Diagnosis of Bipolar Disorder: Strengths and Limitations of DSM-5 Updates

Bipolar disorder: depressive episodes
Bipolar disorder: depressive episodes
Updates made to the DSM-5 will clarify the diagnosis of bipolar disorder and related disorders.
The following article is part of live conference coverage from the 2017 Psych Congress in New Orleans, Louisiana. Psychiatry Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in psychiatry, as well as presentations from the Congress. Visit Psychiatry Advisor’s conference section for continuous coverage live from Psych Congress 2017.

New Orleans — Terence A. Ketter, MD, professor emeritus in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, weighed in on the strengths and limitations of updates made in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) with regard to how they affect bipolar disorder diagnosis in a presentation at the 2017 US Psych Congress.

Dr Ketter cited changes to the DSM-5 that will aid in the diagnosis of bipolar disorder and related disorders, including the addition of a “with mixed features” specifier for manic, hypomanic, and major depressive episodes and the use of the term “mixed episode” to replace “manic episode with mixed features.” These changes permit mixed episodes to exist within unipolar disorder.

With the mixed features specifier, the DSM-5 allows for mixed depression in both bipolar disorder and unipolar major depression, which could prevent overdiagnosis of bipolar disorder by allowing for a unipolar major depression subtype.

The DSM-5 further expands upon characteristics of mood elevation. They include early-onset age, atypical symptoms, treatment misadventures with antidepressants, as well as a family history of bipolar disorder.

The DSM-5 also requires 3 nonoverlapping opposite pole symptoms for mixed depression. These include elevated or expansive mood, impulsivity, racing thoughts, decreased need for sleep, and overtalkativeness. 

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However, the DSM-5 omits such overlapping symptoms as psychomotor agitation, distractibility, and irritability, which might make mixed depression less commonly diagnosed than it should be and ignore the importance of psychomotor agitation in depression.

Dr Ketter also offered advice in regard to correctly identifying disease state as patients will often present for depression more than they will for mood elevation. 

“When patients come in, they are complaining of depressive episodes, and they won’t have in mind things that happened 6 months ago, or a year ago,” Dr Ketter noted in is presentation. His solution is to collect collateral information, including history from the patient’s significant other.

Visit Psychiatry Advisor’s conference section for continuous coverage live from Psych Congress 2017.


Ketter TA. Solving clinical challenges in bipolar disorder. Presentation at: Psych Congress; September 16-19, 2017; New Orleans, LA.