Note: Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity (e.g., major depressive episode to manic episode).
Note: The essential feature of a rapid-cycling bipolar disorder is the occurrence of at least four mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and symptom number criteria for a major depressive, manic, or hypomanic episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Manic and hypomanic episodes are counted as being on the same pole. Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapid- cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g., cocaine, corticoste- roids) or another medical condition.
With melancholic features:
A.
B.
One of the following is present during the most severe period of the current episode: 1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
Three (or more) of the following: 1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
Depression that is regularly worse in the morning.
EarIy-morning awakening (i.e., at least 2 hours before usual awakening).
Marked psychomotor agitation or retardation.
Significant anorexia or weight loss.
Excessive or inappropriate guilt.
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Note: The specifier “with melancholic features“ is applied if these features are pres- ent at the most severe stage of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked brightening of mood. Either mood does not brighten at all, or it brightens only partially (e.g., up to 20%-40% of normal for only minutes at a time). The “dis- tinct quality” of mood that is characteristic of the “with melancholic features" speci- fier is experienced as qualitatively different from that during a nonmelancholic depressive episode. A depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality. Psy- chomotor changes are nearly always present and are observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpa- tients; are less likely to occur in milder than in more severe major depressive epi- sodes; and are more likely to occur in those with psychotic features.
With atypical features: This specifier can be applied when these features predomi- nate during the majority of days of the current or most recent major depressive epi- sode.
A.
B.
Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
Two (or more) of the following features: 1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi- sodes of mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for “with melancholic features" or “with catatonia“ during the same episode.