Depressive Disorders Flashcards
Depressive Disorders in DSM 5
- disruptive mood dysregulation disorder
- major depressive disorder
- persistent mood disorder (dysthymia)
- premenstrual dysphoric disorder
- substance medication induced depressive disorder
- unspecified depressive disorder
Common Features of Depressive Disorders
Presence of sad, empty or irritable mood, accompanied by somatic and cognitive changes that significantly affect functioning. Duration, timing and presumed etiology are what distinguish one disorder from another.
Disruptive Mood Dysregulation Disorder 296.99 (F34.8) Diagnostic Criteria
Diagnostic Criteria
A. Severe recurrent temper outbursts (verbal rages) and/or behaviorally outbursts that are out of proportion in intensity or duration to the situation or provocation.
B. Temper outburst are inconsistent with developmental level.
C. The temper outbursts occur, on avg. 3+ times weekly
D. The mood between outbursts is irritable and angry most of the day, most days.
E. Criteria A-D present for 12 months. Never a 3 month period without all symptoms in A-D.
F. Criteria A-D exist in 2 of 3 settings (home, school, peers)
G. The diagnosis not made before age 6.
H. Age of onset following criteria A-E is before age 10
I. Never one day with manic/hypomanic episode
J. Behaviors do not occur exclusively during an episode of. major depressive disorder and are not better explained by another mental disorder
Disruptive Mood Dysregulation Disorder Exceptions:
Dx cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder. But, can exist with MDD, ADHD, conduct disorder and mood dysregulation disorder.
If an individual has ever experienced a manic or hypomanic episode, the dx of disruptive mood dysregulation disorder should not be assigned.
Core features of Disruptive Mood Dysregulation Disorder
The core feature of DMDD is chronic, severe persistent, irritability.
- frequent temper outbursts common
- typically occurrence is in response to frustration and can be verbal or behavioral
- Irritability
DMDD Differential Dx
- Pediatric bipolar disorder–Bipolar I-II are episodic and that is key differentiator. Also the presentation of expansive mood or grandiosity is a key to Dx.
- Oppositional defiant disorder–the disruptive behavior is not typically followed by interim mood disturbance.
- ADHD–can be comorbid with DMDD.
- MDD and anxiety disorders can also have comorbidity
DMDD Comorbidity
comorbidity is high with MDD, anxiety, ADHD, oppositional defiant disorder, however a bipolar disorder diagnoses always supersedes DMDD.
Prevalence of DMDD
2%-5% occurring primarily in males. The conversion rate of DMDD are more at risk to develop adult unipolar depression and anxiety.
Major Depressive Disorder MDD
Diagnostic Criteria
A. 5 or more of the following symptoms have been present in same 2 week period and represent a change from normal functioning. Must have either (1) loss of function or (2) loss of interest or pleasure
Symptoms:
1. Depressed mood most of the day, nearly every day, (sad, empty, hopeless, teenagers persistent irritability)
2. Markedly diminished interest or pleasure in all or almost all activities
3. Significant weight loss or gain (5% in one month)
4. Insomnia/hypersomnia
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive inappropriate guilt
8. Diminished ability to think or concentrate or indecisiveness, nearly every day
9. Recurrent thoughts of death (not just fear of dying)
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
C. The episodes aren’t related to substance or other medical condition
D. MDD not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or unspecified schizophrenia spectrum disorders.
Grief vs. MDD
Grief the predominant affect is feelings of emptiness and loss, while MDE is a persistent depressed mood and the ability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves. During these waves, thoughts tend to be associated with thought or reminders of the deceased. The depressed state is more persistent and not tied to specific thoughts or preoccupations. In grief, self-esteem is generally preserved.
Coding and Recording for MDE
Diagnostic code for MDD is based on whether it is a single episode or recurrent episode, current severity, and whether there is the presence of psychotic features, and remission status.
Severity/course specifier Mild/Moderate/Severe with psychotic features In partial remission In full remission Unspecified
Order of coding MDD
Major Depressive Disorder, recurrent episode, severity/psychotic/remission specifiers followed by as many of the following specifiers with our codes that apply to the current episode
MDD with Anxious Distress Specifier
With anxious distress: defined as the presence of at least two of the following symptoms during the majority of days of a major depressive episode or persistent depressive disorder (dysthymia):
1. Feeling keyed up or tense
2. Felling unusually restless
3. Difficulty concentrating because of worry
4. Fear that something awful might happen
5. Feeling that the individual might lose control of himself or herself
Mild–2 symptoms
Moderate–3 symptoms
Moderate-severe–4-5 symptoms
Severe–4-5 symptoms with motor agitation
MDD with Mixed Features specifier
A. At least 3 of the following manic/hypomanic symptoms are present nearly every day during the majority of days of a MDE:
1. Elevated, expansive mood
2. Inflated self-esteem grandiosity
3. More talkative and pressure to keep talking
4. Flight of ideas
5. Increase in energy or goal directed activity
6. Increase or excessive involvement in activities that have a high potential for painful consequence (unrestrained buying sprees, sexual discretions, foolish business, investments).
7. Decreased need for sleep
B. Mixed symptoms are observable by others and represent a change
C. For individuals who meet full criteria for either mania or hypomania, the Dx should be bipolar I or II
D. Not related to substance or other medical condition
*Mixed features increase risk for development of bipolar I or II.
MDD with Melancholic Features Specifier
A. 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, doesn’t typically feel better even temporarily when something good happens.
B. 3 or more of the following:
1. A distinct quality of depressed mood characterized by profound despondency, despair or moroseness or empty-mood.
2. Depression that is regularly worse in the morning
3. Early-morning awakening
4. Marked psychomotor agitation or retardation
5. Significant anorexia or weight loss
6. Excessive or inappropriate guilt
Melancholic features are typically present at the most severe stage of the episode. They are more frequent in inpatients than outpatients and more likely to occur when there are psychotic features.
MDD with Atypical Features Specifier
A. Mood reactivity (mood brightens in response to actual or potential positive events).
B. 2 or more of the following:
1. significant weight gain or increase in appetite
2. hypersomnia
3. leaden paralysis (heavy, leaden feelings in arms and legs)
4. A long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment.
C. Criteria are not met for the melancholic features or with catatonia during the same episode
MDD with Psychotic Features Specifier
Delusions and/or hallucinations
Mood-congruent psychotic features: related to typical MDD themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
Mood-incongruent psychotic features: doesn’t involve typical depressive themes
MDD with Catatonia Feature Specifier
The catatonia specifier can apply to an episode of depression if catatonic features are present during most of the episode.
MDD with Peripartum onset Specifier
Onset of symptoms occur either during pregnancy or postpartum. Between 3%-6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery.
50% of episodes begin before delivery. Common comorbid features are to have severe anxiety, panic. Mood symptoms can present with or without psychotic features. Infanticide most associated with postpartum psychotic features of command hallucinations to kill the infant or delusions that the infant is possessed. Most common with a family history of bipolar disorder.
MDD with Seasonal pattern:
The specifier applies to recurrent major depressive disorder.
A. There has been regular temporal relationship between the onset of major depressive episodes in MDD and a particular time of year.
B. Full remissions or change from MDD to mania or hypomania occur at a characteristic time of the year
C. In the last 2 years, two MDE’s have occurred that demonstrate the temporal seasonal relationship
D. Seasonal MDE substantially outnumber the nonseasonal MDE’s that may have occurred over patients lifetime.
MDD Prevalence
12 month prevalence is 7% with marked differences by age group such that the prevalence in 18-29 year olds is 3x’s that of individuals 60+. Females experience MDD 1.5-3x’s more than males beginning in early adolescence.
Development and Course of MDD
MDD can occur at any age, and increase with puberty. Incidence peaks int 20’s, however, later life onset isn’t uncommon. 2 of 5 individuals will begin to see symptom improvement within 3 months after onset and within 1 year in 4/5 individuals. MDD with psychotic features can convert to schizophrenia.
Risk and prognostic factors of MDD
- Tempermental: Neuroticism (negative affectivity) is well-established risk factor.
- Environmental: Adverse childhood experience
- Genetic and physiological: first degree family members of individuals with MDD, have higher risk 2-4 x’s higher than the general population.
- Course Modifiers: substance use, anxiety, personality disorders, chronic or disabling medical conditions
Differential Diagnoses MDD
- Manic Episodes or mixed: MDD with chronic irritable mood may be difficult to distinguish from manic episodes with irritable mood or from mixed episodes.
- Due to another medical condition
- Substance/medication-induced depressive or BPD
- ADHD: distractibility and low frustration tolerance can occur in both ADHD and MDD. ADHD can be diagnosed in addition to MDD.
- Adjustment Disorder with depressed mood: A MDE that occurs in response to a psychosocial stressor is distinguished from adjustment disorder with depressed mood by the fact that the full criteria for a MDE are not met in adjustment disorder.
- Sadness:
MDD comorbidity
Substance related disorders, panic, old, anorexia, bulimia, and BPD
Persistent Depressive Disorder (Dysthymia)
300.4 (F34.1) Diagnostic Criteria
A. Depressed mood most of the day, form more days than not, for at least 2 years
Note: children 1 year
B. Presence, while depressed of two or more:
1. poor appetite or overeating
2. Insomnia/hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
C. During the 2 yr period (1 for children), the individual has never been without symptoms in Criteria A-B for more than 2 months at a time.
D. Criteria for a MDE may be continuously present for 2 years
E. Never manic or hypomanic
F. Not better explained by persistent Schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum or psychotic disorder.
G. Not caused by substance
H. Clinically significant distress or impairment
Diagnostic specifiers for PDD
Specify if: anxious distress mixed features melancholic atypical mood-congruent mood incongruent permpartum onset
partial remission
full remission
Early onset
late onset
Pure dysthymic syndrome: full criteria for a MDE have not been met is at leas the preceding 2 years.
With Persistent MDE: Full criteria for a MDE have been met thought the preceding 2 year period
With intermittent MDE, with current episode
With intermittent MDE, without current episode
Mild
Moderate
Severe
PDD Diagnostic Features
Depressed mood that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year in children.
12 month Prevalence PDD
.5% persistent depressive disorder and 1.5% for chronic major depressive disorder
Differential Diagnosis for PDD
MDD: 2 year duration is the differentiator. MDD is a specifier for PDD.
Psychotic disorders: PDD not made if the symptoms only occur during psychotic episode
Bipolar or depressive disorder related to a medication
