Bipolar disorder in DSM-5-TR and ICD-11
Both systems recognize two main forms of bipolar disorder: bipolar type I (which requires a manic episode) and bipolar type II (which requires hypomania plus depression). The core structure agrees. Some threshold and duration details differ enough that the same episode can meet criteria in one system and not the other. This is what actually differs.
DSM-5-TR Bipolar and related disorders ICD-10-CM F31.x (bipolar II F31.81)
ICD-11 Bipolar or related disorders 6A60, 6A61
Side by side
| What | DSM-5-TR | ICD-11 |
|---|---|---|
| Bipolar I definition Both agree on structure. | One or more manic episodes. A hypomanic or depressive episode may occur but is not required. | At least one manic or mixed episode. Depression is common but not required. |
| Bipolar II definition Aligned. | At least one hypomanic episode and at least one major depressive episode. No history of full mania. | At least one hypomanic episode and at least one depressive episode. No history of full mania. |
| Manic episode duration Same. | At least 1 week (or any duration if hospitalization is needed). | At least 1 week, or shorter if hospitalization is needed. |
| Hypomanic episode duration ICD-11 accepts slightly more clinical flexibility around the 4-day threshold. | At least 4 consecutive days. | At least several days (specified as approximately 4 days but with more flexibility). |
| Mixed features This is a real structural difference. | Handled as a specifier on the current episode: 'with mixed features.' No separate mixed episode diagnosis. | Recognizes 'mixed episode' as a distinct episode type (6A61). |
| Required symptoms during mania DSM-5-TR is more prescriptive on the symptom count. | Elevated, expansive, or irritable mood AND increased goal-directed activity or energy. Plus 3 or more of a 7-item list (4 if mood is only irritable). | Same core mood/energy requirement. Requires several additional symptoms consistent with the mania picture, without specifying an exact count. |
| Increased activity requirement This is a change from DSM-IV and ICD-10, where activity change was not required. | Added in DSM-5 (2013). Activity/energy change is required, not optional. | Also required. ICD-11 aligned with DSM-5 here. |
| Cyclothymic disorder Aligned. | Cyclothymic disorder: at least 2 years of numerous hypomanic and depressive symptoms below threshold. | Cyclothymic disorder (6A62): same 2-year duration, similar symptom picture. |
Key differences
- DSM-5-TR treats mixed features as a specifier on the current episode. ICD-11 has a separate mixed episode diagnosis. The clinical picture may look identical.
- DSM-5-TR is more prescriptive on the symptom count required during mania (3-4 additional symptoms). ICD-11 requires 'several' without a hard count.
- Both systems added the requirement for increased activity/energy during mania. This is aligned across the two systems and is a change from earlier editions.
- Duration thresholds are essentially the same: 1 week for mania, 4 days for hypomania. ICD-11 accepts slightly more flexibility around the hypomania threshold.
- Cyclothymic disorder criteria are aligned.
Clinical implications
- Cross-system agreement is high for classical bipolar I. Agreement is somewhat lower for hypomanic episodes near the 4-day threshold or for mixed presentations.
- The removal of the mixed-episode diagnosis from DSM-IV to DSM-5 changed how mixed states get recorded. ICD-11 restored the separate mixed episode, so the two systems now diverge on this point.
- For patients receiving care across systems (e.g., an international transfer of care), the underlying picture is usually the same; the record just uses different language.
- For antidepressant use in bipolar depression, both systems flag the same caution about switching to mania. The evidence base is the same.
## Why this crosswalk exists
Bipolar diagnosis has a longer history of cross-system disagreement than depression, in part because hypomania is genuinely hard to catch and criteria have moved over time. This page walks through the DSM-5-TR and ICD-11 criteria side by side. The remaining differences are real and affect how the same episode gets recorded.
## Sources
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Section on Bipolar and Related Disorders. 2022.
- World Health Organization. International Classification of Diseases 11th Revision (ICD-11). Chapter 6, 6A60-6A62 Bipolar or related disorders. 2022.
- Reed GM, First MB, Kogan CS, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry. 2019;18(1):3-19.
- First MB, Gaebel W, Maj M, et al. An organization-and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5. World Psychiatry. 2021;20(1):34-51.
- Kupfer DJ, Angst J, Berk M, et al. Advances in bipolar disorder: selected sessions from the 2011 International Conference on Bipolar Disorder. Annals of the New York Academy of Sciences. 2011;1242:1-25.