Bipolar I

Although depression is the prevailing mood state for many people who have a bipolar diagnosis, it’s the manic symptoms that dictate which particular diagnosis is given. Even one full-blown manic episode during a person’s lifetime—regardless of history of depression—equals bipolar I. However, there is an exception in each category for mood episodes caused by a medical condition or drug, legal or otherwise. Manic episodes are hard for observers to miss (although the person in mania may not see it), so that a diagnosis of bipolar I often occurs when someone has been hospitalized or has a brush with the law, or relatives insist on getting help.

Bipolar II

This diagnosis calls for at least one lifetime episode of major depression plus at least one hypomanic episode. It can be challenging for clinicians to distinguish bipolar II from major depressive disorder because people may not even recognize hypomania. “They’ve got more energy than usual, they’re more creative than usual, but they’re not experiencing it as a problem,” clinical psychologist Eric Youngstrom, PhD* says. And when he’s asking about past history, “people will remember if they’ve been hospitalized or gotten arrested, but anything less severe than that doesn’t seem as important once time has passed.”

Cyclothymic Disorder

This diagnosis indicates “there’ve been mood issues that haven’t gotten all the way to a depression, haven’t gotten all the way to mania, but they’ve lasted a long time,” Youngstrom says. Specifically, periods of manic symptoms and periods of depressive symptoms occur frequently over the span of at least two years, causing significant distress but never qualifying as a diagnosable mood episode. Moreover, the individual doesn’t stay symptom-free for more than two months at a time.

Other Specified Bipolar

Formerly called Bipolar Disorder Not Otherwise Specified, this is a kind of stopgap when symptoms don’t clearly indicate one of the other bipolar diagnoses. For example, hypomanic periods recur without any depressive interludes, or there are near-hypomanic episodes that don’t last four days or don’t have the right number of symptoms. DSM-5 gives more specifics on the various options for “other specified” and pushes for more documentation on “why the person doesn’t meet the full criteria for bipolar I or bipolar II,” Ellen Frank* says. “It gives us more clinical information about how to treat, about prognosis, and so on.”

Rapid cycling

This is not actually a diagnostic category. Rather, it’s a “specifier” that is added to the diagnosis to indicate that four or more separate mood episodes of any stripe occurred within a single year. It’s also a widely misunderstood term, often used to describe symptoms that fluctuate by the day or even the hour. Youngstrom prefers “rapid relapsing” or “rapid episoding” to indicate the pattern of distinct but recurring mood shifts. “What that tells us is that even if we get you back to where we want you, we have to be on guard for relapse because this has jumped you already four different times in the past year,” he explains.

With psychotic features

This specifier can be applied to either a manic or depressive episode to indicate a break with reality, such as hallucinations (seeing or hearing things which aren’t there) and delusions (believing things that aren’t true). Hearing voices, receiving special messages, taking on a different identity (often that of a religious or famous figure), and being convinced of a special mission (again, often religious) are common psychotic symptoms. Paranoia and disordered thinking (not making sense) are other hallmarks of psychosis. Catatonia (paralysis of movement and speech) can occur during severe depression.

With mixed features

This new specifier takes the place of “mixed episode” and can be applied when depressive features are present during an episode of mania or hypomania—Youngstrom uses the metaphor of vanilla ice cream with fudge swirled through—or features of mania or hypomania are present during an episode of major depression, which would be chocolate ice cream with marshmallow swirls.

With anxious distress

This specifier was added to indicate symptoms of anxiety that don’t meet the full criteria for panic disorder, generalized anxiety disorder or one of the other anxiety disorders. “This is an attempt to recognize the fact that even anxiety that doesn’t meet the full criteria for a disorder is something important to note and has implications for treatment,” Frank says

*Eric Youngstrom, PhD is a clinical psychologist and acting director of the Center of Excellence for Research and Treatment of Bipolar Disorder at the University of North Carolina at Chapel Hill, where he is also a professor of psychology and psychiatry. His clinic has been working on a “roadmap to better assessment” that plugs in a lot of information beyond DSM symptoms to make diagnosis more accurate.

**Ellen Frank is a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at the medical center’s Western Psychiatric Institute and Clinic.