A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
- The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
- The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by a bipolar or related disorder that is not substance/medication-induced. Such evidence of an independent bipolar or related disorder could include the following:
- The symptoms precede the onset of the substance/medication use.
- The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication.
- There is other evidence suggesting the existence of an independent non-substance/medication-induced bipolar and related disorder (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: If a mild substance use disorder is comorbid with the substance-induced bipolar and related disorder, the clinician should record "mild [substance] use disorder" before the substance-induced bipolar and related disorder (e.g., "mild cocaine use disorder with cocaine-induced bipolar and related disorder"). If a moderate or severe substance use disorder is comorbid with the substance-induced bipolar and related disorder, the clinican should record "moderate [substance] use disorder" or "severe [substance] use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the clinician should record only the substance-induced bipolar and related disorder.
- With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
- With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
The name of the substance/medication-induced bipolar and related disorder begins with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing the bipolar mood symptoms. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.
When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced bipolar and related disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal). For example, in the case of irritable symptoms occurring during intoxication in a man with a severe cocaine use disorder, the diagnosis is severe cocaine use disorder with cocaine-induced bipolar and related disorder, with onset during intoxication. A separate diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced bipolar and related disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., amphetmine-induced bipolar and related disorder, with onset during intoxication). When more than one substance is judged to play a significant role in the development of bipolar mood symptoms, each should be listed separately (e.g., severe methylphenidate use disorder with methylphenidate-induced bipolar and related disorder, with onset during intoxication; dexamethasone-induced bipolar and related disorder, with onset during intoxication).
Substance/medication-induced bipolar and related disorder should be differentiated from other bipolar disorders, substance intoxication or substance-induced delirium, and medication side effects. A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a bipolar I diagnosis. A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a bipolar II diagnosis only is preceded by a major depressive episode.