DSM-5 Bipolar: Not Much Difference from DSM-IV Bipolar

Patient Expert

This is the second (and final) of our look at the DSM-5, the latest version of psychiatry's diagnostic bible, which has superseded the DSM-IV, dating from 1994. In case you're wondering, the stylistic change from the Roman numeral IV to the modernistic 5 represents the DSM's major innovation. Just about everything else is distressingly same-old, same-old.

Last week, in  The DSM-5 Debacle, we looked at the failure of the DSM-5 to address the problem of clinicians who misdiagnose patients with depression. Except in cases where a patient is presenting in obvious mania, very few clinicians get the bipolar diagnosis right the first time around. The sad result is patients being prescribed the one drug that runs a strong risk of making their condition worse - antidepressants.

Perhaps you are wondering: Wouldn't it be a good thing if we could clarify diagnostic criteria to reduce the risk of the suffering caused by misdiagnosis? The people responsible for the DSM-5 did not think so.

This week's installment is far more bland and prosaic. It focuses on the changes the DSM-5 actually made to the bipolar diagnosis. This means a mercifully short post.

Mixed Episodes

The most significant change involves the widening of criteria for mixed episodes. Mixed episodes involve depressed symptoms and manic symptoms occurring at once. These typically involve agitated depressions or manias or hypomanias where you feel terrible (dysphoric) rather than euphoric. In my book "Living Well with Depression and Bipolar Disorder," I put it this way:

If one thinks of either pure or mild mania as the music of Duke Ellington and Louis Armstrong on a clear summer night, mixed mania is heavy metal and rap in a thunderstorm, the blast of jackhammers, the frizzle-frazzle of shorted-out power lines, and the elbows on the black keys of every neuron in the brain vibrating to extinction.

A similar description would apply to agitated depressions. We are talking extreme psychic distress.

Under the old DSM, mixed episodes were unrealistically restricted to mania. As well as full-blown mania, one also had to simultaneously experience full-blown depression. The new DSM widens the criteria for mixed episodes in a number of ways:

  • Manic episodes no longer have to include full-blown depression. Just three simultaneous DSM depressive symptoms will do.
  • Mixed episodes may also include hypomanic states, again with the minimum of three simultaneous depression symptoms. Think of those times you experienced road rage while shopping in Walmart.
  • Mixed states may also occur in depressive episodes, with a minimum of three simultaneous (hypo)manic symptoms.

If this looks like a counting-angels-on-the-head-of-a-pin exercise, you are correct. There is little to distinguish an agitated depression from a dysphoric (hypo)mania other than, perhaps, a pure depression that grows more complex or a pure (hypo)mania that turns against itself. Inexplicably, the DSM-5 left out those states involving "a little bit" of (hypo)mania accompanied by a "little bit" of depression, but let's not quibble.

The important point is that the DSM view of mixed states now much more closely corresponds with the real world.


Anxiety is a frequent co-traveler with bipolar. The DSM-5 puts clinicians on notice with that "anxious distress" may accompany (hypo)mania and depression. This need not be full-blown anxiety in its numerous DSM manifestations (such as panic disorder or social anxiety disorder). Just a little bit of anxiety will do, say two symptoms from the following five:

  • Feeling keyed up or tense.
  • Feeling unusually restless.
  • Difficulty concentrating because of worry.
  • Fear that something awful may happen.
  • Feeling that the individual might lose control of himself or herself.

Clinicians are also urged to specify severity, from mild to severe.

One can argue that there has never been a (hypomanic) or depressive episode where the affected party did not experience at least two of these symptoms, which arguably renders this specifier redundant. On the the other hand, it does put clinicians on notice that anxiety is as much a part of bipolar as depression and (hypo)mania, and that they need to be looking for it.

Activity and Energy

The old DSM Criterion A (just above the symptom list) for mania and hypomania restricted itself to mood (as in "abnormally and persistently elevated, expansive or irritable mood"). The new Criterion A adds "abnormally and persistently increased activity or energy."

The American Psychiatric Association, publishers of the DSM-5, felt this change was important enough to highlight in a media release. Perhaps, on a slow news day.


My book, "Living Well with Depression and Bipolar Disorder," came out in 2006, when the DSM-IV reigned supreme. Back then, I thought I would have to do a substantial rewrite when the DSM-5 came out. I won't. Enough said.