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Flashcards in Mood Disorders Deck (104)
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manic-depressive illness

an old name for bipolar disorder


To count as a new manic or depressive episode ____

  • 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. 


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

 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. 


What about psychosis?

 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. 



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. 


Bipolar I Disorder D's

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


Rapid cycling

High rates of this in bipolar II


Comorbidity in bipolar II

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


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



Bipolar II D's

  • 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)


Coding notes Bipolar II

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).


Persistent Depressive Disorder (Dysthymia) other names

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



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 


% of adults with PDD (lifetime)



Old psychodynamic way of labeling PDD?

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


PDD, what happened from DSM IV to V?

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


A note on PDD vs chronic major depression

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


Essential features of Persistent Depressive Disorder (Dysthymia)

“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.


PDD Fine Print (re: Children)

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


PDD, the D's

  • 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)


PDD coding notes

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.


Essential features of cyclothymic disorder

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.


Cyclothymic Disorder

  • 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)


How common is premenstrual dysphoric disorder?

~7% of women


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

Age 30 (symptoms go unrecognized)


Risk factors and comorbid conditions for PMDD

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.


Essential Features of Premenstrual Dysphoric Disorder

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.



  • 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)


PMDD coding note

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


PMDD diagnosis

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).