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. Following are the DSM-5 diagnostic criteria for each mood episode type.
Manic episode
A manic episode is a period of abnormally elevated energy and mood that interferes with a person's ability to function as he normally does. 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 "abnormally and persistently elevated, expansive, or irritable mood and abnormally 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 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 shift topics rapidly and indiscriminately — and/or the feeling that one's thoughts are racing
Inability to concentrate and being easily distracted by insignificant external stimuli
Significant increase in goal-directed activity (socially, at work or school, or sexually) or significant physical movement or agitation (aimless activity)
Excessive involvement in risky, potentially self-destructive activities, including sexual indiscretions, unrestrained shopping sprees, and optimistic investments in pyramid schemes
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 herself or others, or
Cause psychotic features (paranoia, hallucinations, or delusions) indicating that the person is out of touch with reality
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 that is caused by a medical condition is identified as a separate form 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 your hypomanic behavior may make people around you uncomfortable. On the other hand, hypomania can make you more engaging, so you may become the center of attention, at least until the mania intensifies, which may bring much unwanted attention.
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 must be present for at least two weeks straight. These symptoms must be changes from usual behavior, and the episode must include at least one symptom of depressed mood or loss of interest or pleasure.
Depressed mood most of the day nearly every day
Markedly diminished interest nearly every day in activities previously considered pleasurable, which may include sex
Notable increase or decrease in appetite nearly every day or a marked change in weight, up or down (5 percent or more) in a span of one month or less that isn't due to planned dietary changes
Sleeping too much or too little nearly every day
Moving uncharacteristically slowly or having physical agitation observable by others, not just internal sensations
Daily fatigue
Feelings of worthlessness, excessive guilt, or inappropriate guilt nearly every day
Uncharacteristic indecisiveness or diminished ability to think clearly or concentrate on a given task nearly every day, experienced internally and/or observed by others
Recurrent thoughts of death or suicide (suicide ideation), a suicide attempt, or a plan to commit suicide
These symptoms must cause significant problems in your day-to-day life and function to qualify as indicators of a major depressive episode. If they occur solely in response to use of a medication or substance, or another medical condition, then the episode has its own category, such as substance/medication-induced depressive disorder or depressive disorder due to another medical condition, and, therefore, doesn't count toward a diagnosis of either unipolar or bipolar depression.
Of course, people who experience a significant loss or crisis in their lives may have many of these same symptoms. Doctors must rely on their clinical experience, observations, and what their patient tells them in order to determine whether the person is experiencing a major depressive episode or intense sadness that's a normal part of the grieving process. In addition, cultural factors may play a role in how deeply a person feels and expresses emotion in response to a loss.
Not your average moodiness
Most people experience mood fluctuations to some acceptable degree, but bipolar mood episodes are amplified and extend far beyond the levels of discomfort — to the point of impairing a person's ability to function and enjoy life. Episodes associated with bipolar disorder make a person think, feel, speak, and behave in ways that are extremely uncharacteristic of the individual. And they may drag on for weeks or even months. They strain relationships, disrupt lives, and often land people in the hospital or in legal trouble. And they're not something a person can just snap out of. The figure illustrates the difference between normal mood fluctuations and those related to bipolar disorder.
