Bipolar disorder

What it is

With a history of both major depression and mania, a patient is classified as having bipolar I disorder. A manic episode is a period of persistently elevated, expansive mood lasting for at least 1 week, and during the period of mood disturbance at least 3 of the following are present: 1) grandiosity; 2) decreased need to sleep; 3) more talkative than usual; 4) flight of idea or thought racing; 5) distractibility; 6) increased goal-directed activity at work, socially or sexually; 7) mood disturbance causing significant impairment in the patient's function; 8) the symptom not explained by another medical cause, substance misuse or another psychiatric illness. A second page puts the same feature list as 3 or more if the mood is elated and 4 or more if it is irritable.

Hypomania warrants the diagnosis of bipolar disorder type II. It differs from mania in three ways: no psychotic symptoms, no or minimal impairment in function, and the patient is not admitted in the hospital for the current episode. When symptoms of mania or hypomania overlap with symptoms of depression, the episode is called a mixed affective state; in DSM 5, bipolar disorder with mixed features is diagnosed when full criteria of a manic or hypomanic episode are met plus at least three symptoms of a depressive episode. The condition is set out in four named forms: 1) bipolar I, at least one manic or mixed episode, which may alternate with major depressive or hypomanic episodes; 2) bipolar II, at least one major depressive episode and one hypomanic episode, in a patient who does not meet criteria for full manic or mixed episodes - so what makes a case type II is the absence of a full manic or mixed episode, not the presence of the depression, and a patient with depression whose high phase never met criteria for mania is type II; 3) rapid cycling, four or more episodes, major depressive, manic, mixed or hypomanic, in 1 year; 4) cyclothymia, chronic and less severe than rapid cycling, with alternating episodes of hypomania and moderate depression, written elsewhere as 2 years or more of mood swings without full episodes. The episodes are told apart by how long they last: 1) mania, 1 week or more, with raised energy, a decreased need for sleep, grandiosity, distractibility and risky behavior, and hospitalization or psychosis makes it mania; 2) hypomania, 4 days or more, the same as mania but milder, with no hospitalization and no psychosis; 3) depression, 2 weeks or more, 5 symptoms or more including low mood or lost interest, with weight, appetite and sleep changes, guilt and SI, and it may include psychosis. The specifiers are rapid cycling, 4 or more episodes a year; mixed features, manic and depressive features at the same time; and mood-congruent psychosis, where the delusions match the mood, such as grandiosity.