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Home Bipolar disorder Criteria for a Manic/Hypomanic Episodes Criteria for a Manic/Hypomanic Episodes PDF Print E-mail

Table 1.1: DSM-IV Criteria for a Manic / Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalisation is necessary)

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) 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 three hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation to prevent harm to self or other, or there are psychotic features

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism)

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count towards a diagnosis of Bipolar I disorder Criteria for a Hypomanic Episode

Here it is more interesting to note the similarities and differences between the hypomanic episode and the manic one, rather than to reproduce the criteria. To start with the similarities, both a hypomanic and a manic episode share the same key diagnostic symptoms (A: elevated-expansive-irritable mood and B: 3 or 4 manic symptoms out of 7 identified). Also, similarly to the manic episode, the causation of the hypomanic episode cannot be due to substance use or a general medical condition.

But what really differentiates the two episodes or states from each other, is the severity, duration, and from a psychological point of view the experience of each patient. The DSM-IV sets four days as the minimum duration for a hypomanic episode and states that the mood has to be “clearly different from the usual non-depressed mood”. But the two most important criteria (D and E) that refer to functional impairment essentially summarise the major difference between a hypomanic and a manic episode. The hypomanic episode is associated with an “unequivocal change in functioning that is uncharacteristic of the person when not symptomatic” (criterion C of hypomanic episode) and “the episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, and there are no psychotic features” (criterion D).

The four-day duration for hypomania has been challenged clinically, and more recently empirically (Benazzi and Akiskal, 2006). More recent criteria proposed by Swiss researchers (“Zurich criteria”, Angst et al., 2003), discuss at least a two-day duration for hypomania. These criteria make the diagnosis of Bipolar disorder easier in cases with brief hypomanias, but also tend to inflate the diagnosis of Bipolar disorder, and the time spent in syndromal states and number of episodes, that are usually reported in prospective naturalist studies on Bipolar symptoms (Bauer, Grof et al. 2006).

Any diagnostic definitions that rely on duration and severity of symptom states, especially in a variable condition such as a Bipolar disorder, require continuous monitoring in order to be accurate, and make prospective designs with multiple measurements a necessity.

Two more episodes that are often present in Bipolar disorder are major depressive and mixed episodes. Their symptoms and diagnostic criteria are given below. According to the DSM-IV, the diagnostic criteria and symptoms of a major depressive episode are the same both in Bipolar and Unipolar disorders. Mixed episodes by definition can only be present in Bipolar disorder as they require the presence of both a depressive and a manic episode.


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