Changes in the DSM-5 for Bipolar Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and contains the formal requirements for classifying and diagnosing mental illnesses. You will often find references to both the fourth and fifth editions of the DSM. The DSM-IV was published in 1994 and the DSM-5 replaced it in 2013.

The DSM is important because it contains diagnostic codes for mental illnesses, similar to those for physical illnesses. For example, if a doctor orders blood tests and gives you a paper to take to the lab, the lab may insist that there be a diagnostic code on the order because they have to provide it to an insurance company.

It's the same with mental illnesses: A psychiatrist can't simply tell your insurance, "This patient has bipolar disorder." A specific code must be provided for the type of bipolar disorder.

History of the DSM

The first edition of the DSM was published in 1952, listing 102 broad categories of disorders. Each of these included a short list of symptoms, along with some information about suspected causes.

The 1968 version contained 100 disorders, and in 1979, the third edition shifted away from psychoanalytic emphasis, contained over 200 diagnostic categories, and introduced the multi-axial system (Axis I to Axis V).

• Axis I - Clinical Disorders (including bipolar disorder)
• Axis II - Personality Disorders and Mental Retardation
• Axis III - General Medical Conditions
• Axis IV - Psychosocial and Environmental Problems (stressors)
• Axis V - Global Assessment of Functioning

DSM-IV was first published in 1994, and a revised edition was released in 2000, called the DSM-IV-TR (though the "TR," or text revision, often wasn't included in articles referencing the manual). While sticking with the Axis system, this edition broke diagnoses and symptoms down into sections or "decision trees," including which symptoms must be included for a diagnosis and which must not be present.

Changes in DSM-5

Published in 2013, the DSM-5 makes many changes. The most obvious of these is the switch from using Roman to Arabic numerals (it's called the DSM-5 instead of DSM-V).

Another significant change is that the Axis system was dropped. Instead, there are 20 chapters containing categories of related disorders. "Bipolar and Related Disorders" is one such category. Other examples are:

• Anxiety disorders
• Obsessive-compulsive and related disorders
• Depressive disorders
• Feeding and eating disorders
• Personality disorders

Bipolar Disorder in the DSM-5

Even though childhood bipolar disorder has been well-defined and used for many years, pediatric bipolar disorder is not a new diagnosis in the DSM-5. Instead, a category of depressive disorders has been added called disruptive mood dysregulation disorder (DMDD). The driver for this was a concern that the diagnosis of pediatric bipolar disorder was being inconsistently and overly applied to different types of childhood irritability.

For bipolar disorder under the DSM-5, there are now seven possible diagnoses:

• Bipolar I disorder
• Bipolar II disorder
• Cyclothymic disorder
• Substance/medication-induced bipolar and related disorder
• Bipolar and related disorder due to another medical condition
• Other specified bipolar and related disorder
• Unspecified bipolar and related disorder

Additional changes include:

• Elimination of "mixed episode." Instead, a manic, hypomanic, or depressive episode can be specified as "with mixed features," a specifier with its own definition in the manual.
• The bipolar II diagnosis in the DSM-IV excluded a history of mixed episodes. This exclusion has been removed, which was an important change.
• A subtle change is that the word "abnormally" was not included in the DSM-IV criterion A for a hypomanic episode, while it was in criterion A for a manic episode. In the DSM-5, this language is present for both episodes. This brings the full criteria for the two distinct types of episodes closer together.

Each type of bipolar disorder has what are called specifiers (such as "with mixed features," above or other specifiers such as "with anxious distress" or "with rapid cycling") that further clarify the illness.

Bipolar Disorder in the DSM-5-TR

The DSM-5-TR, issued in 2022, made some further changes to bipolar disorder. Criterion B in bipolar I disorder was revised.

• Original DSM-5 criteria: "The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder."

However, mood episodes can't be better explained by psychotic disorders because mood episodes are not symptoms of psychotic disorders (with the exception of schizoaffective disorder). The text was revised to the below.

• Revised DSM-5-TR criteria: "At least one manic episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder."

A similar change was made to criteria C for bipolar II. The DSM-5-TR reads: "At least one hypomanic episode and at least one major depressive episode are not better explained by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder."

The specifiers indicating the severity of a manic episode were also adjusted from the DSM-5 to the DSM-5-TR. Previously, the bipolar severity specifiers were mild, moderate, and severe. But these terms only made sense for labeling depressive episodes, not manic episodes. "Mild," in the DSM-5, indicated no impairment in functioning, whereas manic episodes are defined by impairment in functioning.

The specifiers for manic episodes were updated in the DSM-5-TR to the following:

• Mild: The manic episode meets the minimum symptom criteria
• Moderate: The manic episode causes a very significant increase in impairment
• Severe: The person experiencing the manic episode needs nearly continual supervision to prevent harm from being done to themselves and/or others