Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

Table 2 Comparison of diagnostic criteria for manic and hypomanic episodes

	ICD-11-CDDR	DSM-5
Manic episode
Gate/entry level criteria	Both extreme and persistent mood changes (euphoria, irritability, expansiveness, mood lability) and abnormally increased activity or subjective experience of increased energy	Both abnormal and persistent mood changes (elevated, expansive, or irritable) and abnormal and persistent increase in goal-directed activity or energy1
Accessory criteria	Significant changes in several of the following seven areas: talkativeness/pressured speech, flight of ideas/racing thoughts, increased self-esteem/grandiosity, decreased need for sleep, distractibility, impulsive/reckless behaviour, increased sexual or social drive/increased goal directed activity	Significant and noticeable changes in three of the seven accessory symptoms; four if mood is only irritable; accessory criteria almost identical to the ICD-11 definition
Persistence and duration	Symptoms present most of the day, nearly every day for a minimum of one week unless shortened by treatment	Symptoms present most of the day, nearly every day for a minimum of one week unless shortened by hospitalization
Functional impairment	Significant impairment in all the areas of functioning; the patient may require intensive treatment/hospitalization to prevent self-harm or violence; the episode may be accompanied by psychotic symptoms	Significant impairment in all the areas of functioning; the patient may require hospitalization to prevent self-harm or violence; the episode may be accompanied by psychotic symptoms
Exclusions	Mania secondary to medical conditions or substance use; mixed episodes excluded	Mania secondary to medical conditions or substance use; manic episodes with mixed features allowed
Effects of antidepressant treatment	The episode should be considered a manic one if all the criteria are met even after the effects of treatment have diminished	The episode should be considered a manic one if all the criteria are met even after the effects of treatment have diminished
Grading of severity	Severity not graded	Severity graded as mild, moderate, or severe based on the number of symptoms, their intensity, and functional impairment
Psychotic symptoms	No distinction between mood-congruent and incongruent symptoms	Mood-congruent and incongruent symptoms distinguished
Hypomanic episode
Gate/entry criteria	Both persistent mood changes (elevation, irritability, mood lability) and abnormally increased activity or subjective experience of increased energy that are significantly different from the usual mood state; changes are apparent to others and do not include changes that are appropriate to the circumstances2	Both abnormal and persistent mood changes (elevated, expansive, or irritable) and abnormal and persistent increase in activity or energy; changes in mood differ significantly from the usual state and are apparent to others
Accessory criteria	Significant changes in several of the seven accessory symptoms that are identical to the definition of mania; these changes are apparent to others	Significant and noticeable changes in three of the seven accessory symptoms, four if mood is only irritable; accessory criteria are the same as those for mania and almost identical to the ICD-11 definition
Persistence and duration	Symptoms present most of the day, nearly every day for at least several days	Symptoms present most of the day, nearly every day for a minimum of four consecutive days
Functional impairment, hospitalization, and psychotic symptoms	Socio-occupational functioning is not markedly impaired; the patient does not require intensive treatment or hospitalization to prevent self-harm or violence; the episode is not accompanied by psychotic symptoms	Clear change in socio-occupational functioning from the usual state apparent to others, but functioning is not markedly impaired; the patient does not require hospitalization to prevent self-harm or violence; the episode is not accompanied by psychotic symptoms
Exclusions	Hypomania secondary to medical conditions or substance use; mixed episodes are excluded	Hypomania secondary to substance use3; hypomanic episodes with mixed features allowed
Effects of antidepressant treatment	The episode should be considered a hypomanic one if all the criteria are met even after effects of treatment have diminished	The episode should be considered a hypomanic one if all the criteria are met even after effects of treatment have diminished; however, full syndromal manifestation of hypomania is necessary

¹Updated in 2015 to persistent increase in activity or energy (“goal-directed” removed)[28].

²In the ICD-11 CDDR, the word “extreme” is not used to describe the mood change in hypomania as in manic episodes, possibly denoting a reduced severity of mood alterations; no such distinction is present in the DSM-5.

³Updated in 2015 to include hypomania secondary to medical conditions[28].

DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5^th edition[6]; ICD-11-CDDR: International Classification of Diseases, 11^th version, Clinical Descriptions and Diagnostic Requirements[8].