be submitted for payment to be made. The DSM-III was released at the same time, and it designated ICD-9 codes for all psychiatric diagnoses. When DSM-5 was released in 2013, the authors added ICD-10 codes in anticipation of the 2015 transition of all medical billing systems to ICD-10. Although the two systems have always had their differences, the current systems are closely aligned.

The APA and WHO work together closely to coordinate their efforts. So, in clinical practice, a doctor using one manual should arrive at a similar diagnosis as a doctor using the other.

Exploring the Poles of Bipolar Disorder: Mania and Depression

Bipolar diagnoses rely heavily on the type of mood episode(s) a person is experiencing or has experienced in the past, so to understand the different diagnoses, you need to know what constitutes a mood episode - specifically a manic, hypomanic, and major depressive episode. In the following sections, we present the DSM-5-TR diagnostic criteria for each type of mood episode.

Manic episode

A manic episode is a period of abnormally elevated energy and mood that interferes with a person's ability to function as typical for that individual. Merely having some manic symptoms isn't the same as experiencing a manic episode. The symptoms must meet the following four criteria.

Distinct period

The episode must last for at least one week or require hospitalization, and it must be characterized by atypically and persistently elevated, expansive, or irritable mood and atypically and persistently increased goal-directed activity or energy that's "present most of the day, nearly every day."

Three or more manic symptoms

Three of the following symptoms must also be present during the week of mania (four, if the mood is irritable rather than elevated or expansive). The symptoms must be present to a significant degree and represent a change from the person's usual behavior.

• Markedly inflated self-esteem or grandiosity
• Decreased need for sleep (for example, feeling well rested after three hours or less of sleep)
• Excessive talking or the need to talk continuously (pressured speech)
• Flight of ideas - when thoughts flow rapidly and topics shift rapidly and indiscriminately - and/or the feeling that one's thoughts are racing
• Distractibility - attention too easily drawn to unimportant or irrelevant external stimuli as reported or observed
• Significant increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation - purposeless, non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences, including sexual indiscretions, unrestrained shopping sprees, and/or overly optimistic investments

Functional impairment

The mood episode must be severe enough to

• Impair the person's ability to socialize or work, or
• Require hospitalization to prevent the person from harming themselves or others, or
• Cause psychotic features (paranoia, hallucinations, or delusions) indicating that the person is out of touch with reality (see the section, "Presence or absence of psychosis," later in this chapter)

Not caused by something else

For a manic episode to count toward bipolar diagnosis, the mania must satisfy the following conditions:

• The mania can't be exclusively drug-induced or attributed to medical treatments. For example, if you're taking an antidepressant, steroid, or cocaine at the time you experience manic symptoms, then the episode doesn't count toward a diagnosis of bipolar disorder, unless symptoms persist after the effects of the substance have worn off.
• The mania isn't attributable to another medical condition. Mania caused by a medical condition is identified as a separate form of bipolar disorder, as described in the later section, "Distinguishing Types of Bipolar Disorder."

Hypomanic episode

A hypomanic episode requires the same number and types of symptoms as a manic episode that we discuss in the preceding section. For instance, the symptoms must represent a distinct change from a person's usual behavior patterns, and the changes must be observable by others. However, a hypomanic episode differs from a manic episode in the following ways:

• May be shorter in duration (just four consecutive days is enough to qualify as a hypomanic episode)
• Doesn't cause severe functional impairment
• Doesn't require hospitalization
• Doesn't include psychosis

Hypomania doesn't typically result in serious relationship problems or extremely risky behavior, but it may make others feel uncomfortable. On the other hand, hypomania can make you more engaging, so you may become the center of attention, which may feel good to some people or awful to others. For some people, hypomania creates periods of high creativity and/or productivity that are positive experiences.

Major depressive episode

During a major depressive episode, you may feel like you're swimming in a sea of molasses. Everything is slow, dark, and heavy. To qualify as a major depressive episode, five or more of the following symptoms...