Mood Disorders

Question 1

Length of major depressive episode

Answer 1

two weeks

Question 2

length of manic episode

Answer 2

at least one week. Needs marked social/work impairment, may need hospitalization

Question 3

MDD will be either _______

Answer 3

recurrent or single episode

Question 4

Persistent depressive disorder

Answer 4

• No high phases (mania)
• Lasts much longer than typical major depressive disorder.
• Not usually severe enough to be called an episode of major depression (though chronic major depression is now included here)

Question 5

Disruptive mood dysregulation disorder

Answer 5

A child’s mood is persistently negative between frequent, severe explosions of temper

Question 6

Premenstrual dysphoric disorder

Answer 6

A few days before her menses, a woman experiences symptoms of depression and anxiety

Question 7

Depressive disorder due to another medical condition

Answer 7

A variety of medical and neurological conditions can produce depressive symptoms; these need not meet criteria for any of the conditions above

Question 8

Qhat percent of patients with mood disorders experience manic or hypomanic episodes?

Answer 8

25%

Question 9

Bipolar I Disorder

Answer 9

At least one manic episode;

most patients with bipolar I have also had a major depressive episode

Question 10

Bipolar II Disorder

Answer 10

• at least one hypomanic episode plus
• at least one major depressive episode

Question 11

Cyclothymic disorder

Answer 11

Patients have had repeated mood swings, but none that are severe enough to be called major depressive episodes or manic episodes

Question 12

Substance/medication- induced bipolar disorder

Answer 12

Alcohol or other substances (intoxication or withdrawal) can cause manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Question 13

Other causes of manic or depressive symptoms

Answer 13

• Schizoaffective disorder. In these patients, symptoms suggestive of schizophrenia coexist with a major depressive or a manic episode (p. 88).
• Major and mild neurocognitive disorders with behavioral disturbance. The qualifier with behavioral disturbance can be coded into the diagnosis of major or mild neurocognitive disorder. OK, so mood symptoms don’t sound all that behavioral, but that’s how DSM-5 elects to indicate the cognitive disorders with depression.
• Adjustment disorder with depressed mood. This term codes one way of adapting to a life stress (p. 228).
• Personality disorders. Dysphoric mood is specifically mentioned in the criteria for borderline personality disorder, but depressed mood commonly accompanies avoidant, dependent, and histrionic personality disorders.
• Uncomplicated bereavement. Sadness at the death of a relative or friend is a common experience. Because uncomplicated bereavement is a normal reaction to a particular type of stressor, it is recorded not as a disorder, but as a Z-code [V-code].
• Other disorders. Depression can accompany many other mental disorders, including schizophrenia, the eating disorders, somatic symptom disorder, sexual dysfunctions, and gender dysphorias. Mood symptoms are likely in patients with an anxiety disorder (especially panic disorder and the phobic disorders), obsessive– compulsive disorder, and posttraumatic stress disorder.

Question 14

Specifiers fo mood disorders

Answer 14

These descriptors help characterize the most recent major depressive episode; all but the first two can also apply to a manic episode. (Note that the specifiers for severity and remission are described on p. 158.) With atypical features With melancolic features With anxious distress With catatonic features With mixed features With peripartum onset WIth psychotic features

Question 15

Specifiers describing course of recurring episodes

Answer 15

These specifiers describe the overall course of a mood disorder, not just the form of an individual episode With rapid cycling With seasonal pattern

Question 16

With rapid cycling

Answer 16

Within 1 year, the patient has had at least four episodes (in any combination) fulfilling criteria for major depressive, manic, or hypomanic episodes

Question 17

With seasonal pattern

Answer 17

These patients regularly become ill at a certain time of the year, such as fall or winter

Question 18

Mood

Answer 18

sustained emotion that colors the way we view life

Question 19

Affective disorders

Answer 19

Old term for mood disorders

Question 20

Affect

Answer 20

term affect covers more than just a patient’s statement of emotion. It also encompasses how the patient appears to be feeling, as shown by physical clues such as facial expression, posture, eye contact, and tearfulness

Question 21

Major depressive episode

Answer 21

Not a codable diagnosis, but important building block

Question 22

What are the major requirements for a mood episode?

Answer 22

(1) a quality of depressed mood (or loss of interest or pleasure) that (2) has existed for a minimum period of time, (3) is accompanied by a required number of symptoms, (4) has resulted in distress or disability, and (5) violates none of the listed exclusions.

Question 23

Quality of mood for MDE

Answer 23

Can be subjective, but does patient report feeling sad, do others say they are sad, do they look sad

Question 24

Duration for MDE

Answer 24

The patient must have felt bad most of the day, almost every day, for at least 2 weeks. This requirement is included to ensure that major depressive episodes are differentiated from the transient “down” spells that most of us sometimes feel.

Question 25

Symptoms for MDE

Answer 25

SIGECAPS

Question 26

To count as a symptom for MDE ____

Answer 26

the behaviors listed above must occur nearly every day. However, thoughts about death or suicide need only be “recurrent.” A single suicide attempt or a specific suicide plan will also qualify.

Question 27

What are three situations in which you should not count a symptom toward a diagnosis of MDE

Answer 27

1. a symptom is fully explained by another medical condition. For example, you wouldn’t count fatigue in a patient who is recovering from major surgery; in that situation, you expect fatigue. 2. a symptom results from mood- incongruent delusions or hallucinations. For example, don’t count insomnia that is a response to hallucinated voices that keep the patient awake throughout the night. 3. Feelings of guilt or worthlessness that occur because the patient is too depressed to fulfill responsibilities. Such feelings are too common in depression to carry any diagnostic weight. Rather, look for guilt feelings that are way outside the boundaries of what’s reasonable. an extreme example: a woman believes that her wickedness caused the tragedies of 9/11.

Question 28

Impairment needed for MDE

Answer 28

The episode must be serious enough to cause material distress or to impair the patient’s work (or school) performance, social life (withdrawal or discord), or some other area of functioning, including sex.

Question 29

MDE Essential Featuers

Answer 29

These people are miserable. Most feel sad, down, depressed, or some equivalent; however, some few will instead insist that they’ve only lost interest in nearly all their once-loved activities. All will admit to varying numbers of other symptoms—such as fatigue, inability to concentrate, feeling worthless or guilty, and wishes for death or thoughts of suicide. In addition, three symptom areas may show either an increase or a decrease from normal: sleep, appetite/weight, and psychomotor activity. (For each of these, the classic picture is a decrease from normal—in appetite, for example—but some “atypical” patients will report an increase.)

Question 30

MDE fine print

Answer 30

Also, children or adolescents may only feel or seem irritable, not depressed.

Question 31

MDE D’s

Answer 31

Duration (most of nearly every day, 2+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders)

Question 32

What happened to the bereavement exclusion?

Answer 32

The bereavement exclusion that was used through DSM-IV is not to be found in DSM-5, because recent research has determined that depressions closely preceded by the death or loss of a loved one do not differ substantially from depressions preceded by other stressors (or possibly by none at all).

Question 33

What % of adults will have a manic episode?

Answer 33

~1%

Question 34

Features needed to diagnose manic episode

Answer 34

(1) A mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions.

Question 35

Quality of mood for manic episode

Answer 35

Some patients with relatively mild symptoms just feel jolly; this bumptious good humor can be quite infectious and may make others feel like laughing with them. But as mania worsens, this humor becomes less cheerful as it takes on a “driven,” unfunny quality that creates discomfort in patients and listeners alike. A few patients will have mood that is only irritable; euphoria and irritability sometimes occur together.

Question 36

Duration of manic episode

Answer 36

The patient must have had symptoms for a minimum of 1 week. This time requirement helps to differentiate manic episode from hypomanic episode.

Question 37

Manic episode symptoms

Answer 37

DIGFAST

Question 38

Symptoms of manic episode not listed in criteria

Answer 38

1. Even during an acute manic episode, many patients have brief periods of depression. These “microdepressions” are relatively common; depending on the symptoms associated with them, they may suggest that the specifier with mixed features is appropriate (p. 161). 2. Patients may use substances (especially alcohol) in an attempt to relieve the uncomfortable, driven feeling that accompanies a severe manic episode. Less often, the substance use temporarily obscures the symptoms of the mood episode. When clinicians become confused about whether the substance use or the mania came first, the question can usually be sorted out with the help of informants. 3. Catatonic symptoms occasionally occur during a manic episode, sometimes causing the episode to resemble schizophrenia. But a history (obtained from informants) of acute onset and previous episodes with recovery can help clarify the diagnosis. Then the specifier with catatonic features may be indicated (p. 100).

Question 39

What if meds, like an SSRI, cause the manic episode?

Answer 39

To count as evidence for either manic or hypomanic episode, DSM-5 requires that the full criteria (not just a couple of symptoms, such as agitation or irritability) be present, and that the symptoms last longer than the expected physiological effects of the treatment.

Question 40

Manic episode impairment

Answer 40

Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.

Question 41

Manic episode impairment

Answer 41

Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.

Question 42

Exclusions for manic episode

Answer 42

The exclusions for manic episode are the same as for major depressive episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain psychoactive substances (especially amphetamines) will appear speeded up and may report feeling strong, powerful, and euphoric.

Question 43

Essential featuers for manic episode

Answer 43

Patients in the throes of mania are almost unmistakable. These people feel euphoric (though sometimes they’re only irritable), and there’s no way you can ignore their energy and frenetic activity. They are full of plans, few of which they carry through (they are so distractible). They talk and laugh, and talk some more, often very fast, often with flight of ideas. They sleep less than usual (“a waste of time, when there’s so much to do”), but feel great anyway. Grandiosity is sometimes so exaggerated that they become psychotic, believing that they are exalted personages (monarchs, rock stars) or that they have superhuman powers. With deteriorating judgment (they spend money unwisely, engage in ill- conceived sexual adventures), functioning becomes impaired, often to the point they must be hospitalized to force treatment or for their own protection or that of other people.

Question 44

Manic Episode D’s

Answer 44

• Duration (most of nearly every day, 1+ weeks) • Distress or disability (work/ educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, schizoaffective disorder, neurocognitive disorders, hypomanic episodes, cyclothymia)

Question 45

Comparing hypomanic and manic episode (table)

Answer 45

INSERT TABLE

Question 46

Hypomanic episode requires

Answer 46

Hypomanic episode requires (1) a mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions. Table 3.1 compares the features of manic and hypomanic episodes.

Question 47

Quality of mood in hypomanic episode

Answer 47

The quality of mood in hypomanic episode tends to be euphoric without the driven quality present in manic episode, though mood can instead be irritable. However described, it is clearly different from the patient’s usual nondepressed mood.

Question 48

Duration of hypomanic episode

Answer 48

The patient must have had symptoms for a minimum of 4 days—a marginally shorter time requirement than that for manic episode.

Question 49

Symptoms in hypomanic episode

Answer 49

As with manic episode, in addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level—but again, only for 4 days. Then at least three symptoms from the same list must be present to an important degree (and represent a noticeable change) during this 4 days. If the patient’s abnormal mood is irritable and not elevated, four symptoms are required. Note that hypomanic episode precipitated by treatment can be adduced as evidence for, say, bipolar II disorder—if it persists longer than the expected physiological effects of the treatment. The sleep of hypomanic patients may be brief, and activity level may be increased, sometimes to the point of agitation. Although the degree of agitation is less than in a manic episode, hypomanic patients can also feel driven and uncomfortable. Judgment deteriorates, and may lead to untoward consequences for finances or for work or social life. Speech may become rapid and pressured; racing thoughts or flight of ideas may be noticeable. Easily becoming distracted can be a feature of hypomanic episode. Heightened self- esteem is never so grandiose that it becomes delusional, and hypomanic patients are never psychotic. In addition to the DSM-5 criteria, note that in hypomanic episode, as in manic episode, substance use is common.

Question 50

Impairment in hypomanic episode

Answer 50

How severe can the impairment be without qualifying as a manic episode? This is to some extent a judgment call for the practitioner. Lapses of judgment, such as spending sprees and sexual indiscretions, can occur in both manic and hypomanic episodes— but, by definition, only the patient who is truly manic will be seriously impaired. If behavior becomes so extreme that hospitalization is needed or psychosis is evident, the patient can no longer be considered hypomanic, and the label must be changed

Question 51

Exclusions for hypomanic episode

Answer 51

The exclusions are the same as those for manic episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain substances (especially amphetamines) will appear speeded up and may also report feeling strong, powerful, and euphoric.

Question 52

Essential featuers of hypomanic episode

Answer 52

Hypomania is “mania lite”—many of the same symptoms, but never to the same outrageous degree. These people feel euphoric or irritable and they experience high energy or activity. They are full of plans, which, despite some distractibility, they sometimes actually implement. They talk a lot, reflecting their racing thoughts, and may have flight of ideas. Judgment (sex and spending) may be impaired, but not to the point of requiring hospitalization for their own protection or that of others. Though the patients are sometimes grandiose and self- important, these features never reach the point of delusion. You would notice the change in such a person, but it doesn’t impair functioning; indeed, sometimes these folks get quite a lot done!

Question 53

The D’s for hypomanic episode

Answer 53

• Duration (most of nearly every day, 4+ days) • Disability (work/educational, social, and personal functioning are not especially impaired) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)

Question 54

MDD prevalence

Answer 54

~7%

Question 55

MDD Female:Male ratio

Answer 55

~2:1

Question 56

Average length of MDE

Answer 56

6 to 9 months (but range from weeks to years)

Question 57

How many patients with a MDE have another?

Answer 57

About half

Question 58

To count as a second episode of major depression, how much time needs to pass between episodes?

Answer 58

Two months

Question 59

What percent of patients with MDD commit suicide?

Answer 59

~4%

Question 60

A note on somatic symptom disorder

Answer 60

There’s a situation in which I like to be extra careful about diagnosing MDD. That’s when a patient also has somatic symptom disorder (see p. 251). The problem is that many people who seem to have too many physical symptoms can also have mood symptoms that closely resemble major depressive episodes (and sometimes manic episodes). Over the years, I’ve found that these people tend to get treatment with medication, electroconvulsive therapy (EcT), and other physical therapies that don’t seem to help them much— certainly not for long. I’m not saying that drugs never work; I maintain only that if you encounter a patient with somatic symptom disorder who is depressed, other treatments (such as cognitive- behavioral therapy or other forms of behavior modification) may be more effective and less fraught with complications.

Reminds me of patient MB on 4S as a PGY2 (with Dr. Lenet)

Question 61

manic-depressive illness

Answer 61

an old name for bipolar disorder

Question 62

To count as a new manic or depressive episode ____

Answer 62

• it must either represent a change of polarity (for example, from major depressive to manic or hypomanic episode), or
• it must be separated from the previous episode by a normal mood that lasts at least 2 months.

Question 63

How to think about treatment- induced manic or hypomanic episode (diagnostically)

Answer 63

can only be used to make the diagnosis of a bipolar I (or, for that matter, bipolar II) condition if the symptoms persist beyond the physiological effect of that treatment. Even then, DSM-5 urges caution: Demand the full number of manic or hypomanic symptoms, not just edginess or agitation that some patients experience following treatment of depression.

Question 64

What about psychosis?

Answer 64

note the warning that the mood episodes must not be superimposed on a psychotic disorder— specifically schizophrenia, schizophreniform disorder, delusional disorder, or unspecified psychotic disorder.

Question 65

Specifiers

Answer 65

Usually a manic episode will be current, and the patient will have been admitted to a hospital. Occasionally, you might use the category current or most recent episode manic for a newly diagnosed patient who is on a mood- stabilizing regimen.

Most will have had at least one previous manic, major depressive, or hypomanic episode. However, a single manic episode is hardly rare, especially early in the course of bipolar I disorder. Of course, the vast majority of such patients will later have subsequent major depressive episodes, as well as additional manic ones.

Males are more likely than females to have a first episode that is manic.

Current episode depressed (I’m intentionally shorthanding the long and unwieldy official phrase) will be one of the most frequently used of the bipolar I subtypes; nearly all patients with this disorder will receive this diagnosis at some point during their lifetimes.

Question 66

Bipolar I Disorder D’s

Answer 66

• Differential diagnosis (substance use and physical disorders, other bipolar disorders, psychotic disorder)

Question 67

Rapid cycling

Answer 67

High rates of this in bipolar II

Question 68

Comorbidity in bipolar II

Answer 68

Comorbidity is a way of life for patients with bipolar II. Mostly they will have anxiety and substance use disorders, though eating disorders will also be in the mix, especially for female patients

Question 69

About how many patients with bipolar II eventually experience a full blown manic episode?

Answer 69

~10%

Question 70

Bipolar II D’s

Answer 70

• Distress or disability (work/educational, social, or personal impairment, but only for depressive episodes or for switches between episodes)
• Differential diagnosis (substance use and physical disorders, other bipolar disorders, major depressive disorder)

Question 71

Coding notes Bipolar II

Answer 71

Specify current or most recent episode as {hypomanic}{depressed}. Choose any relevant specifiers, summarized in Table 3.3. For most recent episode, you can mention severity (free choice: mild, moderate, severe).

Question 72

Persistent Depressive Disorder (Dysthymia) other names

Answer 72

goes by several names—dysthymic disorder, dysthymia, chronic depression, and now persistent depressive disorder.

Question 73

PDD

Answer 73

For years at a time, they have many of the same symptoms found in major depressive episodes, including low mood, fatigue, hopelessness, trouble concentrating, and problems with appetite and sleep. But notice what’s absent from this list of symptoms (and from the criteria): inappropriate guilt feelings and thoughts of death or suicidal ideas. In short, most of these patients have an illness that’s enduring, but also relatively
mild.

Question 74

% of adults with PDD (lifetime)

Answer 74

~6%

Question 75

Old psychodynamic way of labeling PDD?

Answer 75

In the distant past, clinicians regarded these patients as having depressive personality or depressive neurosis

Question 76

PDD, what happened from DSM IV to V?

Answer 76

DSM-IV differentiated between dysthymic disorder and chronic major depressive disorder, but research has not borne out the distinction. So what DSM-5 now calls persistent depressive disorder is a combination of the two separate DSM-IV conditions

Question 77

A note on PDD vs chronic major depression

Answer 77

There’s one other feature that results from the lumping together of dysthymia and chronic major depression. because some major depression symptoms do not occur in the dysthymia criteria set, it is possible (as DSM-5 notes) that a few patients with chronic major depression won’t meet criteria for dysthymia: The combination of psychomotor slowing, suicidal ideas, and low mood/energy/interest would fit that picture (of those symptoms, only low energy appears among the b criteria for dysthymia). Improbable, I know, but there you are. We are advised that such patients should be given a diagnosis of major depressive disorder if their symptoms meet criteria during the current episode; if not, we’ll have to retreat to other specified (or unspecified) depressive disorder

Question 78

Essential features of Persistent Depressive Disorder (Dysthymia)

Answer 78

“Low-grade depression” is how these symptoms are often described, and they occur most of the time for 2 years (they are never absent for longer than 2 months running). Some patients aren’t even aware that they are depressed, though others can see it. They will acknowledge such symptoms as fatigue, problems with concentration or decision making, poor self-image, and feeling hopeless. Sleep and appetite can be either increased or decreased. They may meet full requirements for a major depressive episode, but the concept of mania is foreign to them.

Question 79

PDD Fine Print (re: Children)

Answer 79

For children, mood may be irritable rather than depressed, and the time requirement is 1 year rather than 2.

Question 80

PDD, the D’s

Answer 80

• Duration (more days than not, 2+ years)
• Distress or disability (work/educational, social, or personal impairment)
• Differential diagnosis (substance use and physical disorders, ordinary grief and sadness, adjustment to a long- standing stressor, bipolar disorders, major depressive disorder)

Question 81

PDD coding notes

Answer 81

Specify severity.
Specify onset:

• Early onset, if it begins by age 20.
• Late onset, if it begins at age 21 or later.

Specify if:

• With pure dysthymic syndrome. Doesn’t meet criteria for major depressive episode.
• With persistent major depressive episode. Does meet criteria throughout preceding 2 years.
• With intermittent major depressive episodes, with current episode. Meets major depressive criteria now, but at times hasn’t.
• With intermittent major depressive episodes, without current episode. Has met major depressive criteria in the past, though doesn’t currently.

Specify if: With anxious distress.

Question 82

Essential features of cyclothymic disorder

Answer 82

The patient has had many ups and downs of mood that don’t meet criteria for any of the mood episodes (major depressive, hypomanic, manic). Although symptoms occur most of the time, as much as a couple of months of level mood can go by.

Question 83

Cyclothymic Disorder

Answer 83

• Duration (2+ years; 1+ year in children and adolescents)
• Distress or disability (work/educational, social, or personal impairment)
• Differential diagnosis (substance use and physical disorders, other bipolar disorders)

Question 84

How common is premenstrual dysphoric disorder?

Answer 84

~7% of women

Question 85

Typical patient with PMDD doesn’t receive treatment until what age?

Answer 85

Age 30 (symptoms go unrecognized)

Question 86

Risk factors and comorbid conditions for PMDD

Answer 86

include excessive weight, stress, and trauma (including a history of abuse); there appears to be a robust genetic component.

Comorbid are anxiety disorders and other mood disorders, including bipolar conditions.

Question 87

Essential Features of Premenstrual Dysphoric Disorder

Answer 87

For a few days before menstruating, a patient experiences pronounced mood shifts, depression, anxiety, anger, or other expressions of dysphoria. She will also admit to typical symptoms of depression, including trouble concentrating, loss of interest, fatigue, feeling out of control, and changes in appetite or sleep. She may have physical symptoms such as sensitivity of breasts, muscle pain, weight gain, and a sensation of abdominal distention. Shortly after menstruation begins, she snaps back to normal.

Question 88

PMDD D’s

Answer 88

• Duration (for several days around menstrual periods, for most cycles during the past year)
• Distress or disability (social, occupational, or personal impairment)
• Differential diagnosis (substance use— including hormone replacement therapy; physical disorders; major depressive disorder or dysthymia; ordinary grief/sadness)

Question 89

PMDD coding note

Answer 89

DSM-5 says that the diagnosis can only be stated as (provisional) until you’ve obtained prospective ratings of two menstrual cycles. What you as a clinician decide to do with this is, of course, your business

Question 90

PMDD diagnosis

Answer 90

A: Majority of menstrual cycles, at least 5 symptoms (out of 11) in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses

B: One (or more) of the following symptoms must be present:

• Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C: One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

• Decreased interest in usual activities (e.g., work, school, friends, hobbies).
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.
• Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the preceding year.

D: The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).

E: The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F: Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)

G: The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

Question 91

How many children with DMDD meet criteria for oppositional defiant disorder?

Answer 91

~80% of children with DMDD will also meet criteria for oppositional defiant disorder, in which case you would only diagnose DMDD

Question 92

Do not make DMDD diagnosis prior to age ___

Answer 92

Age 6

Question 93

: Why was DMDD not included in the same chapter with the disruptive, impulse-control, and conduct disorders?

Answer 93

The original impetus was to give clinicians a mood-related alternative to bipolar I disorder.

However, the prominent feature of persistently depressed (or irritable) behavior throughout the course of illness seems reason enough for placement with other mood disorders.

Question 94

In aggregate, a number of features seem to set these youngsters well apart from traditional patients with bipolar disorder

Answer 94

(1) Limited follow-up studies find some increase in depression, not mania, in these children as they mature.
(2) Family history studies find no excess of bipolar disorder in relatives of these patients.
(3) The sex ratio is about 2:1 in favor of boys, which is disparate with the 1:1 ratio for bipolar disorder in older patients.
(4) Studies of pathophysiology suggest that brain mechanisms may differentiate the two conditions.
(5) The diagnosis of childhood bipolar disorder has been made far more often in the United States than elsewhere in the world.
(6) Follow-up studies find far more manic or hypomanic episodes in children with bipolar disorder diagnosed according to traditional criteria than in those whose principal issue was with severe mood dysregulation

Question 95

Essential features of DMDD

Answer 95

For at least a year, several times a week, on slight provocation a child has severe tantrums— screaming or actually attacking someone (or something)—that are inappropriate for the patient’s age and stage of development. Between outbursts, the child seems mostly angry, grumpy, or sad. The attacks and intervening moods occur across multiple settings (home, school, with friends). These patients have no manic episodes

Question 96

DMDD D’s

Answer 96

• Duration and demographics (1+ years, and never absent longer than 3 months, starting before age 10; the diagnosis can only be made from age 6 through 17)
• Distress or disability (symptoms are severe in at least one setting— home, school, with other kids—and present in other settings)
• Differential diagnosis (substance use and physical disorders, major depressive disorder, bipolar disorders, oppositional defiant disorder, attention-deficit/hyperactivity disorder, behavioral outbursts consistent with developmental age)

Question 97

Coding for Bipolar I and MDD

Answer 97

Question 98

Severity Codes (for manic and depressive episodes)

Answer 98

• Mild. Symptoms barely fulfill the criteria and result in little distress or interference with the patient’s ability to work, study, or socialize.
• Moderate. Intermediate between mild and severe.
• Severe. There are several symptoms more than the minimum for diagnosis, and they markedly interfere with patient’s work, social, or personal functioning.

Question 99

Remission codes

Answer 99

In partial remission. A patient who formerly met full criteria and now either (1) has fewer than the required number of symptoms or (2) has had no symptoms at all, but for under 2 months.

In full remission. For at least 2 months, the patient has had no important symptoms of the mood episode.

Question 100

With anxious distress

Answer 100

Patients with bipolar I, bipolar II, cyclothymic, major depressive, or persistent depressive disorder may experience symptoms of high anxiety. These patients may have a greater than average potential for suicide and for chronicity of illness

During a major depressive/manic/hypomanic episode or dysthymia, the patient feels notably edgy or tense, and may be extra restless. Typically, it is hard to focus attention because of worries—“Something terrible could happen,” or “I could lose control and [fill in the awful consequence] . . . ”

Coding Notes
Specify severity:

• mild (2 symptoms of anxious distress),
• moderate (3 symptoms),
• moderate–severe (4–5 symptoms), severe (4–5 symptoms plus physical agitation)

Question 101

With atypical features

Answer 101

Not all seriously depressed patients have the classic vegetative symptoms typical of melancholia (see below). Patients who have atypical features seem almost the reverse: Instead of sleeping and eating too little, they sleep and eat too much. This pattern is especially common among younger (teenage and college-age) patients. Indeed, it is common enough that it might better be called nonclassic depression.

Two reasons make it important to specify with atypical features. First, because such patients’ symptoms often include anxiety and sensitivity to rejection, they risk being mislabeled as having an anxiety disorder or a personality disorder. Second, they may respond differently to treatment than do patients with melancholic features. Atypical patients may respond to specific antidepressants (monoamine oxidase inhibitors), and may also show a favorable response to bright light therapy for seasonal (winter) depression.

Question 102

Essential Features of With Atypical Features

Answer 102

A patient experiencing a major depressive episode feels better when something good happens (“mood reactivity,” which obtains whether the patient is depressed or well). The patient also has other atypical symptoms: an increase in appetite or weight (the classic depressed patient reports a decrease), excessive sleeping (as opposed to insomnia), a feeling of being sluggish or paralyzed, and long- existing (not just when depressed) sensitivity to rejection.

The Fine Print: The with atypical features specifier cannot be used if your patient also has melancholia or catatonic features. See Table 3.3 for application.

Question 103

With catatonia

Answer 103

The catatonia specifier, first mentioned in Chapter 2 in association with the psychotic disorders (p. 100), can be applied to manic and major depressive (but not hypomanic) episodes of mood disorders as well. The definitions of the various terms are given in the sidebar on page 101. When you use it, you have to add a line of extra code after listing and coding the other mental disorder