Criteria Changes for Bipolar Disorder Proposed for DSM-5

Deborah Brauser

June 17, 2011

June 17, 2011 (Pittsburgh, Pennsylvania) — The upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), may include revisions for diagnosing mixed episodes while keeping the current duration criteria for hypomanic episodes in bipolar disorders, according to 2 presentations by members of the DSM-5 Mood Disorders Work Group at the 9th International Conference on Bipolar Disorder (ICBD).

Clinicians frequently refer to episodes of bipolar illness as "mixed" when in fact these episodes infrequently meet the criteria listed in the DSM, Fourth Edition (DSM-4).As a result, the Work Group is now proposing the addition of a mixed specifier to the new manual.

"This would allow the clinician to indicate the presence of 2 to 3 manic or hypomanic symptoms occurring for at least 2 to 3 days simultaneously with a fully syndromal episode of depression," Ellen Frank, PhD, distinguished professor of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania, told ICBD delegates.

Dr. Ellen Frank

She added that these manic/hypomanic symptoms "would be limited to those that do not have the potential for overlap with the symptoms of depression."

Dr. Frank told Medscape Medical News that the Work Group wants the criteria to better reflect clinical practice.

"In the DSM-5, we've tried to make the criteria for mixed episodes conform to how clinicians actually use that terminology. The criteria, as previously listed, rarely existed in the real world," she said.

More Realistic Criteria

Mixed episode criteria described in the DSM-4 includes the simultaneous presence of a fully manic and a fully depressive syndrome nearly every day during at a minimum a 1-week period.

However, she said, the full criteria are too restrictive and often not present.

"From my perspective, it's a lovely idea but just like I have never seen a unicorn, I don't think I have ever seen a patient in my 30 years of working in bipolar disorder who simultaneously met all those criteria," said Dr. Frank.

"So for the DSM-5, we set out to elaborate a set of criteria that are more consistent with the way in which the term 'mixed episode' is used — and more consistent with what is found in clinical epidemiologic studies."

The proposed mixed specifier would apply to episodes of both depression and mania.

Dr. Frank added that the criteria will not be limited to bipolar disorder but could be applied to episodes of depression experienced by patients with a lifetime diagnosis of a unipolar or bipolar disorder.

Symptom Markers

She explained that the specifier would be used if full criteria are met for a manic or hypomanic episode with at least 3 of the following depressive symptoms occurring concurrently nearly every day during the episode:

  • Subjective depression;

  • Worry;

  • Self-reproach/guilt;

  • Negative evaluation of self;

  • Hopelessness;

  • Suicidal ideation or behavior;

  • Anhedonia;

  • Fatigue; or

  • Psychomotor retardation.

It would also be used if full criteria are met for a major depressive episode with at least 3 of the following concurrent hypomanic symptoms:

  • Elevated mood;

  • Decreased need for sleep;

  • Goal-directed activity;

  • Increased energy and visible hyperactivity;

  • Grandiosity;

  • Accelerated speech; or

  • Racing thoughts.

Symptoms that are characteristic of both depression and mania are not included in the new mixed specifier, including distractibility, irritability, insomnia, or indecisiveness.

Risks of Incorrect Use

Dr. Frank noted that the consequences of incorrectly using the current mixed episode definitions include an underestimation of suicide risk, inappropriate treatment selection, and a failure to identify those at an increased risk of progressing from unipolar disorder to bipolar disorder.

"I think we're talking not simply about something that we conceptualize from our rating scales but something that is very pronounced in the lives of patients. And we hope that this proposed revision to the DSM-5 will fit better with the reality."

The Work Group is also recommending that the DSM-4's 4-day requirement for a diagnosis of a hypomanic episode be retained.

"The appropriate and best definition for the duration of symptoms used to define hypomanic episodes has been long debated with passionate proponents on all sides of the discussion," said Trish Suppes, MD, from Stanford University School of Medicine in Palo Alto, California, and the Veterans Affairs Palo Alto Health Care System during the second presentation.

Dr. Trish Suppes

She noted that although the 4-day duration has been questioned vigorously, "review of the existing literature does not necessarily clarify the impact of changing the duration requirement."

So the recommendation to keep the current duration essentially preserves the diagnostic criteria for bipolar II disorder.

However, the committee is proposing that bipolar disorder not otherwise specified (NOS) will now include specified and coded subcategories, including those specifically designed to discuss patients who have shorter durations of hypomania (of 2 to 3 days).

"We're suggesting that the NOS be divided into 3 broad categories: subsyndromal, other specified, and unspecified due to insufficient information."

Activity as Important as Mood

The committee is also recommending the addition of "activity or energy" to the Criterion A section of the Manual.

"This is based on many studies supporting that activity or energy is as important as mood. This was implicit in the DSM-4 but it was important to make it explicit in the DSM-5 to heighten clarity that this is a core symptom of mania and hypomania."

The activity inclusion will now specify "a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy." The symptom lists, as shown in Criterion B, will essentially not be changed.

"Many of these revisions are an effort to capture more clearly what our patients experience and to provide an opportunity to study in a more focused manner the full spectrum of mood disorders," said Dr. Suppes.

"We're basically working towards a new classification system, with new codes and new billable options, and I think it's likely that out of this, new [Food and Drug Administration] targets for drug development will emerge."

9th International Conference on Bipolar Disorder (ICBD): Symposium 2, # 6 and 7. Presented June 9, 2011.


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