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Depression: Major Depression & Unipolar Varieties
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History and Evolution of Bipolar Disorder Diagnosis

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D.

Just as the information about bipolar disorder evolved in the medical literature, the criteria for bipolar disorder diagnosis have changed with successive versions of the Diagnostic and Statistical Manual of Mental Disorders, mentioned earlier. Each edition of the DSM reflects a continuing appreciation and incorporation of scientific data with regard to mental disorders. The purpose of the DSM is to provide clinicians and researchers with accurate, clearly defined diagnostic terms and a common language for disorders to efficiently treat patients. In the first DSM, published in 1952, bipolar disorder diagnoses were strongly influenced by the psychodynamic approach which provided no sharp distinction between normal and abnormal states. All disorders were considered reactions of the personality to psychological, environmental, and biological factors, with mental disorders existing on a continuum of behavior.

The DSM-II was published in 1968 and continued to define mental disorders from a largely theoretical psychodynamic perspective. In 1980, however, the third edition of the DSM was published, reflecting a radical change of perspective. A biomedical approach was substituted for the psychodynamic conceptualization, making way for a clear distinction between normal and abnormal behaviors and reformulating psychiatric illnesses in terms of empirical research and statistical knowledge.

It was in the DSM-III that the term 'bipolar disorder' replaced the older term 'manic depressive disorder'. The new term, 'bipolar disorder' reflects the defining feature of mood polarity rather than simply pointing to the consequences of that polarity: mania and depression. Also, in the DSM-III, the distinction between adult and pediatric bipolar disorder diagnoses was indicated for the first time. This acknowledgment was the result of years of research suggesting that mainly Attention Deficit Disorder and other disorders to a lesser degree are predisposing factors for developing bipolar illness.

In the DSM-III-R (1987), further improvement was made to the diagnosis of bipolar depression as research about mood disorders and disorders of childhood and adolescence were added. Hence, this was the first time that bipolar diagnoses were supplemented with subtyped classifications such as Bipolar Disorder-Mixed, Bipolar Disorder-Manic, Bipolar Disorder-Depressed, Bipolar Disorder-Not Otherwise Specified, and Cyclothymia.

In the DSM-IV (1994) and the most recent DSM-IV-TR (DSM-IV-text revision, 2000), the definition of bipolar disorder diagnosis has evolved from a monolithic disorder with a single set of criteria, to a more nuanced subtype system, where Bipolar I and Bipolar II forms of the disorder are recognized and separately diagnosed. These two forms are distinguished primarily by the type of mania experienced by individuals - mania versus hypomania. In Bipolar I Disorder patients suffer from at least one manic episode and one depressive episode, while in Bipolar II Disorder, individuals experience at least one hypomanic episode and at least one major depressive episode. It is almost certain that the disorder will continue to be revised in future editions of the DSM, as research-informed knowledge about the nature of the illness continues to be uncovered.

Bipolar Disorder Diagnosis in the DSM and ICD

The International Statistical Classification of Diseases and Related Health Problems (ICD) is a detailed description of known diseases and injuries published by the World Health Organization and is used worldwide for classifying and reporting morbidity and mortality statistics. The need for clinicians and scientists to be able to communicate on an international level using a single diagnostic classification scheme was realized in 1968 when the DSM-II was based on the ICD, eighth revision (ICD-8). Since then, the DSM-III has coincided with the publication of ICD-9, and the DSM-IV with ICD-10.