cutory. On the whole, however, associations  between delusions and particular medical
conditions appear to be less specific  than is the case for hallucinations.
In determining whether the ps ychotic disturbance is attributable to another medical
condition, the presence of a medical condition must be identified and considered to be the
etiology of the psychosis through a physiol ogical mechanism. Although there are no
infallible guidelines for determining whether th e relationship between the psychotic distur-
bance and the medical condition is etiological, several considerations provide some guidance.
One consideration is the presen ce of a temporal association between the onset, exacerba-
tion, or remission of the medical condition an d that of the psychotic disturbance. A second
consideration is the presence of features that  are atypical for a psychotic disorder (e.g.,
atypical age at onset or presence of visual or  olfactory hallucinations). The disturbance must
also be distinguished from a substance/medication-induced psychotic disorder or an-
other mental disorder (e.g.,  an adjustment disorder).
Associated Features Supporting Diagnosis
The temporal association of th e onset or exacerbation of th e medical condition offers the
greatest diagnostic certainty that the delusions  or hallucinations are attributable to a med-
ical condition. Additional factors may incl ude concomitant treatments for the underlying
medical condition that confer a risk for psychosis independently, such as steroid treatment
for autoimmune disorders.
Prevalence
Prevalence rates for psychotic di sorder due to another medical condition are difficult to es-
timate given the wide variety of underlying medical etiologies. Life time prevalence has


Psychotic Disorder Due to Another Medical Condition 117
been estimated to range from 0.21% to 0.54%. When the prevalence findings are stratified
by age group, individuals older than 65 years have a significantly greater prevalence of
0.74% compared with those in younger age grou ps. Rates of psychosis also vary according
to the underlying medical condition; cond itions most commonly  associated with psy-
chosis include untreated endocrine and metabo lic disorders, autoim mune disorders (e.g.,
systemic lupus erythematosus, N-methyl- D-aspartate (NMDA) receptor autoimmune en-
cephalitis), or temporal lobe epilepsy. Psycho sis due to epilepsy has been further differ-
entiated into ictal, postictal, and interictal  psychosis. The most common of these is postictal
psychosis, observed in 2%–7.8% of epilepsy patients. Among older individuals, there may
be a higher prevalence of the disorder in fe males, although additional gender-related fea-
tures are not clear and vary considerably with  the gender distributions of the underlying
medical conditions.
Development and Course
Psychotic disorder due to another medical condition may be a single transient state or it
may be recurrent, cycling with  exacerbations and remissions of the underlying medical
condition. Although treatment of the underlyi ng medical condition often results in a res-
olution of the psychosis, this is not always  the case, and psychotic symptoms may persist
long after the medical event (e.g ., psychotic disorder due to fo cal brain injury). In the con-
text of chronic conditions such as multiple sc lerosis or chronic interictal psychosis of epi-
lepsy, the psychosis may assume a long-term course.
The expression of psychotic disorder due to  another medical cond ition does not differ


The expression of psychotic disorder due to  another medical cond ition does not differ
substantially in phenomenology depending on  age at occurrence. However, older age
groups have a higher prevalence of the disorder, which is most likely due to the increasing
medical burden associated with advanced ag e and the cumulative effects of deleterious
exposures and age-related processes (e.g., athe rosclerosis). The nature of the underlying
medical conditions is likely to change across  the lifespan, with younger age groups more
affected by epilepsy, head trauma, autoimmune , and neoplastic diseas es of early to mid-
life, and older age groups more affected by stroke disease, anoxic events, and multiple sys-
tem comorbidities. Underlying factors with in creasing age, such as preexisting cognitive
impairment as well as vision and hearing impairments, may incur a greater risk for psy-
chosis, possibly by serving to lower th e threshold for experiencing psychosis.
Risk and Prognostic Factors
Course modifiers. Identification and treatment of the underlying medical condition has
the greatest impact on course, although pr eexisting central nervou s system injury may
confer a worse course outcome (e.g., head trauma, cerebr ovascular disease).
Diagnostic Markers
The diagnosis of psychotic disorder due to an other medical condition depends on the clin-
ical condition of each individual, and the diag nostic tests will vary according to that con-
dition. A variety of medical conditions ma y cause psychotic symp toms. These include
neurological condit ions (e.g., neoplasms, cerebrovascular disease, Huntington's disease,
multiple sclerosis, epilepsy, auditory or visual nerve injury or impairment, deafness,
migraine, central nervous  system infections), endocrine co nditions (e.g., hyper- and hypo-


thyroidism, hyper- and hypopa rathyroidism, hyper- and hypo adrenocorticism), metabolic
conditions (e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances,
hepatic or renal diseases, and autoimmune di sorders with central nervous system involve-
ment (e.g., systemic lupus er ythematosus). The associated physical examination findings,
laboratory findings, and patterns of prevalen ce or onset reflect th e etiological medical
condition.


118 Schizophrenia Spectrum and Other Psychotic Disorders
Suicide Risk
Suicide risk in the context of psychotic diso rder due to another me dical condition is not
clearly delineated, although certain conditions  such as epilepsy and multiple sclerosis are
associated with increased rates of suicide, which may be further increased in the presence
of psychosis.
Functional Consequences of Psychotic Disorder
Due to Another Medical Condition
Functional disability is typically severe in the context of psychotic di sorder due to another
medical condition but will vary  considerably by the type of condition and likely improve
with successful resolution of the condition.
Differential Diagnosis
Delirium. Hallucinations and delusions commonly occur in the context of a delirium;
however, a separate diagnosis of psychotic disorder due to another medical condition is
not given if the disturbance occurs exclusively during the co urse of a delirium. Delusions
in the context of a major or mild neurocogni tive disorder would be diagnosed as major or
mild neurocognitive disorder, with behavioral disturbance.
Substance/medication-induced psychotic disorder. If there is evidence of recent or
prolonged substance use (including medicati ons with psychoactive effects), withdrawal
from a substance, or exposure to a toxin (e.g ., LSD [lysergic acid diethylamide] intoxica-
tion, alcohol withdrawal), a substance/medica tion-induced psychotic disorder should be
considered. Symptoms that occur during or shor tly after (i.e., within 4 weeks) of substance
intoxication or withdrawal or after medication use may be es pecially indicative of a sub-
stance-induced psychotic disorder, depending on the character, duration, or amount of
the substance used. If the clin ician has ascertained that the disturbance is due to both a


medical condition and substance use, both diag noses (i.e., psychotic disorder due to an-
other medical condition and substance/medication-induced psychotic disorder) can be
given.
Psychotic disorder. Psychotic disorder due to another medical condition must be distin-
guished from a psychotic disord er (e.g., schizophrenia, delusi onal disorder, schizoaffective
disorder) or a depressive or bipolar disorder , with psychotic featur es. In psychotic disor-
ders and in depressive or bipolar disorders, wi th psychotic features, no specific and direct
causative physiological mechanisms associated with a medical condition can be demon-
strated. Late age at onset and the absence of a personal or family history of schizophrenia
or delusional disorder suggest the need for a thorough ass essment to rule out the diagno-
sis of psychotic disorder due to another medical condition. Auditory hallucinations that
involve voices speaking complex sentences ar e more characteristic of schizophrenia than
of psychotic disorder due to a medical condition. Other types of hallucinations (e.g., vi-
sual, olfactory) commonly signal a psychotic disorder due to another medical condition or
a substance/medication-induced psychotic disorder.
Comorbidity
Psychotic disorder due to another medical co ndition in individuals older than 80 years is
associated with concurrent major neurocognitive disorder (dementia).


Catatonia Associated With Another Mental Disorder (Catatonia Specifier) 119
Catatonia
Catatonia can occur in the context of several disorders, including neurodevelopmental,
psychotic, bipolar, depressive disorders, and other medical cond itions (e.g., cerebral folate
deficiency, rare autoimmune and paraneoplastic disorders.  The manual does not treat
catatonia as an independent class but recognizes  a) catatonia associated with another men-
tal disorder (i.e., a neurodevelopmental, psychotic disord er, a bipolar disorder, a depres-
sive disorder, or other mental disorder), b)  catatonic disorder due to another medical
condition, and c) unspecified catatonia.
Catatonia is defined by the pres ence of three or more of 12 psychomotor features in the
diagnostic criteria for catatoni a associated with another mental disorder and catatonic dis-
order due to another medical condition. The es sential feature of cata tonia is a marked psy-
chomotor disturbance that may involve decr eased motor activity, decreased engagement
during interview or physical examination, or excessive and peculiar motor activity. The
clinical presentation of ca tatonia can be puzzling, as th e psychomotor disturbance may
range from marked unresponsiveness to marked  agitation. Motoric immobility may be se-
vere (stupor) or moderate (catalepsy and waxy flexibility). Similarly, decreased engage-
ment may be severe (mutism) or moderate  (negativism). Excessive and peculiar motor
behaviors can be complex (e.g.,  stereotypy) or simple (agitation) and may include echola-
lia and echopraxia. In extreme cases, the same individual may wax and wane between de-


creased and excessive motor activity. The se emingly opposing clinical features and
variable manifestations of the diagnosis cont ribute to a lack of awareness and decreased
recognition of catatonia. During  severe stages of catatonia, the individual may need care-
ful supervision to avoid self-h arm or harming others. There are potential risks from mal-
nutrition, exhaustion, hyperpyr exia and self-inflicted injury.
Catatonia Associated With Another
Mental Disorder (Catatonia Specifier)
293.89 (F06.1)
A. The clinical picture is dominated by three (or more) of the following symptoms:
1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).
Coding note:  Indicate the name of the associated mental disorder when recording the


Coding note:  Indicate the name of the associated mental disorder when recording the
name of the condition (i.e., 293.89 [F06.1] catatonia associated with major depressive dis-
order). Code first the associated mental disorder (e.g., neurodevelopmental disorder, brief


120 Schizophrenia Spectrum and Other Psychotic Disorders
psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder,
bipolar disorder, major depressive disorder, or other mental disorder) (e.g., 295.70 [F25.1]
schizoaffective disorder, depressive type; 293.89 [F06.1] catatonia associated with
schizoaffective disorder).
Diagnostic Features
Catatonia associated with another mental diso rder (catatonia specifier) may be used when
criteria are met for catatonia during the course of a neurodevelopmental, psychotic, bipo-
lar, depressive, or other mental disorder. The catatonia specifier is appropriate when the
clinical picture is characterized by marked ps ychomotor distur bance and involves at least
three of the 12 diagnostic features listed in Cr iterion A. Catatonia is typically diagnosed in
an inpatient setting and occurs in up to 35% of individuals with schizophrenia, but the ma-
jority of catatonia cases invol ve individuals with depressive  or bipolar disorders. Before
the catatonia specifier is used in neurodevel opmental, psychotic, bipolar, depressive, or
other mental disorders, a wide variety of ot her medical conditions need to be ruled out;
these conditions include, but are not limited to, medical cond itions due to infectious, met-
abolic, or neurological conditions (see “Catatonic Disorder Due to Another Medical Con-
dition”). Catatonia can also be a side effect of a medication (see the chapter “Medication-
Induced Movement Disorders and Other Advers e Effects of Medication”). Because of the
seriousness of the complications, particular attention should be paid to the possibility that
the catatonia is attributable to 333.92 (G21.0) neuroleptic malignant syndrome.


Catatonic Disorder Due to
Another Medical Condition
Diagnostic Criteria 293.89 (F06.1)
A. The clinical picture is dominated by three (or more) of the following symptoms:
1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [ Note:  not applicable if there is an
established aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).
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 (e.g., a manic episode).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.


Unspecified Catatonia 121
Coding note:  Include the name of the medical condition in the name of the mental disor-
der (e.g., 293.89 [F06.1]) catatonic disorder due to hepatic encephalopathy). The other
medical condition should be coded and listed separately immediately before the cata-
tonic disorder due to the medical condition (e.g., 572.2 [K71.90] hepatic encephalopathy;
293.89 [F06.1] catatonic disorder due to hepatic encephalopathy).
Diagnostic Features
The essential feature of catato nic disorder due to another me dical condition is the presence
of catatonia that is judged to be attributed to the physiological effects of another medical
condition. Catatonia can be diagnosed by the pres ence of at least three of the 12 clinical fea-
tures in Criterion A. There must be evidence  from the history, physical examination, or
laboratory findings that the catatonia is attr ibutable to another medical condition (Crite-
rion B). The diagnosis is not given if the ca tatonia is better explained by another mental
disorder (e.g., manic episode) (Criterion C) or if it occurs exclusivel y during the course of
a delirium (Criterion D).
Associated Features Supporting Diagnosis
A variety of medical conditions may cause catatonia, especially neurological conditions
(e.g., neoplasms, head trauma, cerebrovascular  disease, encephalitis) and metabolic con-
ditions (e.g., hypercalcemia, hepatic encepha lopathy, homocystinuria , diabetic ketoacido-
sis). The associated physical examination find ings, laboratory findings, and patterns of
prevalence and onset reflect those of  the etiological medical condition.


prevalence and onset reflect those of  the etiological medical condition.
Differential Diagnosis
A separate diagnosis of catatonic disorder due to another medical condition is not given if
the catatonia occurs exclusively during the course of a delirium or neuroleptic malignant
syndrome. If the individual is currently taking neurolep tic medication, consideration
should be given to medication -induced movement disorders (e.g., abnormal positioning
may be due to neuroleptic-induced acute dy stonia) or neuroleptic malignant syndrome
(e.g., catatonic-like features may be present,  along with associated vital sign and/or labo-
ratory abnormalities). Catatonic symptoms ma y be present in any of the following five
psychotic disorders: brief psychotic disorder , schizophreniform disorder, schizophrenia,
schizoaffective disorder, and substance/medication-induced psychotic disorder. It may
also be present in some of the neurodevelopme ntal disorders, in all of the bipolar and de-
pressive disorders,  and in other mental disorders.
Unspecified Catatonia

This category applies to presentations in which symptoms characteristic of catatonia
cause clinically significant distress or impairm ent in social, occupational, or other impor-
tant areas of functioning but either the nature of the underlying mental disorder or other
medical condition is unclear, full criteria for catatonia are not met, or there is insufficient
information to make a more specific diagnosis (e.g., in emergency room settings).
Coding note:  Code first 781.99 (R29.818)  other symptoms involving nervous and muscu-
loskeletal systems, followed by 293.89 (F06.1)  unspecified catatonia.


122 Schizophrenia Spectrum and Other Psychotic Disorders
Other Specified Schizophrenia Spectrum and
Other Psychotic Disorder
298.8 (F28)
This category applies to presentations in which symptoms characteristic of a schizophre-
nia spectrum and other psychotic disorder that cause clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning predominate but
do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other
psychotic disorders diagnostic class. The other specified schizophrenia spectrum and oth-
er psychotic disorder category is used in situations in which the clinician chooses to com-
municate the specific reason that the presentation does not meet the criteria for any
specific schizophrenia spectrum and other psychotic disorder. This is done by recording “oth-
er specified schizophrenia spectrum and other psychotic disorder” followed by the specific
reason (e.g., “persistent auditory hallucinations”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Persistent auditory hallucinations  occurring in the absence of any other features.
2.Delusions with significant overlapping mood episodes:  This includes persistent
delusions with periods of overlapping mood episodes that are present for a substantial
portion of the delusional disturbance (such that  the criterion stipulating only brief mood
disturbance in delusional disorder is not met).
3.Attenuated psychosis syndrome: This syndrome is characterized by psychotic-like
symptoms that are below a threshold for full psychosis (e.g., the symptoms are less
severe and more transient, and insight is relatively maintained).
4.Delusional symptoms in partner of individual with delusional disorder:  In the
context of a relationship, the delusional ma terial from the dominant partner provides
content for delusional belief by the individual who may not otherwise entirely meet cri-


content for delusional belief by the individual who may not otherwise entirely meet cri-
teria for delusional disorder.
Unspecified Schizophrenia Spectrum and
Other Psychotic Disorder
298.9 (F29)
This category applies to presentations in which symptoms characteristic of a schizophre-
nia spectrum and other psychotic disorder that cause clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning predominate but
do not meet the full criteria for any of the disorders in the schizophrenia spectrum and oth-
er psychotic disorders diagnostic class. The unspecified schizophrenia spectrum and oth-
er psychotic 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 schizophrenia spectrum and
other psychotic disorder, and includes presentatio ns in which there is insufficient informa-
tion to make a more specific diagnosis (e.g., in emergency room settings).


123Bipolar and
 Related Disorders
Bipolar and related  disorders are separated from  the depressive disorders in
DSM-5 and placed between the chapters on schizophrenia spectrum and other psychotic
disorders and depressive disord ers in recognition of their place as a bridge between the
two diagnostic classes in terms of symptomato logy, family history, and genetics. The di-
agnoses included in this chapter are bipola r I disorder, bipolar II disorder, cyclothymic
disorder, substance/medication-induced bipo lar and related disorder, bipolar and relat-
ed disorder due to another medical condition, other specified bipolar and related disor-
der, and unspecified bipolar and related disorder.
The bipolar I disorder criter ia represent the modern understanding of the classic
manic-depressive disorder or affective psycho sis described in the ni neteenth century, dif-
fering from that classic description only to th e 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 criter ia 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 episode of major de-
pression and at least one hypomanic episode, is no longer thought to be a “milder” condition
than bipolar I disorder, largely because of th e amount of time individuals with this con-
dition spend in depression and because the in stability of mood experienced by individuals
with bipolar II disorder is typically accompanied by serious impairment in work and social
functioning.
The diagnosis of cyclothymic disorder is give n to adults who experience at least 2 years
(for children, a full year) of both hypomanic and depressive periods without ever fulfilling


(for children, a full year) of both hypomanic and depressive periods without ever fulfilling
the criteria for an episode of mani a, hypomania, or major depression.
A large number of substances of abuse, some prescribed medi cations, 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 bipo-
lar and related disorder due to another medical condition.
The recognition that many individuals, partic ularly children and, to a lesser extent, ad-
olescents, experience bipolar-like phenomena that  do not meet the criteria for bipolar I, bi-
polar II, or cyclothymic disorder is reflected in the availability of the other specified
bipolar and related disorder category. Indeed, specific criteria for a disorder involving
short-duration hypomania are provided in Section III in the hope of encouraging further
study of this disorder.
Bipolar I Disorder
Diagnostic Criteria
For a diagnosis of bipolar I disorder, it is nece ssary to meet the following criteria for a manic
episode. The manic episode may have been preceded by and may be followed by hypo-
manic or major depressive episodes.


124 Bipolar and Related Disorders
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-d irected activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if hospi-
talization 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 sig-
nificant degree and represent a notic eable 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 dr awn 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 conse-
quences (e.g., engaging in unrestrained buyin g 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 oth-
ers, 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 treatm ent) or to another medical condition.


of abuse, a medication, other treatm ent) or to another medical condition.
Note:  A full manic episode that emerges during antidepressant treatment (e.g., medi-
cation, 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 re-
quired 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 consec-
utive 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, rep-
resent 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 dr awn 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 conse-
quences (e.g., engaging in unrestrained buyin g sprees, sexual indiscretions, or
foolish business investments).


Bipolar I Disorder 125
C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic 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 occupa-
tional 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).
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 in-
creased irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi-
polar 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 2-week
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 condi-
tion.
1. Depressed mood most of the day, nearly every day, as indicated by either subjec-


tive 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 al l, 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 dec rease 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 delu-
sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-
ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-
out 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, occupa-
tional, 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 requi red for the diagnosis of bipolar I disorder.


common in bipolar I disorder but are not requi red 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


126 Bipolar and Related Disorders
sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Cri-
terion A, which may resemble a depressive episode. Although such symptoms may be un-
derstandable 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 Ep-
isode” above).
B. The occurrence of the manic and major depressive episode(s) is not better explained
by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional dis-
order, 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 epi-
sode 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 current ly met for a manic, hypomanic, or major depres-
sive episode. Codes are as follows:
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 MDE it is persistent
depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is


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 reminder s of the deceased. The
depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations.
The pain of grief may be accompanied by positi ve emotions and humor th at are uncharacteristic
of the pervasive unhappiness and misery charac teristic of a major depressive episode. The
thought content associated with grief generally  features a preoccupation with thoughts and
memories of the deceased, rather than the self-c ritical or pessimistic ruminations seen in a MDE.
In grief, self-esteem is generally preserved, whereas in a MDE, feelings of worthlessness and self-
loathing are common. If self-derog atory ideation is present in grief, it typically involves per-
ceived failings vis-à-vis the deceased (e.g., no t visiting frequently enough, not telling the
deceased how much he or she was loved). If a be reaved individual thinks  about death and dying,
such thoughts are generally focu sed on the deceased and possibl y about “joining” the deceased,
whereas in a major depressive episode such th oughts are focused on ending one’s own life
because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.Bipolar I disorderCurrent or
most recent
episode
manicCurrent or
most recent
episode
hypomanic* Current or
most recent
episode
depressedCurrent or
most recent
episode
unspecified**
Mild (p. 154) 296.41


unspecified**
Mild (p. 154) 296.41
(F31.11)NA 296.51
(F31.31)NA
Moderate (p. 154) 296.42
(F31.12)NA 296.52
(F31.32)NA
Severe (p. 154) 296.43
(F31.13)NA 296.53
(F31.4)NA


Bipolar I Disorder 127
In recording the name of a diagnosis, terms should be listed in the following order: bipolar
I disorder, type of current or most recent episode, severity/psychotic/remission specifiers,
followed by as many specifiers without codes as apply to the current or most recent epi-
sode.
Specify:
With anxious distress (p. 149)
With mixed features (pp. 149–150)
With rapid cycling (pp. 150–151)
With melancholic features (p. 151)
With atypical features  (pp. 151–152)
With mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features  (p. 152)
With catatonia  (p. 152). Coding note:  Use additional code 293.89 (F06.1).
With peripartum onset  (pp. 152–153)
With seasonal pattern (pp. 153–154)
Diagnostic Features
The essential feature of a manic episode is a distinct period during which there is an ab-
normally, 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 hospitalizatio n is necessary), accompanied by at least three
additional symptoms from Criterion B. If the mo od is irritable rather than elevated or ex-
pansive, at least fo ur 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 hap-
hazard enthusiasm for interpersonal, sexual, or occupational inte ractions. For example,
the individual may spontaneously start extens ive conversations with strangers in public.
Often the predominant mood is irritable rather than elevated, particularly when the indi-
vidual’s wishes are denied or if the individu al has been using substances. Rapid shifts in
mood over brief periods of time may occur and are referred to as lability (i.e., the alterna-With psychotic
features***
(p. 152)296.44
(F31.2)NA 296.54
(F31.5)NA
In partial
remission (p. 154)296.45
(F31.73)296.45
(F31.71)296.55
(F31.75)NA
In full remission
(p. 154)296.46
(F31.74)296.46
(F31.72)296.56
(F31.76)NA
Unspecified 296.40
(F31.9)296.40
(F31.9)296.50
(F31.9)NA
*Severity and psychotic specifiers do not apply; code 296.40 (F31.0) for cases not in remission.
**Severity, psychotic, and remission specif iers do not apply. Code 296.7 (F31.9).
***If psychotic features are present, code the “with psychotic features” specifier irrespective of epi-
sode severity.Bipolar I disorderCurrent or
most recent
episode
manicCurrent or
most recent
episode
hypomanic* Current or
most recent
episode


episode
hypomanic* Current or
most recent
episode
depressedCurrent or
most recent
episode
unspecified**


128 Bipolar and Related Disorders
tion among euphoria, dysphoria,  and irritability). In children, happiness, silliness and
“goofiness” are normal in the context of spec ial occasions; however, if these symptoms are
recurrent, inappropriate to the context, and beyond what is expected for the developmen-
tal level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e.,
distinct from baseline), and the mood change occurs at the same ti me as symptoms that
meet Criterion B for mania, diagnostic certainty is increased; however, the mood change
must be accompanied by persistently increased activity or energy levels that are obvious
to those who know the child well.
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 levels may manife st at unusual hours of
the day.
Inflated self-esteem is typicall y present, ranging from uncritical self-confidence to marked
grandiosity, and may reach delusi onal proportions (Criterion B1).  Despite lack of any partic-
ular experience or talent, the individual may embark on comple x tasks such as writing a novel
or seeking publicity for some im practical invention. Grandiose delusions (e.g., of having a
special relationship to a famous person) are co mmon. In children, overe stimation 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 cl ear evidence to the contrary or the child at-
tempts feats that are clearly dangerous and, most important,  represent a change from the
child’s normal behavior, the grandiosity criterion should be considered satisfied.


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) and is
distinct from insomnia in which the individual wants to sleep or feels the need to sleep but
is unable. 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 individ-
ual may go for days without sleep, yet not feel  tired. Often a decreased need for sleep her-
alds the onset of a manic episode.
Speech can be rapid, pressured, loud, and diff icult to interrupt (Criterion B3). Individ-
uals may talk continuously and without regard for others’ wi shes to communicate, often
in an intrusive manner or without concern for the relevance of what is said. Speech is
sometimes characterized by jokes, puns, amus ing 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 ma de to interrupt the individual. Both Criterion
A and Criterion B symptoms may be accompanie d by symptoms of the opposite (i.e., de-
pressive) pole (see “with mixed features” specifier, pp. 149–150).
Often the individual’s thoughts race at a rate faster than they 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 se-


vere, speech may become disorganized, incoherent , and particularly distressful to the individ-
ual. 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, backgr ound noises or conversations, furnishings in
the room) and often prevents individuals expe riencing mania from holding a rational con-
versation or attending to instructions.


the room) and often prevents individuals expe riencing mania from holding a rational con-
versation or attending to instructions.
The increase in goal -directed ac tivity often consists of excessive planning and partici-
pation in multiple activities, including sexual, occupational, political, or religious activi-
ties. Increased sexual drive, fantasies, and be havior 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 display psychomotor agitation or rest-
lessness (i.e., purposeless acti vity) by pacing or by holding multiple conversations simulta-


Bipolar I Disorder 129
neously. 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 diffic ult to ascertain in children; however, when
the child takes on many tasks simultaneously, starts devising elaborate and unrealistic
plans for projects, develops previously abse nt and developmentally inappropriate sexual
preoccupations (not accounted for by sexual abuse or exposure  to sexually explicit mate-
rial), 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 associa-
tion with other symptoms of mania.
The expansive mood, excessive optimism, gr andiosity, and poor judgment often lead
to reckless involvement in activities such as spending sprees, giving away possessions,
reckless driving, foolish business investments,  and sexual promiscuity that is unusual for
the individual, even though these activities ar e 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 behavior may include infidelity
or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually
transmitted diseases or in terpersonal consequences.
The manic episode must result in marked impairment in social or occupational func-
tioning or require hospitalizatio n to prevent harm to self or others (e.g., financial losses, il-
legal activities, loss of employment, self-injur ious behavior). By definition, the presence of
psychotic features during a manic episode also satisfies Criterion C.


psychotic features during a manic episode also satisfies Criterion C.
Manic symptoms or syndromes that are attrib utable to the 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 an-
other medical condition do not count toward the diagnosis of bipolar I disorder. However,
a fully syndromal manic episode that arises duri ng treatment (e.g., with medications, elec-
troconvulsive therapy, light ther apy) or drug use and persists beyond the physiological ef-
fect of the inducing agent (i.e., after a medica tion 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 di agnosis (Criterion D). Caution is indicated so
that one or two symptoms (particularly increa sed irritability, edginess, or agitation follow-
ing antidepressant use) are not taken as suffi cient for diagnosis of a manic or hypomanic
episode, nor necessarily an indication of a bi polar disorder diathesis. It is necessary to
meet criteria for a manic episode to make a diag nosis of bipolar I disorder, but it is not re-
quired to have hypomanic or major depressi ve episodes. However, they may precede or
follow a manic episode. Full descriptions of the diagnostic features of a hypomanic epi-
sode may be found within the text for bipola r II disorder, and the features of a major de-
pressive episode are described within th e text for major depressive disorder.
Associated Features Supporting Diagnosis
During a manic episode, individuals often do not perceive that they are ill or in need of treat-


ment and vehemently resist efforts to be treated. Individuals may change their dress, makeup,
or personal appearance to a more sexually su ggestive or flamboyant style. Some perceive a
sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany
the manic episode. Some individuals may become  hostile and physically threatening to others


sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany
the manic episode. Some individuals may become  hostile and physically threatening to others
and, when delusional, may become physically  assaultive or suicidal. Catastrophic conse-
quences 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.
Mood may shift very rapidly to anger or depression. Depressive  symptoms may occur
during a manic episode and, if present, may last moments, hour s, or, more rarely, days (see
“with mixed features” specifier, pp. 149–150).


130 Bipolar and Related Disorders
Prevalence
The 12-month prevalence estimate in the contin ental United States was 0.6% for bipolar I
disorder as defined in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11
countries ranged from 0.0% to 0.6%. The life time male-to-female prevalence ratio is ap-
proximately 1.1:1.
Development and Course
Mean age at onset of the first manic, hypomanic, or major depressive episode is approxi-
mately 18 years for bipola r I disorder. Special considerations are necessary to detect the di-
agnosis in children. Since children of the same chronological age may be at different
developmental stages, it is difficult to defi ne with precision what is “normal” or “ex-
pected” at any given point. Therefore, each ch ild should be judged according to his or her
own baseline. Onset occurs throughout the life  cycle, including firs t onsets in the 60s or
70s. Onset of manic symptoms (e.g., sexual or so cial disinhibition) in late mid-life or late-
life should prompt consideratio n of medical conditions (e.g., frontotemporal neurocogni-
tive disorder) and of substance ingestion or withdrawal.
More than 90% of individuals who have a sin gle 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 depressi ve, manic, or hypomanic) within 1 year receive the speci-
fier “with rapid cycling.”
Risk and Prognostic Factors


fier “with rapid cycling.”
Risk and Prognostic Factors
Environmental. Bipolar disorder is mo re common in high-income than in low-income
countries (1.4 vs. 0.7%). Separated, divorced,  or widowed individuals have higher rates of
bipolar I disorder than do individuals who ar e married or have neve r been married, but
the direction of the association is unclear.
Genetic and physiological. A family history of bipolar diso rder is one of the strongest and
most consistent risk factors for bipolar disord ers. There is an average 10-fold increased risk
among adult relatives of individuals with bipo lar I and bipolar II disorders. Magnitude of
risk increases with degree of kinship. Schizophrenia and bipolar disorder likely share a ge-
netic origin, reflected in familial co-aggregat ion of schizophrenia and bipolar disorder.
Course modifiers. After an individual has a manic episode with psychotic features, subse-
quent manic episodes are more likely to in clude psychotic featur es. Incomplete inter-
episode recovery is more common when th e current episode is accompanied by mood-
incongruent psychotic features.
Culture-Related Diagnostic Issues
Little information exists on specific cultural differences in the expression of bipolar I dis-
order. One possible explanation for this ma y be that diagnostic instruments are often
translated and applied in diff erent cultures with no transcultural validation. In one U.S.
study, 12-month prevalence of bipolar I diso rder was significantly lower for Afro-Carib-
beans than for African Americans or whites.
Gender-Related Diagnostic Issues
Females are more likely to experience rapid cycling and mixed states, and to have patterns of
comorbidity that differ from th ose of males, including higher rates of lifetime eating disor-


ders. Females with bipolar I or II disorder are more likely to experience depressive symptoms
than males. They also have a higher lifetime risk of alcohol use disorder than are males and a
much greater likelihood of alcohol use disorder  than do females in the general population.


Bipolar I Disorder 131
Suicide Risk
The lifetime risk of suicide in individuals with  bipolar disorder is estimated to be at least
15 times that of the general population. In fa ct, bipolar disorder may account for one-quar-
ter of all completed su icides. A past history of suicide attempt and percent days spent de-
pressed in the past year are associated with gr eater risk of suicide attempts or completions.
Functional Consequences of Bipolar I Disorder
Although many individuals with bipolar disord er return to a fully functional level be-
tween episodes, approximately 30%  show severe impairment in  work role function. Func-
tional recovery lags substantially behind reco very from symptoms, especially with respect
to occupational recovery, resulting in lower socioeconomic status despite equivalent lev-
els of education when compared with the ge neral population. Individuals with bipolar I
disorder perform more poorly than healthy in dividuals on cognitive tests. Cognitive im-
pairments may contribute to vocational and interpersonal difficulties and persist through
the lifespan, even during euthymic periods.
Differential Diagnosis
Major depressive disorder. Major depressive disorder may also be accompanied by hy-
pomanic or manic symptoms (i.e., fewer symptoms or for a shorter duration than required
for mania or hypomania). When the individual presents in an episode of major depression,
one must depend on corroborating history re garding past episodes of mania or hypoma-
nia. Symptoms of irritability may be associated with either major depressive disorder or
bipolar disorder, adding to  diagnostic complexity.
Other bipolar disorders. Diagnosis of bipolar I disorder is differentiated from bipolar II
disorder by determining whether there have be en any past episodes of mania. Other spec-
ified and unspecified bipolar and related disord ers should be differentiated from bipolar I


ified and unspecified bipolar and related disord ers should be differentiated from bipolar I
and II disorders by considering whether eith er the episodes invol ving manic or hypo-
manic symptoms or the episodes of depressive symptoms fail  to meet the full criteria for
those conditions.
Bipolar disorder due to another medical co ndition may be distinguished from bipolar
I and II disorders by identifying, based on best  clinical evidence, a causally related medical
condition.
Generalized anxiety disorder, panic disorder , posttraumatic stress disorder, or other
anxiety disorders. These disorders need to be consider ed in the differential diagnosis as
either the primary disorder or, in some case s, a comorbid disorder. A careful history of
symptoms is needed to  differentiate generalized anxiety disorder from bipolar disorder,
as anxious ruminations may be mistaken for ra cing thoughts, and efforts to minimize anx-
ious feelings may be taken as impulsive beha vior. Similarly, sympto ms of posttraumatic
stress disorder need to be differentiated from bipolar disorder. It is helpful to assess the ep-
isodic nature of the symptoms described, as well as to consider symptom triggers, in mak-
ing this differential diagnosis.
Substance/medication-induced bipolar disorder. Substance use disorders may mani-
fest with substance.medicati on-induced manic symptoms th at must be distinguished
from bipolar I disorder; response to mood stabilizers during a substance/medication-
induced mania may not necessarily be diagnost ic for bipolar disorder. There may be sub-
stantial overlap in view of the tendency for individuals with bipolar I disorder to overuse
substances during an episode. A primary diagnosis of bipolar disorder must be estab-
lished based on symptoms that remain once  substances are no longer being used.
Attention-deficit/hyperactivity disorder. This disorder may be misdiagnosed as bipolar


Attention-deficit/hyperactivity disorder. This disorder may be misdiagnosed as bipolar
disorder, especially in adolescents and children. Many symptoms overlap with the symp-


132 Bipolar and Related Disorders
toms of mania, such as rapid speech, racing thoughts, distra ctibility, and less need for
sleep. The “double counting” of symptoms toward both ADHD and bipolar disorder can
be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode.
Personality disorders. Personality disorders such as borderline personality disorder
may have substantial symptomatic overlap wi th bipolar disorders, since mood lability
and impulsivity are common in both conditions . Symptoms must represent a distinct ep-
isode, and the noticeable increase over baseline required for the diagnosis of bipolar dis-
order must be present. A diagnosis of a personality disorder should not be made during an
untreated mood episode.
Disorders with prominent irritability. In individuals with severe irritability, particularly
children and adolescents, care must be take n to apply the diagnosis of bipolar disorder
only to those who have had a clear episode of  mania or hypomania—tha t is, a distinct time
period, of the required  duration, during which the irritability was clearly different from
the individual’s baseline and was accompan ied by the onset of Criterion B symptoms.
When a child’s irritability is persistent and pa rticularly severe, the diagnosis of disruptive
mood dysregulation disorder wo uld be more appropriate. Indeed, when any child is being
assessed for mania, it is essential that th e symptoms represent a clear change from the
child’s typical behavior.
Comorbidity
Co-occurring mental disorders are common, wi th the most frequent disorders being any
anxiety disorder (e.g., pa nic attacks, social anxiety disorder [social phobia], specific pho-
bia), occurring in approximatel y three-fourths of individuals; ADHD, any disruptive, im-
pulse-control, or conduct disorder (e.g., intermittent explosive disorder, oppositional


pulse-control, or conduct disorder (e.g., intermittent explosive disorder, oppositional
defiant disorder, conduct disorder), and any su bstance use disorder (e.g., alcohol use dis-
order) occur in over half of individuals with bipolar I disorder. Adults with bipolar I dis-
order have high rates of serious and/or untreated co-occurring medical conditions.
Metabolic syndrome and migraine are more common among individuals with bipolar dis-
order than in the general population. More than half of individuals whose symptoms meet
criteria for bipolar disorder have an alcoho l use disorder, and those with both disorders
are at greater risk for suicide attempt.
Bipolar II Disorder
Diagnostic Criteria 296.89 (F31.81)
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a cur-
rent or past hypomanic episode and the following criteria for a current or past major de-
pressive 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 consec-
utive days and present most of the day, nearly every day.
B. During the period of mood disturbance and in creased energy and activity, three (or more)
of the following symptoms have persisted (four if the mood is only irritable), represent a no-
ticeable 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.


Bipolar II Disorder 133
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 conse-
quences (e.g., engaging in unrestrained buyin g sprees, sexual indiscretions, or
foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic 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 occupa-
tional 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 or other treatment).
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 in-
creased irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi-
polar diathesis.
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week


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 subjec-
tive 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 al l, 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 dec rease 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 delu-
sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-
ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-
out a specific plan, a suicide attempt, or a specific plan for committing suicide.


out a specific plan, a suicide attempt, or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another
medical condition.


134 Bipolar and Related Disorders
Note:  Criteria A–C above constitute a major depressive episode.
Note:  Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat-
ural disaster, a serious medical illness or disability) may include the feelings of intense sad-
ness, 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 under-
standable 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 ex ercise of clinical judgment ba sed 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 “Hypo-
manic 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. The occurrence of the hypomanic episode( s) and major depressive episode(s) is not
better explained by schizoaffective disorder, schizophrenia, schizophreniform disor-
der, 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 be-
tween periods of depression and hypomania caus es clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning.
Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: 296.89 (F31.81). Its status with respect to cur-


rent severity, presence of psychotic features, course, and other specifiers cannot be
coded but should be indicated in writing (e.g., 296.89 [F31.81] bipolar II disorder, current
episode depressed, moderate severity, with mi xed features; 296.89 [F31.81] bipolar II dis-
order, most recent episode depressed, in partial remission).
Specify current or most recent episode:
Hypomanic
Depressed
Specify if:
With anxious distress (p. 149)
With mixed features (pp. 149–150)
1In distinguishing grief from a major  depressive episode (MDE), it is useful to consider that in grief
the predominant affect is feelings of emptiness an d loss, while in a 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 re minders of the deceased. The depressed mood of a
MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may
be accompanied by positive emotions and humor th at are uncharacteristic of the pervasive unhap-
piness and misery characteristic of a MDE. The thought content associated with grief generally fea-
tures a preoccupation with thoughts and memories of the deceased, rather than the self-critical or
pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a
MDE feelings of worthlessness and self-loathing ar e common. If self-derogatory ideation is present
in grief, it typically involves pe rceived 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 genera lly focused on the deceased and possibly about
“'joining” the deceased, whereas in a 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.


Bipolar II Disorder 135
With rapid cycling (pp. 150–151)
With mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features  (p. 152)
With catatonia  (p. 152). Coding note:  Use additional code 293.89 (F06.1).
With peripartum onset  (pp. 152–153)
With seasonal pattern  (pp. 153–154): Applies only to the pattern of major depressive
episodes.
Specify course if full criteria for a mood episode are not currently met:
In partial remission  (p. 154)
In full remission  (p. 154)
Specify severity if full criteria for a mood episode are currently met:
Mild (p. 154)
Moderate  (p. 154)
Severe (p. 154)
Diagnostic Features
Bipolar II disorder is characterized by a clin ical course of recurr ing mood episodes con-
sisting of one or more majo r depressive episodes (Criteria A–C under “Major Depressive
Episode”) and at least one hypomanic epis ode (Criteria A–F under “Hypomanic Epi-
sode”). The major depressive episode must last at least 2 weeks, and the hypomanic epi-
sode must last at least 4 days, to meet the di agnostic criteria. During the mood episode(s),
the requisite number of symptoms  must be present most of th e day, nearly every day, and
represent a noticeable change from usual behavior and functioning. The presence of a
manic episode during the course of illness pr ecludes the diagnosis of bipolar II disorder
(Criterion B under “Bipolar II Disorder”). Episodes of substance/medication-induced de-


pressive disorder or substance/medication-i nduced bipolar and related disorder (repre-
senting the physiological effects of a medicati on, other somatic treatments for depression,
drugs of abuse, or toxin exposure) or of de pressive and related disorder due to another
medical condition or bipolar and related disord er due to another medi cal condition do not
count toward a diagnosis of bi polar II disorder unless they persist beyond the physiolog-
ical effects of the treatment or substance and then meet duration criteria for an episode. In
addition, the episodes must not be better acco unted for by schizoaffective disorder and are
not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or
other specified or unspecified schizophrenia spectrum or other psychotic disorders (Cri-
terion C under “Bipolar II Disorder”). The de pressive episodes or hypomanic fluctuations
must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criterion D under “Bipolar II Disorder ”); however, for hy-
pomanic episodes, this requirement does not have to be met. A hypomanic episode that
causes significant impairment would likely qu alify for the diagnosis of manic episode and,
therefore, for a lifetime diagnosis of bipolar I disorder. The recurrent major depressive ep-
isodes are often more frequent and lengthier than those occurring in bipolar I disorder.
Individuals with bipolar II d isorder typically present to a clinician during a major de-
pressive episode and are unlikely to complain  initially of hypomania. Typically, the hy-
pomanic episodes themselves do not cause im pairment. Instead, th e impairment results
from the major depressive episodes or from a persistent pattern of unpredictable mood
changes and fluctuating, unreliable interperso nal or occupational functioning. Individu-


changes and fluctuating, unreliable interperso nal or occupational functioning. Individu-
als with bipolar II disorder may not view the hypomanic episodes as pathological or dis-
advantageous, although others may be troubled by the indi vidual’s erratic behavior.
Clinical information from other informants, such as close friends or relatives, is often use-
ful in establishing the diagnosis of bipolar II disorder.


136 Bipolar and Related Disorders
A hypomanic episode should not be confused wi th the several days of euthymia and re-
stored energy or activity that may follow remiss ion of a major depressive  episode. Despite the
substantial differences in duration and severi ty between a manic and hypomanic episode, bi-
polar II disorder is not a “milder form” of bipo lar I disorder. Compared with individuals with
bipolar I disorder, individuals with bipolar II di sorder 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. Depressive symptoms co-occurr ing with a hypomanic episode or hypomanic
symptoms co-occurring with a depressive episod e are common in individuals with bipolar II
disorder and are overrepresented in females, pa rticularly hypomania with mixed features. In-
dividuals experiencing hypomania with mixed fe atures may not label their symptoms as hy-
pomania, but instead experience them as depr ession with increased energy or irritability.
Associated Features Supporting Diagnosis
A common feature of bipolar II disorder is impulsivity, which can contribute to suicide at-
tempts and substance use disorders. Impulsivit y may also stem from a concurrent person-
ality disorder, substance use disorder, anxiet y disorder, another mental disorder, or a
medical condition. There may be heightened levels of creativity in some individuals with
a bipolar disorder. However, that relationship  may be nonlinear; th at is, greater lifetime
creative accomplishments have been associated  with milder forms of  bipolar disorder, and
higher creativity has been f ound in unaffected family members. The individual’s attach-
ment to heightened creativity during hypomanic episodes may contribute to ambivalence


ment to 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 disord er, internationally, is  0.3%. In the United
States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder is
difficult to establish. DSM-IV bipolar I, bipola r II, and bipolar disorder not otherwise spec-
ified yield a combined prevalence rate of 1. 8% in U.S. and non-U.S. community samples,
with higher rates (2.7% inclusive) in youths age 12 years or older.
Development and Course
Although bipolar II disorder can begin in late adolescence and throughout adulthood, av-
erage age at onset is the mid-20s, which is slight ly later than for bipolar I disorder but ear-
lier than for major depressive  disorder. The illness most of ten begins with a depressive
episode and is not recognized as bipolar II d isorder until a hypomanic episode occurs; this
happens in about 12% of individuals with the initial diagnosis of major depressive disor-
der. Anxiety, substance use, or eating diso rders may also precede the diagnosis, compli-
cating its detection. Many individuals expe rience several episodes of major depression
prior to the first recognized hypomanic episode.
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 experi-
ence hypomanic symptoms than  are individuals with bipolar II disorder.The interval
between mood episodes in the co urse of bipolar II disorder tends to decrease as the indi-


vidual ages. While the hypomanic episode is the feature that defines bipolar II disorder,
depressive episodes are more enduring and disabling over time. Despite the predomi-
nance of depression, once a hypomanic epis ode has occurred, the diagnosis becomes bi-
polar II disorder and never reve rts to major depressive disorder.
Approximately 5%–15% of individuals with bipolar II disorder ha ve multiple (four or
more) mood episodes (hypomanic or major depressive) within the previous 12 months. If


Bipolar II Disorder 137
this pattern is present, it is noted by the specifier “with rapid cycling.” By definition, psy-
chotic symptoms do not occur in hypomanic episodes, and they appear to be less frequent
in the major depressive episodes in bipolar II di sorder than in those of bipolar I disorder.
Switching from a depressive episode to a manic or hypomanic episode (with or with-
out mixed features) may occur, both spontane ously and during treatment for depression.
About 5%–15% of individuals with bipolar II disorder will ultimately develop a manic ep-
isode, 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 irritabil-
ity 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 dis-
orders and major depressive disorder, but not bipolar disorder, in ad ulthood. Persistently
irritable youths have lower familial rates of bipolar disorder than do  youths who have bi-
polar disorder. For a hypomanic episode to be  diagnosed, the child’s symptoms must ex-
ceed what is expected in a given environment and culture for the child’s developmental
stage. 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, dis-
tinguishing individuals older than 60 years with bipolar II disorder by late versus early
age at onset does not appear to have any clinical utility.
Risk and Prognostic Factors


Risk and Prognostic Factors
Genetic and physiological. The risk of bipolar II disorder  tends to be highest among rel-
atives of individuals with bipolar II disorder, as opposed to individuals with bipolar I dis-
order or major depressive disorder. There ma y be genetic factors influencing the age at
onset for bipolar disorders.
Course modifiers. A rapid-cycling pattern is associated  with a poorer prognosis. Return
to previous level of social fu nction for individuals with bipolar II disorder is more likely
for individuals of younger age and with less severe depression, sugge sting adverse effects
of prolonged illness on recovery. More education, fewer ye ars of illness, and being mar-
ried are independently associated with functi onal 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.
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,
whereas some, but not all, clinical samples su ggest that bipolar II disorder is more com-
mon in females than in males, which may refl ect gender differences in treatment seeking
or other factors.
Patterns of illness and comorbidity, however,  seem to differ by gender, with females
being more likely than males to report hypomania with mixed depressive features and a
rapid-cycling course. Childbirth may be a spec ific 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 hypomani a from the elated mood and reduced sleep
that normally accompany the birth of a chil d may be challenging. Postpartum hypomania
may foreshadow the onset of a depression that occurs in abou t half of females who expe-
rience postpartum “highs.” Accurate detectio n of bipolar II disorder may help in estab-
lishing appropriate treatment of the depression , which may reduce the risk of suicide and
infanticide.


138 Bipolar and Related Disorders
Suicide Risk
Suicide risk is high in bipolar II disorder. Approximately one-third of individuals with bi-
polar II disorder report a lifetime history of suicide attempt. The prev alence rates of life-
time attempted suicide in bipolar II and bipola r I disorder appear to be similar (32.4% and
36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio of at-
tempts to completed suicides, may be higher in individuals with bipolar II disorder com-
pared with individuals with bipolar I disorder. There may be an association between
genetic markers and increased risk for suicidal behavior in individuals with bipolar dis-
order, including a 6.5-fold higher risk of su icide among first-degree relatives of bipolar II
probands compared with those with bipolar I disorder.
Functional Consequences  of Bipolar II Disorder
Although many in dividuals with bipolar II disorder return to a fully functional level be-
tween mood episodes, at least 15% continue to have some in ter-episode dysfunction, and
20% transition directly into another mood episode without inter-ep isode recovery. Func-
tional recovery lags substantially behind recovery from symptoms of bipolar II disorder,
especially in regard to occupational recovery , resulting in lower socioeconomic status de-
spite equivalent levels of education with the general population. Individuals with bipolar
II disorder perform more  poorly than healthy individuals on cognitive tests and, with the
exception of memory and semantic fluency, ha ve similar cognitive impairment as do in-
dividuals with bipolar I disord er. Cognitive impairments associ ated with bipolar II disor-
der may contribute to vocational difficulti es. Prolonged unemployment in individuals
with bipolar disorder is associated with more episodes of depression, older age, increased


with bipolar disorder is associated with more episodes of depression, older age, increased
rates of current panic disorder, and lif etime history of alcohol use disorder.
Differential Diagnosis
Major depressive disorder. Perhaps the most challenging differential diagnosis to con-
sider is major depressive di sorder, which may be accompanied by hypomanic or manic
symptoms that do not meet full criteria (i.e., either fewer symptoms or a shorter duration
than required for a hypomanic episode). This is  especially true in evaluating individuals
with symptoms of irritability, which may be associated with either  major depressive dis-
order or bipolar II disorder.
Cyclothymic disorder. In cyclothymic disorder, there are numerous periods of hypo-
manic symptoms and numerous periods of depr essive symptoms that do not meet symp-
tom or duration criteria for a major depressive  episode. Bipolar II disorder is distinguished
from cyclothymic disorder by the presence of  one or more major depressive episodes. If a
major depressive episode occurs after the firs t 2 years of cyclothymic disorder, the addi-
tional diagnosis of bipolar II disorder is given.
Schizophrenia spectrum and other related psychotic disorders. Bipolar II disorder must
be distinguished from psychotic disorders (e .g., schizoaffective disorder, schizophrenia,
and delusional disorder). Sc hizophrenia, schizoaffective di sorder, and delusional disor-
der are all characterized by periods of psychotic symptoms that occur in the absence of
prominent mood symptoms. Other helpful considerations incl ude the accompanying
symptoms, previous cour se, and family history.
Panic disorder or other anxiety disorders. Anxiety disorders need to be considered in
the differential diagnosis and may frequent ly be present as co-occurring disorders.


the differential diagnosis and may frequent ly be present as co-occurring disorders.
Substance use disorders. Substance use disorders are included in the differential diag-
nosis.
Attention-deficit/hype ractivity disorder. Attention-deficit/hypera ctivity disorder (ADHD)
may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many


Cyclothymic Disorder 139
symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need
for sleep, overlap with the symp toms of hypomania. The double  counting of symptoms to-
ward both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether
the symptoms represent a distin ct episode and if the noticeab le increase over baseline re-
quired for the diagnosis of bipo lar II disorder is present.
Personality disorders. The same convention as applies for ADHD also applies when
evaluating an individual for a personality disorder such as borderline personality disor-
der, since mood lability and impulsivity are common in both personality disorders and bi-
polar II disorder. Symptoms must represent a di stinct episode, and the noticeable increase
over baseline required for the diagnosis of bipo lar 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 pr esence of a personality disorder.
Other bipolar disorders. 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 unspecifie d bipolar and related disorders by confirm-
ing the presence of fully synd romal 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 individ-
uals with bipolar II disorder  have three or more co-occurr ing mental disorders; 75% have
an anxiety disorder; and 37% have a substa nce use disorder. Children and adolescents
with bipolar II disorder have a higher rate  of co-occurring anxiety disorders compared


with bipolar II disorder have a higher rate  of co-occurring anxiety disorders compared
with those with bipolar I diso rder, and the anxiety disorder most often predates the bi-
polar disorder. Anxiety and substance use diso rders occur in individuals with bipolar II
disorder at a higher rate than in the genera l population. Approximately 14% of individuals
with bipolar II disorder have at least one lif etime eating disorder, with binge-eating dis-
order being more common than bulim ia nervosa and anorexia nervosa.
These commonly co-occurring disorders do no t seem to follow a course of illness that
is truly independent from that of the bipolar disorder, but rather have strong associations
with mood states. For example, anxiety and ea ting disorders tend to associate most with
depressive symptoms, and substance use disord ers are moderately associated with manic
symptoms.
Cyclothymic Disorder
Diagnostic Criteria 301.13 (F34.0)
A. For at least 2 years (at least 1 year in children and adolescents) there have been nu-
merous periods with hypomanic symptoms that do not meet criteria for a hypomanic
episode and numerous periods with depressive sym ptoms that do not meet criteria for
a major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), the hypomanic
and depressive periods 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 un-


schizophrenia, schizophreniform disorder, delusional disorder, or other specified or un-
specified 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).


140 Bipolar and Related Disorders
F. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Specify if:
With anxious distress (see p. 149)
Diagnostic Features
The essential feature of cyclot hymic disorder is a chronic, fluctuating mood disturbance
involving numerous periods of hypomanic symptoms and periods of depressive symp-
toms that are distinct from each other (Criterion A). The hypomanic symptoms are of
insufficient number, severity, pervasiveness, or  duration to meet full criteria for a hypo-
manic episode, and the depressive symptoms ar e of insufficient nu mber, severity, perva-
siveness, 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 (pres-
ent more days than not), and any symptom-fr ee 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 su bsequently (i.e., after the initial 2 years in
adults or 1 year in children or adolescents) experiences a major depressive, manic, or hy-
pomanic episode, the diagnosis changes to majo r depressive disorder , bipolar I disorder,
or other specified or unspecified bipolar and related disorder (subclassified as hypomanic
episode without prior major depressive episod e), respectively, and the cyclothymic disor-
der 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, delu-


explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delu-
sional disorder, or other specified and un specified schizophrenia spectrum and other
psychotic disorders (Criterion D), in which c ase the mood symptoms are considered asso-
ciated features of the psychoti c disorder. The mood disturbanc e must also not be attribut-
able to the physiological effe cts of a substance (e.g., a dr ug of abuse, a medication) or
another medical condition (e.g., hyperthyroidis m) (Criterion E). Although some individ-
uals may function particularly  well during some of the pe riods of hypomania, over the
prolonged course of the disorder , there must be clinically significant distress or impair-
ment in social, occupational, or other import ant areas of functioning as a result of the
mood disturbance (Criterion F). The impairment may develop as a result of prolonged pe-
riods of cyclical, often unpredictable mood ch anges (e.g., the individual may be regarded
as temperamental, moody, unpredicta ble, inconsistent , or unreliable).
Prevalence
The lifetime prevalence of cyclothymic diso rder is approximately 0.4%–1%. Prevalence in
mood disorders clinics may rang e 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 lik ely to present for tr eatment than males.
Development and Course
Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes
considered to reflect a temperamental predispo sition to other disorders in this chapter.
Cyclothymic disorder usually has an insidious onset and a persistent course. There is a


15%–50% risk that an individual with cyclothy mic disorder will subsequently develop bi-
polar I disorder or bipolar II disorder. Onset of persistent, fluctuating hypomanic and de-
pressive symptoms late in adult life needs to  be clearly differentiated from bipolar and


Cyclothymic Disorder 141
related disorder due to another medical condition and depressi ve disorder due to another
medical condition (e.g., multiple  sclerosis) before the cyclothymic disorder diagnosis is as-
signed. Among children with cyclothymic diso rder, the mean age at onset of symptoms is
6.5 years of age.
Risk and Prognostic Factors
Genetic and physiological. Major depressive disorder, bipolar I disorder, and bipolar II
disorder are more common among first-degree bi ological relatives of individuals with cyclo-
thymic disorder than in the general population. There may also be an increased familial risk of
substance-related disorders. Cyclothymic disord er may be more common in the first-degree
biological relatives of individuals with bipolar I disorder than in the general population.
Differential Diagnosis
Bipolar and related disorder due to anothe r medical condition and depressive disorder
due to another medical condition. The diagnosis of bipolar and related disorder due to
another medical condition or depressive 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, or laboratory findings. If it is judged that the
hypomanic and depressive symptoms are not the physiological consequence of the med-
ical condition, then the primary mental disorder (i.e., cyclothymi c disorder) and the med-
ical 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 de-
pressive symptoms and the medical condition.


pressive symptoms and the medical condition.
Substance/medication-induced bipolar and related disorder and substance/medica-
tion-induced depressive disorder. Substance/medication-induced bipolar and related
disorder and substance/medica tion-induced depressive diso rder are distinguished from
cyclothymic disorder by the judgment that  a substance/medication (especially stimu-
lants) is etiologically related to  the mood disturbance. The fr equent mood swings in these
disorders that are suggestive of cyclothymic disorder usually resolv e following cessation
of substance/medication use.
Bipolar I disorder, with rapid cycling, an d bipolar II disorder, with rapid cycling.
Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts
in mood. By definition, in cyclothymic disord er the criteria for a major depressive, manic,
or hypomanic episode has never been met, wh ereas the bipolar I di sorder and bipolar II
disorder specifier “with rapid cycling” requ ires that full mood ep isodes be present.
Borderline person ality disorder. Borderline personality diso rder is associated with
marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for
both disorders, both borderline personality disorder and cyclothymic disorder may be di-
agnosed.
Comorbidity
Substance-related disorders and sleep disorder s (i.e., difficulties in initiating and main-
taining sleep) may be present in individuals with cyclothy mic disorder. Most children
with cyclothymic disorder treated in outpati ent psychiatric settings have comorbid mental
conditions; they are more likely than other pediatric patients with  mental disorders to
have comorbid attention-defi cit/hyperactivity disorder.


142 Bipolar and Related Disorders
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 elevated, expansive, or irritable mood, with or without depressed
mood, or markedly diminished interest or plea sure in all, or almost all, activities.
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 a medication.
2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.
C. The disturbance is not better explained by a bipolar or related disorder that is not sub-
stance/medication-induced. Such evidence of an independent bipolar or related disor-
der could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms per-
sist 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 non-substance/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, occupa-
tional, or other important areas of functioning.
Coding note:  The ICD-9-CM and ICD-10-CM codes fo r the [specific substance/medication]-
induced bipolar and related disorders are indicated in the table below. Note that the ICD-10-


CM code depends on whether or not there is a co morbid substance use disorder present for
the same class of substance. 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 dis-
order (e.g., “mild cocaine use disorder with coca ine-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 “moder-
ate [substance] use disorder” or “severe [subs tance] 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
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.89 F10.14 F10.24 F10.94
Phencyclidine 292.84 F16.14 F16.24 F16.94
Other hallucinogen 292.84 F16.14 F16.24 F16.94


Substance/Medication-Induced Bipolar and Related Disorder 143
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):
With onset during intoxication:  If the criteria are met for intoxication with the sub-
stance 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.
Recording Procedures
ICD-9-CM. The name of the substance/medication -induced bipolar and related disor-
der begins with the specific su bstance (e.g., cocaine, dexame thasone) that is presumed to
be causing the bipolar mood symptoms. The diag nostic code is selected from the table in-
cluded in the criteria set, which is based on the drug class. For substances that do not fit
into any of the classes (e.g., dexamethason e), the code for “other 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 category “unknown substance” should be used.
The name of the disorder is followed by the sp ecification of onset (i.e., onset during in-
toxication, onset during with drawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a single
code, for ICD-9-CM a separate diagnostic code  is given for the substance use disorder. For
example, in the case of irritable symptoms oc curring during intoxica tion in a man with a
severe cocaine use disorder, the diagnosis is 292.84 cocaine-induced bipolar and related