Tests and diagnosis

By Mayo Clinic Staff

When doctors suspect someone has bipolar disorder, they typically do a number of tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications. These can include:

  • Physical exam. This may involve measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
  • Lab tests. These may include blood and urine tests. These tests can help identify any physical problems that could be causing your symptoms.
  • Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.
  • Mood charting. To identify exactly what's going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.

Diagnostic criteria for bipolar disorder

To be diagnosed with bipolar disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment. Diagnostic criteria for bipolar disorder are based on the specific type of bipolar disorder.

  • Bipolar I disorder. You've had at least one manic or one mixed episode. You may or may not have had a major depressive episode. Because bipolar I varies from person to person, there are more-specific subcategories of diagnosis based on your particular signs and symptoms.
  • Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode (but not a fully manic or mixed episode). With bipolar II, symptoms cause distress or difficulty in some area of your life — such as relationships or work. Bipolar II disorder also has subcategories based on your particular signs and symptoms.
  • Cyclothymic disorder. You've had numerous hypomanic episodes and periods of depression — but you've never had a full manic episode, a major depressive episode or a mixed episode. For a diagnosis of cyclothymic disorder, symptoms last two years or more (one year in children and adolescents). During that time, symptoms never go away for more than two months. Symptoms cause significant distress or difficulty in some area of your life — such as in relationships or at work.

The DSM has very specific criteria for manic, hypomanic, major depressive and mixed episodes.

Criteria for a manic episode

A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (for example, you feel rested after only three hours of sleep)
  • Unusual talkativeness
  • Racing thoughts
  • Distractibility
  • Increased goal-directed activity (either socially, at work or school, or sexually)
  • Doing things that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a manic episode:

  • The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in usual social activities or relationships; to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
  • Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.

Criteria for a hypomanic episode

A hypomanic episode is a distinct period of elevated, expansive or irritable mood that lasts at least four days, and is different from the usual nondepressed mood. During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (for example, you feel rested after only three hours of sleep)
  • Unusual talkativeness
  • Racing thoughts
  • Distractibility
  • Increased goal-directed activity (either socially, at work or school, or sexually)
  • Doing things that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a hypomanic episode:

  • The mood disturbance must be severe enough to cause a noticeable and uncharacteristic change in functioning.
  • The episode isn't severe enough to cause significant difficulty at work, at school or in usual social activities or relationships; to require hospitalization; or to trigger a break from reality (psychosis).
  • Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.

Criteria for a major depressive episode

To be diagnosed with a major depressive episode, you must have five (or more) of the following symptoms over a two-week period. At least one of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms can be based on your own feelings or on the observations of someone else. They include:

  • Depressed mood most of the day, nearly every day, such as feeling sad, empty or tearful (in children and adolescents, depressed mood can appear as constant irritability)
  • Diminished interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
  • Insomnia or increased desire to sleep nearly every day
  • Either restlessness or slowed behavior that can be observed by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death or suicide, or a suicide attempt

To be considered a major depressive episode:

  • Symptoms don't meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships with others.
  • Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism.
  • Symptoms are not caused by grieving, such as after the loss of a loved one.

Criteria for mixed episode

  • The criteria are met both for a manic episode and for a major depressive episode nearly every day during at least a one-week period.
  • The mood disturbance must be severe enough to cause noticeable difficulty at work, at school, or in usual social activities or relationships; to require hospitalization to prevent harm to self or others; or to cause a break from reality (psychosis).
  • Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism.

Diagnosis in children

The same official criteria used to diagnose bipolar disorder in adults are used to diagnose children and adolescents. However, bipolar symptoms in children and adolescents often have different patterns than they do in adults, and may not fit neatly into the categories used for diagnosis. While adults generally tend to have distinct periods of mania and depression, children and adolescents may have erratic, rapid changes in mood, behavior and energy levels.

It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. To make it even more difficult, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems.

Although bipolar disorder can occur in young children, diagnosis in children preschool age or younger is especially difficult. The current criteria used for diagnosis have not been proved in young children, and a wide range of issues other than bipolar disorder can cause mood and behavior problems at this age.

Oct. 16, 2014

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