DSM-IV

Diagnostic Criteria

A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

B. 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 hospitalization to prevent harm to self or others, or there are psychotic features.

C. 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: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Specifiers

Severity/Psychotic/Remission Specifiers

These specifiers apply to a Mixed Episode in Bipolar I Disorder only if it is the most recent type of mood episode. If criteria are currently met for the Mixed Episode, it can be classified as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria are no longer met, the specifier indicates whether the episode is in partial or full remission.

Criteria

Note: Can be applied to a Mixed Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

  • Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode.
  • Moderate: Symptoms or functional impairment between "mild" and "severe."
  • Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.
  • Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
    • Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.
    • Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. Included are such symptoms as persecutory delusions (not directly related to grandiose or depressive themes), thought insertion, and delusions of being controlled.
  • In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.
  • In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.
  • Unspecified
Mild, Moderate, Severe Without Psychotic Features

Severity is judged to be mild, moderate, or severe based on the number of criteria symptoms, the severity of the symptoms, the degree of functional disability, and the need for supervision. Mild episodes are characterized by the presence of only three or four manic symptoms and five or six depressive symptoms. Moderate episodes are characterized by an extreme increase in activity or impairment in judgement. Episodes that are Severe Without Psychotic Features are characterized by the need for almost continual supervision to protect the individual from harm to self or others.

Severe With Psychotic Features

This specifier indicates the presence of either delusions or hallucinations (typically auditory). Most commonly, the content of the delusions or hallucinations is consistent with either the manic or depressive themes, that is, they are mood-congruent psychotic features. For example, God's voice may be heard explaining that the person has a special mission. Persecutory delusions may be based on the idea that the person is being persecuted because of being especially deserving of punishment or having some special relationship or attribute.

Less commonly, the content of the hallucinations or delusions has no apparent relationship to either manic or depressive themes, that is, they are mood-incongruent psychotic features. These may include delusions of thought insertion (i.e., one's thoughts are not one's own), delusions of thought broadcasting (i.e., others can hear one's thoughts), and delusions of control (i.e., one's actions are under outside control). These features are associated with a poorer prognosis. The clinician can indicate the nature of the psychotic features by specifying With Mood-Congruent Features or With Mood-Incongruent Features.

In Partial Remission, In Full Remission

Full Remission requires a period of at least 2 months in which there are no significant symptoms of mania or depression. There are two ways of the episode to be In Partial Remission: 1) symptoms of a Mixed Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a Mixed Episode, but the period of remission has been less than 2 months.

Differential Diagnosis

Mood Disorder Due to a General Medical Condition

A Mixed Episode must be distinguished from a Mood Disorder Due to a General Medical Condition. The diagnosis of Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, brain tumor, Cushing's syndrome). This determination is based on the history, laboratory findings, or physical examination. If it is judged that the mixed manic and depressive symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded (e.g., Bipolar I Disorder) and the general medical condition is recorded separately (e.g., myocardial infarction).

Substance-Induced Mood Disorder

A Substance-Induced Moos Disorder is distinguished from a Mixed Episode by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the mood disturbance. Symptoms like those seen in a Mixed Episode may be precipitated by use of a drug of abuse (e.g., mixed manic and depressive symptoms that occur only in the context of intoxication with cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Mixed Features, With Onset During Intoxication.) Symptoms like those seen in a Mixed Episode may also be precipitated by antidepressant treatment such as medication, electroconvulsive therapy, or light therapy. Such episodes are also diagnosed as Substance-Induced Mood Disorders (e.g., Amitriptyline-Induced Mood Disorder, With Mixed Features; Electroconvulsive Therapy-Induced Mood Disorder, With Mixed Features).

Major Depressive and Manic Episodes

Major Depressive Episodes with prominent irritable mood and Manic Episodes with prominent irritable mood may be difficult to distinguish from Mixed Episodes. This determination requires a careful clinical evaluation of the simultaneous presence of symptoms that are characteristic of both a full Manic Episode and a full Major Depressive Episode (except for duration).

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder and a Mixed Episode are both characterized by excessive activity, impulsive behavior, poor judgment, and denial of problems. Attention-Deficit/Hyperactivity Disorder is distinguished from a Mixed Episode by its characteristic early onset (i.e., before age 7 years), chronic rather than episodic course, lack of relatively clear onsets and offsets, and the absence of abnormally expansive or elevated mood or psychotic features. Children with Attention-Deficit/Hyperactivity Disorder also sometimes show depressive symptoms such as low self-esteem and frustration tolerance. If criteria are met for both, Attention-Deficit/Hyperactivity Disorder may be diagnosed in addition to the Mood Disorder.

DSM-5

As of DSM-5, this type of episode is no longer part of the DSM.

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