# 03 - Bipolar and Related Disorders

# Bipolar and Related Disorders

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Bipolar and Related Disorders
Bipolar and related disorders are found between the chapters on schizophrenia
spectrum and other psychotic disorders and depressive disorders in DSM-5-TR in recognition of
their place as a bridge between those two diagnostic classes in terms of symptomatology, family
history, and genetics. The diagnoses included in this chapter are 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, and unspecified bipolar and related disorder.
The bipolar I disorder criteria represent the modern understanding of the classic manicdepressive disorder or affective psychosis described in the nineteenth century, differing from that
classic description only to the extent that neither psychosis nor the lifetime experience of a major
depressive episode is a requirement. However, the vast majority of individuals whose symptoms
meet the criteria for a fully syndromal manic episode also experience major depressive episodes
during the course of their lives.
Bipolar II disorder, requiring the lifetime experience of at least one major depressive episode
and at least one hypomanic episode (but no history of mania), is no longer thought to be a less
severe condition than bipolar I disorder, largely because of the burden of depression in bipolar II
disorder and because the instability of mood experienced by individuals with bipolar II disorder
is often accompanied by serious impairment in work and social functioning.
The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years (for
children, a full year) of both hypomanic and depressive periods without ever fulfilling the criteria
for an episode of mania, hypomania, or major depression.
A large number of substances of abuse, some prescribed medications, and several medical
conditions can be associated with manic-like phenomena. This fact is recognized in the
diagnoses of substance/medication-induced bipolar and related disorder and bipolar and related
disorder due to another medical condition.
The recognition that there are individuals who experience bipolar-like phenomena with
symptoms that do not meet the criteria for bipolar I, bipolar II, or cyclothymic disorder is
reflected in the availability of the other specified bipolar and related disorder category. Specific
criteria for a disorder involving short-duration hypomania are provided in Section III in the hope
of encouraging further study of this presentation of bipolar disorder symptomatology and its
course.
Bipolar I Disorder
Diagnostic Criteria

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for
a manic episode. The manic episode may have been preceded by and may be
followed by hypomanic or major depressive episodes.
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if
hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to
a significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation (i.e., purposeless non-goal-directed
activity).
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in
social or occupational functioning or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment) or another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level
beyond the physiological effect of that treatment is sufficient evidence for a
manic episode and, therefore, a bipolar I diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder.
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at
least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual behavior, and have been
present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by
others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment
(e.g., medication, electroconvulsive therapy) but persists at a fully syndromal
level beyond the physiological effect of that treatment is sufficient evidence for a
hypomanic episode diagnosis. However, caution is indicated so that one or two
symptoms (particularly increased irritability, edginess, or agitation following
antidepressant use) are not taken as sufficient for diagnosis of a hypomanic
episode, nor necessarily indicative of a bipolar diathesis.
Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are
common in bipolar I disorder but are not required for the diagnosis of bipolar I
disorder.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2week period and represent a change from previous functioning; at least one of
the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical
condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, or hopeless) or observation made by
others (e.g., appears tearful). (Note: In children and adolescents, can be
irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or
observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite
nearly every day. (Note: In children, consider failure to make expected weight
gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
suicide.
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or
another medical condition.
Note: Criteria A–C constitute a major depressive episode. Major depressive
episodes are common in bipolar I disorder but are not required for the diagnosis of
bipolar I disorder.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from
a natural disaster, a serious medical illness or disability) may include the feelings of
intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss
noted in Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a
significant loss should also be carefully considered. This decision inevitably requires

the exercise of clinical judgment based on the individual’s history and the cultural
norms for the expression of distress in the context of loss.1
Bipolar I Disorder
A. Criteria have been met for at least one manic episode (Criteria A–D under
“Manic Episode” above).
B. 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.
Coding and Recording Procedures
The diagnostic code for bipolar I disorder is based on type of current or most recent
episode and its status with respect to current severity, presence of psychotic
features, and remission status. Current severity and psychotic features are only
indicated if full criteria are currently met for a manic or major depressive episode.
Remission specifiers are only indicated if the full criteria are not currently met for a
manic, hypomanic, or major depressive episode. Codes are as follows:
Bipolar I disorder
Current or
most
recent
episode
manic
Current or
most recent
episode
hypomanic*
Current or
most
recent
episode
depressed
Current or
most recent
episode
unspecified**
Mild (p. 175)
F31.11
NA
F31.31
NA
Moderate (p. 175)
F31.12
NA
F31.32
NA
Severe (p. 175)
F31.13
NA
F31.4
NA
With psychotic features*** (p. 173)
F31.2
NA
F31.5
NA
In partial remission (p. 175)
F31.73
F31.71
F31.75
NA
In full remission (p. 175)
F31.74
F31.72
F31.76
NA
Unspecified
F31.9
F31.9
F31.9
NA
*Severity and psychotic specifiers do not apply; code F31.0 for cases not in remission.
**Severity, psychotic, and remission specifiers do not apply. Code F31.9.
***If psychotic features are present, code the “with psychotic features” specifier irrespective of episode severity.
In recording the name of a diagnosis, terms should be listed in the following order:
bipolar I disorder, type of current episode (or most recent episode if bipolar I
disorder is in partial or full remission), severity/psychotic/remission specifiers,
followed by as many of the following specifiers without codes as apply to the
current episode (or the most recent episode if bipolar I disorder is in partial or full
remission). Note: The specifiers “with rapid cycling” and “with seasonal pattern”
describe the pattern of mood episodes.

Specify if:
With anxious distress (pp. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With melancholic features (pp. 171–172)
With atypical features (pp. 172–173)
With mood-congruent psychotic features (p. 173; applies to manic episode
and/or major depressive episode)
With mood-incongruent psychotic features (p. 173; applies to manic episode
and/or major depressive episode)
With catatonia (p. 173). Coding note: Use additional code F06.1.
With peripartum onset (pp. 173–174)
With seasonal pattern (pp. 174–175)
Diagnostic Features
Bipolar I disorder is characterized by a clinical course of recurring mood episodes (manic,
depressive, and hypomanic), but the occurrence of at least one manic episode is necessary for the
diagnosis of bipolar I disorder. The essential feature of a manic episode is a distinct period
during which there is an abnormally, persistently elevated, expansive, or irritable mood and
persistently increased activity or energy that is present for most of the day, nearly every day, for
a period of at least 1 week (or any duration if hospitalization is necessary), accompanied by at
least three additional symptoms from Criterion B. If the mood is irritable rather than elevated or
expansive, at least four Criterion B symptoms must be present.
Mood in a manic episode is often described as euphoric, excessively cheerful, high, or
“feeling on top of the world.” In some cases, the mood is of such a highly infectious quality that
it is easily recognized as excessive and may be characterized by unlimited and
haphazard enthusiasm for interpersonal, sexual, or occupational interactions. For example,
the individual may spontaneously start extensive conversations with strangers in public. Often
the predominant mood is irritable rather than elevated, particularly when the individual’s wishes
are denied or if the individual has been using substances. Rapid shifts in mood over brief periods
of time may occur and are referred to as lability (i.e., the alternation among euphoria, dysphoria,
and irritability). In children, happiness, silliness, and “goofiness” are normal in many social
contexts; however, if these symptoms are recurrent, inappropriate to the context, and beyond
what is expected for the developmental level of the child, they may meet the Criterion A mood
requirement of abnormally elevated mood. For the happiness or silliness of a child to meet
Criterion A, it must be distinctly increased from the child’s baseline and accompanied by
persistently increased activity or energy levels that to those who know the child well are clearly
unusual for that child. For a child’s symptoms to meet criteria for a manic episode, the symptoms

must also meet Criterion B for mania and must also represent a change from the child’s usual
baseline.
During the manic episode, the individual may engage in multiple overlapping new projects.
The projects are often initiated with little knowledge of the topic, and nothing seems out of the
individual’s reach. The increased activity or energy levels may manifest at unusual hours of the
day, such as during the individual’s normal sleep phase.
Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked
grandiosity, and may reach delusional proportions (Criterion B1). Despite lack of any particular
experience or talent, the individual may embark on complex tasks such as writing a novel or
seeking publicity for some impractical invention. Grandiose delusions (e.g., of having a special
relationship to a famous person) are common. In children, overestimation of abilities and belief
that, for example, they are the best at a sport or the smartest in the class is normal; however,
when such beliefs are present despite clear evidence to the contrary or the child attempts feats
that are clearly dangerous and, most important, represent a change from the child’s normal
behavior, the grandiosity criterion should be considered satisfied.
One of the most common features is a decreased need for sleep (Criterion B2), which is
distinct from insomnia (during which the individual wants to sleep or feels the need to sleep but
is unable to). The individual may sleep little, if at all, or may awaken several hours earlier than
usual, feeling rested and full of energy. When the sleep disturbance is severe, the individual may
go for days without sleep, yet not feel tired. Often decreased need for sleep heralds the onset of a
manic episode.
Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individuals
may talk continuously and without regard for others’ wishes to communicate, often in an
intrusive manner or without concern for the relevance of what is said. Speech is sometimes
characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms,
singing, and excessive gesturing. Loudness and forcefulness of speech often become more
important than what is conveyed. If the individual’s mood is more irritable than expansive,
speech may be marked by complaints, hostile comments, or angry tirades, particularly if attempts
are made to interrupt the individual. Both Criterion A and Criterion B symptoms may be
accompanied by symptoms of the opposite (i.e., depressive) pole (see “with mixed features”
specifier, pp. 170–171).
Often the individual’s thoughts race at a rate faster than can be expressed through speech
(Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow of
accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is severe,
speech may become disorganized, incoherent, and particularly distressing to the individual.
Sometimes thoughts are experienced as so crowded that it is very difficult to speak.
Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external
stimuli (e.g., the interviewer’s attire, background noises or conversations, furnishings in the
room) and often prevents individuals experiencing mania from holding a rational conversation or
attending to instructions.
The increase in goal-directed activity (Criterion B6) often consists of excessive planning and
participation in multiple activities, including sexual, occupational, political, or religious

activities. Increased sexual drive, fantasies, and behavior are often present. Individuals in a
manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or
contacting friends or even strangers), without regard to the intrusive, domineering, and
demanding nature of these interactions. They often also display psychomotor agitation or
restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations
simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on
many different topics to friends, public figures, or the media.
The increased activity criterion can be difficult to ascertain in children; however, when the
child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for
projects, develops previously absent and developmentally inappropriate sexual preoccupations
(not accounted for by sexual abuse or exposure to sexually explicit material), then Criterion B
might be met based on clinical judgment. It is essential to determine whether the behavior
represents a change from the child’s baseline behavior; occurs most of the day, nearly every day
for the requisite time period; and occurs in temporal association with other symptoms of mania.
The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to
reckless involvement in activities such as spending sprees, giving away possessions, reckless
driving, foolish business investments, and sexual indiscretions that are unusual for the individual,
even though these activities are likely to have catastrophic consequences (Criterion B7). The
individual may purchase many unneeded items without the money to pay for them and, in some
cases, give them away. Sexual indiscretions may include infidelity or indiscriminate sexual
encounters with strangers, often disregarding the risk of sexually transmitted diseases or
interpersonal consequences.
The manic episode must result in marked impairment in social or occupational functioning
(e.g., financial losses, loss of employment, school failure, divorce) or require hospitalization to
prevent harm to self or others (e.g., physical exhaustion or hyperthermia from manic excitement,
self-injurious behavior). By definition, the presence of psychotic features during a manic episode
also satisfies Criterion C.
Manic symptoms or syndromes that are attributable to the direct physiological effects of a
drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects of
medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or another medical
condition do not count toward the diagnosis of bipolar I disorder. However, a fully syndromal
manic episode that arises during treatment (e.g., with medications, electroconvulsive therapy,
light therapy) and persists beyond the physiological effect of the inducing agent (e.g., after a
medication is fully out of the individual’s system or the effects of electroconvulsive therapy
would be expected to have dissipated completely) is sufficient evidence for a manic episode that
is considered due to bipolar I disorder (Criterion D). Caution is indicated so that one or two
symptoms (particularly increased irritability, edginess, or agitation following antidepressant use)
are not taken as sufficient for diagnosis of a manic or hypomanic episode, nor necessarily an
indication of a bipolar disorder diathesis. Although not essential to a diagnosis of bipolar I
disorder, hypomanic or depressive episodes often precede or follow a manic episode. Full
descriptions of the diagnostic features of a hypomanic episode may be found within the text for
bipolar II disorder, and the features of a major depressive episode are described within the text
for major depressive disorder.

Associated Features
During a manic episode, individuals often do not perceive that they are ill or in need of treatment
and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or
personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper
sense of smell, hearing, or vision. Gambling and antisocial behaviors
may accompany the manic episode. Mood may shift very rapidly to anger or depression; some
individuals may become hostile and physically threatening to others and, when delusional,
become physically assaultive or suicidal. Serious consequences of a manic episode (e.g.,
involuntary hospitalization, difficulties with the law, serious financial difficulties) often result
from poor judgment, loss of insight, and hyperactivity. Depressive symptoms occur in some 35%
of manic episodes (see “with mixed features” specifier, p. 170), and mixed features are
associated with poorer outcome and increased suicide attempts. Bipolar I disorder is also
associated with significant decrements in quality of life and well-being.
Trait-like features associated with the diagnosis include hyperthymic, depressive,
cyclothymic, anxious, and irritable temperaments, sleep and circadian rhythm disturbances,
reward sensitivity, and creativity. Having a first-degree relative with bipolar disorder increases
the risk of diagnosis approximately 10-fold.
Prevalence
The 12-month prevalence of DSM-5 bipolar I disorder in a nationally representative U.S. adult
sample was 1.5% and did not differ between men (1.6%) and women (1.5%). Compared with
non-Hispanic Whites, prevalence of bipolar I disorder appears to be higher among Native
Americans and lower among African Americans, Hispanics, and Asians/Pacific Islanders.
Twelve-month prevalence of DSM-IV bipolar I disorder across 11 countries ranged from 0.0% to
0.6% and was greater in high-income countries than in low- and middle-income countries, except
in Japan, where prevalence was low (0.01%). The lifetime prevalence ratio in men to women is
approximately 1.1:1.
Development and Course
The peak age at onset of bipolar I disorder across studies is between 20 and 30 years, but onset
occurs throughout the life cycle. In the United States, mean age at onset of DSM-5 bipolar I
disorder is 22 years and slightly younger for women (21.5 years) than for men (23.0 years). In a
comparison of six international sites, median age at onset of DSM-IV-TR bipolar I disorder was
24.3 years. Special considerations are necessary to apply the diagnosis in children. Because
children of the same chronological age may be at different developmental stages, it is difficult to
define with precision what is “normal” or “expected” at any given point. Therefore, each child
should be judged according to his or her own baseline in determining whether a particular
behavior is “normal” or evidence of a manic episode. Although age at first onset may occur in
the 60s or 70s, onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or
late-life should prompt consideration of medical conditions (e.g., frontotemporal neurocognitive
disorder) and of substance ingestion or withdrawal.

Environmental.
Genetic and physiological.
More than 90% of individuals who have a single manic episode go on to have recurrent mood
episodes. Approximately 60% of manic episodes occur immediately before a major depressive
episode. Individuals with bipolar I disorder who have multiple (four or more) mood episodes
(major depressive, manic, or hypomanic) occurring in the prior 12 months receive the specifier
“with rapid cycling,” a common variant associated with poorer outcomes. About half of
individuals diagnosed with bipolar disorder exhibit a predominant polarity (relapse tending to be
either depressive or manic), with one international study of bipolar I disorder finding 31.3% with
predominant mania, 21.4% with predominant depression, and 47.3% without polarity
predominance.
The course of bipolar I disorder is highly heterogeneous. Some patterns have been noted
across episodes (e.g., a manic episode with psychotic features may be associated with psychotic
features in subsequent manic episodes). Polarity of first episode tends to be associated with
predominant polarity of future episodes and clinical features (e.g., depressive onset is associated
with greater density of depressive episodes and suicidal behavior). The
presence of mixed features in a manic episode is associated with a poorer prognosis, poorer
lithium response, and suicidal behavior.
Risk and Prognostic Factors
Childhood 
adversity 
(including 
early 
emotional 
trauma, 
parental
psychopathology, and family conflict) is a known risk factor for bipolar disorder and appears to
predispose to early onset of bipolar disorder. Childhood adversity is also associated with poorer
prognosis and a worse clinical picture that may include medical or psychiatric comorbidities,
suicide, and associated psychotic features. More proximally, recent life stress and other negative
life events increase depressive relapse risk in individuals diagnosed with bipolar disorder,
whereas manic relapse appears to be specifically linked to goal-attainment life events (e.g.,
getting married, completing a degree). Cannabis and other substance use is associated with
exacerbation of manic symptoms among individuals diagnosed with bipolar disorder, as well as
first onset of manic symptoms in the general population. There is some evidence that becoming
married is less common among individuals with bipolar disorder than in the general population
and that a diagnosis of bipolar disorder is associated with being previously as opposed to
currently married.
Genetic processes strongly affect predisposition to bipolar disorder,
with heritability estimates around 90% in some twin studies. Risk of bipolar disorder in the
general population is around 1%, while risk in a first-degree relative is 5%–10%. However,
monozygotic concordance rates are significantly less than 100% (40%–70%), indicating that
much risk is left unexplained by genes alone. The mechanism of heritability is not Mendelian,
and involves multiple genes (or more complex genetic mechanisms) of small effect, interacting
with each other, the environment, and random factors. Emerging genetic findings suggest that
mania- and depression-proneness are inherited separately, and bipolar disorder shares a genetic
origin with schizophrenia.

Culture-Related Diagnostic Issues
Bipolar I disorder symptoms tend to be consistent across cultural contexts, but some variation
exists in symptom expression and interpretation. For example, individuals from different cultural
backgrounds with bipolar I disorder, with psychotic features, may vary in the prevalence of flight
of ideas or types of delusions (e.g., grandiose, persecutory, sexual, religious, or somatic).
Cultural factors may affect disorder prevalence. For example, countries with reward-oriented
cultural values that place significance on individual pursuit of reward have a relatively higher
prevalence of bipolar disorder. In the United States, individuals with bipolar disorder had an
earlier age at onset than those in Europe and were more likely to have a family history of
psychiatric disorder.
Culture also influences clinician diagnostic practices regarding bipolar disorder. Compared
with non-Latinx Whites in the United States, African Americans with bipolar I disorder are at
higher risk of being misdiagnosed with schizophrenia. Possible reasons include underrecognition
of mood symptoms, cultural and linguistic misunderstanding between clinicians and the
individuals presenting for treatment (e.g., misinterpretation of cultural mistrust as paranoia),
more florid psychotic symptoms at presentation due to delay in receiving services, and diagnoses
based on shorter clinical assessments. These factors may result in discriminatory misdiagnosis of
schizophrenia, particularly in African Americans with mood disorders who present with
psychotic features.
Sex- and Gender-Related Diagnostic Issues
Women may be more likely to experience rapid cycling and mixed states, and to have patterns of
comorbidity that differ from those of men, including higher rates of lifetime eating
disorders. Women with bipolar I or II disorder are more likely to experience depressive
symptoms than are men. They also have a higher lifetime risk of alcohol use disorder than do
men and a much greater likelihood of alcohol use disorder than do women in the general
population.
Some women with bipolar disorder experience exacerbation of mood symptoms during the
premenstrual time period, and this has been associated with a worse course of illness. Many
women with bipolar disorder also report severe emotional disturbances during perimenopause
when estrogen levels are decreasing. There does not appear to be an increased risk of mood
episodes in pregnant women with bipolar disorder except in those who discontinue medications
for pregnancy. In contrast, there is strong and consistent evidence for an increased risk of mood
episodes (both depression and mania) in women with bipolar I disorder in the postpartum period.
The specifier “with peripartum onset” should be used for mood episodes that begin during
pregnancy or within 4 weeks of delivery. “Postpartum psychosis” typically resembles a manic or
mixed mood episode with psychotic symptoms and is strongly associated with bipolar I disorder.
Association With Suicidal Thoughts or Behavior
The lifetime risk of suicide in individuals with bipolar disorder is estimated to be 20- to 30-fold
greater than in the general population. An estimated 5%–6% of individuals with bipolar disorders

Major depressive disorder.
Other bipolar disorders.
Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety
disorders.
Bipolar and related disorder due to another medical condition.
die by suicide. While suicide attempts are higher in women, lethal suicide is more common in
men with bipolar disorder. A past history of suicide attempt and percent days spent depressed in
the past year are associated with greater risk of suicide attempts or completions. Nearly half of
individuals whose symptoms meet criteria for bipolar disorder have an alcohol use disorder, and
those with both disorders are at greater risk for suicide attempt and suicide death.
Functional Consequences of Bipolar I Disorder
Approximately 30% of individuals with bipolar disorder show severe impairment in work role
functioning, although many individuals return to a fully functional level between episodes.
Functional recovery lags substantially behind recovery from symptoms, especially with respect
to occupational recovery, resulting in lower socioeconomic status despite equivalent levels of
education when compared with the general population. Cognitive impairments persist through
the lifespan, even during euthymic periods, and may contribute to vocational and interpersonal
difficulties. Higher level of self-perceived stigma is associated with lower level of functioning.
Differential Diagnosis
There is a risk of misdiagnosing bipolar I disorder as unipolar
depression because of the prominence of depression in the presentation of bipolar I disorder: 1)
the first episode of bipolar disorder is often depressive, 2) depressive symptoms are the most
frequent symptoms experienced across the long-term course of bipolar I disorder, and 3) the
problem for which individuals typically seek help is depression. When the individual presents in
an episode of major depression, it is therefore important to actively probe for a history of mania
or hypomania. Factors that might indicate that the diagnosis is bipolar I disorder rather than
major depressive disorder in an individual presenting with a current depressive episode include
family history of bipolar disorder, onset of illness in early 20s, numerous past episodes, presence
of psychotic symptoms, and a history of lack of response to antidepressant treatment or the
emergence of a manic episode during antidepressant treatment (e.g., medication,
electroconvulsive therapy).
Bipolar II disorder, cyclothymic disorder, and other specified bipolar and
related disorder are similar to bipolar I disorder by virtue of their including
periods of hypomanic symptoms in their presentations but are differentiated from bipolar I
disorder by the absence of any manic episodes.
A
careful history of symptoms is needed to differentiate generalized anxiety disorder from bipolar
disorder, as anxious ruminations may be mistaken for racing thoughts (and vice versa), and
efforts to minimize anxious feelings may be taken as impulsive behavior. Similarly, symptoms of
posttraumatic stress disorder need to be differentiated from bipolar disorder. It is helpful to
assess the episodic nature of the symptoms described (classical bipolar I is episodic), as well as
to consider symptom triggers, in making this differential diagnosis.
The diagnosis of bipolar and related

Substance/medication-induced bipolar and related disorder.
Schizoaffective disorder.
Attention-deficit/hyperactivity disorder.
Disruptive mood dysregulation disorder.
Personality disorders.
disorder due to another medical condition should be made instead of bipolar I disorder if the
manic episodes are judged, based on history, laboratory findings, or physical examination, to be
the direct physiological consequence of another medical condition (e.g., Cushing’s disease,
multiple sclerosis).
A substance/medication-induced bipolar
and related disorder is distinguished from bipolar I disorder by the fact that a substance (e.g.,
stimulants, phencyclidine) or medication (e.g., steroids) is judged to be etiologically related to
the manic episode. Because individuals with a manic episode have a tendency to overuse
substances during an episode, it is important to determine whether the substance use is a
consequence of a primary manic episode or whether the manic-like episode has been caused by
the substance use. In some cases, a definitive diagnosis may involve establishing that the manic
symptoms remain once the individual is no longer using the substance. Note that manic episodes
emerging in the context of treatment with an antidepressant medication but that persist at a fully
syndromal level beyond the physiological effect of the medication warrant a diagnosis of bipolar
I disorder rather than substance/medication-induced bipolar and related disorder.
Schizoaffective disorder is characterized by periods in which manic and
major depressive episodes are concurrent with the active phase symptoms of schizophrenia and
periods in which delusions or hallucinations occur for at least 2 weeks in the absence of a manic
or major depressive episode. The diagnosis is “bipolar I disorder, with psychotic features” if the
psychotic symptoms have occurred exclusively during manic and major depressive episodes.
Attention-deficit/hyperactivity disorder is characterized by
persistent symptoms of inattention, hyperactivity, and impulsivity, which may resemble the
symptoms of a manic episode (e.g., distractibility, increased activity, impulsive behavior) and
have their onset by age 12. In contrast, the symptoms of mania in bipolar I disorder occur in
distinct episodes and typically begin in late adolescence or early adulthood.
In individuals with severe irritability, particularly children
and adolescents, care must be taken to apply the diagnosis of bipolar I disorder only to those who
have had a clear episode of mania or hypomania—that is, a distinct time period, of the required
duration, during which the irritability was clearly different from the individual’s baseline and
was accompanied by the onset of the other characteristic symptoms of mania (e.g., grandiosity,
decreased need for sleep, pressured speech, involvement in activities with a high potential for
painful consequences). When a child’s irritability is persistent and particularly severe, the
diagnosis of disruptive mood dysregulation disorder would be more appropriate. Indeed, when
any child is being assessed for mania, it is essential that the symptoms represent a clear change
from the child’s typical behavior.
Personality disorders such as borderline personality disorder may have
substantial symptomatic overlap with bipolar I disorder, since mood lability and impulsivity are
common in both conditions. In order to make a diagnosis of bipolar I disorder, symptoms of
mood lability and impulsivity must represent a distinct episode of illness, or there must be a
noticeable increase in these symptoms over the individual’s baseline in order to justify an
additional diagnosis of bipolar I disorder.

F31.81
Comorbidity
Co-occurring mental disorders are the norm in bipolar I disorder, with the majority of individuals
having a history of three or more disorders. The most frequently comorbid disorders are anxiety
disorders, alcohol use disorder, other substance use disorder, and attention-deficit/hyperactivity
disorder. Sociocultural factors influence the pattern of comorbid conditions in bipolar disorder.
For example, countries with cultural prohibitions against alcohol or other substance use may
have a lower prevalence of substance use comorbidity. Bipolar I disorder is frequently associated
with borderline, schizotypal, and antisocial personality disorder. In particular, although the
underlying nature of the relationship between bipolar I disorder and borderline personality
disorder is unclear, the substantial comorbidity between the two may reflect similarities in
phenomenology (i.e., misdiagnosing the emotional extremes of borderline personality disorder as
bipolar I disorder), the influence of borderline personality features on vulnerability to bipolar I
disorder, and the impact of early childhood adversity on the development of both bipolar I and
borderline personality disorder.
Individuals with bipolar I disorder also have high rates of serious co-occurring and often
untreated medical conditions, which largely explain the shortened life expectancy of those with
bipolar disorder. Comorbidities appear in multiple organ systems, with cardiovascular and
autoimmune diseases, obstructive sleep apnea, metabolic syndrome, and migraine more common
among individuals with bipolar disorder than in the general population. Comorbid
overweight/obesity is a particular concern for individuals with bipolar disorder and is associated
with poor treatment outcomes.
Bipolar II Disorder
Diagnostic Criteria
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for
a current or past hypomanic episode and the following criteria for a current or past
major depressive episode:
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at
least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms have persisted (four if the mood is only
irritable), represent a noticeable change from usual behavior, and have been
present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.

151
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by
others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment
(e.g., medication, electroconvulsive therapy) but persists at a fully syndromal
level beyond the physiological effect of that treatment is sufficient evidence for a
hypomanic episode diagnosis. However, caution is indicated so that one or two
symptoms (particularly increased irritability, edginess, or agitation following
antidepressant use) are not taken as sufficient for diagnosis of a hypomanic
episode, nor necessarily indicative of a bipolar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2week period and represent a change from previous functioning; at least one of
the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical
condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, or hopeless) or observation made by
others (e.g., appears tearful). (Note: In children and adolescents, can be
irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or
observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite
nearly every day. (Note: In children, consider failure to make expected weight

gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
suicide.
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or
another medical condition.
Note: Criteria A–C constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from
a natural disaster, a serious medical illness or disability) may include the feelings of
intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss
noted in Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a
significant loss should be carefully considered. This decision inevitably requires the
exercise of clinical judgment based on the individual’s history and the cultural norms
for the expression of distress in the context of loss.1
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria A–F under
“Hypomanic Episode” above) and at least one major depressive episode (Criteria
A–C under “Major Depressive Episode” above).
B. There has never been a manic episode.
C. 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.
D. The symptoms of depression or the unpredictability caused by frequent
alternation between periods of depression and hypomania causes clinically
significant distress or impairment in social, occupational, or other important

areas of functioning.
Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: F31.81. Its status with respect to current
severity, presence of psychotic features, course, and other specifiers cannot be
coded but should be indicated in writing (e.g., F31.81 bipolar II disorder, current
episode depressed, moderate severity, with mixed features; F31.81 bipolar II
disorder, most recent episode depressed, in partial remission).
Specify current or most recent episode:
Hypomanic
Depressed
If current episode is hypomanic (or most recent episode if bipolar II disorder is in
partial or full remission):
In recording the diagnosis, terms should be listed in the following order: bipolar II
disorder, current or most recent episode hypomanic, in partial remission/in full
remission (p. 175) (if full criteria for a hypomanic episode are not currently met),
plus any of the following hypomanic episode specifiers that are applicable. Note:
The specifiers “with rapid cycling” and “with seasonal pattern” describe the
pattern of mood episodes.
Specify if:
With anxious distress (p. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With peripartum onset (pp. 173–174)
With seasonal pattern (pp. 174–175)
If current episode is depressed (or most recent episode if bipolar II disorder is in
partial or full remission):
In recording the diagnosis, terms should be listed in the following order: bipolar II
disorder, current or most recent episode depressed, mild/moderate/severe (if full
criteria for a major depressive episode are currently met), in partial remission/in
full remission (if full criteria for a major depressive episode are not currently met)
(p. 175), plus any of the following major depressive episode specifiers that are
applicable. Note: The specifiers “with rapid cycling” and “with seasonal pattern”
describe the pattern of mood episodes.
Specify if:
With anxious distress (pp. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With melancholic features (pp. 171–172)

With atypical features (pp. 172–173)
With mood-congruent psychotic features (p. 173)
With mood-incongruent psychotic features (p. 173)
With catatonia (p. 173). Coding note: Use additional code F06.1.
With peripartum onset (pp. 172–174)
With seasonal pattern (pp. 174–175)
Specify course if full criteria for a mood episode are not currently met:
In partial remission (p. 175)
In full remission (p. 175)
Specify severity if full criteria for a major depressive episode are currently met:
Mild (p. 175)
Moderate (p. 175)
Severe (p. 175)
Diagnostic Features
Bipolar II disorder is characterized by a clinical course of recurring mood episodes consisting of
one or more major depressive episodes (Criteria A–C under “Major Depressive Episode”) and at
least one hypomanic episode (Criteria A–F under “Hypomanic Episode”). A diagnosis of a major
depressive episode requires that there be a period of depressed mood, or as an alternative,
marked diminished interest or pleasure, for most of the day nearly every day, lasting for a
minimum of 2 weeks. The depressed mood or loss of interest must be accompanied by additional
symptoms occurring nearly every day (e.g., sleep disturbance, psychomotor agitation or
retardation) for a total of at least five symptoms. The diagnosis of a hypomanic episode requires
that there be a distinct period of
abnormally and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased activity or energy for most of the day, nearly every day, for at least 4
consecutive days accompanied by three (or four if mood is only irritable) additional symptoms
(e.g., inflated self-esteem, decreased need for sleep, distractibility) that persist and represent a
noticeable change from usual behavior and functioning. By definition, psychotic symptoms do
not occur in hypomanic episodes, and they appear to be less frequent in the major depressive
episodes in bipolar II disorder than in those of bipolar I disorder. The presence of a manic
episode during the course of illness precludes the diagnosis of bipolar II disorder (Criterion B
under “Bipolar II Disorder”). Moreover, for depressive and hypomanic episodes to count toward
the diagnosis of bipolar II disorder, at least one of the depressive episodes and at least one of the
hypomanic episodes must not be attributable to the physiological effects of a substance (i.e.,
medication, drug of abuse, or toxin exposure) or another medical condition. Note that hypomanic
episodes that emerge during antidepressant treatment and persist for at least 4 days at a fully
syndromal level beyond the physiological effects of the treatment are not considered to be

substance-induced and do count toward the diagnosis of bipolar II disorder. In addition, at least
one hypomanic episode and at least one major depressive episode are not explained by a
diagnosis of schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia
spectrum or other psychotic disorder (Criterion C under “Bipolar II Disorder”). The depressive
episodes or the pattern of unpredictable mood changes must cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning (Criterion D under
“Bipolar II Disorder”). The recurrent major depressive episodes are often more frequent and
lengthier than those occurring in bipolar I disorder.
Individuals with bipolar II disorder typically present to a clinician during a major depressive
episode. They are unlikely to complain initially of hypomania, because either they do not
recognize the symptoms of hypomania or they consider hypomania desirable. Hypomanic
episodes by definition do not cause significant impairment. Instead, the impairment results from
the major depressive episodes or from a persistent pattern of unpredictable mood changes and
fluctuating, unreliable interpersonal or occupational functioning. Individuals with bipolar II
disorder may not view the hypomanic episodes as pathological or disadvantageous, although
others may be troubled by the individual’s erratic behavior. Clinical information from other
informants, such as close friends or relatives, is often useful in establishing the diagnosis of
bipolar II disorder.
A hypomanic episode should not be confused with the several days of euthymia and restored
energy or activity that may follow remission of a major depressive episode. Despite the
substantial differences in duration and severity between a manic and hypomanic episode, bipolar
II disorder is not a “milder form” of bipolar I disorder. Compared to individuals with bipolar I
disorder, individuals with bipolar II disorder have greater chronicity of illness and spend, on
average, more time in the depressive phase of their illness, which can be severe and/or disabling.
Although the diagnostic requirements for major depressive episodes are identical whether
they occur in the context of bipolar II disorder or major depressive disorder, certain clinical
features of the episodes may hint at possible differential diagnosis. For instance, the coexistence
of both insomnia and hypersomnia is not uncommon in major depressive episodes in both bipolar
II disorder and major depressive disorder; however, both insomnia and hypersomnia are
overrepresented among women with bipolar II disorder. Similarly, atypical depressive symptoms
(hypersomnia, hyperphagia) are common in both disorders, but more so in those with bipolar II
disorder.
Depressive symptoms co-occurring with a hypomanic episode or hypomanic symptoms cooccurring with a depressive episode are common in individuals with bipolar II disorder and are
overrepresented in females, particularly hypomania with mixed features.
Individuals experiencing hypomania with mixed features may not label their symptoms as
hypomania, but instead experience them as depression with increased energy or irritability.
Associated Features
A common feature of bipolar II disorder is impulsivity, which can contribute to suicide attempts

and substance use disorders.
There may be heightened levels of creativity during hypomanic episodes in some individuals
with a bipolar II disorder. However, that relationship may be nonlinear; that is, greater lifetime
creative accomplishments have been associated with milder forms of bipolar disorder, and higher
creativity has been found in unaffected family members. The individual’s attachment to the
prospect of heightened creativity during hypomanic episodes may contribute to ambivalence
about seeking treatment or undermine adherence to treatment.
Prevalence
The 12-month prevalence of bipolar II disorder in the United States is 0.8%. The 12-month
prevalence internationally is 0.3%. The prevalence rate of pediatric bipolar II disorder is difficult
to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise specified yield a
combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher rates
(2.7% inclusive) in youth age 12 years or older.
Development and Course
Although bipolar II disorder can begin in late adolescence and throughout adulthood, average
age at onset is the mid-20s, which is slightly later than for bipolar I disorder but earlier than for
major depressive disorder. Age at onset does not reliably distinguish between bipolar I and II
disorder. The illness most often begins with a depressive episode and is not recognized as bipolar
II disorder until a hypomanic episode occurs; this happens in about 12% of individuals with the
initial diagnosis of major depressive disorder. Anxiety, substance use, or eating disorders may
also precede the diagnosis, complicating its detection. Many individuals experience several
episodes of major depression prior to the first recognized hypomanic episode, with typically a
more than 10-year lag between illness onset and the diagnosis of a bipolar disorder.
Bipolar II disorder is a highly recurrent disorder, with over 50% of individuals experiencing
a new episode within a year after their first episode. Individuals with bipolar II disorder also
have more seasonal variation in mood compared to those with bipolar I disorder.
The number of lifetime episodes (both hypomanic and major depressive episodes) tends to be
higher for bipolar II disorder than for major depressive disorder or bipolar I disorder. However,
individuals with bipolar I disorder are actually more likely to experience hypomanic symptoms
than are individuals with bipolar II disorder. The interval between mood episodes in the course
of bipolar II disorder tends to decrease as the individual ages. While the hypomanic episode is
the feature that defines bipolar II disorder, depressive episodes are more enduring and disabling
over time. Despite the predominance of depression, once a hypomanic episode has occurred, the
diagnosis becomes bipolar II disorder and never reverts to major depressive disorder.
Approximately 5%–15% of individuals with bipolar II disorder have multiple (four or more)
mood episodes (hypomanic or major depressive) within the previous 12 months. If this pattern is
present, it is noted by the specifier “with rapid cycling.” Rapid cycling is more common in
women and may reflect an overall worsening of the bipolar disorder.
Switching from a depressive episode to a manic or hypomanic episode (with or without
mixed features) may occur, both spontaneously and during treatment for depression.

Genetic and physiological.
Course modifiers.
About 5%–15% of individuals with bipolar II disorder will ultimately develop a manic
episode, which changes the diagnosis to bipolar I disorder, regardless of subsequent course.
Making the diagnosis in children is often a challenge, especially in those with irritability and
hyperarousal that is nonepisodic (i.e., lacks the well-demarcated periods of altered mood).
Nonepisodic irritability in youth is associated with an elevated risk for anxiety disorders and
major depressive disorder, but not bipolar disorder, in adulthood. Persistently irritable youth
have lower familial rates of bipolar disorder than do youth who have bipolar disorder. For a
hypomanic episode to be diagnosed, the child’s symptoms must exceed what is expected in a
given environment and culture for the child’s developmental stage. Similar to adults, youth with
bipolar II disorder spend less time hypomanic compared to those with bipolar I disorder, and the
initial presenting episode is typically depression. Compared with adult onset of bipolar II
disorder, childhood or adolescent onset of the disorder may be associated with a more severe
lifetime course.
The 3-year incidence rate of first-onset bipolar II disorder in adults older than 60 years is
0.34%. However, distinguishing individuals older than 60 years with bipolar II disorder by late
versus early age at onset does not appear to have any clinical utility. The presence of cooccurring hypomanic symptoms during a depressive episode is more common during bipolar II
depressive episodes relative to depressive episodes occurring in the context of major depression
and may help distinguish older individuals with bipolar II disorder from those with major
depressive disorder. In any later life presentation of bipolar disorder, it is important to consider
medical factors, including possible medical and neurological causes of new symptoms.
Risk and Prognostic Factors
The risk of bipolar II disorder tends to be highest among relatives of
individuals with bipolar II disorder, as opposed to individuals with bipolar I disorder or major
depressive disorder. About a third of individuals with bipolar II disorder reported a family
history of bipolar disorder. There may be genetic factors influencing the age at onset for bipolar
disorders. Th ere is also evidence that bipolar II disorder may have a genetic architecture that is
at least partially distinct from bipolar I disorder and from schizophrenia.
A rapid-cycling pattern is associated with a poorer prognosis. Return to
previous level of social function for individuals with bipolar II disorder is more likely for
individuals of younger age and with less severe depression, suggesting adverse effects of
prolonged illness on recovery. More education, fewer years of illness, and being married are
independently associated with functional recovery in individuals with bipolar disorder, even after
diagnostic type (I vs. II), current depressive symptoms, and presence of psychiatric comorbidity
are taken into account.
Sex- and Gender-Related Diagnostic Issues
Whereas the gender ratio for bipolar I disorder is equal, findings on gender differences in bipolar
II disorder are mixed, differing by type of sample (i.e., registry, community, or clinical) and
country of origin. There is little to no evidence of bipolar gender differences in the general
population, whereas some, but not all, clinical samples suggest that bipolar II disorder is more
common in women than in men, which may reflect gender differences in treatment seeking or
other factors.

Major depressive disorder.
Patterns of illness and comorbidity, however, seem to differ by sex, with females being more
likely than males to report hypomania with mixed depressive features and a rapid-cycling course.
Childbirth may also be a specific trigger for a hypomanic episode, which can occur in 10%–20%
of females in nonclinical populations and most typically in the early postpartum period.
Distinguishing hypomania from the elated mood and reduced sleep
that normally accompany the birth of a child may be challenging. Postpartum hypomania
may foreshadow the onset of a depression that occurs in about half of females who experience
postpartum “highs.” The perimenopause transition can also be a time of mood instability in
bipolar II disorder. No major sex differences have been found in several clinical variables,
including rates of depressive episodes, age at and polarity of onset, symptoms, and severity of
the illness.
Association With Suicidal Thoughts or Behavior
Approximately one-third of individuals with bipolar II disorder report a lifetime history of
suicide attempt. The risk and incidence of attempted suicide in bipolar II and bipolar I disorder
appear to be similar. Overall there appears to be about equal rates of suicide attempts and suicide
deaths across individuals with bipolar II and bipolar I disorder, although overall the rates for both
attempts and deaths are significantly higher than in the general population. Time spent in a
depressive episode is associated more significantly with the diagnosis of bipolar I or bipolar II in
terms of suicide attempt risk. However, the lethality of attempts, as defined by a lower ratio of
attempts to suicide deaths, may be higher in individuals with bipolar II disorder compared to
individuals with bipolar I disorder. There may be an association between genetic markers and
increased risk for suicidal behavior in individuals with bipolar disorder, including a 6.5-fold
higher risk of suicide among first-degree relatives of bipolar II probands compared with firstdegree relatives of bipolar I probands.
Functional Consequences of Bipolar II Disorder
Although many individuals with bipolar II disorder return to a fully functional level between
mood episodes, at least 15% continue to have some interepisode dysfunction, and 20% transition
directly into another mood episode without interepisode recovery. Functional recovery lags
substantially behind recovery from symptoms of bipolar II disorder, especially in regard to
occupational recovery, resulting in lower socioeconomic status despite equivalent levels of
education with the general population. Individuals with bipolar II disorder perform more poorly
than healthy individuals on cognitive tests. Cognitive impairments associated with bipolar II
disorder may contribute to vocational difficulties. Prolonged unemployment in individuals with
bipolar disorder is associated with more episodes of depression, older age, increased rates of
current panic disorder, and lifetime history of alcohol use disorder.
Differential Diagnosis
Major depressive disorder is characterized by the absence of both
manic episodes and hypomanic episodes. Given that the presence of some manic or hypomanic

Cyclothymic disorder.
Schizophrenia.
Schizoaffective disorder.
Bipolar and related disorder due to another medical condition.
Substance/medication-induced bipolar and related disorder.
symptoms (e.g., fewer symptoms or shorter duration than required for hypomania) may still be
compatible with a diagnosis of major depressive disorder, it is important to ascertain whether the
symptoms meet criteria for a hypomanic episode to determine whether it is more appropriate to
make the diagnosis of bipolar II disorder. Depressive episodes dominate the overall course of
illness for most individuals with bipolar II disorder, contributing to the decade-long lag between
illness onset and the diagnosis of bipolar II disorder. Because the diagnostic criteria for major
depressive episode are identical in major depressive disorder and bipolar II disorder, the
diagnosis of bipolar II disorder can be made only by eliciting information about at least one prior
hypomanic episode in order to distinguish the bipolar II disorder from major depressive disorder.
In cyclothymic disorder, there are numerous periods of hypomanic
symptoms that do not meet symptom or duration criteria for a hypomanic episode and numerous
periods of depressive symptoms that do not meet symptom or duration criteria for a major
depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the
presence of one or more hypomanic episodes and one or more major depressive episodes.
Schizophrenia is characterized by active-phase psychotic symptoms that may be
accompanied by major depressive episodes. The diagnosis of schizophrenia is made if no major
depressive episodes have occurred concurrently with the active-phase symptoms. If they have
occurred concurrently, the diagnosis of schizophrenia is made if the major depressive episodes
have been present for only a minority of the time. The diagnosis is bipolar II disorder, with
psychotic features, if the psychotic symptoms have occurred exclusively during major depressive
episodes.
Schizoaffective disorder is characterized by periods in which depressive
symptoms are concurrent with the active-phase symptoms of schizophrenia and periods in which
delusions or hallucinations occur for at least 2 weeks in the absence of a major depressive
episode. The diagnosis is bipolar II disorder, with psychotic features, if the psychotic symptoms
have occurred exclusively during major depressive episodes.
The diagnosis of bipolar and related
disorder due to another medical condition should be made instead of bipolar II disorder if the
hypomanic episodes are judged, based on history, laboratory findings, or physical examination,
to be the direct physiological consequence of another medical condition (e.g., Cushing’s disease,
multiple sclerosis).
A substance/medication-induced bipolar
and related disorder is distinguished from bipolar II disorder by the fact that a substance (e.g.,
stimulants, phencyclidine) or medication (e.g., steroids) is judged to be etiologically related to
the hypomanic and major depressive episodes. Because individuals with a hypomanic episode
have a tendency to overuse substances during an episode, it is important to determine whether
the substance use is a consequence of a primary hypomanic episode or whether the hypomaniclike episode has been caused by the substance use. In some cases, a definitive diagnosis may
involve establishing that the hypomanic symptoms or depressive symptoms remain once the
individual is no longer using the substance. Note that hypomanic episodes emerging in the
context of treatment with an antidepressant medication but persisting at a fully syndromal level

Attention-deficit/hyperactivity disorder.
Personality disorders.
Other bipolar disorders.
beyond the physiological effect of the medication warrant a diagnosis of bipolar II disorder
rather than substance/medication-induced bipolar and related disorder.
Attention-deficit/hyperactivity disorder (ADHD) may be
misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of
ADHD, such as excessive talking, distractibility, and less need for sleep, overlap with the
symptoms of hypomania. The double counting of symptoms toward both ADHD and bipolar II
disorder can be avoided if the clinician clarifies whether the symptoms represent a distinct
episode and if the noticeable increase over baseline required for the diagnosis of bipolar II
disorder is present.
The same convention as applies for ADHD also applies when evaluating an
individual for a personality disorder such as borderline personality disorder because mood
lability and impulsivity are common in both personality disorders and bipolar II disorder.
Symptoms must represent a distinct episode, and the noticeable increase over baseline required
for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder
should not be made during an untreated mood episode unless the lifetime history supports the
presence of a personality disorder.
Diagnosis of bipolar II disorder should be differentiated from bipolar I
disorder by carefully considering whether there have been any past episodes of mania and from
other specified and unspecified bipolar and related disorders by confirming the presence of fully
syndromal hypomania and depression.
Comorbidity
Bipolar II disorder is more often than not associated with one or more co-occurring mental
disorders, with anxiety disorders being the most common. Approximately 60% of individuals
with bipolar II disorder have three or more co-occurring mental disorders; 75% have an anxiety
disorder, most commonly social anxiety (38%), specific phobia (36%), and generalized anxiety
(30%). Lifetime prevalence of comorbid anxiety disorder does not differ between bipolar I and
bipolar II disorders but is associated with a worse course of illness. Children and adolescents
with bipolar II disorder have a higher rate of co-occurring anxiety disorders compared to those
with bipolar I disorder, and the anxiety disorder most often predates the bipolar disorder.
Anxiety and substance use disorders occur in individuals with bipolar II disorder at a higher
rate than in the general population. It should be noted that co-occurring anxiety and substance
use disorder do not seem to follow a course of illness that is truly independent from that of
bipolar II disorder, but rather have strong associations with mood states. For example, anxiety
disorders tend to associate most with depressive symptoms, and substance use disorders are
moderately associated with hypomanic symptoms.
The prevalence of substance use disorders appears to be similar between bipolar I and bipolar
II disorders, most commonly alcohol use (42%) and cannabis use (20%) disorders. Sociocultural
factors influence the pattern of comorbid conditions in bipolar II disorder. For example,
countries with cultural prohibitions against alcohol or other substance use may have a lower
prevalence of substance use comorbidity.
Individuals with bipolar II disorder appear to have lower rates of comorbid posttraumatic

F34.0
stress disorder compared to individuals with bipolar I disorder.
Approximately 14% of individuals with bipolar II disorder have at least one lifetime eating
disorder, with binge-eating disorder being more common than bulimia nervosa and anorexia
nervosa.
Premenstrual syndrome and premenstrual dysphoric disorder are common in women with
bipolar disorder, especially in those with bipolar II disorder. Among women who have
premenstrual syndrome and/or premenstrual dysphoric disorder, bipolar mood symptoms and
lability may be more severe.
Individuals with bipolar II disorder also have comorbid medical conditions, which have the
potential to substantially complicate course and prognosis. These include cardiovascular disease,
migraine, and autoimmune disorders.
Cyclothymic Disorder
Diagnostic Criteria
A. For at least 2 years (at least 1 year in children and adolescents) there have been
numerous periods with hypomanic symptoms that do not meet criteria for a
hypomanic episode and numerous periods with depressive symptoms that do
not meet criteria for a major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), Criterion A
symptoms have been present for at least half the time and the individual has not
been without the symptoms for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been
met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified
or unspecified schizophrenia spectrum and other psychotic disorder.
E. The symptoms are not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
With anxious distress (see pp. 169–170)
Diagnostic Features
The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance

involving numerous periods of hypomanic symptoms and periods of depressive symptoms
(Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness,
and/or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of
insufficient number, severity, pervasiveness, and/or duration to meet full criteria for a major
depressive episode. During the initial 2-year period (1 year for children or adolescents), the
symptoms must be persistent (present more days than not), and any symptom-free intervals last
no longer than 2 months (Criterion B). The diagnosis of cyclothymic disorder is made only if the
criteria for a major depressive, manic, or hypomanic episode have never been met (Criterion C).
If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in adults
or 1 year in children or adolescents) experiences a major depressive, manic, or hypomanic
episode, the diagnosis changes to major depressive disorder, bipolar I disorder, or other specified
or unspecified bipolar and related disorder (subclassified as hypomanic episode without prior
major depressive episode), respectively, and the cyclothymic disorder diagnosis is dropped.
The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better
explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia spectrum and other psychotic
disorders (Criterion D), in which case the mood symptoms are considered associated features of
the psychotic disorder. The mood disturbance must also not be attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism) (Criterion E). Although some individuals may function particularly well during
some of the periods of hypomania, over the prolonged course of the disorder, there must be
clinically significant distress or impairment in social, occupational, or other important areas of
functioning as a result of the mood disturbance (Criterion F). The prolonged pattern of repeated,
often unpredictable mood changes may lead to impairment attributable to the negative effects of
the symptoms themselves combined with negative effects that the pattern of unpredictability and
inconsistency has on interpersonal functioning and role performance (i.e., familial, occupational
roles).
Prevalence
The lifetime prevalence of cyclothymic disorder in the United States and Europe is
approximately 0.4%–2.5%. Prevalence in mood disorders clinics may range from 3% to 5%. In
the general population, cyclothymic disorder is apparently equally common in males and
females. In clinical settings, females with cyclothymic disorder may be more likely to present for
treatment than males.
Development and Course
Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes
considered to reflect a temperamental predisposition to other disorders in this chapter. The vast
majority of youth with cyclothymic disorder experience the onset of mood symptoms before age
10. Cyclothymic disorder usually has an insidious onset and a persistent course. There is a 15%–
50% risk that an individual with cyclothymic disorder will

Genetic and physiological.
Bipolar and related disorder due to another medical condition.
Substance/medication-induced bipolar and related disorder and substance/medication-induced
depressive disorder.
Bipolar I disorder, with rapid cycling, and bipolar II disorder, with rapid cycling.
Borderline personality disorder.
subsequently develop bipolar I disorder or bipolar II disorder; diagnostic conversion rates are
higher in youth than in adults. Onset of persistent, fluctuating hypomanic and depressive
symptoms late in adult life needs to be clearly differentiated from bipolar and related disorder
due to another medical condition and depressive disorder due to another medical condition (e.g.,
multiple sclerosis) before the cyclothymic disorder diagnosis is assigned.
Risk and Prognostic Factors
Major depressive disorder, bipolar I disorder, and bipolar II disorder
are more common among first-degree biological relatives of individuals with cyclothymic
disorder than in the general population. There may also be an increased familial risk of
substance-related disorders. Cyclothymic disorder may be more common in the first-degree
biological relatives of individuals with bipolar I disorder than in the general population.
Differential Diagnosis
The diagnosis of bipolar and related
disorder due to another medical condition is made when the mood disturbance is judged to be
attributable to the physiological effect of a specific, usually chronic medical condition (e.g.,
hyperthyroidism). This determination is based on the history, physical examination, and/or
laboratory findings. If it is judged that the hypomanic and depressive symptoms are not the
physiological consequence of the medical condition, then the primary mental disorder (i.e.,
cyclothymic disorder) and the medical condition are coded. For example, this would be the case
if the mood symptoms are considered to be the psychological (not the physiological)
consequence of having a chronic medical condition, or if there is no etiological relationship
between the hypomanic and depressive symptoms and the medical condition.
Substance/medication-induced bipolar and related disorder and substance/medication-induced
depressive disorder are distinguished from cyclothymic disorder by the judgment that a
substance/medication (especially stimulants) is etiologically related to the mood disturbance. The
frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually
resolve following cessation of substance/medication use.
Both 
disorders 
may
resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. By definition, in
cyclothymic disorder the criteria for a major depressive, manic, or hypomanic episode have
never been met, whereas the bipolar I disorder and bipolar II disorder specifier “with rapid
cycling” requires that full mood episodes be present.
Borderline personality disorder is associated with recurrent, brief
marked shifts in mood that may suggest cyclothymic disorder. Engagement in potentially selfdamaging behaviors can be seen in both conditions but would need to occur in the context of
other hypomanic symptoms to be related to cyclothymia. Mood instability in borderline
personality disorder occurs in the domains of anxiety, irritability, and sadness, whereas elation,
euphoria, and/or increased energy are not characteristic features of borderline personality
disorder. If the criteria are met for both disorders, both borderline personality disorder and
cyclothymic disorder may be diagnosed.

Comorbidity
Substance-related disorders and sleep disorders (i.e., difficulties in initiating and maintaining
sleep) may be present in individuals with cyclothymic disorder. Rates of comorbid
psychiatric disorders in children with cyclothymic disorder treated in outpatient psychiatric
settings are greater than those in children with disruptive behavior/attention-deficit/hyperactivity
disorder and similar to those in children with bipolar I or II disorder.
Substance/Medication-Induced Bipolar and Related
Disorder
Diagnostic Criteria
A. A prominent and persistent disturbance in mood that predominates in the clinical
picture and is characterized by abnormally elevated, expansive, or irritable mood
and abnormally increased activity or energy.
B. There is evidence from the history, physical examination, or laboratory findings
of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to or withdrawal from a
medication.
2. The involved substance/medication is capable of producing the symptoms in
Criterion A.
C. The disturbance is not better explained by a bipolar or related disorder that is not
substance/medication-induced. Such evidence of an independent bipolar or
related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month) after
the cessation of acute withdrawal or severe intoxication; or there is other
evidence 
suggesting 
the 
existence 
of 
an 
independent 
nonsubstance/medication-induced bipolar and related disorder (e.g., a history of
recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance
intoxication or substance withdrawal only when the symptoms in Criterion A
predominate in the clinical picture and when they are sufficiently severe to warrant

clinical attention.
Coding note: The ICD-10-CM codes for the [specific substance/medication]-induced
bipolar and related disorders are indicated in the table below. Note that the ICD-10CM code depends on whether or not there is a comorbid substance use disorder
present for the same class of substance. In any case, an additional separate
diagnosis of a substance use disorder is not given. If a mild substance use disorder
is comorbid with the substance-induced bipolar and related disorder, the 4th position
character is “1,” and the clinician should record “mild [substance] use disorder”
before the substance-induced bipolar and related disorder (e.g., “mild cocaine use
disorder with cocaine-induced bipolar and related disorder”). If a moderate or severe
substance use disorder is comorbid with the substance-induced bipolar and related
disorder, the 4th position character is “2,” and the clinician should record “moderate
[substance] use disorder” or “severe [substance] use disorder,” depending on the
severity of the comorbid substance use disorder. If there is no comorbid substance
use disorder (e.g., after a one-time heavy use of the substance), then the 4th
position character is “9,” and the clinician should record only the substance-induced
bipolar and related disorder.
ICD-10-CM
With mild use
disorder
With moderate or
severe use disorder
Without use
disorder
Alcohol
F10.14
F10.24
F10.94
Phencyclidine
F16.14
F16.24
F16.94
Other hallucinogen
F16.14
F16.24
F16.94
Sedative, hypnotic, or anxiolytic
F13.14
F13.24
F13.94
Amphetamine-type substance (or other
stimulant)
F15.14
F15.24
F15.94
Cocaine
F14.14
F14.24
F14.94
Other (or unknown) substance
F19.14
F19.24
F19.94
Specify (see Table 1 in the chapter “Substance-Related and Addictive Disorders,”
which indicates whether “with onset during intoxication” and/or “with onset during
withdrawal” applies to a given substance class; or specify “with onset after
medication use”):
With onset during intoxication: If criteria are met for intoxication with the
substance and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the
substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use: If symptoms developed at initiation of
medication, with a change in use of medication, or during withdrawal of
medication.

Recording Procedures
The name of the substance/medication-induced bipolar and related disorder begins with the
specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing the bipolar
mood symptoms. The diagnostic code is selected from the table included in the criteria set,
which is based on the drug class and presence or absence of a comorbid substance use disorder.
For substances that do not fit into any of the classes (e.g., dexamethasone), the code for “other
(or unknown) substance” should be used; and in cases in which a substance is judged to be an
etiological factor but the specific class of substance is unknown, the same code should also be
used.
When recording the name of the disorder, the comorbid substance use disorder (if any) is
listed first, followed by the word “with,” followed by the name of the substance-induced bipolar
and related disorder, followed by the specification of onset (i.e., onset during intoxication, onset
during withdrawal). For example, in the case of irritable symptoms occurring during intoxication
in a man with a severe cocaine use disorder, the diagnosis is F14.24 severe cocaine use disorder
with cocaine-induced bipolar and related disorder, with onset during intoxication. A separate
diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced
bipolar and related disorder occurs without a comorbid substance use disorder (e.g., after a onetime heavy use of the substance), no accompanying substance use disorder is noted (e.g., F15.94
amphetamine-induced bipolar and related disorder, with onset during intoxication). When more
than one substance is judged to play a significant role in the development of bipolar mood
symptoms, each should be listed separately (e.g., F15.24 severe methylphenidate use disorder
with methylphenidate-induced bipolar and related disorder, with onset during intoxication;
F19.94 dexamethasone-induced bipolar and related disorder, with onset during intoxication).
Diagnostic Features
The essential feature of substance/medication-induced bipolar and related disorder is a prominent
and persistent disturbance in mood that predominates in the clinical picture and is characterized
by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy
(Criterion A); these symptoms are judged to be attributable to the effects of a substance (e.g., a
drug of abuse, a medication, or a toxin exposure) (Criterion B).
To meet criteria for the diagnosis, the abnormally elevated, expansive, or irritable mood and
increased activity or energy must have developed during or soon after substance intoxication or
withdrawal or after exposure to or withdrawal from a medication, as evidenced by clinical
history, physical examination, or laboratory findings (Criterion B1), and the involved
substance/medication must be capable of producing the abnormally elevated, expansive, or
irritable mood and increased activity or energy (Criterion B2). In addition, the abnormally
elevated, expansive, or irritable mood and increased activity or energy are not better explained
by a non-substance/medication-induced bipolar and related disorder.
Evidence of an independent bipolar and related disorder includes the observation that the
abnormally elevated, expansive, or irritable mood and increased activity or energy preceded the
onset of substance/medication use, the symptoms persist beyond a substantial period of time after
the cessation of acute withdrawal or severe intoxication (i.e., usually longer than 1 month), or

there is other evidence that suggests the existence of an independent non-substance/medicationinduced bipolar and related disorder (Criterion C), such as a history of recurrent non-substanceinduced manic episodes. Diagnosis of substance/medication-induced bipolar and related disorder
should not be made when symptoms occur exclusively during the course of a delirium (Criterion
D). Finally, the diagnosis requires that the substance/medication-induced symptoms cause
clinically significant distress or impairment in social, occupational, or other important areas of
functioning (Criterion E). The substance-induced bipolar and related disorder diagnosis should
be made instead of a diagnosis of substance intoxication or substance withdrawal only when the
symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to
warrant independent clinical attention.
A key exception to the diagnosis of substance/medication-induced bipolar and related
disorder is the case of hypomania or mania that occurs after antidepressant medication use or
other treatments and persists beyond the physiological effects of the medication. The persistence
of hypomania or mania is considered an indicator of true bipolar disorder, not
substance/medication-induced bipolar and related disorder. Similarly, individuals with apparent
electroconvulsive therapy–induced manic or hypomanic episodes that persist beyond the
physiological effects of the treatment are diagnosed with bipolar disorder, not
substance/medication-induced bipolar and related disorder. Furthermore, substance/medicationinduced bipolar and related symptoms may suggest an underlying bipolar diathesis in individuals
previously not diagnosed with bipolar disorders.
Side effects of some antidepressants and other psychotropic drugs (e.g., edginess, agitation)
may resemble the primary symptoms of a manic syndrome, but they are fundamentally distinct
from bipolar symptoms and are insufficient for the diagnosis. That is, the criterion symptoms of
mania/hypomania have specificity (simple agitation is not the same as excess involvement in
purposeful activities), and a sufficient number of symptoms must be present (not just one or two
symptoms) to make these diagnoses. In particular, the appearance of one or two nonspecific
symptoms—irritability, edginess, or agitation during antidepressant treatment—in the absence of
a full manic or hypomanic syndrome should not be taken to support a diagnosis of a bipolar
disorder.
Associated Features
Substances/medications that are typically considered to be associated with substance/medicationinduced bipolar and related disorder include the stimulant class of drugs, as
well as phencyclidine and steroids; however, a number of potential substances continue to
emerge as new compounds are synthesized (e.g., so-called bath salts).
Prevalence
Limited epidemiological data exist regarding the prevalence of substance/medication-induced
mania or bipolar disorder. Prevalence of substance-induced bipolar disorder will depend on
substance availability and level of substance use in a society; for example, countries with cultural
prohibitions against alcohol or other substance use may have a lower prevalence of substance-

Substance intoxication and substance withdrawal.
related disorders.
Development and Course
In phencyclidine-induced mania, the initial presentation may be one of a delirium with affective
features, which then becomes an atypically appearing manic or mixed manic state. This condition
follows the ingestion or inhalation quickly, usually within hours or, at the most, a few days. In
stimulant-induced manic or hypomanic states, the response is in minutes to 1 hour after one or
several ingestions or injections. The episode is very brief and typically resolves over 1–2 days.
With corticosteroids and some immunosuppressant medications, the mania (or mixed or
depressed state) usually follows several days of ingestion, and the higher doses appear to have a
much greater likelihood of producing bipolar symptoms.
Diagnostic Markers
Determination of the substance of use can be made through markers in the blood or urine to
corroborate diagnosis.
Differential Diagnosis
Substance/medication-induced bipolar and related disorder should be differentiated from other
bipolar disorders, substance intoxication, substance withdrawal, substance-induced delirium, and
medication side effects (as noted earlier). A full manic episode that emerges during
antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that treatment is sufficient evidence for a
bipolar I diagnosis. A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a bipolar II diagnosis only if
preceded by a major depressive episode.
Euphoria, irritability, and increased energy may
occur in substance intoxication (e.g., stimulant intoxication) or substance withdrawal (e.g.,
cannabis withdrawal). The diagnosis of the substance-specific intoxication or substance-specific
withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of
substance/medication-induced bipolar and related disorder either with onset during intoxication
or with onset during withdrawal should be made instead of a diagnosis of substance intoxication
or substance withdrawal when the euphoric or irritable mood or increased energy symptoms are
predominant in the clinical picture and are sufficiently severe to warrant clinical attention.
Comorbidity
Comorbidities are those associated with the use of illicit substances (in the case of illegal
stimulants or phencyclidine) or diversion of prescribed stimulants. Comorbidities related to
steroid or immunosuppressant medications are those medical indications for these preparations.
Delirium can occur before or along with manic symptoms in individuals ingesting phencyclidine
or those who are prescribed steroid medications or other immunosuppressant medications.

Bipolar and Related Disorder Due to Another Medical
Condition
Diagnostic Criteria
A. A prominent and persistent disturbance in mood that predominates in the clinical
picture and is characterized by abnormally elevated, expansive, or irritable mood
and abnormally increased activity or energy.
B. There is evidence from the history, physical examination, or laboratory findings
that the disturbance is the direct pathophysiological consequence of another
medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning, or necessitates
hospitalization to prevent harm to self or others, or there are psychotic features.
Coding note: The ICD-10-CM code depends on the specifier (see below).
Specify if:
F06.33 With manic features: Full criteria are not met for a manic or hypomanic
episode.
F06.33 With manic- or hypomanic-like episode: Full criteria are met except
Criterion D for a manic episode or except Criterion F for a hypomanic episode.
F06.34 With mixed features: Symptoms of depression are also present but do
not predominate in the clinical picture.
Coding note: Include the name of the other medical condition in the name of the
mental disorder (e.g., F06.33 bipolar disorder due to hyperthyroidism, with manic
features). The other medical condition should also be coded and listed separately
immediately before the bipolar and related disorder due to the medical condition
(e.g., E05.90 hyperthyroidism; F06.33 bipolar disorder due to hyperthyroidism, with
manic features).
Diagnostic Features
The essential features of bipolar and related disorder due to another medical condition are
presence of a prominent and persistent period of abnormally elevated, expansive, or irritable
mood and abnormally increased activity or energy predominating in the clinical picture
(Criterion A) that is attributable to another medical condition (Criterion B). In most cases the
manic or hypomanic picture may appear during the initial presentation of the medical condition
(i.e., within 1 month); however, there are exceptions, especially in chronic medical conditions
that might worsen or relapse and herald the appearance of the manic or hypomanic picture.
Bipolar and related disorder due to another medical condition would not be diagnosed when the

manic or hypomanic episodes definitely preceded the medical condition, because the proper
diagnosis would be bipolar disorder (except in the unusual circumstance in which all preceding
manic or hypomanic episodes—or, when only one such episode has occurred, the preceding
manic or hypomanic episode—were associated with ingestion of a substance/medication). The
diagnosis of bipolar and related disorder due to another medical condition should not be made
during the course of a delirium (Criterion D). The manic or hypomanic episode in bipolar and
related disorder due to another medical condition must cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning to qualify for this
diagnosis (Criterion E).
Associated Features
The listing of medical conditions that are said to be able to induce mania is never complete, and
the clinician’s best judgment is the essence of this diagnosis. Among the best known of the
medical conditions that can cause a bipolar manic or hypomanic condition are Cushing’s disease
and multiple sclerosis, as well as stroke and traumatic brain injuries. Antibodies to the N-methylD-aspartate (NMDA) receptor have been associated with manic or mixed mood and psychotic
symptoms. In such cases, the causative medical condition would be anti-NMDA receptor
encephalitis.
Development and Course
Bipolar and related disorder due to another medical condition usually has its onset acutely or
subacutely within the first weeks or month of the onset of the associated medical condition.
However, this is not always the case, as a worsening or later relapse of the associated medical
condition may precede the onset of the manic or hypomanic syndrome. The clinician must make
a clinical judgment in these situations about whether the medical condition is causative, based on
temporal sequence as well as plausibility of a causal relationship. Finally, the condition may
remit before or just after the medical condition remits, particularly when treatment of the
manic/hypomanic symptoms is effective.
Culture-Related Diagnostic Issues
Culture-related differences, to the extent that there is any evidence, pertain to those associated
with the medical condition (e.g., rates of multiple sclerosis and stroke vary around the world
based on dietary factors, genetic factors, and other environmental factors).
Sex- and Gender-Related Diagnostic Issues
Gender differences pertain to those associated with the medical condition (e.g., systemic lupus
erythematosus is more common in females; stroke is somewhat more common in middle-age
males compared with females).
Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (e.g., steroid levels in

Delirium and major or mild neurocognitive disorder.
Symptoms of catatonia and acute anxiety.
Medication-induced depressive or manic symptoms.
blood or urine to help corroborate the diagnosis of Cushing’s disease, which can be associated
with manic or depressive syndromes; laboratory tests confirming the diagnosis of multiple
sclerosis).
Functional Consequences of Bipolar and Related Disorder Due to
Another Medical Condition
Functional consequences of the bipolar symptoms may exacerbate impairments associated with
the medical condition and may incur worse outcomes because of interference with medical
treatment.
Differential Diagnosis
A separate diagnosis of bipolar and related
disorder due to another medical condition is not given if the mood disturbance occurs exclusively
during the course of a delirium. However, a diagnosis of bipolar and related disorder due to
another medical condition may be given in addition to a diagnosis of major or mild
neurocognitive disorder if the mood disturbance is judged to be a physiological consequence of
the pathological process causing the neurocognitive disorder and if symptoms of irritability or
elevated mood are a prominent part of the clinical presentation.
It is important to differentiate symptoms of mania from
excited catatonic symptoms and from agitation related to acute anxiety states.
An important differential diagnostic observation
is that the other medical condition may be treated with medications (e.g., steroids or alphainterferon) that can induce depressive or manic symptoms. In these cases, clinical judgment
using all of the evidence in hand is the best way to try to separate the most likely and/or the most
important of two etiological factors (i.e., association with the medical condition vs. a
substance/medication-induced syndrome). The differential diagnosis of the associated medical
conditions is relevant but largely beyond the scope of the present manual.
Comorbidity
Conditions comorbid with bipolar and related disorder due to another medical condition are
those associated with the medical conditions of etiological relevance. Delirium can occur before
or along with manic symptoms in individuals with Cushing’s disease.
Other Specified Bipolar and Related Disorder
F31.89
This category applies to presentations in which symptoms characteristic of a bipolar
and related disorder that cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning predominate but do not meet
the full criteria for any of the disorders in the bipolar and related disorders diagnostic
class. The other specified bipolar and related disorder category is used in situations
in which the clinician chooses to communicate the specific reason that the
presentation does not meet the criteria for any specific bipolar and related disorder.
This is done by recording “other specified bipolar and related disorder” followed by
the specific reason (e.g., “short-duration cyclothymia”).
Examples of presentations that can be specified using the “other specified”
designation include the following:
1. Short-duration hypomanic episodes (2–3 days) and major depressive
episodes: A lifetime history of one or more major depressive episodes in
individuals whose presentation has never met full criteria for a manic or
hypomanic episode but who have experienced two or more episodes of shortduration hypomania that meet the full symptomatic criteria for a hypomanic
episode but that only last for 2–3 days. The episodes of hypomanic symptoms do
not overlap in time with the major depressive episodes, so the disturbance does
not meet criteria for major depressive episode, with mixed features.
2. Hypomanic episodes with insufficient symptoms and major depressive
episodes: A lifetime history of one or more major depressive episodes in
individuals whose presentation has never met full criteria for a manic or
hypomanic episode but who have experienced one or more episodes of
hypomania that do not meet full symptomatic criteria (i.e., at least 4 consecutive
days of elevated mood and one or two of the other symptoms of a hypomanic
episode, or irritable mood and two or three of the other symptoms of a
hypomanic episode). The episodes of hypomanic symptoms do not overlap in
time with the major depressive episodes, so the disturbance does not meet
criteria for major depressive episode, with mixed features.
3. Hypomanic episode without prior major depressive episode: One or more
hypomanic episodes in an individual whose presentation has never met full
criteria for a major depressive episode or a manic episode.
4. Short-duration cyclothymia (less than 24 months): Multiple episodes of
hypomanic symptoms that do not meet criteria for a hypomanic episode and
multiple episodes of depressive symptoms that do not meet criteria for a major
depressive episode that persist over a period of less than 24 months (less than
12 months for children or adolescents) in an individual whose presentation has
never met full criteria for a major depressive, manic, or hypomanic episode and
does not meet criteria for any psychotic disorder. During the course of the
disorder, the hypomanic or depressive symptoms are present for more days than
not, the individual has not been without symptoms for more than 2 months at a
time, and the symptoms cause clinically significant distress or impairment.
5. Manic episode superimposed on schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and unspecified schizophrenia spectrum

and other psychotic disorder. Note: Manic episodes that are part of
schizoaffective disorder do not merit an additional diagnosis of other specified
bipolar and related disorder.
Unspecified Bipolar and Related Disorder
F31.9
This category applies to presentations in which symptoms characteristic of a bipolar
and related disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not meet
the full criteria for any of the disorders in the bipolar and related disorders diagnostic
class. The unspecified bipolar and related disorder category is used in situations in
which the clinician chooses not to specify the reason that the criteria are not met for
a specific bipolar and related disorder, and includes presentations in which there is
insufficient information to make a more specific diagnosis (e.g., in emergency room
settings).
Unspecified Mood Disorder
F39
This category applies to presentations in which symptoms characteristic of a mood
dis-order that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not at the
time of the evaluation meet the full criteria for any of the disorders in either the
bipolar or the depressive disorders diagnostic classes and in which it is difficult to
choose between unspecified bipolar and related disorder and unspecified depressive
disorder (e.g., acute agitation).
Specifiers for Bipolar and Related Disorders
Specify if:
With anxious distress: The presence of at least two of the following symptoms
during the majority of days of the current manic, hypomanic, or major depressive
episode in bipolar I disorder (or the most recent episode if bipolar I disorder is in
partial or full remission); or of the current hypomanic or major depressive
episode in bipolar II disorder (or the most recent episode if bipolar II disorder is
in partial or full remission); or during the majority of symptomatic days in
cyclothymic disorder:

1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.
Specify current severity:
Mild: Two symptoms.
Moderate: Three symptoms.
Moderate-severe: Four or five symptoms.
Severe: Four or five symptoms with motor agitation.
Note: Anxious distress has been noted as a prominent feature of both bipolar
and major depressive disorders in both primary care and specialty mental
health settings. High levels of anxiety have been associated with higher
suicide risk, longer duration of illness, and greater likelihood of treatment
nonresponse. As a result, it is clinically useful to specify accurately the
presence and severity levels of anxious distress for treatment planning and
monitoring of response to treatment.
With mixed features: The mixed features specifier can apply to the current
manic, hypomanic, or major depressive episode in bipolar I disorder (or the most
recent episode if bipolar I disorder is in partial or full remission) or to the current
hypomanic or major depressive episode in bipolar II disorder (or the most recent
episode if bipolar II disorder is in partial or full remission):
Manic or hypomanic episode, with mixed features:
A. Full criteria are met for a manic episode or hypomanic episode, and at least
three of the following symptoms are present during the majority of days of
the current or most recent episode of mania or hypomania:
1. Prominent dysphoria or depressed mood as indicated by either
subjective report (e.g., feels sad or empty) or observation made by
others (e.g., appears tearful).
2. Diminished interest or pleasure in all, or almost all, activities (as
indicated by either subjective account or observation made by others).
3. Psychomotor retardation nearly every day (observable by others; not
merely subjective feelings of being slowed down).
4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely
self-reproach or guilt about being sick).
6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for

committing suicide.
B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania
and depression simultaneously, the diagnosis should be manic episode,
with mixed features, due to the marked impairment and clinical severity of
full mania.
D. The mixed symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication or other treatment).
Depressive episode, with mixed features:
A. Full criteria are met for a major depressive episode, and at least three of the
following manic/hypomanic symptoms are present during the majority of
days of the current or most recent episode of depression:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or
school, or sexually).
6. Increased or excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than
usual; to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania
and depression simultaneously, the diagnosis should be manic episode,
with mixed features.
D. The mixed symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication or other treatment).
Note: Mixed features associated with a major depressive episode have been
found to be a significant risk factor for the development of bipolar I or bipolar II
disorder. As a result, it is clinically useful to note the presence of this specifier
for treatment planning and monitoring of response to treatment.
With rapid cycling: Presence of at least four mood episodes in the previous 12
months that meet the criteria for manic, hypomanic, or major depressive episode
in bipolar I disorder or that meet the criteria for hypomanic or major depressive

episode in bipolar II disorder.
Note: Episodes are demarcated by either partial or full remissions of at least 2
months or a switch to an episode of the opposite polarity (e.g., major
depressive episode to manic episode).
Note: The essential feature of a rapid-cycling bipolar disorder is the
occurrence of at least four mood episodes during the previous 12 months.
These episodes can occur in any combination and order. The episodes must
meet both the duration and the symptom number criteria for a major
depressive, manic, or hypomanic episode and must be demarcated by either a
period of full remission or a switch to an episode of the opposite polarity.
Manic and hypomanic episodes are counted as being on the same pole.
Except for the fact that they occur more frequently, the episodes that occur in
a rapid-cycling pattern are no different from those that occur in a non-rapidcycling pattern. Mood episodes that count toward defining a rapid-cycling
pattern exclude those episodes directly caused by a substance (e.g., cocaine,
corticosteroids) or another medical condition.
With melancholic features:
A. One of the following is present during the most severe period of the current
major depressive episode (or the most recent major depressive episode if
bipolar I or bipolar II disorder is currently in partial or full remission):
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better,
even temporarily, when something good happens).
B. Three (or more) of the following:
1. A distinct quality of depressed mood characterized by profound
despondency, despair, and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note: The specifier “with melancholic features” is applied if these features
are present at the most severe stage of the episode. There is a nearcomplete absence of the capacity for pleasure, not merely a diminution. A
guideline for evaluating the lack of reactivity of mood is that even highly
desired events are not associated with marked brightening of mood. Either
mood does not brighten at all, or it brightens only partially (e.g., up to 20%–
40% of normal for only minutes at a time). The “distinct quality” of mood

that is characteristic of the “with melancholic features” specifier is
experienced as qualitatively different from that during a nonmelancholic
depressive episode. A depressed mood that is described as merely more
severe, longer lasting, or present without a reason is not considered
distinct in quality. Psychomotor changes are nearly always present and are
observable by others.
 Melancholic features exhibit only a modest tendency to repeat across
episodes in the same individual. They are more frequent in inpatients, as
opposed to outpatients; are less likely to occur in milder than in more
severe major depressive episodes; and are more likely to occur in
individuals with psychotic features.
With atypical features: This specifier is applied when these features predominate
during the majority of days of the current major depressive episode (or the most
recent major depressive episode if bipolar I or bipolar II disorder is currently in
partial or full remission).
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive
events).
B. Two (or more) of the following:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to
episodes of mood disturbance) that results in significant social or
occupational impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during
the same episode.
Note: “Atypical depression” has historical significance (i.e., atypical in
contradistinction to the more classical agitated, “endogenous” presentations of
depression that were the norm when depression was rarely diagnosed in
outpatients and almost never in adolescents or younger adults) and today
does not connote an uncommon or unusual clinical presentation as the term
might imply.
 Mood reactivity is the capacity to be cheered up when presented with
positive events (e.g., a visit from children, compliments from others). Mood
may become euthymic (not sad) even for extended periods of time if the
external circumstances remain favorable. Increased appetite may be
manifested by an obvious increase in food intake or by weight gain.
Hypersomnia may include either an extended period of nighttime sleep or
daytime napping that totals at least 10 hours of sleep per day (or at least 2
hours more than when not depressed). Leaden paralysis is defined as feeling
heavy, leaden, or weighted down, usually in the arms or legs. This sensation is
generally present for at least an hour a day but often lasts for many

173
hours at a time. Unlike the other atypical features, pathological sensitivity to
perceived interpersonal rejection is a trait that has an early onset and persists
throughout most of adult life. Rejection sensitivity occurs both when the person
is and is not depressed, though it may be exacerbated during depressive
periods.
With psychotic features: Delusions or hallucinations are present at any time in
the current manic or major depressive episode in bipolar I disorder (or the most
recent manic or major depressive episode if bipolar I disorder is currently in
partial or full remission) or in the current major depressive episode in bipolar II
disorder (or the most recent major depressive episode if bipolar II disorder is
currently in partial or full remission). If psychotic features are present, specify if
mood-congruent or mood-incongruent:
When applied to current or most recent manic episode (in bipolar I disorder):
With mood-congruent psychotic features: The content of all delusions
and hallucinations is consistent with the typical manic themes of grandiosity,
invulnerability, etc., but may also include themes of suspiciousness or
paranoia, especially with respect to others’ doubts about the individual’s
capacities, accomplishments, and so forth.
With mood-incongruent psychotic features: The content of the delusions
and hallucinations does not involve typical manic themes as described
above, or the content is a mixture of mood-incongruent and mood-congruent
themes.
When applied to current or most recent major depressive episode (in bipolar I
disorder or bipolar II disorder):
With mood-congruent psychotic features: The content of all delusions
and hallucinations is consistent with the typical depressive themes of
personal inadequacy, guilt, disease, death, nihilism, or deserved
punishment.
With mood-incongruent psychotic features: The content of the delusions
and hallucinations does not involve typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the
content is a mixture of mood-incongruent and mood-congruent themes.
With catatonia: This specifier is applied to the current manic or major
depressive episode in bipolar I disorder (or the most recent manic or major
depressive episode if bipolar I disorder is currently in partial or full remission)
or to the current major depressive episode in bipolar II disorder (or the most
recent major depressive episode if bipolar II disorder is currently in partial or
full remission) if catatonic features are present during most of the episode.
See criteria for catatonia associated with a mental disorder in the chapter
“Schizophrenia Spectrum and Other Psychotic Disorders.”

With peripartum onset: This specifier is applied to the current manic,
hypomanic, or major depressive episode in bipolar I disorder (or the most
recent manic, hypomanic, or major depressive episode if bipolar I disorder is
currently in partial or full remission) or to the current hypomanic or major
depressive episode in bipolar II disorder (or the most recent hypomanic or
major depressive episode if bipolar II disorder is currently in partial or full
remission) if onset of mood symptoms occurs during pregnancy or in the 4
weeks following delivery.
Note: Mood episodes can have their onset either during pregnancy or
postpartum. About 50% of postpartum major depressive episodes begin
prior to delivery. Thus, these episodes are referred to collectively as
peripartum episodes.
 Between conception and birth, about 9% of women will experience a
major depressive episode. The best estimate for prevalence of a major
depressive episode between birth and 12 months postpartum is just below
7%.
 Peripartum-onset mood episodes can present either with or without
psychotic features. Infanticide (a rare occurrence) is most often associated
with postpartum
psychotic episodes that are characterized by command hallucinations to kill
the infant or delusions that the infant is possessed, but psychotic symptoms
can also occur in severe postpartum mood episodes without such specific
delusions or hallucinations.
 Postpartum mood (major depressive or manic) episodes with psychotic
features appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be
more common in primiparous women. The risk of postpartum episodes with
psychotic features is particularly increased for women with prior postpartum
psychotic mood episodes but is also elevated for those with a prior history of
a depressive or bipolar disorder (especially bipolar I disorder) and those with
a family history of bipolar disorders.
 Once a woman has had a postpartum episode with psychotic features, the
risk of recurrence with each subsequent delivery is between 30% and 50%.
Postpartum episodes must be differentiated from delirium occurring in the
postpartum period, which is distinguished by a fluctuating level of
awareness or attention.
 Peripartum-onset depressive disorders must be distinguished from the
much more common “maternity blues,” or what is known in lay terms as
“baby blues.” Maternity blues is not considered to be a mental disorder and
is characterized by sudden changes in mood (e.g., the sudden onset of
tearfulness in the absence of depression) that do not cause functional
impairment and that are likely caused by physiological changes occurring
after delivery. It is temporary and self-limited, typically improving quickly

(within a week) without the need for treatment. Other symptoms of maternity
blues include sleep disturbance and even confusion that can occur shortly
after delivery.
 Perinatal women may be at higher risk for depressive disorders due to
thyroid abnormalities as well as other medical conditions that can cause
depressive symptoms. If the depressive symptoms are judged to be due to
another medical condition related to the perinatal period, depressive
disorder due to another medical condition should be diagnosed instead of a
major depressive episode, with peripartum onset.
With seasonal pattern: This specifier applies to the lifetime pattern of mood
episodes. The essential feature is a regular seasonal pattern of at least one
type of episode (i.e., mania, hypomania, or depression). The other types of
episodes may not follow this pattern. For example, an individual may have
seasonal manias but have depressions that do not regularly occur at a specific
time of year.
A. There has been a regular temporal relationship between the onset of manic,
hypomanic, or major depressive episodes and a particular time of the year
(e.g., in the fall or winter) in bipolar I or bipolar II disorder.
Note: Do not include cases in which there is an obvious effect of seasonally
related psychosocial stressors (e.g., regularly being unemployed every
winter).
B. Full remissions (or a change from major depression to mania or hypomania
or vice versa) also occur at a characteristic time of the year (e.g.,
depression disappears in the spring).
C. In the last 2 years, the individual’s manic, hypomanic, or major depressive
episodes have demonstrated a temporal seasonal relationship, as defined
above, and no nonseasonal episodes of that polarity have occurred during
that 2-year period.
D. Seasonal manias, hypomanias, or depressions (as described above)
substantially outnumber any nonseasonal manias, hypomanias, or
depressions that may have occurred over the individual’s lifetime.
Note: The specifier “with seasonal pattern” can apply to the pattern of major
depressive episodes in bipolar I and bipolar II disorder, to the pattern of
manic episodes
and hypomanic episodes in bipolar I disorder, and to the pattern of
hypomanic episodes in bipolar II disorder. The essential feature is the onset
and remission of major depressive, manic, or hypomanic episodes at
characteristic times of the year. In most cases, the seasonal major
depressive episodes begin in fall or winter and remit in spring. Less
commonly, there may be recurrent summer depressive episodes. This

pattern of onset and remission of episodes must have occurred during at
least a 2-year period, without any nonseasonal episodes occurring during
this period. In addition, the seasonal depressive, manic, or hypomanic
episodes must substantially outnumber any nonseasonal depressive, manic,
or hypomanic episodes over the individual’s lifetime.
 This specifier does not apply to those situations in which the pattern is
better explained by seasonally linked psychosocial stressors (e.g., seasonal
unemployment or school schedule). It is unclear whether a seasonal pattern
of major depressive episodes is more likely in recurrent major depressive
disorder or in bipolar disorders. However, within the bipolar disorders group,
a seasonal pattern of major depressive episodes appears to be more likely
in bipolar II disorder than in bipolar I disorder. In some individuals, the onset
of manic or hypomanic episodes may also be linked to a particular season,
with peak seasonality of mania or hypomania from spring through summer.
 The prevalence of winter-type seasonal pattern appears to vary with
latitude, age, and sex. Prevalence increases with higher latitudes. Age is
also a strong predictor of seasonality, with younger persons at higher risk for
winter depressive episodes.
Specify if:
In partial remission: Symptoms of the immediately previous manic, hypomanic,
or major depressive episode are present but full criteria are not met, or there is a
period lasting less than 2 months without any significant symptoms of a manic,
hypomanic, or major depressive episode following the end of such an episode.
In full remission: During the past 2 months, no significant signs or symptoms of
the disturbance were present.
Specify current severity of manic episode:
Severity is based on the number of criterion symptoms, the severity of those
symptoms, and the degree of functional disability.
Mild: Minimum symptom criteria are met for a manic episode.
Moderate: Very significant increase in activity or impairment in judgment.
Severe: Almost continual supervision is required in order to prevent physical
harm to self or others.
Specify current severity of major depressive episode:
Severity is based on the number of criterion symptoms, the severity of those
symptoms, and the degree of functional disability.
Mild: Few, if any, symptoms in excess of those required to make the diagnosis
are present, the intensity of the symptoms is distressing but manageable, and
the symptoms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional
impairment are between those specified for “mild” and “severe.”
Severe: The number of symptoms is substantially in excess of that required to
make the diagnosis, the intensity of the symptoms is seriously distressing and

unmanageable, and the symptoms markedly interfere with social and
occupational functioning.
1In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is
feelings of emptiness and loss, while in an MDE it is persistent depressed mood and the inability to anticipate happiness or
pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of an MDE is more
persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and
humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of an MDE. The thought content
associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical
or pessimistic ruminations seen in an MDE. In grief, self-esteem is generally preserved, whereas in an MDE, feelings of
worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings
vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved
individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “joining” the
deceased, whereas in an MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of
life, or unable to cope with the pain of depression.
1In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is
feelings of emptiness and loss, while in an MDE it is persistent depressed mood and the inability to anticipate happiness or
pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of an MDE is more
persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and
humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of an MDE. The thought content
associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical
or pessimistic ruminations seen in an MDE. In grief, self-esteem is generally preserved, whereas in an MDE feelings of
worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings
vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved
individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “joining” the
deceased, whereas in an MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of
life, or unable to cope with the pain of depression.