____________________________________________________________ A Clinician’s Guide to the DSM-5-TR
do not meet the current DSM criteria for bipolar II disorder, which requires hypomanic episodes to last at least four con- secutive days. The inclusion of this condition in the DSM-5-TR reflects grow- ing recognition that shorter periods of hypomania may be clini- cally significant and more common than previously thought. Research suggests that individuals with depressive episodes and short-duration hypomania may represent a distinct clinical group that falls on a spectrum between unipolar depression and bipolar II disorder. These patients often experience mood instability, increased energy levels, and changes in behavior during their brief hypomanic periods, which can impact their overall functioning and treatment needs. The study of this condition aims to improve diagnostic accuracy and potentially lead to more appropriate treatment strategies for individuals who may be currently misdiagnosed with unipolar depression. However, there is ongoing debate in the psychiatric community about the optimal duration criterion for hypomania and the potential implications of broadening the bipolar spectrum. Proposed Criteria for Depressive Episodes with Short- Duration Hypomania Lifetime experience of at least one major depressive episode meeting the following criteria [1]: • Five (or more) of the following criteria have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) a depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms clearly attributable to a medical condition.): ‒ Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: It can be an irritable mood in children and adolescents.) ‒ Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation) ‒ Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly daily (Note: In children, consider failure to make expected weight gain.) ‒ Insomnia or hypersomnia nearly every day ‒ Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
‒ Fatigue or loss of energy nearly every day ‒ Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) ‒ Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) ‒ Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The disturbance is not attributable to the physiological effects of a substance or another medical condition. • The disturbance is not better explained by schizoaffective disorder. It is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. At least two lifetime episodes of hypomanic periods that involve the required criterion symptoms below but are of insufficient duration (at least two days but less than four consecutive days) to meet the criteria for a hypomanic episode. The criterion symptoms are as follows [1]: • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy. • During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree: ‒ Inflated self-esteem or grandiosity ‒ Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) ‒ More talkative than usual or pressured to keep talking ‒ Flight of ideas or subjective experience that thoughts are racing ‒ Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed ‒ Increase goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation
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