Changes in the DSM-5 for Bipolar Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and contains the formal requirements for classifying and diagnosing mental illnesses. You will often find references to both the fourth and fifth editions of the DSM. The DSM-IV was published in 1994 and the DSM-5 replaced it in 2013.

One importance of the DSM is that it contains diagnostic codes for mental illnesses, similar to those for physical illnesses. For example, if a doctor orders blood tests and gives you a paper to take to the lab, the lab may insist that there be a diagnostic code on the order because they have to provide it to your insurance company.

It's the same with mental illnesses: A psychiatrist can't simply tell your insurance, "This patient has bipolar disorder." A specific code must be provided for the type of bipolar disorder.

History of the DSM

The first edition of the DSM was published in 1952, listing 102 broad categories of disorders. Each of these included a short list of symptoms, along with some information about suspected causes.

The 1968 version contained 100 disorders, and in 1979, the third edition shifted away from psychoanalytic emphasis, contained over 200 diagnostic categories, and introduced the multi-axial system (Axis I to Axis V).

  • Axis I - Clinical Disorders (including bipolar disorder)
  • Axis II - Personality Disorders and Mental Retardation
  • Axis III - General Medical Conditions
  • Axis IV - Psychosocial and Environmental Problems (stressors)
  • Axis V - Global Assessment of Functioning

The term “mental retardation” is generally no longer used, as it is considered insensitive. The more common term now is “intellectual disability.”

DSM-IV was first published in 1994, and a revised edition in 2000, called the DSM-IV-TR (though the "TR," or text revision, often wasn't included in articles referencing the manual). While sticking with the Axis system, this edition broke diagnoses and symptoms down into sections or "decision trees," including which symptoms must be included for a diagnosis and which must not be present.

Changes in DSM-5

Published in 2013, the DSM-5 makes many changes, some of them controversial, some not. The most obvious of these is that it's called the DSM-5 instead of DSM-V. Switching from Roman to Arabic numerals means that, instead of using the cumbersome system in which the 2000 edition was called "DSM-IV-TR," any revisions can now be called "DSM-5.1," etc., making things much clearer.

Another significant change is that the Axis system has been dropped. Instead, there are 20 chapters containing categories of related disorders. "Bipolar and Related Disorders" is one such category. Other examples are:

One of the controversies is that the DSM-5 reclassified Asperger's syndrome (AS) under autism spectrum disorder. Research reveals that, for people who had initially received this diagnosis, removing it is a "threat to their identity, social status, and access to supports."

Bipolar Disorder in the DSM-5

Even though childhood bipolar disorder has been well-defined and used for many years, pediatric bipolar disorder is not a new diagnosis in the DSM-5. Instead, a category of depressive disorders has been added called disruptive mood dysregulation disorder (DMDD). The driver for this was a concern that the diagnosis of pediatric bipolar disorder was being inconsistently and overly applied to different types of childhood irritability.

For bipolar disorder under the DSM-5, there are now seven possible diagnoses:

  • Bipolar I Disorder
  • Bipolar II Disorder
  • Cyclothymic Disorder
  • Substance/Medication-Induced Bipolar and Related Disorder
  • Bipolar and Related Disorder Due to Another Medical Condition
  • Other Specified Bipolar and Related Disorder
  • Unspecified Bipolar and Related Disorder

Additional changes include:

  • Elimination of "Mixed Episode." Instead, a manic, hypomanic, or depressive episode can be specified as "With Mixed Features," a specifier with its own definition in the manual.
  • The Bipolar II diagnosis in the DSM-IV excluded a history of mixed episodes. This exclusion has been removed, an important change.
  • A subtle change is that the word "abnormally" was not included in the DSM-IV Criterion A for a hypomanic episode, while it was in Criterion A for a manic episode. In the DSM-5, this language is present for both episodes. This brings the full criteria for the two distinct types of episodes closer together.

Each type of bipolar disorder has what are called specifiers (such as "With Mixed Features," above or other specifiers such as "With Anxious Distress" or "With Rapid Cycling") that further clarify the illness.

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3 Sources
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  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 2019.

  2. Kawa S, Giordano J. A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: issues and implications for the future of psychiatric canon and practice. Philos Ethics Humanit Med. 2012;7(2). doi:10.1186/1714-5341-7-2

  3. Huynh S, McCrimmon A, Strong T. The change in classification of Asperger Syndrome: an exploration of its effects on self-identity. The Qualitative Report. 2020;25(2):379-98.