Understanding Bipolar Disorders in the DSM-5

According to the World Health Organization, about 40 million people live with bipolar disorder ^[1]. This is a startling number who must deal with the extreme and sometimes overwhelming highs and lows of mania, hypomania, and depression. But it is not a one-size-fits-all condition. In fact, there are a number of different types of bipolar disorder, and it is commonly misdiagnosed.

For a person to receive the proper support and treatment, it is vital that their form of bipolar disorder is correctly understood and diagnosed. Whether it’s the dramatic highs of bipolar I disorder, the subtler but still distressing shifts in bipolar II disorder, or the ongoing ups and downs of cyclothymia, understanding their differences paves the way for treatment and healing.

So, let’s break down what we need to know about the varying forms bipolar disorder can take.

Bipolar I Disorder

To be diagnosed with bipolar I or Type I bipolar disorder, a person needs to have at least one manic episode lasting for at least seven consecutive days, or it needs to be severe enough that a person should be hospitalized ^[2].

This manic episode is the defining feature of this type of bipolar disorder, as hypomania or major depression may or may not be present.

But what exactly defines a manic episode? While it may look different depending on the person, the major signs and symptoms are described below:

• A person could exhibit a marked “elevated” mood or excessive happiness, or they may be excessively irritable.
• They typically show an uncharacteristic spike in energy levels, seeming hyperactive to those around them.
• They may become extremely impulsive and lack any understanding of consequences. This could include excessive spending, risky sexual behavior, reckless driving, substance use, or other sudden, excessive, and risky behaviors that have potentially severe implications.
• In a severe episode, a person may also show psychotic symptoms, such as delusions and hallucinations. These psychotic symptoms can complicate the diagnosis for clinicians.

Remember, a diagnosis of bipolar I disorder requires at least one manic episode lasting one week or longer. If the symptoms are extremely severe, a person may need to be hospitalized for their own safety.
However, although the hallmark is the manic episode, many people with bipolar I disorder also experience major depressive episodes that can last for weeks and make it extremely difficult to function. They also may or may not have hypomanic episodes, which are much milder than full mania.

Bipolar II Disorder

Bipolar II disorder is specifically characterized by at least one major depressive episode (lasting at least two weeks) and at least one hypomanic episode (lasting at least four days), without any history of full manic episodes ^[3].

This means the main differences between bipolar I and bipolar II disorders are the absence of mania in bipolar II disorder and, instead, the focus on cycling between the “high” of hypomania and the “low” of depression.

Individuals with bipolar II disorder also tend to suffer more depressive episodes, so they often seek help for depression. Because they may not be aware of their hypomanic episodes, these cases are often misdiagnosed as depression. In fact, studies suggest that its lifetime prevalence may be around 5%, much higher than the 0.5% previously thought ^[3].

The table below compares the symptoms of hypomania and depression, but keep in mind that, unlike manic episodes, hypomanic episodes do not require hospitalization and are less likely to impair functioning in daily life. Although this isn’t to say that a hypomanic episode is not disruptive or difficult to navigate.

Symptoms	Hypomania	Depression
Mood	Elevated (happy or excited) or irritable	Sad, empty, or irritable
Energy Levels	Increased	Fatigue, apathy, or loss of energy
Sleep Patterns	Decreased need for sleep	Insomnia or hypersomnia
Thoughts	Racing thoughts, flight of new ideas	Difficulty concentrating, indecisiveness, brain fog
Activity Levels	More goal-directed activities, may start a number of new hobbies or activities	Loss of interest and pleasure in activities or hobbies; can struggle to complete daily tasks (like showering or getting out of bed) in severe cases
Talkativeness	Excessive talking or feeling pressure to speak	Withdrawn, reduced communication, may self-isolate
Self-Perception	Inflated self-esteem and confidence or grandiosity	Feelings of worthlessness, inadequacy, shame, or excessive guilt
Risk-Taking	Impulsive, high-risk behaviors	Thoughts of death or suicidal ideation

Cyclothymic Disorder

Cyclothymic disorder, also known as cyclothymia, features chronic periods of hypomanic and depressive symptoms, much like bipolar II disorder, except they do not meet the full criteria for either manic or major depressive episodes ^[4].

While cyclothymia includes numerous periods of time with hypomanic symptoms (like increased energy and irritability) and depressive signs (like prolonged sadness), they are usually milder and less intense than those experienced with bipolar II disorder.

Nevertheless, these episodes are still chronic, lasting for at least two years for the diagnosis (or one year for children and teens). A person with cyclothymia will have these symptoms for more than half the time during these two years, and their symptom-free intervals don’t last longer than two months.

This chronic nature of the disorder means that even though the symptoms are considered milder, it is still distressing, affecting a person’s quality of life and their ability to function.

More troubling is that cyclothymia can often be a precursor to more severe issues, such as bipolar I or II disorders.

Rapid-Cycling Bipolar Disorder

Rapid cycling bipolar disorder is not a different kind of bipolar disorder so much as a “course specifier” or a specific way that bipolar disorder can manifest in a person. It involves a specific pattern of four or more distinct mood episodes (which can include manic, hypomanic, or depressive episodes) within a 12-month period ^[5].

These episodes can often happen back-to-back. To qualify, a manic episode has to last at least seven days, hypomania has to last at least four days, and a major depressive episode needs to last at least two weeks.

Each episode must be distinct from the other, followed by either its opposite (such as a manic episode followed by a depressive episode) or a period of remission (no symptoms) after an episode.

This kind of bipolar disorder can occur in as many as 5% to 33% of bipolar disorder cases, and it is more common in women and those with bipolar II type. There is a link between episodes that start with depression and are treated with antidepressants and rapid-cycling ^[6].

Bipolar Disorder with Mixed Features

Bipolar disorder with mixed features is gaining recognition among clinicians, and it tends to be more severe than other forms. It is one of the more complex forms, where a person may experience symptoms of both mania and depression in the same episode at the same time ^[7].

This means that during a single episode a person may have the high energy levels typical in mania while also expressing the hopelessness and sadness of depression.

According to the Diagnostic and Statistical Manual of Mental Disorder (DSM-5), the criteria for diagnosing mixed features include:

• The presence of at least three manic or hypomanic symptoms during a depressive episode, or,
• the presence of at least three depressive symptoms during a manic or hypomanic episode.

This confusing mix of symptoms can make this disorder very hard to diagnose, and it can also complicate treatment. Bipolar disorder with mixed features often has more comorbid conditions and, sadly, also has a higher rate of suicide than other forms of bipolar disorder. It is one of the hardest types of bipolar to function with and can be the most resistant to treatment, so it is vital to diagnose it correctly as early as possible.

Seasonal Affective Bipolar Disorder

Seasonal affective bipolar disorder is a subtype that features mood episodes linked to the changing seasons. This could be depressive episodes in the winter and manic or or hypomanic episodes in the spring or summer ^[8].

Signs and symptoms over the seasons tend to vary:

Season	Typical Pattern & Symptoms	Less Common (Opposite) Pattern & Symptoms
Fall/Winter	Depressive Episodes – Low energy, loss of interest – Hypersomnia – Weight gain (carb cravings)	Manic/Hypomanic Episodes – Elevated mood – Increased energy – Heightened activity levels
Spring/Summer	Manic/Hypomanic Episodes – Elevated mood – Increased energy – Heightened activity levels	Depressive Episodes – Low energy, loss of interest – Hypersomnia – Weight gain (carb cravings)

About 15% to 22% of people with bipolar disorder report their moods changing with the seasons, and naturally, the lack of sunlight in the winter can affect the mood of the general population.

For clinicians, it can be recognized as a form of bipolar disorder with a seasonal pattern, where mood episodes align with specific times of the year.

The DSM-5 recognizes this pattern under the broader category of seasonal affective disorder (SAD), which can occur alongside bipolar disorders.

Unspecified Bipolar Disorder (NOS)

Unspecified bipolar disorder, also known as bipolar disorder not otherwise specified (NOS), is a category used for patients who show symptoms that look consistent with bipolar disorder but do not meet the full criteria for any specific type ^[9].

Unspecified bipolar disorder is diagnosed when:

• Symptoms are present that resemble those of bipolar disorder, such as mood swings, irritability, or changes in energy levels.
• However, the symptoms do not meet the criteria for any specific type of bipolar disorder, including bipolar I, bipolar II, or cyclothymic disorder. They may not last long enough or be severe enough to qualify for those diagnoses.

Those with unspecified bipolar disorder may experience:

• Manic or hypomanic symptoms that are too brief to meet the criteria for a manic episode.
• Depressive symptoms that do not last long enough to qualify as a major depressive episode.
• Rapid cycling between mood states that does not meet the criteria for the duration of rapid cycling disorder.

This kind of bipolar is usually diagnosed when doctors can’t make a clear diagnosis right away. This usually happens when they don’t have enough information, like in emergency situations where things are moving fast or with a lack of sufficient historical information.

Also, other factors, like drugs or health problems, might influence the symptoms, so more tests and time are needed before a clinician can diagnose another kind of bipolar disorder. Yet, the person still needs treatment for their mood fluctuations in order to be able to function.

Importance of an Accurate Bipolar Diagnosis

Getting the right diagnosis for bipolar disorder is crucial because it helps doctors choose the right treatment. If someone is misdiagnosed, they might end up taking the wrong medication, which can make things worse and cause unnecessary harm to the patient ^[10].

Why Diagnosing Bipolar Disorder is Complicated

Each type of bipolar has different symptoms and treatment approaches. Around 60% of people are initially misdiagnosed, often thought to be traditional depression ^[11]. This frequently occurs because they see a doctor during a depressive episode and may not realize or mention the times when they feel overly energetic or impulsive.

What Happens If It’s Misdiagnosed?

If bipolar disorder isn’t diagnosed correctly, it can lead to a number of complications:

• People might be given antidepressants without mood stabilizers, which can inadvertently trigger manic episodes or possible rapid cycling.
• It often takes 5 to 10 years to get the right diagnosis, meaning people struggle longer than they need to and delaying correct treatment.
• Misdiagnosis doesn’t just hurt the person dealing with it; it also puts stress on their family and increases healthcare costs in the long run.

How to Improve Diagnosis

To make sure someone gets the right diagnosis, clinicians need to do these things:

• Conduct thorough interviews about past mood swings, not just current feelings.
• Use screening tests that can point out possible bipolar disorder signs.
• Check family history since bipolar disorder can run in families.
• Work through a comprehensive differential diagnosis to make sure there are no other explanations, such as substance use.

When bipolar disorder is diagnosed correctly, people can get the right treatment, helping them feel better and live a more balanced life.

Conclusion

While the markers of bipolar are episodes of hypomania, mania, and depression, the exact pattern and ways these episodes present can differ vastly. Since this disorder is so often misdiagnosed, it is absolutely critical that clinicians identify the markers of the different types as early as possible.

An early, correct diagnosis can set the foundation for a treatment plan that best helps the individual manage their disorder and improve their quality of life.